1
|
Schweiberger K, Hoberman A, Iagnemma J, Schoemer P, White GE, Wolfson D, Ray KN. Pediatric Primary Care Clinicians' Perspectives on Telemedicine Use, 2020 Versus 2021. Telemed J E Health 2024. [PMID: 38621152 DOI: 10.1089/tmj.2023.0507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Objective: We examined the change in pediatric primary care clinician attitudes and perceptions about telemedicine after one year of telemedicine use. Methods: We administered a survey to pediatric primary care clinicians across 50 primary care practices in Pennsylvania in 2020 and 2021. Surveys were linked using a combination of deterministic and probabilistic matching. We used McNemar's test to compare change in responses from 2020 to 2021. Results: Among pediatric primary care clinicians surveyed in 2020 and 2021 (n = 101), clinicians agreed that telemedicine could always or usually deliver high-quality care for mental health (80% in 2020 and 78% in 2021), care coordination (77% in 2020 and 70% in 2021), acute care (33% in 2020 and 34% in 2021), or preventive care (25% in 2020 and 18% in 2021) and this did not significantly change. Clinician perceptions of usability, while high, declined over time with fewer endorsing ease of use (93% in 2020 and 80% in 2021) and reliability (14% in 2020 and 0% in 2021) over time. Despite this, 62% of clinicians agreed that they were satisfied with their use of telemedicine at both time points. Respondents anticipated positive impact on equity and timeliness of care from telemedicine use but did not anticipate positive impact across child health, health care delivery, or clinician experience. Perceptions across these domains did not change over time. Conclusions: With one year of telemedicine experience, primary care clinicians maintained beliefs that telemedicine could deliver high-quality care for specific clinical needs but had worsening perceptions of usability over time.
Collapse
Affiliation(s)
- Kelsey Schweiberger
- Division of General Academic Pediatrics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Children's Community Pediatrics, Wexford, Pennsylvania, USA
| | | | - Pamela Schoemer
- UPMC Children's Community Pediatrics, Wexford, Pennsylvania, USA
| | - Gretchen E White
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David Wolfson
- UPMC Children's Community Pediatrics, Wexford, Pennsylvania, USA
| | - Kristin N Ray
- Division of General Academic Pediatrics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- UPMC Children's Community Pediatrics, Wexford, Pennsylvania, USA
| |
Collapse
|
2
|
Shaikh N, Conway SJ, Kovačević J, Condessa F, Shope TR, Haralam MA, Campese C, Lee MC, Larsson T, Cavdar Z, Hoberman A. Development and Validation of an Automated Classifier to Diagnose Acute Otitis Media in Children. JAMA Pediatr 2024; 178:401-407. [PMID: 38436941 PMCID: PMC10985552 DOI: 10.1001/jamapediatrics.2024.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/17/2023] [Indexed: 03/05/2024]
Abstract
Importance Acute otitis media (AOM) is a frequently diagnosed illness in children, yet the accuracy of diagnosis has been consistently low. Multiple neural networks have been developed to recognize the presence of AOM with limited clinical application. Objective To develop and internally validate an artificial intelligence decision-support tool to interpret videos of the tympanic membrane and enhance accuracy in the diagnosis of AOM. Design, Setting, and Participants This diagnostic study analyzed otoscopic videos of the tympanic membrane captured using a smartphone during outpatient clinic visits at 2 sites in Pennsylvania between 2018 and 2023. Eligible participants included children who presented for sick visits or wellness visits. Exposure Otoscopic examination. Main Outcomes and Measures Using the otoscopic videos that were annotated by validated otoscopists, a deep residual-recurrent neural network was trained to predict both features of the tympanic membrane and the diagnosis of AOM vs no AOM. The accuracy of this network was compared with a second network trained using a decision tree approach. A noise quality filter was also trained to prompt users that the video segment acquired may not be adequate for diagnostic purposes. Results Using 1151 videos from 635 children (majority younger than 3 years of age), the deep residual-recurrent neural network had almost identical diagnostic accuracy as the decision tree network. The finalized deep residual-recurrent neural network algorithm classified tympanic membrane videos into AOM vs no AOM categories with a sensitivity of 93.8% (95% CI, 92.6%-95.0%) and specificity of 93.5% (95% CI, 92.8%-94.3%) and the decision tree model had a sensitivity of 93.7% (95% CI, 92.4%-94.9%) and specificity of 93.3% (92.5%-94.1%). Of the tympanic membrane features outputted, bulging of the TM most closely aligned with the predicted diagnosis; bulging was present in 230 of 230 cases (100%) in which the diagnosis was predicted to be AOM in the test set. Conclusions and Relevance These findings suggest that given its high accuracy, the algorithm and medical-grade application that facilitates image acquisition and quality filtering could reasonably be used in primary care or acute care settings to aid with automated diagnosis of AOM and decisions regarding treatment.
Collapse
Affiliation(s)
- Nader Shaikh
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pennsylvania
| | - Shannon J. Conway
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pennsylvania
| | - Jelena Kovačević
- Tandon School of Engineering, New York University, New York, New York
| | - Filipe Condessa
- Bosch Center for Artificial Intelligence, Pittsburgh, Pennsylvania
| | - Timothy R. Shope
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pennsylvania
| | - Mary Ann Haralam
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pennsylvania
| | - Catherine Campese
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pennsylvania
| | - Matthew C. Lee
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pennsylvania
| | | | | | - Alejandro Hoberman
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pennsylvania
| |
Collapse
|
3
|
Wittman SR, Hoberman A, Mehrotra A, Sabik LM, Yabes JG, Ray KN. Antibiotic Receipt for Pediatric Telemedicine Visits With Primary Care vs Direct-to-Consumer Vendors. JAMA Netw Open 2024; 7:e242359. [PMID: 38483387 PMCID: PMC10940962 DOI: 10.1001/jamanetworkopen.2024.2359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/23/2024] [Indexed: 03/17/2024] Open
Abstract
Importance Prior research found that pediatric direct-to-consumer (DTC) telemedicine visits are associated with more antibiotic prescribing than in-person primary care visits. It is unclear whether this difference is associated with modality of care (telemedicine vs in-person) or with the context of telemedicine care (primary care vs not primary care). Objective To compare antibiotic management during telemedicine visits with primary care practitioners (PCPs) vs commercial direct-to-consumer (DTC) telemedicine companies for pediatric acute respiratory tract infections (ARTIs). Design, Setting, and Participants This retrospective, cross-sectional study of visits for ARTIs by commercially insured children 17 years of age or younger analyzed deidentified medical and pharmacy claims in OptumLabs Data Warehouse data, a national sample of commercial enrollees, between January 1 and December 31, 2022. Exposure Setting of telemedicine visit as PCP vs DTC. Main Outcomes and Measures The primary outcome was percentage of visits with antibiotic receipt. Secondary outcomes were the percentages of visits with diagnoses for which prescription of an antibiotic was potentially appropriate, guideline-concordant antibiotic management, and follow-up ARTI visits within the ensuing 1 to 2 days and 3 to 14 days. The ARTI telemedicine visits with PCP vs DTC telemedicine companies were matched on child demographic characteristics. Generalized estimated equation log-binomial regression models were used to compute marginal outcomes. Results In total, data from 27 686 children (mean [SD] age, 8.9 [5.0] years; 13 893 [50.2%] male) were included in this study. There were 14 202 PCP telemedicine index visits matched to 14 627 DTC telemedicine index visits. The percentage of visits involving receipt of an antibiotic was lower for PCP (28.9% [95% CI, 28.1%-29.7%]) than for DTC (37.2% [95% CI, 36.0%-38.5%]) telemedicine visits. Additionally, fewer PCP telemedicine visits involved receipt of a diagnosis in which the use of antibiotics may be appropriate (19.0% [95% CI, 18.4%-19.7%] vs 28.4% [95% CI, 27.3%-29.6%]), but no differences were observed in receipt of nonguideline-concordant antibiotic management based on a given diagnosis between PCP (20.2% [95% CI, 19.5%-20.9%]) and DTC (20.1% [95% CI, 19.1%-21.0%]) telemedicine visits. Fewer PCP telemedicine visits involved a follow-up visit within the ensuing 1 to 2 days (5.0% [95% CI, 4.7%-5.4%] vs 8.0% [95% CI, 7.3%-8.7%]) and 3 to 14 days (8.2% [95% CI, 7.8%-8.7%] vs 9.6% [95% CI, 8.8%-10.3%]). Conclusions and Relevance Compared with virtual-only DTC telemedicine companies, telemedicine integrated within primary care was associated with lower rates of antibiotic receipt and follow-up care. Supporting use of telemedicine integrated within pediatric primary care may be one strategy to reduce antibiotic receipt through telemedicine visits.
Collapse
Affiliation(s)
- Samuel R. Wittman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Jonathan G. Yabes
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
4
|
Burns SK, Krishnamurti T, Doan TT, Hanmer J, Hoberman A, Kahn JM, Schweiberger K, Ray KN. Parent Perceptions of Telemedicine for Acute Pediatric Respiratory Tract Infections: Sequential Mixed Methods Study. JMIR Pediatr Parent 2024; 7:e49170. [PMID: 38227360 PMCID: PMC10828946 DOI: 10.2196/49170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 11/01/2023] [Accepted: 12/13/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Since 2020, parents have had increasing opportunities to use telemedicine for their children, but how parents decide whether to use telemedicine for acute pediatric care relative to alternative sites of care is not clear. One of the most common reasons parents seek acute care for their children is for acute respiratory tract infections (ARTIs). OBJECTIVE This study aims to examine parental expectations of care via telemedicine for pediatric ARTIs, contrasting expectations of care delivered via primary care telemedicine and direct-to-consumer (DTC) telemedicine. METHODS We performed a sequential mixed methods analysis to examine how parents assess telemedicine for their children's acute care. We used ARTIs as a case study for examining parent perceptions of telemedicine. First, we analyzed semistructured interviews focused on parent responses about the use of telemedicine. Each factor discussed by parents was coded to reflect whether parents indicated it incentivized or disincentivized their preferences for telemedicine versus in-person care. Results were organized by a 7-dimension framework of parental health care seeking that was generated previously, which included dimensions related to care sites (expected access, affordability, clinical quality, and site quality) and dimensions related to child or family factors (perceived illness severity, perceived child susceptibility, and parent self-efficacy). Second, we analyzed responses to a national survey, which inquired about parental expectations of primary care telemedicine, commercial DTC telemedicine, and 3 in-person sites of care (primary care, urgent care, and emergency department) across 21 factors identified through prior qualitative work. To assess whether parents had different expectations of different telemedicine models, we compared survey responses for primary care telemedicine and commercial DTC telemedicine using weighted logistic regression. RESULTS Interview participants (n=40) described factors affecting their perceptions of telemedicine as a care modality for pediatric ARTIs. Generally, factors aligned with access and affordability (eg, decreased wait time and lower out-of-pocket cost) were discussed as potential incentives for telemedicine use, while factors aligned with perceived illness severity, child susceptibility, and clinician quality (eg, trustworthiness) were discussed as potential disincentives for telemedicine use. In survey responses (n=1206), primary care and commercial DTC telemedicine were rated similarly on items related to expected accessibility and affordability. In contrast, on items related to expected quality of care, primary care telemedicine was viewed similarly to in-person primary care, while commercial DTC telemedicine was rated lower. For example, 69.7% (weighted; 842/1197) of respondents anticipated their children would be comfortable and cooperative with primary care telemedicine versus 49.7% (weighted; 584/1193) with commercial DTC telemedicine (P<.001). CONCLUSIONS In a mixed methods analysis focused on telemedicine for ARTIs, parents expressed more concerns about telemedicine quality in commercial DTC models compared with primary care-based telemedicine. These results could help health systems better design telemedicine initiatives to support family-centered care.
Collapse
Affiliation(s)
- Sarah K Burns
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tamar Krishnamurti
- Department of Medicine, University Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tran T Doan
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Janel Hanmer
- Department of Medicine, University Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jeremy M Kahn
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| |
Collapse
|
5
|
Shaikh N, Hoberman A. Nonsuperiority of Standard Therapy Compared to Short-Course Therapy in Symptomatic UTIs-Reply. JAMA Pediatr 2023; 177:1361. [PMID: 37812406 DOI: 10.1001/jamapediatrics.2023.4059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Affiliation(s)
- Nader Shaikh
- Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pennsylvania
| |
Collapse
|
6
|
Lobb B, Lee MC, McElheny CL, Doi Y, Yahner K, Hoberman A, Martin JM, Hirota JA, Doxey AC, Shaikh N. Genomic classification and antimicrobial resistance profiling of Streptococcus pneumoniae and Haemophilus influenza isolates associated with paediatric otitis media and upper respiratory infection. BMC Infect Dis 2023; 23:596. [PMID: 37700242 PMCID: PMC10498559 DOI: 10.1186/s12879-023-08560-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/24/2023] [Indexed: 09/14/2023] Open
Abstract
Acute otitis media (AOM) is the most common childhood bacterial infectious disease requiring antimicrobial therapy. Most cases of AOM are caused by translocation of Streptococcus pneumoniae or Haemophilus influenzae from the nasopharynx to the middle ear during an upper respiratory tract infection (URI). Ongoing genomic surveillance of these pathogens is important for vaccine design and tracking of emerging variants, as well as for monitoring patterns of antibiotic resistance to inform treatment strategies and stewardship.In this work, we examined the ability of a genomics-based workflow to determine microbiological and clinically relevant information from cultured bacterial isolates obtained from patients with AOM or an URI. We performed whole genome sequencing (WGS) and analysis of 148 bacterial isolates cultured from the nasopharynx (N = 124, 94 AOM and 30 URI) and ear (N = 24, all AOM) of 101 children aged 6-35 months presenting with AOM or an URI. We then performed WGS-based sequence typing and antimicrobial resistance profiling of each strain and compared results to those obtained from traditional microbiological phenotyping.WGS of clinical isolates resulted in 71 S. pneumoniae genomes and 76 H. influenzae genomes. Multilocus sequencing typing (MSLT) identified 33 sequence types for S. pneumoniae and 19 predicted serotypes including the most frequent serotypes 35B and 3. Genome analysis predicted 30% of S. pneumoniae isolates to have complete or intermediate penicillin resistance. AMR predictions for S. pneumoniae isolates had strong agreement with clinical susceptibility testing results for beta-lactam and non beta-lactam antibiotics, with a mean sensitivity of 93% (86-100%) and a mean specificity of 98% (94-100%). MLST identified 29 H. influenzae sequence types. Genome analysis identified beta-lactamase genes in 30% of H. influenzae strains, which was 100% in agreement with clinical beta-lactamase testing. We also identified a divergent highly antibiotic-resistant strain of S. pneumoniae, and found its closest sequenced strains, also isolated from nasopharyngeal samples from over 15 years ago.Ultimately, our work provides the groundwork for clinical WGS-based workflows to aid in detection and analysis of H. influenzae and S. pneumoniae isolates.
