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Grochowska M, Strzelak A, Krenke K. Complicated pneumonia caused by group A Streptococcus in children - 2022/2023 infectious season outbreak and update on clinical characteristics. J Infect Chemother 2024; 30:1047-1053. [PMID: 38631479 DOI: 10.1016/j.jiac.2024.04.006] [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: 12/15/2023] [Revised: 04/05/2024] [Accepted: 04/11/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND An increased incidence of group A Streptococcus (GAS) infections has been observed in pediatric population post-COVID-19 pandemic. While the majority of reports refer to scarlet fever or invasive GAS disease, detailed data on pulmonary manifestations such as complicated community-acquired pneumonia (CAP) are scarce. The aim of this study was to assess the contribution of GAS to complicated CAP in children during the 2022/2023 infectious season. METHODS We retrospectively analyzed the etiology and clinical presentation of complicated CAP patients hospitalized in our tertiary care center in Warsaw, Poland, between August 2022 and May 2023. RESULTS Among 91 patients with complicated CAP, GAS was the dominant cause constituting 24.2% (22/91; 95% CI 15.8-34.3%) of the study group. 68.2% of GAS pneumonia patients presented symptoms of scarlet fever, and 27.3% had preceding or concurrent viral infection. GAS complicated CAP was associated with longer hospitalization, higher incidence of chest tube insertion, but shorter duration of chest tube drainage than complicated CAP of other etiology. Children with GAS complicated CAP had higher procalcitonin concentration (28.1 vs. 1.5 ng/dL; p<0.0001) and a lower platelets level (254.5 vs. 422 × 103/μL; p = 0.0031) than those with non-GAS infection. CONCLUSIONS GAS is currently the predominant pathogen of complicated CAP in children. Clinicians should be aware of the current epidemiological situation and a more severe course of GAS pneumonia in this age group, and should monitor patients presenting with symptoms of scarlet fever and preceding viral infection closely.
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Affiliation(s)
- Magdalena Grochowska
- Department of Pediatric Pulmonology and Allergy, Medical University of Warsaw, Warsaw, Poland; Doctoral School, Medical University of Warsaw, Warsaw, Poland.
| | - Agnieszka Strzelak
- Department of Pediatric Pulmonology and Allergy, Medical University of Warsaw, Warsaw, Poland.
| | - Katarzyna Krenke
- Department of Pediatric Pulmonology and Allergy, Medical University of Warsaw, Warsaw, Poland.
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Cotter JM, Hall M, Neuman MI, Blaschke AJ, Brogan TV, Cogen JD, Gerber JS, Hersh AL, Lipsett SC, Shapiro DJ, Ambroggio L. Antibiotic route and outcomes for children hospitalized with pneumonia. J Hosp Med 2024; 19:693-701. [PMID: 38678444 PMCID: PMC11332399 DOI: 10.1002/jhm.13382] [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: 01/18/2024] [Revised: 04/06/2024] [Accepted: 04/18/2024] [Indexed: 04/30/2024]
Abstract
BACKGROUND Emerging evidence suggests that initial oral and intravenous (IV) antibiotics have similar efficacy in pediatric community-acquired pneumonia (CAP), but further data are needed. OBJECTIVE We determined the association between hospital-level initial oral antibiotic rates and outcomes in pediatric CAP. DESIGNS, SETTINGS, AND PARTICIPANTS This retrospective cohort study included children hospitalized with CAP at 43 hospitals in the Pediatric Health Information System (2016-2022). Hospitals were grouped by whether initial antibiotics were given orally in a high, moderate, or low proportion of patients. MAIN OUTCOME AND MEASURES Regression models examined associations between high versus low oral-utilizing hospitals and length of stay (LOS, primary outcome), intensive care unit (ICU) transfers, escalated respiratory care, complicated CAP, cost, readmissions, and emergency department (ED) revisits. RESULTS Initial oral antibiotics were used in 16% (interquartile range: 10%-20%) of 30,207 encounters, ranging from 1% to 68% across hospitals. Comparing high versus low oral-utilizing hospitals (oral rate: 32% [27%-47%] and 10% [9%-11%], respectively), there were no differences in LOS, intensive care unit, complicated CAP, cost, or ED revisits. Escalated respiratory care occurred in 1.3% and 0.5% of high and low oral-utilizing hospitals, respectively (relative ratio [RR]: 2.96 [1.12, 7.81]), and readmissions occurred in 1.5% and 0.8% (RR: 1.68 [1.31, 2.17]). Initial oral antibiotics varied across hospitals without a difference in LOS. While high oral-utilizing hospitals had higher escalated respiratory care and readmission rates, these were rare, the clinical significance of these small differences is uncertain, and there were no differences in other clinically relevant outcomes. This suggests some children may benefit from initial IV antibiotics, but most would probably do well with oral antibiotics.
