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Starnes LS, Starnes JR, Stopczynski T, Amarin JZ, Charnogursky C, Hayek H, Talj R, Parra DA, Clark DE, Patrick AE, Katz SE, Howard LM, Peetluk L, Rankin D, Spieker AJ, Halasa NB. Clinical prediction model: Multisystem inflammatory syndrome in children versus Kawasaki disease. J Hosp Med 2024; 19:175-184. [PMID: 38282424 PMCID: PMC10922780 DOI: 10.1002/jhm.13290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/14/2023] [Accepted: 01/09/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious complication of severe acute respiratory syndrome coronavirus 2 infection. Features of MIS-C overlap with those of Kawasaki disease (KD). OBJECTIVE The study objective was to develop a prediction model to assist with this diagnostic dilemma. METHODS Data from a retrospective cohort of children hospitalized with KD before the coronavirus disease 2019 pandemic were compared to a prospective cohort of children hospitalized with MIS-C. A bootstrapped backwards selection process was used to develop a logistic regression model predicting the probability of MIS-C diagnosis. A nomogram was created for application to individual patients. RESULTS Compared to children with incomplete and complete KD (N = 602), children with MIS-C (N = 105) were older and had longer hospitalizations; more frequent intensive care unit admissions and vasopressor use; lower white blood cell count, lymphocyte count, erythrocyte sedimentation rate, platelet count, sodium, and alanine aminotransferase; and higher hemoglobin and C-reactive protein (CRP) at admission. Left ventricular dysfunction was more frequent in patients with MIS-C, whereas coronary abnormalities were more common in those with KD. The final prediction model included age, sodium, platelet count, alanine aminotransferase, reduction in left ventricular ejection fraction, and CRP. The model exhibited good discrimination with AUC 0.96 (95% confidence interval: [0.94-0.98]) and was well calibrated (optimism-corrected intercept of -0.020 and slope of 0.99). CONCLUSIONS A diagnostic prediction model utilizing admission information provides excellent discrimination between MIS-C and KD. This model may be useful for diagnosis of MIS-C but requires external validation.
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Affiliation(s)
- Lauren S Starnes
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Hospital Medicine, Nashville, Tennessee, USA
| | - Joseph R Starnes
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Cardiology, Nashville, Tennessee, USA
| | - Tess Stopczynski
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin Z Amarin
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, Tennessee, USA
- Epidemiology Doctoral Program, Vanderbilt University School of Medicine, Tennessee, USA
| | - Cara Charnogursky
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, Tennessee, USA
| | - Haya Hayek
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, Tennessee, USA
| | - Rana Talj
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, Tennessee, USA
| | - David A Parra
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Cardiology, Nashville, Tennessee, USA
| | - Daniel E Clark
- Department of Medicine, School of Medicine, Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Anna E Patrick
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Rheumatology, Nashville, Tennessee, USA
| | - Sophie E Katz
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, Tennessee, USA
| | - Leigh M Howard
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, Tennessee, USA
| | - Lauren Peetluk
- Department of Medicine, Vanderbilt University Medical Center, Division of Epidemiology, Nashville, Tennessee, USA
- Optum Epidemiology, Massachusetts, Boston, USA
| | - Danielle Rankin
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, Tennessee, USA
- Vanderbilt Epidemiology PhD Program, School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrew J Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Natasha B Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Division of Pediatric Infectious Diseases, Nashville, Tennessee, USA
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Lee JJY, Feldman BM, McCrindle BW, Li P, Yeung RS, Widdifield J. Evaluating the time-varying risk of hypertension, cardiac events, and mortality following Kawasaki disease diagnosis. Pediatr Res 2022; 93:1439-1446. [PMID: 36002584 DOI: 10.1038/s41390-022-02273-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study evaluated the risk of hypertension, major adverse cardiac events (MACE), and all-cause mortality in Kawasaki disease (KD) patients up to young adulthood. METHODS An inception cohort of 1169 KD patients between 1991 and 2008 from a tertiary-level hospital in Ontario, Canada was linked with health administrative data to ascertain outcomes up to 28 years of follow-up. Their risk was compared with 11,690 matched population comparators. The primary outcome was hypertension and secondary outcomes were MACE and death. RESULTS After a median follow-up of 20 years [IQR: 8.3], the cumulative incidence of hypertension and MACE in the KD group was 3.8% (95% CI: 2.5-5.5) and 1.2% (95% CI: 0.6-2.4%), respectively. The overall survival probability in the KD group was 98.6% (95% CI: 97.2-99.3%). Relative to comparators, KD patients were at an increased risk for hypertension [aHR: 2.2 (95% CI: 1.5-3.4)], death [aHR: 2.5 (95% CI: 1.3-5.0)], and MACE [aHR: 10.7 (95% CI: 6.4-17.9)]. For hypertension and MACE, the aHR was the highest following diagnosis and then the excess risk diminished after 16 and 13 years of follow-up, respectively. MACE occurred largely in KD patients with coronary aneurysms [cumulative incidence: 12.8%]. CONCLUSIONS KD patients demonstrated a reassuring cardiac prognosis up to young adulthood with low events and excellent survival. KD patients were at increased risk for hypertension, but this excess risk occurred early and declined with time. IMPACT With the current standard of care, KD patients demonstrated favorable cardiac prognosis, with low events of hypertension, MACE, and excellent survival. Hypertension and MACE risk appear to be highest around the time of KD diagnosis. MACE occurred primarily in KD patients with coronary aneurysms. Our findings are reassuring to KD patients, families, and their providers. Our study demonstrated an association between KD exposure and hypertension. This association is relatively novel. Previous studies have remained conflicting if KD contributes to long-term atherosclerotic risk.