Collapse
Affiliation(s)
- Briallen Lobb
- Department of Biology and Waterloo Centre for Microbial Research, University of Waterloo, Waterloo, ON, Canada
| | - Matthew C Lee
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, Pittsburgh, USA
| | - Christi L McElheny
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yohei Doi
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kristin Yahner
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, Pittsburgh, USA
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, Pittsburgh, USA
| | - Judith M Martin
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, Pittsburgh, USA
| | - Jeremy A Hirota
- Department of Biology and Waterloo Centre for Microbial Research, University of Waterloo, Waterloo, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health, St. Joseph's Hospital, Hamilton, ON, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Andrew C Doxey
- Department of Biology and Waterloo Centre for Microbial Research, University of Waterloo, Waterloo, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Nader Shaikh
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, Pittsburgh, USA.
| |
Collapse
|
7
|
Shaikh N, Hoberman A, Paradise JL, Rockette HE, Kurs-Lasky M, Martin JM. Association Between Nasopharyngeal Colonization and Clinical Outcome in Children With Acute Otitis Media. Pediatr Infect Dis J 2023; 42:e274-e277. [PMID: 37171965 PMCID: PMC10523893 DOI: 10.1097/inf.0000000000003956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Young children with acute otitis media (AOM) frequently exhibit nasopharyngeal colonization with either Streptococcus pneumoniae, Haemophilus influenzae or both pathogens. We aimed to determine if antibiotics could be spared or shortened in those without nasopharyngeal colonization with either pathogen. METHODS In 2 separate randomized clinical trials in children aged 6-23 months with stringently-diagnosed AOM, we performed bacterial cultures on nasopharyngeal specimens collected at the time of diagnosis. In the first trial, we compared the efficacy of amoxicillin/clavulanate (amox/clav) administered for 10 days vs. that of placebo, and in the second trial, we compared the efficacy of amox/clav administered for 10 days vs. 5 days. In each trial, we classified children as being colonized with both S. pneumoniae and H. influenzae, S. pneumoniae alone, H. influenzae alone, or neither pathogen, and as experiencing either clinical success or clinical failure at the end-of-therapy visit, based on previously reported a priori criteria. RESULTS We evaluated 796 children. Among children randomized to amox/clav, those colonized with either S. pneumoniae or H. influenzae or both were approximately twice as likely to experience clinical failure as children not colonized with either pathogen (odds ratio: 1.8; confidence intervals: 1.2-2.9). In contrast, among children randomized to placebo, clinical failure at the end-of-therapy visit was not associated with nasopharyngeal culture results at the time of diagnosis. CONCLUSIONS Children colonized with either S. pneumoniae or H. influenzae or both have a greater chance of treatment failure than children colonized with neither pathogen.
Collapse
Affiliation(s)
- Nader Shaikh
- Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, Divisions of General Academic Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, Divisions of General Academic Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jack L. Paradise
- Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, Divisions of General Academic Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Howard E. Rockette
- Department of Biostatistics, Graduate School of Public Heath, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marcia Kurs-Lasky
- Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, Divisions of General Academic Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Judith M. Martin
- Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, Divisions of General Academic Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
8
|
Zaoutis T, Shaikh N, Fisher BT, Coffin SE, Bhatnagar S, Downes KJ, Gerber JS, Shope TR, Martin JM, Muniz GB, Green M, Nagg JP, Myers SR, Mistry RD, O'Connor S, Faig W, Black S, Rowley E, Liston K, Hoberman A. Short-Course Therapy for Urinary Tract Infections in Children: The SCOUT Randomized Clinical Trial. JAMA Pediatr 2023; 177:782-789. [PMID: 37358858 PMCID: PMC10294016 DOI: 10.1001/jamapediatrics.2023.1979] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/02/2023] [Indexed: 06/27/2023]
Abstract
Importance There is a paucity of pediatric-specific comparative data to guide duration of therapy recommendations in children with urinary tract infection (UTI). Objective To compare the efficacy of standard-course and short-course therapy for children with UTI. Design, Setting, Participants The Short Course Therapy for Urinary Tract Infections (SCOUT) randomized clinical noninferiority trial took place at outpatient clinics and emergency departments at 2 children's hospitals from May 2012, through, August 2019. Data were analyzed from January 2020, through, February 2023. Participants included children aged 2 months to 10 years with UTI exhibiting clinical improvement after 5 days of antimicrobials. Intervention Another 5 days of antimicrobials (standard-course therapy) or 5 days of placebo (short-course therapy). Main Outcome Measures The primary outcome, treatment failure, was defined as symptomatic UTI at or before the first follow-up visit (day 11 to 14). Secondary outcomes included UTI after the first follow-up visit, asymptomatic bacteriuria, positive urine culture, and gastrointestinal colonization with resistant organisms. Results Analysis for the primary outcome included 664 randomized children (639 female [96%]; median age, 4 years). Among children evaluable for the primary outcome, 2 of 328 assigned to standard-course (0.6%) and 14 of 336 assigned to short-course (4.2%) had a treatment failure (absolute difference of 3.6% with upper bound 95% CI of 5.5.%). Children receiving short-course therapy were more likely to have asymptomatic bacteriuria or a positive urine culture at or by the first follow-up visit. There were no differences between groups in rates of UTI after the first follow-up visit, incidence of adverse events, or incidence of gastrointestinal colonization with resistant organisms. Conclusions and Relevance In this randomized clinical trial, children assigned to standard-course therapy had lower rates of treatment failure than children assigned to short-course therapy. However, the low failure rate of short-course therapy suggests that it could be considered as a reasonable option for children exhibiting clinical improvement after 5 days of antimicrobial treatment. Trial Registration ClinicalTrials.gov Identifier: NCT01595529.
Collapse
Affiliation(s)
- Theoklis Zaoutis
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia
| | - Nader Shaikh
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Brian T Fisher
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia
| | - Susan E Coffin
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia
| | - Sonika Bhatnagar
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Kevin J Downes
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia
| | - Jeffrey S Gerber
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia
| | - Timothy R Shope
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Judith M Martin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Gysella B Muniz
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Michael Green
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Jennifer P Nagg
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Sage R Myers
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia
| | - Rakesh D Mistry
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia
| | - Shawn O'Connor
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia
| | - Walter Faig
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia
| | - Stephen Black
- Westat-Biostatistics and Data Management Core, Philadelphia, Pennsylvania
| | - Elizabeth Rowley
- Westat-Biostatistics and Data Management Core, Philadelphia, Pennsylvania
| | - Kellie Liston
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| |
Collapse
|
9
|
Shaikh N, Hoberman A, Shope TR, Jeong JH, Kurs-Lasky M, Martin JM, Bhatnagar S, Muniz GB, Block SL, Andrasko M, Lee MC, Rajakumar K, Wald ER. Identifying Children Likely to Benefit From Antibiotics for Acute Sinusitis: A Randomized Clinical Trial. JAMA 2023; 330:349-358. [PMID: 37490085 PMCID: PMC10370259 DOI: 10.1001/jama.2023.10854] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/01/2023] [Indexed: 07/26/2023]
Abstract
Importance The large overlap between symptoms of acute sinusitis and viral upper respiratory tract infection suggests that certain subgroups of children being diagnosed with acute sinusitis, and subsequently treated with antibiotics, derive little benefit from antibiotic use. Objective To assess if antibiotic therapy could be appropriately withheld in prespecified subgroups. Design, Setting, and Participants Randomized clinical trial including 515 children aged 2 to 11 years diagnosed with acute sinusitis based on clinical criteria. The trial was conducted between February 2016 and April 2022 at primary care offices affiliated with 6 US institutions and was designed to evaluate whether symptom burden differed in subgroups defined by nasopharyngeal Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis on bacterial culture and by the presence of colored nasal discharge. Interventions Oral amoxicillin (90 mg/kg/d) and clavulanate (6.4 mg/kg/d) (n = 254) or placebo (n = 256) for 10 days. Main Outcomes and Measures The primary outcome was symptom burden based on daily symptom scores on a validated scale (range, 0-40) during the 10 days after diagnosis. Secondary outcomes included treatment failure, adverse events including clinically significant diarrhea, and resource use by families. Results Most of the 510 included children were aged 2 to 5 years (64%), male (54%), White (52%), and not Hispanic (89%). The mean symptom scores were significantly lower in children in the amoxicillin and clavulanate group (9.04 [95% CI, 8.71 to 9.37]) compared with those in the placebo group (10.60 [95% CI, 10.27 to 10.93]) (between-group difference, -1.69 [95% CI, -2.07 to -1.31]). The length of time to symptom resolution was significantly lower for children in the antibiotic group (7.0 days) than in the placebo group (9.0 days) (P = .003). Children without nasopharyngeal pathogens detected did not benefit from antibiotic treatment as much as those with pathogens detected; the between-group difference in mean symptom scores was -0.88 (95% CI, -1.63 to -0.12) in those without pathogens detected compared with -1.95 (95% CI, -2.40 to -1.51) in those with pathogens detected. Efficacy did not differ significantly according to whether colored nasal discharge was present (the between-group difference was -1.62 [95% CI, -2.09 to -1.16] for colored nasal discharge vs -1.70 [95% CI, -2.38 to -1.03] for clear nasal discharge; P = .52 for the interaction between treatment group and the presence of colored nasal discharge). Conclusions In children with acute sinusitis, antibiotic treatment had minimal benefit for those without nasopharyngeal bacterial pathogens on presentation, and its effects did not depend on the color of nasal discharge. Testing for specific bacteria on presentation may represent a strategy to reduce antibiotic use in this condition. Trial Registration ClinicalTrials.gov Identifier: NCT02554383.
Collapse
Affiliation(s)
- Nader Shaikh
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy R. Shope
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jong-Hyeon Jeong
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Marcia Kurs-Lasky
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Judith M. Martin
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonika Bhatnagar
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gysella B. Muniz
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Melissa Andrasko
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew C. Lee
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kumaravel Rajakumar
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ellen R. Wald
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison
| |
Collapse
|
10
|
Ray KN, Wittman SR, Yabes JG, Sabik LM, Hoberman A, Mehrotra A. Telemedicine Visits to Children During the Pandemic: Practice-Based Telemedicine Versus Telemedicine-Only Providers. Acad Pediatr 2023; 23:265-270. [PMID: 35589062 PMCID: PMC9666718 DOI: 10.1016/j.acap.2022.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/11/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In March 2020, regulatory and payment changes allowed "brick and mortar" pediatric practices to offer practice-based telemedicine for the first time, joining direct-to-consumer (DTC) telemedicine vendors in the ability to offer visits for common acute pediatric concerns via telemedicine. We sought to characterize the relative contribution of practice-based telemedicine versus commercial DTC telemedicine models in provision of children's telemedicine from 2018 through 2021. METHODS Using January 2018 to September 2021 data from Optum's de-identified Clinformatics® Data Mart Database, we identified telemedicine visits by children ≤17, excluding preventive visits and visits to specialists, emergency departments, and urgent care. Among included visits, we defined "telemedicine-only" providers as those with ≥80% of visits via telemedicine and practice-based telemedicine providers as those with ≤50% of visits via telemedicine. We then described the telemedicine visit volume and diagnoses for these categories overall and per 1000 children per month. RESULTS From January 2018 to February 2020, telemedicine-only providers accounted for 57,815 telemedicine visits (90.8%), while practice-based telemedicine accounted for 4192 telemedicine visits (6.6%). From March 2020 to September 2021, telemedicine-only providers accounted for 38,282 telemedicine visits (6.1%), while practice-based telemedicine accounted for 555,125 telemedicine visits (88.2%). Per month, telemedicine visits to practice-based telemedicine providers increased from pre-pandemic to pandemic periods (0.1 vs 12.9 visits per 1000 children/month), while telemedicine visits to telemedicine-only providers occurred at a similar rate from pre-pandemic to pandemic periods (0.92 vs 0.96 visits per 1000 children/month). CONCLUSIONS We observed a large increase in telemedicine visits during the pandemic, with the growth in visits exclusively occurring among visits to practice-based telemedicine providers as opposed to telemedicine-only providers.
