Corticosteroids may improve clinical outcomes during hospitalization for Henoch-Schönlein purpura

Clinical characteristics and risk factors of IgA vasculitis with intussusception and intestinal perforation

AIM

Intussusception is the most common surgical complication of IgA vasculitis (IgAV), and intestinal perforation is usually associated with intussusception. If they are not recognised and treated in a timely manner, serious consequences may occur. The objective is to summarise the clinical features of IgAV complicated by intussusception and intestinal perforation and explore its risk factors.

METHODS

The clinical data of 32 patients with IgAV complicated by surgical complications (25 cases of intussusception and 7 cases of intestinal perforation) were retrospectively analysed. A total of 160 IgAV children with gastrointestinal (GI) involvement but without surgical complications were randomly selected as a control group. Binary logistic regression analysis was performed to explore the risk factors for IgAV with intussusception and intestinal perforation.

RESULTS

Compared with the intussusception group, the intestinal perforation group had a significantly higher number of patients with GI symptoms prior to skin purpura and GI bleeding, a significantly higher number of days of abdominal pain, a significantly higher Wong-Baker score, and a significantly higher white blood cell count. Multivariate logistic regression analysis indicated that age ≤7 years, GI symptoms prior to skin purpura, abdominal pain intensity (Wong-Baker scale) and timing of glucocorticoid treatment were independent risk factors of IgAV with intussusception and intestinal perforation.

CONCLUSION

Age less than 7 years, severe abdominal pain, and GI symptoms prior to skin purpura were risk factors for IgAV with intussusception and intestinal perforation. Early use of glucocorticoids may prevent intussusception and intestinal perforation.

Does age at disease onset affect the clinical presentation and outcome in children with immunoglobulin A vasculitis?

Objectives

The study aimed to determine whether there is a relationship between the age at diagnosis and the clinical, laboratory, and prognostic features in pediatric immunoglobulin A vasculitis (IgAV) patients.

Patients and methods

In this study, 539 pediatric IgAV patients (298 males, 241 females; mean age: 7.74±3.36 years; range, 1 to 17.8 years) were retrospectively evaluated between January 2005 and July 2020. The relationship between clinical findings and age at diagnosis was analyzed by univariate logistic regression analysis. Factors associated with renal involvement, steroid-dependent or refractory disease, and recurrence were examined.

Results

The median age of diagnosis was 7.1 (1-17.8) years in all patients. At the time of admission, purpura, abdominal pain, and arthritis were the most common clinical findings. At the time of diagnosis, there was a positive association between age and purpura and an inverse association with the presence of arthritis. There were associations between renal involvement and age at diagnosis (odds ratio=1.22, 95% confidence interval 1.13-1.31, p<0.001), follow-up time (p<0.001), no history of previous infection (p<0.001), and presence of gastrointestinal (GI) involvement (p=0.003). Significant relationships were found between the age at diagnosis, follow-up time, GI involvement, renal involvement, scrotal involvement, the C-reactive protein value at the time of diagnosis, and the presence of steroid-dependent disease. An association was found between recurrence and GI involvement. All refractory patients had renal involvement. Age at diagnosis (p<0.001) and follow-up time (p<0.001) was found to be associated with refractory disease.

Conclusion

Age at diagnosis and follow-up time may be associated with renal involvement and refractory and steroid-dependent disease in IgAV. In addition, there may be a relationship between steroid-dependent disease and renal, GI, and scrotal involvement and between GI involvement and recurrence.

Delayed diagnosis of abdominal Henoch-Schonlein purpura in children: A case report

BACKGROUND

For children with abdominal Henoch-Schonlein purpura presenting abdominal pain as an initial symptom and severe clinical manifestations, but without purpura appearance on the skin, the diagnosis and treatment are relatively difficult. This study summarized the characteristics of this group of patients by literature review and provided additional references for further refinement of glucocorticoid therapy in this vasculitis.

CASE SUMMARY

A 6-year-old girl presented mainly with repeated abdominal pain and had received short-term out-of-hospital treatment with hydrocortisone. On day 7 after onset, gastroscopy revealed chronic non-atrophic gastritis and erosive duodenitis without purpuric rash, and no obvious resolution of the abdominal pain was found after treatment against infection and for protection of gastric mucosa. On day 14 the inflammatory indices continued to rise and the pain was relieved after enhanced anti-infective therapy, but without complete resolution. On day 19, the patient presented with aggravated abdominal pain with purplish-red dots on the lower limbs, by which Henoch-Schonlein purpura was confirmed. After 5 d of sequential treatment with methylprednisolone and prednisone, abdominal pain disappeared and she was discharged.

CONCLUSION

Henoch-Schonlein purpura-related rash may appear after long-term abdominal pain, and should be distinguished from acute and chronic gastrointestinal diseases at the early stage without typical rash. For bacterial infection-induced Henoch-Schonlein purpura, glucocorticoid therapy alone without clearing the infection may not relieve symptoms.

A case series on recurrent and persisting IgA vasculitis (Henoch Schonlein purpura) in children

BACKGROUND

IgA vasculitis (IgAV) is a small vessel vasculitis that is more common in childhood. Very limited evidence exists on patients who experience an atypical disease course. The aim of this study was to describe a cohort of children diagnosed with recurrent or persisting IgAV to identify any themes associated with their disease course and areas of unmet needs.

METHODS

A single centre retrospective study of children diagnosed with recurrent or persisting IgAV at Alder Hey Children's Hospital (Liverpool, UK). Clinical data, including features at presentation and during follow up, potential triggers, abnormal laboratory and histology results, treatment and outcome at last clinical review were retrospectively collected. Key themes were identified.

RESULTS

A total of 13 children met the inclusion criteria (recurrent disease, n = 4; persisting disease, n = 9). Median age at first presentation was 10.2 years [2.6-15.5], female:male ratio 1.2:1. Children in the atypical cohort were significantly older than a larger cohort of children who followed a non-complicated disease course (median age 5.5 years (range [0.6-16.7], p = 0.003)). All children re-presented with a purpuric rash (either recurring or persisting), accompanied by joint involvement in 92% of patients (12/13). Disease-modifying anti-rheumatic drugs (DMARDs) were used in 8/13 (62%) children. The median time from first presentation to diagnosis of atypical disease was 18.4 months [5.3-150.8] and the time from first presentation to treatment was 24.1 months [1.8-95.4]. Use of corticosteroids was significantly higher in children with renal involvement (p = 0.026). During follow up, 8/13 (62%) children were admitted at least once, whilst 10/13 (77%) had re-presented at least once to the emergency department. Five (38%) children were referred to psychology services and 7 (54%) children reported feelings of frustration.