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Affiliation(s)
- Jennifer J Y Lee
- The Hospital for Sick Children (SickKids), Toronto, ON, Canada. .,ICES, Toronto, ON, Canada. .,University of Toronto, Toronto, ON, Canada.
| | - Brian M Feldman
- The Hospital for Sick Children (SickKids), Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Brian W McCrindle
- The Hospital for Sick Children (SickKids), Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | | | - Rae Sm Yeung
- The Hospital for Sick Children (SickKids), Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Jessica Widdifield
- ICES, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management, & Evaluation, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada
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胡 慧, 陈 笑, 张 永, 杜 忠. [Association of liver damage with coronary artery lesion and no response to intravenous immunoglobulin in the acute stage of Kawasaki disease]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:681-686. [PMID: 35762436 PMCID: PMC9250406 DOI: 10.7499/j.issn.1008-8830.2112094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/06/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To summarize the clinical features of liver damage in children in the acute stage of Kawasaki disease (KD), and to investigate the clinical value of liver damage in predicting coronary artery lesion and no response to intravenous immunoglobulin (IVIG) in children with KD. METHODS The medical data were collected from 925 children who were diagnosed with KD for the first time in Beijing Children's Hospital from January 1, 2016 to December 31, 2017. According to the presence or absence of abnormal alanine aminotransferase (ALT) level on admission, the children were divided into a liver damage group (n=284) and a non-liver damage group (n=641). A logistic regression analysis was used to investigate the clinical value of the indicators including liver damage in predicting coronary artery lesion and no response to IVIG in children with KD. RESULTS Compared with the non-liver damage group, the liver damage group had a significantly earlier admission time and significantly higher serum levels of inflammatory indicators (P<0.05). The liver damage group had a significantly higher incidence rate of coronary artery lesion on admission than the non-liver damage group (P=0.034). After initial IVIG therapy, the liver damage group had a significantly higher proportion of children with no response to IVIG than the non-liver damage group (P<0.001). In children with KD, coronary artery lesion was associated with the reduction in the hemoglobin level and the increases in platelet count, C-reactive protein, and ALT (P<0.05), and no response to IVIG was associated with limb changes, the reduction in the hemoglobin level, the increases in platelet count, C-reactive protein, and ALT, and coronary artery lesion (P<0.05). CONCLUSIONS Compared with those without liver damage, the children in the early stage of KD with liver damage tend to develop clinical symptoms early and have higher levels of inflammatory indicators, and they are more likely to have coronary artery lesion and show no response to IVIG treatment.
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Affiliation(s)
| | - 笑征 陈
- 首都医科大学附属北京妇产医院/北京妇幼保健院儿童保健科北京100006
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Miyata K, Miura M, Kaneko T, Morikawa Y, Matsushima T, Sakakibara H, Misawa M, Kobayashi T, Yamagishi H. Evaluation of a Kawasaki Disease Risk Model for Predicting Coronary Artery Aneurysms in a Japanese Population: An Analysis of Post RAISE. J Pediatr 2021; 237:96-101.e3. [PMID: 34147499 DOI: 10.1016/j.jpeds.2021.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/10/2021] [Accepted: 06/14/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To test the performance of the Son risk score, which was created to predict coronary artery abnormalities from baseline variables in North American patients with Kawasaki disease. STUDY DESIGN The dataset from Post RAISE, the largest prospective cohort study of Japanese patients with Kawasaki disease to date, was used for the present study. With high risk defined as ≥3 points, sensitivity, specificity, positive predictive value, and negative predictive value for coronary artery abnormality development were calculated. To evaluate the effect of each risk factor in the Son score, the OR and 95% CIs were calculated using logistic regression analysis with the presence of coronary artery abnormality at 1 month after disease onset. RESULTS Post RAISE enrolled 2628 consecutive patients with Kawasaki disease, and 304 patients had a high-risk score, of whom 15.1% showed coronary artery abnormality. At the cutoff ≥3 points, the sensitivity was 37.7%, and the specificity was 87.2%. The maximum z score at baseline ≥2.0 (OR 3.5, 95% CI 2.3-5.2) and age <6 months at disease onset (OR 3.2, 95% CI 1.9-5.4), were significantly associated with coronary artery abnormality development. However, a high concentration of C-reactive protein was not associated with coronary artery abnormality. The area under the receiver operating characteristic curve for the Son score was 0.65 (95% CI 0.59-0.71). CONCLUSIONS The Son score had insufficient sensitivity and good specificity in a Japanese cohort of patients with Kawasaki disease. Among the variables comprising the Son score, a large baseline z score and young age at disease onset were significant, independent predictors of coronary artery abnormality development.
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Affiliation(s)
- Koichi Miyata
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.
| | - Tetsuji Kaneko
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Teikyo Academic Research Center, Teikyo University, Tokyo, Japan
| | - Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Takahiro Matsushima
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Sakakibara
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masahiro Misawa
- Department of Pediatrics, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tohru Kobayashi
- Department of Data Science, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroyuki Yamagishi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
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Purtell R, Tam RP, Avondet E, Gradick K. We are part of the problem: the role of children's hospitals in addressing health inequity. Hosp Pract (1995) 2021; 49:445-455. [PMID: 35061953 DOI: 10.1080/21548331.2022.2032072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
Racism is an ongoing public health crisis that undermines health equity for all children in hospitals across our nation. The presence and impact of institutionalized racism contributes to health inequity and is under described in the medical literature. In this review, we focus on key interdependent areas to foster inclusion, diversity, and equity in Children's Hospitals, including 1) promotion of workforce diversity 2) provision of anti-racist, equitable hospital patient care, and 3) prioritization of academic scholarship focused on health equity research, quality improvement, medical education, and advocacy. We discuss the implications for clinical and academic practice.Plain Language Summary: Racism in Children's Hospitals harms children. We as health-care providers and hospital systems are part of the problem. We reviewed the literature for the best ways to foster inclusion, diversity, and equity in hospitals. Hospitals can be leaders in improving child health equity by supporting a more diverse workforce, providing anti-racist patient care, and prioritizing health equity scholarship.
