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Grubenhoff JA, Bakel LA, Dominguez F, Leonard J, Widmer K, Sanders JS, Spencer SP, Stein JM, Searns JB. Clinical Pathway Adherence and Missed Diagnostic Opportunities Among Children with Musculoskeletal Infections. Jt Comm J Qual Patient Saf 2023; 49:547-556. [PMID: 37495472 DOI: 10.1016/j.jcjq.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Clinical care pathways (CPs) integrate best evidence into the local care delivery context to promote efficiency and patient safety. However, the impact of CPs on diagnostic performance remains poorly understood. The objectives of this study were to evaluate adherence to a musculoskeletal infection (MSKI) diagnostic CP and identify recurrent failure points leading to missed diagnostic opportunities (MDOs). METHODS Retrospective chart review was performed from January 2018 to February 2022 for children 6 months to 18 years of age who had an unplanned admission for MSKI after being evaluated and discharged from the pediatric emergency department (PED) for related complaints within the previous 10 days. MDOs were identified using the Revised Safer Dx. Demographic and clinical characteristics of children with and without MDOs were compared using bivariate descriptive statistics. An improvement team reviewed the diagnostic trajectories of MDOs for deviations from the MSKI CP and developed a fishbone diagram to describe contributing factors to CP deviations. RESULTS The study identified 21 children with and 13 children without MSKI-associated MDOs. Children with MDOs were more likely to have an initial C-reactive protein value > 2 mg/dL (90.0% vs. 0%, p = 0.01) and returned to care earlier than children without MDOs (median 2.8 days vs. 6.7 days, p = 0.004). Factors contributing to MDOs included failure to obtain screening laboratory tests, misinterpretation of laboratory values, failure to obtain orthopedic consultation, and failure to obtain definitive imaging. CONCLUSION Several recurrent deviations from an MSKI diagnostic CP were found to be associated with MDOs. Future quality improvement efforts to improve adherence to this MSKI CP may prevent MDOs.
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O'Reilly H, Barrett M, Melody L, Nolan B, Rea D, Regan MO'. This infant is having a stroke: an illustrative case report. Ir J Med Sci 2023; 192:2467-2473. [PMID: 36451003 DOI: 10.1007/s11845-022-03236-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Paediatric stroke is a rare event, and timely intervention is required to minimise long-term disability, reduced quality of life and financial implications. Although reperfusion strategies such as thrombolysis and thrombectomy are now well established in the adult population, and paediatric consensus guidelines allow for reperfusion therapies in children, access is currently limited due to diagnostic delays. This challenge is partly due to the rarity of presentation, infrastructure and public awareness to support early diagnosis as exists in the adult setting. We use an illustrative case and literature to describe an achieved case of paediatric stroke within an Irish setting. METHODS We use the case of an 8-month-old male infant presenting with acute-onset left-sided hemiplegia to illustrate what can be achieved in an Irish setting. RESULTS Stroke was identified quickly following presentation, timely neuroimaging and multidisciplinary involvement with disposition to paediatric intensive care unit where thrombolysis was administered. Although the patient has some speech delay, he is recovering well with normal gross motor function. CONCLUSIONS Paediatric stroke care should be available to all children presenting with acute stroke symptoms; however, the rarity of the diagnosis would suggest a national strategy will be required to provide equitable care at a national level.
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Affiliation(s)
- Hugh O'Reilly
- Department of Paediatric Emergency Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland.
| | - Michael Barrett
- Department of Paediatric Emergency Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland
- School of Medicine, Women's and Children's Health, University College Dublin, Dublin, Ireland
| | - Laura Melody
- Department of Paediatric Emergency Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Beatrice Nolan
- Department of Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - David Rea
- Department of Radiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Mary O ' Regan
- Department of Neurology, Children's Health Ireland at Crumlin, Dublin, Ireland
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3
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Sun LR, Lynch JK. Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke. Neurotherapeutics 2023; 20:633-654. [PMID: 37072548 PMCID: PMC10112833 DOI: 10.1007/s13311-023-01373-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.
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Affiliation(s)
- Lisa R Sun
- Divisions of Pediatric Neurology and Cerebrovascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Ste 2158, Baltimore, MD, 21287, USA.
| | - John K Lynch
- Acute Stroke Research Section, Stroke Branch (SB), National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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Bindslev JB, Hansen K, Laugesen NG, Benndorf G, Hoei-Hansen CE, Truelsen T. Acute triage of childhood stroke in Denmark. Eur Stroke J 2023; 8:483-491. [DOI: 10.1177/23969873231161381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Objective: This 2-year observational study aimed to test the feasibility of implementing a pediatric stroke triage-setup that connected frontline providers with vascular neurologists and to examine final diagnoses in children triaged for suspected stroke. Methods: Prospective, consecutive registration of children with suspected stroke triaged by a team of vascular neurologists from Jan 1st, 2020 and through Dec 2021, Eastern Denmark (census 530,000 children). Based on the provided clinical information, the children were triaged to either assessment at the Comprehensive Stroke Center (CSC) in Copenhagen or to a pediatric department. All included children were retrospectively followed-up for clinical presentations and final diagnosis. Results: A total of 163 children with 166 suspected stroke events were triaged by the vascular neurologists. Cerebrovascular disease was present in 15 (9.0%) suspected stroke events; one child had intracerebral hemorrhage, one had subarachnoid hemorrhage, two children presented with three TIA events and nine children presented with 10 ischemic stroke events. Two children with ischemic stroke were eligible for acute revascularization treatment of which both were triaged to the CSC. The sensitivity of the triage by acute revascularization indication was 1.00 (95% confidence interval (95% CI): 0.15–1.00) and specificity 0.65 (95% CI: 0.57–0.73). Non-stroke neurological emergencies were present in 34 (20.5%) children, including seizures in 18 (10.8%) and acute demyelinating disorders in 7 (4.2%). Conclusion: Implementing regional triage-setup that connected frontline providers to vascular neurologists was feasible; this system was activated for the majority of children with ischemic stroke according to an expected incidence and led to identification of children eligible for revascularization treatments.
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Affiliation(s)
- Julie Brix Bindslev
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Pediatrics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Goetz Benndorf
- Department of Radiology, University Hospital of Copenhagen, Rigshopitalet, Copenhagen, Denmark
- Baylor College of Medicine, Houston, TX, USA
| | - Christina Engel Hoei-Hansen
- Department of Pediatrics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Truelsen
- Department of Neurology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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5
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Imaging of Suspected Stroke in Children, From the AJR Special Series on Emergency Radiology. AJR Am J Roentgenol 2023; 220:330-342. [PMID: 36043606 DOI: 10.2214/ajr.22.27816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Pediatric stroke encompasses different causes, clinical presentations, and associated conditions across ages. Although it is relatively uncommon, pediatric stroke presents with poor short- and long-term outcomes in many cases. Because of a wide range of overlapping presenting symptoms between pediatric stroke and other more common conditions, such as migraine and seizures, stroke diagnosis can be challenging or delayed in children. When combined with a comprehensive medical history and physical examination, neuroimaging plays a crucial role in diagnosing stroke and differentiating stroke mimics. This review highlights the current neuroimaging workup for diagnosing pediatric stroke in the emergency department, describes advantages and disadvantages of different imaging modalities, highlights disorders that predispose children to infarct or hemorrhage, and presents an overview of stroke mimics. Key differences in the initial approach to suspected stroke between children and adults are also discussed.
