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Thomson AM, McHugh TA, Oron AP, Teply C, Lonberg N, Vilchis Tella V, Wilner LB, Fuller K, Hagins H, Aboagye RG, Aboye MB, Abu-Gharbieh E, Abu-Zaid A, Addo IY, Ahinkorah BO, Ahmad A, AlRyalat SAS, Amu H, Aravkin AY, Arulappan J, Atout MMW, Badiye AD, Bagherieh S, Banach M, Banakar M, Bardhan M, Barrow A, Bedane DA, Bensenor IM, Bhagavathula AS, Bhardwaj P, Bhardwaj PV, Bhat AN, Bhutta ZA, Bilalaga MM, Bishai JD, Bitaraf S, Boloor A, Butt MH, Chattu VK, Chu DT, Dadras O, Dai X, Danaei B, Dang AK, Demisse FW, Dhimal M, Diaz D, Djalalinia S, Dongarwar D, Elhadi M, Elmonem MA, Esezobor CI, Etaee F, Eyawo O, Fagbamigbe AF, Fatehizadeh A, Force LM, Gardner WM, Ghaffari K, Gill PS, Golechha M, Goleij P, Gupta VK, Hasani H, Hassan TS, Hassen MB, Ibitoye SE, Ikiroma AI, Iwu CCD, James PB, Jayaram S, Jebai R, Jha RP, Joseph N, Kalantar F, Kandel H, Karaye IM, Kassahun WD, Khan IA, Khanmohammadi S, Kisa A, Kompani F, Krishan K, Landires I, Lim SS, Mahajan PB, Mahjoub S, Majeed A, Marasini BP, Meresa HA, Mestrovic T, Minhas S, Misganaw A, Mokdad AH, Monasta L, Mustafa G, Nair TS, Narasimha Swamy S, Nassereldine H, Natto ZS, Naveed M, Nayak BP, Noubiap JJ, Noyes T, Nri-ezedi CA, Nwatah VE, Nzoputam CI, Nzoputam OJ, Okonji OC, Onikan AO, Owolabi MO, Patel J, Pati S, Pawar S, Petcu IR, Piel FB, Qattea I, Rahimi M, Rahman M, Rawaf S, Redwan EMM, Rezaei N, Saddik B, Saeed U, Saheb Sharif-Askari F, Samy AM, Schumacher AE, Shaker E, Shetty A, Sibhat MM, Singh JA, Suleman M, Sunuwar DR, Szeto MD, Tamuzi JJLL, Tat NY, Taye BT, Temsah MH, Umair M, Valadan Tahbaz S, Wang C, Wickramasinghe ND, Yigit A, Yiğit V, Yunusa I, Zaman BA, Zangiabadian M, Zheng P, Hay SI, Naghavi M, Murray CJL, Kassebaum NJ. Global, regional, and national prevalence and mortality burden of sickle cell disease, 2000-2021: a systematic analysis from the Global Burden of Disease Study 2021. Lancet Haematol 2023:S2352-3026(23)00118-7. [PMID: 37331373 PMCID: PMC10390339 DOI: 10.1016/s2352-3026(23)00118-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Previous global analyses, with known underdiagnosis and single cause per death attribution systems, provide only a small insight into the suspected high population health effect of sickle cell disease. Completed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, this study delivers a comprehensive global assessment of prevalence of sickle cell disease and mortality burden by age and sex for 204 countries and territories from 2000 to 2021. METHODS We estimated cause-specific sickle cell disease mortality using standardised GBD approaches, in which each death is assigned to a single underlying cause, to estimate mortality rates from the International Classification of Diseases (ICD)-coded vital registration, surveillance, and verbal autopsy data. In parallel, our goal was to estimate a more accurate account of sickle cell disease health burden using four types of epidemiological data on sickle cell disease: birth incidence, age-specific prevalence, with-condition mortality (total deaths), and excess mortality (excess deaths). Systematic reviews, supplemented with ICD-coded hospital discharge and insurance claims data, informed this modelling approach. We employed DisMod-MR 2.1 to triangulate between these measures-borrowing strength from predictive covariates and across age, time, and geography-and generated internally consistent estimates of incidence, prevalence, and mortality for three distinct genotypes of sickle cell disease: homozygous sickle cell disease and severe sickle cell β-thalassaemia, sickle-haemoglobin C disease, and mild sickle cell β-thalassaemia. Summing the three models yielded final estimates of incidence at birth, prevalence by age and sex, and total sickle cell disease mortality, the latter of which was compared directly against cause-specific mortality estimates to evaluate differences in mortality burden assessment and implications for the Sustainable Development Goals (SDGs). FINDINGS Between 2000 and 2021, national incidence rates of sickle cell disease were relatively stable, but total births of babies with sickle cell disease increased globally by 13·7% (95% uncertainty interval 11·1-16·5), to 515 000 (425 000-614 000), primarily due to population growth in the Caribbean and western and central sub-Saharan Africa. The number of people living with sickle cell disease globally increased by 41·4% (38·3-44·9), from 5·46 million (4·62-6·45) in 2000 to 7·74 million (6·51-9·2) in 2021. We estimated 34 400 (25 000-45 200) cause-specific all-age deaths globally in 2021, but total sickle cell disease mortality burden was nearly 11-times higher at 376 000 (303 000-467 000). In children younger than 5 years, there were 81 100 (58 800-108 000) deaths, ranking total sickle cell disease mortality as 12th (compared to 40th for cause-specific sickle cell disease mortality) across all causes estimated by the GBD in 2021. INTERPRETATION Our findings show a strikingly high contribution of sickle cell disease to all-cause mortality that is not apparent when each death is assigned to only a single cause. Sickle cell disease mortality burden is highest in children, especially in countries with the greatest under-5 mortality rates. Without comprehensive strategies to address morbidity and mortality associated with sickle cell disease, attainment of SDG 3.1, 3.2, and 3.4 is uncertain. Widespread data gaps and correspondingly high uncertainty in the estimates highlight the urgent need for routine and sustained surveillance efforts, further research to assess the contribution of conditions associated with sickle cell disease, and widespread deployment of evidence-based prevention and treatment for those with sickle cell disease. FUNDING Bill & Melinda Gates Foundation.
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Kawade A, Dayma G, Apte A, Telang N, Satpute M, Pearce E, Roalfe L, Patil R, Wang Y, Noori N, Gondhali A, Juvekar S, Oron AP, Sanghavi S, Goldblatt D, Dagan R, Bavdekar A. Effect of reduced two-dose (1+1) schedule of 10 and 13-valent pneumococcal conjugate vaccines (Synflorix TM and Prevenar13 TM)) on nasopharyngeal carriage and serotype-specific immune response in the first two years of life: Results from an open-labelled randomized controlled trial in Indian children. Vaccine 2023; 41:3066-3079. [PMID: 37045679 DOI: 10.1016/j.vaccine.2023.04.008] [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] [Received: 11/28/2022] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023]
Abstract
INTRODUCTION This study aimed to assess the effect of a reduced dose regime (1 + 1) of PCV10 and PCV13 along with 3-dose regimes on pneumococcal vaccine-type (VT) carriage and immunogenicity in the first two years of life in PCV-naïve Indian children. METHODS A total of 805 healthy infants aged 6-8 weeks were randomised to 7 groups (n = 115). Six groups received SynflorixTM(PCV10) or Prevenar13TM(PCV13) in the following schedules: 3 + 0 (three primary at 6, 10, and 14 weeks); 2 + 1 (two primary 6 and 14 weeks with booster at 9 months; 1 + 1 (one primary at 14 weeks with booster at 9 months). The 7th group was a PCV-naïve control group. Nasopharyngeal swabs were collected at 6, 18 weeks, 9, 10, 15, and 18 months of age. Venous blood samples were collected at 18 weeks, 9, 10, and 18 months of age for assessment of sero-specific IgG antibodies. Additionally, functional activity using a serotype specific opsonophagocytic assay (OPA) was assessed at 10 and 18 months of age in a subset (20%) of participants. RESULTS All schedules of PCV13 showed significant 13VT carriage reduction in the second year of life as compared to control. At 15 months of age, PCV13 (1 + 1) showed 45 % reduction in 13VT-carriage compared to the control [OR = 0.55 (95% CI; 0.31-0.97), p= 0.038]. None of the PCV10 schedules showed significant reduction in 10VT carriage in the second year. Although not powered for these outcomes, at 18 months of age, 1 + 1 and 2 + 1 schedules of both vaccines demonstrated higher sero-responders for all serotypes, higher geometric mean concentrations (GMC) for all serotypes except 23F [with both vaccines], higher percent OPA responders and OPA geometric mean titres (GMT) compared to the 3 + 0 schedules for all serotypes. CONCLUSION The reduced dose schedule (1 + 1) of PCV13 results in significant VT-carriage reduction in the second year of life. Immune protection provided by 1 + 1 schedules of PCV10 and PCV13 in the second year of life is comparable to WHO-recommended 3-dose schedules.
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Affiliation(s)
- Anand Kawade
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India.
| | - Girish Dayma
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - Aditi Apte
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - Nilima Telang
- Department of Microbiology, KEM Hospital, Pune, India
| | | | - Emma Pearce
- Infection, Immunity and Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Lucy Roalfe
- Infection, Immunity and Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Rakesh Patil
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - Yanyun Wang
- Infection, Immunity and Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Navideh Noori
- Institute for Disease Modeling, Global Health Division, Bill and Melinda Gates Foundation, 500 5th Ave N, Seattle, WA, USA
| | - Arun Gondhali
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - Sanjay Juvekar
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India
| | - Assaf P Oron
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA
| | | | - David Goldblatt
- Infection, Immunity and Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Ron Dagan
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ashish Bavdekar
- Vadu Rural Health Program, KEM Hospital Research Centre, Pune, India.
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Chao DL, Oron AP, Chabot-Couture G, Sopekan A, Nnebe-Agumadu U, Bates I, Piel FB, Nnodu O. Contribution of malaria and sickle cell disease to anaemia among children aged 6-59 months in Nigeria: a cross-sectional study using data from the 2018 Demographic and Health Survey. BMJ Open 2022; 12:e063369. [PMID: 36385021 PMCID: PMC9670918 DOI: 10.1136/bmjopen-2022-063369] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To estimate the fraction of anaemia attributable to malaria and sickle cell disease (SCD) among children aged 6-59 months in Nigeria. DESIGN Cross-sectional analysis of data from Nigeria's 2018 Demographic and Health Survey (DHS). SETTING Nigeria. PARTICIPANTS 11 536 children aged 6-59 months from randomly selected households were eligible for participation, of whom 11 142 had complete and valid biomarker data required for this analysis. Maternal education data were available from 10 305 of these children. PRIMARY OUTCOME MEASURE Haemoglobin concentration. RESULTS We found that 70.6% (95% CI: 62.7% to 78.5%) of severe anaemia was attributable to malaria compared with 12.4% (95% CI: 11.1% to 13.7%) of mild-to-severe and 29.6% (95% CI: 29.6% to 31.8%) of moderate-to-severe anaemia and that SCD contributed 0.6% (95% CI: 0.4% to 0.9%), 1.3% (95% CI: 1.0% to 1.7%) and 10.6% (95% CI: 6.7% to 14.9%) mild-to-severe, moderate-to-severe and severe anaemia, respectively. Sickle trait was protective against anaemia and was associated with higher haemoglobin concentration compared with children with normal haemoglobin (HbAA) among malaria-positive but not malaria-negative children. CONCLUSIONS This approach used offers a new tool to estimate the contribution of malaria to anaemia in many settings using widely available DHS data. The fraction of anaemia among young children in Nigeria attributable to malaria and SCD is higher at more severe levels of anaemia. Prevention of malaria and SCD and timely treatment of affected individuals would reduce cases of severe anaemia.
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Affiliation(s)
- Dennis L Chao
- Institute for Disease Modeling, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Assaf P Oron
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | | | - Alayo Sopekan
- Department of Public Health, Federal Ministry of Health, Abuja, Nigeria
| | - Uche Nnebe-Agumadu
- Department of Paediatrics, University of Abuja College of Health Sciences, Abuja, Nigeria
| | - Imelda Bates
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Frédéric B Piel
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Obiageli Nnodu
- Centre of Excellence for Sickle Cell Disease Research & Training (CESRTA), University of Abuja, Abuja, Nigeria
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Noori N, Skrip LA, Oron AP, McCarthy KA, Proctor JL, Chabot-Couture G, Althouse BM, Phelan KPQ, Trehan I. Potential Impacts of Mass Nutritional Supplementation on Measles Dynamics: A Simulation Study. Am J Trop Med Hyg 2022; 107:863-872. [PMID: 36096407 DOI: 10.4269/ajtmh.21-1083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 06/10/2022] [Indexed: 11/07/2022] Open
Abstract
The bidirectional interaction between undernutrition and infection can be devastating to child health. Nutritional deficiencies impair immunity and increase susceptibility to infection. Simultaneously, infections compound undernutrition by increasing metabolic demand and impairing nutrient absorption. Treatment of acute malnutrition (wasting) can reverse some of its deleterious effects and reduce susceptibility to infectious diseases. Nutrition-specific approaches may be packaged with other interventions, including immunization, to support overall child health. To understand how mass nutritional supplementation, treatment of wasting, and vaccination affect the dynamics of a vaccine-preventable infection, we developed a population-level, compartmental model of measles transmission stratified by age and nutrition status. We simulated a range of scenarios to assess the potential reductions in measles infection and mortality associated with targeted therapeutic feeding for children who are wasted and with a mass supplementation intervention. Nutrition interventions were assumed to increase engagement with the health sector, leading to increased vaccination rates. We found that the combination of wasting treatment and mass supplementation coverage followed by an increase in vaccination coverage of nonwasted children from a baseline of 75% to 85%, leads to 34% to 57% and 65% to 77% reduction in measles infection and mortality and 56% to 60% reduction in overall mortality among wasted children, compared with the wasting treatment alone. Our work highlights the synergistic benefits that may be achieved by leveraging mass nutritional supplementation as a touch point with the health system to increase rates of vaccination and improve child survival beyond what would be expected from the additive benefits of each intervention.
