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Al-Ahmad M, Al Zaabi A, Madkour A, Alqaraghuli HA, Al Hayaan H, Mobayed H, Idrees M, Al Busaidi N, Zeineldine S. Expert consensus on oral corticosteroids stewardship for the treatment of severe asthma in the Middle East and Africa. Respir Med 2024; 228:107674. [PMID: 38782138 DOI: 10.1016/j.rmed.2024.107674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 05/25/2024]
Abstract
In the Middle East and Africa (MEA) region, overuse of oral corticosteroids (OCS) for asthma management, both as burst and maintenance therapy, poses a significant challenge. Gaps in knowledge regarding the need to taper OCS in patients with severe asthma and the use of OCS in comorbid conditions have been noted. OCS stewardship can help attain optimal and effective OCS tapering along with reducing OCS overuse and over-reliance. In this paper, we discuss current practices regarding the use of OCS in asthma, globally and in the MEA region. Expert recommendations for achieving OCS stewardship in the MEA region have also been presented. Regional experts recommend increasing awareness among patients about the consequences of OCS overuse, engaging community pharmacists, and educating primary healthcare professionals about the benefits of prompt appropriate referral. Innovative local referral tools like ReferID can be utilized to refer patients with asthma to specialist care. The experts also endorse a multidisciplinary team approach and accelerating access to newer medicines like biologics to implement OCS stewardship and optimize asthma care in the MEA region.
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Affiliation(s)
- Mona Al-Ahmad
- Microbiology Department, College of Medicine, Kuwait University, Kuwait.
| | | | | | | | | | | | - Majdy Idrees
- Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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2
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Deng L, Wei SL, Wang L, Huang JQ. Feruloylated Oligosaccharides Prevented Influenza-Induced Lung Inflammation via the RIG-I/MAVS/TRAF3 Pathway. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2024; 72:9782-9794. [PMID: 38597360 DOI: 10.1021/acs.jafc.3c09390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Uncontrolled inflammation contributes significantly to the mortality in acute respiratory infections. Our previous research has demonstrated that maize bran feruloylated oligosaccharides (FOs) possess notable anti-inflammatory properties linked to the NF-kB pathway regulation. In this study, we clarified that the oral administration of FOs moderately inhibited H1N1 virus infection and reduced lung inflammation in influenza-infected mice by decreasing a wide spectrum of cytokines (IFN-α, IFN-β, IL-6, IL-10, and IL-23) in the lungs. The mechanism involves FOs suppressing the transduction of the RIG-I/MAVS/TRAF3 signaling pathway, subsequently lowering the expression of NF-κB. In silico analysis suggests that FOs have a greater binding affinity for the RIG-I/MAVS signaling complex. This indicates that FOs have potential as promising targets for immune modulation. Moreover, in MAVS knockout mice, we confirmed that the anti-inflammatory function of FOs against influenza depends on MAVS. Comprehensive analysis using 16S rRNA gene sequencing and metabolite profiling techniques showed that FOs have the potential to restore immunity by modulating the gut microbiota. In conclusion, our study demonstrates that FOs are effective anti-inflammatory phytochemicals in inhibiting lung inflammation caused by influenza. This suggests that FOs could serve as a potential nutritional strategy for preventing the H1N1 virus infection and associated lung inflammation.
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Affiliation(s)
- Li Deng
- School of Traditional Chinese Medicine, Jinan University, Guangzhou 510632, China
| | - Shu-Lei Wei
- School of Traditional Chinese Medicine, Jinan University, Guangzhou 510632, China
| | - Lu Wang
- School of Traditional Chinese Medicine, Jinan University, Guangzhou 510632, China
| | - Jun-Qing Huang
- School of Traditional Chinese Medicine, Jinan University, Guangzhou 510632, China
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3
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Russo A, Mazzone S, Landolina L, Colucci R, Baccari F, Fetta A, Boni A, Cordelli DM. Efficacy and Safety of Pulse Intravenous Methylprednisolone in Pediatric Epileptic Encephalopathies: Timing and Networks Consideration. J Clin Med 2024; 13:2497. [PMID: 38731025 PMCID: PMC11084200 DOI: 10.3390/jcm13092497] [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: 03/05/2024] [Revised: 04/10/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Epileptic encephalopathies (EE) are characterized by severe drug-resistant seizures, early onset, and unfavorable developmental outcomes. This article discusses the use of intravenous methylprednisolone (IVMP) pulse therapy in pediatric patients with EE to evaluate its efficacy and tolerability. Methods: This is a retrospective study from 2020 to 2023. Inclusion criteria were ≤18 years at the time of IVMP pulse therapy and at least 6 months of follow-up. Efficacy and outcome, defined as seizure reduction > 50% (responder rate), were evaluated at 6 and 9 months of therapy, and 6 months after therapy suspension; quality of life (QoL) was also assessed. Variables predicting positive post-IVMP outcomes were identified using statistical analysis. Results: The study included 21 patients, with a responder rate of 85.7% at 6 and 9 months of therapy, and 80.9% at 6 months after therapy suspension. Variables significantly predicting favorable outcome were etiology (p = 0.0475) and epilepsy type (p = 0.0475), with the best outcome achieved in patients with genetic epilepsy and those with encephalopathy related to electrical status epilepticus during slow-wave sleep (ESES). All patients evidenced improvements in QoL at the last follow-up, with no relevant adverse events reported. Conclusions: Our study confirmed the efficacy and high tolerability of IVMP pulse therapy in pediatric patients with EE. Genetic epilepsy and ESES were positive predictors of a favorable clinical outcome. QOL, EEG tracing, and postural-motor development showed an improving trend as well. IVMP pulse therapy should be considered earlier in patients with EE.
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Affiliation(s)
- Angelo Russo
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
| | - Serena Mazzone
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
| | - Laura Landolina
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
| | - Roberta Colucci
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
| | - Flavia Baccari
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOS Epidemiologia e Biostatistica, 40139 Bologna, Italy;
| | - Anna Fetta
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
| | - Antonella Boni
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
| | - Duccio Maria Cordelli
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, UOC Neuropsichiatria Dell’età Pediatrica, 40139 Bologna, Italy; (S.M.); (L.L.); (R.C.); (A.F.); (A.B.); (D.M.C.)
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Università di Bologna, 40126 Bologna, Italy
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4
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Chisholm K, Daines L, Turner S. Challenges in diagnosing asthma in children. BMJ 2024; 384:e075924. [PMID: 38350681 DOI: 10.1136/bmj-2023-075924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Affiliation(s)
| | - Luke Daines
- Usher Institute, University of Edinburgh, Edinburgh
| | - Steve Turner
- Women and Children's Division, NHS Grampian, Aberdeen, UK
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Woods CR, Bradley JS, Chatterjee A, Kronman MP, Arnold SR, Robinson J, Copley LA, Arrieta AC, Fowler SL, Harrison C, Eppes SC, Creech CB, Stadler LP, Shah SS, Mazur LJ, Carrillo-Marquez MA, Allen CH, Lavergne V. Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics. J Pediatric Infect Dis Soc 2024; 13:1-59. [PMID: 37941444 DOI: 10.1093/jpids/piad089] [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: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Tennessee Health Sciences Center College of Medicine Chattanooga, Chattanooga, Tennessee
| | - John S Bradley
- Division of Infectious Diseases, Department of Pediatrics, University of California San Diego, School of Medicine, and Rady Children's Hospital, San Diego, California
| | - Archana Chatterjee
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Sandra R Arnold
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lawson A Copley
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Antonio C Arrieta
- Division of Infectious Diseases, Children's Hospital of Orange County and University of California, Irvine, California
| | - Sandra L Fowler
- Division of Infectious Diseases, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Laura P Stadler
- Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lynnette J Mazur
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas
| | - Maria A Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Coburn H Allen
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, Texas
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada
- University of Montreal Research Center, Montreal, Quebec, Canada
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6
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Leal I, Steeples LR, Wong SW, Giuffrè C, Pockar S, Sharma V, Green EKY, Payne J, Jones NP, Chieng ASE, Ashworth J. Update on the systemic management of noninfectious uveitis in children and adolescents. Surv Ophthalmol 2024; 69:103-121. [PMID: 36682467 DOI: 10.1016/j.survophthal.2023.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/22/2022] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
Noninfectious uveitis (NIU) in children and adolescents is a rare but treatable cause of visual impairment in children. Treatments for pediatric NIU and their side effects, along with the risks of vision loss and the need for long-term disease monitoring, pose significant challenges for young patients and their families. Treatment includes local and systemic approaches and this review will focus on systemic therapies that encompass corticosteroids, conventional synthetic disease-modifying antirheumatic drugs (csDMARD), and biological disease-modifying antirheumatic drugs (bDMARD). Treatment is generally planned in a stepwise approach. Methotrexate is well-established as the preferential csDMARD in pediatric NIU. Adalimumab, an antitumor necrosis factor (TNF) agent, is the only bDMARD formally approved for pediatric NIU and has a good safety and efficacy profile. Biosimilars are gaining increasing visibility in the treatment of pediatric NIU. Other bDMARD with some evidence in literature for the treatment of pediatric NIU include infliximab, tocilizumab, abatacept, rituximab and, more recently, Janus kinase inhibitors. Important aspects of managing children on these systemic therapies include vaccination issues, risk of infection, and psychological distress. Also, strategies need to address regarding primary nonresponse/secondary loss of response to anti-TNF treatment, biological switching, and monitoring regimens for these drugs. Optimal management of pediatric uveitis involves a multidisciplinary team, including specialist pediatric uveitis and rheumatology nurses, pediatric rheumatologists, psychological support, orthoptic and optometry support, and play specialists.
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Affiliation(s)
- Inês Leal
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Visual Sciences Study Centre, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
| | - Laura R Steeples
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Academic Health Science Centre, Manchester, UK
| | - Shiao Wei Wong
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Chiara Giuffrè
- Centro Europeo di Oftalmologia, Palermo, Italy; Ophthalmology Department, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Sasa Pockar
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Vinod Sharma
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Elspeth K Y Green
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Janine Payne
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Nicholas P Jones
- School of Biological Sciences, University of Manchester, Manchester, UK
| | | | - Jane Ashworth
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Division of Evolution & Genomic Sciences, University of Manchester, Manchester, UK
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7
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Kong Z, Zhu L, Liu Y, Liu Y, Chen G, Jiang T, Wang H. Effects of azithromycin exposure during pregnancy at different stages, doses and courses on testicular development in fetal mice. Biomed Pharmacother 2024; 170:116063. [PMID: 38154271 DOI: 10.1016/j.biopha.2023.116063] [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: 10/14/2023] [Revised: 12/16/2023] [Accepted: 12/21/2023] [Indexed: 12/30/2023] Open
Abstract
Azithromycin is a commonly used antibiotic during pregnancy, but some studies have suggested its potential developmental toxicity. Currently, the effects and mechanisms of prenatal azithromycin exposure (PAzE) on fetal testicular development are still unclear. The effects of prenatal exposure to the same drug on fetal testicular development could vary depending on different stages, doses, and courses. Hence, in this study, based on clinical medication characteristics, Kunming mice was administered intragastrically with azithromycin at different stages (mid-/late-pregnancy), doses (50, 100, 200 mg/kg·d), and courses (single-/multi-course). Fetal blood and testicular samples were collected on GD18 for relevant assessments. The results indicated that PAzE led to changes in fetal testicular morphology, reduced cell proliferation, increased apoptosis, and decreased expression of markers related to Leydig cells (Star), Sertoli cells (Wt1), and spermatogonia (Plzf). Further investigation revealed that the effects of PAzE on fetal testicular development were characterized by mid-pregnancy, high dose (clinical dose), and single course having more pronounced effects. Additionally, the TGFβ/Smad and Nrf2 signaling pathways may be involved in the changes in fetal testicular development induced by PAzE. In summary, this study confirmed that PAzE influences fetal testicular morphological development and multicellular function. It provided theoretical and experimental evidence for guiding the rational use of azithromycin during pregnancy and further exploring the mechanisms underlying its developmental toxicity on fetal testicles.
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Affiliation(s)
- Ziyu Kong
- Department of Pharmacology, Wuhan University School of Basic Medical Sciences, Wuhan 430071, China
| | - Lu Zhu
- Department of Pharmacology, Wuhan University School of Basic Medical Sciences, Wuhan 430071, China
| | - Yi Liu
- Department of Pharmacology, Wuhan University School of Basic Medical Sciences, Wuhan 430071, China
| | - Yi Liu
- Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Guanghui Chen
- Wuhan University People's Hospital, Wuhan 430071, China
| | - Tao Jiang
- Suizhou Emergency Medical Center, Suizhou 441300, China.
| | - Hui Wang
- Department of Pharmacology, Wuhan University School of Basic Medical Sciences, Wuhan 430071, China; Hubei Provincial Key Laboratory of Developmentally Originated Disease, Wuhan 430071, China.