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6
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Alloush R, Eldin NS, El-Khawas H, Shatla R, Nada M, Mohammed MZ, Alloush A. Pediatric vs. adult stroke: comparative study in a tertiary referral hospital, Cairo, Egypt. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022; 58:82. [PMID: 35818474 PMCID: PMC9261250 DOI: 10.1186/s41983-022-00514-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background Even though stroke is rare in children, it is associated with serious or life-threatening consequences. Despite its rarity, the occurrence of stroke in children has age-related differences in risk factors, etiopathogenesis, and clinical presentations. Unlike adults, who have arteriosclerosis as the major cause of stroke, risk factors for pediatric strokes are multiple, including cardiac disorders, infection, prothrombotic disorders, moyamoya disease, moyamoya syndrome, and others. The goal of the current study was to compare the characteristics, clinical features, etiology, subtypes, and workup of pediatric and adult strokes. Methods This was a hospital-based observational study conducted on 222 participants. All patients underwent a full clinical and neurological examination, full laboratory study, cardiac evaluation, and neuroimaging; CT scan, MRI, MRA, MRV, carotid duplex, and transcranial Doppler (TCD). Ischemic stroke (IS) etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, the "proposed classification for subtypes of arterial ischemic stroke in children," and the Oxfordshire Community Stroke Project (OCSP). Stroke severity was determined by the National Institutes of Health Stroke Scale (NIHSS) and PedNIHSS on admission. Results The proportion of pediatric ischemic strokes in the current study was 63.4 percent, while hemorrhagic strokes were 36.5%. The majority of the adult patients had ischemic strokes (84.1%), while hemorrhagic strokes were noted in 15.8% of the patients. According to the original TOAST classification, in the current study, the etiology of pediatric IS was other determined causes in 63.6%, undetermined etiology in 27.2%, and cardioembolic in 9.0%. For the adult group, the major stroke subtypes were large artery disease, small vessel disease, cardioembolic, other determined causes, and undetermined etiology at 49.6%, 28.6%, 6.9%, 0.6%, and 12.5%, respectively. Conclusions There is a greater etiological role for non-atherosclerotic arteriopathies, coagulopathies, and hematological disorders in pediatric stroke, while adults have more atherothrombotic causes. The co-existence of multiple risk factors in pediatric ischemic stroke is noticed. Thrombophilia evaluation is helpful in every case of childhood stroke. Children who have had a stroke should undergo vascular imaging as soon as possible. Imaging modalities include TCD and Doppler ultrasound, CT, MRI, MRA, and MRV, and cerebral angiography.
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Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
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Gong Y, Chen Q, Zhang Y. The Role of the Clinical Pharmacist on the Health Outcomes of Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD). Int J Chron Obstruct Pulmon Dis 2022; 17:1863-1870. [PMID: 35996393 PMCID: PMC9391938 DOI: 10.2147/copd.s370532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/02/2022] [Indexed: 11/23/2022] Open
Abstract
Background Clinical pharmacists play a significant role in clinical practice, but their work in the clinical pathway (CP) of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) remains undefined. Methods This prospective study included patients who met the discharge criteria during hospitalization at the department of respiratory medicine of the Second Affiliated Hospital of Fujian Medical University from March to December 2017 (no pharmacists involved) and from March 2018 to January 2019 (pharmacists involved). The adverse drug reaction (ADR) reporting rate, the average DDD number of antibacterial drugs, the per capita cost of pharmaceutical services, and the benefit-cost ratio (B/C) were analyzed. Results and Discussion Eighty participants were enrolled during the traditional period and eighty-five participants during the clinical pharmacist period. The average hospital stays (9.2±0.4 vs 10.7±0.6 days, P=0.032), the total cost of hospitalization expenses (¥ 14,058±826 vs ¥ 18,765±1434, P=0.004), the total cost of drugs (¥ 5717±449 vs ¥ 8002±755, P=0.004), and cost of antimicrobial drugs (¥ 3639±379 vs ¥ 5636±641, P=0.007) were all lower in the clinical pharmacist group than in the traditional group. The B/C was 10.38 and 5.05 in the total cost of hospitalization expenses and the total cost of drugs, respectively. The clinical pharmacists’ participation was independently associated with the total cost of hospitalization expenses (β=−0.201, 95% confidence interval: −0.390, −0.055, P=0.010). What is New and Conclusion The participation of the clinical pharmacist in implementing an AECOPD CP significantly reduces patients’ hospitalization days, the total cost of hospitalization expenses, and antibiotic use and improves the B/C of AECOPD management. The clinical pharmacists’ participation was independently associated with the total hospitalization expenses.
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Affiliation(s)
- Yanqing Gong
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China.,Department of Pharmacy, Gaoxin Branch of the First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Qiying Chen
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
| | - Yin Zhang
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, People's Republic of China
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9
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Harrar DB, Benedetti GM, Jayakar A, Carpenter JL, Mangum TK, Chung M, Appavu B. Pediatric Acute Stroke Protocols in the United States and Canada. J Pediatr 2022; 242:220-227.e7. [PMID: 34774972 DOI: 10.1016/j.jpeds.2021.10.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/13/2021] [Accepted: 10/26/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe existing pediatric acute stroke protocols to better understand how pediatric centers might implement such pathways within the context of institution-specific structures. STUDY DESIGN We administered an Internet-based survey of pediatric stroke specialists. The survey included questions about hospital demographics, child neurology and pediatric stroke demographics, acute stroke response, imaging, and hyperacute treatment. RESULTS Forty-seven surveys were analyzed. Most respondents practiced at a large, freestanding children's hospital with a moderate-sized neurology department and at least 1 neurologist with expertise in pediatric stroke. Although there was variability in how the hospitals deployed stroke protocols, particularly in regard to staffing, the majority of institutions had an acute stroke pathway, and almost all included activation of a stroke alert page. Most institutions preferred magnetic resonance imaging (MRI) over computed tomography (CT) and used abbreviated MRI protocols for acute stroke imaging. Most institutions also had either CT-based or magnetic resonance-based perfusion imaging available. At least 1 patient was treated with intravenous tissue plasminogen activator (IV-tPA) or mechanical thrombectomy at the majority of institutions during the year before our survey. CONCLUSIONS An acute stroke protocol is utilized in at least 41 pediatric centers in the US and Canada. Most acute stroke response teams are multidisciplinary, prefer abbreviated MRI over CT for diagnosis, and have experience providing IV-tPA and mechanical thrombectomy. Further studies are needed to standardize practices of pediatric acute stroke diagnosis and hyperacute management.