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Affiliation(s)
- Rebecca Purtell
- Assistant Professor of Pediatrics, Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Reena P Tam
- Assistant Professor of Pediatrics, Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Erin Avondet
- Assistant Professor of Pediatrics, Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Katie Gradick
- Assistant Professor of Pediatrics, Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Lo J, Gauvreau K, Baker AL, de Ferranti SD, Friedman KG, Lo MS, Dedeoglu F, Sundel RP, Newburger JW, Son MBF. Multiple Emergency Department Visits for a Diagnosis of Kawasaki Disease: An Examination of Risk Factors and Outcomes. J Pediatr 2021; 232:127-132.e3. [PMID: 33453202 DOI: 10.1016/j.jpeds.2021.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/31/2020] [Accepted: 01/07/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine predictors of >1 emergency department (ED) visit for a Kawasaki disease diagnosis in a quaternary care pediatric hospital and compare outcomes between patients with 1 vs >1 visit for Kawasaki disease diagnosis. STUDY DESIGN Medical records of patients evaluated for Kawasaki disease between January 2006 and August 2018 at Boston Children's Hospital were abstracted for demographic and clinical data. Predictors of >1 visit were explored using logistic regression and classification and regression tree analysis. RESULTS Of 530 patients diagnosed with Kawasaki disease, 117 (22%) required multiple ED visits for Kawasaki disease diagnosis. Multivariable regression and classification and regression tree analysis identified ≤2 Kawasaki disease criteria (OR 33.9; 95% CI 18.1-63.6), <3 days of fever at the first visit (OR 3.47; 95% CI 1.77-6.84), and non-White race (OR 2.15; 95% CI 1.18-3.95) as predictors of >1 visit. There were no significant differences in duration of hospitalization, day of illness at initial Kawasaki disease treatment, intravenous immunoglobulin resistance, need for adjunctive therapies, or coronary artery outcomes between patients diagnosed with Kawasaki disease at initial visit vs subsequent visits. CONCLUSIONS Incomplete Kawasaki disease criteria, fewer days of fever, and non-White race were significant predictors of multiple ED visits for Kawasaki disease diagnosis in this single institution study. Our findings underscore the importance of maintaining a high index of suspicion for Kawasaki disease in patients with <4 Kawasaki disease criteria. Further research is needed to determine causes for increased healthcare use in non-White patients to receive a Kawasaki disease diagnosis.
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Affiliation(s)
- Jeffrey Lo
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Annette L Baker
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Robert P Sundel
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Mary Beth F Son
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
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Zheng X, Li J, Yue P, Liu L, Li J, Zhou K, Hua Y, Li Y. Is there an association between intravenous immunoglobulin resistance and coronary artery lesion in Kawasaki disease?-Current evidence based on a meta-analysis. PLoS One 2021; 16:e0248812. [PMID: 33764989 PMCID: PMC7993784 DOI: 10.1371/journal.pone.0248812] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 03/06/2021] [Indexed: 11/25/2022] Open
Abstract
Background Coronary artery lesion (CAL) caused by Kawasaki disease (KD) is a leading cause of acquired heart disease in children. Initial treatment of intravenous immunoglobulin (IVIG) can reduce the incidence of CAL. Although most of the current studies have shown a certain correlation between CAL and IVIG resistance, the conclusions are not completely consistent. Thus, we performed this meta-analysis to evaluate the association between IVIG resistance and CAL in KD. Methods PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and China National Knowledge Infrastructure through April 21, 2020 were searched to detect relevant studies. Data analysis was performed with STATA 15.1. Results A total of 53 relevant studies were eligible to this analysis, including 30312 KD patients, of which 4750 were IVIG resistance and 25562 were responders. There was a significant difference found between IVIG resistance and IVIG response groups in the incidence of CAL (P < 0.001, odds ratio (OR), 3.89; 95% confidence interval (CI) (3.18, 4.75)). The heterogeneity test results showed that the I2 value was 74.8%. The meta-regression analysis showed that the study regions might be the sources of heterogeneity. The subgroup analysis suggested that the incidence of CAL in the IVIG resistance group was still higher than that in the IVIG response group under different regions, IVIG resistance diagnostic criteria, CAL diagnostic criteria, and study types. Meanwhile, the sensitivity analysis did not find any significant impact from every single study. Conclusions This is the first meta-analysis to reveal the incidence of CAL was associated with IVIG resistance in KD patients. Further well-designed studies with uniform criteria are needed to evaluate the incidence of CAL in IVIG resistant patients.
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Affiliation(s)
- Xiaolan Zheng
- Department of Pediatrics in West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jinhui Li
- Department of Pediatrics in West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Peng Yue
- Department of Pediatrics in West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lei Liu
- Department of Pediatrics in West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiawen Li
- Department of Pediatrics in West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Kaiyu Zhou
- Department of Pediatrics in West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yimin Hua
- Department of Pediatrics in West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yifei Li
- Department of Pediatrics in West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- * E-mail:
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8
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Feldstein LR, Tenforde MW, Friedman KG, Newhams M, Rose EB, Dapul H, Soma VL, Maddux AB, Mourani PM, Bowens C, Maamari M, Hall MW, Riggs BJ, Giuliano JS, Singh AR, Li S, Kong M, Schuster JE, McLaughlin GE, Schwartz SP, Walker TC, Loftis LL, Hobbs CV, Halasa NB, Doymaz S, Babbitt CJ, Hume JR, Gertz SJ, Irby K, Clouser KN, Cvijanovich NZ, Bradford TT, Smith LS, Heidemann SM, Zackai SP, Wellnitz K, Nofziger RA, Horwitz SM, Carroll RW, Rowan CM, Tarquinio KM, Mack EH, Fitzgerald JC, Coates BM, Jackson AM, Young CC, Son MBF, Patel MM, Newburger JW, Randolph AG. Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA 2021; 325:1074-1087. [PMID: 33625505 PMCID: PMC7905703 DOI: 10.1001/jama.2021.2091] [Citation(s) in RCA: 548] [Impact Index Per Article: 182.