Collapse
Affiliation(s)
- Kristin N Ray
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
| | - Samuel R Wittman
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Jonathan G Yabes
- Department of Medicine (J Yabes), University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Lindsay M Sabik
- Department of Health Policy & Management ( L Sabik), University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pa
| | - Alejandro Hoberman
- Department of Pediatrics (KN Ray, SR Wittman, and A Hoberman), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Ateev Mehrotra
- Department of Health Care Policy (A Mehrotra), Harvard Medical School, Boston, Mass
| |
Collapse
|
11
|
Noorbakhsh KA, Liu H, Kurs-Lasky M, Smith KJ, Hoberman A, Shaikh N. Cost-effectiveness of management strategies in recurrent acute otitis media. J Pediatr 2022; 256:11-17.e2. [PMID: 36470464 DOI: 10.1016/j.jpeds.2022.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/21/2022] [Accepted: 11/30/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of tympanostomy tube placementvs nonsurgical medical management, with the option of tympanostomy tube placement in the event of treatment failure, in children with recurrent acute otitis media (AOM). STUDY DESIGN A Markov decision model compared management strategies in children ages 6-35 months, using patient-level data from a recently completed, multicenter, randomized clinical trial of tympanostomy tube placement vs medical management. The model ran over a 2-year time horizon using a societal perspective. Probabilities, including risk of AOM symptoms, were derived from prospectively collected patient diaries. Costs and quality-of-life measures were derived from the literature. We performed one-way and probabilistic sensitivity analyses, and secondary analyses in predetermined low- and high-risk subgroups. The primary outcome was incremental cost per quality-adjusted life-year gained. RESULTS Tympanostomy tubes cost $989 more per child than medical management. Children managed with tympanostomy tubes gained 0.69 more quality-adjusted life-days than children managed medically, corresponding to $520 855 per quality-adjusted life-year gained. Results were sensitive to the costs of oral antibiotics, missed work, special childcare, the societal cost of antibiotic resistance, and the quality of life associated with AOM. In probabilistic sensitivity analyses, medical management was favored in 66% of model iterations at a willingness-to-pay threshold of $100 000/quality-adjusted life-year. Medical management was preferred in secondary analyses of low- and high-risk subgroups. CONCLUSIONS For young children with recurrent AOM, the additional cost associated with tympanostomy tube placement outweighs the small improvement in quality of life. Medical management for these children is an economically reasonable strategy. TRIAL REGISTRATION ClinicalTrials.gov number, NCT02567825.
Collapse
Affiliation(s)
| | - Hui Liu
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Marcia Kurs-Lasky
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nader Shaikh
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
12
|
Hoberman A. CEC06-02 Pregnancy and nonclinical developmental/reproductive toxicity testing and classification. Toxicol Lett 2022. [DOI: 10.1016/j.toxlet.2022.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
13
|
Shope TR, Shaikh N, Hoberman A. More Recent Literature Does Not Support Premise or Conclusions. JAMA Pediatr 2022; 176:826-827. [PMID: 35696190 DOI: 10.1001/jamapediatrics.2022.1760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Timothy R Shope
- Division of General Academic Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nader Shaikh
- Division of General Academic Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
14
|
Lee C, Preciado D, Hoberman A. Tympanostomy Tubes for Recurrent Otitis Media. N Engl J Med 2022; 387:83-85. [PMID: 35793211 DOI: 10.1056/nejmclde2202050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
15
|
Shaikh N, Lee M, Stokes LR, Miller E, Kurs-Lasky M, Conway I, Shope TR, Hoberman A. Reassessment of the Role of Race in Calculating the Risk for Urinary Tract Infection: A Systematic Review and Meta-analysis. JAMA Pediatr 2022; 176:569-575. [PMID: 35435935 PMCID: PMC9016605 DOI: 10.1001/jamapediatrics.2022.0700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE A previously reported prediction model included a child's race to estimate risk of urinary tract infection (UTI), but race-conscious medicine encourages investigating how race is likely to be a proxy for other factors that should instead be used for risk prediction. OBJECTIVES To systematically review the available literature to evaluate the robustness of the association between race and UTI and to assess whether other variables could replace race as a variable in a previously developed prediction tool without adversely affecting its accuracy. DATA SOURCE MEDLINE was searched through May 28, 2021. STUDY SELECTION English-language studies that reported data on the prevalence of UTI according to race for children younger than 18 years were included. DATA EXTRACTION AND SYNTHESIS Two independent reviewers assessed studies for risk of bias and abstracted data. Random-effects models were used to pool odds ratios, and meta-regression was used to explore heterogeneity. MAIN OUTCOMES AND MEASURES Odds of UTI among non-Black children vs Black children. RESULTS Sixteen studies (17 845 children) were included. In the primary analysis, which included 11 studies, the pooled odds ratio of UTI among non-Black children was 2.44-fold higher (95% CI, 1.87-3.20) than among Black children. The corresponding odds ratio in studies with low or very low risk of bias was 4.84-fold higher (95% CI, 3.16-7.41; I2 = 0%) among non-Black children than among Black children. Replacing race with history of UTI and duration of fever resulted in a model with similar accuracy (training cohort: overall sensitivity, 96% [95% CI, 94%-98%]; overall specificity, 35% [95%, 32%-38%]; overall area under the receiver operating characteristic curve, 0.80 [95% CI, 0.77-0.82]; validation cohort: overall sensitivity, 97% [95% CI, 90%-100%]; overall specificity, 32% [95% CI, 26%-37%]; overall area under the receiver operating characteristic curve, 0.84 [95% CI, 0.77-0.92]). CONCLUSIONS AND RELEVANCE Although previous studies suggested that an association between race and UTI exists, because of the issues associated with the inclusion of race in decision models, we replaced the variable of race with history of UTI and duration of fever in a previously developed risk prediction model and found similar accuracy.
Collapse
Affiliation(s)
- Nader Shaikh
- Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew Lee
- Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lynissa R. Stokes
- Division of Adolescent and Young Adult Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marcia Kurs-Lasky
- Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Isabella Conway
- Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy R. Shope
- Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
16
|
Freeman MC, Freeman TJ, Iagnemma J, Rasmussen J, Heidenreich K, Wells A, Hoberman A, Mitchell SL. Performance of the Sofia SARS-CoV-2 Rapid Antigen Test in Symptomatic and Asymptomatic Pediatric Patients. J Pediatric Infect Dis Soc 2022; 11:417-421. [PMID: 35607860 PMCID: PMC9213844 DOI: 10.1093/jpids/piac035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 05/06/2022] [Indexed: 11/12/2022]
Abstract
The sensitivity and specificity of SARS-CoV-2 antigen tests have not been widely assessed in children. We evaluated children presenting to outpatient care with Quidel Sofia SARS-CoV-2 antigen test (Sofia-Ag-RDT) compared against Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV reverse transcriptase-polymerase chain reaction test from November 2020 to April 2021. Sofia-Ag-RDT had the highest sensitivity in symptomatic (82%; 95% confidence interval, 68%-91%) children.
Collapse
Affiliation(s)
- Megan Culler Freeman
- Department of Pediatrics, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tanner J Freeman
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Jayne Rasmussen
- Clinical Microbiology Laboratory, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Alan Wells
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stephanie L Mitchell
- Corresponding Author: Stephanie L. Mitchell, PhD, 3477 Euler Way, Clinical Laboratory Building, 6th Floor, Pittsburgh, PA 15213, USA. E-mail:
| |
Collapse
|
17
|
Muniz GB, Shope TR, Bhatnagar S, Shaikh N, Haralam MA, Liu H, Martin JM, Pogoda JM, Hoberman A. Intranasal Surfactant for Acute Otitis Media: A Randomized Trial. Pediatrics 2021; 148:183389. [PMID: 34851411 DOI: 10.1542/peds.2021-051703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Acute otitis media (AOM) is the most frequent reason for children to be prescribed antimicrobial treatment. Surfactants are naturally occurring substances that may restore the eustachian tube's function and potentially enhance resolution of AOM. METHODS This was a phase 2a, single-center, double-blind, randomized, placebo-controlled, parallel group clinical trial to assess safety, tolerability, and efficacy of 20 mg per day intranasal OP0201 as an adjunct therapy to oral antimicrobial agents for treating AOM in young children. We randomly assigned 103 children aged 6 to 24 months with AOM to receive either OP0201 or placebo twice daily for 10 days. All children received amoxicillin-clavulanate 90/6.4 mg/kg per day in 2 divided doses for 10 days. Participants were managed for up to 1 month. Postrandomization visits occurred between days 4 and 6 (visit 2), days 12 and 14 (visit 3), and days 26 and 30 (visit 4). Primary efficacy endpoints were resolution of a bulging tympanic membrane at visit 2 and resolution of middle-ear effusion at visit 3. RESULTS No clinically meaningful differences between treatment groups were apparent for primary or secondary endpoints. There were no safety concerns identified. CONCLUSIONS In young children with AOM, intranasally administered surfactant (OP0201) did not improve clinical outcomes. Further research may be warranted among children with persistent middle-ear effusion.
Collapse
Affiliation(s)
- Gysella B Muniz
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy R Shope
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonika Bhatnagar
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nader Shaikh
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary Ann Haralam
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hui Liu
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Judith M Martin
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Alejandro Hoberman
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
18
|
Mitchell SL, Orris S, Freeman T, Freeman MC, Adam M, Axe M, Gribschaw J, Suyama J, Hoberman A, Wells A. Performance of SARS-CoV-2 antigen testing in symptomatic and asymptomatic adults: a single-center evaluation. BMC Infect Dis 2021. [PMID: 34663212 DOI: 10.1186/s12879-021-06716-1/tables/2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Antigen testing offers rapid and inexpensive testing for SARS-CoV-2 but concerns regarding performance, especially sensitivity, remain. Limited data exists for use of antigen testing in asymptomatic patients; thus, performance and reliability of antigen testing remains unclear. METHODS 148 symptomatic and 144 asymptomatic adults were included. A nasal swab was collected for testing by Quidel Sofia SARS IFA (Sofia) as point of care. A nasopharyngeal swab was also collected and transported to the laboratory for testing by Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV RT-PCR (Cepheid). RESULTS Overall, Sofia had good agreement with Cepheid (> 95%) in adults, however was less sensitive. Sofia had a sensitivity of 87.8% and 33.3% for symptomatic and asymptomatic patients, respectively. Among symptomatic patients, testing > 5 days post symptom onset resulted in lower sensitivity (82%) when compared with testing within 5 days of symptom onset (90%). Of the four Sofia false-negative results in the asymptomatic cohort, 50% went on to develop COVID-19 disease within 5 days of testing. Specificity in both symptomatic and asymptomatic cohorts was 100%. CONCLUSIONS Sofia has acceptable performance in symptomatic adults when tested < 5 days of symptom onset. Caution should be taken when testing patients with ≥ 5 days of symptoms. The combination of low prevalence and reduced sensitivity results in relatively poor performance of in asymptomatic patients. NAAT-based diagnostic assays should be considered in when antigen testing is unreliable, particularly in symptomatic patients with > 5 days of symptom onset and asymptomatic patients.
Collapse
Affiliation(s)
- Stephanie L Mitchell
- Department of Pathology, University of Pittsburgh, 3477 Euler Way, Clinical Laboratory Building-6th Floor, Pittsburgh, PA, 15213, USA.
| | - Steven Orris
- Division of General Internal Medicine, Center for Research On Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tanner Freeman
- Department of Pathology, University of Pittsburgh, 3477 Euler Way, Clinical Laboratory Building-6th Floor, Pittsburgh, PA, 15213, USA
| | - Megan C Freeman
- Department of Pediatrics, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Michelle Adam
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jamie Gribschaw
- Clinical Microbiology Laboratory, UPMC Hospital System, Pittsburgh, PA, 15261, USA
| | - Joe Suyama
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Alan Wells
- Department of Pathology, University of Pittsburgh, 3477 Euler Way, Clinical Laboratory Building-6th Floor, Pittsburgh, PA, 15213, USA
| |
Collapse
|
19
|
Mitchell SL, Orris S, Freeman T, Freeman MC, Adam M, Axe M, Gribschaw J, Suyama J, Hoberman A, Wells A. Performance of SARS-CoV-2 antigen testing in symptomatic and asymptomatic adults: a single-center evaluation. BMC Infect Dis 2021; 21:1071. [PMID: 34663212 PMCID: PMC8521263 DOI: 10.1186/s12879-021-06716-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/22/2021] [Indexed: 01/09/2023] Open
Abstract
Background Antigen testing offers rapid and inexpensive testing for SARS-CoV-2 but concerns regarding performance, especially sensitivity, remain. Limited data exists for use of antigen testing in asymptomatic patients; thus, performance and reliability of antigen testing remains unclear. Methods 148 symptomatic and 144 asymptomatic adults were included. A nasal swab was collected for testing by Quidel Sofia SARS IFA (Sofia) as point of care. A nasopharyngeal swab was also collected and transported to the laboratory for testing by Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV RT-PCR (Cepheid). Results Overall, Sofia had good agreement with Cepheid (> 95%) in adults, however was less sensitive. Sofia had a sensitivity of 87.8% and 33.3% for symptomatic and asymptomatic patients, respectively. Among symptomatic patients, testing > 5 days post symptom onset resulted in lower sensitivity (82%) when compared with testing within 5 days of symptom onset (90%). Of the four Sofia false-negative results in the asymptomatic cohort, 50% went on to develop COVID-19 disease within 5 days of testing. Specificity in both symptomatic and asymptomatic cohorts was 100%. Conclusions Sofia has acceptable performance in symptomatic adults when tested < 5 days of symptom onset. Caution should be taken when testing patients with ≥ 5 days of symptoms. The combination of low prevalence and reduced sensitivity results in relatively poor performance of in asymptomatic patients. NAAT-based diagnostic assays should be considered in when antigen testing is unreliable, particularly in symptomatic patients with > 5 days of symptom onset and asymptomatic patients.