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Cao Y, Song Y, Ding Y, Ni J, Zhu B, Shen J, Miao L. The role of hormones in the pathogenesis and treatment mechanisms of delirium in ICU: The past, the present, and the future. J Steroid Biochem Mol Biol 2023; 233:106356. [PMID: 37385414 DOI: 10.1016/j.jsbmb.2023.106356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/18/2023] [Accepted: 06/26/2023] [Indexed: 07/01/2023]
Abstract
Delirium is an acute brain dysfunction. As one of the common psychiatric disorders in ICU, it can seriously affect the prognosis of patients. Hormones are important messenger substances found in the human body that help to regulate and maintain the function and metabolism of various tissues and organs. They are also one of the most commonly used drugs in clinical practice. Recent evidences suggest that aberrant swings in cortisol and non-cortisol hormones might induce severe cognitive impairment, eventually leading to delirium. However, the role of hormones in the pathogenesis of delirium still remains controversial. This article reviews the recent research on risk factors of delirium and the association between several types of hormones and cognitive dysfunction. These mechanisms are expected to offer novel ideas and clinical relevance for the treatment and prevention of delirium.
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Affiliation(s)
- Yuchun Cao
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Yuwei Song
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Yuan Ding
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Jiayuan Ni
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Bin Zhu
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Jianqin Shen
- Department of Blood Purification Center, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China.
| | - Liying Miao
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China.
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9
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Alhammadi NA, Mohammed Al Oudhah SM, Mofareh Asiri MA, Alshehri MA, Almutairi BAB, Mohammed Abdullah Thalibah A, Asiri FNM, Alshahrani ASA. Public awareness of side effects of systemic steroids in Asir region, Saudi Arabia. J Family Med Prim Care 2023; 12:1854-1858. [PMID: 38024924 PMCID: PMC10657041 DOI: 10.4103/jfmpc.jfmpc_2202_22] [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: 11/13/2022] [Revised: 12/14/2022] [Accepted: 04/10/2023] [Indexed: 12/01/2023] Open
Abstract
Background Corticosteroids have been used since the 50s and it represent the most important and frequently used class of anti-inflammatory and immunosuppressive drugs for the treatment of several diseases such as numerous neoplastic, asthma, allergy, rheumatoid arthritis, and dermatological disorders. This study aims to determine the public awareness of side effects of systemic steroids in Asir region, Saudi Arabia. Methods A descriptive cross-sectional web-based study was used. An online questionnaire was developed by the study researchers based on the literature review and consultations of the field experts. The questionnaire included the following components: Participants demographic data, medical history, and steroids use. Also, it covered participants awareness regarding systemic steroids and side effects. Results A total of 439 participants fulfilling the inclusion criteria completed the study questionnaire. Ages ranged from 18 to 65 years with mean age of 26.1 ± 13.9 years old, of those, 227 (51.7%) respondents were males. Around 346 (78.8%) had poor overall awareness level while only 93 (21.2%) had good awareness regarding systematic steroids. The study also showed that awareness was significantly higher among young aged participants in the health care field and among those who previously used steroids. Two hundred and eighty two (64.2%) of the respondents reported previous use of steroids. Conclusion In conclusion, the current study showed that nearly one out of each five people know about systemic steroids and related side effects which is below the satisfactory level. Higher awareness was observed with regards drug associated side effects and long-term use consequences.
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Affiliation(s)
- Nouf Ahmed Alhammadi
- Department of Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia
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10
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Pitrez PM, Nanthapisal S, Castro APBM, Teli C, P G A. Managing moderate-to-severe paediatric asthma: a scoping review of the efficacy and safety of fluticasone propionate/salmeterol. BMJ Open Respir Res 2023; 10:e001706. [PMID: 37620110 PMCID: PMC10450074 DOI: 10.1136/bmjresp-2023-001706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/20/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Fluticasone propionate/salmeterol xinafoate (FP/SAL) is an inhaled corticosteroid (ICS) and long-acting β2-agonist (LABA) combination, indicated for the regular treatment of children (aged >4 years) with asthma that is inadequately controlled with ICS monotherapy plus as-needed short-acting β2-agonists, or already adequately controlled with ICS/LABA. OBJECTIVE Compared with the adult population, fewer clinical studies have investigated the efficacy of FP/SAL in paediatric patients with moderate and moderate-to-severe asthma. In this review, we synthesise the available evidence for the efficacy and safety of FP/SAL in the paediatric population, compared with other available therapies indicated for asthma in children. ELIGIBILITY CRITERIA A literature review identified randomised controlled trials and observational studies of FP/SAL in the paediatric population with moderate-to-severe asthma. SOURCES OF EVIDENCE The Medline database was searched using PubMed (https://pubmed.ncbi.nlm.nih.gov/), with no publication date restrictions. Search strategies were developed and refined by authors. CHARTING METHODS Selected articles were screened for clinical outcome data (exacerbation reduction, nocturnal awakenings, lung function, symptom control, rescue medication use and safety) and a table of key parameters developed. RESULTS Improvements in asthma outcomes with FP/SAL include reduced risk of asthma-related emergency department visits and hospitalisations, protection against exercise-induced asthma and improvements in measures of lung function. Compared with FP monotherapy, greater improvements in measures of lung function and asthma control are reported. In addition, reduced incidence of exacerbations, hospitalisations and rescue medication use is observed with FP/SAL compared with ICS and leukotriene receptor antagonist therapy. Furthermore, FP/SAL therapy can reduce exposure to both inhaled and oral corticosteroids. CONCLUSIONS FP/SAL is a reliable treatment option in patients not achieving control with ICS monotherapy or a different ICS/LABA combination. Evidence shows that FP/SAL is well tolerated and has a similar safety profile to FP monotherapy. Thus, FP/SAL provides an effective option for the management of moderate-to-severe asthma in the paediatric population.
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Affiliation(s)
- Paulo Marcio Pitrez
- Pediatric Pulmonology Division, Hospital Santa Casa de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Sira Nanthapisal
- Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
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11
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Rollins CK, Calderon J, Wypij D, Taylor AM, Davalji Kanjiker TS, Rohde JS, Maiman M, Zambrano LD, Newhams MM, Rodriguez S, Hart N, Worhach J, Kucukak S, Poussaint TY, Son MBF, Friedman ML, Gertz SJ, Hobbs CV, Kong M, Maddux AB, McGuire JL, Licht PA, Staat MA, Yonker LM, Mazumdar M, Randolph AG, Campbell AP, Newburger JW. Neurological and Psychological Sequelae Associated With Multisystem Inflammatory Syndrome in Children. JAMA Netw Open 2023; 6:e2324369. [PMID: 37466939 PMCID: PMC10357334 DOI: 10.1001/jamanetworkopen.2023.24369] [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: 04/03/2023] [Accepted: 06/04/2023] [Indexed: 07/20/2023] Open
Abstract
Importance Acute neurological involvement occurs in some patients with multisystem inflammatory syndrome in children (MIS-C), but few data report neurological and psychological sequelae, and no investigations include direct assessments of cognitive function 6 to 12 months after discharge. Objective To characterize neurological, psychological, and quality of life sequelae after MIS-C. Design, Setting, and Participants This cross-sectional cohort study was conducted in the US and Canada. Participants included children with MIS-C diagnosed from November 2020 through November 2021, 6 to 12 months after hospital discharge, and their sibling or community controls, when available. Data analysis was performed from August 2022 to May 2023. Exposure Diagnosis of MIS-C. Main Outcomes and Measures A central study site remotely administered a onetime neurological examination and in-depth neuropsychological assessment including measures of cognition, behavior, quality of life, and daily function. Generalized estimating equations, accounting for matching, assessed for group differences. Results Sixty-four patients with MIS-C (mean [SD] age, 11.5 [3.9] years; 20 girls [31%]) and 44 control participants (mean [SD] age, 12.6 [3.7] years; 20 girls [45%]) were enrolled. The MIS-C group exhibited abnormalities on neurological examination more frequently than controls (15 of 61 children [25%] vs 3 of 43 children [7%]; odds ratio, 4.7; 95% CI, 1.3-16.7). Although the 2 groups performed similarly on most cognitive measures, the MIS-C group scored lower on the National Institutes of Health Cognition Toolbox List Sort Working Memory Test, a measure of executive functioning (mean [SD] scores, 96.1 [14.3] vs 103.1 [10.5]). Parents reported worse psychological outcomes in cases compared with controls, particularly higher scores for depression symptoms (mean [SD] scores, 52.6 [13.1] vs 47.8 [9.4]) and somatization (mean [SD] scores, 55.5 [15.5] vs 47.0 [7.6]). Self-reported (mean [SD] scores, 79.6 [13.1] vs 85.5 [12.3]) and parent-reported (mean [SD] scores, 80.3 [15.5] vs 88.6 [13.0]) quality of life scores were also lower in cases than controls. Conclusions and Relevance In this cohort study, compared with contemporaneous sibling or community controls, patients with MIS-C had more abnormal neurologic examinations, worse working memory scores, more somatization and depression symptoms, and lower quality of life 6 to 12 months after hospital discharge. Although these findings need to be confirmed in larger studies, enhanced monitoring may be warranted for early identification and treatment of neurological and psychological symptoms.
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Affiliation(s)
- Caitlin K. Rollins
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Johanna Calderon
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- National Institute of Health and Medical Research INSERM U1046, PhyMedExp, Montpellier, France
- Department of Psychiatry, Boston Children’s Hospital, Boston, Massachusetts
| | - David Wypij
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alex M. Taylor
- Department of Psychiatry, Boston Children’s Hospital, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | | | - Julia S. Rohde
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Moshe Maiman
- Department of Psychiatry, Boston Children’s Hospital, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Laura D. Zambrano
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Margaret M. Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Susan Rodriguez
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Nicholas Hart
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Jennifer Worhach
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
| | - Suden Kucukak
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Tina Y. Poussaint
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Mary Beth F. Son
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Immunology, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Matthew L. Friedman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis
| | - Shira J. Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, New Jersey
| | - Charlotte V. Hobbs
- Division of Infectious Diseases, Department of Pediatrics, Department of Microbiology, University of Mississippi Medical Center, Jackson
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | - Jennifer L. McGuire
- Division of Neurology at The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Paul A. Licht
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Mary Allen Staat
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lael M. Yonker
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Division of Pediatric Pulmonary and Mucosal Immunology and Biology Research Center, Division of Infectious Disease, Massachusetts General Hospital, Boston
| | - Maitreyi Mazumdar
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Adrienne G. Randolph
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Angela P. Campbell
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Becker LL, Kaindl AM. Corticosteroids in childhood epilepsies: A systematic review. Front Neurol 2023; 14:1142253. [PMID: 36970534 PMCID: PMC10036579 DOI: 10.3389/fneur.2023.1142253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 03/12/2023] Open
Abstract
Corticosteroids have been used for the treatment of patients with epilepsy for more than 6 decades, based on the hypothesis of inflammation in the genesis and/or promotion of epilepsy. We, therefore, aimed to provide a systematic overview of the use of corticosteroid regimes in childhood epilepsies in line with the PRISMA guidelines. We performed a structured literature search via PubMed and identified 160 papers with only three randomized controlled trials excluding the substantial trials on epileptic spasms. Corticosteroid regimes, duration of treatment (days to several months), and dosage protocols were highly variable in these studies. Evidence supports the use of steroids in epileptic spasms; however, there is only limited evidence for a positive effect for other epilepsy syndromes, e.g., epileptic encephalopathy with spike-and-wave activity in sleep [(D)EE-SWAS] or drug-resistant epilepsies (DREs). In (D)EE-SWAS (nine studies, 126 patients), 64% of patients showed an improvement either in the EEG or in their language/cognition following various steroid treatment regimes. In DRE (15 studies, 436 patients), a positive effect with a seizure reduction in 50% of pediatric and adult patients and seizure freedom in 15% was identified; however, no recommendation can be drawn due to the heterozygous cohort. This review highlights the immense need for controlled studies using steroids, especially in DRE, to offer patients new treatment options.
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Affiliation(s)
- Lena-Luise Becker
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Angela M. Kaindl
- Department of Pediatric Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Chronically Sick Children, Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Epilepsy Center for Children and Adolescents, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Cell- and Neurobiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Angela M. Kaindl
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13
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Duffey H, Leonard J, Mistry RD. Variation in diagnosis and management of allergic reactions among emergency medicine and allergy immunology providers. Allergy Asthma Proc 2023; 44:51-58. [PMID: 36719699 DOI: 10.2500/aap.2023.44.220088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Children with anaphylaxis often emergently present for treatment. Providers' adherence to the principles of optimal management according to the most recent national guidelines is unknown. Objective: To assess the variation in management approaches for allergic reactions and anaphylaxis between allergy/immunology (AI) and emergency medicine (EM) providers. Methods: This was a cross-sectional survey study of AI and EM providers in the University of Colorado affiliated hospitals and Colorado Asthma and Allergy Society. The survey consisted of six cases of patients with allergic reactions, with four cases that represented patients with anaphylaxis that resolved by the time of discharge. For each vignette, the participants were asked about preferred initial therapy, adjunctive therapies, monitoring, outpatient prescription medications, and discharge instructions provided. Survey derivation and validation was accomplished by a multidisciplinary team of experts by using a modified Delphi process. Results: A total of 413 clinicians were contacted, of whom 194, (47%) responded, including 69 pediatric EM, 50 general EM, and 49 AI providers, and 26 did not identify a provider type. There were no statistically significant differences in correct recognition of anaphylaxis between the AI and EM providers. For each case, statistically significant differences were noted in the use of corticosteroids during and after resolution of anaphylaxis: AI providers reported giving fewer prescriptions than did the EM providers for corticosteroids in all cases of anaphylaxis (p < 0.001). The AI providers were less likely to prescribe scheduled antihistamines than were the EM providers in half of the cases (p < 0.02). Conclusion: Across the specialties, there were high rates of recognition of epinephrine as first-line treatment for anaphylaxis. The majority of the EM providers prescribed scheduled corticosteroids and antihistamines after resolution of anaphylaxis, whereas most of the AI providers did not prescribe scheduled corticosteroids. Analysis of the current data suggests against the routine use of corticosteroids in the management of anaphylaxis, particularly continued use after resolution of symptoms. AI involvement in the creation of EM and hospital protocols for allergic reactions could improve overall care.