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Affiliation(s)
- Navideh Noori
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington
| | - Laura A Skrip
- School of Public Health, University of Liberia, Monrovia, Liberia
| | - Assaf P Oron
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington
| | - Kevin A McCarthy
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington
| | - Josh L Proctor
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington
| | - Guillaume Chabot-Couture
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington
| | - Benjamin M Althouse
- Information School, University of Washington, Seattle, Washington.,Department of Biology, New Mexico State University, Las Cruces, New Mexico
| | - Kevin P Q Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Indi Trehan
- Department of Pediatrics, Global Health, and Epidemiology, University of Washington, Seattle, Washington
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Noori N, Proctor JL, Efevbera Y, Oron AP. Effect of adolescent pregnancy on child mortality in 46 countries. BMJ Glob Health 2022; 7:bmjgh-2021-007681. [PMID: 35504693 PMCID: PMC9066488 DOI: 10.1136/bmjgh-2021-007681] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 10/11/2021] [Accepted: 03/27/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Adolescent pregnancy is a known health risk to mother and child. Statements and reports of health outcomes typically group mothers under 20 years old together. Few studies examined this risk at a finer age resolution, none of them comprehensively, and with differing results. METHODS We analysed Demographic and Health Surveys data from 2004 to 2018 in sub-Saharan Africa (SSA) and South Asia, on firstborn children of mothers 25 years old or younger. We examined the association between maternal age and stillbirths, and neonatal mortality rate (NNMR), infant mortality rate (IMR) and under-5 mortality rate (U5MR), using mixed-effects logistic regression adjusting for major demographic variables and exploring the impact of maternal health-seeking. RESULTS In both regions and across all endpoints, mortality rates of children born to mothers aged <16 years, 16-17 years and 18-19 years at first birth were about 2-4 times, 1.5-2 times and 1.2-1.5 times higher, respectively, than among firstborn children of mothers aged 23-25. Absolute mortality rates declined over time, but the age gradient remained similar across time periods and regions. Adjusting for rural/urban residence and maternal education, in SSA in 2014-2018 having a <16-year-old mother was associated with ORs of 3.71 (95% CI: 2.50 to 5.51) for stillbirth, 1.92 (1.60-2.30) for NNMR, 2.13 (1.85-2.46) for IMR and 2.39 (2.13-2.68) for U5MR, compared with having a mother aged 23-25. In South Asia, in 2014-2018 ORs were 5.12 (2.85-9.20) for stillbirth, 2.46 (2.03-2.97) for NNMR, 2.62 (2.22-3.08) for IMR and 2.59 (2.22-3.03) for U5MR. Part of the effect on NNMR and IMR may be mediated by a lower maternal health-seeking rate. CONCLUSIONS Adolescent pregnancy is associated with dramatically worse child survival and mitigated by health-seeking behaviour, likely reflecting a combination of biological and social factors. Refining maternal age reporting will avoid masking the increased risk to children born to very young adolescent mothers. Collection of additional biological and social data may better reveal mediators of this relationship. Targeted intervention strategies to reduce unintended pregnancy at earlier ages may also improve child survival.
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Affiliation(s)
- Navideh Noori
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Joshua L Proctor
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Yvette Efevbera
- Gender Equality Division, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Assaf P Oron
- University of Washington, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
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von Saint Andre-von Arnim AO, Kumar RK, Clark JD, Wilfond BS, Nguyen QUP, Mutonga DM, Zimmerman JJ, Oron AP, Walson JL. Family-Assisted Severity of Illness Monitoring for Hospitalized Children in Low-Resource Settings-A Two-Arm Interventional Feasibility Study. Front Pediatr 2022; 10:804346. [PMID: 35676898 PMCID: PMC9169086 DOI: 10.3389/fped.2022.804346] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/15/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Pediatric mortality remains unacceptably high in many low-resource settings, with inpatient deaths often associated with delayed recognition of clinical deterioration. The Family-Assisted Severe Febrile Illness ThERapy (FASTER) tool has been developed for caregivers to assist in monitoring their hospitalized children and alert clinicians. This study evaluates feasibility of implementation by caregivers and clinicians. METHODS Randomized controlled feasibility study at Kenyatta National Hospital, Kenya. Children hospitalized with acute febrile illness with caregivers at the bedside for 24 h were enrolled. Caregivers were trained using the FASTER tool. The primary outcome was the frequency of clinician reassessments between intervention (FASTER) and standard care arms. Poisson regression with random intercept for grouping by patient was used, adjusting for admission pediatric early warning score, age, gender. Secondary outcomes included survey assessments of clinician and caregiver experiences with FASTER. RESULTS One hundred and fifty patient/caregiver pairs were enrolled, 139 included in the analysis, 74 in the intervention, 65 in the control arm. Patients' median age was 0.9 (range 0.2-10) and 1.1 years (range 0.2-12) in intervention vs. control arms. The most common diagnoses were pneumonia (80[58%]), meningitis (58[38%]) and malaria (34 [24%]). 134 (96%) caregivers were patients' mothers. Clinician visits/hour increased with patients' illness severity in both arms, but without difference in frequency between arms (point estimate for difference -0.9%, p = 0.97). Of the 16 deaths, 8 (four/arm) occurred within 2 days of enrollment. Forty clinicians were surveyed, 33 (82%) reporting that FASTER could improve outcomes of very sick children in low-resource settings; 26 (65%) rating caregivers as able to adequately capture patients' severity of illness. Of 70 caregivers surveyed, 63 (90%) reported that FASTER training was easy to understand; all (100%) agreed that the intervention would improve care of hospitalized children and help identify sick children in their community. DISCUSSION We observed no difference in recorded frequency of clinician visits with FASTER monitoring. However, the tool was rated positively by caregivers and clinicians., Implementation appears feasible but requires optimization. These feasibility data may inform a larger trial powered to measure morbidity and mortality outcomes to determine the utility of FASTER in detecting and responding to clinical deterioration in low-resource settings. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT03513861.
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Affiliation(s)
- Amelie O von Saint Andre-von Arnim
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington and Seattle Children's, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States
| | - Rashmi K Kumar
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Jonna D Clark
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington and Seattle Children's, Seattle, WA, United States.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States.,Divisions of Bioethics & Palliative Care and Pulmonary & Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Quynh-Uyen P Nguyen
- Department of Pediatrics, University of Washington and Seattle Children's, Seattle, WA, United States
| | - Daniel M Mutonga
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington and Seattle Children's, Seattle, WA, United States
| | - Assaf P Oron
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States
| | - Judd L Walson
- Departments of Global Health, Epidemiology, Infectious Disease, University of Washington, Seattle, WA, United States.,Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
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Nnodu OE, Oron AP, Sopekan A, Akaba GO, Piel FB, Chao DL. Child mortality from sickle cell disease in Nigeria: a model-estimated, population-level analysis of data from the 2018 Demographic and Health Survey. Lancet Haematol 2021; 8:e723-e731. [PMID: 34481551 PMCID: PMC8460996 DOI: 10.1016/s2352-3026(21)00216-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/29/2021] [Accepted: 07/13/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Child mortality from sickle cell disease in sub-Saharan Africa is presumed to be high but is not well quantified. This uncertainty contributes to the neglect of sickle cell disease and delays the prioritisation of interventions. In this study, we estimated the mortality of children in Nigeria with sickle cell disease, and the proportion of national under-5 mortality attributable to sickle cell disease. METHODS We did a model-estimated, population-level analysis of data from Nigeria's 2018 Demographic and Health Survey (DHS) to estimate the prevalence and geographical distribution of HbSS and HbSC genotypes assuming Hardy-Weinberg equilibrium near birth. Interviews for the survey were done between Aug 14 and Dec 29, 2018, and the embedded sickle cell disease survey was done in a randomly selected third of the overall survey's households. We developed an approach for estimating child mortality from sickle cell disease by combining information on tested children and their untested siblings. Tested children were aged 6-59 months at the time of the survey. Untested siblings born 0-14 years before the survey were also included in analyses. Testing as part of the DHS was done without regard to disease status. We analysed mortality differences using the inheritance-derived genotypic distribution of untested siblings older than the tested cohort, enabling us to estimate excess mortality from sickle cell disease for the older-sibling cohort (ie, those born between 2003 and 2013). FINDINGS We analysed test results for 11 186 children aged 6-59 months from 7411 households in Nigeria. The estimated average birth prevalence of HbSS was 1·21% (95% CI 1·09-1·37) and was 0·24% (0·19-0·31) for HbSC. We obtained data for estimating child mortality from 10 195 tested children (who could be matched to the individual mother survey) and 17 205 of their untested siblings. 15 227 of the siblings were in the older-sibling cohort. The group of children with sickle cell disease born between 2003 and 2013 with at least one younger sibling in the survey had about 370 excess under-5 deaths per 1000 livebirths (95% CI 150-580; p=0·0008) than children with HbAA. The estimated national average under-5 mortality for children with sickle cell disease born between 2003 and 2013 was 490 per 1000 livebirths (95% CI 270-700), 4·0 times higher (95% CI 2·1-6·0) than children with HbAA. About 4·2% (95% CI 1·7-6·9) of national under-5 mortality was attributable to excess mortality from sickle cell disease. INTERPRETATION The burden of child mortality from sickle cell disease in Nigeria continues to be disproportionately higher than the burden of mortality of children without sickle cell disease. Most of these deaths could be prevented if adequate resources were allocated and available focused interventions were implemented. The methods developed in this study could be used to estimate the burden of sickle cell disease elsewhere in Africa and south Asia. FUNDING Sickle Pan African Research Consortium, and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Obiageli E Nnodu
- Centre of Excellence for Sickle Cell Disease Research and Training, University of Abuja, Abuja, Nigeria
| | - Assaf P Oron
- Institute for Disease Modeling, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Alayo Sopekan
- Sickle Cell Disease Desk, Noncommunicable Diseases Control Programme, Department of Public Health, Federal Ministry of Health, Abuja, Nigeria
| | - Godwin O Akaba
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Abuja, Abuja, Nigeria
| | - Frédéric B Piel
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Dennis L Chao
- Institute for Disease Modeling, Bill & Melinda Gates Foundation, Seattle, WA, USA.
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Noori N, Derra K, Valea I, Oron AP, Welgo A, Rouamba T, Boua PR, Somé AM, Rouamba E, Wenger E, Sorgho H, Tinto H, Ouédraogo AL. Patterns of child mortality in rural area of Burkina Faso: evidence from the Nanoro health and demographic surveillance system (HDSS). BMC Public Health 2021; 21:1425. [PMID: 34281547 PMCID: PMC8287796 DOI: 10.1186/s12889-021-11483-4] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/06/2021] [Indexed: 11/16/2022] Open
Abstract
Background Half of global child deaths occur in sub-Saharan Africa. Understanding child mortality patterns and risk factors will help inform interventions to reduce this heavy toll. The Nanoro Health and Demographic Surveillance System (HDSS), Burkina Faso was described previously, but patterns and potential drivers of heterogeneity in child mortality in the district had not been studied. Similar studies in other districts indicated proximity to health facilities as a risk factor, usually without distinction between facility types. Methods Using Nanoro HDSS data from 2009 to 2013, we estimated the association between under-5 mortality and proximity to inpatient and outpatient health facilities, seasonality of death, age group, and standard demographic risk factors. Results Living in homes 40–60 min and > 60 min travel time from an inpatient facility was associated with 1.52 (95% CI: 1.13–2.06) and 1.74 (95% CI: 1.27–2.40) greater hazard of under-5 mortality, respectively, than living in homes < 20 min from an inpatient facility. No such association was found for outpatient facilities. The wet season (July–November) was associated with 1.28 (95% CI: 1.07, 1.53) higher under-5 mortality than the dry season (December–June), likely reflecting the malaria season. Conclusions Our results emphasize the importance of geographical proximity to health care, distinguish between inpatient and outpatient facilities, and also show a seasonal effect, probably driven by malaria. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11483-4.
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Affiliation(s)
- Navideh Noori
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, 500 5th Ave N, Seattle, WA, 98109, USA.
| | - Karim Derra
- Institut de Recherche en Sciences de la Santé (IRSS)/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Innocent Valea
- Institut de Recherche en Sciences de la Santé (IRSS)/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso.,Laboratory of Parasitology and Entomology, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Assaf P Oron
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, 500 5th Ave N, Seattle, WA, 98109, USA
| | - Aminata Welgo
- Institut de Recherche en Sciences de la Santé (IRSS)/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Toussaint Rouamba
- Institut de Recherche en Sciences de la Santé (IRSS)/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Palwende Romuald Boua
- Institut de Recherche en Sciences de la Santé (IRSS)/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Athanase M Somé
- Institut de Recherche en Sciences de la Santé (IRSS)/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Eli Rouamba
- Institut de Recherche en Sciences de la Santé (IRSS)/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Edward Wenger
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, 500 5th Ave N, Seattle, WA, 98109, USA
| | - Hermann Sorgho
- Institut de Recherche en Sciences de la Santé (IRSS)/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé (IRSS)/Clinical Research Unit of Nanoro (CRUN), Nanoro, Burkina Faso.,Laboratory of Parasitology and Entomology, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Andre Lin Ouédraogo
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, 500 5th Ave N, Seattle, WA, 98109, USA
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9
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Kerr CC, Stuart RM, Mistry D, Abeysuriya RG, Rosenfeld K, Hart GR, Núñez RC, Cohen JA, Selvaraj P, Hagedorn B, George L, Jastrzębski M, Izzo AS, Fowler G, Palmer A, Delport D, Scott N, Kelly SL, Bennette CS, Wagner BG, Chang ST, Oron AP, Wenger EA, Panovska-Griffiths J, Famulare M, Klein DJ. Covasim: An agent-based model of COVID-19 dynamics and interventions. PLoS Comput Biol 2021; 17:e1009149. [PMID: 34310589 DOI: 10.1101/2020.05.10.20097469] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 08/05/2021] [Accepted: 06/05/2021] [Indexed: 05/24/2023] Open
Abstract
The COVID-19 pandemic has created an urgent need for models that can project epidemic trends, explore intervention scenarios, and estimate resource needs. Here we describe the methodology of Covasim (COVID-19 Agent-based Simulator), an open-source model developed to help address these questions. Covasim includes country-specific demographic information on age structure and population size; realistic transmission networks in different social layers, including households, schools, workplaces, long-term care facilities, and communities; age-specific disease outcomes; and intrahost viral dynamics, including viral-load-based transmissibility. Covasim also supports an extensive set of interventions, including non-pharmaceutical interventions, such as physical distancing and protective equipment; pharmaceutical interventions, including vaccination; and testing interventions, such as symptomatic and asymptomatic testing, isolation, contact tracing, and quarantine. These interventions can incorporate the effects of delays, loss-to-follow-up, micro-targeting, and other factors. Implemented in pure Python, Covasim has been designed with equal emphasis on performance, ease of use, and flexibility: realistic and highly customized scenarios can be run on a standard laptop in under a minute. In collaboration with local health agencies and policymakers, Covasim has already been applied to examine epidemic dynamics and inform policy decisions in more than a dozen countries in Africa, Asia-Pacific, Europe, and North America.