CONCLUSIONS

This series describes some characteristics of a small cohort of children with atypical IgAV. It also identifies unmet needs in children with atypical IgAV, which includes delays in diagnosis and lengthy waits for treatment, lack of high-quality evidence regarding treatment choices and a high unrecognised disease burden. Further research is needed to study this subgroup of children as evidence is lacking.

Vasculitis and Kidney Disease

Pediatric vasculitis is a complex group of disorders that commonly presents with multisystem involvement. Renal vasculitis can be isolated to the kidneys or can occur as part of a broader multiorgan vasculitis. Depending on severity, renal vasculitis may present as acute glomerulonephritis (AGN) often associated with hypertension and sometimes with a rapidly deteriorating clinical course. Prompt diagnosis and initiation of therapy are key to preserving kidney function and preventing long-term morbidity and mortality. This review focuses on the clinical presentation, diagnosis, and treatment objectives for common forms of renal vasculitis seen in pediatric patients.

Dapsone for Refractory Gastrointestinal Symptoms in Children With Immunoglobulin A Vasculitis

Immunoglobulin A vasculitis (IgAV) is a systemic small-vessel vasculitis. Although corticosteroids (CS) are the primary treatment for gastrointestinal manifestations associated with IgAV, some patients develop refractory or recurrent symptoms such as vomiting and abdominal pain despite CS treatment. Dapsone, a synthetic sulfone antimicrobial, has been used to treat cutaneous purpura in IgAV, but few authors have reported its use for refractory gastrointestinal symptoms. In this retrospective observational study, we describe results in 7 children with IgAV who were treated with dapsone for abdominal pain resistant to CS. Dapsone rapidly relieved abdominal pain in all 7 patients, who then were tapered off CS without relapse. Side effects of mild methemoglobinemia and hemolysis appeared to be manageable with planned monitoring and dose adjustment; a single patient who discontinued dapsone had fatigue and hypoxia associated with methemoglobinemia. No side effects were life-threatening. Dapsone may be considered as a therapeutic option for gastrointestinal symptoms refractory to CS in children with IgAV.

Clinico-Epidemiological Profile and Outcome of Children with IgA Vasculitis in Aseer Region, Southwestern Saudi Arabia

Introduction: Immunoglobulin A (IgA) vasculitis is one of the most common forms of primary vasculitis in children; it typically has a benign course but can be aggressive and require intervention. Aim of the work: The aim of this retrospective study was to evaluate the epidemiological and clinical profile and treatment modalities used for children with IgA vasculitis in the southwestern region of Saudi Arabia. Material and Methods: We reviewed the medical records of 89 children admitted to Abha Maternity and Children Hospital in the southwestern region of Saudi Arabia from January 2016 to December 2020 with a confirmed diagnosis of IgA vasculitis according to the European League Against Rheumatism/Paediatric Rheumatology International Trials Organisation/Pediatric Rheumatology European Society criteria. Results: Eighty-nine children had a confirmed diagnosis of IgA vasculitis, with 50 boys (56.2%) and 39 girls (43.8%; male-to-female ratio of 1.28:1) and a mean age at diagnosis of 5.87 ± 2.81 years. The mean hospital stay duration was 5.66 ± 4.72 days. Infections preceded 29.2% of the cases, with upper respiratory tract infections comprising 24.7%. Approximately 31.5% of the cases were diagnosed in summer, followed by autumn in 28% of the cases. Rash was present in 100%, arthritis in 72.2%, gastrointestinal tract involvement in 60.7%, and renal involvement in 23.5% of cases. Thrombocytosis and leukocytosis were found in 35% and 46% of all cases, and 52.3% and 47.6.25% of cases with renal involvement, respectively (OR = 2.035, 95% CI: 0.75-5.52 and OR = 1.393, 95% CI: 0.522-1.716, respectively). Approximately 26% of cases experienced relapses. Treatment was conservative in 23.6%, oral prednisolone in 23.6%, and pulse steroid in 45% of cases. Abdominal pain with lower gastrointestinal tract bleeding was the primary indication for initiating pulse steroid treatment. Conclusions: There were similarities and differences in the epidemiology and frequency of clinical manifestations of patients with IgA vasculitis compared to previous studies. Children presenting with such epidemiological and clinical profile need to be closely monitored and long-term follow-up is recommended to improve the outcomes.

Focal Seizures and Posterior Reversible Encephalopathy Syndrome as Presenting Signs of IgA Vasculitis/Henoch-Schoenlein Purpura-An Educative Case and Systematic Review of the Literature

Background: IgA vasculitis/Henoch-Schoenlein purpura (IgAV/HSP) is a systemic small vessel vasculitis of unknown pathogenesis predominantly affecting children. While skin, GI tract, joints, and kidneys are frequently affected and considered, central nervous system (CNS) involvement of this disease is underestimated. Methods: We provide a case report and systematically review the literature on IgAV, collecting data on the spectrum of neurological manifestations. Results: We report on a 7-year-old girl with IgAV who presented with diplopia and afebrile focal seizures, which preceded the onset of purpura. Cranial magnetic resonance imaging was consistent with posterior reversible encephalopathy syndrome (PRES), showing typical focal bilateral parietal swelling and cortical and subcortical high signal intensities on T2-fluid attenuated inversion recovery (FLAIR) images predominantly without diffusion restriction. Cerebrospinal fluid analysis and blood tests excluded systemic inflammation or vasculitis. Interestingly, hypertension was not a hallmark of the developing disease in the initial phase of PRES manifestation. Renal disease and other secondary causes for PRES were also excluded. Supportive- and steroid treatment resulted in restitution ad integrum. Reviewing the literature, we identified 28 other cases of IgAV with CNS involvement. Severe CNS involvement includes seizures, cerebral edema, or hemorrhage, as well as PRES. Thirteen patients fulfilled all diagnostic criteria of PRES. The mean age was 11.2 years (median 8.0, range 5-42 years), with no reported bias toward gender or ethnic background. Treatment regimens varied from watchful waiting to oral and intravenously steroids up to plasmapheresis. Three cases showed permanent CNS impairment. Conclusion: Collectively, our data demonstrate that (I) severe CNS involvement such as PRES is an underappreciated feature of IgAV, (II) CNS symptoms may precede other features of IgAV, (III) PRES can occur in IgAV, and differentiation from CNS vasculitis is challenging, (IV) pathogenesis of PRES in the context of IgAV remains elusive, which hampers treatment decisions. We, therefore, conclude that clinical awareness and the collection of structured data are necessary to elucidate the pathophysiological connection of IgAV and PRES.