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Affiliation(s)
- Hannah Duffey
- From the Department of Dermatology, University of Utah, Salt Lake City, Utah, and
| | - Jan Leonard
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Rakesh D Mistry
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado
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14
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Babl FE, Herd D, Borland ML, Kochar A, Lawton B, Hort J, West A, George S, Zhang M, Velusamy K, Sullivan F, Oakley E, Davidson A, Hopper SM, Cheek JA, Berkowitz RG, Hearps S, Wilson CL, Williams A, Elborough H, Legge D, Mackay MT, Lee KJ, Dalziel SR. Efficacy of Prednisolone for Bell Palsy in Children: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial. Neurology 2022; 99:e2241-e2252. [PMID: 36008143 DOI: 10.1212/wnl.0000000000201164] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 07/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Corticosteroids are used to treat the early stages of idiopathic facial paralysis (Bell palsy) in children, but their effectiveness is uncertain. We set out to determine whether prednisolone improves the proportion of children with Bell palsy with complete recovery at 1 month. METHODS We conducted a double-blind, placebo-controlled, randomized trial of prednisolone in children presenting to emergency departments with Bell palsy. Patients aged 6 months to younger than 18 years were recruited within 72 hours after the symptom onset and were randomly assigned to receive 10 days of treatment with oral prednisolone (approximately 1 mg/kg) or placebo. The primary outcome was complete recovery of facial function at 1 month rated on the House-Brackmann scale. Secondary outcomes included facial function, adverse events, and pain up to 6 months. Target recruitment was n = 540 (270 per group). RESULTS Between October 13, 2015, and August 23, 2020, 187 children were randomized (94 to prednisolone and 93 to placebo) and included in the intention-to-treat analysis. At 1 month, the proportions of patients who had recovered facial function were 49% (n = 43/87) in the prednisolone group compared with 57% (n = 50/87) in the placebo group (risk difference -8.1%, 95% CI -22.8 to 6.7; adjusted odds ratio [aOR] 0.7, 95% CI 0.4 to 1.3). At 3 months, these proportions were 90% (n = 71/79) for the prednisolone group vs 85% (n = 72/85) for the placebo group (risk difference 5.2%, 95% CI -5.0 to 15.3; aOR 1.2, 95% CI 0.4 to 3.0) and, at 6 months, 99% (n = 77/78) and 93% (n = 76/82), respectively (risk difference 6.0%, 95% CI -0.1 to 12.2; aOR 3.0, 95% CI 0.5 to 17.7). There were no serious adverse events and little evidence for group differences in secondary outcomes. DISCUSSION In children with Bell palsy, the vast majority recover without treatment. This study, although underpowered, does not provide evidence that early treatment with prednisolone improves complete recovery. TRIAL REGISTRATION INFORMATION Registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000563561, registered June 1, 2015. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368505&isReview=true. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for children with Bell palsy, prednisolone does not significantly change recovery of complete facial function at 1 month. However, this study lacked the precision to exclude an important harm or benefit from prednisolone.
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Affiliation(s)
- Franz E Babl
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand.
| | - David Herd
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Meredith L Borland
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Amit Kochar
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Ben Lawton
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Jason Hort
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Adam West
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Shane George
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Michael Zhang
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Karthik Velusamy
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Frank Sullivan
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Ed Oakley
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Andrew Davidson
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Sandy M Hopper
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - John A Cheek
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Robert G Berkowitz
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Stephen Hearps
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Catherine L Wilson
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Amanda Williams
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Hannah Elborough
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Donna Legge
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Mark T Mackay
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Katherine J Lee
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
| | - Stuart R Dalziel
- From the Emergency Department (F.E.B., E.O., S.M.H., J.A.C., A. Williams, H.E.), Royal Children's Hospital; Clinical Sciences (F.E.B., E.O., A.D., S.M.H., J.A.C., R.G.B., S.H., C.L.W., A. Williams, H.E., M.T.M.), Murdoch Children's Research Institute, Parkville; Departments of Paediatrics (F.E.B., E.O., A.D., S.M.H., R.G.B., M.T.M., K.J.L.) and Critical Care (F.E.B., E.O., S.H.), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria; Emergency Department (D.H.), Queensland Children's Hospital; University of Queensland (D.H.); Mater Research Institute (D.H.), Brisbane, Queensland; Emergency Department (M.L.B.), Perth Children's Hospital; Divisions of Emergency Medicine and Paediatrics (M.L.B.), University of Western Australia, Perth; Emergency Department (A.K.), Women's and Children's Hospital, Adelaide; Emergency Department (B.L.), Logan Hospital, Brisbane, Queensland; Emergency Department (J.H.), The Children's Hospital at Westmead, Sydney; Emergency Department (A. West, J.A.C.), Monash Medical Centre, Clayton, Victoria; Department of Emergency Medicine (S.G.), Gold Coast University Hospital, Southport; School of Medicine and Menzies Health Institute Queensland (S.G.), Griffith University, Southport; Child Health Research Centre (S.G.), The University of Queensland, South Brisbane; Emergency Department (M.Z.), John Hunter Hospital, Newcastle, New South Wales; Emergency Department (K.V.), Townsville Hospital; James Cook University College of Medicine and Dentistry (K.V.), Townsville, Australia; University of St Andrews (F.S.), School of Medicine, Edinburgh, United Kingdom; North York General Hospital (F.S.), Department of Family & Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada; Department of Anaesthesia (A.D.), Royal Children's Hospital; Department of Otolaryngology (R.G.B.), Pharmacy Department (D.L.), and Department of Neurology (M.T.M.), Royal Children's Hospital; Clinical Epidemiology and Biostatistics Unit (K.J.L.) and Melbourne Children's Trial Centre (A.D., K.J.L.), Murdoch Children's Research Institute, Parkville, Victoria, Australia; Children's Emergency Department (S.R.D.), Starship Children's Hospital, Auckland; and Departments of Surgery and Paediatrics: Child and Youth Health (S.R.D.), University of Auckland, New Zealand
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15
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King C, Hawcutt DB. Paediatric glucocorticoid toxicity index: new possibilities in assessment. Nat Rev Rheumatol 2022; 18:677-678. [PMID: 36138124 DOI: 10.1038/s41584-022-00848-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Charlotte King
- Department of Women and Child's Health, Institute of Life Course and Medical Studies, University of Liverpool, Liverpool, UK
| | - Daniel B Hawcutt
- Department of Women and Child's Health, Institute of Life Course and Medical Studies, University of Liverpool, Liverpool, UK. .,NIHR Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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16
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Levison SW, Rocha-Ferreira E, Kim BH, Hagberg H, Fleiss B, Gressens P, Dobrowolski R. Mechanisms of Tertiary Neurodegeneration after Neonatal Hypoxic-Ischemic Brain Damage. PEDIATRIC MEDICINE (HONG KONG, CHINA) 2022; 5:28. [PMID: 37601279 PMCID: PMC10438849 DOI: 10.21037/pm-20-104] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Neonatal encephalopathy linked to hypoxia-ischemia (H-I) which is regarded as the most important neurological problem of the newborn, can lead to a spectrum of adverse neurodevelopmental outcomes such as cerebral palsy, epilepsy, hyperactivity, cognitive impairment and learning difficulties. There have been numerous reviews that have focused on the epidemiology, diagnosis and treatment of neonatal H-I; however, a topic that is less often considered is the extent to which the injury might worsen over time, which is the focus of this review. Similarly, there have been numerous reviews that have focused on mechanisms that contribute to the acute or subacute injury; however, there is a tertiary phase of recovery that can be defined by cellular and molecular changes that occur many weeks and months after brain injury and this topic has not been the focus of any review for over a decade. Therefore, in this article we review both the clinical and pre-clinical data that show that tertiary neurodegeneration is a significant contributor to the final outcome, especially after mild to moderate injuries. We discuss the contributing roles of apoptosis, necroptosis, autophagy, protein homeostasis, inflammation, microgliosis and astrogliosis. We also review the limited number of studies that have shown that significant neuroprotection and preservation of neurological function can be achieved administering drugs during the period of tertiary neurodegeneration. As the tertiary phase of neurodegeneration is a stage when interventions are eminently feasible, it is our hope that this review will stimulate a new focus on this stage of recovery towards the goal of producing new treatment options for neonatal hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Steven W. Levison
- Department of Pharmacology, Physiology, and Neuroscience, Rutgers University, New Jersey Medical School, Cancer Center, 205 South Orange Avenue, Newark, NJ 07103, USA
| | - Eridan Rocha-Ferreira
- Centre of Perinatal Medicine & Health, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Brian H. Kim
- Department of Pharmacology, Physiology, and Neuroscience, Rutgers University, New Jersey Medical School, Cancer Center, 205 South Orange Avenue, Newark, NJ 07103, USA
| | - Henrik Hagberg
- Centre of Perinatal Medicine & Health, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King’s College London, King’s Health Partners, St. Thomas’ Hospital, London, SE1 7EH, UK
| | - Bobbi Fleiss
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King’s College London, King’s Health Partners, St. Thomas’ Hospital, London, SE1 7EH, UK
- Université de Paris, NeuroDiderot, Inserm, F-75019 Paris, France
- School of Health and Biomedical Sciences, RMIT University, Bundoora, 3083, VIC, Australia
| | - Pierre Gressens
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King’s College London, King’s Health Partners, St. Thomas’ Hospital, London, SE1 7EH, UK
- Université de Paris, NeuroDiderot, Inserm, F-75019 Paris, France
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17
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Reiter J, Ramagopal M, Gileles-Hillel A, Forno E. Sleep disorders in children with asthma. Pediatr Pulmonol 2022; 57:1851-1859. [PMID: 33647191 PMCID: PMC8408281 DOI: 10.1002/ppul.25264] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/03/2021] [Accepted: 01/07/2021] [Indexed: 11/07/2022]
Abstract
Asthma and sleep disorders are both common in childhood, and often co-exist in the same child. Moreover, studies have shown that in many children the rate of one is influenced by the other. Sleep disorders can be classified into six different groups-insomnia, hypersomnia, parasomnia, movement disorders, circadian disorders, and sleep-related breathing disorders. Children with asthma often present with complaints of insomnia with poor sleep quality, difficulty falling asleep and sleep disruptions. These complains are often associated with asthma control. They may also complain of daytime sleepiness and have higher rates of parasomnias, such as night terrors and nocturnal enuresis when compared with their healthy peers. Whether movement and circadian disorders are also more prevalent in children with asthma is less clear. Finally, there is a complex bidirectional interaction between sleep-related breathing disorders and asthma: poor sleep and sleep disorders may worsen asthma, and asthma, particularly when it is poorly controlled, may impair sleep. In the current review we examine the association of each of the sleep disorders with asthma and review the common pathophysiological pathways. We hope to convince the reader that appropriate management of asthma must include inquiries into the patient's sleep, and vice versa.
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Affiliation(s)
- Joel Reiter
- Pediatric Pulmonary and Sleep Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Maya Ramagopal
- Division of Pulmonary Medicine and Cystic Fibrosis Center, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New-Jersey, USA
| | - Alex Gileles-Hillel
- Pediatric Pulmonary and Sleep Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Erick Forno
- Division of Pulmonary Medicine, Department of Pediatrics, Children’s Hospital of Pittsburgh and University of Pittsburgh, PA
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18
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Alharbi AS, Yousef AA, Alharbi SA, Almaghamsi TM, Al Qwaiee MM, Al-Somali FM, Alahmadi TS, Alhaider SA, Alotaibi WH, Albalawi MA, Alotaibi FN, Alenizi AS, Alsaadi MM, Said YS. Severe asthma in children: An official statement from Saudi Pediatric Pulmonology Association. Saudi Med J 2022; 43:329-340. [PMID: 35414610 PMCID: PMC9998054 DOI: 10.15537/smj.2022.4.43.20210756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/08/2022] [Indexed: 11/16/2022] Open
Abstract
In Saudi Arabia, the prevalence of pediatric asthma ranges between 8% and 25%. However, there are no sufficient data regarding severe asthma in childhood in Saudi Arabia. Therefore, a task force has been formed by the Saudi Pediatric Pulmonology Association which is a subsidiary group of the Saudi Thoracic Society and consists of Saudi experts with well-respected academic and clinical backgrounds in the fields of pediatric asthma as well as other respiratory diseases to write a consensus on definitions, phenotypes, and pathophysiology, evaluation, and management. To achieve this, the subject was divided into various sections, each of which was assigned to at least 2 experts. Without a central literature review, the authors searched the literature using their own strategies. To reach an agreement, the entire panel reviewed and voted on proposed findings and recommendations.
