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Huang W, Schinasi LH, Kenyon CC, Auchincloss AH, Moore K, Melly S, Robinson LF, Forrest CB, De Roos AJ. Do respiratory virus infections modify associations of asthma exacerbation with aeroallergens or fine particulate matter? A time series study in Philadelphia PA. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2024:1-12. [PMID: 38164931 DOI: 10.1080/09603123.2023.2299249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
Respiratory virus infections are related to over 80% of childhood asthma exacerbations. They enhance pro-inflammatory mediator release, especially for sensitized individuals exposed to pollens/molds. Using a time-series study design, we investigated possible effect modification by respiratory virus infections of the associations between aeroallergens/PM2.5 and asthma exacerbation rates. Outpatient, emergency department (ED), and inpatient visits for asthma exacerbation among children with asthma (28,540/24,444 [warm/cold season]), as well as viral infection counts were obtained from electronic health records of the Children's Hospital of Philadelphia from 2011 to 2016. Rate ratios (RRs, 90th percentile vs. 0) for late-season grass pollen were 1.00 (0.85-1.17), 1.04 (0.95-1.15), and 1.12 (0.96-1.32), respectively, for respiratory syncytial virus (RSV) counts within each tertile. However, similar trends were not observed for weed pollens/molds or PM2.5. Overall, our study provides little evidence supporting effect modification by respiratory viral infections.
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Affiliation(s)
- Wanyu Huang
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Leah H Schinasi
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Chén C Kenyon
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amy H Auchincloss
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Kari Moore
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Steven Melly
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Lucy F Robinson
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Christopher B Forrest
- The Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anneclaire J De Roos
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
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Srivastava T, Shen AK, Browne S, Michel JJ, Tan ASL, Kornides ML. Comparing COVID-19 Vaccination Outcomes with Parental Values, Beliefs, Attitudes, and Hesitancy Status, 2021-2022. Vaccines (Basel) 2022; 10:vaccines10101632. [PMID: 36298497 PMCID: PMC9611997 DOI: 10.3390/vaccines10101632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Despite the availability of safe and effective COVID-19 vaccines, vaccine acceptance has been low, particularly among parents. More information is needed on parental decision-making. We conducted a prospective cohort study from October 2021 to March 2022 among 334 parents in a large urban/suburban pediatric primary care network and linked longitudinal survey responses about attitudes and beliefs on vaccination, social norms, and access to vaccination services for COVID-19 to electronic health-record-derived vaccination outcomes for their eldest age-eligible children in June 2022. The odds of accepting two doses of COVID-19 vaccine for their child was higher in respondents who indicated the COVID-19 vaccine would be very safe (aOR [CI]: 2.69 [1.47−4.99], p = 0.001), as well as those who previously vaccinated their child against influenza (aOR [CI]: 4.07 [2.08−8.12], p < 0.001). The odds of vaccinating their child were lower for respondents who attended suburban vs. urban practices (aOR [CI]: 0.38 [0.21−0.67], p = 0.001). Parents in the cohort were active users of social media; the majority (78%) used their phone to check social media platforms at least once per day. Our findings suggest that healthcare providers and policymakers can focus on improving vaccination coverage among children living in suburban neighborhoods through targeted mobile-based messaging emphasizing safety to their parents.