Recent Advances in Pediatric Vasculitis

This article provides an overview of the clinical presentation and diagnosis of select pediatric primary systemic vasculitides. Important advances in understanding the pathogenesis of these rare diseases also are discussed and efforts to harmonize treatment through consensus-based guidelines and multicenter and international collaborations highlighted.

Onset age is a risk factor for refractory pediatric IgA vasculitis: a retrospective cohort study

BACKGROUND

Though outcome differences between children and adults with immunoglobulin A vasculitis (IgAV) has been well documented, it remains unclear if disease features in pediatric IgAV patients vary with onset age. We aimed to explore clinical features and prognosis of pediatric IgAV stratified by onset age.

METHODS

We retrospectively reviewed records of patients under 18 years old diagnosed with IgAV from January 1999 to December 2018 in one tertiary medical center in Taiwan. Patients were grouped by onset age: ≤ 6 years old, 6-12 years old (> 6, ≤ 12), and 12-18 years old (> 12, < 18). Demographics, laboratory data, incidence of gastrointestinal, renal, and joint involvement, corticosteroid dependence, recurrence, and refractory disease were analyzed. Recurrence was defined as disease flare-up after complete remission and discontinuation of all medications for at least 3 months. Corticosteroid dependence was defined by more than 6 weeks of daily oral corticosteroid intake. Refractory disease was defined as not achieving complete remission 6 months after disease onset. Statistical analysis was performed using R software (v3.6.0).

RESULTS

There were 484 IgAV patients, with an onset age of 6.10 (4.72-8.58) (median (IQR)) years old. There were 234 (48.3%) patients ≤6 years old, 210 (43.4%) 6-12 years old, and 40 (8.3%) 12-18 years old. One hundred and thirty (26.9%) patients had renal involvement, which was more frequent in older children (≤ 6 years old, 18.4%; 6-12 years old, 31.0%; 12-18 years old, 55.0%; p <  0.001). There were 361 patients (74.6%) with joint involvement; younger children were affected more frequently (≤ 6 years old, 82.1%; 6-12 years old, 71.9%; 12-18 years old, 45.0%; p <  0.001). Gastrointestinal involvement was present in 311 (64.3%) patients, showing no difference among age groups. There were 46 patients (9.5%) with recurrent IgA vasculitis, 136 (28.1%) with corticosteroid dependent and 76 (15.7%) with refractory disease. Corticosteroid dependence and refractory disease occurred more frequently as onset age increased (p <  0.001).

CONCLUSION

Pediatric IgAV with different onset ages are associated with distinct clinical manifestations and outcomes. The risk of developing corticosteroid dependence, refractory disease and renal involvement increased with onset age.

Fatal gastrointestinal bleeding due to IgA vasculitis complicated with tuberculous lymphadenitis: A case report and literature review

We report a case of IgA vasculitis that developed during the treatment of tuberculosis. Patients with tuberculosis who are on antituberculosis treatment can be administered steroids for severe disease or complications.

Rapid progression and recovery of massive gastric mucosal damage complicated by Henoch‑Sch�nlein purpura in a patient with liver cirrhosis: A case report

Endoscopic findings associated with gastric ischemia include friable gastric mucosa, irregular ulceration, petechiae and purpura. The etiology of gastric ischemia includes shock, sepsis, thrombosis, embolism and vasculitis. Henoch-Schönlein purpura (HSP) is a leukocytoclastic vasculitis that affects small vessels in the skin, kidney and gastrointestinal (GI) tract. Rapid progression of HSP manifested with acute gastric mucosal bleeding has been rarely reported. The present case study reports on a patient who had undergone endoscopic variceal ligation for esophageal varix bleeding and the gastric mucosa exhibited no evidence of HSP. After 9 days, reexamination using endoscopy to check for new-onset hematemesis revealed massive necrosis in the gastric mucosa, friable mucosal tissue and acute ischemic GI bleeding. The patient was treated with corticosteroid injections for 7 days, which caused a marked regression of the hemorrhagic gastric mucosa. The present case study reported on this patient with acute GI bleeding caused by HSP who was successfully treated with corticosteroids.

Infection Rates Before and After Diagnosis of IgA Vasculitis in Childhood: A Population-wide Study Using Non-exposed Matched Controls

OBJECTIVE

Clinical data suggest that infections can trigger IgA vasculitis (IgAV), but longterm observations are lacking. We compared rates, types, and microorganisms for serious infection before and after diagnosis for children with IgAV and non-exposed controls.

METHODS

Using population-based administrative linked health datasets we estimated incidence rates (IR) for serious infection per 1000 person-months for patients with IgAV (n = 504, age 5 yrs, 59.1% males) and controls matched for age, sex, and year of presentation (n = 1281, age 6 yrs, 66% males). Time zero (T0) was the date of IgAV diagnosis or equivalent date in controls, lookback (median 38 mos) was the period prior to T0, and followup (median 239 mos) was the period after T0.

RESULTS

During lookback, prevalence of serious infection was similar in patients with IgAV and controls (11.5% vs 9.5%, respectively), but patients with IgAV had a higher rate of upper respiratory tract infections [incidence rate ratio (IRR) 1.79; 95% CI 1.39-2.31] with shorter time between first serious infection and T0 (27 vs 43 mos; p = 0.02). During followup, patients were at a constant increased risk for serious infections (IRR 1.46, 95% CI 1.35-1.58). These rates were higher during followup: sepsis (IRR 12.6), pneumonia (IRR 6.19), upper respiratory tract infections (IRR 2.36), and skin infections (IRR 1.85). There was little overlap between patients with serious infections in the lookback and followup periods.

CONCLUSION

In patients with childhood IgAV there is an increased longterm risk for a broader spectrum of infections, which is unrelated to serious infections prior to diagnosis or treatment. This suggests disease-specific factors may have a lasting effect on immune competence in childhood IgAV.

Immunoglobulin A Nephropathy and Immunoglobulin A Vasculitis

Henoch-Schönlein purpura nephritis and immunoglobulin A nephropathy are common glomerulopathies in the pediatric population that deserve special attention. In some cases the primary care provider can follow the patient but others need more intensive management. Delaying this treatment can lead to worse morbidity. This article provides information on the pathogenesis, outcomes, and follow-up strategies that will aid in the diagnosis and referral of patients at risk for kidney disease.