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Affiliation(s)
- Dana B Harrar
- Department of Neurology, Children's National Hospital and Departments of Neurology and Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Giulia M Benedetti
- Department of Neurology, Seattle Children's Hospital and University of Washington, Seattle, WA
| | - Anuj Jayakar
- Department of Neurology, Nicklaus Children's Hospital, Miami, FL
| | - Jessica L Carpenter
- Department of Neurology, Children's National Hospital and Departments of Neurology and Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Tara K Mangum
- Department of Neurology, Phoenix Children's Hospital, Phoenix, AZ
| | - Melissa Chung
- Divisions of Critical Care Medicine and Pediatric Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Brian Appavu
- Department of Neurology, Phoenix Children's Hospital, Phoenix, AZ
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10
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Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, Wildgruber M. Childhood stroke. Nat Rev Dis Primers 2022; 8:12. [PMID: 35210461 DOI: 10.1038/s41572-022-00337-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 01/09/2023]
Abstract
Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, and Epidemiology and Biostatistics, Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, CA, USA
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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Mastrangelo M, Giordo L, Ricciardi G, De Michele M, Toni D, Leuzzi V. Acute ischemic stroke in childhood: a comprehensive review. Eur J Pediatr 2022; 181:45-58. [PMID: 34327611 PMCID: PMC8760225 DOI: 10.1007/s00431-021-04212-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/10/2021] [Accepted: 07/15/2021] [Indexed: 12/27/2022]
Abstract
This review provides an updated analysis of the main aspects involving the diagnosis and the management of children with acute ischemic stroke. Acute ischemic stroke is an emergency of rare occurrence in children (rate of incidence of 1/3500 live birth in newborns and 1-2/100,000 per year during childhood with peaks of incidence during the perinatal period, under the age of 5 and in adolescence). The management of ischemic stroke in the paediatric age is often challenging because of pleomorphic age-dependent risk factors and aetiologies, high frequency of subtle or atypical clinical presentation, and lacking evidence-based data about acute recanalization therapies. Each pediatric tertiary centre should activate adequate institutional protocols for the optimization of diagnostic work-up and treatments.Conclusion: The implementation of institutional standard operating procedures, summarizing the steps for the selection of candidate for neuroimaging among the ones presenting with acute neurological symptoms, may contribute to shorten the times for thrombolysis and/or endovascular treatments and to improve the long-term outcome. What is Known: •Acute ischemic stroke has a higher incidence in newborns than in older children (1/3500 live birth versus 1-2/100,000 per year). •Randomized clinical trial assessing safety and efficacy of thrombolysis and/or endovascular treatment were never performed in children What is New: •Recent studies evidenced a low risk (2.1% of the cases) of intracranial haemorrhages in children treated with thrombolysis. •A faster access to neuroimaging and hyper-acute therapies was associated with the implementation of institutional protocols for the emergency management of pediatric stroke.
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Affiliation(s)
- Mario Mastrangelo
- Child Neurology and Infantile Psychiatry Unit, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Laura Giordo
- Child Neurology and Infantile Psychiatry Unit, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Giacomina Ricciardi
- Child Neurology and Infantile Psychiatry Unit, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Manuela De Michele
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Leuzzi
- Child Neurology and Infantile Psychiatry Unit, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
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Paek SH, Kim DK, Kwak YH, Jung JY, Lee S, Park JW. Effectiveness of the implementation of pediatric intussusception clinical pathway: A pre- and postintervention trial. Medicine (Baltimore) 2021; 100:e27971. [PMID: 35049201 PMCID: PMC9191323 DOI: 10.1097/md.0000000000027971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 11/09/2021] [Indexed: 12/13/2022] Open
Abstract
Intussusception is common among children at the pediatric emergency department (ED) with acute abdomen. Diagnosis and treatment delay remain a challenge. This study aimed to evaluate the impact of intussusception clinical pathways (CPs) implementation, including bedside point-of-care ultrasonography, on patient management in a pediatric ED.In January 2017, an intussusception management protocol was implemented for children with symptoms of intussusception. We retrospectively examined the charts of patients diagnosed with intussusception during the preprotocol (January 2015 to December 2016) and postprotocol (January 2017 to January 2019) periods and compared their outcomes.A total of 106 and 108 patients were included in the preprotocol and postprotocol groups, respectively. After CP implementation, the median door-to-ultrasonography time decreased from 66.5 (range: 13, 761) to 54 (20, 191) minutes; meanwhile, door-to-reduction time decreased from 121.5 (37, 1077) to 80.5 (40, 285) minutes; the median ED length of stay decreased from 440 to 303.5 minutes; and finally, admission rate increased from 18.9% to 40.7% (P < .01). There was no between-group difference in the rates of complications, readmission, emergency surgery, or reduction failure.The implementation of an intussusception CP decreased time-to-diagnosis, time-to-treatment, and ED length of stay estimates among children screened using point-of-care ultrasonography. The present findings suggest that the implementation of an intussusception CP may improve the efficiency of time and resource use.
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Affiliation(s)
- So Hyun Paek
- Department of Emergency Medicine, CHA Bundang Medical Center, Gyeonggi-do, Republic of Korea
| | - Do Kyun Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seuk Lee
- Department of Emergency Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Joong Wan Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Manning WA, Bakel LA. Adaptation of Adult Pathways to Improve the Care of Adult Patients at Pediatric Hospitals. Hosp Pediatr 2021; 11:e164-e166. [PMID: 34326163 DOI: 10.1542/hpeds.2020-004093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- W Aaron Manning
- Children's Hospital Colorado, Aurora, Colorado .,UCHealth University of Colorado Hospital, Aurora, Colorado
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14
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Pediatric Patient with Ischemic Stroke: Initial Approach and Early Management. CHILDREN 2021; 8:children8080649. [PMID: 34438540 PMCID: PMC8394345 DOI: 10.3390/children8080649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/05/2023]
Abstract
Acute Ischemic Stroke (AIS) in children is an acute neurologic emergency associated with significant morbidity and mortality. Although the incidence of AIS in pediatric patients is considerably lower than in adults, the overall cumulative negative impact of the quality of life could be even higher in children. The age-related variable clinical presentation could result in a delay in diagnosis and could negatively influence the overall outcome. The early management should be based on early recognition, acute transfer to pediatric AIS centre, standardised approach (ABCDE), early neurologic examination together with neuroimaging (preferable Magnetic Resonance Imaging—MRI). The treatment is based on supportive therapy (normoxemia, normocapnia, normotension and normoglycemia) in combination with intravenous/intraarterial thrombolytic therapy and/or mechanical thrombectomy in selected cases. Pediatric stroke centres, together with the implementation of local stroke management protocols, could further improve the outcome of pediatric patients with AIS.
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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Kannikeswaran N, Desai L, Farooqi A, Sivaswamy L. Effectiveness of Standard Combination Therapy in Pediatric Migraine. Pediatr Neurol 2021; 116:68-73. [PMID: 33493999 DOI: 10.1016/j.pediatrneurol.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/14/2020] [Accepted: 12/10/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND A combination of parenteral medications (often referred to as standard combination therapy) is frequently used in the treatment of acute migraine in the pediatric emergency department (PED). The primary aim of this study was to evaluate the two-hour, 24-hour, and seven-day impact of one such regimen on pain in children who present to the PED. Standard combination therapy for purposes of our study is defined as a bolus of intravenous saline, and a combination of intravenous ketorolac, prochlorperazine, and diphenhydramine. METHODS This prospective observational study included 120 children between the ages seven and 18 years who presented to the PED with migraine, whose parents could read and understand the consent form in English, and who were treated with standard combination therapy. The primary outcome measure for this study was the change in severity of pain as noted by the child using the Faces Pain Scale-Revised. We analyzed normally distributed continuous variables by mean and standard deviation, whereas non-normally distributed continuous variables are reported by median and interquartile range. RESULTS Nonparametric Friedman testing on the entire cohort (n = 120) noted that there was a statistically significant change in the Faces pain scale from before administration of standard combination therapy to the two-hour, 24-hour, and one-week time point with a reduction in pain score of 87.5%, 100%, and 50%, respectively, at the three time points. CONCLUSIONS This study noted moderate relief of pain after administration of standard combination therapy, which persisted at one-week after administration.