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Refinement of criteria for multisystem inflammatory syndrome in children (MIS-C) may inform efforts to improve health outcomes. OBJECTIVE To compare clinical characteristics and outcomes of children and adolescents with MIS-C vs those with severe coronavirus disease 2019 (COVID-19). SETTING, DESIGN, AND PARTICIPANTS Case series of 1116 patients aged younger than 21 years hospitalized between March 15 and October 31, 2020, at 66 US hospitals in 31 states. Final date of follow-up was January 5, 2021. Patients with MIS-C had fever, inflammation, multisystem involvement, and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) or antibody test results or recent exposure with no alternate diagnosis. Patients with COVID-19 had positive RT-PCR test results and severe organ system involvement. EXPOSURE SARS-CoV-2. MAIN OUTCOMES AND MEASURES Presenting symptoms, organ system complications, laboratory biomarkers, interventions, and clinical outcomes. Multivariable regression was used to compute adjusted risk ratios (aRRs) of factors associated with MIS-C vs COVID-19. RESULTS Of 1116 patients (median age, 9.7 years; 45% female), 539 (48%) were diagnosed with MIS-C and 577 (52%) with COVID-19. Compared with patients with COVID-19, patients with MIS-C were more likely to be 6 to 12 years old (40.8% vs 19.4%; absolute risk difference [RD], 21.4% [95% CI, 16.1%-26.7%]; aRR, 1.51 [95% CI, 1.33-1.72] vs 0-5 years) and non-Hispanic Black (32.3% vs 21.5%; RD, 10.8% [95% CI, 5.6%-16.0%]; aRR, 1.43 [95% CI, 1.17-1.76] vs White). Compared with patients with COVID-19, patients with MIS-C were more likely to have cardiorespiratory involvement (56.0% vs 8.8%; RD, 47.2% [95% CI, 42.4%-52.0%]; aRR, 2.99 [95% CI, 2.55-3.50] vs respiratory involvement), cardiovascular without respiratory involvement (10.6% vs 2.9%; RD, 7.7% [95% CI, 4.7%-10.6%]; aRR, 2.49 [95% CI, 2.05-3.02] vs respiratory involvement), and mucocutaneous without cardiorespiratory involvement (7.1% vs 2.3%; RD, 4.8% [95% CI, 2.3%-7.3%]; aRR, 2.29 [95% CI, 1.84-2.85] vs respiratory involvement). Patients with MIS-C had higher neutrophil to lymphocyte ratio (median, 6.4 vs 2.7, P < .001), higher C-reactive protein level (median, 152 mg/L vs 33 mg/L; P < .001), and lower platelet count (<150 ×103 cells/μL [212/523 {41%} vs 84/486 {17%}, P < .001]). A total of 398 patients (73.8%) with MIS-C and 253 (43.8%) with COVID-19 were admitted to the intensive care unit, and 10 (1.9%) with MIS-C and 8 (1.4%) with COVID-19 died during hospitalization. Among patients with MIS-C with reduced left ventricular systolic function (172/503, 34.2%) and coronary artery aneurysm (57/424, 13.4%), an estimated 91.0% (95% CI, 86.0%-94.7%) and 79.1% (95% CI, 67.1%-89.1%), respectively, normalized within 30 days. CONCLUSIONS AND RELEVANCE This case series of patients with MIS-C and with COVID-19 identified patterns of clinical presentation and organ system involvement. These patterns may help differentiate between MIS-C and COVID-19.
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Affiliation(s)
- Leora R. Feldstein
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Mark W. Tenforde
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Margaret Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Erica Billig Rose
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Heda Dapul
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - Vijaya L. Soma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Cindy Bowens
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern, Children’s Medical Center Dallas, Dallas
| | - Mia Maamari
- Division of Critical Care Medicine, Department of Pediatrics, University of Texas Southwestern, Children’s Medical Center Dallas, Dallas
| | - Mark W. Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Becky J. Riggs
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - John S. Giuliano
- Division of Critical Care, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Aalok R. Singh
- Pediatric Critical Care Division, Maria Fareri Children’s Hospital at Westchester Medical Center and New York Medical College, Valhalla
| | - Simon Li
- Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children’s Hospital, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Jennifer E. Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Gwenn E. McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Stephanie P. Schwartz
- Department of Pediatrics, University of North Carolina at Chapel Hill Children’s Hospital
| | - Tracie C. Walker
- Department of Pediatrics, University of North Carolina at Chapel Hill Children’s Hospital
| | - Laura L. Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Charlotte V. Hobbs
- Division of Infectious Diseases, Department of Pediatrics, Department of Microbiology, University of Mississippi Medical Center, Jackson
| | - Natasha B. Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sule Doymaz
- Division of Pediatric Critical Care, Department of Pediatrics, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Christopher J. Babbitt
- Division of Pediatric Critical Care, Miller Children’s and Women’s Hospital of Long Beach, Long Beach, California
| | - Janet R. Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children’s Hospital, Minneapolis
| | - Shira J. Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children’s Hospital, Little Rock
| | - Katharine N. Clouser
- Division of Hospital Medicine, Department of Pediatrics, Hackensack University Medical Center, Hackensack, New Jersey
| | - Natalie Z. Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children’s Hospital Oakland, Oakland, California
| | - Tamara T. Bradford
- Division of Cardiology, Department of Pediatrics, Louisiana State University Health Sciences Center and Children’s Hospital of New Orleans, New Orleans
| | - Lincoln S. Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle
| | - Sabrina M. Heidemann
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Central Michigan University, Detroit
| | - Sheemon P. Zackai
- Pediatric Critical Care Medicine, Department of Pediatrics, Icahn School of Medicine at the Mount Sinai Kravis Children’s Hospital, New York, New York
| | - Kari Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City
| | - Ryan A. Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children’s Hospital, Akron, Ohio
| | - Steven M. Horwitz
- Department of Pediatrics, Division of Critical Care, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Ryan W. Carroll
- Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Courtney M. Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Elizabeth H. Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston
| | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Bria M. Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Ashley M. Jackson
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cameron C. Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Mary Beth F. Son
- Division of Immunology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Manish M. Patel
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Anesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
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9
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Padilla LA, Collins JL, Idigo AJ, Lau Y, Portman MA, Shrestha S. Kawasaki Disease and Clinical Outcome Disparities Among Black Children. J Pediatr 2021; 229:54-60.e2. [PMID: 32980379 PMCID: PMC7513890 DOI: 10.1016/j.jpeds.2020.09.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine whether Black children with Kawasaki disease exhibit disparities in prevalence, sequelae, and response to intravenous gamma globulin (IVIG) treatment. STUDY DESIGN International Classification of Diseases codes were used to identify children with Kawasaki disease admitted to a tertiary center in the southeastern US. Subjects diagnosed and treated according to American Heart Association criteria were included. Demographic, laboratory, clinical, and echocardiographic data from the electronic medical record (2000-2015) were compared between Blacks and Whites. RESULTS Data from 369 subjects (52% Whites and 48% Blacks) were included in our analysis. No significant differences related to timely admission, IVIG treatment, or coronary artery (CA) abnormalities during hospitalization were observed. Blacks showed lower IVIG response rates than Whites for patients administered IVIG within 10 days of fever onset (86.6% vs 95.6%; P = .007). Blacks received more ancillary drugs (9.6% vs 2.6%; P = .003), and endured longer hospitalizations (mean, 5 ± 3.9 days vs 3.4 ± 2.2 days; P = .001). Blacks presented with higher C-reactive protein level and erythrocyte sedimentation rate and lower hemoglobin, albumin, and sodium levels. Blacks had a higher proportion of persistent CA abnormalities than Whites at second follow-up echocardiogram (14.5% vs 6.3%; P = .03), and at third follow-up echocardiogram (21.2% vs 6.9%; P = .01). CONCLUSIONS Compared with White children, Black children with Kawasaki disease had higher IVIG refractory prevalence, more severe inflammation, more ancillary treatments, and longer hospitalizations. Despite no racial differences in time to diagnosis or initial treatment, there was greater CA abnormality persistence among Black children at follow-up.