Rituximab treatment for chronic steroid-dependent Henoch-Schonlein purpura: 8 cases and a review of the literature

BACKGROUND

Henoch-Schonlein purpura (HSP) is a small vessel vasculitis that is characterized by non-thrombocytopenic purpura, abdominal pain, arthritis, and glomerulonephritis. Typically, HSP is self-limited requiring only supportive care, but more severe cases may require corticosteroid (CS) treatment. Rarely, a subset of these patients has persistent rash, arthritis, abdominal involvement, or renal disease despite treatment with CS, or has disease recurrence on CS tapering. Refractory HSP has been effectively treated with a variety of CS sparing therapies. For life-threatening refractory HSP, the B cell depleting agent, rituximab (RTX), has been reported as beneficial for children with substantial renal or central nervous system involvement. However, RTX use for children with less severe HSP, but chronic CS dependent disease refractory to CS sparing immunomodulatory agents, has been less well explored. Herein, we describe 8 children treated with RTX for chronic refractory HSP and report a reduction in recurrent hospitalizations and eventual CS discontinuation.

METHODS

This is a retrospective analysis of eight children who were treated with RTX for chronic CS dependent HSP during the years 2006-2014 at a single institution. A chart review of the electronic medical record was performed to determine the presenting symptoms, the type and duration of treatment received, and the number of hospitalizations prior to and after RTX. The number of hospitalizations and oral corticosteroid burden were analyzed using the Wilcoxon signed rank test.

RESULTS

Prior to receiving RTX, seven patients had at least one hospitalization for HSP (median 1.5, range 0-3). Following RTX, only two patients were hospitalized, each a single time for recurrent abdominal pain. The median oral CS burden was 0.345 mg/kg/day before RTX and 0 mg/kg/day at 6 months (p = 0.078), 1 year (p = 0.0625), and 2 years (p = 0.03) following RTX infusion. Seven out of eight children met remission criteria, defined as no active rash, arthritis, nephritis (hematuria and proteinuria), or gastrointestinal distress following RTX. No serious adverse events were noted.

CONCLUSION

Overall, RTX effectively reduced the number of hospital admissions and oral CS burden. RTX also helped most all children achieve clinical remission. RTX appears to be an effective and safe alternative for chronic CS dependent and immunomodulatory refractory childhood HSP.

Risk factors of long hospital stay for immunoglobulin A vasculitis: Single-center study

BACKGROUND

Immunoglobulin A (IgA) vasculitis is a common, systemic childhood disease that occasionally interferes with oral intake of food and necessitates hospitalization. In Japan, there are no reports on the length of hospitalization or factors related to long-term hospitalization in children with IgA vasculitis. In this study, we investigated the factors related to long-term hospitalization.

METHODS

We reviewed the medical records of children aged ≤15 years with IgA vasculitis who were admitted to the National Center for Child Health and Development (Tokyo, Japan) between March 2008 and April 2017. We reviewed their gender, age, previous episodes, digestive symptoms, fever, laboratory data, urine analysis, ultrasound, and use of glucocorticoid on admission day. We compared the long-stay (≥10 days) group (L) and the short-stay (≤9 days) group (S) on logistic regression analysis.

RESULTS

Of the 68 children included in the analysis, 34 were male, and the average age was 71.9 ± 26.4 months. The median period of hospitalization was 10.5 days (range, 0.5-75 days), and 36 children were allocated to group L. In the logistic regression model including age, gender, gastrointestinal (GI) bleeding, and use of glucocorticoid, male sex (OR: 4.2; 95%CI: 1.3-13.5) and GI bleeding (OR: 7.6; 95%CI: 1.4-41.5) were significantly associated with hospitalization ≥10 days.

CONCLUSIONS

In children with IgA vasculitis, male patients and those with GI bleeding were more likely to have a hospital stay ≥10 days.

Hemorrhagic bullous lesions in Henoch-Schönlein purpura: a case report and review of the literature

Background

Henoch-Schönlein purpura (HSP) is a common vasculitis in childhood characterized by purpura, arthritis, abdominal pain and renal involvement. However, bullous HSP is a rare cutaneous manifestation, and a few cases have been reported.

Case presentation

Herein, we report a 15-year-old male with bullous HSP who presented with severe abdominal pain and hemorrhagic bullous lesions over his lower extremities. He was treated with corticosteroid, after which the symptoms improved dramatically. No recurrence was noted after follow-up, though scarring was present. We also reviewed the literature related to bullous HSP and identified 39 cases, most of whom were treated with corticosteroids.

Conclusion

Clinicians should be aware of the atypical types of HSP, including bullous HSP. Most patients with bullous HSP have a good prognosis.

Incidence and risk factors for recurrent Henoch-Schönlein purpura in children from a 16-year nationwide database

BACKGROUND

The recurrence rate of Henoch-Schönlein purpura (HSP) is 2.7%-30%, with varied average intervals between the first and second episodes. Few studies have explored the incidence and risk factors for recurrent HSP.

METHODS

We used a 16-year nationwide database to analyze the incidence of recurrent HSP. Patients with HSP were identified, and risk factors for recurrent HSP were explored. Kaplan-Meier and Cox regression model analyses were performed, and covariates were adjusted in the multivariate model.

RESULTS

From January 1, 1997 to December 31, 2012, among 2,886,836 individuals in the National Health Insurance Research Database, 1002 HSP patients aged < 18 years were identified. Among them, 164 had ≥2 HSP episodes (recurrence rate, 16.4%; incidence of recurrent HSP, 7.05 per 100 person-years); 83.6% patients with one HSP episode remained free of secondary HSP. The average time intervals between the first and second and second and third HSP episodes were 9.2 and 6.4 months, respectively. After adjusting for demographic parameters, comorbidities, and socioeconomic status, recurrent HSP was found to occur more frequently in patients who had renal involvement (adjusted hazard ratio, 2.41; 95% confidence interval [CI], 1.64-3.54; p < 0.001), were receiving steroid therapy for > 10 days (adjusted hazard ratio, 8.13; 95%CI, 2.51-26.36; p < 0.001), and had allergic rhinitis (adjusted hazard ratio, 1.63; 95%CI, 1.06-2.50; p = 0.026).

CONCLUSIONS

The annual incidence of recurrent HSP was low. However, children who had underlying allergic rhinitis, presented with renal involvement, and received steroid treatment for > 10 days should be notified regarding the possibility of recurrence.

IgA Vasculitis: Genetics and Clinical and Therapeutic Management

PURPOSE OF REVIEW

The purpose of the study is to perform an update on the current knowledge on genetics, clinical manifestations, and therapy in immunoglobulin A vasculitis (IgAV) (Henoch-Schönlein purpura).