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Affiliation(s)
- Cliff C Kerr
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Robyn M Stuart
- Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark
- Burnet Institute, Melbourne, Victoria, Australia
| | - Dina Mistry
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | | | - Katherine Rosenfeld
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Gregory R Hart
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Rafael C Núñez
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Jamie A Cohen
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Prashanth Selvaraj
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Brittany Hagedorn
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Lauren George
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | | | - Amanda S Izzo
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Greer Fowler
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Anna Palmer
- Burnet Institute, Melbourne, Victoria, Australia
| | | | - Nick Scott
- Burnet Institute, Melbourne, Victoria, Australia
| | | | - Caroline S Bennette
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Bradley G Wagner
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Stewart T Chang
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Assaf P Oron
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Edward A Wenger
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Jasmina Panovska-Griffiths
- Big Data Institute, University of Oxford, Oxford, United Kingdom
- Wolfson Centre for Mathematical Biology and The Queen's College, University of Oxford, Oxford, United Kingdom
| | - Michael Famulare
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Daniel J Klein
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
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10
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Pham QD, Stuart RM, Nguyen TV, Luong QC, Tran QD, Pham TQ, Phan LT, Dang TQ, Tran DN, Do HT, Mistry D, Klein DJ, Abeysuriya RG, Oron AP, Kerr CC. Estimating and mitigating the risk of COVID-19 epidemic rebound associated with reopening of international borders in Vietnam: a modelling study. Lancet Glob Health 2021; 9:e916-e924. [PMID: 33857499 PMCID: PMC8041387 DOI: 10.1016/s2214-109x(21)00103-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/19/2021] [Accepted: 02/25/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Vietnam has emerged as one of the world's leading success stories in responding to COVID-19. After a prolonged period of little to no transmission, there was an outbreak of unknown source in July, 2020, in the Da Nang region, but the outbreak was quickly suppressed. We aimed to use epidemiological, behavioural, demographic, and policy data from the COVID-19 outbreak in Da Nang to calibrate an agent-based model of COVID-19 transmission for Vietnam, and to estimate the risk of future outbreaks associated with reopening of international borders in the country. METHODS For this modelling study, we used comprehensive data from June 15 to Oct 15, 2020, on testing, COVID-19 cases, and quarantine breaches within an agent-based model of SARS-CoV-2 transmission to model a COVID-19 outbreak in Da Nang in July, 2020. We applied this model to quantify the risk of future outbreaks in Vietnam in the 3 months after the reopening of international borders, under different behavioural scenarios, policy responses (ie, closure of workplaces and schools), and ongoing testing. FINDINGS We estimated that the outbreak in Da Nang between July and August, 2020, resulted in substantial community transmission, and that higher levels of symptomatic testing could have mitigated this transmission. We estimated that the outbreak peaked on Aug 2, 2020, with an estimated 1060 active infections (95% projection interval 890-1280). If the population of Vietnam remains highly compliant with mask-wearing policies, our projections indicate that the epidemic would remain under control even if a small but steady flow of imported infections escaped quarantine into the community. However, if complacency increases and testing rates are relatively low (10% of symptomatic individuals are tested), the epidemic could rebound again, resulting in an estimated 2100 infections (95% projected interval 1050-3610) in 3 months. These outcomes could be mitigated if the behaviour of the general population responds dynamically to increases in locally acquired cases that exceed specific thresholds, but only if testing of symptomatic individuals is also increased. INTERPRETATION The successful response to COVID-19 in Vietnam could be improved even further with higher levels of symptomatic testing. If the previous approaches are used in response to new COVID-19 outbreaks, epidemic control is possible even in the presence of low levels of imported cases. FUNDING Ministry of Science and Technology (Vietnam). TRANSLATION For the Vietnamese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Quang D Pham
- Pasteur Institute of Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Robyn M Stuart
- Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark; Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia.
| | - Thuong V Nguyen
- Pasteur Institute of Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Quang C Luong
- Pasteur Institute of Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Quang D Tran
- General Department of Preventive Medicine, Ministry of Health, Hanoi, Vietnam
| | - Thai Q Pham
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam; School of Preventive Medicine and Public Health, Hanoi University, Hanoi, Vietnam
| | - Lan T Phan
- Pasteur Institute of Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Tan Q Dang
- General Department of Preventive Medicine, Ministry of Health, Hanoi, Vietnam
| | - Duong N Tran
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | - Hung T Do
- Pasteur Institute of Nha Trang, Nha Trang, Vietnam
| | - Dina Mistry
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Daniel J Klein
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | | | - Assaf P Oron
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Cliff C Kerr
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, WA, USA; School of Physics, University of Sydney, Sydney, NSW, Australia
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11
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Kerr CC, Stuart RM, Mistry D, Abeysuriya RG, Rosenfeld K, Hart GR, Núñez RC, Cohen JA, Selvaraj P, Hagedorn B, George L, Jastrzębski M, Izzo AS, Fowler G, Palmer A, Delport D, Scott N, Kelly SL, Bennette CS, Wagner BG, Chang ST, Oron AP, Wenger EA, Panovska-Griffiths J, Famulare M, Klein DJ. Covasim: An agent-based model of COVID-19 dynamics and interventions. PLoS Comput Biol 2021; 17:e1009149. [PMID: 34310589 PMCID: PMC8341708 DOI: 10.1371/journal.pcbi.1009149] [Citation(s) in RCA: 175] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 08/05/2021] [Accepted: 06/05/2021] [Indexed: 12/23/2022] Open
Abstract
The COVID-19 pandemic has created an urgent need for models that can project epidemic trends, explore intervention scenarios, and estimate resource needs. Here we describe the methodology of Covasim (COVID-19 Agent-based Simulator), an open-source model developed to help address these questions. Covasim includes country-specific demographic information on age structure and population size; realistic transmission networks in different social layers, including households, schools, workplaces, long-term care facilities, and communities; age-specific disease outcomes; and intrahost viral dynamics, including viral-load-based transmissibility. Covasim also supports an extensive set of interventions, including non-pharmaceutical interventions, such as physical distancing and protective equipment; pharmaceutical interventions, including vaccination; and testing interventions, such as symptomatic and asymptomatic testing, isolation, contact tracing, and quarantine. These interventions can incorporate the effects of delays, loss-to-follow-up, micro-targeting, and other factors. Implemented in pure Python, Covasim has been designed with equal emphasis on performance, ease of use, and flexibility: realistic and highly customized scenarios can be run on a standard laptop in under a minute. In collaboration with local health agencies and policymakers, Covasim has already been applied to examine epidemic dynamics and inform policy decisions in more than a dozen countries in Africa, Asia-Pacific, Europe, and North America.
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Affiliation(s)
- Cliff C. Kerr
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Robyn M. Stuart
- Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark
- Burnet Institute, Melbourne, Victoria, Australia
| | - Dina Mistry
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | | | - Katherine Rosenfeld
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Gregory R. Hart
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Rafael C. Núñez
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Jamie A. Cohen
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Prashanth Selvaraj
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Brittany Hagedorn
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Lauren George
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | | | - Amanda S. Izzo
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Greer Fowler
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Anna Palmer
- Burnet Institute, Melbourne, Victoria, Australia
| | | | - Nick Scott
- Burnet Institute, Melbourne, Victoria, Australia
| | | | - Caroline S. Bennette
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Bradley G. Wagner
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Stewart T. Chang
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Assaf P. Oron
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Edward A. Wenger
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Jasmina Panovska-Griffiths
- Big Data Institute, University of Oxford, Oxford, United Kingdom
- Wolfson Centre for Mathematical Biology and The Queen’s College, University of Oxford, Oxford, United Kingdom
| | - Michael Famulare
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Daniel J. Klein
- Institute for Disease Modeling, Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
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12
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von Saint Andre-von Arnim AO, Kumar RK, Oron AP, Nguyen QUP, Mutonga DM, Zimmerman J, Walson JL. Feasibility of Family-Assisted Severity of Illness Monitoring for Hospitalized Children in Low-Income Settings. Pediatr Crit Care Med 2021; 22:e115-e124. [PMID: 33031354 DOI: 10.1097/pcc.0000000000002582] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the feasibility of having caregivers assist in recognition of clinical deterioration in children hospitalized with febrile illness in a resource-limited setting. DESIGN Single-center, prospective, interventional pilot study. SETTING General pediatric wards at Kenyatta National Hospital, Nairobi, Kenya's largest public tertiary-care hospital. PATIENTS Children hospitalized with acute febrile illness, accompanied by caregivers available at the bedside for 24 hours soon after hospital admission. INTERVENTIONS Caregivers were trained to recognize signs of critical illness using the Family-Assisted Severe Febrile Illness Therapy tool, which quantifies patients' work of breathing, mental status, and perfusion, producing color-coded flags to signal illness severity. Caregivers' Family-Assisted Severe Febrile Illness Therapy assessments were compared with healthcare professional assessments and to established Pediatric Early Warning Scores (PEWS). An initial study stage was followed by refinement of training and a larger second stage with intervention/control arms. MEASUREMENTS AND MAIN RESULTS A total of 107 patient/caregiver pairs were enrolled in the interventional arm; 106 caregivers underwent Family-Assisted Severe Febrile Illness Therapy training and were included in the analysis. Patient characteristics included median age 1.1 years (0.2-10 yr), 55 (52%) female, and diagnoses: pneumonia (64 [60%]), meningitis (38 [36%]), gastroenteritis (24 [23%]), and malaria (21 [20%]). Most caregivers had primary (34 [32%]) or secondary (53 [50%]) school education. Fourteen of 106 patients (13%) died during their stay, six within 2 days. Across all severity levels, caregiver Family-Assisted Severe Febrile Illness Therapy assessments matched professionals in 87% and 94% for stages 1 and 2, respectively. Caregiver Family-Assisted Severe Febrile Illness Therapy assessments had a moderate to strong correlation with coinciding Pediatric Early Warning Scores and were sensitive to life-threatening deterioration: for all six patients who died within 2 days of admission, caregiver assessment reached the highest alert level. CONCLUSIONS Caregiver involvement in recognition of critical illness in hospitalized children in low-resource settings may be feasible. This may facilitate earlier detection of clinical deterioration where staffing is severely limited by constrained resources. Further validation of the Family-Assisted Severe Febrile Illness Therapy tool is warranted, followed by its application in a larger multisite patient population to assess provider response and associated clinical outcomes.
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Affiliation(s)
- Amelie O von Saint Andre-von Arnim
- Division of Pediatric Critical Care, Department of Pediatrics, Seattle Children's, University of Washington, Seattle, WA
- Department of Global Health, Seattle Children's, University of Washington, Seattle, WA
| | - Rashmi K Kumar
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Assaf P Oron
- Maternal, Newborn, and Child Health, Institute for Disease Modeling, Seattle, WA
| | - Quynh-Uyen P Nguyen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Stanford, CA
| | - Daniel M Mutonga
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Jerry Zimmerman
- Division of Pediatric Critical Care, Department of Pediatrics, Seattle Children's, University of Washington, Seattle, WA
| | - Judd L Walson
- Departments of Global Health, Epidemiology, Infectious Disease, University of Washington, Seattle, WA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
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13
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Porco TC, Oldenburg CE, Arzika AM, Kalua K, Mrango Z, Cook C, Lebas E, Bailey RL, West SK, Oron AP, Keenan JD, Lietman TM, For The Mordor Study Group. Efficacy of Mass Azithromycin Distribution for Reducing Childhood Mortality Across Geographic Regions. Am J Trop Med Hyg 2020; 103:1291-1294. [PMID: 30734695 PMCID: PMC7470520 DOI: 10.4269/ajtmh.18-1003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Mass azithromycin distribution has been shown to reduce all-cause mortality in preschool children in sub-Saharan Africa. However, substantial heterogeneity in the apparent effect has been noted across geographic settings, suggesting a greater relative benefit in higher mortality settings. Here, we evaluated the relationship between the underlying mortality rate and the efficacy of azithromycin for the prevention of child mortality using data from multiple sites in Ethiopia, Malawi, Niger, and Tanzania. Between regions, we find no strong evidence of effect modification of the efficacy of azithromycin distribution for the prevention of child mortality by the underlying mortality rate (P = 0.12), although a modest effect is consistent with our findings. Higher mortality settings could be prioritized, however, because of the larger number of deaths which could be averted with azithromycin distribution.
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Affiliation(s)
- Travis C Porco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
| | - Catherine E Oldenburg
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
| | | | - Khumbo Kalua
- College of Medicine, University of Malawi, Blantyre, Malawi.,Blantyre Institute for Community Outreach, Blantyre, Malawi
| | - Zakayo Mrango
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Catherine Cook
- Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
| | - Elodie Lebas
- Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
| | - Robin L Bailey
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sheila K West
- The Dana Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Assaf P Oron
- Institute for Disease Modeling, Bellevue, Washington
| | - Jeremy D Keenan
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California
| | - Thomas M Lietman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California
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14
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Oron AP, Burstein R, Mercer LD, Arzika AM, Kalua K, Mrango Z, West SK, Bailey RL, Porco TC, Lietman TM. Effect Modification by Baseline Mortality in the MORDOR Azithromycin Trial. Am J Trop Med Hyg 2020; 103:1295-1300. [PMID: 30734696 PMCID: PMC7470539 DOI: 10.4269/ajtmh.18-1004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
We examined whether baseline mortality risk, as a function of child age and site, modified the azithromycin mortality-reduction effect in the Macrolide Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) clinical trial. We used the Cox proportional hazards model with an interaction term. Three models were examined representing three sources for the baseline-risk covariate: two using sources external to MORDOR and the third leveraging data within MORDOR. All three models provided moderate evidence for the effect becoming stronger with increasing baseline mortality (P = 0.02, 0.02, and 0.07, respectively) at the rate of approximately 6–12% additional mortality reduction per doubling of baseline mortality. Etiological and programmatic implications of these findings are discussed.
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Affiliation(s)
- Assaf P Oron
- Institute for Disease Modeling, Bellevue, Washington
| | - Roy Burstein
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington
| | | | | | - Khumbo Kalua
- Blantyre Institute for Community Outreach and the College of Medicine, University of Malawi, Blantyre
| | - Zakayo Mrango
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Sheila K West
- The Dana Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robin L Bailey
- The London School of Tropical Hygiene and Medicine, London, United Kingdom
| | - Travis C Porco
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Thomas M Lietman
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I Proctor Foundation, University of California, San Francisco, San Francisco, California
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15
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Nembaware V, Mazandu GK, Hotchkiss J, Safari Serufuri JM, Kent J, Kengne AP, Anie K, Munung NS, Bukini D, Bitoungui VJN, Munube D, Chirwa U, Chunda-Liyoka C, Jonathan A, Flor-Park MV, Esoh KK, Jonas M, Mnika K, Oosterwyk C, Masamu U, Morrice J, Uwineza A, Nguweneza A, Banda K, Nyanor I, Adjei DN, Siebu NE, Nkanyemka M, Kuona P, Tayo BO, Campbell A, Oron AP, Nnodu OE, Painstil V, Makani J, Mulder N, Wonkam A. The Sickle Cell Disease Ontology: Enabling Collaborative Research and Co-Designing of New Planetary Health Applications. OMICS 2020; 24:559-567. [PMID: 33021900 PMCID: PMC7549008 DOI: 10.1089/omi.2020.0153] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Sickle cell disease (SCD) is one of the most common blood disorders impacting planetary health. Over 300,000 newborns are diagnosed with SCD each year globally, with an increasing trend. The sickle cell disease ontology (SCDO) is the most comprehensive multidisciplinary SCD knowledge portal. The SCDO was collaboratively developed by the SCDO working group, which includes experts in SCD and data standards from across the globe. This expert review presents highlights and lessons learned from the fourth SCDO workshop that marked the beginning of applications toward planetary health impact, and with an eye to empower and cultivate multisite SCD collaborative research. The workshop was organized by the Sickle Africa Data Coordinating Center (SADaCC) and attended by 44 participants from 14 countries, with 2 participants connecting remotely. Notably, from the standpoint of democratizing and innovating scientific meeting design, an SCD patient advocate also presented at the workshop, giving a broader real-life perspective on patients' aspirations, needs, and challenges. A major component of the workshop was new approaches to harness SCDO to harmonize data elements used by different studies. This was facilitated by a web-based platform onto which participants uploaded data elements from previous or ongoing SCD-relevant research studies before the workshop, making multisite collaborative research studies based on existing SCD data possible, including multisite cohort, SCD global clinical trials, and SCD community engagement approaches. Trainees presented proposals for systematic literature reviews in key SCD research areas. This expert review emphasizes potential and prospects of SCDO-enabled data standards and harmonization to facilitate large-scale global SCD collaborative initiatives. As the fields of public and global health continue to broaden toward planetary health, the SCDO is well poised to play a prominent role to decipher SCD pathophysiology further, and co-design diagnostics and therapeutics innovation in the field.