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Affiliation(s)
- Nirupama Kannikeswaran
- Professor of Pediatrics and Emergency Medicine, Children's Hospital of Michigan/Central Michigan University, Detroit, Michigan
| | - Lavina Desai
- Resident in Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Ahmad Farooqi
- Biostatistician, Children's Hospital of Michigan, Detroit, Michigan
| | - Lalitha Sivaswamy
- Professor of Pediatrics and Neurology, Children's Hospital of Michigan/Central Michigan University, Detroit, Michigan.
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Pediatric Hyperacute Arterial Ischemic Stroke Pathways at Canadian Tertiary Care Hospitals. Can J Neurol Sci 2021; 48:831-838. [PMID: 33568245 DOI: 10.1017/cjn.2021.27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Childhood acute arterial ischemic stroke (AIS) is diagnosed at a median of 23 hours post-symptom onset, delaying treatment. Pediatric stroke pathways can expedite diagnosis. Our goal was to understand the similarities and differences between Canadian pediatric stroke protocols with the aim of optimizing AIS management. METHODS We contacted neurologists at all 16 Canadian pediatric hospitals regarding AIS management. Established protocols were analyzed for similarities and differences in eight domains. RESULTS Response rate was 100%. Seven (44%) centers have an established AIS protocol and two (13%) have a protocol under development. Seven centers do not have a protocol; two redirect patients to adult neurology, five rely on a case-by-case approach for management. Analysis of the seven protocols revealed differences in: 1) IV-tPA dosage: age-dependent 0.75-0.9 mg/kg (N = 1) versus age-independent 0.9 mg/kg (N = 6), with maximum doses of 75 mg (N = 1) or 90 mg (N = 6); 2) IV-tPA lower age cut-off: 2 years (N = 5) versus 3 or 10 years (each N = 1); 3) IV-tPA exclusion criteria: PedNIHSS score <4 (N = 3), <5 (N = 1), <6 (N = 3); 4) first choice of pre-treatment neuroimaging: computed tomography (CT) (N = 3), magnetic resonance imaging (MRI) (N = 2) or either (N = 2); 5) intra-arterial tPA use (N = 3) and; 6) mechanical thrombectomy timeframe: <6 hour (N = 3), <24 hour (N = 2), unspecified (N = 2). CONCLUSIONS Although 44% of Canadian pediatric hospitals have established AIS management pathways, several differences remain among centers. Some criteria (dosage, imaging) reflect adult AIS literature. Canadian expert consensus regarding IV-tPA and endovascular treatment should be established to standardize and implement AIS protocols across Canada.
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Abstract
Emergent imaging of the brain is often required to diagnose and manage serious and life-threatening conditions for children presenting to the emergency department. In an effort to reduce children's exposure to ionizing radiation, the use of magnetic resonance imaging (MRI) as an alternative to computed tomography (CT) is increasing. In some conditions, an urgent MRI rather than CT is critical for making management decisions. The purpose of this review is to highlight 3 emergency medical conditions-acute stroke, traumatic brain injury, and hydrocephalus-in which timely MRI of the brain is required for diagnosis and management. Another aim will be to guide providers in determining when and what limited MRI sequences of the brain can be used in lieu of CT in these emergency medical conditions.
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20
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De Jong G, Kannikeswaran N, DeLaroche A, Farooqi A, Sivaswamy L. Rapid Sequence MRI Protocol in the Evaluation of Pediatric Brain Attacks. Pediatr Neurol 2020; 107:77-83. [PMID: 32111563 DOI: 10.1016/j.pediatrneurol.2019.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/02/2019] [Accepted: 12/08/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND The objective of our study was to evaluate the clinical utility of rapid sequence magnetic resonance imaging (MRI) utilizing diffusion-weighted imaging and fluid-attenuated inversion recovery sequences in children with acute ischemic strokes and nonstroke brain attacks. METHODS We performed a retrospective chart review of patients aged one month to 25 years for whom a pediatric stroke clinical pathway was activated. Diffusion-weighted imaging and fluid-attenuated inversion recovery were obtained followed by a complete MRI. Imaging was interpreted by a pediatric radiologist and the study neurologist. We collected information regarding patient demographics, neuroimaging results, and final diagnosis. RESULTS The Pediatric Stroke Clinical Pathway was activated for 59 patients of whom 52 were included for analysis. The majority of patients were female (n = 29, 55.8%) and African American (n = 32, 61.5%), with a median age of 12 years (interquartile range 9, 16). Six patients had an ischemic stroke. Seizures, migraines, and psychosomatic disorders (each with n = 7; 13.5%) were the most common nonstroke diagnoses. Diffusion-weighted imaging was more sensitive (100% [55.0% to 100%] versus 80 % [32% to 99%]) and specific (73.9% [68% to 74%] versus 37.2% [32% to 39%]) compared with fluid-attenuated inversion recovery in identification of an ischemic stroke. However, fluid-attenuated inversion recovery was useful in the identification of inflammatory and metabolic disorders. CONCLUSION Rapid sequence MRI can be utilized as a screening imaging modality in children with suspected brain attacks in cases where there may be delays in obtaining full sequence brain imaging.
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Affiliation(s)
- Gracia De Jong
- Pediatric Resident, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Amy DeLaroche
- Division of Emergency Medicine, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Ahmad Farooqi
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
| | - Lalitha Sivaswamy
- Division of Neurology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan
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Wharton JD, Barry MM, Lee CA, Massey K, Ladner TR, Jordan LC. Pediatric Acute Stroke Protocol Implementation and Utilization Over 7 Years. J Pediatr 2020; 220:214-220.e1. [PMID: 32147216 DOI: 10.1016/j.jpeds.2020.01.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the implementation and utilization of a pediatric acute stroke protocol over a 7-year period, hypothesizing improvements in protocol implementation and increased protocol use over time. STUDY DESIGN Clinical and demographic data for this retrospective observational study from 2011 through 2018 were obtained from a quality improvement database and medical records of children for whom the acute stroke protocol was activated. The initial 43 months of the protocol (period 1) were compared with the subsequent 43 months (period 2). RESULTS Over the 7-year period, a total of 385 stroke alerts were activated, in 150 children (39%) in period 1 and 235 (61%) in period 2, representing a 56% increase in protocol activation. Stroke was the final diagnosis in 80 children overall (21%), including 38 (25%) in period 1 and 42 (19%) in period 2 (P = .078). The combined frequency of diagnosed stroke, transient ischemic attack (TIA), and other neurologic emergencies remained stable across the 2 time periods at 39% and 37%, respectively (P = .745). Pediatric National Institutes of Health Stroke Scale (PedNIHSS) documentation increased from 42% in period 1 to 82% in period 2 (P < .001). Magnetic resonance imaging (MRI) was the first neuroimaging study for 68% of the children in period 1 vs 78% in period 2 (P = .038). All children with acute stroke received immediate supportive care. CONCLUSIONS Pediatric stroke protocol implementation improved over time with increased use of the PedNIHSS and use of MRI as the first imaging study. However, with increased utilization, the frequency of confirmed strokes and other neurologic emergencies remained stable. The frequency of stroke and other neurologic emergencies in these children affirms the importance of implementing and maintaining a pediatric acute stroke protocol.