RECENT FINDINGS

A strong genetic predisposition in individuals with IgAV was confirmed. It was due to the association with the HLA class II region that in people of European background is mainly related to HLA-DRB1*01 allele. Recent reports support the claim that kidney disease is more common in adults than in children with IgAV. The clinical spectrum and outcome of adults with IgAV depends on the age of onset. Relapses are not uncommon in IgAV. The presence of renal impairment or proteinuria excretion exceeding 1 g/24 h at the time of disease diagnosis and the degree of renal damage on the kidney biopsy are the best predictors of end-stage renal failure in adults with IgAV. The levels of urinary IgA at the onset of the disease may predict a poor renal outcome. The use of prednisone does not seem to prevent persistent kidney disease in children with IgAV. No additional benefit of adding cyclophosphamide to glucocorticoids in adults with IgAV was found. Rituximab seems to be a promising therapy in the management of adults with IgAV. In this overview, we focus on the genetics, clinical manifestations, and therapy of IgA vasculitis, emphasizing the main differences in the clinical expression of the disease between children and adults.

Late Relapse of Henoch-Schönlein Purpura in an Adolescent Presenting as Severe Gastroduodenitis

Henoch-Schönlein purpura is a systemic vasculitis, commonly affecting children. Gastrointestinal manifestations are observed in 50-75% of patients; it is well known they may occur before skin lesions in about 20% of cases during the first vasculitic episode. Relapses occur in about one third of patients, typically within 4 months from the initial presentation and with milder symptoms. We report the case of a 17-year old girl with an atypical relapse of Henoch-Schönlein purpura, presenting with acute abdominal symptoms 5 years after the first episode. Esophagogastroduodenoscopy showed duodenal multiple hyperemic and hemorrhagic lesions. To our knowledge this is the first case of hemorrhagic-erosive duodenitis representing a relapse of Henoch-Schönlein purpura occurring several years after the initial episode. Duodenojejunal inflammation should be considered as primary manifestation of Henoch-Schönlein purpura, not only during the first episode, but also in relapses. Endoscopy can be helpful for differential diagnosis, especially in patients with atypical manifestations. Further studies are needed to evaluate risk factors for Henoch-Schönlein purpura recurrence and the possible role of fecal calprotectin as an early marker for gastrointestinal involvement.

Usual and Unusual Manifestations of Systemic and Central Nervous System Vasculitis

The idiopathic vasculitides are a group of inflammatory and immune-mediated conditions associated with inflammation of blood vessels. They affect multiple organ and body systems, and vary in their clinical manifestations, severity, prognosis, and pathology. They frequently present a diagnostic challenge for clinicians because of their complexity, overlapping features, and similar findings to other noninflammatory, genetic, or infectious conditions. This article summarizes some of the common pediatric vasculitides, emphasizing both the characteristic and unusual clinical manifestations of these diseases.

Update on the use of immunoglobulin in human disease: A review of evidence

Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.

The Relationship of Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio with Gastrointestinal Bleeding in Henoch-Schonlein Purpura

Objectives

Henoch-Schonlein Purpura (HSP) is the most widespread systemic vasculitis during childhood. Gastrointestinal tract retention and gastrointestinal bleeding are among its major complications. Neutrophil-Lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are indicators related to inflammatory diseases. This study evaluated the relationship between NLR or PLR and gastrointestinal bleeding in HSP.

Methods

The study consisted of 119 patients and 40 healthy children in the same age group. White Blood Cell (WBC) count, hemoglobin level, platelet count, mean platelet volume (MPV), neutrophil count and lymphocyte count were recorded. The NLR and PLR were calculated based on the results of complete blood count tests performed during the first visit to the hospital.

Results

The average neutrophil count and NLR of the patients with HSP were found to be significantly increased compared to the control group (P = 0.0001). No significant difference was observed between the PLR average of HSP and control groups (P = 0.053). Platelet count average (P = 0.0001) and PLR (P = 0.001) of the patients with gastrointestinal system (GIS) bleeding were found to be statistically significantly increased compared to those who did not have gastrointestinal bleeding. No significant difference was found in the NLR of the patients with and without gastrointestinal bleeding (P = 0.060).

Conclusions

While the NLR was significantly increased in patients with HSP in this study, the PLR was found to be more significant in patients with gastrointestinal bleeding. Similar to NLR, PLR may also be used as an inflammatory indicator among children with HSP, who have gastrointestinal bleeding.

Henoch-Schonlein Purpura in Children Hospitalized at a Tertiary Hospital during 2004-2015 in Korea: Epidemiology and Clinical Management

PURPOSE

To investigate the epidemiology, clinical manifestations, investigations and management, and prognosis of patients with Henoch-Schonlein purpura (HSP).

METHODS

We performed a retrospective review of 212 HSP patients under the age of 18 years who were admitted to Inje University Sanggye Paik Hospital between 2004 and 2015.

RESULTS

The mean age of the HSP patients was 6.93 years, and the ratio of boys to girls was 1.23:1. HSP occurred most frequently in the winter (33.0%) and least frequently in the summer (11.3%). Palpable purpura spots were found in 208 patients (98.1%), and gastrointestinal (GI) and joint symptoms were observed in 159 (75.0%) and 148 (69.8%) patients, respectively. There were 57 patients (26.9%) with renal involvement and 10 patients (4.7%) with nephrotic syndrome. The incidence of renal involvement and nephrotic syndrome was significantly higher in patients with severe GI symptoms and in those over 7 years old. The majority of patients (88.7%) were treated with steroids. There was no significant difference in the incidence of renal involvement or nephrotic syndrome among patients receiving different doses of steroids.

CONCLUSION

In this study, the epidemiologic features of HSP in children were similar to those described in previous studies, but GI and joint symptoms manifested more frequently. It is essential to carefully monitor renal involvement and progression to chronic renal disease in patients ≥7 years old and in patients affected by severe GI symptoms. It can be assumed that there is no direct association between early doses of steroids and prognosis.

Azathioprine therapy for steroid-resistant Henoch-Schönlein purpura: a report of 6 cases

BACKGROUND

A small percentage of children with Henoch-Schönlein purpura (HSP) develop a chronic form of the disease that often requires prolonged corticosteroid therapy. Disease modifying anti-rheumatic agents (DMARDs) or biologics have been successfully used to treat those refractory cases. Azathioprine is a DMARD that has been reported to be effective in HSP nephritis and in adult cutaneous leukocytoclastic vasculitis, a condition with cutaneous histology similar to HSP.

CASE PRESENTATION

A description of 6 cases with relapsing HSP without significant renal involvement, treated with azathioprine are reported. All 6 cases met the classification criteria for the diagnosis of HSP, had relapsing symptoms despite corticosteroid use, were successfully treated with azathioprine and were tapered off of corticosteroids. The duration of azathioprine therapy ranged from 7-21 months and no adverse events were reported.

CONCLUSIONS

Azathioprine is effective in controlling prolonged relapsing symptoms of HSP, allowing earlier discontinuation of corticosteroids. This report shows that azathioprine can be included in the therapeutic options for relapsing HSP and is the first case series in the literature of azathioprine use in HSP without significant renal involvement.