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Affiliation(s)
- Adel S. Alharbi
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Abdullah A. Yousef
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Saleh A. Alharbi
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Talal M. Almaghamsi
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Mansour M. Al Qwaiee
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Faisal M. Al-Somali
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Turki S. Alahmadi
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Sami A. Alhaider
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Wadha H. Alotaibi
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Mona A. Albalawi
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Faisal N. Alotaibi
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Ahmed S. Alenizi
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Muslim M. Alsaadi
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Yazan S. Said
- From the Department of Pediatrics (A. Alharbi, Alotaibi), Pediatric Pulmonology Division and Pediatric Sleep Center, from the Department of Pediatrics (Al-Somali), Pediatric Pulmonary Division, Prince Sultan Military City, from the Departments of Pediatric Pulmonology & Sleep Medicine (Albalawi), King Fahad Medical City, from the Pediatric Pulmonology And Sleep Medicine Department (Alenizi), Children’s Hospital, King Saud Medical City, from the Department of Pediatrics (Alenizi), College of Medicine and King Khalid University Hospital, King Saud University, From the Pediatric Department (Said), Security Forces Hospital, Riyadh; from the Department of Pediatrics (Yousef), Imam Abdulrahman Bin Faisal University, College of Medicine; from the Department of Pediatrics (Almaghamsi, Alhaider), King Fahad Specialist Hospital, Dammam; King Fahd Hospital of the University (Yousef), from the Department of Pediatrics (Alahmadi), Dr. Sulaiman Al Habib Hospital, Al-Khobar; Department of Pediatrics (S. Alharbi), Faculty of Medicine, Umm Alqura University, Mecca; from the Department of Pediatrics (S. Alharbi), Dr. Soliman Fakeeh Hospital; from the Pediatric Department (Al Qwaiee), King Faisal specialist hospital & Research Center, from the Department of Pediatrics (Alotaibi), Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
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19
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Abrams EM, Greenhawt M, Shaker M, Alqurashi W. Separating Fact from Fiction in the Diagnosis and Management of Food Allergy. J Pediatr 2022; 241:221-228. [PMID: 34678246 DOI: 10.1016/j.jpeds.2021.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/01/2021] [Accepted: 10/14/2021] [Indexed: 01/09/2023]
Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba; Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Canada.
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy and Immunology, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora
| | - Marcus Shaker
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon; Geisel School of Medicine at Dartmouth, Hanover
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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20
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Antibiotics prior to age 2 years have limited association with preschool growth trajectory. Int J Obes (Lond) 2022; 46:843-850. [PMID: 34999718 PMCID: PMC8967797 DOI: 10.1038/s41366-021-01023-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/20/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022]
Abstract
Background: Prior studies of early antibiotic use and growth have shown mixed results, primarily on cross-sectional outcomes. This study examined the effect of oral antibiotics before age 24 months on growth trajectory at age 2–5 years. Methods: We captured oral antibiotic prescriptions and anthropometrics from electronic health records through PCORnet, for children with ≥1 height and weight at 0–12 months of age, ≥1 at 12–30 months, and ≥2 between 25 and 72 months. Prescriptions were grouped into episodes by time and by antimicrobial spectrum. Longitudinal rate regression was used to assess differences in growth rate from 25 to 72 months of age. Models were adjusted for sex, race/ethnicity, steroid use, diagnosed asthma, complex chronic conditions, and infections. Results: 430,376 children from 29 health U.S. systems were included, with 58% receiving antibiotics before 24 months. Exposure to any antibiotic was associated with an average 0.7% (95% CI 0.5, 0.9, p < 0.0001) greater rate of weight gain, corresponding to 0.05 kg additional weight. The estimated effect was slightly greater for narrow-spectrum (0.8% [0.6, 1.1]) than broad-spectrum (0.6% [0.3, 0.8], p < 0.0001) drugs. There was a small dose response relationship between the number of antibiotic episodes and weight gain. Conclusion: Oral antibiotic use prior to 24 months of age was associated with very small changes in average growth rate at ages 2–5 years. The small effect size is unlikely to affect individual prescribing decisions, though it may reflect a biologic effect that can combine with others.
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21
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Christian MT, Maxted AP. Optimizing the corticosteroid dose in steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2022; 37:37-47. [PMID: 33611671 PMCID: PMC7896825 DOI: 10.1007/s00467-021-04985-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/13/2021] [Accepted: 02/03/2021] [Indexed: 01/31/2023]
Abstract
The use of corticosteroids in the treatment of steroid-sensitive nephrotic (SSNS) syndrome in children has evolved surprisingly slowly since the ISKDC consensus over 50 years ago. From a move towards longer courses of corticosteroid to treat the first episode in the 1990s and 2000s, more recent large, well-designed randomized controlled trials (RCTs) have unequivocally shown no benefit from an extended course, although doubt remains whether this applies across all age groups. With regard to prevention of relapses, daily ultra-low-dose prednisolone has recently been shown to be more effective than low-dose alternate-day prednisolone. Daily low-dose prednisolone for a week at the time of acute viral infection seems to be effective in the prevention of relapses but the results of a larger RCT are awaited. Recently, corticosteroid dosing to treat relapses has been questioned, with data suggesting lower doses may be as effective. The need for large RCTs to address the question of whether corticosteroid doses can be reduced was the conclusion of the authors of the recent corticosteroid therapy for nephrotic syndrome in children Cochrane update. This review summarizes development in thinking on corticosteroid use in SSNS and makes suggestions for areas that merit further scrutiny.
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Affiliation(s)
- Martin T Christian
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK.
| | - Andrew P Maxted
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK
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22
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Stagi S, Municchi G, Ferrari M, Wasniewska MG. An Overview on Different L-Thyroxine (l-T 4) Formulations and Factors Potentially Influencing the Treatment of Congenital Hypothyroidism During the First 3 Years of Life. Front Endocrinol (Lausanne) 2022; 13:859487. [PMID: 35757415 PMCID: PMC9218053 DOI: 10.3389/fendo.2022.859487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/29/2022] [Indexed: 11/29/2022] Open
Abstract
Congenital hypothyroidism (CH) is a relatively frequent congenital endocrine disorder, caused by defective production of thyroid hormones (THs) at birth. Because THs are essential for the development of normal neuronal networks, CH is also a common preventable cause of irreversible intellectual disability (ID) in children. Prolonged hypothyroidism, particularly during the THs-dependent processes of brain development in the first years of life, due to delays in diagnosis, inadequate timing and dosing of levothyroxine (l-thyroxine or l-T4), the non-compliance of families, incorrect follow-up and the interference of foods, drugs and medications affecting the absorption of l-T4, may be responsible for more severe ID. In this review we evaluate the main factors influencing levels of THs and the absorption of l-T4 in order to provide a practical guide, based on the existing literature, to allow optimal follow-up for these patients.
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Affiliation(s)
- Stefano Stagi
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
- *Correspondence: Stefano Stagi,
| | - Giovanna Municchi
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
| | - Marta Ferrari
- Department of Health Sciences, University of Florence, Anna Meyer Children’s University Hospital, Florence, Italy
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23
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Tyler A, Bryan MA, Zhou C, Mangione-Smith R, Williams D, Johnson DP, Kenyon CC, Rasooly I, Neubauer HC, Wilson KM. Variation in Dexamethasone Dosing and Use Outcomes for Inpatient Croup. Hosp Pediatr 2022; 12:22-29. [PMID: 34846064 PMCID: PMC8882347 DOI: 10.1542/hpeds.2021-005854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Evaluate the association between dexamethasone dosing and outcomes for children hospitalized with croup. METHODS This study was nested within a multisite prospective cohort study of children aged 6 months to 6 years admitted to 1 of 5 US children's hospitals between July 2014 and June /2016. Multivariable linear and logistic mixed-effects regression models were used to examine the association between the number of dexamethasone doses (1 vs >1) and outcomes (length of stay [LOS], cost, and 30-day same-cause reuse). All multivariable analyses included a site-specific random effect to account for clustering within hospital and were adjusted for age, sex, race and ethnicity, presenting severity, medical complexity, insurance, caregiver education, and hospital. In cost analyses, we controlled for LOS. RESULTS Among 234 children hospitalized with croup, patient characteristics did not differ by number of doses. The proportion receiving >1 dose varied by hospital (range 27.9%-57.1%). In adjusted analyses, >1 dose was not associated with same-cause reuse (odds ratio 0.87 [95% confidence interval (CI): 0.26 to 2.95]) but was associated with 45% longer LOS (relative risk = 1.45 [95% CI: 1.30 to 1.62]). When we controlled for LOS, >1 dose was not associated with differential cost ($-31.2 [95% CI $-424.4 to $362.0]). Eighty-two (35%) children received dexamethasone before presentation. CONCLUSIONS We found significant interhospital variation in dexamethasone dosing and LOS. When we controlled for severity on presentation, >1 dexamethasone dose was associated with longer LOS but not reuse. Although incomplete adjustment for severity is one possible explanation, some providers may routinely keep children hospitalized to administer multiple dexamethasone doses.
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Affiliation(s)
- Amy Tyler
- Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO and Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS)
| | - Mersine A. Bryan
- Department of Pediatrics, University of Washington, Seattle, WA,Seattle Children’s Research Institute, Seattle, WA
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, WA,Seattle Children’s Research Institute, Seattle, WA
| | | | - Derek Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - David P. Johnson
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Chén C Kenyon
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Irit Rasooly
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Hannah C. Neubauer
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Karen M. Wilson
- Kravis Children’s Hospital at the Icahn School of Medicine at Mount Sinai, New York City, NY
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24
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Christian MT, Webb NJA, Woolley RL, Afentou N, Mehta S, Frew E, Brettell EA, Khan AR, Milford DV, Bockenhauer D, Saleem MA, Hall AS, Koziell A, Maxwell H, Hegde S, Finlay ER, Gilbert RD, Jones C, McKeever K, Cook W, Ives N. Daily low-dose prednisolone to prevent relapse of steroid-sensitive nephrotic syndrome in children with an upper respiratory tract infection: PREDNOS2 RCT. Health Technol Assess 2022; 26:1-94. [DOI: 10.3310/wtfc5658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
Most children with steroid-sensitive nephrotic syndrome have relapses that are triggered by upper respiratory tract infections. Four small trials, mostly in children already taking maintenance corticosteroid in countries of different upper respiratory tract infection epidemiology, showed that giving daily low-dose prednisone/prednisolone for 5–7 days during an upper respiratory tract infection reduces the risk of relapse.
Objectives
To determine if these findings were replicated in a large UK population of children with relapsing steroid-sensitive nephrotic syndrome on different background medication or none.
Design
A randomised double-blind placebo-controlled trial, including a cost-effectiveness analysis.
Setting
A total of 122 UK paediatric departments, of which 91 recruited patients.
Participants
A total of 365 children with relapsing steroid-sensitive nephrotic syndrome (mean age 7.6 ± 3.5 years) were randomised (1 : 1) according to a minimisation algorithm based on background treatment. Eighty children completed 12 months of follow-up without an upper respiratory tract infection. Thirty-two children were withdrawn from the trial (14 prior to an upper respiratory tract infection), leaving a modified intention-to-treat analysis population of 271 children (134 and 137 children in the prednisolone and placebo arms, respectively).
Interventions
At the start of an upper respiratory tract infection, children received 6 days of prednisolone (15 mg/m2) or an equivalent dose of placebo.
Main outcome measures
The primary outcome was the incidence of first upper respiratory tract infection-related relapse following any upper respiratory tract infection over 12 months. The secondary outcomes were the overall rate of relapse, changes in background treatment, cumulative dose of prednisolone, rates of serious adverse events, incidence of corticosteroid adverse effects, change in Achenbach Child Behaviour Checklist score and quality of life. Analysis was by intention-to-treat principle. The cost-effectiveness analysis used trial data and a decision-analytic model to estimate quality-adjusted life-years and costs at 1 year, which were then extrapolated over 16 years.
Results
There were 384 upper respiratory tract infections and 82 upper respiratory tract infection-related relapses in the prednisolone arm, and 407 upper respiratory tract infections and 82 upper respiratory tract infection-related relapses in the placebo arm. The number of patients experiencing an upper respiratory tract infection-related relapse was 56 (42.7%) and 58 (44.3%) in the prednisolone and placebo arms, respectively (adjusted risk difference –0.024, 95% confidence interval –0.14 to 0.09; p = 0.70). There was no evidence that the treatment effect differed when data were analysed according to background treatment. There were no significant differences in secondary outcomes between treatment arms. Giving daily prednisolone at the time of an upper respiratory tract infection was associated with increased quality-adjusted life-years (0.9427 vs. 0.9424) and decreased average costs (£252 vs. £254), when compared with standard care. The cost saving was driven by background therapy and hospitalisations after relapse. The finding was robust to sensitivity analysis.