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Affiliation(s)
- Victoria Nembaware
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Gaston K Mazandu
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jade Hotchkiss
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | - Jill Kent
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Kofi Anie
- London North West University Healthcare NHS Trust and Imperial College London, London, UK.,Sickle Cell Disease Genomics Network of Africa (SickleGenAfrica), University of Ghana, Accra, Ghana
| | - Nchangwi Syntia Munung
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Daima Bukini
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Valentina Josiane Ngo Bitoungui
- Department of Microbiology, Hematology and Immunology, Faculty of Medicine and Pharmaceutical Sciences of the University of Dschang, Dschang, Cameroon
| | - Deogratias Munube
- Department of Paediatric and Child Health, Makerere University/Mulago National Referral Hospital, Kampala, Uganda
| | - Uzima Chirwa
- University Teaching Hospitals-Children's Hospital, University of Zambia, School of Medicine, Lusaka, Zambia
| | - Catherine Chunda-Liyoka
- University Teaching Hospitals-Children's Hospital, University of Zambia, School of Medicine, Lusaka, Zambia
| | - Agnes Jonathan
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Miriam V Flor-Park
- Onco-hematology Unit, Instituto da Criança, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Kevin Kum Esoh
- Department of Biochemistry, Faculty of Science, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Mario Jonas
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Khuthala Mnika
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Chandré Oosterwyk
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Upendo Masamu
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Jack Morrice
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Annette Uwineza
- University of Rwanda, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Arthemon Nguweneza
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kambe Banda
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Isaac Nyanor
- Kumasi Centre for Sickle Cell Disease, Komfo Anokye Teaching Hospital, Accra, Ghana
| | - David Nana Adjei
- Sickle Cell Disease Genomics Network of Africa (SickleGenAfrica), University of Ghana, Accra, Ghana
| | - Nathan Edward Siebu
- Sickle Cell Disease Genomics Network of Africa (SickleGenAfrica), University of Ghana, Accra, Ghana
| | - Malula Nkanyemka
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Patience Kuona
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Bamidele O Tayo
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois, USA
| | - Andrew Campbell
- Division of Hematology, Center for Cancer and Blood Disorders, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Assaf P Oron
- Maternal, Newborn and Child Health, Institute for Disease Modeling, Bellevue, Washington, USA
| | - Obiageli E Nnodu
- Centre of Excellence for Sickle Cell Disease Research and Training, University of Abuja, Abuja, Nigeria
| | - Vivian Painstil
- Department of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Julie Makani
- Sickle Cell Programme, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Nicola Mulder
- Computational Biology Division, Faculty of Health Sciences, Cape Town, South Africa
| | - Ambroise Wonkam
- Division of Human Genetics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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16
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Oron AP, Chao DL, Ezeanolue EE, Ezenwa LN, Piel FB, Ojogun OT, Uyoga S, Williams TN, Nnodu OE. Caring for Africa's sickle cell children: will we rise to the challenge? BMC Med 2020; 18:92. [PMID: 32340612 PMCID: PMC7187492 DOI: 10.1186/s12916-020-01557-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/12/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Most of the world's sickle cell disease (SCD) burden is in Africa, where it is a major contributor to child morbidity and mortality. Despite the low cost of many preventive SCD interventions, insufficient resources have been allocated, and progress in alleviating the SCD burden has lagged behind other public-health efforts in Africa. The recent announcement of massive new funding for research into curative SCD therapies is encouraging in the long term, but over the next few decades, it is unlikely to help Africa's SCD children substantially. MAIN DISCUSSION A major barrier to progress has been the absence of large-scale early-life screening. Most SCD deaths in Africa probably occur before cases are even diagnosed. In the last few years, novel inexpensive SCD point-of-care test kits have become widely available and have been deployed successfully in African field settings. These kits could potentially enable universal early SCD screening. Other recent developments are the expansion of the pneumococcal conjugate vaccine towards near-universal coverage, and the demonstrated safety, efficacy, and increasing availability and affordability of hydroxyurea across the continent. Most elements of standard healthcare for SCD children that are already proven to work in the West, could and should now be implemented at scale in Africa. National and continental SCD research and care networks in Africa have also made substantial progress, assembling care guidelines and enabling the deployment and scale-up of SCD public-health systems. Substantial logistical, cultural, and awareness barriers remain, but with sufficient financial and political will, similar barriers have already been overcome in efforts to control other diseases in Africa. CONCLUSION AND RECOMMENDATIONS Despite remaining challenges, several high-SCD-burden African countries have the political will and infrastructure for the rapid implementation and scale-up of comprehensive SCD childcare programs. A globally funded effort starting with these countries and expanding elsewhere in Africa and to other high-burden countries, including India, could transform the lives of SCD children worldwide and help countries to attain their Sustainable Development Goals. This endeavor would also require ongoing research focused on the unique needs and challenges of SCD patients, and children in particular, in regions of high prevalence.
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Affiliation(s)
- Assaf P Oron
- Maternal, Newborn and Child Health, Institute for Disease Modeling, Bellevue, WA, USA
| | - Dennis L Chao
- Maternal, Newborn and Child Health, Institute for Disease Modeling, Bellevue, WA, USA
| | - Echezona E Ezeanolue
- Healthy Sunrise Foundation, Las Vegas, NV, USA
- College of Medicine, University of Nigeria, Nsukka, Nigeria
| | | | - Frédéric B Piel
- Department of Epidemiology & Biostatistics, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | | | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | | | - Obiageli E Nnodu
- Centre of Excellence for Sickle Cell Disease Research & Training, University of Abuja, Abuja, Nigeria
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Zhao Y, Iyer RS, Reichley L, Oron AP, Gove NE, Kitsch AE, Biswas D, Friedman S, Partridge SC, Wallace CA. A Pilot Study of Infrared Thermal Imaging to Detect Active Bone Lesions in Children With Chronic Nonbacterial Osteomyelitis. Arthritis Care Res (Hoboken) 2020; 71:1430-1435. [PMID: 30387916 DOI: 10.1002/acr.23804] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 10/30/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Chronic nonbacterial osteomyelitis (CNO) is an autoinflammatory bone disease. An inexpensive and rapid imaging tool, infrared thermal imaging, was evaluated for its utility to detect active bone lesions in extremities of children with CNO. METHODS Children with suspected active CNO and healthy controls were enrolled. All subjects underwent infrared thermal imaging of the lower extremities. Patients in the CNO group also received a magnetic resonance imaging (MRI) examination. Hyperintensity within bone marrow on a fluid-sensitive T2-weighted MRI sequence was considered confirmatory for inflammation. Infrared thermal data were analyzed using custom software by dividing the leg below the knee into 3 equal segments longitudinally and adding the distal femur segment as an equal length above the knee. Median and 95th percentile temperatures were recorded for each leg segment. Temperature differences between inflamed and uninflamed segments in all subjects (both intersubject and intrasubject) were evaluated using a linear mixed-effects model. RESULTS Thirty children in the suspected/known CNO group and 31 healthy children were enrolled. In the healthy control group, males had significantly higher temperature in their lower extremities than females (P < 0.05). There was no difference in temperature detected between inflamed leg segments of patients with CNO versus uninflamed leg segments of the healthy control group. However, within the CNO group, significantly higher temperatures were detected for inflamed versus uninflamed distal tibia/fibula segments (P < 0.01). CONCLUSION Children with active CNO lesions in the distal tibia/fibula exhibited higher regional temperatures on average than healthy extremities. Larger studies are warranted to further evaluate the clinical utility of infrared thermal imaging for CNO detection.
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Affiliation(s)
- Yongdong Zhao
- Seattle Children's Hospital and University of Washington, Seattle
| | - Ramesh S Iyer
- Seattle Children's Hospital and University of Washington, Seattle
| | - Lucas Reichley
- Seattle Children's Hospital and University of Washington, Seattle
| | | | - Nancy E Gove
- Seattle Children's Research Institute, Seattle, Washington
| | - Averi E Kitsch
- University of Washington and Seattle Cancer Care Alliance, Seattle
| | - Debosmita Biswas
- University of Washington and Seattle Cancer Care Alliance, Seattle
| | - Seth Friedman
- Seattle Children's Hospital and University of Washington, Seattle
| | | | - Carol A Wallace
- Seattle Children's Hospital and University of Washington, Seattle
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18
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Wong M, Oron AP, Faino A, Stanford S, Stevens J, Crowell CS, Javid PJ. Variation in hospital costs for gastroschisis closure techniques. Am J Surg 2020; 219:764-768. [PMID: 32199604 DOI: 10.1016/j.amjsurg.2020.03.003] [Citation(s) in RCA: 2] [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] [Received: 11/05/2019] [Revised: 02/28/2020] [Accepted: 03/01/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND In newborns with gastroschisis, both primary repair and delayed fascial closure with initial silo placement are considered safe with similar outcomes although cost differences have not been explored. METHODS A retrospective review was performed of newborns admitted with gastroschisis at a single center from 2011 to 2016. Demographic, clinical, and cost data during the initial hospitalization were collected. Differences between procedure costs and clinical endpoints were analyzed using multivariable linear regression adjusting for prematurity, complicated gastroschisis, and performance of additional operations. RESULTS 80 patients with gastroschisis met inclusion criteria. Rates of primary fascial, primary umbilical cord closure, and delayed closure were 14%, 65%, and 21%, respectively. Delayed closure was associated with an increase in total hospital costs by 57% compared to primary repair (p < 0.001). In addition, delayed closure was associated with increased total and NICU LOS (p < 0.05), parenteral nutrition duration (p = 0.02), ventilator days (p < 0.001), time to goal enteral feeds (p = 0.01), and all cost sub-categories except ward room costs (p < 0.01). CONCLUSION Delayed fascial closure was associated with significantly greater hospital costs during the index admission.
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Affiliation(s)
- Melissa Wong
- University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Assaf P Oron
- Institute for Disease Modeling, Bellevue, WA, 98005, USA; Seattle Children's Research Institute, Seattle, WA, 98101, USA
| | - Anna Faino
- Seattle Children's Research Institute, Seattle, WA, 98101, USA
| | | | | | | | - Patrick J Javid
- University of Washington School of Medicine, Seattle, WA, 98195, USA; Seattle Children's Hospital, Seattle, WA, 98105, USA.
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19
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Neam VC, Oron AP, Nair D, Edwards T, Horslen SP, Javid PJ. Factors Associated with Health-Related Quality of Life in Children with Intestinal Failure. J Pediatr 2020; 216:13-18.e1. [PMID: 31590945 DOI: 10.1016/j.jpeds.2019.08.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 06/14/2019] [Revised: 08/20/2019] [Accepted: 08/26/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate disease-specific and age-related factors contributing to health-related quality of life (HRQOL). in children with intestinal failure. STUDY DESIGN A prospective study of HRQOL was performed in a regional intestinal rehabilitation program. Parent-proxy Pediatric Quality of Life Inventory surveys were administered annually to families of 91 children with intestinal failure over a 6-year period. Survey data was stratified by age and compared with pediatric HRQOL data in healthy and chronically ill populations. Linear mixed-effect models using multivariable regression were constructed to identify associations with HRQOL. RESULTS A total of 180 surveys were completed by 91 children and their families. HRQOL scores were lowest for children ages 5-7 years (P < .001) and 8-12 years (P < .01), and these changes were primarily related to school dimension scores. In multivariable regression, age of 5 years and older and developmental delay were independently associated with lower HRQOL scores. The trend toward lower HRQOL scores parallels reference data from healthy and chronically ill children, although patients with intestinal failure scored lower than both populations at school age. CONCLUSIONS Children with intestinal failure experience lower parent-proxy HRQOL scores in the 5-7 and 8-12 year age groups primarily related to school dimension scores. Multicenter data to validate these findings and identify interventions to improve QOL for children with intestinal failure are needed.
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Affiliation(s)
| | | | | | - Todd Edwards
- University of Washington School of Public Health, Seattle, WA
| | - Simon P Horslen
- Seattle Children's Hospital, Seattle, WA; University of Washington School of Medicine, Seattle, WA
| | - Patrick J Javid
- Seattle Children's Hospital, Seattle, WA; University of Washington School of Medicine, Seattle, WA
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20
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Bonow RH, Oron AP, Hanak BW, Browd SR, Chesnut RM, Ellenbogen RG, Vavilala MS, Rivara FP. Post-Traumatic Hydrocephalus in Children: A Retrospective Study in 42 Pediatric Hospitals Using the Pediatric Health Information System. Neurosurgery 2019; 83:732-739. [PMID: 29029289 DOI: 10.1093/neuros/nyx470] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 08/30/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Post-traumatic hydrocephalus (PTH) is a potentially treatable cause of poor recovery from traumatic brain injury (TBI) that remains poorly understood, particularly among children. OBJECTIVE To better understand the risk factors for pediatric PTH using a large, multi-institutional database. METHODS We conducted a retrospective cohort study using administrative data from 42 pediatric hospitals participating in the Pediatric Health Information System. All patients ≤21 yr surviving a hospitalization with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for TBI were identified. The primary outcome was PTH, defined by an ICD-9-CM procedure code for surgical management of hydrocephalus within 6 mo. Data were analyzed using multivariable logistic regression. RESULTS We identified 91 583 patients ≤21 yr with TBI, 846 of whom developed PTH. Odds of PTH were significantly higher in children <1 yr compared to older age groups. A total of 48.7% of PTH cases were victims of abuse (adjusted odds ratio [aOR] 2.62, 95% confidence interval [CI] 2.16-3.18). PTH was more common after craniotomy (aOR 1.60, 95% CI 1.30-1.97). Craniectomy without early cranioplasty was associated with markedly increased odds of PTH (aOR 3.67, 95% CI 2.66-5.07), an effect not seen in those undergoing cranioplasty within 30 d (aOR 1.19, 95% CI 0.75-1.89). CONCLUSION PTH was seen in 0.9% of children who sustained a TBI and was more common in those <1 yr. Severe injury, abuse, and craniectomy with delayed cranioplasty were associated with greatly increased likelihood of PTH. Early cranioplasty in children who require craniectomy may reduce the risk for PTH.