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Affiliation(s)
- Jillian M. Cotter
- Section of Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | | | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
| | - Anne J. Blaschke
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Thomas V. Brogan
- Division of Critical Care, Seattle Children’s Hospital, Seattle, WA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Jonathan D. Cogen
- Division of Pulmonary Medicine and Sleep Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA
| | - Jeffrey S. Gerber
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam L. Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Susan C. Lipsett
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
| | - Daniel J. Shapiro
- Division of Pediatric Emergency Medicine, University of California, San Francisco, San Francisco, CA
| | - Lilliam Ambroggio
- Section of Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
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Geanacopoulos AT, Amirault JP, Michelson KA, Monuteaux MC, Lipsett SC, Hirsch AW, Neuman MI. Community-Acquired Pneumonia Diagnosis Following Emergency Department Visits for Respiratory Illness. Clin Pediatr (Phila) 2024:99228241254153. [PMID: 38757645 DOI: 10.1177/00099228241254153] [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] [Indexed: 05/18/2024]
Abstract
Community-acquired pneumonia (CAP) is often considered for children presenting to the emergency department (ED) with respiratory symptoms. It is unclear how often children are diagnosed with CAP following an ED visit for respiratory illness. We performed a retrospective case-control study to evaluate 7-day CAP diagnosis among children 3 months to 18 years discharged from the ED with respiratory illness from 2011 to 2021 and who receive care at 4 hospital-affiliated primary care clinics. Logistic regression was performed to assess for predictors of 7-day CAP diagnosis. Seventy-four (0.7%, 95% confidence interval [CI] = 0.6%, 0.9%) of 10 329 children were diagnosed with CAP within 7 days, and fever at the index visit was associated with increased odds of diagnosis (odds ratio [OR] = 3.32, 95% CI = 1.75-6.28). Community-acquired pneumonia diagnosis after discharge from the ED with respiratory illness is rare, even among children who are febrile at time of initial evaluation.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Janine P Amirault
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Kenneth A Michelson
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michael C Monuteaux
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Susan C Lipsett
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Alexander W Hirsch
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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Amirault JP, Porter JJ, Hirsch AW, Lipsett SC, Neuman MI. Diagnosis and Management of Pneumonia in Infants Less Than 90 Days of Age. Hosp Pediatr 2023; 13:694-707. [PMID: 37492932 DOI: 10.1542/hpeds.2022-007062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Current guidelines and recent studies on pediatric pneumonia pertain to children older than 3 months of age. Little information exists regarding the diagnostic evaluation, management, and outcomes of infants less than 90 days with pneumonia. METHODS We compared infants <90 days of age diagnosed with pneumonia across 38 US children's hospitals from 2016 to 2021 to children 90 days to 5 years of age. We evaluated whether differences exist in patient characteristics, diagnostic testing, antibiotic treatment, and outcomes between young infants and older children. Additionally, we assessed seasonal variability and trends over time in pneumonia diagnoses by age group. RESULTS Among 109 796 children diagnosed with pneumonia, 3128 (2.8%) were <90 days of age. Compared with older children, infants <90 days had more laboratory testing performed (88.6% vs 48.8%, P < .001; median number of laboratory tests 4 [interquartile range: 2-5] vs 0 [interquartile range: 0-3] respectively), with wide variation in testing across hospitals. Chest radiograph utilization did not differ by age group. Infants <90 days were more likely to be hospitalized and require respiratory support than older children. Seasonal variation was observed for pneumonia encounters in both age groups. CONCLUSIONS Infants <90 days with pneumonia were more likely to undergo laboratory testing, be hospitalized, and require respiratory support than children 90 days to 5 years of age. This may reflect inherent differences in the pathophysiology of pneumonia by age, the manner in which pneumonia is diagnosed, or possible overuse of testing in infants.
