1
|
Dechnik A, Kahane CG, Nigrovic LE, Lyons TW. Utility of Synovial Fluid Biomarkers for Culture-Positive Septic Arthritis in a Lyme Disease-Endemic Region. Pediatr Emerg Care 2024:00006565-990000000-00427. [PMID: 38563800 DOI: 10.1097/pec.0000000000003188] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE To evaluate the performance of synovial fluid biomarkers to identify children with culture-positive septic arthritis. METHODS We identified children 6 months to 18 years old presenting to a single emergency department between 2007 and 2022 undergoing evaluation for septic arthritis defined by having a synovial fluid culture obtained. Our primary outcome was septic arthritis defined by a positive synovial fluid culture. We evaluated the ability of synovial fluid biomarkers to identify children with septic arthritis using area under the receiver operating characteristic curve (AUC) analyses. We measured the sensitivity and specificity of commonly used synovial fluid biomarkers. RESULTS We included 796 children, of whom 79 (10%) had septic arthritis. Compared with synovial white blood cell count (AUC, 0.72; 95% confidence interval [CI], 0.65-0.78), absolute neutrophil count (AUC, 0.72; 95% CI, 0.66-0.79; P = 0.09), percent neutrophils (AUC, 0.66; 95% CI, 0.60-0.71; P = 0.12), and glucose (AUC, 0.78; 95% CI, 0.67-0.90; P = 0.33) performed similarly, whereas protein (AUC, 0.52; 95% CI, 0.40-0.63, P = 0.04) had lower diagnostic accuracy. Synovial fluid white blood cell count ≥50,000 cells/μL had a sensitivity of 62.0% (95% CI, 50.4%-72.7%) and a specificity of 67.0% (95% CI, 63.4%-70.4%), whereas a positive synovial fluid Gram stain had a sensitivity of 48.1% (95% CI, 36.5%-59.7%) and specificity of 99.1% (95% CI, 98.1%-99.7%) for septic arthritis. CONCLUSIONS None of the routinely available synovial fluid biomarkers had sufficient accuracy to be used in isolation in the identification of children with septic arthritis. New approaches including multivariate clinical prediction rules and novel biomarkers are needed.
Collapse
Affiliation(s)
- Andzelika Dechnik
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University, New York, NY
| | - Caroline G Kahane
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| |
Collapse
|
2
|
Green RS, Sartori LF, Florin TA, Aronson PL, Lee BE, Chamberlain JM, Hunt KM, Michelson KA, Nigrovic LE. Predictors of Invasive Bacterial Infection in Febrile Infants Aged 2 to 6 Months in the Emergency Department. J Pediatr 2024; 270:114017. [PMID: 38508484 DOI: 10.1016/j.jpeds.2024.114017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/29/2024] [Accepted: 03/12/2024] [Indexed: 03/22/2024]
Abstract
Our goal was to identify predictors of invasive bacterial infection (ie, bacteremia and bacterial meningitis) in febrile infants aged 2-6 months. In our multicenter retrospective cohort, older age and lower temperature identified infants at low risk for invasive bacterial infection who could safely avoid routine testing.
Collapse
Affiliation(s)
- Rebecca S Green
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Laura F Sartori
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Todd A Florin
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Brian E Lee
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Emergency Medicine, Children's National Hospital, Washington, DC
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington, DC
| | - Kathryn M Hunt
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| |
Collapse
|
3
|
Heideman LC, Nigrovic LE. Diagnostic Stewardship in the Evaluation of a Child With a Potential Central Nervous System Infection. Pediatr Infect Dis J 2024:00006454-990000000-00779. [PMID: 38451891 DOI: 10.1097/inf.0000000000004304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Affiliation(s)
- Lotte C Heideman
- From the Leiden University Medical Center; Leiden, The Netherlands
| | - Lise E Nigrovic
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| |
Collapse
|
4
|
O'Connor TM, Guaman MC, Randell KA, Keenan HT, Snowden J, Mack JW, Camp EA, Perez O, Chang ML, Myers AL, Nigrovic LE, O'Toole J, Reed JL, Reese J, Rosenberg AR, Slater AC, Wootton SH, Ziniel SI, Yost HJ, Murray KO, Shekerdemian L, Chumpitazi CE. Impact of the COVID-19 pandemic on pediatric faculty: a report from nine academic institutions. Pediatr Res 2024; 95:775-784. [PMID: 37454186 DOI: 10.1038/s41390-023-02726-8] [Citation(s) in RCA: 2] [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] [Received: 04/10/2023] [Revised: 06/05/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The COVID-19 pandemic affected home and work routines, which may exacerbate existing academic professional disparities. Objectives were to