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Affiliation(s)
- Luz A. Padilla
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL,Reprint requests: Luz A. Padilla, MD, Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL 35294
| | - Jacqueline L. Collins
- Department of Pediatric Cardiology, School of Medicine, University of Alabama at Birmingham and the Pediatric and Congenital Heart Center of Alabama, Children's of Alabama, Birmingham, AL
| | - Adeniyi J. Idigo
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Yung Lau
- Department of Pediatric Cardiology, School of Medicine, University of Alabama at Birmingham and the Pediatric and Congenital Heart Center of Alabama, Children's of Alabama, Birmingham, AL
| | - Michael A. Portman
- Division of Pediatric Cardiology, Department of Pediatrics, University of Washington and Seattle Children's Research Institute, Seattle, WA
| | - Sadeep Shrestha
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
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10
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Son MBF, Gauvreau K, Tremoulet AH, Lo M, Baker AL, de Ferranti S, Dedeoglu F, Sundel RP, Friedman KG, Burns JC, Newburger JW. Risk Model Development and Validation for Prediction of Coronary Artery Aneurysms in Kawasaki Disease in a North American Population. J Am Heart Assoc 2020; 8:e011319. [PMID: 31130036 PMCID: PMC6585355 DOI: 10.1161/jaha.118.011319] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Accurate prediction of coronary artery aneurysms (CAAs) in patients with Kawasaki disease remains challenging in North American cohorts. We sought to develop and validate a risk model for CAA prediction. Methods and Results A binary outcome of CAA was defined as left anterior descending or right coronary artery Z score ≥2.5 at 2 to 8 weeks after fever onset in a development cohort (n=903) and a validation cohort (n=185) of patients with Kawasaki disease. Associations of baseline clinical, laboratory, and echocardiographic variables with later CAA were assessed in the development cohort using logistic regression. Discrimination (c statistic) and calibration (Hosmer‐Lemeshow) of the final model were evaluated. A practical risk score assigning points to each variable in the final model was created based on model coefficients from the development cohort. Predictors of CAAs at 2 to 8 weeks were baseline Z score of left anterior descending or right coronary artery ≥2.0, age <6 months, Asian race, and C‐reactive protein ≥13 mg/dL (c=0.82 in the development cohort, c=0.93 in the validation cohort). The CAA risk score assigned 2 points for baseline Z score of left anterior descending or right coronary artery ≥2.0 and 1 point for each of the other variables, with creation of low‐ (0–1), moderate‐ (2), and high‐ (3–5) risk groups. The odds of CAAs were 16‐fold greater in the high‐ versus the low‐risk groups in the development cohort (odds ratio, 16.4; 95% CI, 9.71–27.7 [P<0.001]), and >40‐fold greater in the validation cohort (odds ratio, 44.0; 95% CI, 10.8–180 [P<0.001]). Conclusions Our risk model for CAA in Kawasaki disease consisting of baseline demographic, laboratory, and echocardiographic variables had excellent predictive utility and should undergo prospective testing.
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Affiliation(s)
- Mary Beth F Son
- 1 Division of Immunology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | | | - Adriana H Tremoulet
- 4 Department of Pediatrics University of California San Diego School of Medicine La Jolla CA.,5 Department of Pediatrics Rady Children's Hospital San Diego San Diego USA
| | - Mindy Lo
- 1 Division of Immunology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | - Annette L Baker
- 2 Department of Cardiology Boston Children's Hospital Boston MA
| | - Sarah de Ferranti
- 2 Department of Cardiology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | - Fatma Dedeoglu
- 1 Division of Immunology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | - Robert P Sundel
- 1 Division of Immunology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | - Kevin G Friedman
- 2 Department of Cardiology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
| | - Jane C Burns
- 4 Department of Pediatrics University of California San Diego School of Medicine La Jolla CA.,5 Department of Pediatrics Rady Children's Hospital San Diego San Diego USA
| | - Jane W Newburger
- 2 Department of Cardiology Boston Children's Hospital Boston MA.,3 Department of Pediatrics Harvard Medical School Boston MA
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11
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Hicar MD. Antibodies and Immunity During Kawasaki Disease. Front Cardiovasc Med 2020; 7:94. [PMID: 32671098 PMCID: PMC7326051 DOI: 10.3389/fcvm.2020.00094] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/30/2020] [Indexed: 12/14/2022] Open
Abstract
The cause of Kawasaki disease (KD), the leading cause of acquired heart disease in children, is currently unknown. Epidemiology studies support that an infectious disease is involved in at least starting the inflammatory cascade set off during KD. Clues from epidemiology support that humoral immunity can have a protective effect. However, the role of the immune system, particularly of B cells and antibodies, in pathogenesis of KD is still unclear. Intravenous immunoglobulin (IVIG) and other therapies targeted at modulating inflammation can prevent development of coronary aneurysms. A number of autoantibody responses have been reported in children with KD and antibodies have been generated from aneurysmal plasma cell infiltrates. Recent reports show that children with KD have similar plasmablast responses as other children with infectious diseases, further supporting an infectious starting point. As ongoing studies are attempting to identify the etiology of KD through study of antibody responses, we sought to review the role of humoral immunity in KD pathogenesis, treatment, and recovery.