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Affiliation(s)
- Robert H Bonow
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
| | - Assaf P Oron
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Brian W Hanak
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Samuel R Browd
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Monica S Vavilala
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Frederick P Rivara
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle, Washington
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21
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Affiliation(s)
- Nancy Flournoy
- Department of Statistics, University of Missouri, Columbia, MO, USA
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22
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Hawken S, Ducharme R, Fell DB, Oron AP, Wilson K. Effects of sex and birth weight on non-specific health services use following whole-cell pertussis vaccination: a self-controlled case series analysis. Hum Vaccin Immunother 2019; 15:2399-2404. [PMID: 30829106 PMCID: PMC6816393 DOI: 10.1080/21645515.2019.1586029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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] [Indexed: 12/02/2022] Open
Abstract
Previous studies from low-resource countries have highlighted concerns surrounding non-specific effects of whole-cell pertussis vaccination, particularly in females. We sought to examine the effects of sex and birth weight on health services utilization following first exposure to whole-cell pertussis vaccine. Using a self-controlled case series design and by calculating relative incidence ratios (RIRs), we compared the relative incidence of emergency department visits and/or hospital admissions between sexes and between birth weight quintiles. Females had a higher relative incidence of events following vaccination compared to males (RIR = 1.13, 95% CI: 0.99, 1.30), which persisted after adjustment for birth weight (RIR = 1.12, 95% CI: 0.97, 1.28). We also observed a trend of increasing relative incidence of events over decreasing quintiles of birth weight; infants in the lowest quintile had a 26% higher relative event rate compared to the highest quintile, which was robust to adjustment for sex (Unadjusted RIR = 1.26, 95% CI: 1.01, 1.56; Adjusted RIR = 1.23, 95% CI: 0.99, 1.53). The risk of all-cause health services utilization immediately following vaccination, was elevated in female infants and infants having lower birth weight. Further study is warranted to determine if vaccine dosing should take infant weight into account.
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Affiliation(s)
- Steven Hawken
- Clinical Epidemiology Program, Ottawa Hospital Research Institute , Ottawa , Ontario , Canada.,School of Epidemiology and Public Health, University of Ottawa , Ottawa , Canada.,ICES, University of Ottawa , Ottawa , Canada
| | - Robin Ducharme
- Clinical Epidemiology Program, Ottawa Hospital Research Institute , Ottawa , Ontario , Canada
| | - Deshayne B Fell
- School of Epidemiology and Public Health, University of Ottawa , Ottawa , Canada.,ICES, University of Ottawa , Ottawa , Canada.,Children's Hospital of Eastern Ontario (CHEO) Research Institute, Children's Hospital of Eastern Ontario (CHEO) , Ottawa , Ontario , Canada
| | - Assaf P Oron
- Maternal, Newborn, and Child Health, Institute for Disease Modeling , Bellevue , Washington , USA
| | - Kumanan Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute , Ottawa , Ontario , Canada.,School of Epidemiology and Public Health, University of Ottawa , Ottawa , Canada.,ICES, University of Ottawa , Ottawa , Canada.,Department of Medicine, University of Ottawa , Ottawa , Ontario , Canada
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23
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Wedlock PT, Mitgang EA, Oron AP, Hagedorn BL, Leonard J, Brown ST, Bakal J, Siegmund SS, Lee BY. Modeling the economic impact of different vial-opening thresholds for measles-containing vaccines. Vaccine 2019; 37:2356-2368. [PMID: 30914223 PMCID: PMC6467546 DOI: 10.1016/j.vaccine.2019.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 12/12/2018] [Revised: 03/07/2019] [Accepted: 03/11/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The lack of specific policies on how many children must be present at a vaccinating location before a healthcare worker can open a measles-containing vaccine (MCV) - i.e. the vial-opening threshold - has led to inconsistent practices, which can have wide-ranging systems effects. METHODS Using HERMES-generated simulation models of the routine immunization supply chains of Benin, Mozambique and Niger, we evaluated the impact of different vial-opening thresholds (none, 30% of doses must be used, 60%) and MCV presentations (10-dose, 5-dose) on each supply chain. We linked these outputs to a clinical- and economic-outcomes model which translated the change in vaccine availability to associated infections, medical costs, and DALYs. We calculated the economic impact of each policy from the health system perspective. RESULTS The vial-opening threshold that maximizes vaccine availability while minimizing costs varies between individual countries. In Benin (median session size = 5), implementing a 30% vial-opening threshold and tailoring distribution of 10-dose and 5-dose MCVs to clinics based on session size is the most cost-effective policy, preventing 671 DALYs ($471/DALY averted) compared to baseline (no threshold, 10-dose MCVs). In Niger (median MCV session size = 9), setting a 60% vial-opening threshold and tailoring MCV presentations is the most cost-effective policy, preventing 2897 DALYs ($16.05/ DALY averted). In Mozambique (median session size = 3), setting a 30% vial-opening threshold using 10-dose MCVs is the only beneficial policy compared to baseline, preventing 3081 DALYs ($85.98/DALY averted). Across all three countries, however, a 30% vial-opening threshold using 10-dose MCVs everywhere is the only MCV threshold that consistently benefits each system compared to baseline. CONCLUSION While the ideal vial-opening threshold policy for MCV varies by supply chain, implementing a 30% vial-opening threshold for 10-dose MCVs benefits each system by improving overall vaccine availability and reducing associated medical costs and DALYs compared to no threshold.
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Affiliation(s)
- Patrick T Wedlock
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Global Obesity Prevention Center (GOPC) at Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Elizabeth A Mitgang
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Global Obesity Prevention Center (GOPC) at Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Assaf P Oron
- Institute for Disease Modeling, Bellevue, WA, United States
| | | | - Jim Leonard
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Pittsburgh Supercomputing Center, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Shawn T Brown
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; McGill Centre for Integrative Neuroscience, McGill Neurological Institute, McGill University, Montreal, Canada
| | - Jennifer Bakal
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Pittsburgh Supercomputing Center, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Sheryl S Siegmund
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Global Obesity Prevention Center (GOPC) at Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Bruce Y Lee
- HERMES Logistics Modeling Team, Baltimore, MD & Pittsburgh, PA, United States; Global Obesity Prevention Center (GOPC) at Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
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Salehi P, Herzig L, Capone G, Lu A, Oron AP, Kim SJ. Comparison of Aberrant Behavior Checklist profiles across Prader-Willi syndrome, Down syndrome, and autism spectrum disorder. Am J Med Genet A 2018; 176:2751-2759. [DOI: 10.1002/ajmg.a.40665] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 03/12/2018] [Accepted: 09/04/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Parisa Salehi
- Seattle Children's Hospital, Division of Endocrine; University of Washington; Seattle Washington
| | - Lisa Herzig
- Seattle Children's Hospital, Division of Developmental Medicine; University of Washington; Seattle Washington
| | - George Capone
- Kennedy Krieger Institute, Johns Hopkins University School of Medicine; Baltimore Maryland
| | - Amanda Lu
- Seattle Children's Hospital; University of Washington; Seattle Washington
| | - Assaf P. Oron
- Epidemiology Section; Institute for Disease Modeling; Bellevue Washington
| | - Soo-Jeong Kim
- Seattle Children's Hospital, Division of Psychiatry; University of Washington; Seattle Washington
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Pollack AH, Oron AP, Flynn JT, Munshi R. Using dynamic treatment regimes to understand erythropoietin-stimulating agent hyporesponsiveness. Pediatr Nephrol 2018; 33:1411-1417. [PMID: 29619552 PMCID: PMC6827568 DOI: 10.1007/s00467-018-3948-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 09/05/2017] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Erythropoietin-stimulating agent hyporesponsiveness (ESAH) is associated with increased cardiovascular mortality in patients with end-stage renal disease (ESRD) on hemodialysis. Dynamic treatment regimes (DTR), a clinical decision support (CDS) tool that guides the prescription of specific therapies in response to variations in patient states, have been used to guide treatment for chronic illnesses that require frequent monitoring and therapy changes. Our objective is to explore the role of utilizing a DTR to reduce ESAH in pediatric hemodialysis patients. METHODS Retrospective analysis of ESRD patients on hemodialysis who received ESAs. Dosing was adjusted using a locally developed protocol designed to target a hemoglobin between 10 and 12 g/dl. Analyzing this protocol as a DTR, we assessed adherence to the protocol over time measuring how the hyporesponse index (ESA dose/hemoglobin value) changed due to varying levels of adherence. RESULTS Eighteen patients met study criteria. Median hemoglobin was 11.4 g/dl (range 6.1-15.4), and median weekly ESA dose (darbepoetin-equivalent) was 0.4 mcg/kg/dose (range 0-2.1). Full adherence to the DTR was identified in 266 (71%) of the 4-week periods, with a median average adherence score of 0.80 (range 0.63-0.91). As adherence to the DTR improved, ESAH decreased. During the last 12 weeks, 13 out of 18 patients had lower average ESA/hemoglobin ratio than the first 12 weeks. CONCLUSIONS A DTR appears to be well-suited to the treatment of anemia in ESRD and reduces ESAH. Our work shows the potential of DTRs to drive the development and evaluation of clinical practice guidelines.
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Affiliation(s)
- Ari H Pollack
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA.
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
| | - Assaf P Oron
- Section of Epidemiology, Institute for Disease Modeling, Bellevue, WA, USA
| | - Joseph T Flynn
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Raj Munshi
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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26
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Javid PJ, Oron AP, Duggan C, Squires RH, Horslen SP. The extent of intestinal failure-associated liver disease in patients referred for intestinal rehabilitation is associated with increased mortality: an analysis of the Pediatric Intestinal Failure Consortium database. J Pediatr Surg 2018; 53:1399-1402. [PMID: 28943136 PMCID: PMC5837922 DOI: 10.1016/j.jpedsurg.2017.08.049] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 04/21/2017] [Revised: 07/31/2017] [Accepted: 08/27/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The advent of regional multidisciplinary intestinal rehabilitation programs has been associated with improved survival in pediatric intestinal failure. Yet, the optimal timing of referral for intestinal rehabilitation remains unknown. We hypothesized that the degree of intestinal failure-associated liver disease (IFALD) at initiation of intestinal rehabilitation would be associated with overall outcome. METHODS The multicenter, retrospective Pediatric Intestinal Failure Consortium (PIFCon) database was used to identify all subjects with baseline bilirubin data. Conjugated bilirubin (CBili) was used as a marker for IFALD, and we stratified baseline bilirubin values as CBili<2 mg/dL, CBili 2-4 mg/dL, and CBili>4 mg/dL. The association between baseline CBili and mortality was examined using Cox proportional hazards regression. RESULTS Of 272 subjects in the database, 191 (70%) children had baseline bilirubin data collected. 38% and 28% of patients had CBili >4 mg/dL and CBili <2 mg/dL, respectively, at baseline. All-cause mortality was 23%. On univariate analysis, mortality was associated with CBili 2-4 mg/dL, CBili >4 mg/dL, prematurity, race, and small bowel atresia. On regression analysis controlling for age, prematurity, and diagnosis, the risk of mortality was increased by 3-fold for baseline CBili 2-4 mg/dL (HR 3.25 [1.07-9.92], p=0.04) and 4-fold for baseline CBili >4 mg/dL (HR 4.24 [1.51-11.92], p=0.006). On secondary analysis, CBili >4 mg/dL at baseline was associated with a lower chance of attaining enteral autonomy. CONCLUSION In children with intestinal failure treated at intestinal rehabilitation programs, more advanced IFALD at referral is associated with increased mortality and decreased prospect of attaining enteral autonomy. Early referral of children with intestinal failure to intestinal rehabilitation programs should be strongly encouraged. LEVEL OF EVIDENCE Treatment Study, Level III.
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Affiliation(s)
- Patrick J. Javid
- Seattle Children's Hospital and University of Washington School of Medicine
| | - Assaf P. Oron
- Seattle Children's Hospital and University of Washington School of Medicine
| | | | | | - Simon P. Horslen
- Seattle Children's Hospital and University of Washington School of Medicine
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27
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Zhao Y, Rascoff NE, Iyer RS, Thapa M, Reichley L, Oron AP, Wallace CA. Flares of Disease in Children with Clinically Inactive Juvenile Idiopathic Arthritis Were Not Correlated with Ultrasound Findings. J Rheumatol 2018; 45:851-857. [PMID: 29606669 DOI: 10.3899/jrheum.170681] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The validity of our current definitions for clinically inactive disease (CID) in juvenile idiopathic arthritis (JIA) based on physical examination is challenged by the development of advanced musculoskeletal imaging tools. We aimed to prospectively determine the prevalence of abnormal ultrasound (US) findings in children with CID in JIA and their clinical significance. METHODS Children aged ≥ 4 years with CID and a history of arthritis from a single tertiary center were approached over 1 year. Standard US of knees, tibiotalar joints, subtalar joints, and wrists were performed at baseline and at a followup visit. US images were scored by 2 pediatric musculoskeletal radiologists. RESULTS Forty children with CID were enrolled and followed clinically. The median duration of inactive disease was 1 year. The most common International League of Associations for Rheumatology JIA categories were extended oligoarticular JIA (30%) and rheumatoid factor-negative polyarthritis (38%). At baseline, among a total of 289 joints scanned, 24 joints (8%) had at least 1 abnormal finding in 18 (45%) of 40 subjects. When evaluated at the individual joint level against flares identified during followup exams, these baseline US findings had a sensitivity of 15% and a positive predictive value of 12%. The predictive performance of the second US was even less. CONCLUSION Our study demonstrates that nearly half of children with CID had abnormal US findings in 1 of 8 commonly affected joints. These findings did not correlate with subsequent clinical flares in up to 2 years of followup.