Collapse
Affiliation(s)
- Stephanie L Mitchell
- Department of Pathology, University of Pittsburgh, 3477 Euler Way, Clinical Laboratory Building-6th Floor, Pittsburgh, PA, 15213, USA.
| | - Steven Orris
- Division of General Internal Medicine, Center for Research On Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tanner Freeman
- Department of Pathology, University of Pittsburgh, 3477 Euler Way, Clinical Laboratory Building-6th Floor, Pittsburgh, PA, 15213, USA
| | - Megan C Freeman
- Department of Pediatrics, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Michelle Adam
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Meredith Axe
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jamie Gribschaw
- Clinical Microbiology Laboratory, UPMC Hospital System, Pittsburgh, PA, 15261, USA
| | - Joe Suyama
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Alan Wells
- Department of Pathology, University of Pittsburgh, 3477 Euler Way, Clinical Laboratory Building-6th Floor, Pittsburgh, PA, 15213, USA
| |
Collapse
|
20
|
Ray KN, Martin JM, Wolfson D, Schweiberger K, Schoemer P, Cepullio C, Iagnemma J, Hoberman A. Antibiotic Prescribing for Acute Respiratory Tract Infections During Telemedicine Visits Within a Pediatric Primary Care Network. Acad Pediatr 2021; 21:1239-1243. [PMID: 33741531 DOI: 10.1016/j.acap.2021.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/28/2021] [Accepted: 03/12/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Regulatory and payment changes associated with COVID-19 facilitated wide-spread use of telehealth within pediatric primary care starting in March 2020. Given prior quality concerns about antibiotic management for children during telemedicine visits outside of primary care, we sought to examine acute respiratory tract infection (ARTI) visit volume and antibiotic management for children via telemedicine integrated within pediatric primary care. METHODS Using electronic health record data from 47 practices within a large pediatric primary care network, we identified visits for ARTI from April to September 2020. For these visits, we categorized antibiotic management consistent with clinical guidelines as guideline concordant. We compared telemedicine and in-person visit guideline-concordant antibiotic management, diagnoses, and antibiotic prescribing using chi-square tests and examined trends over time using descriptive statistics. Antibiotic stewardship during the study period included learning collaborative videoconferences and sharing of clinic and clinician-level metrics through an interactive dashboard. RESULTS During the 6-month period, 8332 ARTI visits were identified, with 3003 (36%) via telemedicine. Guideline-concordant antibiotic management occurred in 92.5% of telemedicine visits compared to 90.7% of in-person office visits (P = .004). Telemedicine ARTI visits receiving diagnoses of acute otitis media or streptococcal pharyngitis declined from peak of 52% (May) to 7% (September). Guideline-concordant antibiotic management of sinusitis and viral ARTI during telemedicine visits increased from 88% (April) to 97% (September). CONCLUSION With active antibiotic stewardship, pediatricians practicing within certified medical homes consistently delivered highly guideline-concordant care for ARTIs to their patient population via telemedicine integrated into primary care.
Collapse
Affiliation(s)
- Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
| | - Judith M Martin
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | | | - Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| | - Pam Schoemer
- UPMC Children's Community Pediatrics, Wexford, Pa
| | | | | | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa
| |
Collapse
|
21
|
Shaikh N, Friedlander EJ, Tate PJ, Liu H, Chang CCH, Wells A, Hoberman A. Performance of a Rapid SARS-CoV-2 Antigen Detection Assay in Symptomatic Children. Pediatrics 2021; 148:peds.2021-050832. [PMID: 34039718 DOI: 10.1542/peds.2021-050832] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Eric J Friedlander
- Children's Community Pediatrics; University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick J Tate
- Children's Community Pediatrics; University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Alan Wells
- Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | |
Collapse
|
22
|
Burgette JM, Ok SH, Ray KN, Faulds S, Stiles A, Hoberman A, Martin B. Race and payor type for child visits with public health dental hygienist practitioners. J Public Health Dent 2021; 82:53-60. [PMID: 34378198 DOI: 10.1111/jphd.12474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/12/2021] [Accepted: 07/29/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To examine whether growth in visits to public health dental hygiene practitioners (PHDHPs) providing preventative dental services at a pediatric hospital clinic was predominantly among children receiving public insurance and children of minority background from 2013 to 2017. METHODS Longitudinal descriptive data analysis from electronic health records for 6856 children under age 18 years who visited PHDHPs co-located at a hospital clinic in Pittsburgh, PA, from 2013 to 2017. We compared visits between white versus non-white children and between children with public, private, and no or missing insurance by year. RESULTS Visit volume doubled from 2013 (n = 811) to 2017 (n = 1868). The proportion of PHDHP visits with non-white children increased from 77% (n = 625) in 2013 to 87% (n = 1472) in 2017 (p < 0.001). The proportion of PHDHP visits with children with public insurance increased from 72% (n = 585) in 2013 to 82% (n = 1377) in 2017 (p < 0.001). CONCLUSIONS PHDHPs co-located at a pediatric hospital clinic saw a high proportion of visits from children of non-white race and with public insurance. Visits from children of minority race and with public insurance increased disproportionately as visit volume grew from 2013 to 2017, depicting a vehicle through which historically underserved children increasingly accessed preventive dental services.
Collapse
Affiliation(s)
- Jacqueline M Burgette
- Departments of Dental Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sally H Ok
- Department of Pediatric Dentistry, University of Pittsburgh School of Dental Medicine, Pittsburgh, Pennsylvania, USA
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,General Academic Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samantha Faulds
- General Academic Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amy Stiles
- Division of Pediatric Dentistry, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,General Academic Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian Martin
- Division of Pediatric Dentistry, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.,Medical Affairs, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
23
|
Hoberman A, Preciado D, Paradise JL, Chi DH, Haralam M, Block SL, Kearney DH, Bhatnagar S, Muñiz Pujalt GB, Shope TR, Martin JM, Felten DE, Kurs-Lasky M, Liu H, Yahner K, Jeong JH, Cohen NL, Czervionke B, Nagg JP, Dohar JE, Shaikh N. Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media. N Engl J Med 2021; 384:1789-1799. [PMID: 33979487 PMCID: PMC8969083 DOI: 10.1056/nejmoa2027278] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Official recommendations differ regarding tympanostomy-tube placement for children with recurrent acute otitis media. METHODS We randomly assigned children 6 to 35 months of age who had had at least three episodes of acute otitis media within 6 months, or at least four episodes within 12 months with at least one episode within the preceding 6 months, to either undergo tympanostomy-tube placement or receive medical management involving episodic antimicrobial treatment. The primary outcome was the mean number of episodes of acute otitis media per child-year (rate) during a 2-year period. RESULTS In our main, intention-to-treat analysis, the rate (±SE) of episodes of acute otitis media per child-year during a 2-year period was 1.48±0.08 in the tympanostomy-tube group and 1.56±0.08 in the medical-management group (P = 0.66). Because 10% of the children in the tympanostomy-tube group did not undergo tympanostomy-tube placement and 16% of the children in the medical-management group underwent tympanostomy-tube placement at parental request, we conducted a per-protocol analysis, which gave corresponding episode rates of 1.47±0.08 and 1.72±0.11, respectively. Among secondary outcomes in the main analysis, results were mixed. Favoring tympanostomy-tube placement were the time to a first episode of acute otitis media, various episode-related clinical findings, and the percentage of children meeting specified criteria for treatment failure. Favoring medical management was children's cumulative number of days with otorrhea. Outcomes that did not show substantial differences included the frequency distribution of episodes of acute otitis media, the percentage of episodes considered to be severe, and antimicrobial resistance among respiratory isolates. Trial-related adverse events were limited to those included among the secondary outcomes of the trial. CONCLUSIONS Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management. (Funded by the National Institute on Deafness and Other Communication Disorders and others; ClinicalTrials.gov number, NCT02567825.).
Collapse
Affiliation(s)
- Alejandro Hoberman
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Diego Preciado
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Jack L Paradise
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - David H Chi
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - MaryAnn Haralam
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Stan L Block
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Diana H Kearney
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Sonika Bhatnagar
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Gysella B Muñiz Pujalt
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Timothy R Shope
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Judith M Martin
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Daniel E Felten
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Marcia Kurs-Lasky
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Hui Liu
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Kristin Yahner
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Jong-Hyeon Jeong
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Norman L Cohen
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Brian Czervionke
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Jennifer P Nagg
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Joseph E Dohar
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Nader Shaikh
- From the Departments of Pediatrics (A.H., J.L.P., M.H., D.H.K., S.B., G.B.M.P., T.R.S., J.M.M., M.K.-L., H.L., K.Y., J.P.N., N.S.) and Otolaryngology (D.H.C., J.E.D.), University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, the Department of Biostatistics, University of Pittsburgh Graduate School of Public Health (J.-H.J.), and Children's Community Pediatrics (N.L.C., B.C.) - all in Pittsburgh; Children's National Medical Center, Washington, DC (D.P., D.E.F.); and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| |
Collapse
|
24
|
Zaoutis T, Bhatnagar S, Black SI, Coffin SE, Coffin SE, Downes KJ, Fisher BT, Fisher BT, Gerber J, Green MD, Lautenbach E, Liston K, Martin J, Muniz G, Myers SR, O’Connor S, Rowley E, Shaikh N, Shope T, Hoberman A. 639. Short Course Therapy for Urinary Tract Infections (SCOUT) in Children. Open Forum Infect Dis 2020. [PMCID: PMC7777724 DOI: 10.1093/ofid/ofaa439.833] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background The AAP recommends 7 to 14-days of antimicrobials for the treatment of urinary tract infections (UTIs), one of the most common bacterial infections of childhood. However, most physicians routinely prescribe at least 10 days of therapy. Prior observational studies suggest that courses shorter than 10 days might be effective. Methods The primary objective was to determine if halting antimicrobial therapy in children who improved clinically after 5 days of therapy (short course therapy) results in a similar failure rate as children who continue antimicrobials for an additional 5 days (standard course therapy). This was a multi-center, randomized, double-blind, placebo-controlled non-inferiority clinical trial of children ages 2 to 10 years with UTI. Subjects treated with 1 of 5 antibiotics (trimethoprim-sulfamethoxazole, amoxicillin-clavulanate, cefixime, cefdinir or cephalexin) were eligible. Children were stratified by presence or absence of fever and were enrolled if they had clinical improvement before Day 5 of treatment. The a priori equivalence interval was set at 0.05 for a one-sided analysis. The primary outcome was development of a symptomatic UTI defined as the presence of symptoms, pyuria, and a positive urine culture. The Intent-to-Treat population included children who took at least one dose of study medication. Results A total of 693 children were randomized, 345 to short course and 348 to standard course. Median age was 4 years old (IQR; 2-6), 652 (96.3%) were female and 255 were febrile (37%). Treatment success rate was 322/336 (96%) for short course and 326/328 (99%) for standard course. The 95% upper CI limit for the difference was 0.054. Treatment failure was not related to age group, fever at presentation, antibiotic type, or study site. There were no significant differences between groups the in the rates of adverse events, recurrent infection, clinical symptoms that may have been related to UTI, or emergent antibiotic resistance. Conclusion In children aged 2 months to 10 years with UTI, halting antimicrobial therapy in children who had exhibited clinical improvement after 5 days and continuing for an additional 5 days both resulted in high success rates. However, short course was inferior to treatment for 10 days. Disclosures Kevin J. Downes, MD, Merck, Inc. (Grant/Research Support) Brian T. Fisher, DO, MPH, MSCE, Astellas (Advisor or Review Panel member)Merck (Grant/Research Support)Pfizer (Grant/Research Support)
Collapse
Affiliation(s)
| | - Sonika Bhatnagar
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Susan E Coffin
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan E Coffin
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin J Downes
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian T Fisher
- Children’s Hospital of Philadelphia; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian T Fisher
- Children’s Hospital of Philadelphia; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey Gerber
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael D Green
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Kellie Liston
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Gysella Muniz
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sage R Myers
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shawn O’Connor
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Nader Shaikh
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy Shope
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | |
Collapse
|
25
|
Schweiberger K, Hoberman A, Iagnemma J, Schoemer P, Squire J, Taormina J, Wolfson D, Ray KN. Practice-Level Variation in Telemedicine Use in a Pediatric Primary Care Network During the COVID-19 Pandemic: Retrospective Analysis and Survey Study. J Med Internet Res 2020; 22:e24345. [PMID: 33290244 PMCID: PMC7752181 DOI: 10.2196/24345] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 01/18/2023] Open
Abstract
Background Telehealth, the delivery of health care through telecommunication technology, has potential to address multiple health system concerns. Despite this potential, only 15% of pediatric primary care clinicians reported using telemedicine as of 2016, with the majority identifying inadequate payment for these services as the largest barrier to their adoption. The COVID-19 pandemic led to rapid changes in payment and regulations surrounding telehealth, enabling its integration into primary care pediatrics. Objective Due to limited use of telemedicine in primary care pediatrics prior to the COVID-19 pandemic, much is unknown about the role of telemedicine in pediatric primary care. To address this gap in knowledge, we examined the association between practice-level telemedicine use within a large pediatric primary care network and practice characteristics, telemedicine visit diagnoses, in-person visit volumes, child-level variations in telemedicine use, and clinician attitudes toward telemedicine. Methods We analyzed electronic health record data from 45 primary care practices and administered a clinician survey to practice clinicians. Practices were stratified into tertiles based on rates of telemedicine use (low, intermediate, high) per 1000 patients per week during a two-week period (April 19 to May 2, 2020). By practice tertile, we compared (1) practice characteristics, (2) telemedicine visit diagnoses, (3) rates of in-person visits to the office, urgent care, and the emergency department, (4) child-level variation in telemedicine use, and (5) clinician attitudes toward telemedicine across these practices. Results Across pediatric primary care practices, telemedicine visit rates ranged from 5 to 23 telemedicine visits per 1000 patients per week. Across all tertiles, the most frequent telemedicine visit diagnoses were mental health (28%-36% of visits) and dermatologic (15%-28%). Compared to low telemedicine use practices, high telemedicine use practices had fewer in-person office visits (10 vs 16 visits per 1000 patients per week, P=.005) but more total encounters overall (in-office and telemedicine: 28 vs 22 visits per 1000 patients per week, P=.006). Telemedicine use varied with child age, race and ethnicity, and recent preventive care; however, no significant interactions existed between these characteristics and practice-level telemedicine use. Finally, clinician attitudes regarding the usability and impact of telemedicine did not vary significantly across tertiles. Conclusions Across a network of pediatric practices, we identified significant practice-level variation in telemedicine use, with increased use associated with more varied telemedicine diagnoses, fewer in-person office visits, and increased overall primary care encounter volume. Thus, in the context of the pandemic, when underutilization of primary care was prevalent, higher practice-level telemedicine use supported pediatric primary care encounter volume closer to usual rates. Child-level telemedicine use differed by child age, race and ethnicity, and recent preventive care, building upon prior concerns about differences in access to telemedicine. However, increased practice-level use of telemedicine services was not associated with reduced or increased differences in use, suggesting that further work is needed to promote equitable access to primary care telemedicine.