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Affiliation(s)
- Mark Daniel Hicar
- University at Buffalo, Buffalo, NY, United States.,John R. Oishei Children's Hospital, Buffalo, NY, United States.,Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States
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12
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Piram M, Darce Bello M, Tellier S, Di Filippo S, Boralevi F, Madhi F, Meinzer U, Cimaz R, Piedvache C, Koné-Paut I. Defining the risk of first intravenous immunoglobulin unresponsiveness in non-Asian patients with Kawasaki disease. Sci Rep 2020; 10:3125. [PMID: 32080307 PMCID: PMC7033244 DOI: 10.1038/s41598-020-59972-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 01/27/2020] [Indexed: 11/22/2022] Open
Abstract
About 10–20% of patients with Kawasaki disease (KD) are unresponsive to intravenous immunoglobulin (IVIg) and are at increased risk of coronary artery abnormalities (CAAs). Early identification is critical to initiate aggressive therapies, but available scoring systems lack sensitivity in non-Japanese populations. We investigated the accuracy of 3 Japanese scoring systems and studied factors associated with IVIg unresponsiveness in a large multiethnic French population of children with KD to build a new scoring system. Children admitted for KD between 2011–2014 in 65 centers were enrolled. Factors associated with second line-treatment; i.e. unresponsiveness to initial IVIg treatment, were analyzed by multivariate regression analysis. The performance of our score and the Kobayashi, Egami and Sano scores were compared in our population and in ethnic subgroups. Overall, 465 children were reported by 84 physicians; 425 were classified with KD (55% European Caucasian, 12% North African/Middle Eastern, 10% African/Afro-Caribbean, 3% Asian and 11% mixed). Eighty patients (23%) needed second-line treatment. Japanese scores had poor performance in our whole population (sensitivity 14–61%). On multivariate regression analysis, predictors of secondary treatment after initial IVIG were hepatomegaly, ALT level ≥30 IU/L, lymphocyte count <2400/mm3 and time to treatment <5 days. The best sensitivity (77%) and specificity (60%) of this model was with 1 point per variable and cut-off ≥2 points. The sensitivity remained good in our 3 main ethnic subgroups (74–88%). We identified predictors of IVIg resistance and built a new score with good sensitivity and acceptable specificity in a non-Asian population.
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Affiliation(s)
- Maryam Piram
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Inserm, 1018, Le Kremlin Bicêtre, France. .,AP-HP, CHU de Bicêtre, Pediatric Rheumatology, CEREMAIA, Le Kremlin Bicêtre, France.
| | - Martha Darce Bello
- AP-HP, CHU de Bicêtre, Pediatric Rheumatology, CEREMAIA, Le Kremlin Bicêtre, France
| | - Stéphanie Tellier
- CHU de de Toulouse, Paediatric Rheumatology, Nephrology and Internal medicine, Toulouse, France
| | | | | | | | - Ulrich Meinzer
- APHP, CHU Robert Debré, Paediatrics,Paediatric Internal Medicine,Rheumatology and Infectious Diseases, RAISE, Paris, France
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Celine Piedvache
- APHP, CHU de Bicêtre, Clinical Research Unit, Le Kremlin Bicêtre, France
| | - Isabelle Koné-Paut
- Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP, Inserm, 1018, Le Kremlin Bicêtre, France.,AP-HP, CHU de Bicêtre, Pediatric Rheumatology, CEREMAIA, Le Kremlin Bicêtre, France
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13
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Deep Neck Space Involvement of Kawasaki Disease in the US: A Population-Based Study. J Pediatr 2019; 215:118-122. [PMID: 31477383 DOI: 10.1016/j.jpeds.2019.07.054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/05/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To describe the rate and risk factors of deep neck space involvement of Kawasaki disease. STUDY DESIGN We performed a retrospective analysis using the Kids' Inpatient Database from 2006, 2009, 2012, and 2016. Kawasaki disease and deep neck space involvement cases were identified using International Classification of Diseases codes among children aged <12 years. Demographic and outcome data of Kawasaki disease cases with and without deep neck space involvement were compared. RESULTS Of 20 787 patients with Kawasaki disease, 0.6% (130 cases) had deep neck space involvement. On multivariable analysis, children aged ≥4 years (OR 8.41; 95% CI 3.79-18.7 in those aged 6-11 years), Asian or Pacific Islanders (OR 3.72; 95% CI 1.90-7.27), non-Hispanic black children (OR 2.39; 95% CI 1.34-4.28), and Northeast hospital region (OR 2.32; 95% CI 1.21-4.46) were associated with deep neck space involvement. Surgical drainage was performed in 21.7% of patients with deep neck space involvement. Deep neck space involvement was associated with longer hospital stay and greater costs. CONCLUSIONS Approximately 0.6% of patients with Kawasaki disease present with deep neck space involvement in the US. Deep neck space involvement of Kawasaki disease occurs primarily in older (≥4 years old), non-white, non-Hispanic children. Deep neck space involvement is associated with operative procedures for presumed abscess, longer hospital stay, and greater costs. In caring for children with suspected deep neck space abscess, particularly when they are not responding to antibiotics, clinicians should evaluate them for the possibility of Kawasaki disease.