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Affiliation(s)
- Tuhina Srivastava
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard David Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Angela K. Shen
- Leonard David Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Vaccine Education Center, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Medical Bioethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Correspondence: ; Tel.: +1-(301)-467-7770
| | - Safa Browne
- Vaccine Education Center, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jeremy J. Michel
- General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- ECRI Guidelines Trust, ECRI, Plymouth Meeting, Philadelphia, PA 19462, USA
| | - Andy S. L. Tan
- Leonard David Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Melanie L. Kornides
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard David Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Pediatrics, Division of Adolescent Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Taquechel K, Diwadkar AR, Sayed S, Dudley JW, Grundmeier RW, Kenyon CC, Henrickson SE, Himes BE, Hill DA. Pediatric Asthma Health Care Utilization, Viral Testing, and Air Pollution Changes During the COVID-19 Pandemic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3378-3387.e11. [PMID: 32827728 PMCID: PMC7438361 DOI: 10.1016/j.jaip.2020.07.057] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 07/28/2020] [Accepted: 07/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic caused dramatic changes in daily routines and health care utilization and delivery patterns in the United States. Understanding the influence of these changes and associated public health interventions on asthma care is important to determine effects on patient outcomes and identify measures that will ensure optimal future health care delivery. OBJECTIVE We sought to identify changes in pediatric asthma-related health care utilization, respiratory viral testing, and air pollution during the COVID-19 pandemic. METHODS For the time period January 17 to May 17, 2015 to 2020, asthma-related encounters and weekly summaries of respiratory viral testing data were extracted from Children's Hospital of Philadelphia electronic health records, and pollution data for 4 criteria air pollutants were extracted from AirNow. Changes in encounter characteristics, viral testing patterns, and air pollution before and after Mar 17, 2020, the date public health interventions to limit viral transmission were enacted in Philadelphia, were assessed and compared with data from 2015 to 2019 as a historical reference. RESULTS After March 17, 2020, in-person asthma encounters decreased by 87% (outpatient) and 84% (emergency + inpatient). Video telemedicine, which was not previously available, became the most highly used asthma encounter modality (61% of all visits), and telephone encounters increased by 19%. Concurrently, asthma-related systemic steroid prescriptions and frequency of rhinovirus test positivity decreased, although air pollution levels did not substantially change, compared with historical trends. CONCLUSIONS The COVID-19 pandemic in Philadelphia was accompanied by changes in pediatric asthma health care delivery patterns, including reduced admissions and systemic steroid prescriptions. Reduced rhinovirus infections may have contributed to these patterns.
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Affiliation(s)
- Kiara Taquechel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Avantika R Diwadkar
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Samir Sayed
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jesse W Dudley
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Chén C Kenyon
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Center for Pediatric Clinical Effectiveness and PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Sarah E Henrickson
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Blanca E Himes
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - David A Hill
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
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Gabryszewski SJ, Chang X, Dudley JW, Mentch F, March M, Holmes JH, Moore J, Grundmeier RW, Hakonarson H, Hill DA. Unsupervised modeling and genome-wide association identify novel features of allergic march trajectories. J Allergy Clin Immunol 2020; 147:677-685.e10. [PMID: 32650023 DOI: 10.1016/j.jaci.2020.06.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/07/2020] [Accepted: 06/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The allergic march refers to the natural history of allergic conditions during infancy and childhood. However, population-level disease incidence patterns do not necessarily reflect the development of allergic disease in individuals. A better understanding of the factors that predispose to different allergic trajectories is needed. OBJECTIVE Our aim was to determine the demographic and genetic features that are associated with the major allergic march trajectories. METHODS Presence or absence of common allergic conditions (atopic dermatitis [AD], IgE-mediated food allergy [IgE-FA], asthma, and allergic rhinitis [AR]) was ascertained in a pediatric primary care birth cohort of 158,510 subjects. Hierarchic clustering and decision tree modeling were used to associate demographic features with allergic outcomes. Genome-wide association study was used to test for risk loci associated with specific allergic trajectories. RESULTS We found an association between self-identified black race and progression from AD to asthma. Conversely, Asian or Pacific Islander race was associated with progression from AD to IgE-mediated food allergy, and white race was associated with progression from AD to AR. Genome-wide association study of trajectory groups identified risk loci associated with progression from AD to asthma (rs60242841) and from AD to AR (rs9565267, rs151041509, and rs78171803). Consistent with our epidemiologic associations, rs60242841 was more common in individuals of African ancestry than in individuals of European ancestry, whereas rs9565267 and rs151041509 were more common in individuals of European ancestry than in individuals of African ancestry. CONCLUSION We have identified novel associations between race and progression along distinct allergic trajectories. Ancestral genetic differences may contribute to these associations. These results uncover important health disparities, refine the concept of the allergic march, and represent a step toward developing individualized medical approaches for these conditions.