Collapse
Affiliation(s)
- Kelsey Schweiberger
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| | | | - Pamela Schoemer
- UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| | - Joseph Squire
- UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| | - Jill Taormina
- UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| | - David Wolfson
- UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,UPMC Children's Community Pediatrics, Pittsburgh, PA, United States
| |
Collapse
|
26
|
Burgette JM, Mestre Y, Martin B, Ray KN, Stiles A, Hoberman A. Success rates of pediatric dental referrals made by public health dental hygiene practitioners. J Public Health Dent 2020; 81:169-177. [DOI: 10.1111/jphd.12428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/13/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Jacqueline M. Burgette
- Department of Dental Public Health University of Pittsburgh Pittsburgh PA USA
- Department of Pediatric Dentistry University of Pittsburgh Pittsburgh PA USA
| | | | - Brian Martin
- University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh Pittsburgh PA USA
| | - Kristin N. Ray
- Department of Pediatrics University of Pittsburgh School of Medicine, University of Pittsburgh Pittsburgh PA USA
| | - Amy Stiles
- University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh Pittsburgh PA USA
| | - Alejandro Hoberman
- Department of Pediatrics University of Pittsburgh School of Medicine, University of Pittsburgh Pittsburgh PA USA
| |
Collapse
|
27
|
Bhatnagar S, Hoberman A, Kurs-Lasky M, Kearney DH, Haralam MA, Nagg J, Shaikh N. An innovative recruitment strategy in a pediatric clinical trial. Clin Trials 2020; 17:338-340. [PMID: 32114798 DOI: 10.1177/1740774520910396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sonika Bhatnagar
- Department of Pediatrics, Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alejandro Hoberman
- Department of Pediatrics, Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marcia Kurs-Lasky
- Department of Pediatrics, Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Diana H Kearney
- Department of Pediatrics, Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mary Ann Haralam
- Department of Pediatrics, Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer Nagg
- Department of Pediatrics, Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nader Shaikh
- Department of Pediatrics, Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
28
|
Shaikh N, Martin JM, Hoberman A, Skae M, Milkovich L, McElheny C, Hickey RW, Gabriel LV, Kearney DH, Majd M, Shalaby-Rana E, Tseng G, Kolls J, Horne W, Huo Z, Shope TR. Biomarkers that differentiate false positive urinalyses from true urinary tract infection. Pediatr Nephrol 2020; 35:321-329. [PMID: 31758242 PMCID: PMC6942213 DOI: 10.1007/s00467-019-04403-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/26/2019] [Accepted: 10/16/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND The specificity of the leukocyte esterase test (87%) is suboptimal. The objective of this study was to identify more specific screening tests that could reduce the number of children who unnecessarily receive antimicrobials to treat a presumed urinary tract infection (UTI). METHODS Prospective cross-sectional study to compare inflammatory proteins in blood and urine samples collected at the time of a presumptive diagnosis of UTI. We also evaluated serum RNA expression in a subset. RESULTS We enrolled 200 children; of these, 89 were later demonstrated not to have a UTI based on the results of the urine culture obtained. Urinary proteins that best discriminated between children with UTI and no UTI were involved in T cell response proliferation (IL-9, IL-2), chemoattractants (CXCL12, CXCL1, CXCL8), the cytokine/interferon pathway (IL-13, IL-2, INFγ), or involved in innate immunity (NGAL). The predictive power (as measured by the area under the curve) of a combination of four urinary markers (IL-2, IL-9, IL-8, and NGAL) was 0.94. Genes in the pathways related to inflammation were also upregulated in serum of children with UTI. CONCLUSIONS Urinary proteins involved in the inflammatory response may be useful in identifying children with false positive results with current screening tests for UTI; this may reduce unnecessary treatment.
Collapse
Affiliation(s)
- Nader Shaikh
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA. .,Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA.
| | - Judith M Martin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA.,Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA.,Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Megan Skae
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Linette Milkovich
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Christi McElheny
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Lucine V Gabriel
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Diana H Kearney
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Massoud Majd
- Children's National Health System, Washington, USA
| | | | - George Tseng
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jay Kolls
- Tulane School of Medicine, New Orleans, PA, USA
| | - William Horne
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Zhiguang Huo
- Department of Biostatistics, Biostatistics, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, USA
| | - Timothy R Shope
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA.,Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| |
Collapse
|
29
|
Abstract
IMPORTANCE Although prior studies have suggested that the risk of renal scarring gradually increases with each febrile urinary tract infection (UTI), recent and detailed data are lacking. OBJECTIVE To evaluate how the risk of renal scarring is associated with the number of febrile UTIs. DESIGN, SETTING, AND PARTICIPANTS A post hoc analysis was performed from June 2018 to April 2019 of data collected in the context of 2 multicenter prospective studies (RIVUR [Randomized Intervention for Children With Vesicoureteral Reflux], conducted from June 2007 to June 2013, and CUTIE [Careful Urinary Tract Infection Evaluation], conducted from May 2008 to October 2013), of children with a first UTI without baseline renal abnormalities who were followed up for 2 years for febrile recurrences. EXPOSURE Number of known febrile UTIs. MAIN OUTCOMES AND MEASURES Renal scarring was defined as decreased uptake of tracer associated with the loss of contours or cortical thinning on a technetium 99m dimercaptosuccinic acid renal scan obtained at study exit or approximately 4 months after the last febrile UTI. RESULTS A total of 345 children were included (307 girls and 38 boys; mean [SD] age, 19.4 [18.2] months; 221 with vesicoureteral reflux and 124 without vesicoureteral reflux). The incidence of renal scarring was 2.8% (95% CI, 1.2%-5.8%) after 1 febrile UTI, 25.7% (95% CI, 12.5%-43.3%) after 2 febrile UTIs, and 28.6% (95% CI, 8.4%-58.1%) after 3 or more febrile UTIs. The odds of renal scarring after a second febrile infection were 11.8 (95% CI, 4.1-34.4) times greater than after a single febrile infection, and the odds of renal scarring after 3 or more febrile infections were 13.7 (95% CI, 3.4-54.4) times greater than after a single febrile infection. CONCLUSIONS AND RELEVANCE Although relatively few children have 2 febrile UTIs, those who do have a substantially higher risk of renal scarring compared with children with a single febrile UTI. This finding suggests that research should focus on the identification of biomarkers that could noninvasively identify children at risk for subsequent febrile infections. More research is also needed to understand the molecular basis of the increased risk of renal scarring among children with recurrent febrile UTIs.
Collapse
Affiliation(s)
- Nader Shaikh
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Ann Haralam
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marcia Kurs-Lasky
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
30
|
Shaikh N, Kurs-Lasky M, Hoberman A. Modification of the acute otitis media symptom severity scale. Int J Pediatr Otorhinolaryngol 2019; 122:170-174. [PMID: 31035175 DOI: 10.1016/j.ijporl.2019.04.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/16/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To modify a parent-reported scale we developed to follow symptoms of young children with acute otitis media (AOM-SOS) with the aim of improving its psychometric properties. STUDY DESIGN We modified version 4.0 of the scale by increasing the number of response options from 3 to 6. We compared the distribution of scores, internal reliability, construct validity, and responsiveness of versions 4.0 and 5.0 in children diagnosed with acute otitis media (AOM) in 2 studies. For Version 5.0, we also estimated the minimal important difference (MID) and assessed its construct validity. RESULTS 291 and 70 children were enrolled in the studies evaluating version 4.0 and 5.0, respectively. Version 5.0 had fewer items at the ceiling and better psychometric properties (responsiveness, internal reliability, and test-retest reliability). Changes in the score for Version 5.0 corresponded to changes in clinical status. Factor analysis supported a one-factor solution. Children whose parents reported only a small degree of improvement on the diary (compared to the day before) had a mean decrease in AOM-SOS score of approximately 20%. This value can be used as the MID for this version of the scale. CONCLUSIONS Modification of the AOM-SOS improved its psychometric properties. Data presented here support the use of Version 5.0 of the AOM-SOS as a measure of change in symptom burden in clinical trials of children with acute otitis media.
Collapse
Affiliation(s)
- Nader Shaikh
- University of Pittsburgh School of Medicine, Division of General Academic Pediatrics, USA.
| | - Marcia Kurs-Lasky
- University of Pittsburgh School of Medicine, Division of General Academic Pediatrics, USA.
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine, Division of General Academic Pediatrics, USA.
| |
Collapse
|
31
|
Shaikh N, Martin JM, Hoberman A, Skae M, Milkovich L, Nowalk A, McElheny C, Hickey RW, Kearney D, Majd M, Shalaby-Rana E, Tseng G, Alcorn JF, Kolls J, Kurs-Lasky M, Huo Z, Horne W, Lockhart G, Pohl H, Shope TR. Host and Bacterial Markers that Differ in Children with Cystitis and Pyelonephritis. J Pediatr 2019; 209:146-153.e1. [PMID: 30905425 PMCID: PMC6535366 DOI: 10.1016/j.jpeds.2019.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine whether treatment for urinary tract infections in children could be individualized using biomarkers for acute pyelonephritis. STUDY DESIGN We enrolled 61 children with febrile urinary tract infections, collected blood and urine samples, and performed a renal scan within 2 weeks of diagnosis to identify those with pyelonephritis. Renal scans were interpreted centrally by 2 experts. We measured inflammatory proteins in blood and urine using LUMINEX or an enzyme-linked immunosorbent assay. We evaluated serum RNA expression using RNA sequencing in a subset of children. Finally, for children with Escherichia coli isolated from urine cultures, we performed a polymerase chain reaction for 4 previously identified virulence genes. RESULTS Urinary markers that best differentiated pyelonephritis from cystitis included chemokine (C-X-C motif) ligand (CXCL)1, CXCL9, CXCL12, C-C motif chemokine ligand 2, INF γ, and IL-15. Serum procalcitonin was the best serum marker for pyelonephritis. Genes in the interferon-γ pathway were upregulated in serum of children with pyelonephritis. The presence of E coli virulence genes did not correlate with pyelonephritis. CONCLUSIONS Immune response to pyelonephritis and cystitis differs quantitatively and qualitatively; this may be useful in differentiating these 2 conditions.