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Affiliation(s)
- Jessica D Wharton
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Megan M Barry
- Department of Pediatrics, University of Colorado, Aurora, CO; Department of Neurology, University of Colorado, Aurora, CO
| | - Chelsea A Lee
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Travis R Ladner
- Department of Neurosurgery, Icahn School of Medicine at Mt Sinai, New York, NY
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN; Department of Neurology, Vanderbilt University Medical Center, Nashville, TN; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN.
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Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation 2020; 141:e139-e596. [PMID: 31992061 DOI: 10.1161/cir.0000000000000757] [Citation(s) in RCA: 4861] [Impact Index Per Article: 1215.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals. RESULTS Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Arterial ischemic stroke in non-neonate children: Diagnostic and therapeutic specificities. Rev Neurol (Paris) 2020; 176:20-29. [DOI: 10.1016/j.neurol.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
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Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56-e528. [PMID: 30700139 DOI: 10.1161/cir.0000000000000659] [Citation(s) in RCA: 5341] [Impact Index Per Article: 1068.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Lucas B, Schirrmeister W, Pliske G, Leenen M, Walcher F, Kopschina C. Existence and role of standard operating procedures in the emergency department : A national online survey. Med Klin Intensivmed Notfmed 2019; 116:50-55. [PMID: 31811310 DOI: 10.1007/s00063-019-00642-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 10/01/2019] [Accepted: 10/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND In recent years, increases in the number of patients in emergency departments (ED) have led to continuous work intensification. To handle this problem, the treatment effectiveness has to be maximized. One strategy that may help to optimize workflow is the use of standard operating procedures (SOPs). We investigated the existence of SOPs and subjective effects on treatment in German EDs. METHODS We performed an online survey from February 2015 until June 2016. We collected data regarding the existence of SOPs, health care level, medical field, work experience, and education. All professional groups participating in the treatment of patients were requested to take part in the survey. RESULTS Seventy-five percent of the 589 participants in the survey confirmed the existence of SOPs in their EDs. SOPs were more frequently available in hospitals with higher health care levels. Participants working in EDs without SOPs felt less confident regarding treatment of patients. More than 85% of these participants were in favor of having SOPs. The absence of SOPs was associated with a subjective delay in patient treatment. CONCLUSION Most of the EDs had available SOPs. In departments without SOPs, most physicians wanted them to be implemented. SOPs seemed adequate in terms of supporting workflow and satisfaction with patients' treatment.
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Affiliation(s)
- Benjamin Lucas
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Straße 44, 39120, Magdeburg, Germany.
| | - Wiebke Schirrmeister
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Gerald Pliske
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Michael Leenen
- Emergency Department, Community Hospital Nettetal GmbH, Sassenfelder Kirchweg 1, 41334, Nettetal, Germany
| | - Felix Walcher
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Carsten Kopschina
- Department of Trauma and Orthopaedic Surgery, Hospital Lauf a.d. Pegnitz, Krankenhäuser Nürnberger Land GmbH, Simonshofer Straße 55, 91207, Lauf an der Pegnitz, Germany
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Harriott AM, Karakaya F, Ayata C. Headache after ischemic stroke: A systematic review and meta-analysis. Neurology 2019; 94:e75-e86. [PMID: 31694924 PMCID: PMC7011689 DOI: 10.1212/wnl.0000000000008591] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/26/2019] [Indexed: 01/24/2023] Open
Abstract
Objective Headache associated with ischemic stroke is poorly understood. To gain further insight, we systematically reviewed studies examining the prevalence and characteristics of new-onset poststroke headache. Methods Medline and PubMed databases were queried. A total of 1,812 articles were identified. Of these, 50 were included in this systematic review. Twenty were included in a meta-analysis and meta-regression. Results Headache occurred in 6%–44% of the ischemic stroke population. Most headaches had tension-type features, were moderate to severe, and became chronic in nature. Meta-analysis using an inverse-variance heterogeneity model revealed a pooled prevalence of 0.14 (95% confidence interval [CI] 0.07–0.23) with heterogeneity among studies. Metaregression revealed a significant association between prevalence and study location, the source population's national human development index (HDI), and study quality. We found higher prevalence in European (0.22, 95% CI 0.14–0.30) and North American (0.15, 95% CI 0.05–0.26) studies compared with Middle Eastern and Asian studies (0.08, 95% CI 0.01–0.18). However, within each region, populations from countries with higher HDI (p = 0.03) and studies with higher quality (p = 0.001) had lower prevalence. Calculated crude odds ratios (ORs) showed that posterior circulation stroke (pooled OR 1.92, 95% CI 1.4–2.64; n = 7 studies) and female sex (pooled OR 1.25, 95% CI 1.07–1.46; n = 11 studies) had greater odds of headache associated with ischemic stroke. Conclusions Taken together, these data suggest that headache is common at the onset of or shortly following ischemic stroke and may contribute to poststroke morbidity. Better understanding of headache associated with ischemic stroke is needed to establish treatment guidelines and inform patient management.
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Affiliation(s)
- Andrea M Harriott
- From the Neurovascular Research Laboratory (A.M.H., C.A.), Department of Radiology, Massachusetts General Hospital, Charlestown; Vascular Division (A.M.H., C.A.) and Headache and Neuropathic Pain Division (A.M.H.), Department of Neurology, Massachusetts General Hospital, Boston; and University of Massachusetts Dartmouth (F.K.).
| | - Fahri Karakaya
- From the Neurovascular Research Laboratory (A.M.H., C.A.), Department of Radiology, Massachusetts General Hospital, Charlestown; Vascular Division (A.M.H., C.A.) and Headache and Neuropathic Pain Division (A.M.H.), Department of Neurology, Massachusetts General Hospital, Boston; and University of Massachusetts Dartmouth (F.K.)
| | - Cenk Ayata
- From the Neurovascular Research Laboratory (A.M.H., C.A.), Department of Radiology, Massachusetts General Hospital, Charlestown; Vascular Division (A.M.H., C.A.) and Headache and Neuropathic Pain Division (A.M.H.), Department of Neurology, Massachusetts General Hospital, Boston; and University of Massachusetts Dartmouth (F.K.)
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A Strategy for the Renovation of a Clinical Pathways Program. Pediatr Qual Saf 2019; 4:e178. [PMID: 31579877 PMCID: PMC6594782 DOI: 10.1097/pq9.0000000000000178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 04/24/2019] [Indexed: 12/20/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Clinical pathways (CPs) translate best available evidence to the local care context and intend to inform clinical decision-making, optimize care, and decrease variation. This article describes a CPs program improvement process at a free-standing academic children’s hospital. Aims: (1) improve the pathway development process; (2) identify and address gaps; (3) strengthen measurement; (4) increase efficiency in cycle time to build a pathway; (5) increase multidisciplinary participation; (6) integrate into the electronic health record ; and (7) and increase pathway utilization. Methods: We renovated the CP program using a structured, improvement process. A series of internal stakeholder and external colleague interviews informed the process. To improve the program, we developed and implemented different interventions. Results: The streamlined process reduced the overall time for completion from a median of 15 to 5 months (measured from the date of first meeting with the clinical improvement team to approval), a 70% increase in efficiency. Between 1994 and 2015, the hospital had 33 CPs. There was a 78% increase in the total number of pathways after the renovation with 26 additional pathways. Conclusions: Renovation of the CP program led to early success through an improved development process, alleviation of programmatic gaps, inclusion of measures within each pathway, increased timely completion, multidisciplinary involvement, integration into the electronic health record, and improved utilization. Initial results are encouraging, and the lessons learned should be helpful to other programs. Further program development is ongoing, focusing on continued improvements in implementation and overall program measures.