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Affiliation(s)
| | - Xiao Chang
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jesse W Dudley
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Frank Mentch
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Michael March
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - John H Holmes
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Jason Moore
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - David A Hill
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
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Hill DA, Grundmeier RW, Ramos M, Spergel JM. Eosinophilic Esophagitis Is a Late Manifestation of the Allergic March. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1528-1533. [PMID: 29954692 DOI: 10.1016/j.jaip.2018.05.010] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/08/2018] [Accepted: 05/14/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The allergic march describes the natural history of allergic conditions as they develop during childhood. Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease that can be triggered by specific foods. Despite its allergic pathophysiology, the epidemiologic relationship between EoE and established members of the allergic march is unknown. OBJECTIVE We sought to determine whether EoE meets epidemiologic criteria for being considered a member of the allergic march. METHODS Using a primary care birth cohort of 130,435 children, we determined the natural histories of atopic dermatitis (AD), IgE-mediated food allergy (IgE-FA), asthma, EoE, and allergic rhinitis (AR) in individual patients. We then performed case-control analyses to establish the extent that existing allergic conditions influence the rate of subsequent EoE diagnosis. RESULTS A total of 139 children developed EoE during the observation period (prevalence of 0.11%). The peak age of EoE diagnosis was 2.6 years, as compared with 0.3 years, 1 year, 1.1 years, and 2.1 years for AD, IgE-FA, asthma, and AR, respectively. The presence of AD (hazard ratio [HR] 3.2, 95% confidence interval [CI] 2.2-4.6), IgE-FA (HR 9.1, 95% CI 6.5-12.6), and asthma (HR 1.9, 95% CI 1.3-2.7) was independently and cumulatively associated with subsequent EoE diagnosis. The presence of AR was associated with subsequent EoE diagnosis (HR 2.8, 95% CI 2.0-3.9), and the presence of EoE was associated with subsequent AR diagnosis (HR 2.5, 95% CI 1.7-3.5). CONCLUSIONS Allergic comorbidities are positively associated with EoE diagnosis. Together, our findings suggest that EoE is a late manifestation of the allergic march.
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Affiliation(s)
- David A Hill
- Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Mark Ramos
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jonathan M Spergel
- Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Department of Pediatrics, Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
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Pennington JW, Karavite DJ, Krause EM, Miller J, Bernhardt BA, Grundmeier RW. Genomic decision support needs in pediatric primary care. J Am Med Inform Assoc 2017; 24:851-856. [PMID: 28339689 PMCID: PMC7651914 DOI: 10.1093/jamia/ocw184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/31/2016] [Accepted: 12/23/2016] [Indexed: 11/12/2022] Open
Abstract
Clinical genome and exome sequencing can diagnose pediatric patients with complex conditions that often require follow-up care with multiple specialties. The American Academy of Pediatrics emphasizes the role of the medical home and the primary care pediatrician in coordinating care for patients who need multidisciplinary support. In addition, the electronic health record (EHR) with embedded clinical decision support is recognized as an important component in providing care in this setting. We interviewed 6 clinicians to assess their experience caring for patients with complex and rare genetic findings and hear their opinions about how the EHR currently supports this role. Using these results, we designed a candidate EHR clinical decision support application mock-up and conducted formative exploratory user testing with 26 pediatric primary care providers to capture opinions on its utility in practice with respect to a specific clinical scenario. Our results indicate agreement that the functionality represented by the mock-up would effectively assist with care and warrants further development.
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Affiliation(s)
- Jeffrey W Pennington
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dean J Karavite
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward M Krause
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey Miller
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Barbara A Bernhardt
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Hill DA, Grundmeier RW, Ram G, Spergel JM. The epidemiologic characteristics of healthcare provider-diagnosed eczema, asthma, allergic rhinitis, and food allergy in children: a retrospective cohort study. BMC Pediatr 2016; 16:133. [PMID: 27542726 PMCID: PMC4992234 DOI: 10.1186/s12887-016-0673-z] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 08/10/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The rates of childhood allergic conditions are changing, prompting the need for continued surveillance. Examination of healthcare provider-based diagnosis data is an important and lacking methodology needed to complement existing studies that rely on participant reporting. METHODS Utilizing our care network of 1,050,061 urban and sub-urban children, we defined two retrospective cohorts: (1) a closed birth cohort of 29,662 children and (2) a cross-sectional cohort of 333,200 children. These cohorts were utilized to determine the epidemiologic characteristics of the conditions studied. Logistic regression was utilized to determine the extent to which food allergy was associated with respiratory allergy. RESULTS In our birth cohort, the peak age at diagnosis of eczema, asthma, rhinitis, and food allergy was between 0 and 5 months (7.3 %), 12 and 17 months (8.7 %), 24 and 29 months (2.5 %), and 12 and 17 months (1.9 %), respectively. In our cross-sectional cohort, eczema and rhinitis prevalence rates were 6.7 % and 19.9 %, respectively. Asthma prevalence was 21.8 %, a rate higher than previously reported. Food allergy prevalence was 6.7 %, with the most common allergenic foods being peanut (2.6 %), milk (2.2 %), egg (1.8 %), shellfish (1.5 %), and soy (0.7 %). Food allergy was associated with development of asthma (OR 2.16, 95 % CI 1.94-2.40), and rhinitis (OR 2.72, 95 % CI 2.45-3.03). CONCLUSIONS Compared with previous reports, we measure lower rates of eczema and higher rates of asthma. The distribution of the major allergenic foods diverged from prior figures, and food allergy was associated with the development of respiratory allergy. The utilization of provider-based diagnosis data contributes an important and lacking methodology that complements existing studies.