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Affiliation(s)
- Yongdong Zhao
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA. .,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project.
| | - Nanci E Rascoff
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
| | - Ramesh S Iyer
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
| | - Mahesh Thapa
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
| | - Lucas Reichley
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
| | - Assaf P Oron
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
| | - Carol A Wallace
- From Pediatric Rheumatology, Department of Pediatrics, the Center for Clinical and Translational Research (CCTR), and Pediatric Radiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.,Y. Zhao, MD, PhD, Pediatric Rheumatology, Department of Pediatrics, and CCTR, Seattle Children's Hospital, University of Washington; N.E. Rascoff, MD, MPH, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; R.S. Iyer, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; M. Thapa, MD, Pediatric Radiology, Seattle Children's Hospital, University of Washington; L. Reichley, BA, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington; A.P. Oron, PhD, Epidemiology Section, Institute for Disease Modeling, Bellevue, Washington, USA; C.A. Wallace, MD, Pediatric Rheumatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington. Drs. Zhao and Rascoff contributed equally to the project
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Abstract
BACKGROUND Studies have linked ambient air pollution to chronic obstructive pulmonary disease (COPD) healthcare encounters. However, the association between air quality and rescue medication use is unknown. OBJECTIVES We assessed the role of air pollution exposure for increased short-acting beta-2-agonist (SABA) use in patients with COPD through use of remote monitoring technology. METHODS Participants received a portable electronic inhaler sensor to record the date, time and location for SABA use over a 3-month period. Ambient air pollution data and meteorological data were collected from a centrally located federal monitoring station. Mixed-effects Poisson regression was used to examine the association of daily inhaler use with pollutant levels. Four criteria pollutants (PM2.5, PM10, O3 and NO2), two particulate matter species (elemental carbon (EC) and organic carbon), estimated coarse fraction of PM10 (PM10-2.5) and four multipollutant air quality measures were each examined separately, adjusting for covariates that passed a false discovery rate (FDR) screening. RESULTS We enrolled 35 patients with COPD (94.3% male and mean age: 66.5±8.5) with a mean forced expiratory volume in 1 s (FEV1) % predicted of 44.9+17.2. Participants had a median of 92 observation days (range 52-109). Participants' average SABA inhaler use ranged from 0.4 to 13.1 puffs/day (median 2.8). Controlling for supplemental oxygen use, long-acting anticholinergic use, modified Medical Research Council Dyspnoea Scale and influenza season, an IQR increase in PM10 concentration (8.0 µg/m3) was associated with a 6.6% increase in daily puffs (95% CI 3.5% to 9.9%; FDR <0.001). NO2 and EC concentration were also significantly associated with inhaler use (3.9% and 2.9% per IQR increase, respectively). CONCLUSIONS Exposure to increased ambient air pollution were associated with a significant increase in SABA use for patients with COPD residing in a low-pollution area.
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Affiliation(s)
- Sheryl Magzamen
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA.,Veterans Administration Eastern Colorado Health Care System, Denver, Colorado, USA
| | - Assaf P Oron
- Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA
| | - Emily R Locke
- Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA
| | - Vincent S Fan
- Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA.,School of Medicine, University of Washington, Seattle, Washington, USA
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Affiliation(s)
- Assaf P. Oron
- Children's Core for Biomedical Statistics, Seattle Children's Research Institute, Seattle, WA
| | - Nancy Flournoy
- Department of Statistics, University of Missouri, Columbia, MO
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30
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Lee VS, Evans KN, Perez FA, Oron AP, Perkins JA. Upper Airway Computed Tomography Measures and Receipt of Tracheotomy in Infants With Robin Sequence. JAMA Otolaryngol Head Neck Surg 2017; 142:750-7. [PMID: 27254152 DOI: 10.1001/jamaoto.2016.1010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Airway management in infants with Robin sequence is challenging. Objective upper airway measures associated with severe airway compromise requiring tracheotomy are needed to guide decision making. OBJECTIVES To define objective upper airway measures in infants with Robin sequence from craniofacial computed tomography (CT) and to identify those measures in Robin sequence associated with tracheotomy. DESIGN, SETTING, AND PARTICIPANTS A cohort study (2003 to 2014, over 1-year follow-up) of 37 infants with Robin sequence evaluated for surgical management and 37 selected age- and sex-matched controls without a craniofacial condition conducted in a pediatric institution's craniofacial center. MAIN OUTCOMES AND MEASURES Define and compare CT-generated upper airway measures in these groups: infants with Robin sequence vs controls, and infants with Robin sequence with vs without tracheotomy. A negative difference signifies lower values for the Robin sequence and tracheotomy groups. Clinical data collected included age and height at time of CT scan, sex, tracheotomy presence, associated syndrome, and laboratory indicators of hypoventilation and hypoxemia. To evaluate interrater reliability, 2 raters performed each measurement in the Robin sequence group. RESULTS In 74 infants, 17 of 28 measures were different between infants with Robin sequence and those in the control group. Tracheotomy was performed in 14 of 37 (38%) infants with Robin sequence. Infants with tracheotomy more commonly had associated syndromes (12 of 14 [86%] vs 11 of 23 [48%]) and a history of hypoventilation and hypoxemia (13 of 14 [93%] vs 15 of 23 [65%]). Five of the 11 measures associated with tracheotomy were reliable and simpler to measure with the following mean differences (95% CIs) between groups: tongue length, 0.87 (0.26 to 1.48); tongue position relative to palate, 0.83 (0.22 to 1.45); mandibular total length, -0.8 (-1.42 to -0.19); gonial angle, 0.71 (0.08 to 1.34); and inferior pogonial angle, 0.66 (0.02 to 1.29). Using a receiver operating characteristic analysis, a composite score of these 5 measures for predicting tracheotomy risk yielded an area under the curve of 0.83 and achieved 86% sensitivity and 74% specificity. CONCLUSIONS AND RELEVANCE Computed tomography measures quantifying tongue position and mandibular configuration can identify infants with Robin sequence, and importantly, differentiate those who have severe upper airway compromise requiring tracheotomy. Following validation, these measures can be used for objective upper airway assessment and for expediting clinical decision-making in these challenging cases for which no such tools currently exist.
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Affiliation(s)
- Victoria S Lee
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington and Seattle Children's, Seattle
| | - Kelly N Evans
- Department of Pediatrics, Division of Craniofacial Medicine, University of Washington and Seattle Children's, Seattle
| | - Francisco A Perez
- Department of Radiology, University of Washington and Seattle Children's, Seattle
| | - Assaf P Oron
- Seattle Children's Core for Biomedical Statistics, Seattle, Washington
| | - Jonathan A Perkins
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of Washington and Seattle Children's, Seattle
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Opersteny E, Anderson H, Bates J, Davenport K, Husby J, Myking K, Oron AP. Precision, Sensitivity and Patient Preference of Non-Invasive Thermometers in a Pediatric Surgical Acute Care Setting. J Pediatr Nurs 2017; 35:36-41. [PMID: 28728767 DOI: 10.1016/j.pedn.2017.02.003] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 02/02/2017] [Accepted: 02/03/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of the project was to compare the temporal artery thermometer (TAT) to the digital probe thermometer readings at axillary or oral sites, to determine the relative precision and sensitivity of the three methods of thermometry, to compare their readings to core temperature when feasible, and to survey patient and family thermometer preferences. DESIGN & METHODS A randomized crossover design in a 70-bed surgical unit over eight months. Two sets of temperature measurements were obtained for each patient: TAT, axillary, oral (depending on patient ability) and a bladder temperature representing core body temperature (when available). Each method was used twice on each patient, to examine within-method precision. Following measurement, patients or caregivers provided their thermometer preference. For younger/nonverbal patients, a professional observer recorded a disruption score. N=298 patients were enrolled RESULTS: TAT was more precise than oral and axillary thermometers (p<0.001 vs. axillary, p=0.001 vs. oral). TAT measurements were higher on average than axillary and oral, by 0.7°C and 0.6°C respectively (p<0.001). TAT's disruption score for younger patients was 0.6 points lower on average than axillary (p<0.001). 84% of patients and families who indicated a clear thermometry preference chose TAT. Only 3 patients had bladder-temperature devices, and therefore accuracy could not be analyzed. CONCLUSIONS TAT is more precise, more fever sensitive, less disruptive to younger children, and more preferred by patients and families. PRACTICE IMPLICATIONS TAT is an acceptable temperature measure that could be substituted for oral or axillary temperature in acute care pediatric settings.
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Affiliation(s)
| | | | | | | | | | | | - Assaf P Oron
- Seattle Children's Hospital, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA
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Cogen JD, Oron AP, Gibson RL, Hoffman LR, Kronman MP, Ong T, Rosenfeld M. Characterization of Inpatient Cystic Fibrosis Pulmonary Exacerbations. Pediatrics 2017; 139:peds.2016-2642. [PMID: 28126911 PMCID: PMC5472380 DOI: 10.1542/peds.2016-2642] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [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: 11/18/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pulmonary exacerbations lead to significant morbidity and mortality in patients with cystic fibrosis (CF). National consensus guidelines exist, but few studies report current practice in the treatment and monitoring of pulmonary exacerbations. The goal of this study was to characterize consistency and variability in the inpatient management of CF-related pulmonary exacerbations. We focused on the use of guideline-recommended maintenance therapies, antibiotic selection and treatment regimens, use of systemic corticosteroids, and frequency of lung function testing. We hypothesized that significant variability in these treatment practices exists nationally. METHODS This trial was a retrospective cross-sectional study. It included patients with CF aged ≤18 years hospitalized for pulmonary exacerbations between July 1, 2010, and June 30, 2015, at hospitals within the US Pediatric Health Information System database that are also Cystic Fibrosis Foundation-accredited care centers. One exacerbation per patient was randomly selected over the 5-year study period. RESULTS From 38 hospitals, 4827 individual pulmonary exacerbations were examined. Median length of stay was 10.0 days (interquartile range, 6-14.0 days). Significant variation was seen among centers in the use of hypertonic saline (11%-100%), azithromycin (5%-83%), and systemic corticosteroids (3%-61%) and in the frequency of lung function testing. Four different admission antibiotic regimens were used >10% of the time, and the most commonly used admission antibiotic regimen comprised 2 intravenous antibiotics with no additional oral or inhaled antibiotics (29%). CONCLUSIONS Significant variation exists in the treatment and monitoring of pulmonary exacerbations across Pediatric Health Information System-participating, Cystic Fibrosis Foundation-accredited care centers. Results from this study can inform future research working toward standardized inpatient pulmonary exacerbation management to improve CF care for children and adolescents.
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Affiliation(s)
- Jonathan D. Cogen
- Divisions of Pulmonary Medicine and Sleep Medicine and,Address correspondence to Jonathan D. Cogen, MD, MPH, Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105. E-mail:
| | - Assaf P. Oron
- Core for Biomedical Statistics, Center for Clinical & Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | | | | | - Matthew P. Kronman
- Infectious Diseases, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; and
| | - Thida Ong
- Divisions of Pulmonary Medicine and Sleep Medicine and
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Thomas AA, Uspal NG, Oron AP, Klein EJ. Perceptions on the Impact of a Just-in-Time Room on Trainees and Supervising Physicians in a Pediatric Emergency Department. J Grad Med Educ 2016; 8:754-758. [PMID: 28018542 PMCID: PMC5180532 DOI: 10.4300/jgme-d-15-00730.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Just-in-time (JIT) training refers to education occurring immediately prior to clinical encounters. An in situ JIT room in a pediatric emergency department (ED) was created for procedural education. OBJECTIVE We examined trainee self-reported JIT room use, its impact on trainee self-perception of procedural competence/confidence, and the effect its usage has on the need for intervention by supervising physicians during procedures. METHODS Cross-sectional survey study of a convenience sample of residents rotating through the ED and supervising pediatric emergency medicine physicians. Outcomes included JIT room use, trainee procedural confidence, and frequency of supervisor intervention during procedures. RESULTS Thirty-one of 32 supervising physicians (97%) and 122 of 186 residents (66%) completed the survey, with 71% of trainees reporting improved confidence, and 68% reporting improved procedural skills (P < .05, +1.4-point average skills improvement on a 5-point Likert scale). Trainees perceived no difference among supervising physicians intervening in procedures with or without JIT room use (P = .30, paired difference -0.0 points). Nearly all supervisors reported improved trainee procedural confidence, and 77% reported improved trainee procedural skills after JIT room use (P < .05, paired difference +1.8 points); 58% of supervisors stated they intervene in procedures without trainee JIT room use, compared with 42% with JIT room use (P < .05, paired difference -0.4 points). CONCLUSIONS Use of the JIT room led to improved trainee confidence and supervisor reports of less procedural intervention. Although it carries financial and time costs, an in situ JIT room may be important for convenient JIT training.
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Affiliation(s)
- Anita A. Thomas
- Corresponding author: Anita A. Thomas, MD, MPH, Seattle Children's Hospital, Department of Emergency Medicine, Mailstop MB.7.520, 4800 Sand Point Way NE, Seattle, WA 98145, 206.987.2599, fax 206.729.3070,
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Kronman MP, Oron AP, Ross RK, Hersh AL, Newland JG, Goldin A, Rangel SJ, Weissman SJ, Zerr DM, Gerber JS. Extended- Versus Narrower-Spectrum Antibiotics for Appendicitis. Pediatrics 2016; 138:peds.2015-4547. [PMID: 27354453 DOI: 10.1542/peds.2015-4547] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [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: 04/28/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Appendicitis guidelines recommend either narrower- or extended-spectrum antibiotics for treatment of complicated appendicitis. The goal of this study was to compare the effectiveness of extended-spectrum versus narrower-spectrum antibiotics for children with appendicitis. METHODS We performed a retrospective cohort study of children aged 3 to 18 years discharged between 2011 and 2013 from 23 freestanding children's hospitals with an appendicitis diagnosis and appendectomy performed. Subjects were classified as having complicated appendicitis if they had a postoperative length of stay ≥3 days, a central venous catheter placed, major or severe illness classification, or ICU admission. The exposure of interest was receipt of systemic extended-spectrum antibiotics (piperacillin ± tazobactam, ticarcillin ± clavulanate, ceftazidime, cefepime, or a carbapenem) on the day of appendectomy or the day after. The primary outcome was 30-day readmission for wound infection or repeat abdominal surgery. Multivariable logistic regression, propensity score weighting, and subgroup analyses were used to control for confounding by indication. RESULTS Of 24 984 patients, 17 654 (70.7%) had uncomplicated appendicitis and 7330 (29.3%) had complicated appendicitis. Overall, 664 (2.7%) patients experienced the primary outcome, 1.1% among uncomplicated cases and 6.4% among complicated cases (P < .001). Extended-spectrum antibiotic exposure was significantly associated with the primary outcome in complicated (adjusted odds ratio, 1.43 [95% confidence interval, 1.06 to 1.93]), but not uncomplicated, (adjusted odds ratio, 1.32 [95% confidence interval, 0.88 to 1.98]) appendicitis. These odds ratios remained consistent across additional analyses. CONCLUSIONS Extended-spectrum antibiotics seem to offer no advantage over narrower-spectrum agents for children with surgically managed acute uncomplicated or complicated appendicitis.