Collapse
Affiliation(s)
- Nader Shaikh
- Department of Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, PA.
| | - Judith M. Martin
- University of Pittsburgh School of Medicine,Children’s Hospital of Pittsburgh of UPMC
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine,Children’s Hospital of Pittsburgh of UPMC
| | - Megan Skae
- Children’s Hospital of Pittsburgh of UPMC
| | | | - Andrew Nowalk
- University of Pittsburgh School of Medicine,Children’s Hospital of Pittsburgh of UPMC
| | - Christi McElheny
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine
| | - Robert W. Hickey
- University of Pittsburgh School of Medicine,Children’s Hospital of Pittsburgh of UPMC
| | | | | | | | - George Tseng
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh
| | | | | | | | - Zhiguang Huo
- Department of Biostatistics, College of Public Health & Health Professions, University of Florida
| | | | | | | | - Timothy R. Shope
- University of Pittsburgh School of Medicine,Children’s Hospital of Pittsburgh of UPMC
| |
Collapse
|
32
|
Shaikh N, Wald ER, Jeong JH, Kurs-Lasky M, Nash D, Pichichero ME, Kearney DH, Haralam MA, Bowen A, Flom LL, Hoberman A. Development and Modification of an Outcome Measure to Follow Symptoms of Children with Sinusitis. J Pediatr 2019; 207:103-108.e1. [PMID: 30545562 PMCID: PMC6440829 DOI: 10.1016/j.jpeds.2018.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/09/2018] [Accepted: 11/06/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To develop a parent-reported Pediatric Rhinosinusitis Symptom Scale (PRSS) that could be used to monitor symptoms of young children with acute sinusitis in response to therapy. STUDY DESIGN We developed an 8-item symptom severity scale and evaluated its internal reliability, construct validity, and responsiveness in children 2-12 years of age with acute sinusitis. Parents of 258 children with acute sinusitis completed the PRSS at the time of diagnosis, as a diary at home, and at the follow-up visit at days 10-12. Based on psychometric results and additional parent feedback, we revised the scale. We evaluated the revised version in 185 children with acute sinusitis. RESULTS Correlations between the scale and reference measures on the day of enrollment were in the expected direction and of the expected magnitude. PRSS scores at the time of presentation correlated with radiographic findings (P < .001), functional status (P < .001), and parental assessment of overall symptom severity (P < .001). Responsiveness (standardized response mean) and test-retest reliability of the revised scale were good (2.17 and 0.75, respectively). CONCLUSIONS We have developed an outcome measure to track the symptoms of acute sinusitis. Data presented here support the use of the PRSS as a measure of change in symptom burden in clinical trials of children with acute sinusitis.
Collapse
Affiliation(s)
- Nader Shaikh
- Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Ellen R. Wald
- University of Wisconsin School of Medicine and Public Health
| | | | - Marcia Kurs-Lasky
- University of Pittsburgh School of Medicine, Division of General Academic Pediatrics
| | - David Nash
- University of Pittsburgh School of Medicine, Division of Allergy and Immunology
| | | | - Diana H. Kearney
- University of Pittsburgh School of Medicine, Division of General Academic Pediatrics
| | - Mary Ann Haralam
- University of Pittsburgh School of Medicine, Division of General Academic Pediatrics
| | - A’Delbert Bowen
- Children’s Hospital of Pittsburgh, Division of Pediatric Radiology
| | - Lynda L. Flom
- Children’s Hospital of Pittsburgh, Division of Pediatric Radiology
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine, Division of General Academic Pediatrics
| |
Collapse
|
33
|
Shaikh N, Rajakumar V, Peterson CG, Gorski J, Ivanova A, Gravens Muller L, Miyashita Y, Smith KJ, Mattoo T, Pohl HG, Mathews R, Greenfield SP, Docimo SG, Hoberman A. Cost-Utility of Antimicrobial Prophylaxis for Treatment of Children With Vesicoureteral Reflux. Front Pediatr 2019; 7:530. [PMID: 31998668 PMCID: PMC6965145 DOI: 10.3389/fped.2019.00530] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/05/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: Antimicrobial prophylaxis for children with vesicoureteral reflux (VUR) reduces recurrences of urinary tract infection (UTI) but requires daily antimicrobials for extended periods. We used a cost-utility model to evaluate whether the benefits of antimicrobial prophylaxis outweigh its risks and, if so, to investigate whether the benefits and risks vary according to grade of VUR. Methods: We compared the cost per quality-adjusted life-year (QALY) gained in four treatment strategies in children aged <6 years diagnosed with VUR after a first UTI, considering these treatment strategies: (1) prophylaxis for all children with VUR, (2) prophylaxis for children with Grade III or Grade IV VUR, (3) prophylaxis for children with Grade IV VUR, and (4) no prophylaxis. Costs and effectiveness were estimated over the patient's lifetime. We used $100,000/QALY gained as the threshold for considering a treatment strategy cost effective. Results: Based on current data and plausible ranges to account for data uncertainty, prophylaxis of children with Grades IV VUR costs $37,903 per QALY gained. Treating children with Grade III and IV VUR costs an additional $302,024 per QALY gained. Treating children with all grades of VUR costs an additional $339,740 per QALY gained. Conclusions: Treating children with Grades I, II, and III VUR with long-term antimicrobial prophylaxis costs substantially more than interventions typically considered economically reasonable. Prophylaxis in children with Grade IV VUR is cost effective.
Collapse
Affiliation(s)
- Nader Shaikh
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Vinod Rajakumar
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Caitlin G Peterson
- Nephrology, University of Utah Health, Salt Lake City, UT, United States
| | - Jillian Gorski
- Department of Pediatrics, Indiana University, Indianapolis, IN, United States
| | - Anastasia Ivanova
- Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lisa Gravens Muller
- Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Yosuke Miyashita
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kenneth J Smith
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Tej Mattoo
- Nephrology, Wayne State University School of Medicine, Detroit, MI, United States
| | - Hans G Pohl
- Children's National Medical Center, Washington, DC, United States
| | - Ranjiv Mathews
- Southern Illinois University School of Medicine, Springfield, IL, United States
| | - Saul P Greenfield
- Department of Pediatrics and Urology, Zucker School of Medicine, New York, NY, United States
| | - Steven G Docimo
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| |
Collapse
|
34
|
Shaikh N, Hoberman A, Hum SW, Alberty A, Muniz G, Kurs-Lasky M, Landsittel D, Shope T. Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children. JAMA Pediatr 2018; 172:550-556. [PMID: 29710324 PMCID: PMC6137527 DOI: 10.1001/jamapediatrics.2018.0217] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Accurately estimating the probability of urinary tract infection (UTI) in febrile preverbal children is necessary to appropriately target testing and treatment. OBJECTIVE To develop and test a calculator (UTICalc) that can first estimate the probability of UTI based on clinical variables and then update that probability based on laboratory results. DESIGN, SETTING, AND PARTICIPANTS Review of electronic medical records of febrile children aged 2 to 23 months who were brought to the emergency department of Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania. An independent training database comprising 1686 patients brought to the emergency department between January 1, 2007, and April 30, 2013, and a validation database of 384 patients were created. Five multivariable logistic regression models for predicting risk of UTI were trained and tested. The clinical model included only clinical variables; the remaining models incorporated laboratory results. Data analysis was performed between June 18, 2013, and January 12, 2018. EXPOSURES Documented temperature of 38°C or higher in children aged 2 months to less than 2 years. MAIN OUTCOMES AND MEASURES With the use of culture-confirmed UTI as the main outcome, cutoffs for high and low UTI risk were identified for each model. The resultant models were incorporated into a calculation tool, UTICalc, which was used to evaluate medical records. RESULTS A total of 2070 children were included in the study. The training database comprised 1686 children, of whom 1216 (72.1%) were female and 1167 (69.2%) white. The validation database comprised 384 children, of whom 291 (75.8%) were female and 200 (52.1%) white. Compared with the American Academy of Pediatrics algorithm, the clinical model in UTICalc reduced testing by 8.1% (95% CI, 4.2%-12.0%) and decreased the number of UTIs that were missed from 3 cases to none. Compared with empirically treating all children with a leukocyte esterase test result of 1+ or higher, the dipstick model in UTICalc would have reduced the number of treatment delays by 10.6% (95% CI, 0.9%-20.4%). CONCLUSIONS AND RELEVANCE UTICalc estimates the probability of UTI by evaluating the risk factors present in the individual child. As a result, testing and treatment can be tailored, thereby improving outcomes for children with UTI.
Collapse
Affiliation(s)
- Nader Shaikh
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephanie W. Hum
- Medical student, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anastasia Alberty
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gysella Muniz
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marcia Kurs-Lasky
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Douglas Landsittel
- Institute for Clinical Research Education, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Timothy Shope
- Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
35
|
Abstract
UNLABELLED : media-1vid110.1542/5727212324001PEDS-VA_2017-3006Video Abstract BACKGROUND: A recent study revealed that specific uropathogens are associated with lower odds of pyuria in a general pediatrics population. Children with neurogenic bladders who require clean intermittent catheterization (CIC) frequently have pyuria. Our objective with this study was to determine if an association exists between pyuria and type of uropathogen in CIC-dependent children. METHODS We obtained urinalysis and urine culture results from electronic medical records from January 2008 through December 2014 for patients ≤18 years of age with neurogenic bladders managed at a single institution. Cultures without concurrent urinalyses were excluded from analysis, as were cultures that yielded no growth, fungal growth, or growth of unidentified mixed organisms. We used logistic regression to determine the association of pyuria and leukocyte esterase with specific uropathogens. RESULTS We included 2420 cultures in this analysis. The growth of Enterococcus on urine culture was associated with lower odds of both pyuria and leukocyte esterase. In contrast, the growth of more than 100 000 colony-forming units per milliliter of Proteus mirabilis was associated with increased odds of both pyuria and leukocyte esterase, and the growth of Pseudomonas aeruginosa was associated with increased odds of leukocyte esterase but not pyuria. Certain etiologies of neurogenic bladder, such as bladder exstrophy and cloacal malformations, were also associated with increased odds of pyuria compared with neurogenic bladder due to myelomeningocele. CONCLUSIONS In children with neurogenic bladders who require CIC, Enterococcus may grow in urine culture without pyuria or positive leukocyte esterase. Accordingly, urine cultures should be obtained in symptomatic children, regardless of urinalysis results.
Collapse
Affiliation(s)
- Catherine S. Forster
- Department of Pediatrics Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Nader Shaikh
- Department of Pediatrics, Children’ s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Department of Pediatrics, Children’ s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elizabeth Jackson
- Department of Pediatrics Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Surgery Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
36
|
Martin JM, Hoberman A, Shaikh N, Shope T, onika Bhatnagar S, Block SL, Haralam MA, Kurs-Lasky M, Green M. Changes Over Time in Nasopharyngeal Colonization in Children Under 2 Years of Age at the Time of Diagnosis of Acute Otitis Media (1999-2014). Open Forum Infect Dis 2018; 5:ofy036. [PMID: 29588912 PMCID: PMC5842555 DOI: 10.1093/ofid/ofy036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 02/15/2018] [Indexed: 11/14/2022] Open
Abstract
Background In children with acute otitis media (AOM), a decrease in nasopharyngeal (NP) colonization with vaccine serotypes of Streptococcus pneumoniae has been noted since the introduction of pneumococcal conjugate vaccines (PCVs). The purpose of this study is to describe corresponding changes in colonization with Haemophilus influenzae. Methods In 4 separate studies, we obtained NP cultures from children aged 6-23 months presenting with AOM. Cohort 1 was recruited before routine use of PCV7 (1999-2000); 93% of children in cohort 2 (2003-2005) and 100% in cohort 3 (2006-2009) received ≥2 doses of PCV7. All children in cohort 4 (2012-2014) received ≥2 doses of PCV13. Isolates of H. influenzae were tested for ß-lactamase production; ß-lactamase negative isolates from cohorts 3 and 4 underwent susceptibility testing. Results A total of 899 children were evaluated. NP colonization with H. influenzae was found in 26% of children in cohort 1 (n = 175), 41% in cohort 2 (n = 87), 33% in cohort 3 (n = 282), and 29% in cohort 4 (n = 355). Colonization with H. influenzae increased initially from cohort 1 to cohort 2 (P = .01), then decreased across cohorts 2, 3, and 4 (P = .03, test for trend). The prevalence rates of ß-lactamase production were 27%, 42%, 33%, and 30% in each of the 4 cohorts, respectively (P = .50). Conclusions Although an initial increase in H. influenzae colonization was observed, suggesting an impact of PCVs, the most recent prevalence rates of NP colonization with H. influenzae and ß-lactamase production were like those observed before universal administration of PCV7. This knowledge is critical to guide appropriate treatment recommendations for children with AOM.