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Zeng JQ. The pilot results of 47 148 cases of BJ-DRGs-based payment in China. Int J Health Plann Manage 2019; 34:1386-1398. [PMID: 31286577 DOI: 10.1002/hpm.2818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 05/09/2019] [Accepted: 05/13/2019] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Diagnosis-related groups (DRGs)-based payment is an important tool for containment of inpatient expenditure rise in many countries. As a major developing country, China has introduced DRGs in the health reform. Beijing, the capital of China, developed a local DRGs version (BJ-DRGs) whose performance needs to be evaluated before universal utilization. The objective of this study was to survey the effect of BJ-DRGs-based payment on a pilot hospital. METHODS We surveyed the profit and loss situation of 47 148 cases of hospital discharged patients in 107 groups of pilot BJ-DRGs-based payment from December 2011 to July 2018 in certain top tertiary hospital in Beijing. RESULTS In pilot 107 groups of DRGs, there were 77 groups (71.96%) in profit and 30 groups (28.04%) in loss; average length of inpatient stay was 7.47 days, average inpatient expenditure ¥17 821.19, average DRGs standard unit price ¥15 896.83, average self-pay expenditure ¥1 117.04, and average profit ¥1 849.65; logistic regression showed that whether the pilot hospital of BJ-DRGs-based payment was in profit or loss was correlated negatively with inpatient expenditure, length of inpatient stay, drug expenditure, expenditure of medical consumables, and pilot years, and positively with DRGs standard unit price, self-pay expenditure, and age and gender (P < .0001). CONCLUSION BJ-DRGs-based payment is the first implemented DRGs-based prospective payment system in China. The current DRGs pilot model made the pilot hospital appear profitable as a whole and its length of inpatient stay decline.
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Affiliation(s)
- Jun-Qun Zeng
- Medical Insurance Office, Peking University People's Hospital, Beijing, China
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Watson C, Sivaswamy L, Agarwal R, Du W, Agarwal R. Functional Neurologic Symptom Disorder in Children: Clinical Features, Diagnostic Investigations, and Outcomes at a Tertiary Care Children's Hospital. J Child Neurol 2019; 34:325-331. [PMID: 30819032 DOI: 10.1177/0883073819830193] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the presenting symptoms and short-term outcomes of children diagnosed with functional neurologic symptom disorder and to compare the demographic and clinical characteristics of children who received neurodiagnostic testing to those who did not. STUDY DESIGN Single center, retrospective review of 222 children who presented to the emergency department of a children's hospital, and diagnosed with functional neurologic symptom disorder, between 2010 and 2015. RESULTS Out of 222 visits (females = 156, African Americans = 130, mean age = 13.9 years), neurodiagnostic tests were performed in 102/222 (46%) visits. The most commonly performed investigations were magnetic resonance imaging (MRI) of brain (n = 37) and electroencephalogram (EEG) (n = 56) and were noted to be unremarkable in all instances. Neurodiagnostic tests were more likely to be performed in patients who (1) were non-African American (54% vs 40%; P = .03), (2) presented with new-onset symptoms (55% vs 31%; P < .01), (3) underwent hospitalization (61% vs 17%; P < .01), and (4) were evaluated by a neurologist (59% vs 9%; P < .01) or a psychiatrist (58% vs 28%; P < .01). Common clinical presentations included seizurelike or strokelike symptoms. Short-term follow-up was possible in 20%, with an alternate diagnosis of syncope, noted in only 1 child. CONCLUSIONS Most children who presented with a functional neurologic symptom disorder in our study were noted to have seizurelike or strokelike presentations and were adolescent females. Caucasians were more likely to undergo neurodiagnostic investigations. Radiologic and neurophysiological tests were more commonly performed when neurology and psychiatry consultations were sought. Such investigations had low diagnostic utility.
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Affiliation(s)
- Carla Watson
- 1 Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA.,2 Divisions of Neurology, Wayne State University School of Medicine, Detroit, MI, USA.,3 Divisions of Neurology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Lalitha Sivaswamy
- 1 Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA.,2 Divisions of Neurology, Wayne State University School of Medicine, Detroit, MI, USA.,3 Divisions of Neurology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Roshani Agarwal
- 1 Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA.,4 Divisions of Hospital Medicine, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Wei Du
- 1 Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
| | - Rajkumar Agarwal
- 1 Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA.,2 Divisions of Neurology, Wayne State University School of Medicine, Detroit, MI, USA.,3 Divisions of Neurology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
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30
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Kasmire KE, Hoppa EC, Patel PP, Boch KN, Sacco T, Waynik IY. Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway. Pediatrics 2019; 143:peds.2018-1610. [PMID: 30728272 DOI: 10.1542/peds.2018-1610] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Significant variation in management of febrile infants exists both nationally and within our institution. Risk stratification can be used to identify low-risk infants who can be managed as outpatients without lumbar puncture (LP) or antibiotics. Our objective was to reduce invasive interventions for febrile infants aged 29 to 60 days at low risk for serious bacterial infection (SBI) through implementation of a clinical pathway supported by quality improvement (QI). METHODS The evidence-based clinical pathway was developed and implemented by a multidisciplinary team with continuous-process QI to sustain use. Low-risk infants who underwent LP, received antibiotics, and were admitted to the hospital were compared pre- and postpathway implementation with SBI in low-risk infants and appropriate care for high-risk infants as balancing measures. RESULTS Of 350 included patients, 220 were pre- and 130 were postpathway implementation. With pathway implementation in July 2016, invasive interventions decreased significantly in low-risk infants, with LPs decreasing from 32% to 0%, antibiotic administration from 30% to 1%, and hospital admission from 17% to 2%. Postimplementation, there were 0 SBIs in low-risk infants versus 29.2% in high-risk infants. The percentage of high-risk patients receiving care per pathway remained unchanged. Improvement was sustained for 12 months through QI interventions, including order-set development and e-mail reminders. CONCLUSIONS Implementation of a clinical pathway by using QI methods resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs. Clinical pathways and QI can be key strategies in the delivery of evidence-based care for febrile infants.