Limitations
A larger number of children than expected did not have an upper respiratory tract infection and the sample size attrition rate was adjusted accordingly during the trial.
Conclusions
The clinical analysis indicated that giving 6 days of daily low-dose prednisolone at the time of an upper respiratory tract infection does not reduce the risk of relapse of steroid-sensitive nephrotic syndrome in UK children. However, there was an economic benefit from costs associated with background therapy and relapse, and the health-related quality-of-life impact of having a relapse.
Future work
Further work is needed to investigate the clinical and health economic impact of relapses, interethnic differences in treatment response, the effect of different corticosteroid regimens in treating relapses, and the pathogenesis of individual viral infections and their effect on steroid-sensitive nephrotic syndrome.
Trial registration
Current Controlled Trials ISRCTN10900733 and EudraCT 2012-003476-39.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin T Christian
- Department of Paediatric Nephrology, Nottingham Children’s Hospital, Nottingham, UK
| | - Nicholas JA Webb
- Department of Paediatric Nephrology, University of Manchester, Academic Health Science Centre, Royal Manchester Children’s Hospital, Manchester, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Nafsika Afentou
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Samir Mehta
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Adam R Khan
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - David V Milford
- Department of Paediatric Nephrology, Birmingham Children’s Hospital, Birmingham, UK
| | - Detlef Bockenhauer
- Department of Renal Medicine, University College London, Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, London, UK
| | - Moin A Saleem
- School of Clinical Sciences, University of Bristol, Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Ania Koziell
- Child Health Clinical Academic Group, King’s College London, Department of Paediatric Nephrology, Evelina London Children’s Hospital, London, UK
| | - Heather Maxwell
- Department of Paediatric Nephrology, Royal Hospital for Sick Children, Glasgow, UK
| | - Shivaram Hegde
- Department of Paediatric Nephrology, University Hospital of Wales, Cardiff, UK
| | - Eric R Finlay
- Department of Paediatric Nephrology, Leeds Children’s Hospital, Leeds, UK
| | - Rodney D Gilbert
- Department of Paediatric Nephrology, Southampton Children’s Hospital, Southampton, UK
| | - Caroline Jones
- Department of Paediatric Nephrology, Alder Hey Children’s Hospital, Liverpool, UK
| | - Karl McKeever
- Department of Paediatric Nephrology, Royal Hospital for Sick Children, Belfast, UK
| | - Wendy Cook
- Nephrotic Syndrome Trust (NeST), Taunton, UK
| | - Natalie Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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25
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Shapiro DJ, Palmer NP, Bourgeois FT. Factors Associated With Corticosteroid Treatment for Pediatric Acute Respiratory Tract Infections. J Pediatric Infect Dis Soc 2021; 10:1101-1104. [PMID: 34468742 DOI: 10.1093/jpids/piab082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/24/2021] [Indexed: 11/14/2022]
Abstract
Systemic corticosteroids are not recommended to treat children with acute respiratory tract infections (ARTIs). Using data from a national commercial health care company, we found that corticosteroid treatment occurred in 3.2% of ARTI encounters. The adjusted odds of corticosteroid treatment were highest for bronchitis/bronchiolitis, in emergency departments, and in the South.
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Affiliation(s)
- Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nathan P Palmer
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA
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26
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Menzella F, Ghidoni G, Fontana M, Capobelli S, Livrieri F, Castagnetti C, Facciolongo N. The role of systemic corticosteroids in severe asthma and new evidence in their management and tapering. Expert Rev Clin Immunol 2021; 17:1283-1299. [PMID: 34761712 DOI: 10.1080/1744666x.2021.2004123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Based on the latest literature evidence, between 30% and 60% of adults with severe refractory asthma (SRA) are systemic corticosteroid (SCS) dependent. There are numerous therapeutic options in asthma, which are often not effective in severe forms. In these cases, SCS should be considered, but it is increasingly recognized that their regular use is often associated with significant and potentially serious adverse events. AREAS COVERED The aim of this article is to provide an update about the recent and significant literature on SCS and to establish their role in the management of SRA. We summarized the most important and recent evidence and we provided useful indications for clinicians. EXPERT OPINION There is now strong evidence supporting the increased risk of comorbidities and complications with long-term SCS therapies, regardless of the dose. New evidence on SCS tapering and withdrawal will allow to define protocols to address SCS management with greater safety and effectiveness, after starting efficient steroid-sparing strategies. In the next 5years, it will be necessary to implement corrective actions to address these unmet needs, to reduce the inappropriate use of SCS by maximizing the application of more innovative and effective therapies.
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Affiliation(s)
- Francesco Menzella
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Giulia Ghidoni
- University Hospital of Modena, 208968,Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Matteo Fontana
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Silvia Capobelli
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Francesco Livrieri
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Claudia Castagnetti
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Nicola Facciolongo
- Department of Medical Specialties, Pulmonology Unit, Arcispedale Santa Maria Nuova, Azienda USL Di Reggio Emilia - IRCCS, Reggio Emilia, Italy
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27
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Abstract
Synthetic glucocorticoids are widely used for their anti-inflammatory and immunosuppressive actions. A possible unwanted effect of glucocorticoid treatment is suppression of the hypothalamic-pituitary-adrenal axis, which can lead to adrenal insufficiency. Factors affecting the risk of glucocorticoid induced adrenal insufficiency (GI-AI) include the duration of glucocorticoid therapy, mode of administration, glucocorticoid dose and potency, concomitant drugs that interfere with glucocorticoid metabolism, and individual susceptibility. Patients with exogenous glucocorticoid use may develop features of Cushing's syndrome and, subsequently, glucocorticoid withdrawal syndrome when the treatment is tapered down. Symptoms of glucocorticoid withdrawal can overlap with those of the underlying disorder, as well as of GI-AI. A careful approach to the glucocorticoid taper and appropriate patient counseling are needed to assure a successful taper. Glucocorticoid therapy should not be completely stopped until recovery of adrenal function is achieved. In this review, we discuss the factors affecting the risk of GI-AI, propose a regimen for the glucocorticoid taper, and make suggestions for assessment of adrenal function recovery. We also describe current gaps in the management of patients with GI-AI and make suggestions for an approach to the glucocorticoid withdrawal syndrome, chronic management of glucocorticoid therapy, and education on GI-AI for patients and providers.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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28
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Abrams EM, Greenhawt M, Alqurashi W, Singer AG, Shaker M. The Revenge of Unintended Consequences of Anaphylaxis-Risk Overdiagnosis: How Far We Have Come and How Far We Have to Go. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3911-3917. [PMID: 34147680 DOI: 10.1016/j.jaip.2021.05.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/11/2021] [Accepted: 05/26/2021] [Indexed: 12/13/2022]
Abstract
Overdiagnosis of anaphylaxis risk is an underappreciated aspect of anaphylaxis prevention. Whereas the benefits of anaphylaxis-risk prevention are well known, potential harms resulting from preemptive approaches to mitigate anaphylaxis-risk are not insignificant. Still, great progress has been made in recent years to avoid the unintended consequences of anaphylaxis-risk overdiagnosis. Reflection on recent advances in the use of diagnostic testing, as well as the application of diagnostic labels, provides an important perspective to understand how far the specialty of allergy and immunology has come in improving the lives of patients and families. Examples of recent paradigm shifts in anaphylaxis-risk management include approaches to peanut allergy prevention without screening, deferral of corticosteroids to prevent biphasic anaphylaxis reactions, reevaluation of reflex use of emergency medical services for resolved community anaphylaxis, and an approach to penicillin allergy delabeling with direct oral challenge. Routine medical practices to decrease anaphylaxis risk can have lifelong impacts for patients-beyond just preventing anaphylaxis. As our understanding of these trade-offs evolves, it becomes necessary to weigh both the benefits and the harms of past management approaches. Because medicine remains a science of uncertainty and an art of probability, a critical approach to risk mitigation remains necessary to find the often-elusive balance in anaphylaxis prevention.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Canada
| | - Matthew Greenhawt
- Department of Pediatrics, Section of Allergy/Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | | | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine and Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH.
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29
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Kanthagnany SK, Lane LC, Wood C, Sachdev P, Drake AJ, Cheetham T. Fifteen-minute consultation: An approach to the child receiving glucocorticoids. Arch Dis Child Educ Pract Ed 2021; 106:130-135. [PMID: 32769084 DOI: 10.1136/archdischild-2019-317812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 05/04/2020] [Accepted: 06/30/2020] [Indexed: 11/03/2022]
Abstract
Glucocorticoids (GC) are used in paediatric practice for a broad range of conditions and all paediatricians will prescribe GC, in some form, during their career. A wide variety of GC formulations, doses and administration routes are used for periods of time ranging from days to years. Exposure to exogenous GC can result in hypothalamic-pituitary-adrenal axis suppression-otherwise known as adrenal suppression (AS). Patients with AS may be well most of the time but if GC therapy is reduced or stopped or if additional endogenous GC cannot be generated during illness, then an absolute or relative lack of GC can result in severe illness or death. Here, we highlight the relevance of AS to all paediatricians by providing an overview of the background and discussing the presentation and approaches to the management of this clinical entity.
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Affiliation(s)
| | - Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Claire Wood
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Pooja Sachdev
- Paediatrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Amanda Jane Drake
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Timothy Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK .,Department of Paediatric Endocrinology, Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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30
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Ranford D, Hopkins C. Safety review of current systemic treatments for severe chronic rhinosinusitis with nasal polyps and future directions. Expert Opin Drug Saf 2021; 20:1177-1189. [PMID: 33957840 DOI: 10.1080/14740338.2021.1926981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Chronic rhinosinusitis is a common condition characterized by inflammation of the nasal and sinus linings, rhinorrhea, nasal blockage, facial pain, and loss of sense of smell for longer than 12 weeks. CRS can occur with or without nasal polyps.Areas covered: First-line treatment in chronic rhinosinusitis with nasal polyps is long-term intranasal corticosteroids, which have few adverse events associated with their use, as second-generation intranasal corticosteroids having a bioavailability of <0.5%. Systemic corticosteroids are used when intranasal steroids fail to achieve symptom control. However, the repeated use of oral corticosteroids is associated with numerous adverse events and the benefit from a course of oral corticosteroids is lost within three to six months.Expert opinion: Antibiotics are commonly prescribed in nasal polyposis although there is also very little evidence for their use outside of acute infection. Macrolide antibiotics are also associated with a transient increase in the risk of arrhythmias. Biologics offer a steroid-sparing alternative to the treatment of severe nasal polyposis. They have shown to be relatively well tolerated in studies to date; however, studies suggest that there is no disease modifying effect and that any benefit is lost within weeks of finishing treatment.
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Affiliation(s)
- David Ranford
- ENT Department, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Claire Hopkins
- ENT Department, Guy's and St Thomas NHS Foundation Trust, London, UK
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31
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Karlsson S, Arnason S, Hadziosmanovic N, Laestadius Å, Hultcrantz M, Marsk E, Skogman BH. The facial nerve palsy and cortisone evaluation (FACE) study in children: protocol for a randomized, placebo-controlled, multicenter trial, in a Borrelia burgdorferi endemic area. BMC Pediatr 2021; 21:220. [PMID: 33947355 PMCID: PMC8097886 DOI: 10.1186/s12887-021-02571-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/24/2021] [Indexed: 12/20/2022] Open
Abstract
Background Children with acute peripheral facial nerve palsy cannot yet be recommended corticosteroid treatment based on evidence. Adults with idiopathic facial nerve palsy are treated with corticosteroids, according to guidelines resulting from a meta-analysis comprising two major randomized placebo-controlled trials. Corresponding trials in children are lacking. Furthermore, acute facial nerve palsy in childhood is frequently associated with Lyme neuroborreliosis, caused by the spirochete Borrelia burgdorferi. The efficacy and safety of corticosteroid treatment of acute facial nerve palsy associated with Lyme neuroborreliosis, has not yet been determined in prospective trials in children, nor in adults. Method This randomized double-blind, placebo-controlled study will include a total of 500 Swedish children aged 1–17 years, presenting with acute facial nerve palsy of either idiopathic etiology or associated with Lyme neuroborreliosis. Inclusion is ongoing at 12 pediatric departments, all situated in Borrelia burgdorferi endemic areas. Participants are randomized into active treatment with prednisolone 1 mg/kg/day (maximum 50 mg/day) or placebo for oral intake once daily during 10 days without taper. Cases associated with Lyme neuroborreliosis are treated with antibiotics in addition to the study treatment. The House-Brackmann grading scale and the Sunnybrook facial grading system are used for physician-assessed evaluation of facial impairment at baseline, and at the 1- and 12-month follow-ups. Primary outcome is complete recovery, measured by House-Brackmann grading scale, at the 12-month follow-up. Child/parent-assessed questionnaires are used for evaluation of disease-specific quality of life and facial disability and its correlation to physician-assessed facial impairment will be evaluated. Furthermore, the study will evaluate factors of importance for predicting recovery, as well as the safety profile for short-term prednisolone treatment in children with acute facial nerve palsy. Discussion This article presents the rationale, design and content of a protocol for a study that will determine the efficacy of corticosteroid treatment in children with acute facial nerve palsy of idiopathic etiology, or associated with Lyme neuroborreliosis. Future results will attribute to evidence-based treatment guidelines applicable also in Borrelia burgdorferi endemic areas. Trial registration The study protocol was approved by the Swedish Medical Product Agency (EudraCT nr 2017–004187-35) and published at ClinicalTrials.gov (NCT03781700, initial release 12/14/2018).