Collapse
Affiliation(s)
- Judith M Martin
- Divisions of General Academic Pediatrics and Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
- Correspondence: J. M. Martin, MD, Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 3414 Fifth Ave, CHOB 3rd Floor Room 305, Pittsburgh, PA 15213 ()
| | - Alejandro Hoberman
- Divisions of General Academic Pediatrics and Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nader Shaikh
- Divisions of General Academic Pediatrics and Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy Shope
- Divisions of General Academic Pediatrics and Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - S onika Bhatnagar
- Divisions of General Academic Pediatrics and Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stan L Block
- Kentucky Pediatric Research, Inc., Bardstown, Kentucky
| | - Mary Ann Haralam
- Divisions of General Academic Pediatrics and Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marcia Kurs-Lasky
- Divisions of General Academic Pediatrics and Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Green
- Divisions of General Academic Pediatrics and Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
37
|
Mattoo TK, Skoog SJ, Gravens-Mueller L, Chesney RW, Hoberman A, Mathews R, Moxey-Mims M, Ivanova A, Greenfield SP, Carpenter MA. Interobserver variability for interpretation of DMSA scans in the RIVUR trial. J Pediatr Urol 2017; 13:616.e1-616.e6. [PMID: 28711547 PMCID: PMC5711630 DOI: 10.1016/j.jpurol.2017.03.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/25/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Technetium-99m dimercaptosuccinic acid (DMSA) renal scans are used in the diagnosis of renal scarring. In the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial that randomized 607 children, DMSA renal scans were used for evaluating the presence and the severity of renal scarring. OBJECTIVE The aim was to determine interobserver variability in reporting of DMSA renal scans in the RIVUR trial. STUDY DESIGN We compared DMSA renal scan reports for renal scarring and acute pyelonephritis from all non-reference local radiologists (ALRs) at study sites with adjudicated as well as non-adjudicated reports from two reference radiologists (RRs) of the RIVUR trial. Two-way comparisons of concordant and discrepant responses were analyzed using an unweighted kappa statistic between the ALR and the adjudicated RR interpretations. All analyses were performed using SAS v 9.4 (SAS institute 2015) and significance was determined at the 0.05 level. RESULTS Of the 2872 kidneys evaluated, adjudicated RR reports had 119 (4%) kidneys with renal scarring compared with 212 (7%) by the ALRs. For 79% kidneys the grading for scarring reported by ALRs was either upgraded (24%) or downgraded (55%) by RRs. For acute pyelonephritis (n = 2924), adjudicated RR reports had 85 (3%) kidneys with pyelonephritis compared with 151 (5%) by the ALRs. For 85% kidneys, the grading for pyelonephritis reported by the ALRs was either upgraded (28%) or downgraded (57%) by the RRs. A three-way comparison revealed that all three (RR1, RR2, and ALR) agreed over presence of renal scarring in 19% cases and two of the three agreed in 80% cases. The respective numbers for pyelonephritis were 13% and 84%. The agreement rate for all DMSA scan reports between the RRs and the ALRs was 93%. DISCUSSION The study revealed significant interobserver variability in the reporting of abnormal DMSA renal scans compared with the previously published studies. A noteworthy limitation was a lack of uniformity in local reporting of the scans. CONCLUSIONS Our study highlights the need for optimizing the clinical yield of DMSA renal scans by more specific guidelines, particularly for standardized and uniform interpretation.
Collapse
Affiliation(s)
- Tej K Mattoo
- Nephrology and Hypertension, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA.
| | - Steven J Skoog
- Division of Pediatric Urology, Oregon Health & Science University, Portland, OR, USA
| | - Lisa Gravens-Mueller
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Russell W Chesney
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Ranjiv Mathews
- Department of Urology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Saul P Greenfield
- Division of Pediatric Urology, Women & Children's Hospital of Buffalo, State University of New York at Buffalo School of Medicine & Biomedical Sciences, Buffalo, NY, USA
| | - Myra A Carpenter
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
38
|
Shaikh N, Dando EE, Dunleavy ML, Curran DL, Martin JM, Hoberman A, Smith KJ. A Cost-Utility Analysis of 5 Strategies for the Management of Acute Otitis Media in Children. J Pediatr 2017; 189:54-60.e3. [PMID: 28666536 DOI: 10.1016/j.jpeds.2017.05.047] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 03/30/2017] [Accepted: 05/17/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess whether antimicrobial therapy in young children with acute otitis media reduces time to resolution of symptoms, overall symptom burden, and persistence of otoscopic evidence of infection. We used a cost-utility model to evaluate whether immediate antimicrobial treatment seems to be worthwhile, and if so, which antimicrobial agent is most cost effective. STUDY DESIGN We compared the cost per quality-adjusted life-day of 5 treatment regimens in children younger than 2 years of age with acute otitis media: immediate amoxicillin/clavulanate, immediate amoxicillin, immediate cefdinir, watchful waiting, and delayed prescription (DP) for antibiotic. RESULTS The 5 treatment regimens, listed in order from least effective to most effective were DP, watchful waiting, immediate cefdinir, immediate amoxicillin, and immediate amoxicillin/clavulanate. Listed in order from least costly to most costly, the regimens were DP, immediate amoxicillin, watchful waiting, immediate amoxicillin/clavulanate, and immediate cefdinir. The incremental cost-utility ratio of immediate amoxicillin compared with DP was $101.07 per quality-adjusted life-day gained. The incremental cost-utility ratio of immediate amoxicillin/clavulanate compared with amoxicillin was $2331.28 per quality-adjusted life-day gained. CONCLUSIONS In children younger than 2 years of age with acute otitis media and no recent antibiotic exposure, immediate amoxicillin seems to be the most cost-effective initial treatment.
Collapse
Affiliation(s)
- Nader Shaikh
- Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, Pittsburgh, PA; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Emily E Dando
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | | | - Judith M Martin
- Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, Pittsburgh, PA; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Alejandro Hoberman
- Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, Pittsburgh, PA; Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kenneth J Smith
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
39
|
Schaeffer AJ, Chow JS, Ivanova A, Cui G, Greenfield SP, Zerin JM, Hoberman A, Mathews RI, Mattoo TK, Carpenter MA, Moxey-Mims M, Chesney RW, Nelson CP. Variation in the level of detail in pediatric voiding cystourethrogram reports. J Pediatr Urol 2017; 13:257-262. [PMID: 28277235 PMCID: PMC9771522 DOI: 10.1016/j.jpurol.2016.08.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 08/01/2016] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Voiding cystourethrogram (VCUG) provides a wealth of data on urinary tract function and anatomy, but few standards exist for reporting VCUG findings. OBJECTIVE We aimed to assess variability in VCUG reports and to test our hypothesis that VCUG reports from pediatric facilities and pediatric radiologists are more complete than those performed at other facilities or by non-pediatric radiologists. STUDY DESIGN We analyzed original VCUG reports from children enrolled in the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial. A 23-item checklist was created and used to evaluate reporting of technical (e.g. catheter size), anatomic (e.g. vesicoureteral reflux (VUR) presence and grade, bladder shape), and functional information (e.g. bladder emptying). Radiologists were classified as pediatric or non-pediatric radiologists. Facilities were categorized as to whether they were a free-standing pediatric hospital (FSPH), a pediatric "hospital within a hospital" (PHWH), a non-pediatric hospital (NPH), or an outpatient radiology facility (ORF). Multivariate linear regression was used to analyze factors associated with the completeness of the VCUG reports (percent of items reported from the 23-item checklist). RESULTS Six-hundred and two VCUGs were performed at 90 institutions. Of those, 76% were read by a pediatric radiologist, and 49% were performed at a FSPH (Table). On average, less than half of the 23 items in our standardized assessment tool were included in VCUG reports (mean 48%, SD 12). The completeness of reports varied by facility type: 51% complete at FSPH (SD 11), 50% at PHWH (SD 10), 36% at NPH (SD 11), and 43% at ORF (SD 8) (p < 0.0001). In multivariate analysis, VCUG reports generated at NPH or ORF had 8% fewer items included (95% CI 3.0-12.8, p < 0.01), and those generated at PHWH did not differ from those generated at FSPH. Reports read by a non-pediatric radiologist had 6% fewer items included (95% CI 3-9.7; p < 0.01) compared with those read by a pediatric radiologist. DISCUSSION There is substantial underreporting of findings in VCUG reports when assessing a widely represented sample of routine, community-generated reports using an idealized standard. Although VUR was often reported, other crucial anatomic and functional findings of the VCUG were consistently underreported across all facility types. CONCLUSION Although pediatric radiologist and pediatric hospitals generated more complete VCUG reports compared with those having non-pediatric origins, the differences are small when considering the substantial underreporting of VCUG findings in general. This underscores the opportunities for improvement in reporting of VCUG findings.
Collapse
Affiliation(s)
- Anthony J Schaeffer
- Department of Surgery, Division of Pediatric Urology, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Jeanne S Chow
- Department of Urology, Boston Children's Hospital, Boston, MA, USA; Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gang Cui
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Saul P Greenfield
- Department of Pediatric Urology, Women & Children's Hospital of Buffalo, Buffalo, NY, USA
| | - J Michael Zerin
- Department of Radiology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Alejandro Hoberman
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Ranjiv I Mathews
- Department of Urology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Tej K Mattoo
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Myra A Carpenter
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Russell W Chesney
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
40
|
|
41
|
Shaikh N, Hoberman A, Martin JM, Shope TR. Author's Response: Response to Comments by Drs Schroeder and Jain. Pediatrics 2017; 139:peds.2016-3814C. [PMID: 28246346 DOI: 10.1542/peds.2016-3814c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
42
|
Bedard N, Shope T, Hoberman A, Haralam MA, Shaikh N, Kovačević J, Balram N, Tošić I. Light field otoscope design for 3D in vivo imaging of the middle ear. Biomed Opt Express 2017; 8:260-272. [PMID: 28101416 PMCID: PMC5231297 DOI: 10.1364/boe.8.000260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/30/2016] [Accepted: 12/02/2016] [Indexed: 05/26/2023]
Abstract
We present a light field digital otoscope designed to measure three-dimensional shape of the tympanic membrane. This paper describes the optical and anatomical considerations we used to develop the prototype, along with the simulation and experimental measurements of vignetting, field curvature, and lateral resolution. Using an experimental evaluation procedure, we have determined depth accuracy and depth precision of our system to be 0.05-0.07 mm and 0.21-0.44 mm, respectively. To demonstrate the application of our light field otoscope, we present the first three-dimensional reconstructions of tympanic membranes in normal and otitis media conditions, acquired from children who participated in a feasibility study at the Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center.
Collapse
Affiliation(s)
- Noah Bedard
- Ricoh Innovations Corporation, Cupertino, CA 95014,
USA
| | - Timothy Shope
- Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213,
USA
| | - Alejandro Hoberman
- Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213,
USA
| | - Mary Ann Haralam
- Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213,
USA
| | - Nader Shaikh
- Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA 15213,
USA
| | - Jelena Kovačević
- Department of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA 15213,
USA
| | - Nikhil Balram
- Ricoh Innovations Corporation, Cupertino, CA 95014,
USA
| | - Ivana Tošić
- Ricoh Innovations Corporation, Cupertino, CA 95014,
USA
| |
Collapse
|
43
|
Hoberman A, Paradise JL, Rockette HE, Kearney DH, Bhatnagar S, Shope TR, Martin JM, Kurs-Lasky M, Copelli SJ, Colborn DK, Block SL, Labella JJ, Lynch TG, Cohen NL, Haralam M, Pope MA, Nagg JP, Green MD, Shaikh N. Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children. N Engl J Med 2016; 375:2446-2456. [PMID: 28002709 PMCID: PMC5319589 DOI: 10.1056/nejmoa1606043] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Limiting the duration of antimicrobial treatment constitutes a potential strategy to reduce the risk of antimicrobial resistance among children with acute otitis media. METHODS We assigned 520 children, 6 to 23 months of age, with acute otitis media to receive amoxicillin-clavulanate either for a standard duration of 10 days or for a reduced duration of 5 days followed by placebo for 5 days. We measured rates of clinical response (in a systematic fashion, on the basis of signs and symptomatic response), recurrence, and nasopharyngeal colonization, and we analyzed episode outcomes using a noninferiority approach. Symptom scores ranged from 0 to 14, with higher numbers indicating more severe symptoms. RESULTS Children who were treated with amoxicillin-clavulanate for 5 days were more likely than those who were treated for 10 days to have clinical failure (77 of 229 children [34%] vs. 39 of 238 [16%]; difference, 17 percentage points [based on unrounded data]; 95% confidence interval, 9 to 25). The mean symptom scores over the period from day 6 to day 14 were 1.61 in the 5-day group and 1.34 in the 10-day group (P=0.07); the mean scores at the day-12-to-14 assessment were 1.89 versus 1.20 (P=0.001). The percentage of children whose symptom scores decreased more than 50% (indicating less severe symptoms) from baseline to the end of treatment was lower in the 5-day group than in the 10-day group (181 of 227 children [80%] vs. 211 of 233 [91%], P=0.003). We found no significant between-group differences in rates of recurrence, adverse events, or nasopharyngeal colonization with penicillin-nonsusceptible pathogens. Clinical-failure rates were greater among children who had been exposed to three or more children for 10 or more hours per week than among those with less exposure (P=0.02) and were also greater among children with infection in both ears than among those with infection in one ear (P<0.001). CONCLUSIONS Among children 6 to 23 months of age with acute otitis media, reduced-duration antimicrobial treatment resulted in less favorable outcomes than standard-duration treatment; in addition, neither the rate of adverse events nor the rate of emergence of antimicrobial resistance was lower with the shorter regimen. (Funded by the National Institute of Allergy and Infectious Diseases and the National Center for Research Resources; ClinicalTrials.gov number, NCT01511107 .).