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Affiliation(s)
- Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington; Center for Clinical and Translational Research, and
| | - Assaf P Oron
- Center for Clinical and Translational Research, and
| | - Rachael K Ross
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jason G Newland
- Division of Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Adam Goldin
- Department of Pediatric Surgery, University of Washington, Seattle, Washington; and
| | - Shawn J Rangel
- Department of Pediatric Surgery, Harvard Medical School, Boston, Massachusetts
| | - Scott J Weissman
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington; Center for Global Infectious Diseases Research, Seattle Children's Hospital Research Institute, Seattle, Washington
| | - Danielle M Zerr
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington; Center for Clinical and Translational Research, and
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Abstract
OBJECTIVES Among patients with food-related anaphylaxis, to describe trends in emergency and hospital care and determine the revisit rate. METHODS This retrospective cohort study included children 6 months to 18 years of age with food-related anaphylaxis from 37 children's hospitals between 2007 and 2012. Summary statistics and trends for patient characteristics were evaluated. Multivariable regression was used to identify predictors for hospital admission. Revisit rates to either the emergency department (ED) and/or inpatient unit were calculated. RESULTS 7303 patients were evaluated in the ED; 3652 (50%) were admitted to the hospital. Hospital admission rates varied widely (range, 20%-98%). Food-related anaphylaxis increased from 41 per 100 000 ED visits to 72 per 100 000 while hospital admission rates did not change. Males (odds ratio [OR], 1.2 [95% confidence interval (CI), 1.0-1.4]), patients < 1 year old (OR, 1.8 [95% CI, 1.3-2.5]), those with anaphylaxis to either peanut (OR, 1.2 [95% CI, 1.0-1.5]) or tree nut (OR, 1.7 [95% CI, 1.3-2.1]), and patients with asthma (OR, 7.4 [95% CI, 5.8-9.3]) or a chronic complex condition (OR, 5.2 [95% CI, 3.0-9.0]) were more likely to be admitted to the hospital. The 3-day revisit rate was 3% for patients discharged from the ED and 0.6% for those admitted on the index visit. CONCLUSIONS The incidence of food-related anaphylaxis in pediatric EDs is increasing, but rates of hospital admission are stable. Hospital admission is common but widely variable. Further research is needed to identify optimal management practices for this potentially life-threatening problem.
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Affiliation(s)
- Joshua P Parlaman
- Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington, 98105-0371, USA.; and
| | - Assaf P Oron
- Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington; and Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Neil G Uspal
- Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington; and Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Katherine N DeJong
- Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington; and
| | - Joel S Tieder
- Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington; and Center for Clinical & Translational Research, Seattle Children's Research Institute, Seattle, Washington
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Kronman MP, Hersh AL, Gerber JS, Ross RK, Newland JG, Goldin A, Rangel SJ, Oron AP, Zerr DM. Identifying Antimicrobial Stewardship Targets for Pediatric Surgical Patients. J Pediatric Infect Dis Soc 2015; 4:e100-8. [PMID: 26407258 DOI: 10.1093/jpids/piv022] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [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: 12/19/2014] [Accepted: 03/27/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND More than 80% of surgical inpatients at US children's hospitals receive antibiotics, accounting for >40% of all inpatient pediatric antibiotic use. We aimed to examine the collective pool of all systemic antibiotics prescribed to children hospitalized for surgical conditions and identify common surgical conditions with highly variable and potentially unnecessary antibiotic use, because these conditions may represent antimicrobial stewardship priorities. METHODS We conducted a retrospective cross-sectional study of surgical inpatients discharged in 2012 at 37 freestanding children's hospitals. We captured all systemic antibiotic use as days of therapy (DOT), and we reported surgical conditions by frequency and contribution to overall antibiotic use. We used multivariable logistic and Poisson regression with marginal standardization to estimate (1) the standardized proportion and (2) DOT of condition-specific targeted antibiotic use among top surgical condition patients. RESULTS Among 151 345 surgical inpatients, 82.9% received antimicrobials for a median 2 DOT per subject (interquartile range, 1-5; range, 1-958). The most commonly received antibiotics were cefazolin (16.7% of all DOT), vancomycin (12.5%), and piperacillin/tazobactam (6.9%). The top 10 conditions contributing most to antibiotic use accounted for 51.3% of all antibiotic use. Among these, adjusted use of postoperative and perioperative vancomycin varied across hospitals among craniotomy and cardiothoracic surgery subjects (all P < .001); adjusted use of broad-spectrum antipseudomonal agents varied across hospitals among gastrointestinal surgery subjects (all P < .001). CONCLUSIONS Use of (1) vancomycin for pediatric cardiothoracic and neurosurgical patients and (2) broad-spectrum antipseudomonal agents for gastrointestinal surgery patients represent potentially high-yield targets for stewardship efforts to reduce unnecessary antimicrobial use.
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Affiliation(s)
- Matthew P Kronman
- Department of Pediatrics, Division of Infectious Diseases Department of Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Washington
| | - Adam L Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
| | - Rachael K Ross
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
| | - Jason G Newland
- Division of Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Adam Goldin
- Department of Pediatric Surgery, University of Washington, Seattle
| | - Shawn J Rangel
- Department of Pediatric Surgery, Harvard Medical School, Boston, Massachusetts
| | - Assaf P Oron
- Department of Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Washington
| | - Danielle M Zerr
- Department of Pediatrics, Division of Infectious Diseases Department of Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Washington
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Schulte JK, Fox JR, Oron AP, Larson TV, Simpson CD, Paulsen M, Beaudet N, Kaufman JD, Magzamen S. Neighborhood-Scale Spatial Models of Diesel Exhaust Concentration Profile Using 1-Nitropyrene and Other Nitroarenes. Environ Sci Technol 2015; 49:13422-30. [PMID: 26501773 PMCID: PMC5026850 DOI: 10.1021/acs.est.5b03639] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
With emerging evidence that diesel exhaust exposure poses distinct risks to human health, the need for fine-scale models of diesel exhaust pollutants is growing. We modeled the spatial distribution of several nitrated polycyclic aromatic hydrocarbons (NPAHs) to identify fine-scale gradients in diesel exhaust pollution in two Seattle, WA neighborhoods. Our modeling approach fused land-use regression, meteorological dispersion modeling, and pollutant monitoring from both fixed and mobile platforms. We applied these modeling techniques to concentrations of 1-nitropyrene (1-NP), a highly specific diesel exhaust marker, at the neighborhood scale. We developed models of two additional nitroarenes present in secondary organic aerosol: 2-nitropyrene and 2-nitrofluoranthene. Summer predictors of 1-NP, including distance to railroad, truck emissions, and mobile black carbon measurements, showed a greater specificity to diesel sources than predictors of other NPAHs. Winter sampling results did not yield stable models, likely due to regional mixing of pollutants in turbulent weather conditions. The model of summer 1-NP had an R(2) of 0.87 and cross-validated R(2) of 0.73. The synthesis of high-density sampling and hybrid modeling was successful in predicting diesel exhaust pollution at a very fine scale and identifying clear gradients in NPAH concentrations within urban neighborhoods.
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Affiliation(s)
- Jill K. Schulte
- University of Washington, Box 357234, Seattle, Washington 98195-7234, United States
- Corresponding Author Phone: (360) 407-6374. Fax (360) 407-7534.
| | - Julie R. Fox
- University of Washington, Box 357234, Seattle, Washington 98195-7234, United States
| | - Assaf P. Oron
- Seattle Children's Research Institute, P.O. Box 5371, Seattle, Washington 98145-5005, United States
| | - Timothy V. Larson
- University of Washington, Box 357234, Seattle, Washington 98195-7234, United States
| | | | - Michael Paulsen
- University of Washington, Box 357234, Seattle, Washington 98195-7234, United States
| | - Nancy Beaudet
- University of Washington, Box 357234, Seattle, Washington 98195-7234, United States
| | - Joel D. Kaufman
- University of Washington, Box 357234, Seattle, Washington 98195-7234, United States
| | - Sheryl Magzamen
- Colorado State University, 1681 Campus Delivery, Fort Collins, Colorado 80523-1681, United States
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Uspal NG, Klein EJ, Tieder JS, Oron AP, Simon TD. Variation in the use of procedural sedation for incision and drainage of skin and soft tissue infection in pediatric emergency departments. Hosp Pediatr 2015; 5:185-92. [PMID: 25832973 DOI: 10.1542/hpeds.2014-0115] [Citation(s) in RCA: 9] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Little is known about procedural sedation use for anxiety and pain associated with skin and soft tissue infections (SSTIs) requiring incision and drainage (I&D). Our objectives were therefore (1) to characterize the use of procedural sedation use for SSTI I&D procedures in pediatric emergency departments (EDs), (2) to compare the frequency of procedural sedation for I&D across hospitals, and (3) to determine factors associated with use of procedural sedation for I&D. METHODS We performed a retrospective cohort study of pediatric EDs contributing to the Pediatric Health Information Systems database in 2010. Cases were identified by primary International Classification of Diseases, 9th revision, Clinical Modification procedure codes for I&D. We used descriptive statistics to describe procedural sedation use across hospitals and logistic generalized linear mixed models to identify factors associated with use of procedural sedation. RESULTS There were 6322 I&D procedures, and procedural sedation was used in 24% of cases. Hospital-level use of procedural sedation varied widely, with a range of 2% to 94% (median 17%). Procedural sedation use was positively associated with sensitive body site, female gender, and employer-based insurance, and negatively associated with African American race and increasing age. Estimates of hospital-level use of procedural sedation for a referent case eliminating demographic differences exhibit similar variability with a range of 5% to 97% (median 34%). CONCLUSIONS Use of procedural sedation for SSTI I&D varies widely across pediatric EDs, and the majority of variation is independent of demographic differences. Additional work is needed to understand decision-making and to standardize delivery of procedural sedation in children requiring I&D.
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Affiliation(s)
- Neil G Uspal
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; and Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Eileen J Klein
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; and Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Joel S Tieder
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; and Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Assaf P Oron
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Tamara D Simon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; and Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
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Abstract
Deposition of the complement split product C4d is a phenomenon studied extensively as a marker for complement activation in antibody-mediated transplant rejection. C4d also is observed in placental disease processes including spontaneous abortion, infarct, and villitis of unknown origins. Massive chronic intervillositis is a rare placental abnormality associated with increased risk of growth restriction, fetal death, and recurrent fetal loss. In this study, we evaluated C4d immunostaining in placentas with accumulation of intervillous monocytes with and without villitis. Archived placentas from Kosair Children's Hospital (Louisville, KY) and Seattle Children's Hospital (Seattle, WA) were selected and divided into 4 groups, 16 cases of intervillositis with complicated pregnancy, 15 cases of uncomplicated intervillositis, 20 cases of complicated villitis, and 13 cases of uncomplicated villitis, all with varying degrees of monocytic cells in the intervillous space. Representative specimen blocks were immunohistochemically stained for C4d. The percentage of positive staining of the microvillous surface of the syncytiotrophoblast was scored by five pathologists, and the following consensus score was determined: 0 = 0% to 5%; 1 = 5% to 25%; 2 = 25% to 75%; and 3 ≥ 75%. C4d immunostain localized to the microvillous border of syncytiotrophoblast in many of the placentas. C4d staining was more strongly associated with intervillositis than with villitis (odds ratio: 6.3; confidence interval: 2.1-18.7; P = 0.001).
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Affiliation(s)
- Robert W Bendon
- 1 Department of Pathology, Kosair Children's Hospital, Louisville, KY 40202, USA
| | - Susan Coventry
- 1 Department of Pathology, Kosair Children's Hospital, Louisville, KY 40202, USA
| | - Matthew Thompson
- 1 Department of Pathology, Kosair Children's Hospital, Louisville, KY 40202, USA
| | - Erin R Rudzinski
- 2 Department of Laboratories, Seattle Children's Hospital, Seattle, WA 98105, USA
| | - Elizabeth M Williams
- 2 Department of Laboratories, Seattle Children's Hospital, Seattle, WA 98105, USA
| | - Assaf P Oron
- 3 Core for Biomedical Statistics, Seattle Children's Research Institute, Seattle, WA 98101, USA
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40
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Keller JP, Olives C, Kim SY, Sheppard L, Sampson PD, Szpiro AA, Oron AP, Lindström J, Vedal S, Kaufman JD. A unified spatiotemporal modeling approach for predicting concentrations of multiple air pollutants in the multi-ethnic study of atherosclerosis and air pollution. Environ Health Perspect 2015; 123:301-9. [PMID: 25398188 PMCID: PMC4384200 DOI: 10.1289/ehp.1408145] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 11/11/2014] [Indexed: 05/06/2023]
Abstract
BACKGROUND Cohort studies of the relationship between air pollution exposure and chronic health effects require predictions of exposure over long periods of time. OBJECTIVES We developed a unified modeling approach for predicting fine particulate matter, nitrogen dioxide, oxides of nitrogen, and black carbon (as measured by light absorption coefficient) in six U.S. metropolitan regions from 1999 through early 2012 as part of the Multi-Ethnic Study of Atherosclerosis and Air Pollution (MESA Air). METHODS We obtained monitoring data from regulatory networks and supplemented those data with study-specific measurements collected from MESA Air community locations and participants' homes. In each region, we applied a spatiotemporal model that included a long-term spatial mean, time trends with spatially varying coefficients, and a spatiotemporal residual. The mean structure was derived from a large set of geographic covariates that was reduced using partial least-squares regression. We estimated time trends from observed time series and used spatial smoothing methods to borrow strength between observations. RESULTS Prediction accuracy was high for most models, with cross-validation R2 (R2CV) > 0.80 at regulatory and fixed sites for most regions and pollutants. At home sites, overall R2CV ranged from 0.45 to 0.92, and temporally adjusted R2CV ranged from 0.23 to 0.92. CONCLUSIONS This novel spatiotemporal modeling approach provides accurate fine-scale predictions in multiple regions for four pollutants. We have generated participant-specific predictions for MESA Air to investigate health effects of long-term air pollution exposures. These successes highlight modeling advances that can be adopted more widely in modern cohort studies.
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Affiliation(s)
- Joshua P Keller
- Department of Biostatistics, and Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
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Chesley PM, Ledbetter DJ, Meehan JJ, Oron AP, Javid PJ. Contemporary trends in the use of primary repair for gastroschisis in surgical infants. Am J Surg 2015; 209:901-5; discussion 905-6. [PMID: 25776902 DOI: 10.1016/j.amjsurg.2015.01.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/31/2014] [Accepted: 01/06/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Gastroschisis is a newborn anomaly requiring emergent surgical intervention. We review our experience with gastroschisis to examine trends in contemporary surgical management. METHODS Infants who underwent initial surgical management of gastroschisis from 1996 to 2014 at a pediatric hospital were reviewed. Closure techniques included primary fascial repair using suture or sutureless umbilical closure, and staged repair using sutured or spring-loaded silo (SLS). Data were separated into 3 clinical eras: pre-SLS (1996 to 2004), SLS (2005 to 2008), and umbilical closure (2009 to 2014). RESULTS In the pre-SLS era, 60% (34/57) of infants with gastroschisis underwent primary repair. With the advent of SLS, there was a decrease in primary repair (15%, 10/68, P < .0001). Following introduction of sutureless umbilical closure, 61% (47/77) of infants have undergone primary repair. On multivariate regression, primary repair was associated with shorter intensive care unit stays (P < .001) and time to initiate enteral nutrition (P < .01). CONCLUSIONS Following introduction of a less invasive technique for gastroschisis repair, most infants with gastroschisis were able to be repaired primarily. Primary repair should be considered in all babies with gastroschisis and favorable anatomy.