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Affiliation(s)
- Sofia Karlsson
- Center for Clinical Research Dalarna - Uppsala University, Region Dalarna County, Falun, Sweden. .,Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden. .,Department of Otorhinolaryngology, Region Dalarna County, Falun, Sweden.
| | - Sigurdur Arnason
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Pediatric Infectious Diseases, Astrid Lindgren's Children's Hospital, Karolinska University Hospital, Solna, Sweden
| | | | - Åsa Laestadius
- Department of Pediatric Nephrology, Astrid Lindgren's Children's Hospital, Karolinska University Hospital, Solna, Sweden.,Department of Women and Child Health, Karolinska Institutet, Stockholm, Sweden
| | - Malou Hultcrantz
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Elin Marsk
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden
| | - Barbro H Skogman
- Center for Clinical Research Dalarna - Uppsala University, Region Dalarna County, Falun, Sweden.,Department of Pediatrics, Region Dalarna County, Falun, Sweden.,Faculty of Medical and Health Sciences, Örebro Universitet, Örebro, Sweden
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32
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Sinha A, Bagga A, Banerjee S, Mishra K, Mehta A, Agarwal I, Uthup S, Saha A, Mishra OP. Steroid Sensitive Nephrotic Syndrome: Revised Guidelines. Indian Pediatr 2021. [PMID: 33742610 PMCID: PMC8139225 DOI: 10.1007/s13312-021-2217-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Justification Steroid sensitive nephrotic syndrome (SSNS) is one of the most common chronic kidney diseases in children. These guidelines update the existing Indian Society of Pediatric Nephrology recommendations on its management. Objective To frame revised guidelines on diagnosis, evaluation, management and supportive care of patients with the illness. Process The guidelines combine evidence-based recommendations and expert opinion. Formulation of key questions was followed by review of literature and evaluation of evidence by experts in two face-to-face meetings. Recommendations The initial statements provide advice for evaluation at onset and follow up and indications for kidney biopsy. Subsequent statements provide recommendations for management of the first episode of illness and of disease relapses. Recommendations on the use of immunosuppressive strategies in patients with frequent relapses and steroid dependence are accompanied by suggestions for step-wise approach and plan of monitoring. Guidance is also provided regarding the management of common complications including edema, hypovolemia and serious infections. Advice on immunization and transition of care is given. The revised guideline is intended to improve the management and outcomes of patients with SSNS, and provide directions for future research.
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Affiliation(s)
- Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India. Correspondence to: Dr. Arvind Bagga, Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | | | - Kirtisudha Mishra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi, India
| | - Amarjeet Mehta
- Department of Pediatrics, Sawai Man Singh Medical College, Jaipur, India
| | - Indira Agarwal
- Department of Pediatrics, Christian Medical College, Vellore, India
| | - Susan Uthup
- Department of Pediatrics, Trivandrum Medical College, Thiruvananthapuram, India
| | - Abhijeet Saha
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India
| | - Om Prakash Mishra
- Department of Pediatrics, Institute of Medical Sciences, Benaras Hindu University, Varanasi, India
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33
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Wallace S, Chan NI, Makrinioti H, Phillips B. Can low-dose dexamethasone be used instead of prednisolone in acute asthma attacks? Arch Dis Child 2021; 106:archdischild-2020-320239. [PMID: 33593742 DOI: 10.1136/archdischild-2020-320239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/20/2020] [Accepted: 10/09/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Susan Wallace
- West Middlesex Hospital, Chelsea, and Westminster Foundation Trust, London, UK
| | - Nigel Ij Chan
- Imperial College Healthcare NHS Trust Paediatrics, London, UK
| | - Heidi Makrinioti
- West Middlesex Hospital, Chelsea, and Westminster Foundation Trust, London, UK
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York Alcuin College, York, UK
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34
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Horton DB, Xie F, Chen L, Mannion ML, Curtis JR, Strom BL, Beukelman T. Oral Glucocorticoids and Incident Treatment of Diabetes Mellitus, Hypertension, and Venous Thromboembolism in Children. Am J Epidemiol 2021; 190:403-412. [PMID: 32902632 DOI: 10.1093/aje/kwaa197] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/23/2022] Open
Abstract
Rates of incident treatment were quantified in this study for diabetes mellitus, hypertension, and venous thromboembolism (VTE) associated with oral glucocorticoid exposure in children aged 1-18 years. The retrospective cohort included more than 930,000 children diagnosed with autoimmune diseases (namely, inflammatory bowel disease, juvenile idiopathic arthritis, or psoriasis) or a nonimmune comparator condition (attention-deficit/hyperactivity disorder) identified using US Medicaid claims (2000-2010). Associations of glucocorticoid dose per age- and sex-imputed weight with incident treated diabetes, hypertension, and VTE were estimated using Cox regression models. Crude rates were lowest for VTE (unexposed: 0.5/million person-days (95% confidence interval (CI): 0.4, 0.6); currently exposed: 15.6/million person-days (95% CI: 11.8, 20.1)) and highest for hypertension (unexposed: 6.7/million person-days (95% CI: 6.5, 7.0); currently exposed: 74.4/million person-days (95% CI: 65.7, 83.9)). Absolute rates for all outcomes were higher in unexposed and exposed children with autoimmune diseases compared with those with attention-deficit/hyperactivity disorder. Strong dose-dependent relationships were found between current glucocorticoid exposure and all outcomes (adjusted hazard ratios for high-dose glucocorticoids: for diabetes mellitus, 5.93 (95% CI: 3.94, 8.91); for hypertension, 19.13 (95% CI: 15.43, 23.73); for VTE, 16.16 (95% CI: 8.94, 29.22)). These results suggest strong relative risks, but low absolute risks, of newly treated VTE, diabetes, and especially hypertension in children taking high-dose oral glucocorticoids.
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35
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36
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Steroid-Induced Iatrogenic Adrenal Insufficiency in Children: A Literature Review. ENDOCRINES 2020. [DOI: 10.3390/endocrines1020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The present review focuses on steroid-induced adrenal insufficiency (SIAI) in children and discusses the latest findings by surveying recent studies. SIAI is a condition involving adrenocorticotropic hormone (ACTH) and cortisol suppression due to high doses or prolonged administration of glucocorticoids. While its chronic symptoms, such as fatigue and loss of appetite, are nonspecific, exposure to physical stressors, such as infection and surgery, increases the risk of adrenal crisis development accompanied by hypoglycemia, hypotension, or shock. The low-dose ACTH stimulation test is generally used for diagnosis, and the early morning serum cortisol level has also been shown to be useful in screening for the condition. Medical management includes gradually reducing the amount of steroid treatment, continuing administration of hydrocortisone corresponding to the physiological range, and increasing the dosage when physical stressors are present.
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37
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Sullivan PW, Ghushchyan VH, Skoner DP, LeCocq J, Park S, Zeiger RS. Complications and Health Care Resource Utilization Associated with Systemic Corticosteroids in Children and Adolescents with Persistent Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1541-1551.e9. [PMID: 33290914 PMCID: PMC8393544 DOI: 10.1016/j.jaip.2020.11.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 10/22/2020] [Accepted: 11/20/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND: Limited comparative data are available on the impact of systemic corticosteroid (SCS) use in children and adolescents. OBJECTIVE: To determine if asthmatic children and adolescents treated with SCS have a higher likelihood of developing complications versus those not receiving SCS and to examine health care resource utilization (HCRU) in this population. METHODS: A retrospective study of data from children and adolescents with persistent asthma retrieved from the MarketScan database, a large US health claims data set, for the period 2000 to 2017 was performed. Propensity score matching was used to pair patients in the SCS and control cohorts. For complications, SCS subgroups (≥4 or 1-3 annual prescriptions) were compared with asthmatic controls without SCS using logistic regression, and for HCRU, cohorts were compared using negative binomial regression. RESULTS: A total of 67,081 patients were included (SCS: 23,898; control: 43,183). The odds of having a complication were 2.9 (95% confidence interval [CI], 2.5-3.2; P < .001) and 1.6 (95% CI, 1.6-1.7; P < .001) times higher in the ≥4 and 1 to 3 SCS groups, respectively, in the first year of follow-up versus controls. For asthma-related hospitalizations, the incidence rate ratio (IRR) was 6.9 (95% CI, 5.6-8.6) and 3.1 (95% CI, 2.8-3.4) times greater in the ≥4 SCS and 1 to 3 SCS groups, respectively, versus controls; for asthma-related emergency department visits, IRR was 5.0 (95% CI, 4.4-5.6) and 2.9 (95% CI, 2.7-3.0) times greater, respectively, versus controls (all P < .01). CONCLUSION: Children and adolescents receiving SCS for persistent asthma have an increased risk of developing complications and have greater HCRU in the first year of follow-up versus those without SCS exposure.
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Affiliation(s)
- Patrick W Sullivan
- Department of Pharmacy Practice, Regis University School of Pharmacy, Denver, Colo.
| | - Vahram H Ghushchyan
- Center for Pharmaceutical Outcomes Research, University of Colorado, Aurora, Colo; American University of Armenia, Yerevan, Armenia
| | - David P Skoner
- Department of Pediatrics, West Virginia University, Morgantown, WV
| | - Jason LeCocq
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Siyeon Park
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Md
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente, Southern California Region, San Diego, Calif
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Dellatorre G, Antelo DAP, Bedrikow RB, Cestari TF, Follador I, Ramos DG, Silva de Castro CC. Consensus on the treatment of vitiligo - Brazilian Society of Dermatology. An Bras Dermatol 2020; 95 Suppl 1:70-82. [PMID: 33153826 PMCID: PMC7772607 DOI: 10.1016/j.abd.2020.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/15/2020] [Indexed: 01/20/2023] Open
Abstract
Background Vitiligo is a muco-cutaneous, autoimmune, localized, or disseminated disease, which manifests through hypochromic or achromic macules, with loss in quality of life. The prevalence of vitiligo in Brazil was determined to be 0.54%. There is no on-label medication for its treatment. To date, no Brazilian consensus on the treatment of vitiligo had been written. Objectives The objective of this group of Brazilian dermatologists with experience in the treatment of this disease was to reach a consensus on the clinical and surgical treatment of vitiligo, based on articles with the best scientific evidence. Methods Seven dermatologists were invited, and each was assigned two treatment modalities to review. Each treatment (topical, systemic, and phototherapy) was reviewed by three experts. Two experts reviewed the surgical treatment. Subsequently, the coordinator compiled the different versions and drafted a text about each type of treatment. The new version was returned to all experts, who expressed their opinions and made suggestions for clarity. The final text was written by the coordinator and sent to all participants to prepare the final consensus. Results/Conclusion The experts defined the following as standard treatments of vitiligo: the use of topical corticosteroids and calcineurin inhibitors for localized and unstable cases; corticosteroid minipulse in progressive generalized vitiligo; narrowband UVB phototherapy for extensive forms of the disease. Surgical modalities should be indicated for segmental and stable generalized vitiligo. Topical and systemic anti-JAK drugs are being tested, with promising results.
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Affiliation(s)
- Gerson Dellatorre
- Department of Dermatology, Hospital Santa Casa de Misericórdia de Curitiba, Curitiba, PR, Brazil
| | | | | | - Tania Ferreira Cestari
- Department of Dermatology, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Daniel Gontijo Ramos
- Department of Dermatology, Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, MG, Brazil
| | - Caio Cesar Silva de Castro
- Department of Dermatology, Faculty of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil.