Henoch-Schönlein Purpura in the ED

Diagnosing and treating a child with the most common form of pediatric vasculitis.

Intravenous immunoglobulins for severe gastrointestinal involvement in pediatric Henoch-Schönlein purpura: A French retrospective study

OBJECTIVE

Severe gastrointestinal involvement of Henoch-Schönlein purpura (HSP) is rare but potentially life-threatening. Management of severe gastrointestinal involvement in HSP is not codified. Symptomatic care and steroids are a first-line therapy. Nonsteroidal immunomodulatory therapies have been anecdotally used to treat steroid-refractory forms. The aim of this study was to describe the outcome of patients with severe gastrointestinal involvement of HSP who required nonsteroidal immunomodulatory therapy.

METHODS

A French retrospective case series study was conducted. Pediatric consultants at 31 French academic pediatric centers were contacted. Patients were identified from memory or via an informatics diagnosis-related code system. Clinical, paraclinical, and therapeutic data were collected.

RESULTS

Twenty-nine responding centers provided nine cases, one of which was excluded. Five boys and three girls, aged 3-15years (median: 5.5years) from seven centers were included. Severe gastrointestinal involvement of HSP mainly included intense pain, digestive bleeding, and protein-losing enteropathy. All children had been treated with steroids at first line and intravenous immunoglobulins (IVIg) at second line. Six out of eight showed a complete response to IVIg within 7days and two out of eight had a partial response. Two out of eight relapsed with less severe gastrointestinal involvement requiring a second dose of IVIg and they did not relapse thereafter. Tolerance was good, but two out of eight developed high proteinuria on the day following IVIg infusion.

CONCLUSION

Although a possible link with a flare-up of proteinuria needs to be addressed, IVIg appears to be a good candidate for treatment of severe gastrointestinal involvement of HSP.

The Optimal Cut-Off Value of Neutrophil-to-Lymphocyte Ratio for Predicting Prognosis in Adult Patients with Henoch-Schönlein Purpura

Background

The development of gastrointestinal (GI) bleeding and end-stage renal disease (ESRD) can be a concern in the management of Henoch–Schönlein purpura (HSP). We aimed to evaluate whether the neutrophil-to-lymphocyte ratio (NLR) is associated with the prognosis of adult patients with HSP.

Methods

Clinical data including the NLR of adult patients with HSP were retrospectively analyzed. Patients were classified into three groups as follows: (a) simple recovery, (b) wax & wane without GI bleeding, and (c) development of GI bleeding. The optimal cut-off value was determined using a receiver operating characteristics curve and the Youden index.

Results

A total of 66 adult patients were enrolled. The NLR was higher in the GI bleeding group than in the simple recovery or wax & wane group (simple recovery vs. wax & wane vs. GI bleeding; median [IQR], 2.32 [1.61–3.11] vs. 3.18 [2.16–3.71] vs. 7.52 [4.91–10.23], P<0.001). For the purpose of predicting simple recovery, the optimal cut-off value of NLR was 3.18, and the sensitivity and specificity were 74.1% and 75.0%, respectively. For predicting development of GI bleeding, the optimal cut-off value was 3.90 and the sensitivity and specificity were 87.5% and 88.6%, respectively.

Conclusions

The NLR is useful for predicting development of GI bleeding as well as simple recovery without symptom relapse. Two different cut-off values of NLR, 3.18 for predicting an easy recovery without symptom relapse and 3.90 for predicting GI bleeding can be used in adult patients with HSP.

Henoch-Schönlein purpura with joint involvement: Analysis of 71 cases

BACKGROUND

Although joint involvement is the second most common clinical manifestation after skin involvement in patients with Henoch-Schönlein purpura (HSP), it has not been well characterized. The aim of this study was to profile the clinical characteristics and identify the potential risk factors for kidney damage in HSP patients having joint involvement.

METHODS

We retrospectively reviewed 71 cases of HSP patients with joint involvement who attended our hospital between January 2010 and March 2012 and analyzed their epidemiological profile, clinical characteristics, follow-up findings (up to three years) and overall prognosis. Logistic regression analysis was performed to identify risk factors associated with renal symptoms in HSP patients with joint involvement.

RESULTS

Average age of patients was 8.55 ± 2.13 years with male to female ratio at 1.29:1. The peak age of disease onset was six to 11 years. The most common triggers included upper respiratory infection, vigorous physical activity, and autumn and winter seasons. Forty cases (56.35 %) had gastrointestinal involvement and 37 (52.11 %) had kidney damage; gastrointestinal system, scrotal involvement, and increased D-dimer levels were significantly associated with kidney injury (P < 0.05) by multivariate analysis. Glucocorticoid therapy was effective in alleviating symptoms.

CONCLUSION

Gastrointestinal symptoms, scrotal involvement, and increased D-dimer are the potential risk factors for kidney damage in HSP patients having joint involvement. Rational use of corticosteroids was probably responsible for the good clinical outcomes.

Pediatric Vasculitis

Vasculitis is defined as inflammation of the blood vessels and can result in stenosis or aneurysm, which may in turn lead to occlusion or rupture of the vessel compromising tissue perfusion. The manifestations of these diseases depend on the size and site of the vessels effected. Vasculitis can be secondary to numerous inflammatory and infectious diseases but this review will concentrate on the systemic primary vasculitides and aims to discuss the presentations and approaches to management of a number of these conditions.

Henoch-Schönlein purpura in children: limited benefit of corticosteroids

QUESTION

A child recently presented to my office with lower limb petechiae, arthralgia, and abdominal pain characteristic of Henoch-Schönlein purpura (HSP). Will systemic corticosteroids help relieve these symptoms and prevent potential HSP complications such as intussusception and nephritis?

ANSWER

Henoch-Schönlein purpura is a common and self-limiting disease in children. Current evidence does not support universal treatment of HSP with corticosteroids. Recent trials and meta-analyses found that corticosteroids do not prevent the onset of renal disease or abdominal complications. However, corticosteroids are effective as treatment of abdominal pain, arthralgia, and purpura. Clinicians are advised to use their discretion in choosing which patients might benefit most from oral corticosteroid treatment.

Petechiae and purpura: the ominous and the not-so-obvious?

Petechiae and purpura are among the most alarming findings a pediatrician will commonly observe in the office. Severity of illness can range from a temper tantrum, to common viral infections, to the most deadly infections and diseases. To avoid many of the pitfalls in diagnosis, practitioners will need to be thorough in history taking, assessing fever and immunization status, and physical examination. In addition, a few simple laboratory tests will usually be needed and possibly a manual differential.