describe the impact of the pandemic on pediatric faculty's work productivity, identify groups at risk for widening inequities, and explore mitigation strategies. METHODS A cross-sectional study of faculty members was conducted at nine U.S. pediatric departments. Responses were analyzed by demographics, academic rank, and change in home caregiving responsibility. RESULTS Of 5791 pediatric faculty members eligible, 1504 (26%) completed the survey. The majority were female (64%), over 40 years old (60%), and assistant professors (47%). Only 7% faculty identified as underrepresented in medicine. Overall 41% reported an increase in caregiving during the pandemic. When comparing clinical, administrative, research, and teaching activities, faculty reported worse 1-year outlook for research activities. Faculty with increased caregiving responsibilities were more likely to report concerns over delayed promotion and less likely to have a favorable outlook regarding clinical and research efforts. Participants identified preferred strategies to mitigate challenges. CONCLUSIONS The COVID-19 pandemic negatively impacted pediatric faculty productivity with the greatest effects on those with increased caregiving responsibilities. COVID-19 was particularly disruptive to research outlook. Mitigation strategies are needed to minimize the long-term impacts on academic pediatric careers. IMPACT The COVID-19 pandemic most negatively impacted work productivity of academic pediatric faculty with caregiving responsibilities. COVID-19 was particularly disruptive to short-term (1-year) research outlook among pediatric faculty. Faculty identified mitigation strategies to minimize the long-term impacts of the pandemic on academic pediatric career pathways.
Collapse
Affiliation(s)
- Teresia M O'Connor
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
- Division of Academic General Pediatrics, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - Milenka Cuevas Guaman
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Kimberly A Randell
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Heather T Keenan
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jessica Snowden
- Section of Infectious Disease, Department of Pediatrics, University of Arkansas Medical School, Little Rock, AR, USA
| | - Jennifer W Mack
- Division of Hematology and Oncology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Elizabeth A Camp
- Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Oriana Perez
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Michael L Chang
- Division of Infectious Diseases, Department of Pediatrics, UT Health Houston McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Angela L Myers
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
- University of Kansas School of Medicine, Kansas City, KS, USA
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jennifer O'Toole
- Department of Pediatrics and Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Cincinnati Children's Hospital Medical Center, Division of Hospital Medicine, Cincinnati, OH, USA
- UC Health, Department of Internal Medicine, Cincinnati, OH, USA
| | - Jennifer L Reed
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Cincinnati Children's Hospital Medical Center, Division of Emergency Medicine, Cincinnati, OH, USA
| | - Jennifer Reese
- Division of Hospital Medicine, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Abby R Rosenberg
- Division of Hematology and Oncology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Department of Psychosocial Oncology & Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Anne C Slater
- Division of Emergency Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Susan H Wootton
- Division of Infectious Diseases, Department of Pediatrics, UT Health Houston McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Sonja I Ziniel
- Division of Hospital Medicine, Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - H Joseph Yost
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kristy O Murray
- Division of Tropical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Lara Shekerdemian
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Corrie E Chumpitazi
- Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
5
|
Nigrovic SE, Fine HG, Nigrovic LE, Fine AM. Impact of COVID-19 and the cancellation of the 2020 PAS Meeting on abstract publications. Pediatr Res 2024:10.1038/s41390-024-03035-4. [PMID: 38291177 DOI: 10.1038/s41390-024-03035-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/15/2023] [Indexed: 02/01/2024]
Affiliation(s)
| | | | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Andrew M Fine
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.