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Ranakusuma RW, McCullough AR, Safitri ED, Pitoyo Y, Widyaningsih W, Del Mar CB, Beller EM. Oral prednisolone for acute otitis media in children: a pilot, pragmatic, randomised, open-label, controlled study (OPAL study). Pilot Feasibility Stud 2020; 6:121. [PMID: 32874679 PMCID: PMC7455987 DOI: 10.1186/s40814-020-00671-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 08/19/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Acute otitis media (AOM) is associated with high antibiotic prescribing rates. Antibiotics are somewhat effective in improving pain and middle ear effusion (MEE); however, they have unfavourable effects. Alternative treatments, such as corticosteroids as anti-inflammatory agents, are needed. Evidence for the efficacy of these remains inconclusive. We conducted a pilot study to test feasibility of a proposed large-scale randomised controlled trial (RCT) to assess the efficacy of corticosteroids for AOM. METHODS We conducted a pilot, pragmatic, parallel, open-label RCT of oral corticosteroids for paediatric AOM in primary and secondary/tertiary care centres in Indonesia. Children aged 6 months-12 years with AOM were randomised to either prednisolone or control (1:1). Physicians were blinded to allocation. Our objectives were to test the feasibility of our full RCT procedures and design, and assess the mechanistic effect of corticosteroids, using tympanometry, in suppressing middle ear inflammation by reducing MEE. RESULTS We screened 512 children; 62 (38%) of 161 eligible children were randomised and 60 were analysed for the primary clinical outcome. All study procedures were completed successfully by healthcare personnel and parents/caregivers, despite time constraints and high workload. All eligible, consenting children were appropriately randomised. One child did not take the medication and four received additional oral corticosteroids. Our revised sample size calculation verified 444 children are needed for the full RCT. Oral corticosteroids did not have any discernible effects on MEE resolution and duration. There was no correlation between pain or other symptoms and MEE change. However, prednisolone may reduce pain intensity at day 3 (Visual Analogue Scale mean difference - 7.4 mm, 95% confidence interval (CI) - 13.4 to - 1.3, p = 0.018), but cause drowsiness (relative risk (RR) 1.8, 95% CI 1.1 to 2.8, p = 0.016). Tympanometry curves at day 7 may be improved (RR 1.8, 95% CI 1.0 to 2.9). We cannot yet confirm these as effects of corticosteroids due to insufficient sample size in this pilot study. CONCLUSIONS It is feasible to conduct a large, pragmatic RCT of corticosteroids for paediatric AOM in Indonesia. Although oral corticosteroids may reduce pain and improve tympanometry curves, it requires an adequately powered clinical trial to confirm this. TRIAL REGISTRATION Study registry number: ACTRN12618000049279. Name of registry: the Australian New Zealand Clinical Trials Registry (ANZCTR). Date of registration: 16 January 2018.
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Affiliation(s)
- Respati W. Ranakusuma
- Institute for Evidence-Based Healthcare, Bond University, 14 University Drive, Robina, QLD 4226 Australia
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Amanda R. McCullough
- Institute for Evidence-Based Healthcare, Bond University, 14 University Drive, Robina, QLD 4226 Australia
| | - Eka D. Safitri
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Yupitri Pitoyo
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Widyaningsih Widyaningsih
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Christopher B. Del Mar
- Institute for Evidence-Based Healthcare, Bond University, 14 University Drive, Robina, QLD 4226 Australia
| | - Elaine M. Beller
- Institute for Evidence-Based Healthcare, Bond University, 14 University Drive, Robina, QLD 4226 Australia
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Buddala PK, Chandrasekaran V, Harichandrakumar KT. A 3-day course of 1 mg/kg versus 2 mg/kg bodyweight prednisolone for 1- to 5-year-old children with acute moderate exacerbation of asthma: a randomized double-blind noninferiority trial. Paediatr Child Health 2020; 26:e189-e193. [PMID: 34136056 DOI: 10.1093/pch/pxaa082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background Even though the guidelines on the management of preschool asthma recommend early use of corticosteroids for acute moderate-to-severe exacerbations, considerable variation exists with regard to type and dose of steroids. Objectives To compare the clinical outcomes and side effect profile between 1 mg/kg/day and 2 mg/kg/day of oral prednisolone when administered for 3 days in preschool children with acute moderate asthma exacerbations. Study Design and Setting Randomized double-blind noninferiority trial was done in the paediatric emergency of a teaching hospital. Patients Interventions and Outcomes A total of 128 children aged 1 to 5 years who presented to the paediatric emergency with acute moderate exacerbation of asthma were enrolled. They were randomized into two groups. One group received 1 mg/kg/day and the other 2 mg/kg/day of oral prednisolone for 3 days. Severity of asthma exacerbation was measured by Pediatric Respiratory Assessment Measure (PRAM) score. The PRAM scores, wheeze recurrence, and side effect profile were compared and analyzed between the two groups. Results The difference in the PRAM scores at 1, 2, 3, and 4 hours after intervention between the two groups was statistically insignificant. Need for escalation of therapy, salbutamol nebulization, time for resolution of symptoms, and recurrence of wheeze were similar between the two groups. Vomiting was significantly less frequent in low-dose group with a relative risk of 0.19 to 0.99 compared to high-dose prednisolone. Conclusion Prednisolone at a dose of 1 mg/kg/day was not inferior to 2 mg/kg/day in terms of clinical improvement and recurrence of wheeze within 1 week and has less frequent vomiting compared to higher dose.
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Affiliation(s)
- Pavan Kumar Buddala
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Venkatesh Chandrasekaran
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - K T Harichandrakumar
- Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Chang AB, Oppenheimer JJ, Irwin RS, Adams TM, Altman KW, Azoulay E, Blackhall F, Birring SS, Bolser DC, Boulet LP, Braman SS, Brightling C, Callahan-Lyon P, Chang AB, Cowley T, Davenport P, El Solh AA, Escalante P, Field SK, Fisher D, French CT, Grant C, Harding SM, Harnden A, Hill AT, Irwin RS, Kahrilas PJ, Kavanagh J, Keogh KA, Lai K, Lane AP, Lilly C, Lim K, Lown M, Madison JM, Malesker MA, Mazzone S, McGarvey L, Molasoitis A, Murad MH, Narasimhan M, Oppenheimer J, Russell RJ, Ryu JH, Singh S, Smith MP, Tarlo SM, Vertigan AE. Managing Chronic Cough as a Symptom in Children and Management Algorithms. Chest 2020; 158:303-329. [DOI: 10.1016/j.chest.2020.01.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/11/2019] [Accepted: 01/09/2020] [Indexed: 12/12/2022] Open
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Ricardo JW, Lipner SR. Considerations for safety in the use of systemic medications for psoriasis and atopic dermatitis during the COVID-19 pandemic. Dermatol Ther 2020; 33:e13687. [PMID: 32458536 PMCID: PMC7283778 DOI: 10.1111/dth.13687] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/22/2020] [Indexed: 01/10/2023]
Abstract
Coronavirus disease 2019 (COVID‐19) is responsible for at least 2 546 527 cases and 175 812 deaths as of April 21, 2020. Psoriasis and atopic dermatitis (AD) are common, chronic, inflammatory skin conditions, with immune dysregulation as a shared mechanism; therefore, mainstays of treatment include systemic immunomodulating therapies. It is unknown whether these therapies are associated with increased COVID‐19 susceptibility or worse outcomes in infected patients. In this review, we discuss overall infection risks of nonbiologic and biologic systemic medications for psoriasis and AD and provide therapeutic recommendations. In summary, in patients with active infection, systemic conventional medications, the Janus kinase inhibitor tofacitinib, and biologics for psoriasis should be temporarily held until there is more data; in uninfected patients switching to safer alternatives should be considered. Interleukin (IL)‐17, IL‐12/23, and IL‐23 inhibitors are associated with low infection risk, with IL‐17 and IL‐23 favored over IL‐12/23 inhibitors. Pivotal trials and postmarketing data also suggest that IL‐17 and IL‐23 blockers are safer than tumor necrosis factor alpha blockers. Apremilast, acitretin, and dupilumab have favorable safety data and may be safely initiated and continued in uninfected patients. Without definitive COVID‐19 data, these recommendations may be useful in guiding treatment of psoriasis and AD patients during the COVID‐19 pandemic.
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Affiliation(s)
- Jose W Ricardo
- Department of Dermatology, Weill Cornell Medicine, New York, New York, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York, USA
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43
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Price D, Castro M, Bourdin A, Fucile S, Altman P. Short-course systemic corticosteroids in asthma: striking the balance between efficacy and safety. Eur Respir Rev 2020; 29:29/155/190151. [PMID: 32245768 PMCID: PMC9488828 DOI: 10.1183/16000617.0151-2019] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/20/2020] [Indexed: 01/10/2023] Open
Abstract
Short courses of systemic corticosteroids (SCS), both oral and injectable, are very effective for the resolution of acute asthma symptoms, including exacerbations. However, the benefits of SCS, even short courses, must be balanced against the impact of their side-effects. While the adverse consequences of long-term use are widely recognised, there appears to be a perception in the medical community that short courses of SCS are safe. Limited but growing evidence in the literature suggests that even very brief dosing periods (3–7 days) of SCS are enough to cause significantly negative outcomes for patients. Short courses of SCS are associated with increased risk of adverse events including loss of bone density, hypertension and gastrointestinal ulcers/bleeds, in addition to serious impacts on mental health. Strategies to improve asthma control are recommended, including: 1) as-needed combination therapies in mild asthma; 2) risk factor reduction; 3) improving adherence/inhaler technique; 4) earlier initiation of add-on therapies; 5) use of biologics in appropriate patients; 6) development of new therapies to better control the disease; and 7) widespread education of the medical community. We propose that patients and primary care physicians should consider a cumulative SCS dose of 1 g per year as a highly relevant and easy-to-recall threshold. Inappropriate use of systemic corticosteroids in asthma may add to disease burden. Even short-term, intermittent use is associated with health risks. Strategies to improve asthma control and reduce inappropriate use of systemic corticosteroids are needed. https://bit.ly/3bdieam
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Affiliation(s)
- David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Mario Castro
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kansas School of Medicine, Kansas City, MO, USA
| | - Arnaud Bourdin
- Dept of Respiratory Diseases, Université de Montpellier, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Montpellier, France
| | | | - Pablo Altman
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Altamentova S, Rumajogee P, Hong J, Beldick SR, Park SJ, Yee A, Fehlings MG. Methylprednisolone Reduces Persistent Post-ischemic Inflammation in a Rat Hypoxia-Ischemia Model of Perinatal Stroke. Transl Stroke Res 2020; 11:1117-1136. [PMID: 32140998 DOI: 10.1007/s12975-020-00792-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/12/2020] [Accepted: 02/19/2020] [Indexed: 12/21/2022]
Abstract
In perinatal stroke, the initial injury results in a chronic inflammatory response caused by the release of proinflammatory cytokines, gliosis and microglia activation. This chronic and ongoing inflammatory response exacerbates the brain injury, often resulting in encephalopathy and cerebral palsy (CP). Using a neonatal rat model of hypoxia-ischemia (HI) at postnatal day (P)7, we demonstrated that chronic inflammation is persistent and continues into the tertiary phase of perinatal stroke and can be attenuated by the administration of methylprednisolone sodium-succinate (MPSS, 30 mg/kg), a US Food and Drug Administration (FDA) approved anti-inflammatory agent. The inflammatory response was assessed by real-time quantitative PCR and ELISA for markers of inflammation (CCL3, CCL5, IL18 and TNFα). Structural changes were evaluated by histology (LFB/H&E), while cellular changes were assessed by Iba-1, ED1, GFAP, NeuN, Olig2 and CC1 immunostaining. Functional deficits were assessed with the Cylinder test and Ladder Rung Walking test. MPSS was injected 14 days after HI insult to attenuate chronic inflammation. In neonatal conditions such as CP, P21 is a clinically relevant time-point in rodents, corresponding developmentally to a 2-year-old human. Administration of MPSS resulted in reduced structural damage (corpus callosum, cortex, hippocampus, striatum), gliosis and reactive microglia and partial restoration of the oligodendrocyte population. Furthermore, significant behavioural recovery was observed. In conclusion, we demonstrated that administration of MPSS during the tertiary phase of perinatal stroke results in attenuation of the chronic inflammatory response, leading to pathophysiological and functional recovery. This work validates the high clinical impact of MPSS to treat neonatal conditions linked to chronic inflammation.
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Affiliation(s)
- Svetlana Altamentova
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Prakasham Rumajogee
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - James Hong
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie R Beldick
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Sei Joon Park
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Albert Yee
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada. .,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada. .,Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada. .,Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst St. Suite 4WW-449, Toronto, Ontario, M5T 2S8, Canada.
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An Acute Stress Model in New Zealand White Rabbits Exhibits Altered Immune Response to Infection with West Nile Virus. Pathogens 2019; 8:pathogens8040195. [PMID: 31635289 PMCID: PMC6963736 DOI: 10.3390/pathogens8040195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/14/2019] [Accepted: 10/16/2019] [Indexed: 12/17/2022] Open
Abstract
The immune competence of an individual is a major determinant of morbidity in West Nile virus (WNV)-infection. Previously, we showed that immunocompetent New Zealand White rabbits (NZWRs; Oryctolagus cuniculus) are phenotypically resistant to WNV-induced disease, thus presenting a suitable model for study of virus-control mechanisms. The current study used corticosteroid-treated NZWRs to model acute “stress”-related immunosuppression. Maximal effects on immune parameters were observed on day 3 post dexamethasone-treatment (pdt). However, contrary to our hypothesis, intradermal WNV challenge at this time pdt produced significantly lower viremia 1 day post-infection (dpi) compared to untreated controls, suggestive of changes to antiviral control mechanisms. To examine this further, RNAseq was performed on RNA extracted from draining lymph node—the first site of virus replication and immune detection. Unaffected by dexamethasone-treatment, an early antiviral response, primarily via interferon (IFN)-I, and induction of a range of known and novel IFN-stimulated genes, was observed. However, treatment was associated with expression of a different repertoire of IFN-α-21-like and IFN-ω-1-like subtypes on 1 dpi, which may have driven the different chemokine response on 3 dpi. Ongoing expression of Toll-like receptor-3 and transmembrane protein-173/STING likely contributed to signaling of the treatment-independent IFN-I response. Two novel genes (putative HERC6 and IFIT1B genes), and the SLC16A5 gene were also highlighted as important component of the transcriptomic response. Therefore, the current study shows that rabbits are capable of restricting WNV replication and dissemination by known and novel robust antiviral mechanisms despite environmental challenges such as stress.