Collapse
Affiliation(s)
- Alejandro Hoberman
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Jack L Paradise
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Howard E Rockette
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Diana H Kearney
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Sonika Bhatnagar
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Timothy R Shope
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Judith M Martin
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Marcia Kurs-Lasky
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Susan J Copelli
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - D Kathleen Colborn
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Stan L Block
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - John J Labella
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Thomas G Lynch
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Norman L Cohen
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - MaryAnn Haralam
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Marcia A Pope
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Jennifer P Nagg
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Michael D Green
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| | - Nader Shaikh
- From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.)
| |
Collapse
|
44
|
Gerber JS, Fisher BT, Ross R, Bryan M, Localio R, Barbadora KA, Keren R, Hoberman A, Green M, Zaoutis T. Impact of Antimicrobial Prophylaxis on the Development of Antimicrobial Resistance. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jeffrey S. Gerber
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian T. Fisher
- Division of Infectious Diseases, Department of Pediatrics, Center for Pediatric Clinical Effectiveness, Center for Clinical Epidemiology and Biostatistics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachael Ross
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew Bryan
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Russell Localio
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Ron Keren
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Green
- Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | |
Collapse
|
45
|
Rosenfeld RM, Culpepper L, Doyle KJ, Grundfast KM, Hoberman A, Kenna MA, Lieberthal AS, Mahoney M, Wahl RA, Woods CR, Yawn B. Clinical Practice Guideline: Otitis Media with Effusion. Otolaryngol Head Neck Surg 2016; 130:S95-118. [PMID: 15138413 DOI: 10.1016/j.otohns.2004.02.002] [Citation(s) in RCA: 311] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline “Otitis Media With Effusion in Young Children,” which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children aged 1 to 3 years with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology- Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced practice nursing to revise the OME guideline. The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media (AOM). The subcommittee made recommendations that clinicians should (1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME; (2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk; and (3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown). The subcommittee also made recommendations that (4) hearing testing be conducted when OME persists for 3 months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME; (5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; and (6) when a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure. Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that (1) population-based screening programs for OME not be performed in healthy, asymptomatic children and (2) antihistamines and decongestants are ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management. The subcommittee gave as options that (1) tympanometry can be used to confirm the diagnosis of OME and (2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery), and provide additional relevant information such as history of AOM and developmental status of the child. The subcommittee made no recommendations for (1) complementary and alternative medicine as a treatment for OME based on a lack of scientific evidence documenting efficacy and (2) allergy management as a treatment for OME based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed. The purpose of this guideline is to inform clinicians of evidence-based methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children older than 12 years because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed. This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. (Otolaryngol Head Neck Surg 2004;130:S95.)
Collapse
|
46
|
Shaikh N, Hoberman A, Keren R, Ivanova A, Ziessman HA, Cui G, Mattoo TK, Bhatnagar S, Nadkarni MD, Moxey-Mims M, Primack WA. Utility of sedation for young children undergoing dimercaptosuccinic acid renal scans. Pediatr Radiol 2016; 46:1573-8. [PMID: 27287454 PMCID: PMC5039057 DOI: 10.1007/s00247-016-3649-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/11/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND No studies have examined whether use of sedation during a Tc-99 m dimercaptosuccinic acid (DMSA) renal scan reduces patient discomfort. OBJECTIVE To compare discomfort level during a DMSA scan to the discomfort level during other frequently performed uroradiologic tests, and to determine whether use of sedation during a DMSA scan modifies the level of discomfort. MATERIALS AND METHODS We examined the discomfort level in 798 children enrolled in the Randomized Intervention for children with Vesicoureteral Reflux (RIVUR) and Careful Urinary Tract Infection Evaluation (CUTIE) studies by asking parents to rate their child's discomfort level with each procedure on a scale from 0 to 10. We compared discomfort during the DMSA scan and the DMSA image quality between centers in which sedation was used >90% of the time (sedation centers), centers in which sedation was used <10% of the time (non-sedation centers), and centers in which sedation was used on a case-by-case basis (selective centers). RESULTS Mean discomfort level was highest for voiding cystourethrogram (6.4), followed by DMSA (4.0), followed by ultrasound (2.4; P<0.0001). Mean discomfort level during the DMSA scan was significantly higher at non-sedation centers than at selective centers (P<0.001). No difference was apparent in discomfort level during the DMSA scan between sedation centers and selective centers (P=0.12), or between the sedation centers and non-sedation centers (P=0.80). There were no differences in the proportion with uninterpretable DMSA scans according to sedation use. CONCLUSION Selective use of sedation in children 12-36 months of age can reduce the discomfort level experienced during a DMSA scan.
Collapse
Affiliation(s)
- Nader Shaikh
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, One Children's Hospital Drive, 4401 Penn Ave., Pittsburgh, PA, 15224, USA.
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, One Children's Hospital Drive, 4401 Penn Ave., Pittsburgh, PA 15224, USA
| | - Ron Keren
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Gang Cui
- Collaborative Studies Coordinating Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tej K. Mattoo
- Division of Nephrology and Hypertension, Children's Hospital of Michigan, Wayne State University School of medicine, Detroit, MI, USA
| | - Sonika Bhatnagar
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Division of General Academic Pediatrics, One Children's Hospital Drive, 4401 Penn Ave., Pittsburgh, PA 15224, USA
| | - Milan D. Nadkarni
- Pediatric Emergency Department, Brenner Children's Hospital, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | | |
Collapse
|
47
|
Shaikh N, Mattoo TK, Keren R, Ivanova A, Cui G, Moxey-Mims M, Majd M, Ziessman HA, Hoberman A. Early Antibiotic Treatment for Pediatric Febrile Urinary Tract Infection and Renal Scarring. JAMA Pediatr 2016; 170:848-54. [PMID: 27455161 DOI: 10.1001/jamapediatrics.2016.1181] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Existing data regarding the association between delayed initiation of antimicrobial therapy and the development of renal scarring are inconsistent. OBJECTIVE To determine whether delay in the initiation of antimicrobial therapy for febrile urinary tract infections (UTIs) is associated with the occurrence and severity of renal scarring. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study that combined data from 2 previously conducted longitudinal studies (the Randomized Intervention for Children With Vesicoureteral Reflux trial and the Careful Urinary Tract Infection Evaluation Study). Children younger than 6 years with a first or second UTI were followed up for 2 years. EXPOSURE Duration of the child's fever prior to initiation of antimicrobial therapy for the index UTI. MAIN OUTCOMES AND MEASURES New renal scarring defined as the presence of photopenia plus contour change on a late dimercaptosuccinic acid renal scan (obtained at study exit) that was not present on the baseline scan. RESULTS Of the 482 children included in the analysis, 434 were female (90%), 375 were white (78%), and 375 had vesicoureteral reflux (78%). The median age was 11 months. A total of 35 children (7.2%) developed new renal scarring. Delay in the initiation of antimicrobial therapy was associated with renal scarring; the median (25th, 75th percentiles) duration of fever prior to initiation of antibiotic therapy in those with and without renal scarring was 72 (30, 120) and 48 (24, 72) hours, respectively (P = .003). Older age (OR, 1.03; 95% CI, 1.01-1.05), Hispanic ethnicity (OR, 5.24; 95% CI, 2.15-12.77), recurrent urinary tract infections (OR, 0.97; 95% CI, 0.27-3.45), and bladder and bowel dysfunction (OR, 6.44; 95% CI, 2.89-14.38) were also associated with new renal scarring. Delay in the initiation of antimicrobial therapy remained significantly associated with renal scarring even after adjusting for these variables. CONCLUSIONS AND RELEVANCE Delay in treatment of febrile UTIs and permanent renal scarring are associated. In febrile children, clinicians should not delay testing for UTI.
Collapse
Affiliation(s)
- Nader Shaikh
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Division of General Academic Pediatrics, Pittsburgh, Pennsylvania
| | - Tej K Mattoo
- Wayne State University, Children's Hospital of Michigan, Detroit
| | - Ron Keren
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania4Associate Editor, JAMA Pediatrics
| | - Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Gang Cui
- Collaborative Studies Coordinating Center, Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Marva Moxey-Mims
- National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Massoud Majd
- George Washington University School of Medicine, Children's National Medical Center, Division of Radiology, Washington, DC
| | - Harvey A Ziessman
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Division of General Academic Pediatrics, Pittsburgh, Pennsylvania
| |
Collapse
|
48
|
Shaikh N, Stone MK, Kurs-Lasky M, Hoberman A. Interpretation of tympanic membrane findings varies according to level of experience. Paediatr Child Health 2016; 21:196-8. [PMID: 27429572 DOI: 10.1093/pch/21.4.196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The authors administered a written survey consisting of colour images of 28 tympanic membranes (TM) to four groups of examiners: 86 medical students, 68 paediatric residents, 62 paediatricians and seven expert otoscopists. For each image, examiners were asked to indicate whether redness or bulging of the TM was present and to assign a diagnosis. The odds of diagnosing acute otitis media (AOM) was examined according to perceived redness or bulging of the TM. Medical students and paediatricians attributed approximately equal importance to isolated redness and isolated bulging of the TM. In contrast, experts placed significantly greater importance on isolated bulging of the TM compared with isolated redness of the TM. The authors suggest that training curricula emphasize the strong association between a bulging TM and a diagnosis of AOM, while de-emphasizing the association between TM redness and AOM.
Collapse
Affiliation(s)
- Nader Shaikh
- University of Pittsburgh School of Medicine, Division of General Academic Pediatrics
| | | | - Marcia Kurs-Lasky
- University of Pittsburgh School of Medicine, Division of General Academic Pediatrics
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine, Division of General Academic Pediatrics
| |
Collapse
|
49
|
Abstract
OBJECTIVE We sought to determine factors associated with the absence of pyuria in symptomatic children whose urine culture was positive for a known uropathogen. METHODS We obtained data on children evaluated at the Children's Hospital of Pittsburgh emergency department between 2007 and 2013 with symptoms of urinary tract infection (UTI) who had paired urinalysis and urine cultures. We excluded children with an unknown or bag urine collection method, major genitourinary anomalies, immunocompromising conditions, or with multiple organisms on culture. We chose a single, randomly-selected urine specimen per child and limited the analysis to those with positive cultures. RESULTS There were 46 158 visits during the study period; 1181 children diagnosed with UTI met all inclusion criteria and had a microscopic urinalysis for pyuria. Pyuria (≥5 white blood cells per high-powered field or ≥10 white blood cells per cubic millimeter) was present in 1031 (87%) children and absent in 150 (13%). Children with Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa were significantly less likely to exhibit pyuria than children with Escherichia coli (odds ratio of 0.14, 0.34, and 0.19, respectively). Children with these organisms were also less likely to have a positive leukocyte esterase on dipstick urinalysis. Results were similar when we restricted the analysis to children whose urine samples were collected by bladder catheterization. CONCLUSIONS We found that certain uropathogens are less likely to be associated with pyuria in symptomatic children. Identification of biomarkers more accurate than pyuria or leukocyte esterase may help reduce over- and undertreatment of UTIs.
Collapse
Affiliation(s)
- Nader Shaikh
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Timothy R Shope
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alyssa Vigliotti
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marcia Kurs-Lasky
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Judith M Martin
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
50
|
Nelson CP, Hoberman A, Shaikh N, Keren R, Mathews R, Greenfield SP, Mattoo TK, Gotman N, Ivanova A, Moxey-Mims M, Carpenter MA, Chesney RW. Antimicrobial Resistance and Urinary Tract Infection Recurrence. Pediatrics 2016; 137:peds.2015-2490. [PMID: 26969273 PMCID: PMC4811311 DOI: 10.1542/peds.2015-2490] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial found that recurrent urinary tract infections (rUTI) with resistant organisms were more common in the trimethoprim-sulfamethoxazole prophylaxis (TSP) arm. We describe factors associated with trimethoprim-sulfamethoxazole (TMP-SMX) resistance of rUTIs in RIVUR. METHODS Children aged 2 to 71 months with first or second UTI (index UTI) and grade I to IV vesicoureteral reflux (VUR) were randomized to TSP or placebo and followed for 2 years. Factors associated with TMP-SMX-resistant rUTI were evaluated. RESULTS Among 571 included children, 48% were <12 months old, 43% had grade II VUR, and 38% had grade III VUR. Recurrent UTI occurred in 34 of 278 children receiving TSP versus 67 of 293 children receiving placebo. Among those with rUTI, 76% (26/34) of subjects receiving TSP had TMP-SMX-resistant organisms versus 28% (19/67) of subjects receiving placebo (P < .001). The proportion of TMP-SMX-resistant rUTI decreased over time: in the TSP arm, 96% were resistant during the initial 6 months versus 38% resistant during the final 6 months; corresponding proportions for the placebo arm were 32% and 11%. Among children receiving TSP, 7 (13%) of 55 with TMP-SMX-resistant index UTI had rUTI, whereas 27 (12%) of 223 with TMP-SMX-susceptible index UTI had rUTI (adjusted hazard ratio 1.38, 95% confidence interval 0.54-3.56). Corresponding proportions in placebo arm were 17 (26%) of 65 and 50 (22%) of 228 (adjusted hazard ratio 1.33, 95% confidence interval 0.74-2.38). CONCLUSIONS Although TMP-SMX resistance is more common among children treated with TSP versus placebo, resistance decreased over time. Among children treated with TSP, there was no significant difference in UTI recurrence between those with TMP-SMX-resistant index UTI versus TMP-SMX-susceptible UTI.
Collapse
Affiliation(s)
- Caleb P. Nelson
- Department of Urology, Boston Children’s Hospital, Boston, Massachusetts
| | - Alejandro Hoberman
- Department of Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nader Shaikh
- Department of Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ron Keren
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ranjiv Mathews
- Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Saul P. Greenfield
- Department of Pediatric Urology, Women & Children’s Hospital of Buffalo, Buffalo, New York
| | - Tej K. Mattoo
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, Michigan
| | - Nathan Gotman
- Department of Biostatistics, The University of North Carolina, Chapel Hill, North Carolina
| | - Anastasia Ivanova
- Department of Biostatistics, The University of North Carolina, Chapel Hill, North Carolina
| | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Myra A. Carpenter
- Department of Biostatistics, The University of North Carolina, Chapel Hill, North Carolina
| | - Russell W. Chesney
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| |
Collapse
|