Patient and hospital factors associated with induction mortality in acute lymphoblastic leukemia

BACKGROUND

Deaths during induction chemotherapy for pediatric acute lymphoblastic leukemia (ALL) account for one-tenth of ALL-associated mortality and half of ALL treatment-related mortality. We sought to ascertain patient- and hospital-level factors associated with induction mortality.

PROCEDURE

We performed a retrospective cohort analysis of 8,516 children ages 0 to <19 years with newly diagnosed ALL admitted to freestanding US children's hospitals from 1999 to 2009 using the Pediatric Health Information System database. Induction mortality risk was modeled accounting for demographics, intensive care unit-level interventions, and socioeconomic status (SES) using Cox regression. The association of ALL induction mortality with hospital-level factors including volume, hospital-wide mortality and payer mix was analyzed with multiple linear regression.

RESULTS

ALL induction mortality was 1.12%. Race and patient-level SES factors were not associated with induction mortality. Patients receiving both mechanical ventilation and vasoactive infusions experienced nearly 50% mortality (hazard ratio 122.30, 95% CI 66.56-224.80). Institutions in the highest induction mortality quartile contributed 27% of all patients but nearly half of all deaths (47 of 95). Hospital payer mix was associated with ALL induction mortality after adjustment for other hospital-level factors (P = 0.046).

CONCLUSIONS

The overall risk of induction death is low but substantially increased in patients with cardio-respiratory and other organ failures. Induction mortality varies up to three-fold across hospitals and is correlated with hospital payer mix. Further work is needed to improve induction outcomes in hospitals with higher mortality. These data suggest an induction mortality rate of less than 1% may be an attainable national benchmark.

Diagnosis and management of cutaneous vasculitis in children

Cutaneous vasculitis in children is rare. Causes of cutaneous vasculitis are varied and are typically differentiated by the affected vessel size. A skin biopsy remains the gold standard for diagnosis but other causes for vasculitis, including systemic conditions, should be considered. This article discusses the childhood conditions commonly presenting with cutaneous vasculitis (leukocytoclastic vasculitis, cutaneous polyarteritis nodosa), biopsy recommendations and findings, and management and potential differential diagnoses, and includes a brief summary of other diseases that may include cutaneous symptoms as a constellation of other systemic findings.

Establishment of an 11-year cohort of 8733 pediatric patients hospitalized at United States free-standing children's hospitals with de novo acute lymphoblastic leukemia from health care administrative data

BACKGROUND

Acute lymphoblastic leukemia (ALL) accounts for almost one quarter of pediatric cancer in the United States. Despite cooperative group therapeutic trials, there remains a paucity of large cohort data on which to conduct epidemiology and comparative effectiveness research studies.

RESEARCH DESIGN

We designed a 3-step process utilizing International Classification of Diseases-9 Clinical Modification (ICD-9) discharge diagnoses codes and chemotherapy exposure data contained in the Pediatric Health Information System administrative database to establish a cohort of children with de novo ALL. This process was validated by chart review at 1 of the pediatric centers.

RESULTS

An ALL cohort of 8733 patients was identified with a sensitivity of 88% [95% confidence interval (CI), 83%-92%] and a positive predictive value of 93% (95% CI, 89%-96%). The 30-day all cause inpatient case fatality rate using this 3-step process was 0.80% (95% CI, 0.63%-1.01%), which was significantly different than the case fatality rate of 1.40% (95% CI, 1.23%-1.60%) when ICD-9 codes alone were used.

CONCLUSIONS

This is the first report of assembly and validation of a cohort of de novo ALL patients from a database representative of free-standing children's hospitals across the United States. Our data demonstrate that the use of ICD-9 codes alone to establish cohorts will lead to substantial patient misclassification and result in biased outcome estimates. Systematic methods beyond the use of just ICD-9 codes must be used before analysis to establish accurate cohorts of patients with malignancy. A similar approach should be followed when establishing future cohorts from administrative data.

Outcomes in hospitalized pediatric patients with systemic lupus erythematosus

OBJECTIVE

Disparities in outcomes among adults with systemic lupus erythematosus (SLE) have been documented. We investigated associations between sociodemographic factors and volume of annual inpatient hospital admissions with hospitalization characteristics and poor outcomes among patients with childhood-onset SLE.

METHODS

By using the Pediatric Health Information System, we analyzed admissions for patients aged 3 to <18 years at index admission with ≥ 1 International Classification of Diseases, Ninth Revision code for SLE from January 2006 to September 2011. Summary statistics and univariable analyses were used to examine demographic characteristics of hospital admissions, readmissions, and lengths of stay. We used multivariable logistic regression analyses, controlling for patient gender, age, race, ethnicity, insurance type, hospital volume, US census region, and severity of illness, to examine risk factors for poor outcomes.

RESULTS

A total of 10,724 admissions occurred among 2775 patients over the study period. Hispanic patients had longer lengths of stay, more readmissions, and higher in-hospital mortality. In multivariable analysis, African American race was significantly associated with ICU admission. African American race and Hispanic ethnicity were associated with end-stage renal disease and death. Volume of patients with SLE per hospital and hospital location were not significantly associated with outcomes.

CONCLUSIONS

In this cohort of hospitalized children with SLE, race and ethnicity were associated with outcomes. Further studies are needed to elucidate the relationship between sociodemographic factors and poor outcomes in patients with childhood-onset SLE.

Henoch-Schönlein purpura in children

Henoch-Schönlein purpura is the most common systemic vasculitis of childhood. In the majority of children, the outcome of Henoch-Schönlein purpura is excellent with spontaneous resolution of symptoms and signs. However, a small subset of patients will develop long-term sequelae in the form of chronic kidney disease. While the clinical presentation and diagnosis of Henoch-Schönlein purpura is straightforward, treatment of Henoch-Schönlein purpura nephritis and long-term renal outcomes of more severely affected children are less certain. This review article gives a general overview of Henoch-Schönlein purpura with emphasis on recently published information, including the new classification of childhood vasculitis, insights into pathogenesis of Henoch-Schönlein purpura and a summary of various treatments of established Henoch-Schönlein purpura nephritis.

Association of hospital and provider types on sickle cell disease outcomes

OBJECTIVES

Adolescents and young adults (A/YA) with sickle cell disease (SCD) are hospitalized in both children's and general hospitals. We determined the effect of hospital type and provider specialty on outcomes of hospitalized A/YA with SCD and acute chest syndrome (ACS).