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Affiliation(s)
- David A Hill
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Division of Allergy and Immunology, The Children's Hospital of Philadelphia, 3550 Market St., Philadelphia, PA, 19104, USA. .,Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Robert W Grundmeier
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gita Ram
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Allergy and Immunology, The Children's Hospital of Philadelphia, 3550 Market St., Philadelphia, PA, 19104, USA
| | - Jonathan M Spergel
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Allergy and Immunology, The Children's Hospital of Philadelphia, 3550 Market St., Philadelphia, PA, 19104, USA.,Institute for Immunology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Horton DB, Strom BL, Putt ME, Rose CD, Sherry DD, Sammons JS. Epidemiology of Clostridium difficile Infection-Associated Reactive Arthritis in Children: An Underdiagnosed, Potentially Morbid Condition. JAMA Pediatr 2016; 170:e160217. [PMID: 27182697 PMCID: PMC5069192 DOI: 10.1001/jamapediatrics.2016.0217] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE The incidence of Clostridium difficile infection has increased among children. The epidemiology of pediatric C difficile infection-associated reactive arthritis is poorly understood. OBJECTIVE To characterize the incidence, recognition, and distinguishing clinical features of pediatric C difficile infection-associated reactive arthritis among children with C difficile infection. DESIGN, SETTING, AND PARTICIPANTS In this cohort and nested case-control study using electronic health records from January 1, 2004, to December 31, 2013, across 3 geographically diverse pediatric health care networks, we screened for reactive arthritis among 148 children between ages 2 and 21 years with diagnostic or procedural codes suggesting musculoskeletal disease associated with C difficile diagnosis or positive testing. We identified 26 cases with acute arthritis or tenosynovitis within 4 weeks before to 12 weeks after confirmed C difficile infection with (1) no alternative explanation for arthritis and (2) negative synovial cultures (if obtained). Network-matched C difficile-infected controls without arthritis were randomly selected at the time of cohort member C difficile infections. MAIN OUTCOMES AND MEASURES Incidence of C difficile infection-associated reactive arthritis was calculated based on (1) pediatric source population and (2) children with C difficile infection. Characteristics of cases and controls were compared using conditional logistic regression. RESULTS Based on the cases identified within the source population of the 3 hospital networks, we estimated that C difficile infection-associated reactive arthritis incidence was 5.0 cases per million person-years (95% CI, 3.0-7.8). Reactive arthritis affected 1.4% of children with C difficile infection yearly (95% CI 0.8%-2.3%). Joint symptoms began a median of 10.5 days after initial gastrointestinal symptoms, often accompanied by fever (n = 15 [58%]) or rash (n = 14 [54%]). Only 35% of cases of C difficile infection-associated reactive arthritis were correctly diagnosed by treating health care professionals (range across centers, 0%-64%). Five affected children (19%) were treated for presumed culture-negative septic hip arthritis despite having prior postantibiotic diarrhea and/or other involved joints. Compared with controls, cases of C difficile infection-associated reactive arthritis were less likely to have underlying chronic conditions (odds ratio [OR], 0.3; 95% CI, 0.1-0.8). Although all cases had community-onset C difficile infection and fewer comorbidities, they were more likely to be treated in emergency departments and/or hospitalized (OR, 7.1; 95% CI, 1.6-31.7). CONCLUSIONS AND RELEVANCE C difficile infection-associated reactive arthritis is an underdiagnosed, potentially morbid reactive arthritis associated with C difficile infection occasionally misdiagnosed as septic arthritis. Given the rising incidence of pediatric C difficile infections, better recognition of its associated reactive arthritis is needed.