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Fernandes RM, Wingert A, Vandermeer B, Featherstone R, Ali S, Plint AC, Stang AS, Rowe BH, Johnson DW, Allain D, Klassen TP, Hartling L. Safety of corticosteroids in young children with acute respiratory conditions: a systematic review and meta-analysis. BMJ Open 2019; 9:e028511. [PMID: 31375615 PMCID: PMC6688746 DOI: 10.1136/bmjopen-2018-028511] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Adverse events (AEs) associated with short-term corticosteroid use for respiratory conditions in young children. DESIGN Systematic review of primary studies. DATA SOURCES Medline, Cochrane CENTRAL, Embase and regulatory agencies were searched September 2014; search was updated in 2017. ELIGIBILITY CRITERIA Children <6 years with acute respiratory condition, given inhaled (high-dose) or systemic corticosteroids up to 14 days. DATA EXTRACTION AND SYNTHESIS One reviewer extracted with another reviewer verifying data. Study selection and methodological quality (McHarm scale) involved duplicate independent reviews. We extracted AEs reported by study authors and used a categorisation model by organ systems. Meta-analyses used Peto ORs (pORs) and DerSimonian Laird inverse variance method utilising Mantel-Haenszel Q statistic, with 95% CI. Subgroup analyses were conducted for respiratory condition and dose. RESULTS Eighty-five studies (11 505 children) were included; 68 were randomised trials. Methodological quality was poor overall due to lack of assessment and inadequate reporting of AEs. Meta-analysis (six studies; n=1373) found fewer cases of vomiting comparing oral dexamethasone with prednisone (pOR 0.29, 95% CI 0.17 to 0.48; I2=0%). The mean difference in change-from-baseline height after one year between inhaled corticosteroid and placebo was 0.10 cm (two studies, n=268; 95% CI -0.47 to 0.67). Results from five studies with heterogeneous interventions, comparators and measurements were not pooled; one study found a smaller mean change in height z-score with recurrent high-dose inhaled fluticasone over one year. No significant differences were found comparing systemic or inhaled corticosteroid with placebo, or between corticosteroids, for other AEs; CIs around estimates were often wide, due to small samples and few events. CONCLUSIONS Evidence suggests that short-term high-dose inhaled or systemic corticosteroids use is not associated with an increase in AEs across organ systems. Uncertainties remain, particularly for recurrent use and growth outcomes, due to low study quality, poor reporting and imprecision.
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Affiliation(s)
- Ricardo M Fernandes
- Pediatrics, Hospital de Santa Maria, Lisbon, Portugal
- Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Laboratory of Clinical Pharmacology and Therapeutics, Lisbon, Portugal
| | - Aireen Wingert
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Samina Ali
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Women & Children's Health Research Institute, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Amy C Plint
- Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Antonia S Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brian H Rowe
- Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - David W Johnson
- Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dominic Allain
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Terry P Klassen
- Manitoba Institute of Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Ahmed H, Turner S. Severe asthma in children-a review of definitions, epidemiology, and treatment options in 2019. Pediatr Pulmonol 2019; 54:778-787. [PMID: 30884194 DOI: 10.1002/ppul.24317] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 12/19/2022]
Abstract
Severe asthma is a relatively uncommon condition in children but one which causes morbidity, occasionally mortality, and is a challenging condition to manage. There are several definitions of severe asthma, which have a common theme of poor control despite high dose inhaled corticosteroid treatment. Depending on the definition chosen, the prevalence of severe childhood asthma may be up to 5% within populations with asthma. Collectively, there is some evidence that the treatments used in severe asthma are beneficial, but a solid evidence-base is lacking for many treatments and some treatments have recognized side effects. Evidence supporting the use of maintenance oral prednisolone and intramuscular triamcinolone is weak. Response to systemic corticosteroids is heterogeneous and recognizing phenotypes or endotypes may identify those most likely to gain maximal benefit from treatment. For children aged 6 to 11 years, the anti-IgE biologic omalizumab is effective and anti-IL-5 agent (mepolizumab) has recently been licenced in Europe (but not the US). Biologics, which are licenced for >11 year olds include omalizumab, mepolizumab, benralizumab, reslizumab, and dupilumab. There is plenty that the clinician can offer to the child and adolescent with severe asthma in 2019, including nontherapeutic and therapeutic interventions. To manage severe asthma, practitioners from broad specialities must establish and maintain a close therapeutic relationship with patients. Looking beyond 2019, more treatment options will emerge for severe childhood asthma, and clinical teams will need to continue weighing up benefits and harms.
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Affiliation(s)
- Husam Ahmed
- Child Health, University of Aberdeen, Aberdeen, UK
| | - Steve Turner
- Child Health, University of Aberdeen, Aberdeen, UK
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Maloney E, Iyer RS, Phillips GS, Menon S, Lee JJ, Callahan MJ. Practical administration of intravenous contrast media in children: screening, prophylaxis, administration and treatment of adverse reactions. Pediatr Radiol 2019; 49:433-447. [PMID: 30923875 DOI: 10.1007/s00247-018-4306-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/14/2018] [Accepted: 11/02/2018] [Indexed: 12/28/2022]
Abstract
Administration of intravenous contrast media to children is a routine practice at many clinical imaging centers, that can involve special considerations. In this paper, we provide practical information to facilitate optimal performance and oversight of this task. We provide targeted screening questions that can help to identify high-risk pediatric patients for both iodine-based and gadolinium-based intravenous contrast media administration. These include children at risk for allergic-like reactions, thyroid dysfunction, contrast-induced nephropathy, and nephrogenic systemic fibrosis. We make recommendations for addressing "yes" responses to screening questions using risk stratification schema that are specific to children. We also present criteria for selecting children for premedication prior to intravenous contrast administration, and suggest pediatric regimens. Additionally, we discuss practical nuances of intravenous contrast media administration to children and provide a quick-reference table of appropriate treatments with pediatric dosages for adverse contrast reactions.
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Affiliation(s)
- Ezekiel Maloney
- Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
| | - Ramesh S Iyer
- Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Grace S Phillips
- Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Shina Menon
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA
| | - John J Lee
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
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Berthe-Aucejo A, Nguyen PKH, Angoulvant F, Bellettre X, Albaret P, Weil T, Boulkedid R, Bourdon O, Prot-Labarthe S. Retrospective study of irrational prescribing in French paediatric hospital: prevalence of inappropriate prescription detected by Pediatrics: Omission of Prescription and Inappropriate prescription (POPI) in the emergency unit and in the ambulatory setting. BMJ Open 2019; 9:e019186. [PMID: 30898791 PMCID: PMC6475152 DOI: 10.1136/bmjopen-2017-019186] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Pediatrics: Omission of Prescription and Inappropriate prescription (POPI) is the first detection tool for potentially inappropriate medicines (PIMs) and potentially prescribing omissions (PPOs) in paediatrics. The aim of this study was to evaluate the prevalence of PIM and PPO detected by POPI regarding prescriptions in hospital and for outpatients. The second objective is to determine the risk factors related to PIM and PPO. DESIGN A retrospective, descriptive study was conducted in the emergency department (ED) and community pharmacy (CP) during 6 months. POPI was used to identify PIM and PPO. SETTING Robert-Debré Hospital (France) and Albaret community pharmacy (Seine and Marne). PARTICIPANTS Patients who were under 18 years old and who had one or more drugs prescribed were included. Exclusion criteria consisted of inaccessible medical records for patients consulted in ED and prescription without drugs for outpatients. PRIMARY AND SECONDARY OUTCOME MEASURES PIM and PPO rate and risk factors. RESULTS At the ED, 18 562 prescriptions of 15 973 patients and 4780 prescriptions of 2225 patients at the CP were analysed. The PIM rate and PPO rate were, respectively, 2.9% and 2.3% at the ED and 12.3% and 6.1% at the CP. Respiratory and digestive diseases had the highest rate of PIM. CONCLUSION This is the first study to assess the prevalence of PIM and PPO detected by POPI in a paediatric population. This study assessed PIMs or PPOs within a hospital and a community pharmacy. POPI could be used to improve drug use and patient care and to limit hospitalisation and adverse drug reaction. A prospective multicentric study should be conducted to evaluate the impact and benefit of implementing POPI in clinical practice.
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Affiliation(s)
- Aurore Berthe-Aucejo
- Department of Pharmacy, AP-HP, Robert-Debré Hospital, Paris, France
- UMR-S1123, ECEVE; Inserm U1123, INSERM, Paris, Île-de-France, France
| | | | - François Angoulvant
- UMR-S1123, ECEVE; Inserm U1123, INSERM, Paris, Île-de-France, France
- Emergency Unit, AP-HP, Necker Hospital, Paris, Île-de-France, France
| | - Xavier Bellettre
- Emergency unit, AP-HP, Robert-Debré Hospital, Paris, Île-de-France, France
| | - Patrick Albaret
- Pharmacy, Albaret Pharmacy, Cesson, France
- Clinical Pharmacy, Paris Descartes University, Paris, Île-de-France, France
| | - Thomas Weil
- Department of Pharmacy, AP-HP, Robert-Debré Hospital, Paris, France
| | - Rym Boulkedid
- UMR-S1123, ECEVE; Inserm U1123, INSERM, Paris, Île-de-France, France
- Clinical Epidemiology Unit, Robert-Debré Hospital, Paris, Île-de-France, France
- CIC-EC 1426, AP-HP, Robert-Debré Hospital, Paris, Île-de-France, France
| | - Olivier Bourdon
- Department of Pharmacy, AP-HP, Robert-Debré Hospital, Paris, France
- Clinical Pharmacy, Paris Descartes University, Paris, Île-de-France, France
- Laboratoire Educations et Pratiques de Santé, Paris XIII University, Bobigny, France
- Groupe Pédiatrie, Société Française de Pharmacie Clinique, Paris, France
| | - Sonia Prot-Labarthe
- Department of Pharmacy, AP-HP, Robert-Debré Hospital, Paris, France
- UMR-S1123, ECEVE; Inserm U1123, INSERM, Paris, Île-de-France, France
- Groupe Pédiatrie, Société Française de Pharmacie Clinique, Paris, France
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Zhang L, Lasmar LB, Castro-Rodriguez JA. The impact of asthma and its treatment on growth: an evidence-based review. J Pediatr (Rio J) 2019; 95 Suppl 1:10-22. [PMID: 30472355 DOI: 10.1016/j.jped.2018.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess the impact of asthma and its treatment (inhaled corticosteroids and other control medications) on growth. DATA SOURCES The authors searched PubMed (up to August 24, 2018) and screened the reference lists of retrieved articles. Systematic reviews and meta-analysis were selected. If there was no such article, the authors selected either randomized clinical trials or observational studies. DATA SYNTHESIS A total of 37 articles were included in this review. The findings from 21 studies suggest that asthma per se, especially more severe and/or uncontrolled cases, can transitorily impair child's growth. Two Cochrane reviews of randomized clinical trials showed a small mean reduction in linear growth (-0.91cm/year for beclomethasone, -0.59cm/year for budesonide, and -0.39cm/year for fluticasone) in the first year of treatment with inhaled corticosteroids in prepubertal children with persistent asthma. The effects were likely to be molecule- and dose-dependent. A recent review showed that most of "real-life" observational studies had not found significant effects of inhaled corticosteroids on growth in asthmatic children. Fifteen studies showed that the maintenance systemic corticosteroids could cause a dose-dependent growth suppression in children with severe asthma, but other controllers (cromones, montelukast, salmeterol, and theophylline) had no significant adverse effects no growth. CONCLUSIONS Severe and/or uncontrolled asthma can transitorily impair child's growth. Regular use of inhaled corticosteroids may cause a small reduction in linear growth in children with asthma, but the well-established benefits of inhaled corticosteroids in controlling asthma outweigh the potential adverse effects on growth. Use of the minimally effective dose of inhaled corticosteroids and regular monitoring of child's height during inhaled corticosteroids therapy are recommended.
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Affiliation(s)
- Linjie Zhang
- Universidade Federal do Rio Grande, Faculdade de Medicina, Programa de Pós-Graduação em Ciências da Saúde e Programa de Pós-Graduação em Saúde Pública, Rio Grande, RS, Brazil.
| | - Laura Belizario Lasmar
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Divisão de Pediatria, Unidade de Pneumologia Pediátrica, Belo Horizonte, MG, Brazil
| | - Jose A Castro-Rodriguez
- Pontificia Universidad Católica de Chile, Facultad de Medicina, División de Pediatría, Unidad de Neumología Pediátrica, Santiago, Chile
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