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Affiliation(s)
- Patrick M Chesley
- Division of Pediatric General and Thoracic Surgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA; Department of General Surgery, Madigan Army Medical Center, Fort Lewis, WA, USA
| | - Daniel J Ledbetter
- Division of Pediatric General and Thoracic Surgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - John J Meehan
- Division of Pediatric General and Thoracic Surgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA
| | - Assaf P Oron
- Core for Biostatistics, Seattle Children's Hospital, Seattle, WA, USA
| | - Patrick J Javid
- Division of Pediatric General and Thoracic Surgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA, USA.
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Adar SD, Kaufman JD, Diez-Roux AV, Hoffman EA, D'Souza J, Stukovsky KH, Rich SS, Rotter JI, Guo X, Raffel LJ, Sampson PD, Oron AP, Raghunathan T, Barr RG. Air pollution and percent emphysema identified by computed tomography in the Multi-Ethnic study of Atherosclerosis. Environ Health Perspect 2015; 123:144-51. [PMID: 25302408 PMCID: PMC4314244 DOI: 10.1289/ehp.1307951] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 10/09/2014] [Indexed: 05/27/2023]
Abstract
BACKGROUND Air pollution is linked to low lung function and to respiratory events, yet little is known of associations with lung structure. OBJECTIVES We examined associations of particulate matter (PM2.5, PM10) and nitrogen oxides (NOx) with percent emphysema-like lung on computed tomography (CT). METHODS The Multi-Ethnic Study of Atherosclerosis (MESA) recruited participants (45-84 years of age) in six U.S. states. Percent emphysema was defined as lung regions < -910 Hounsfield Units on cardiac CT scans acquired following a highly standardized protocol. Spirometry was also conducted on a subset. Individual-level 1- and 20-year average air pollution exposures were estimated using spatiotemporal models that included cohort-specific measurements. Multivariable regression was conducted to adjust for traditional risk factors and study location. RESULTS Among 6,515 participants, we found evidence of an association between percent emphysema and long-term pollution concentrations in an analysis leveraging between-city exposure contrasts. Higher concentrations of PM2.5 (5 μg/m3) and NOx (25 ppb) over the previous year were associated with 0.6 (95% CI: 0.1, 1.2%) and 0.5 (95% CI: 0.1, 0.9%) higher average percent emphysema, respectively. However, after adjustment for study site the associations were -0.6% (95% CI: -1.5, 0.3%) for PM2.5 and -0.5% (95% CI: -1.1, 0.02%) for NOx. Lower lung function measures (FEV1 and FVC) were associated with higher PM2.5 and NOx levels in 3,791 participants before and after adjustment for study site, though most associations were not statistically significant. CONCLUSIONS Associations between ambient air pollution and percentage of emphysema-like lung were inconclusive in this cross-sectional study, thus longitudinal analyses may better clarify these associations with percent emphysema.
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Affiliation(s)
- Sara D Adar
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, USA
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Tully HM, Traudt CM, Rue T, Oron AP, Simon TD, Kukull WA, Doherty D. Risk factors for post-hemorrhagic hydrocephalus among infants with intraventricular hemorrhage. Fluids Barriers CNS 2015. [PMCID: PMC4582201 DOI: 10.1186/2045-8118-12-s1-o18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Swaminathan M, Oron AP, Chatterjee S, Piper H, Cope-Yokoyama S, Chakravarti A, Kapur RP. Intestinal Neuronal Dysplasia-Like Submucosal Ganglion Cell Hyperplasia at the Proximal Margins of Hirschsprung Disease Resections. Pediatr Dev Pathol 2015; 18:466-76. [PMID: 26699691 PMCID: PMC4809533 DOI: 10.2350/15-07-1675-oa.1] [Citation(s) in RCA: 18] [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] [Indexed: 12/19/2022]
Abstract
Intestinal neuronal dysplasia type B (IND) denotes an increased proportion of hyperplastic submucosal ganglia, as resolved histochemically in 15-μm-thick frozen sections. IND has been reported proximal to the aganglionic segment in patients with Hirschsprung disease (HSCR) and is putatively associated with a higher rate of postsurgical dysmotility. We developed and validated histological criteria to diagnose IND-like submucosal ganglion cell hyperplasia (IND-SH) in paraffin sections and used the approach to study the incidence and clinical and/or genetic associations of IND-SH at the proximal margins of HSCR pull-through resection specimens. Full-circumference paraffin sections from the proximal margins of 64 HSCR colonic pull-through specimens and 24 autopsy controls were immunostained for neuron-specific Hu antigen, and nucleated ganglion cells in each submucosal ganglion were counted. In controls, an age-related decline in the relative abundance of "giant" ganglia (≥7 nucleated Hu-positive [Hu+] ganglion cells) was observed. A conservative diagnostic threshold for IND-SH (control mean ± 3× standard deviation) was derived from 15 controls less than 25 weeks of age. No control exceeded this threshold, whereas in the same age range, IND-SH was observed at the proximal margins in 15% (7 of 46) of HSCR resections, up to 15 cm proximal to the aganglionic segment. No significant correlation was observed between IND-SH and length of or distance from the aganglionic segment, sex, trisomy 21, RET or SEMA3C/D polymorphisms, or clinical outcome, but analysis of more patients, with better long-term follow-up will be required to clarify the significance of this histological phenotype.
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Affiliation(s)
| | | | - Sumantra Chatterjee
- Center for Complex Disease Genomics, McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine ,Balimore, MD
| | - Hannah Piper
- University of Texas Southwestern, Children's Health, Dallas, TX
| | | | - Aravinda Chakravarti
- Center for Complex Disease Genomics, McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine ,Balimore, MD
| | - Raj P. Kapur
- Seattle Children's Research Institute, Seattle, WA,University of Washington, Pathology, Seattle, WA
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Lindström J, Szpiro AA, Sampson PD, Oron AP, Richards M, Larson TV, Sheppard L. A Flexible Spatio-Temporal Model for Air Pollution with Spatial and Spatio-Temporal Covariates. Environ Ecol Stat 2014; 21:411-433. [PMID: 25264424 PMCID: PMC4174563 DOI: 10.1007/s10651-013-0261-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The development of models that provide accurate spatio-temporal predictions of ambient air pollution at small spatial scales is of great importance for the assessment of potential health effects of air pollution. Here we present a spatio-temporal framework that predicts ambient air pollution by combining data from several different monitoring networks and deterministic air pollution model(s) with geographic information system (GIS) covariates. The model presented in this paper has been implemented in an R package, SpatioTemporal, available on CRAN. The model is used by the EPA funded Multi-Ethnic Study of Atherosclerosis and Air Pollution (MESA Air) to produce estimates of ambient air pollution; MESA Air uses the estimates to investigate the relationship between chronic exposure to air pollution and cardiovascular disease. In this paper we use the model to predict long-term average concentrations of NOx in the Los Angeles area during a ten year period. Predictions are based on measurements from the EPA Air Quality System, MESA Air specific monitoring, and output from a source dispersion model for traffic related air pollution (Caline3QHCR). Accuracy in predicting long-term average concentrations is evaluated using an elaborate cross-validation setup that accounts for a sparse spatio-temporal sampling pattern in the data, and adjusts for temporal effects. The predictive ability of the model is good with cross-validated R2 of approximately 0.7 at subject sites. Replacing four geographic covariate indicators of traffic density with the Caline3QHCR dispersion model output resulted in very similar prediction accuracy from a more parsimonious and more interpretable model. Adding traffic-related geographic covariates to the model that included Caline3QHCR did not further improve the prediction accuracy.
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Affiliation(s)
- Johan Lindström
- University of Washington, Seattle, USA. Lund University, Lund, Sweden
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Abstract
BACKGROUND Pediatrics and pediatric nephrology lag behind adult medicine in producing randomized controlled trials (RCTs). Physician attitudes have been shown to play a significant role in RCT enrollment. METHODS We surveyed members of the American Society of Pediatric Nephrology regarding beliefs about RCTs and factors influencing decisions to recommend RCT enrollment. Regression analyses were used to identify the effects of variables on an aggregate score summarizing attitudes toward RCTs. RESULTS One hundred thirty replies were received. Sixty-six percent had enrolled patients in RCTs. Respondents in practice for more than 15 years were more likely to have recruited a patient to an RCT than those in practice for less than 5 years. Respondents were more willing to recommend RCT enrollment if the study was multicenter, patients were sicker or had a poorer prognosis, or if the parent or participant received a financial incentive versus the provider. In multiple regression analysis, history of enrolling patients in an RCT was the only significant predictor of higher aggregate RCT-friendly attitude. CONCLUSIONS Many pediatric nephrologists have never enrolled a patient in an RCT, particularly those in practice for less than 5 years. Respondents who have not enrolled patients in RCTs have a less RCT-friendly attitude. Provision of improved training and resources might increase participation of junior providers in RCTs.
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Affiliation(s)
- Aaron G Wightman
- From the *Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine; †Division of Nephrology, Seattle Children's Hospital; and ‡Core for Biomedical Statistics, Seattle Children's Hospital, Seattle, WA
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Wightman AG, Oron AP, Symons JM, Flynn JT. Pediatric nephrologists' beliefs regarding randomized controlled trials. J Investig Med 2014; 62. [PMID: 24379023 PMCID: PMC3893707 DOI: 10.231/jim.0000000000000019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Pediatrics and pediatric nephrology lag behind adult medicine in producing randomized controlled trials (RCTs). Physician attitudes have been shown to play a significant role in RCT enrollment. METHODS We surveyed members of the American Society of Pediatric Nephrology regarding beliefs about RCTs and factors influencing decisions to recommend RCT enrollment. Regression analyses were used to identify the effects of variables on an aggregate score summarizing attitudes toward RCTs. RESULTS One hundred thirty replies were received. Sixty-six percent had enrolled patients in RCTs. Respondents in practice for more than 15 years were more likely to have recruited a patient to an RCT than those in practice for less than 5 years. Respondents were more willing to recommend RCT enrollment if the study was multicenter, patients were sicker or had a poorer prognosis, or if the parent or participant received a financial incentive versus the provider. In multiple regression analysis, history of enrolling patients in an RCT was the only significant predictor of higher aggregate RCT-friendly attitude. CONCLUSIONS Many pediatric nephrologists have never enrolled a patient in an RCT, particularly those in practice for less than 5 years. Respondents who have not enrolled patients in RCTs have a less RCT-friendly attitude. Provision of improved training and resources might increase participation of junior providers in RCTs.
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Affiliation(s)
- Aaron G Wightman
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle Children’s Hospital Division of Nephrology, Mailstop: OC.9.820, 4800 Sand Point Way NE Seattle, WA 98105, Fax: 206 987-2636,Corresponding Author: Aaron Wightman, MD, Seattle Children’s Hospital Division of Nephrology, Mailstop: OC.9.820, 4800 Sand Point Way NE Seattle, WA 98105, Phone: 206 987-2524, Fax: 206 987-2636,
| | | | - Jordan M Symons
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle Children’s Hospital Division of Nephrology, Mailstop: OC.9.820, 4800 Sand Point Way NE Seattle, WA 98105, Fax: 206 987-2636
| | - Joseph T Flynn
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle Children’s Hospital Division of Nephrology, Mailstop: OC.9.820, 4800 Sand Point Way NE Seattle, WA 98105, Fax: 206 987-2636
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Krishnan RM, Adar SD, Szpiro AA, Jorgensen NW, Oron AP, Van Hee VC, O'Neill MS, Barr RG, Herrington DM, Polak JF, Kaufman JD. LONG-TERM EXPOSURE TO TRAFFIC RELATED AIR POLLUTION AND ENDOTHELIAL DYSFUNCTION: MULTIETHNIC STUDY OF ATHEROSCLEROSIS AND AIR POLLUTION (MESA AIR). J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)61453-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Affiliation(s)
- Assaf P Oron
- Core for Biomedical Statistics, Seattle Children’s Research Institute, Seattle, WA, USA
- Professional and Continuing Education, University of Washington, Seattle, WA, USA
| | - Peter D Hoff
- Departments of Statistics and Biostatistics, University of Washington, Seattle, WA, USA
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Abstract
Background Novel dose-finding designs for Phase I cancer clinical trials, using estimation to assign the best estimated Maximum Tolerated Dose (MTD) at each point in the experiment, most prominently via Bayesian techniques, have been widely discussed and promoted since 1990. Purpose To examine the small-sample behavior of these ‘Bayesian Phase I’ designs, and also of non-Bayesian designs sharing the same main ‘Long-Memory’ traits of using likelihood estimation and assigning the estimated MTD to the next patient. Methods Data from several recently published experiments are presented and discussed, and Long-Memory designs’ operating principles are explained. Simulation studies compare the small-sample behavior of Long-Memory designs with short-memory ‘Up-and-Down’ designs. Results In simulation, Long-Memory and Up-and-Down designs achieved similar success rates in finding the MTD. However, for all Long-Memory designs examined, the number n* of cohorts treated at the true MTD was highly variable between simulated experiments drawn from the same toxicity-threshold distribution. Further investigation using the same set of thresholds in permuted order indicates that this Long-Memory behavior is driven by sensitivity to the order in which participants enter the experiment. This sensitivity is related to Long-Memory designs’ ‘winner-takes-all’ dose-assignment rule, which grants the early cohorts a disproportionately large influence, and causes many experiments to settle early on a specific dose. Additionally for the Bayesian Long-Memory designs, the prior-predictive distribution over the dose levels has a substantial impact upon MTD-finding performance, long into the experiment. Limitations While the numerical evidence for Long-Memory designs’ order sensitivity is broad, and plausible explanations for it are provided, we do not present a theoretical proof of the phenomenon. Conclusions Method developers, analysts, and practitioners should be aware of Long-Memory designs’ order sensitivity and related phenomena. In particular, they should be informed that settling on a single dose does not guarantee that this dose is the MTD. Presently, Up-and-Down designs offer a simpler and more robust alternative for the sample sizes of 10–40 patients used in most Phase I trials. Future designs might benefit from combining the two approaches. We also suggest that the field’s paradigm change from dose-selection to dose-estimation.
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Affiliation(s)
- Assaf P Oron
- Core for Biomedical Statistics, Seattle Children’s Research Institute, Seattle, WA, USA
- Professional and Continuing Education, University of Washington, Seattle, WA, USA
| | - Peter D Hoff
- Departments of Statistics and Biostatistics, University of Washington, Seattle, WA, USA
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