| |
Collapse
|
6
|
Florin TA, Ramilo O, Banks RK, Schnadower D, Quayle KS, Powell EC, Pickett ML, Nigrovic LE, Mistry R, Leetch AN, Hickey RW, Glissmeyer EW, Dayan PS, Cruz AT, Cohen DM, Bogie A, Balamuth F, Atabaki SM, VanBuren JM, Mahajan P, Kuppermann N. Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study. Emerg Med J 2023; 41:13-19. [PMID: 37770118 PMCID: PMC10841819 DOI: 10.1136/emermed-2023-213089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE The lack of evidence-based criteria to guide chest radiograph (CXR) use in young febrile infants results in variation in its use with resultant suboptimal quality of care. We sought to describe the features associated with radiographic pneumonias in young febrile infants. STUDY DESIGN Secondary analysis of a prospective cohort study in 18 emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network from 2016 to 2019. Febrile (≥38°C) infants aged ≤60 days who received CXRs were included. CXR reports were categorised as 'no', 'possible' or 'definite' pneumonia. We compared demographics, clinical signs and laboratory tests among infants with and without pneumonias. RESULTS Of 2612 infants, 568 (21.7%) had CXRs performed; 19 (3.3%) had definite and 34 (6%) had possible pneumonias. Patients with definite (4/19, 21.1%) or possible (11/34, 32.4%) pneumonias more frequently presented with respiratory distress compared with those without (77/515, 15.0%) pneumonias (adjusted OR 2.17; 95% CI 1.04 to 4.51). There were no differences in temperature or HR in infants with and without radiographic pneumonias. The median serum procalcitonin (PCT) level was higher in the definite (0.7 ng/mL (IQR 0.1, 1.5)) vs no pneumonia (0.1 ng/mL (IQR 0.1, 0.3)) groups, as was the median absolute neutrophil count (ANC) (definite, 5.8 K/mcL (IQR 3.9, 6.9) vs no pneumonia, 3.1 K/mcL (IQR 1.9, 5.3)). No infants with pneumonia had bacteraemia. Viral detection was frequent (no pneumonia (309/422, 73.2%), definite pneumonia (11/16, 68.8%), possible pneumonia (25/29, 86.2%)). Respiratory syncytial virus was the predominant pathogen in the pneumonia groups and rhinovirus in infants without pneumonias. CONCLUSIONS Radiographic pneumonias were uncommon in febrile infants. Viral detection was common. Pneumonia was associated with respiratory distress, but few other factors. Although ANC and PCT levels were elevated in infants with definite pneumonias, further work is necessary to evaluate the role of blood biomarkers in infant pneumonias.
Collapse
Affiliation(s)
- Todd A Florin
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Octavio Ramilo
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Russell K Banks
- Department of Pediatrics, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - David Schnadower
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kimberly S Quayle
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Elizabeth C Powell
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michelle L Pickett
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lise E Nigrovic
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rakesh Mistry
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Aaron N Leetch
- Departments of Emergency Medicine and Pediatrics, University of Arizona Medical Center-Diamond Children's, Tucson, Arizona, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Eric W Glissmeyer
- Department of Pediatrics, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Peter S Dayan
- Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Andrea T Cruz
- Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Daniel M Cohen
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Amanda Bogie
- Department of Pediatrics, The University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Fran Balamuth
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shireen M Atabaki
- Emergency Medicine, Children's National Health System, Washington, District of Columbia, USA
- Department of Pediatrics, Children's National Health System, Washington, District of Columbia, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Prashant Mahajan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, California, USA
| |
Collapse
|
7
|
Brown KM, Glaser NS, McManemy JK, DePiero A, Nigrovic LE, Quayle KS, Stoner MJ, Schunk JE, Trainor JL, Tzimenatos L, Rewers A, Myers SR, Kwok MY, Ghetti S, Casper TC, Olsen CS, Kuppermann N. Rehydration Rates and Outcomes in Overweight Children With Diabetic Ketoacidosis. Pediatrics 2023; 152:e2023062004. [PMID: 37920947 PMCID: PMC10657773 DOI: 10.1542/peds.2023-062004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in Diabetic Ketoacidosis (DKA) (FLUID) Trial found that rapid fluid infusion does not increase the risk of cerebral injury. Concern persists, however, whether fluid rates should be adjusted for overweight or obese patients. We used the FLUID Trial database to evaluate associations between fluid infusion rate and outcomes in these patients. METHODS We compared children and youth who were overweight, obese, or normal weight, in regard to protocol adherence, mental status changes, time to DKA resolution, and electrolyte abnormalities. We investigated associations between outcomes and the amount of fluid received in these groups. RESULTS Obese children and youth were more likely to receive fluids at rates slower than dictated by protocol. Overweight and obese children and youth in the fast fluid arms, who received fluids per the study protocol based on their measured weight, had similar rates of mental status changes or clinically apparent cerebral injury as those with normal weights. Risk of hypophosphatemia was increased in those receiving larger initial bolus volumes and reduced in those receiving higher rehydration rates. No other metabolic outcomes were associated with rehydration. CONCLUSIONS Protocol adherence data in the FLUID Trial suggest that physicians are uncomfortable using weight-based fluid calculations for overweight or obese children. However, higher rates of fluid infusion were not associated with increased risk of mental status changes or cerebral injury, suggesting that physicians should not limit fluid resuscitation in obese children and youth with DKA.