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14
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Money NM, Darby JB. Balancing Value and Risk in Early Discharge of Patients With Kawasaki Disease. Hosp Pediatr 2019; 9:824-826. [PMID: 31548263 DOI: 10.1542/hpeds.2019-0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Nathan M Money
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas; and
| | - John B Darby
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Brenner Children's Hospital and School of Medicine, Wake Forest University, Winston-Salem, North Carolina
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15
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Hester GZ, Watson D, Nickel AJ, Ryan N, Jepson B, Gray J, Bergmann KR. Identifying Patients With Kawasaki Disease Safe for Early Discharge: Development of a Risk Prediction Model at a US Children's Hospital. Hosp Pediatr 2019; 9:749-756. [PMID: 31501220 DOI: 10.1542/hpeds.2019-0049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To develop a model to predict risk of intravenous immunoglobulin (IVIg) nonresponse in patients with Kawasaki disease (KD) to assist in early discharge decision-making. METHODS Retrospective cohort study of 430 patients 0 to 18 years old discharged from a US children's hospital January 1, 2010, through July 31, 2017 with a diagnosis of KD. IVIg nonresponse was defined as at least 1 of the following: temperature ≥38.0°C between 36 hours and 7 days after initial IVIg dose, receipt of a second IVIg dose after a temperature ≥38.0°C at least 20 hours after initial IVIg dose, or readmission within 7 days with administration of a second IVIg dose. Backward stepwise logistic regression was used to select a predictive model. RESULTS IVIg nonresponse occurred in 19% (81 of 430) of patients. We identified a multivariate model (which included white blood cell count, hemoglobin level, platelet count, aspartate aminotransferase level, sodium level, albumin level, temperature within 6 hours of first IVIg dose, and incomplete KD) with good predictive ability (optimism-adjusted concordance index: 0.700) for IVIg nonresponse. Stratifying into 2 groups by a predictive probability cutoff of 0.10, we identified 26% of patients at low risk for IVIg nonresponse, with a sensitivity and specificity of 90% and 30%, respectively, and a negative predictive value of 93%. CONCLUSIONS We developed a model with good predictive value for identifying risk of IVIg nonresponse in patients with KD at a US children's hospital. Patients at lower risk may be considered for early discharge by using shared decision-making. Our model may be used to inform implementation of electronic health record tools and future risk prediction research.
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Affiliation(s)
| | - David Watson
- Children's Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | - Amanda J Nickel
- Children's Research Institute, Children's Minnesota, Minneapolis, Minnesota
| | | | - Bryan Jepson
- Pediatric Residency Program, University of Minnesota, Minneapolis, Minnesota; and
| | - James Gray
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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16
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Dionne A, Bucholz EM, Gauvreau K, Gould P, Son MBF, Baker AL, de Ferranti SD, Fulton DR, Friedman KG, Newburger JW. Impact of Socioeconomic Status on Outcomes of Patients with Kawasaki Disease. J Pediatr 2019; 212:87-92. [PMID: 31229318 DOI: 10.1016/j.jpeds.2019.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 05/08/2019] [Accepted: 05/10/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the association of neighborhood socioeconomic status (SES) with time to intravenous immunoglobulin treatment, length of stay (LOS), and coronary artery aneurysms (CAAs) in patients with Kawasaki disease. STUDY DESIGN We examined the relationship of SES in 915 patients treated at a large academic center between 2000 and 2017. Neighborhood SES was measured using a US census-based score derived from 6 measures related to income, education, and occupation. Linear and logistic regression were used to examine the association of SES with number of days of fever at time of treatment, LOS, and CAA. RESULTS Patients in the lowest SES quartile were treated later than patients with greater SES (7 [IQR 5, 9] vs 6 [IQR 5, 8] days, P = .01). Patients in the lowest SES quartile were more likely to be treated after 10 days of illness, with an OR 1.9 (95% CI 1.3-2.8). In multivariable analysis, SES remained an independent predictor of the number of days of fever at time of treatment (P = .01). Patients in the lowest SES quartile had longer LOS than patients with greater SES (3 [IQR 2, 5] vs 3 [IQR 2, 4], P = .007). In subgroup analysis of white children, those in the lowest SES quartile vs quartiles 2-4 were more likely to develop large/giant CAA 17 (12%) vs 30 (6%), P = .03. CONCLUSIONS Lower SES is associated with delayed treatment, prolonged LOS, and increased risk of large/giant CAA. Novel approaches to diagnosis and education are needed for children living in low-SES neighborhoods.
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Affiliation(s)
- Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Emily M Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Patrick Gould
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Mary Beth F Son
- Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Immunology, Boston Children's Hospital, Boston, MA
| | - Annette L Baker
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - David R Fulton
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
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17
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Portman MA, Dahdah NS, Slee A, Olson AK, Choueiter NF, Soriano BD, Buddhe S, Altman CA. Etanercept With IVIg for Acute Kawasaki Disease: A Randomized Controlled Trial. Pediatrics 2019; 143:peds.2018-3675. [PMID: 31048415 PMCID: PMC6564061 DOI: 10.1542/peds.2018-3675] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Patients with Kawasaki disease can develop life-altering coronary arterial abnormalities, particularly in those resistant to intravenous immunoglobulin (IVIg) therapy. We tested the tumor necrosis factor α receptor antagonist etanercept for reducing both IVIg resistance and coronary artery (CA) disease progression. METHODS In a double-blind multicenter trial, patients with Kawasaki disease received either etanercept (0.8 mg/kg; n = 100) or placebo (n = 101) subcutaneously starting immediately after IVIg infusion. IVIg resistance was the primary outcome with prespecified subgroup analyses according to age, sex, and race. Secondary outcomes included echocardiographic CA measures within subgroups defined by coronary dilation (z score >2.5) at baseline. We used generalized estimating equations to analyze z score change and a prespecified algorithm for change in absolute diameters. RESULTS IVIg resistance occurred in 22% (placebo) and 13% (etanercept) of patients (P = .10). Etanercept reduced IVIg resistance in patients >1 year of age (P = .03). In the entire population, 46 (23%) had a coronary z score >2.5 at baseline. Etanercept reduced coronary z score change in those with and without baseline dilation (P = .04 and P = .001); no improvement occurred in the analogous placebo groups. Etanercept (n = 22) reduced dilation progression compared with placebo (n = 24) by algorithm in those with baseline dilation (P = .03). No difference in the safety profile occurred between etanercept and placebo. CONCLUSIONS Etanercept showed no significant benefit in IVIg resistance in the entire population. However, preplanned analyses showed benefit in patients >1 year. Importantly, etanercept appeared to ameliorate CA dilation, particularly in patients with baseline abnormalities.