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Affiliation(s)
- Janine P Amirault
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Alexander W Hirsch
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Su W, Ju L, Hua Q, Hu J, Qian W. Values of combined C-reactive protein, procalcitonin and serum amyloid A in differential diagnosis of bacterial and non-bacterial community acquired pneumonia in children. Diagn Microbiol Infect Dis 2023; 105:115865. [PMID: 36521211 DOI: 10.1016/j.diagmicrobio.2022.115865] [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: 09/14/2022] [Revised: 10/25/2022] [Accepted: 11/19/2022] [Indexed: 11/26/2022]
Abstract
This research aimed to explore the clinical value of C-reactive protein (CRP), procalcitonin (PCT), and serum amyloid A (SAA) in early diagnosis of bacterial pneumonia. CRP, PCT, and SAA levels of children with bacterial pneumonia, children with non-bacterial pneumonia, and healthy children were compared. The sensitivity and specificity of CRP, PCT, and SAA in the diagnosis of bacterial pneumonia in children were compared. CRP, PCT, and SAA levels were significantly lower in healthy children when compared with children with Community acquired pneumonia (CAP). ROC analyses showed that CRP, PCT, and SAA all had good accuracy in distinguishing bacterial pneumonia from non-bacterial pneumonia. The combination of CRP, PCT, and SAA further enhanced the accuracy in distinguishing bacterial pneumonia from non-bacterial pneumonia. In conclusion, the expression levels of CRP, PCT, and SAA could indicate the status of bacterial pneumonia. The combined test of CRP, PCT, and SAA had the highest diagnostic accuracy.
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Affiliation(s)
- Weiwei Su
- Department of Pediatric Cardiology, the Affiliated Wuxi Children's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Liang Ju
- Department of Pediatric Cardiology, the Affiliated Wuxi Children's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Qi Hua
- Department of Pediatric Cardiology, the Affiliated Wuxi Children's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Jing Hu
- Department of Pediatric Cardiology, the Affiliated Wuxi Children's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China
| | - Wei Qian
- Department of Pediatric Cardiology, the Affiliated Wuxi Children's Hospital of Nanjing Medical University, Wuxi, Jiangsu, China.
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Ramgopal S, Lorenz D, Ambroggio L, Navanandan N, Cotter JM, Florin TA. Identifying Potentially Unnecessary Hospitalizations in Children With Pneumonia. Hosp Pediatr 2022; 12:788-806. [PMID: 36000331 PMCID: PMC11315224 DOI: 10.1542/hpeds.2022-006608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To characterize the outcomes of children with community acquired pneumonia (CAP) across 41 United States hospitals and evaluate factors associated with potentially unnecessary admissions. METHODS We performed a cross-sectional study of patients with CAP from 41 United States pediatric hospitals and evaluated clinical outcomes using a composite ordinal severity outcome: mild-discharged (discharged from the emergency department), mild-admitted (hospitalized without other interventions), moderate (provision of intravenous fluids, supplemental oxygen, broadening of antibiotics, complicated pneumonia, and presumed sepsis) or severe (ICU, positive-pressure ventilation, vasoactive infusion, chest drainage, extracorporeal membrane oxygenation, severe sepsis, or death). Our primary outcome was potentially unnecessary admissions (ie, mild-admitted). Among mild-discharged and mild-admitted patients, we constructed a generalized linear mixed model for mild-admitted severity and assessed the role of fixed (demographics and clinical testing) and random effects (institution) on this outcome. RESULTS Of 125 180 children, 68.3% were classified as mild-discharged, 6.6% as mild-admitted, 20.6% as moderate and 4.5% as severe. Among admitted patients (n = 39 692), 8321 (21%) were in the mild-admitted group, with substantial variability in this group across hospitals (median 19.1%, interquartile range 12.8%-28.4%). In generalized linear mixed models comparing mild-admitted and mild-discharge severity groups, hospital had the greatest contribution to model variability compared to all other variables. CONCLUSIONS One in 5 hospitalized children with CAP do not receive significant interventions. Among patients with mild disease, institutional variation is the most important contributor to predict potentially unnecessary admissions. Improved prognostic tools are needed to reduce potentially unnecessary hospitalization of children with CAP.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky
| | - Lilliam Ambroggio
- Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Jillian M. Cotter
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Todd A. Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Efficacy of Gamma Globulin Combined with Azithromycin Sequential Therapy in the Treatment of RMPP and Its Effect on Th1/Th2 Cytokine Levels. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5162768. [PMID: 35912143 PMCID: PMC9329005 DOI: 10.1155/2022/5162768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 11/27/2022]
Abstract
Objective To investigate the efficacy of gamma globulin combined with azithromycin sequential therapy in the treatment of children with refractory mycoplasma pneumonia and its effect on Th1/Th2 cytokine levels. Method From January 2021 to January 2022, 100 children diagnosed with refractory mycoplasma pneumonia were randomly divided into 2 groups (50 cases in each one), the control group was treated with azithromycin plus comprehensive basic treatment, and the treatment group was treated with combined treatment on the basis of the control group, gamma globulin therapy; the treatment effect and cytokine levels of the two groups were compared. Results Th1, Th2, and Th1/Th2 before treatment were not significantly different between the two groups. Th1, Th2, and Th1/Th2 in the treatment group were significantly downregulated compared with those in the control group after treatment. The levels of IgG, IgA, and IgM in the treatment group were not significantly different from those in the control group before treatment but were significantly upregulated after treatment. IL-10, IL-6, and IL-2 levels were also significantly increased in the treatment group. The disappearance time of clinical symptoms such as fever, cough, and pulmonary rales in the treatment group was significantly shorter than that in the control group, and the cure rate in the treatment group was significantly better than that in the control group. Conclusion The clinical effect of gamma globulin combined with azithromycin sequential therapy in the treatment of children with refractory mycoplasma pneumonia is remarkable, which can reduce inflammatory factors, improve patients' immunity, and promote disease recovery.