Collapse
Affiliation(s)
- Kathleen M. Brown
- Division of Emergency Medicine, Department of Pediatrics, Children’s National Medical Center, the George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | | | - Julie K. McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Andrew DePiero
- Division of Emergency Medicine, Nemours/A.I. DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kimberly S. Quayle
- Division of Emergency Medicine, Department of Pediatrics, St Louis Children’s Hospital, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael J. Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - Jeff E. Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jennifer L. Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leah Tzimenatos
- Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, California
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, the Colorado Children’s Hospital, University of Colorado-Denver School of Medicine, Aurora, Colorado
| | - Sage R. Myers
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria Y. Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Simona Ghetti
- Department of Psychology, University of California, Davis, Davis, California
| | - T. Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nathan Kuppermann
- Departments of Pediatrics
- Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, California
| | | |
Collapse
|
8
|
Thompson AD, Balamuth F, Neville DN, Chapman LL, Levas MN, Kharbanda AB, Branda JA, Ladell MM, Loiselle C, Nigrovic LE. Sensitivity of Two-Tiered Lyme Disease Serology in Children With an Erythema Migrans Lesion. J Pediatric Infect Dis Soc 2023; 12:553-555. [PMID: 37756491 DOI: 10.1093/jpids/piad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/24/2023] [Indexed: 09/29/2023]
Abstract
In our prospective cohort of 192 children with a physician-diagnosed erythema migrans (EM) lesion, two-tier Lyme disease serology had higher sensitivity in children with multiple EM lesions (76.8% multiple lesions vs. 38.1% single EM; difference 38.7%, 95% confidence interval 24.8%-50.4%). The diagnosis of cutaneous Lyme disease should be based on careful physical examination rather than laboratory testing.
Collapse
Affiliation(s)
- Amy D Thompson
- Division of Emergency Medicine, Nemours Children's Hospital and Sidney Kimmel Medical College of Thomas Jefferson University, Wilmington, Delaware, USA
| | - Fran Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Desiree N Neville
- Division of Emergency Medicine, Children's Hospital of Pittsburgh and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura L Chapman
- Division of Pediatric Emergency Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Michael N Levas
- Department of Pediatric Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Anupam B Kharbanda
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Meagan M Ladell
- Department of Pediatric Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Claire Loiselle
- Department of Research, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Trainor JL, Glaser NS, Tzimenatos L, Stoner MJ, Brown KM, McManemy JK, Schunk JE, Quayle KS, Nigrovic LE, Rewers A, Myers SR, Bennett JE, Kwok MY, Olsen CS, Casper TC, Ghetti S, Kuppermann N. Clinical and Laboratory Predictors of Dehydration Severity in Children With Diabetic Ketoacidosis. Ann Emerg Med 2023; 82:167-178. [PMID: 37024382 PMCID: PMC10523885 DOI: 10.1016/j.annemergmed.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 04/08/2023]
Abstract
STUDY OBJECTIVE Our primary objective was to characterize the degree of dehydration in children with diabetic ketoacidosis (DKA) and identify physical examination and biochemical factors associated with dehydration severity. Secondary objectives included describing relationships between dehydration severity and other clinical outcomes. METHODS In this cohort study, we analyzed data from 753 children with 811 episodes of DKA in the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation Study, a randomized clinical trial of fluid resuscitation protocols for children with DKA. We used multivariable regression analyses to identify physical examination and biochemical factors associated with dehydration severity, and we described associations between dehydration severity and DKA outcomes. RESULTS Mean dehydration was 5.7% (SD 3.6%). Mild (0 to <5%), moderate (5 to <10%), and severe (≥10%) dehydration were observed in 47% (N=379), 42% (N=343), and 11% (N=89) of episodes, respectively. In multivariable analyses, more severe dehydration was associated with new onset of diabetes, higher blood urea nitrogen, lower pH, higher anion gap, and diastolic hypertension. However, there was substantial overlap in these variables between dehydration groups. The mean length of hospital stay was longer for patients with moderate and severe dehydration, both in new onset and established diabetes. CONCLUSION Most children with DKA have mild-to-moderate dehydration. Although biochemical measures were more closely associated with the severity of dehydration than clinical assessments, neither were sufficiently predictive to inform rehydration practice.