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Affiliation(s)
- Kathryn E Kasmire
- Connecticut Children's Medical Center, Hartford, Connecticut; .,School of Medicine, University of Connecticut, Farmington, Connecticut; and.,Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Eric C Hoppa
- Connecticut Children's Medical Center, Hartford, Connecticut.,Department of Pediatrics
| | - Pooja P Patel
- School of Medicine, University of Connecticut, Farmington, Connecticut; and
| | - Kelsey N Boch
- School of Medicine, University of Connecticut, Farmington, Connecticut; and
| | - Tina Sacco
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Ilana Y Waynik
- Connecticut Children's Medical Center, Hartford, Connecticut.,Department of Pediatrics
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Lehman LL, Beslow LA, Steinlin M, Kossorotoff M, Mackay MT. What Will Improve Pediatric Acute Stroke Care? Stroke 2019; 50:249-256. [DOI: 10.1161/strokeaha.118.022881] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Laura L. Lehman
- From the Department of Neurology, Boston Children’s Hospital, Harvard Medical School, MA (L.L.L.)
| | - Lauren A. Beslow
- Division of Neurology, Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (L.A.B.)
| | - Maja Steinlin
- Division of Paediatric Neurology, University Children’s Hospital Bern, University of Bern, Switzerland (M.S.)
| | - Manoëlle Kossorotoff
- French Center for Pediatric Stroke, Pediatric Neurology, APHP University Hospital Necker-Enfants Malades, Paris, France (M.K.)
| | - Mark T. Mackay
- Department of Neurology, Royal Children’s Hospital, Murdoch Children’s Research Institute, University of Melbourne, Parkville, Australia (M.T.M.)
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Medley TL, Miteff C, Andrews I, Ware T, Cheung M, Monagle P, Mandelstam S, Wray A, Pridmore C, Troedson C, Dale RC, Fahey M, Sinclair A, Walsh P, Stojanovski B, Mackay MT. Australian Clinical Consensus Guideline: The diagnosis and acute management of childhood stroke. Int J Stroke 2018; 14:94-106. [DOI: 10.1177/1747493018799958] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is among the top 10 causes of death in children and survivors carry resulting disabilities for decades, at substantial cost to themselves and their families. Children are not currently able to access reperfusion therapies, due to limited evidence supporting safety and efficacy and long diagnostic delays. The Australian Clinical Consensus Guideline for the Diagnosis and Acute Management of Childhood Stroke was developed to minimize unwarranted variations in care and document best evidence on the risk factors, etiologies, and conditions mimicking stroke that differ from adults. Clinical questions were formulated to inform systematic database searches from 2007 to 2017, limited to English and pediatric studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and classify the evidence. The Grades of Recommendation, Assessment, Development, and Evaluation system (GRADE) was used to grade evidence as strong or weak. The Guideline provides more than 60 evidence-based recommendations to assist prehospital and acute care clinicians in the rapid identification of childhood stroke, choice of initial investigation, to confirm diagnosis, determine etiology, selection of the most appropriate interventions to salvage brain at risk, and prevent recurrence. Recommendations include advice regarding the management of intracranial pressure and congenital heart disease. Implementation of the Guideline will require reorganization of prehospital and emergency care systems, including the development of regional stroke networks, pediatric Code Stroke, rapid magnetic resonance imaging and accreditation of primary pediatric stroke centers with the capacity to offer reperfusion therapies. The Guideline will allow auditing to benchmark timelines of care, access to acute interventions, and outcomes. It will also facilitate the development of an Australian childhood stroke registry, with data linkage to international registries, to allow for accurate data collection on stroke incidence, treatment, and outcomes.
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Affiliation(s)
- Tanya L Medley
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
| | | | - Ian Andrews
- Sydney Children's Hospital, School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Tyson Ware
- Royal Hobart Hospital, Hobart, Australia
| | - Michael Cheung
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Department of Cardiology Royal Children's Hospital, Melbourne, Australia
| | - Paul Monagle
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Simone Mandelstam
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Alison Wray
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | | | - Christopher Troedson
- Children's Hospital at Westmead, Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Russell C Dale
- Children's Hospital at Westmead and University of Sydney, Sydney Australia
| | - Michael Fahey
- Department of Paediatrics Monash University, Department of Medicine Melbourne University, and Monash Children's Hospital, Melbourne, Australia
| | - Adriane Sinclair
- Lady Cilento Children's Hospital, University of Queensland, Brisbane, Australia
| | | | - Belinda Stojanovski
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Royal Children's Hospital, Melbourne, Australia
| | - Mark T Mackay
- Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
- Department of Paediatrics University of Melbourne, Melbourne, Australia
- Department of Neurology Royal Children's Hospital, Melbourne Australia
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33
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Mackay MT, Steinlin M. Recent developments and new frontiers in childhood arterial ischemic stroke. Int J Stroke 2018; 14:32-43. [PMID: 30079825 DOI: 10.1177/1747493018790064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This review will discuss important developments in childhood arterial ischemic stroke over the past decade, focusing on improved understanding of the causes, consequences, and targets for intervention. Risk factors for childhood arterial ischemic stroke are different to adults. Infections, particularly herpes group viruses, are important precipitants for stroke. Non-atherosclerotic arteriopathies are the most common cause of childhood arterial ischemic stroke and an important predictor of recurrent events. Recent advances include the identification of serum biomarkers for inflammation and endothelial injury, and imaging biomarkers to monitor for vascular progression. Multicenter trials of immunotherapies in focal cerebral arteriopathies are currently in development. Recognition of clinical and radiological phenotypic patterns has facilitated the discovery of multisystem disorders associated with arterial ischemic stroke including ACTA2 arteriopathy and adenosine deaminase 2 deficiency. Identification of these Mendelian disorders provide insights into genetic mechanisms of disease and have implications for medical and surgical management. In contrast to adults, there are long diagnostic delays in childhood arterial ischemic stroke. Refinement of pediatric Code Stroke protocols and clinical decision support tools are essential to improve diagnostic certainty and improve access to reperfusion therapies. Children do not recover better than adults following arterial ischemic stroke, with more than half of survivors having long-term impairments. The physical, cognitive, and behavioral consequences of childhood arterial ischemic stroke are increasingly reported but further research is required to understand their impact on participation, quality of life, psychosocial, and family functioning. Longitudinal studies and the use of advanced imaging techniques, to understand neurobiological correlates of functional reorganization, are essential to developing targeted intervention strategies to facilitate recovery.
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Affiliation(s)
- Mark T Mackay
- 1 Department of Neurology, Royal Children's Hospital, Parkville, Australia.,2 Murdoch Children's Research Institute, Parkville, Australia.,3 Department of Paediatrics, University of Melbourne, Parkville, Australia.,4 Florey Institute of Neurosciences and Mental Health, Parkville, Australia
| | - Maja Steinlin
- 5 Division of Paediatric Neurology, Development and Rehabilitation, University Children's Hospital, Bern, Switzerland.,6 Department of Paediatrics, University of Bern, Bern, Switzerland
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Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Circulation 2018; 137:e67-e492. [PMID: 29386200 DOI: 10.1161/cir.0000000000000558] [Citation(s) in RCA: 4513] [Impact Index Per Article: 752.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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DeLaroche AM, Sivaswamy L, Farooqi A, Kannikeswaran N. Pediatric Stroke and Its Mimics: Limitations of a Pediatric Stroke Clinical Pathway. Pediatr Neurol 2018; 80:35-41. [PMID: 29429783 DOI: 10.1016/j.pediatrneurol.2017.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/29/2017] [Accepted: 10/06/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute stroke protocols improve delivery of care but it is unclear whether these resource intensive protocols are able to differentiate stroke from mimics in children. The aim of this study is to describe our institution's experience with stroke mimics identified through our pediatric stroke clinical pathway (PSCP). METHODS The PSCP was implemented in our level 1 pediatric emergency department in June 2014 for children aged one month to 18 years. For patients managed using the PSCP from June 2014 to December 2016, demographic and clinical data were compared for patients diagnosed with stroke or a stroke mimic. RESULTS A total of 59 children were evaluated with the PSCP. Fourteen children were identified as having a stroke and 45 children had stroke mimics. The most common stroke mimics were functional neurological disorders (20.0%), transient neurological deficits (17.8%), migraine (15.6%), and seizure (11.1%). Patient demographics and time to neuroimaging did not differ between patients with and without stroke. Vomiting was commonly reported by patients with stroke (odds ratio: 4.00, 95% confidence interval: 1.12 to 14.35), whereas weakness was not (odds ratio: 0.7, 95% confidence interval: 0.07 to 0.90), but the physical examination did not differ between patients with and without stroke. CONCLUSIONS The PSCP ensures timely evaluation of patients presenting with neurological deficits but fails to reliably differentiate between patients with stroke and patients with stroke mimics. Further multicentered studies are needed to develop a "stroke screen" that reliably distinguishes pediatric stroke from its mimics.