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Disease Severity and Risk Factors of 30-Day Hospital Readmission in Pediatric Hospitalizations for Pneumonia. J Clin Med 2022; 11:jcm11051185. [PMID: 35268277 PMCID: PMC8911283 DOI: 10.3390/jcm11051185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 02/04/2023] Open
Abstract
Pneumonia is the leading cause of hospitalization in pediatric patients. Disease severity greatly influences pneumonia progression and adverse health outcomes such as hospital readmission. Hospital readmissions have become a measure of healthcare quality to reduce excess expenditures. The aim of this study was to examine 30-day all-cause readmission rates and evaluate the association between pneumonia severity and readmission among pediatric pneumonia hospitalizations. Using 2018 Nationwide Readmissions Database (NRD), we conducted a cross-sectional study of pediatric hospitalizations for pneumonia. Pneumonia severity was defined by the presence of respiratory failure, sepsis, mechanical ventilation, dependence on long-term supplemental oxygen, and/or respiratory intubation. Outcomes of interest were 30-day all-cause readmission, length of stay, and cost. The rate of 30-day readmission for the total sample was 5.9%, 4.7% for non-severe pneumonia, and 8.7% for severe pneumonia (p < 0.01). Among those who were readmitted, hospitalizations for severe pneumonia had a longer length of stay (6.5 vs. 5.4 days, p < 0.01) and higher daily cost (USD 3246 vs. USD 2679, p < 0.01) than admissions for non-severe pneumonia. Factors associated with 30-day readmission were pneumonia severity, immunosuppressive conditions, length of stay, and hospital case volume. To reduce potentially preventable readmissions, clinical interventions to improve the disease course and hospital system interventions are necessary.
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Markham JL, Hackman S, Hall M, Burns A, Goldman JL. Inpatient outcomes for children receiving empiric methicillin-resistant Staphylococcus aureus coverage for complicated pneumonia. J Hosp Med 2022; 17:36-41. [PMID: 35504578 DOI: 10.1002/jhm.2736] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/22/2021] [Accepted: 12/09/2021] [Indexed: 11/07/2022]
Abstract
Rigorous evidence for antibiotic management of pediatric complicated pneumonia is lacking, likely contributing to variation in empiric antibiotic(s). Using the Pediatric Health Information System database, we sought to describe use and clinical outcomes of children hospitalized with complicated pneumonia who received empiric antibiotic regimens with and without methicillin-resistant Staphylococcus aureus (MRSA) coverage. We evaluated empiric antibiotic selection on Day 0-1, grouping based on use of an antibiotic with or without MRSA coverage. We used generalized linear mixed effects models to examine the association of MRSA coverage and outcomes. Across 46 children's hospitals, 71.5% of children (N = 1279) received an empiric antibiotic regimen with MRSA coverage. In adjusted analyses, length of stay, need for repeat pleural drainage procedures, 7-day emergency department revisits and 7-day readmissions were similar between groups. Future prospective studies examining the need for MRSA coverage may assist in refining national treatment guidelines for complicated pneumonia in children.
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Sophia Hackman
- Department of Graduate Medical Education, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Alaina Burns
- Department of Pharmacy, Children's Mercy Kansas City, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri, USA
| | - Jennifer L Goldman
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
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