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Affiliation(s)
- Michael A. Portman
- Seattle Children’s Research Institute, School
of Medicine, University of Washington, Seattle, Washington
| | - Nagib S. Dahdah
- Sainte Justine University Hospital Center, University
of Montreal, Montreal, Canada
| | | | - Aaron K. Olson
- Seattle Children’s Research Institute, School
of Medicine, University of Washington, Seattle, Washington
| | - Nadine F. Choueiter
- Montefiore Children’s Hospital, Albert
Einstein College of Medicine, Bronx, New York; and
| | - Brian D. Soriano
- Seattle Children’s Research Institute, School
of Medicine, University of Washington, Seattle, Washington
| | - Sujatha Buddhe
- Seattle Children’s Research Institute, School
of Medicine, University of Washington, Seattle, Washington
| | - Carolyn A. Altman
- Texas Children’s Hospital, Baylor College of
Medicine, Houston, Texas
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18
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Spatiotemporal Analysis and Epidemiology of Kawasaki Disease in Western New York: A 16-Year Review of Cases Presenting to a Single Tertiary Care Center. Pediatr Infect Dis J 2019; 38:582-588. [PMID: 30418354 DOI: 10.1097/inf.0000000000002239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Kawasaki disease (KD) is one of the leading causes of acquired heart disease in children in developed nations. Epidemiologic evidence suggests that KD is related to an infectious agent; however, the cause remains unknown. Yearly incidence in Japan has been steadily increasing, but few long-term databases of KD cases from North America have been reviewed. METHODS We reviewed the epidemiology of local cases over a 16-year period to study incidence with time and temporal and geographic clustering of cases in a representative cohort in North America. RESULTS The yearly incidence in cases per population <5 years old per 100,000 was 20.2 and 15.9, using International Classification of Disease, ninth revision and detailed chart review, respectively. Using International Classification of Disease, ninth revision alone overestimates our incidence by 27%. We show a distinct seasonality of cases with winter predominance. Applying Kulldorff's spatial scan statistic revealed no significant clustering of cases with either purely spatial or space-time analyses. On purely nonconstrained temporal SaTScan analysis, there was a significant clustering of cases in a 67- to 68-week period in 2000-2001. CONCLUSIONS Our analysis reveals an apparent outbreak of KD in our region in 2000-2001. In contrast to Japan, for the last 14 years, the incidence in our region has been stable.
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The factors affecting the disease course in Kawasaki disease. Rheumatol Int 2019; 39:1343-1349. [PMID: 31139951 DOI: 10.1007/s00296-019-04336-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 05/23/2019] [Indexed: 12/18/2022]
Abstract
The aim of this study was to review the characteristics of patients with Kawasaki disease (KD) from Turkey and to assess the performance of the Kobayashi score (KS), Harada score (HS), Formosa score (FS), Egami score (ES) and other parameters in predicting intravenous immunoglobulin (IVIG) resistance and coronary artery involvement (CAI) in the Turkish population. Patients who were diagnosed as being in the acute phase of KD at Hacettepe University Faculty of Medicine (Ankara, Turkey) between June 2007 and January 2016 reviewed retrospectively, and those between January 2016 and February 2018 reviewed prospectively, were included in this cohort study. A total of 100 patients with KD were included in this study. Statistical Package for Social Sciences for Windows 22.0 (SPSS Inc, Chicago, IL, USA) was used for statistical analysis. Eighty-five patients (85%) responded to IVIG treatment, whereas 15 (5 female, 10 male) were IVIG resistant. CAI was detected in echocardiography at diagnosis in 31 (31%) (9 female; 22 male) patients. For predicting IVIG resistance, KS, ES, FS, and HS had sensitivity of 82.1%, 26.7%, 30.8%, 69.2% and specificity of 35.7%, 94%, 51.2%, 45.8%, respectively. For the association with CAI occurrence, the sensitivities were 17.2%, 3.3%, 35.7%, 70.4% and the specificities were 78.5%, 88.4%, 49.3%, 49.3% for the aforementioned scores, respectively. The multivariate analysis showed white blood cell (WBC) count [Odd's ratio (OR) 4.1; 95% confidence interval (CI) 1.26-13.23; p = 0.019] and hematocrit (OR 3.8; 95% CI 1.15-12.4; p = 0.028), as independent predictors of CAI while gamma-glutamyl transferase (GGT) level (OR 5.7; 95% CI 1.73-27.51; p = 0.018) was detected as the only independent predictor of IVIG resistance. This is the first study from Turkey in KD to evaluate the association of the scoring systems for IVIG resistance and CAI. The risk scoring systems in KD did not predict the risk for IVIG resistance and were not associated with CAI in Turkish population.
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Lindquist ME, Hicar MD. B Cells and Antibodies in Kawasaki Disease. Int J Mol Sci 2019; 20:ijms20081834. [PMID: 31013925 PMCID: PMC6514959 DOI: 10.3390/ijms20081834] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/09/2019] [Accepted: 04/11/2019] [Indexed: 12/22/2022] Open
Abstract
The etiology of Kawasaki disease (KD), the leading cause of acquired heart disease in children, is currently unknown. Epidemiology supports a relationship of KD to an infectious disease. Several pathological mechanisms are being considered, including a superantigen response, direct invasion by an infectious etiology or an autoimmune phenomenon. Treating affected patients with intravenous immunoglobulin is effective at reducing the rates of coronary aneurysms. However, the role of B cells and antibodies in KD pathogenesis remains unclear. Murine models are not clear on the role for B cells and antibodies in pathogenesis. Studies on rare aneurysm specimens reveal plasma cell infiltrates. Antibodies generated from these aneurysmal plasma cell infiltrates showed cross-reaction to intracellular inclusions in the bronchial epithelium of a number of pathologic specimens from children with KD. These antibodies have not defined an etiology. Notably, a number of autoantibody responses have been reported in children with KD. Recent studies show acute B cell responses are similar in children with KD compared to children with infections, lending further support of an infectious disease cause of KD. Here, we will review and discuss the inconsistencies in the literature in relation to B cell responses, specific antibodies, and a potential role for humoral immunity in KD pathogenesis or diagnosis.
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Affiliation(s)
- Michael E Lindquist
- United States Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA.
| | - Mark D Hicar
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14222, USA.
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Predictors of Intravenous Immunoglobulin Nonresponse and Racial Disparities in Kawasaki Disease. Pediatr Infect Dis J 2018; 37:e279-e280. [PMID: 30308604 DOI: 10.1097/inf.0000000000002083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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