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Affiliation(s)
- Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.
| | - Lalitha Sivaswamy
- Division of Neurology, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Ahmad Farooqi
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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Bonfert MV, Badura K, Gerstl J, Borggraefe I, Heinen F, Schroeder S, Olivieri M, Weinberger R, Landgraf MN, Vill K, Tacke M, Berweck S, Reiter K, Hoffmann F, Nicolai T, Gerstl L. Childhood Stroke: Awareness, Interest, and Knowledge Among the Pediatric Community. Front Pediatr 2018; 6:182. [PMID: 29988546 PMCID: PMC6026646 DOI: 10.3389/fped.2018.00182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/04/2018] [Indexed: 12/11/2022] Open
Abstract
Objective: Acute childhood stroke is an emergency requiring a high level of awareness among first-line healthcare providers. This survey serves as an indicator of the awareness of, the interest in, and knowledge of childhood stroke of German pediatricians. Methods: Thousand six hundred and ninety-seven physicians of pediatric in- and outpatient facilities in Bavaria, Germany, were invited via email to an online-survey about childhood stroke. Results: The overall participation rate was 14%. Forty-six percent of participants considered a diagnosis of childhood stroke at least once during the past year, and 47% provide care for patients who have suffered childhood stroke. The acronym FAST (Face-Arm-Speech-Time-Test) was correctly cited in 27% of the questionnaires. Most commonly quoted symptoms of childhood stroke were hemiparesis (90%), speech disorder (58%), seizure (44%), headache (40%), and impaired consciousness (33%). Migraine (63%), seizure (39%), and infections of the brain (31%) were most frequently named as stroke mimics. Main diagnostic measures indicated were magnetic resonance imaging (MRI) (96%) and computer tomography (CT) (55%). Main therapeutic strategies were thrombolysis (80%), anticoagulation (41%), neuroprotective measures, and thrombectomies (15% each). Thirty-nine percent of participants had taken part in training sessions, 61% studied literature, 37% discussed with colleagues, and 25% performed internet research on childhood stroke. Ninety-three percent of participants approve skill enhancement, favoring training sessions (80%), publications (43%), and web based offers (35%). Consent for offering a flyer on the topic to caregivers in facilities was given in 49%. Conclusion: Childhood stroke constitutes a topic of clinical importance to pediatricians. Participants demonstrate a considerable level of comprehension concerning the subject, but room for improvement remains. A multi-modal approach encompassing an elaborate training program, regular educational publications in professional journals, and web based offers could reach a broad range of health care providers. Paired with a public adult and childhood stroke awareness campaign, these efforts could contribute to optimize the care for children suffering from stroke.
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Affiliation(s)
- Michaela V Bonfert
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Katharina Badura
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,Schön Klinik Vogtareuth, Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Vogtareuth, Germany
| | - Julia Gerstl
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,Department of Pediatrics, Facharztzentrum Hauzenberg, Hauzenberg, Germany
| | - Ingo Borggraefe
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Florian Heinen
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Sebastian Schroeder
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Martin Olivieri
- Department of Pediatric Hemostaseology, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,Pediatric Intensive Care Unit, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Raphael Weinberger
- Division of Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Mirjam N Landgraf
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Katharina Vill
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Moritz Tacke
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Steffen Berweck
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany.,Schön Klinik Vogtareuth, Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center for Children and Adolescents, Vogtareuth, Germany
| | - Karl Reiter
- Pediatric Intensive Care Unit, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Florian Hoffmann
- Pediatric Intensive Care Unit, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Thomas Nicolai
- Pediatric Intensive Care Unit, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Lucia Gerstl
- Department of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
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Mackay MT, Monagle P, Babl FE. Improving diagnosis of childhood arterial ischaemic stroke. Expert Rev Neurother 2017; 17:1157-1165. [DOI: 10.1080/14737175.2017.1395699] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mark T. Mackay
- Department of Neurology, Royal Children’s Hospital, Parkville, Australia
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Florey Institute of Neurosciences and Mental Health, Parkville, Australia
| | - Paul Monagle
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Haematology, Royal Children’s Hospital, Parkville, Australia
| | - Franz E. Babl
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Emergency Department, Royal Children’s Hospital Melbourne, Parkville, Australia
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Affiliation(s)
- Lauren A Beslow
- From the Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia and Division of Neurology, Children's Hospital of Philadelphia, PA.
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Mackay MT, Yock-Corrales A, Churilov L, Monagle P, Donnan GA, Babl FE. Accuracy and Reliability of Stroke Diagnosis in the Pediatric Emergency Department. Stroke 2017; 48:1198-1202. [PMID: 28336681 DOI: 10.1161/strokeaha.116.015571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/20/2016] [Accepted: 01/13/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Access to acute stroke interventions in the emergency department (ED) relies on correct clinical diagnosis. Our aims were to determine the accuracy and reliability of pediatric ED physician diagnosis of childhood stroke and other conditions presenting with brain attack symptoms. METHODS Prospective study of consecutive children aged 1 month to 18 years presenting to the ED from June 2009 to December 2010 with focal neurological deficits. Accuracy (sensitivity, specificity, and receiver operator characteristic curves [ROCs]) and interrater agreement (κ) were determined, between ED physician diagnoses, as recorded in the electronic hospital administrative software system, and final neurological diagnosis, after completion of diagnostic work-up. RESULTS Two-hundred eighty-seven children with 301 consecutive presentations were recruited. The most common final brain attack diagnoses included migraine in 84 children, first seizure in 48, Bell's palsy in 29, stroke in 21, and conversion disorders in 18 children. Sensitivity of ED physician stroke diagnosis was 62%, and specificity was 98% (ROC, 0.8). Inter-rater agreement for ED physician and final stroke diagnosis was substantial (κ=0.61). ED physician diagnostic accuracy and reliability was highest for Bell's palsy (ROC=0.98; κ=0.96), and lowest for central nervous system demyelination (ROC=0.5; κ=-0.01) and cerebellitis (ROC=0.50; κ=0.50). CONCLUSIONS ED physician diagnostic accuracy and reliability varies considerably across disorders presenting with brain attack symptoms. Clinical recognition tools are required to assist pediatric ED physicians with diagnosis of stroke and other serious neurological disorders.
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Affiliation(s)
- Mark T Mackay
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.).
| | - Adriana Yock-Corrales
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.)
| | - Leonid Churilov
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.)
| | - Paul Monagle
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.)
| | - Geoffrey A Donnan
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.)
| | - Franz E Babl
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.)
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