METHODS

This retrospective cohort study used the 2007-2009 Premier Database, a large multi-institutional database, to identify 1476 patients ages 16 to 25 years with 2299 admissions with SCD and ACS discharged from 256 US hospitals from 2007 to 2009. Multilevel logistic regression and zero-truncated negative binomial regression were performed after adjustment for patient demographic, clinical, and hospital characteristics to test the association of hospital type and provider specialty on death, endotracheal intubation, simple or exchange transfusion, length of stay (LOS), and 30-day readmission.

RESULTS

Of all admissions, 14 died and 45% were intubated. General hospitals had 13 deaths and were associated with higher intubation rates (predicted probability [PP], 48% [95% confidence interval (CI), 43%-52%]) and longer LOS (predicted mean LOS, 7.6 days [95% CI, 7.2-7.9]) compared with children's hospitals (PP of intubation, 24% [95% CI, 5%-42%]; and predicted mean LOS, 6.8 days [95% CI, 5.6-5.8]). There was no difference by hospital type or provider specialty in PP of simple or exchange transfusion, or 30-day readmission.

CONCLUSIONS

General hospitals carry higher intubation risks for A/YA with SCD and ACS compared with children's hospitals. We need to better understand the drivers of these differences, including the role of staff expertise, hospital volume, and quality of ongoing SCD care.

Clinical manifestations and endoscopic characteristics of adult abdominal type allergic purpura: An analysis of 26 cases

AIM: To summarize the clinical and endoscopic features of abdominal type allergic purpura in adult patients.

METHODS: Clinical and endoscopic data for 26 adult patients with abdominal type allergic purpura were analyzed retrospectively.

RESULTS: All patients had abdominal pain, and 13 patients had digestive tract hemorrhage. Endoscopy revealed hyperaemia, edema, bleeding spots, erosion and ulcer in the gastrointestinal mucosa. Severe mucosal lesions were often found in the duodenum, ileum and caecum.

CONCLUSION: Gastrointestinal endoscopy is helpful for early diagnosis of adult abdominal type allergic purpura.

Effects of hemoperfusion in the treatment of childhood Henoch-Schönlein purpura nephritis

PURPOSE

Immune mediators play a role in the pathogenesis of Henoch-Schönlein purpura (HSP) nephritis. Since hemoperfusion (HP) is able to eliminate the immune mediators in many diseases, we investigated the effects of HP in the treatment of HSP nephritis.

METHODS

90 children with HSP nephritis were enrolled and followed up for 12 months. They were assigned to the HP group or the control group, respectively. Both groups were treated with corticosteroids and other supportive therapy. Patients in the HP group received HP for 3 consecutive days. The major outcomes included the percentage of patients with HSP nephritis, extrarenal symptoms, and recurrences and changes in serum levels of immune mediators.

RESULTS

The percentage of patients with nephritis in the HP group was less than that in the control group at each visit; the differences for prortions at 1, 3, 6, 12 months were 16.7% (p = 0.133), 31.3% (p = 0.004), 10.8% (p = 0.283), and 20.6% (p = 0.003), respectively. The severity and duration of abdominal and joint pains in the acute phase were significantly improved in the HP group compared to those in the control group. Hemoperfusion also significantly reduced patients' serum levels of immune mediators including IgA, TNF-α, IL-6, and LTB4. However, recurrences between the two groups were not significantly different.

CONCLUSIONS

Hemoperfusion in combination with corticosteroid was more effective than corticosteroid alone in treating HSP nephritis. The effects may be achieved by eliminating immune mediators.

Macrophage activation syndrome in children with systemic lupus erythematosus and children with juvenile idiopathic arthritis

OBJECTIVE

To describe patient demographics, interventions, and outcomes in hospitalized children with macrophage activation syndrome (MAS) complicating systemic lupus erythematosus (SLE) or juvenile idiopathic arthritis (JIA).

METHODS

We performed a retrospective cohort study using data recorded in the Pediatric Health Information System (PHIS) database from October 1, 2006 to September 30, 2010. Participants had International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for MAS and either SLE or JIA. The primary outcome was hospital mortality (for the index admission). Secondary outcomes included intensive care unit (ICU) admission, critical care interventions, and medication use.

RESULTS

A total of 121 children at 28 children's hospitals met the inclusion criteria, including 19 children with SLE and 102 children with JIA. The index admission mortality rate was 7% (8 of 121 patients). ICU admission (33%), mechanical ventilation (26%), and inotrope/vasopressor therapy (26%) were common. Compared to children with JIA, those with SLE had a similar mortality rate (6% versus 11%, respectively; exact P = 0.6). More patients with SLE than those with JIA received ICU care (63% versus 27%; P = 0.002), received mechanical ventilation (53% versus 21%; P = 0.003), and had cardiovascular dysfunction (47% versus 23% received inotrope/vasopressor therapy; P = 0.02). Children with SLE and those with JIA received cyclosporine at similar rates, but more children with SLE received cyclophosphamide and mycophenolate mofetil, and more children with JIA received interleukin-1 antagonists.

CONCLUSION

Organ system dysfunction is common in children with rheumatic diseases complicated by MAS, and more organ system support is required in children with underlying SLE than in children with JIA. Current treatment of pediatric MAS varies based on the underlying rheumatic disease.

Variation in surgical outcomes for adolescents and young adults with inflammatory bowel disease

OBJECTIVE

To examine whether hospital type (children's hospital or generalist hospital) and surgeon specialty are associated with variations in surgical outcomes for hospitalized adolescents and young adults with inflammatory bowel disease (IBD) requiring surgery.

METHODS

The 2007-2009 Perspective Data Warehouse was used to identify a retrospective cohort study of all inpatients 16 to 25 years old who received surgery for IBD. Multivariate regression, clustered at the hospital level, examined the association of hospital type and surgical specialty with surgical complications and 30-day readmissions.

RESULTS

Surgery was performed in 917 hospitalizations of 598 patients across 20 children's hospitals and 198 general hospitals by 566 general surgeons, 46 pediatric surgeons, and 305 colorectal surgeons. After adjustment, children's hospitals had higher predicted probabilities of surgical complication (predicted probability [PP]: 35% [95% confidence interval (CI): 28-42]) compared with general hospitals (PP: 26% [95% CI: 23-29]). Despite higher complications among children's hospitals, pediatric surgeons had lowest predicated probabilities of surgical complication or 30-day readmission (PP: 24% [95% CI: 10-39]) compared with general surgeons (PP: 39% [95% CI: 35-43]) and colorectal surgeons (PP: 35% [95% CI: 28-42]).

CONCLUSIONS

Disparate outcomes for adolescents and young adults receiving care in children's versus generalist hospitals and from different types of surgeons reveal the need to better understand how practice setting and surgical specialty may modify outcomes for a population that traverses a variety of health care settings.