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Affiliation(s)
- Daniel B. Horton
- Rutgers Biomedical and Health Sciences, New Brunswick, NJ,Pediatrics, Nemours A.I. duPont Hospital for Children, Division of Pediatric Rheumatology, Wilmington, DE,Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Brian L. Strom
- Rutgers Biomedical and Health Sciences, New Brunswick, NJ,Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mary E. Putt
- Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Carlos D. Rose
- Pediatrics, Nemours A.I. duPont Hospital for Children, Division of Pediatric Rheumatology, Wilmington, DE
| | - David D. Sherry
- Pediatrics, Children's Hospital of Philadelphia, Division of Pediatric Rheumatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Julia S. Sammons
- Pediatrics, Infection Prevention and Control, Division of Infectious Diseases, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Arbogast KB, Curry AE, Pfeiffer MR, Zonfrillo MR, Haarbauer-Krupa J, Breiding MJ, Coronado VG, Master CL. Point of Health Care Entry for Youth With Concussion Within a Large Pediatric Care Network. JAMA Pediatr 2016; 170:e160294. [PMID: 27244368 PMCID: PMC6025897 DOI: 10.1001/jamapediatrics.2016.0294] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Previous epidemiologic research on concussions has primarily been limited to patient populations presenting to sport concussion clinics or to emergency departments (EDs) and to those high school age or older. By examining concussion visits across an entire pediatric health care network, a better estimate of the scope of the problem can be obtained. OBJECTIVE To comprehensively describe point of entry for children with concussion, overall and by relevant factors including age, sex, race/ethnicity, and payor, to quantify where children initially seek care for this injury. DESIGN, SETTING, AND PARTICIPANTS In this descriptive epidemiologic study, data were collected from primary care, specialty care, ED, urgent care, and inpatient settings. The initial concussion-related visit was selected and variation in the initial health care location (primary care, specialty care, ED, or hospital) was examined in relation to relevant variables. All patients aged 0 to 17 years who received their primary care from The Children's Hospital of Philadelphia's (CHOP) network and had 1 or more in-person clinical visits for concussion in the CHOP unified electronic health record (EHR) system (July 1, 2010, to June 30, 2014) were selected. MAIN OUTCOMES AND MEASURES Frequency of initial concussion visits at each type of health care location. Concussion visits in the EHR were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicative of concussion. RESULTS A total of 8083 patients were included (median age, 13 years; interquartile range, 10-15 years). Overall, 81.9% (95% CI, 81.1%-82.8%; n = 6624) had their first visit at CHOP within primary care, 5.2% (95% CI, 4.7%-5.7%; n = 418) within specialty care, and 11.7% (95% CI, 11.0%-12.4%; n = 947) within the ED. Health care entry varied by age: 52% (191/368) of children aged 0 to 4 years entered CHOP via the ED, whereas more than three-quarters of those aged 5 to 17 years entered via primary care (5-11 years: 1995/2492; 12-14 years: 2415/2820; and 15-17 years: 2056/2403). Insurance status also influenced the pattern of health care use, with more Medicaid patients using the ED for concussion care (478/1290 Medicaid patients [37%] used the ED vs 435/6652 private patients [7%] and 34/141 self-pay patients [24%]). CONCLUSIONS AND RELEVANCE The findings suggest estimates of concussion incidence based solely on ED visits underestimate the burden of injury, highlight the importance of the primary care setting in concussion care management, and demonstrate the potential for EHR systems to advance research in this area.
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Affiliation(s)
- Kristy B. Arbogast
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania2University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Allison E. Curry
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melissa R. Pfeiffer
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mark R. Zonfrillo
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania2University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Juliet Haarbauer-Krupa
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew J. Breiding
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Victor G. Coronado
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christina L. Master
- University of Pennsylvania Perelman School of Medicine, Philadelphia4Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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