Collapse
Affiliation(s)
- Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, CA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, CA
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Julie K McManemy
- Division of Emergency Medicine; Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Jeffrey E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, (UT)
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora, CO
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, (UT)
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, (UT)
| | - Simona Ghetti
- Department of Psychology, and the Center for Mind and Brain, University of California Davis, Davis, CA
| | - Nathan Kuppermann
- Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, CA; Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, CA
| |
Collapse
|
10
|
Kahane CG, Nigrovic LE, Kharbanda AB, Neville D, Thompson AD, Balamuth F, Chapman L, Levas MN, Branda JA, Kellogg MD, Monuteaux MC, Lyons TW. Biomarkers for Pediatric Bacterial Musculoskeletal Infections in Lyme Disease-Endemic Regions. Pediatrics 2023:e2023061329. [PMID: 37409396 DOI: 10.1542/peds.2023-061329] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVES Bacterial musculoskeletal infections (MSKIs) are challenging to diagnose because of the clinical overlap with other conditions, including Lyme arthritis. We evaluated the performance of blood biomarkers for the diagnosis of MSKIs in Lyme disease-endemic regions. METHODS We conducted a secondary analysis of a prospective cohort study of children 1 to 21 years old with monoarthritis presenting to 1 of 8 Pedi Lyme Net emergency departments for evaluation of potential Lyme disease. Our primary outcome was an MSKI, which was defined as septic arthritis, osteomyelitis or pyomyositis. We compared the diagnostic accuracy of routinely available biomarkers (absolute neutrophil count, C-reactive protein, erythrocyte sedimentation rate, and procalcitonin) to white blood cells for the identification of an MSKI using the area under the receiver operating characteristic curve (AUC). RESULTS We identified 1423 children with monoarthritis, of which 82 (5.8%) had an MSKI, 405 (28.5%) Lyme arthritis, and 936 (65.8%) other inflammatory arthritis. When compared with white blood cell count (AUC, 0.63; 95% confidence interval [CI], 0.55-0.71), C-reactive protein (0.84; 95% CI, 0.80-0.89; P < .05), procalcitonin (0.82; 95% CI, 0.77-0.88; P < .05), and erythrocyte sedimentation rate (0.77; 95% CI, 0.71-0.82; P < .05) had higher AUCs, whereas absolute neutrophil count (0.67; 95% CI, 0.61-0.74; P < .11) had a similar AUC. CONCLUSIONS Commonly available biomarkers can assist in the initial approach to a potential MSKI in a child. However, no single biomarker has high enough accuracy to be used in isolation, especially in Lyme disease-endemic areas.
Collapse
Affiliation(s)
- Caroline G Kahane
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anupam B Kharbanda
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Desiree Neville
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amy D Thompson
- Division of Emergency Medicine, Nemours Children's Hospital and Sidney Kimmel Medical College of Thomas Jefferson University, Wilmington, Delaware
| | - Fran Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Chapman
- Division of Pediatric Emergency Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael N Levas
- Department of Pediatric Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Mark D Kellogg
- Department of Laboratory Medicine, Boston Children's Hospital and Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
11
|
Glaser NS, Stoner MJ, Kwok MY, Quayle KS, Brown KM, Schunk JE, Trainor JL, McManemy JK, Tzimenatos L, Rewers A, Nigrovic LE, Bennett JE, Myers SR, Smith M, Casper TC, Kuppermann N. Relationships among biochemical measures in children with diabetic ketoacidosis. J Pediatr Endocrinol Metab 2023; 36:313-318. [PMID: 36637392 PMCID: PMC9986464 DOI: 10.1515/jpem-2022-0570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/14/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Investigating empirical relationships among laboratory measures in children with diabetic ketoacidosis (DKA) can provide insights into physiological alterations occurring during DKA. We determined whether alterations in laboratory measures during DKA conform to theoretical predictions. METHODS We used Pearson correlation statistics and linear regression to investigate correlations between blood glucose, electrolytes, pH and PCO2 at emergency department presentation in 1,681 pediatric DKA episodes. Among children with repeat DKA episodes, we also assessed correlations between laboratory measures at the first vs. second episode. RESULTS pH and bicarbonate levels were strongly correlated (r=0.64), however, pH and PCO2 were only loosely correlated (r=0.17). Glucose levels were correlated with indicators of dehydration and kidney function (blood urea nitrogen (BUN), r=0.44; creatinine, r=0.42; glucose-corrected sodium, r=0.32). Among children with repeat DKA episodes, PCO2 levels tended to be similar at the first vs. second episode (r=0.34), although pH levels were only loosely correlated (r=0.19). CONCLUSIONS Elevated glucose levels at DKA presentation largely reflect alterations in glomerular filtration rate. pH and PCO2 are weakly correlated suggesting that respiratory responses to acidosis vary among individuals and may be influenced by pulmonary and central nervous system effects of DKA.
Collapse
Affiliation(s)
- Nicole S Glaser
- Department of Pediatrics, University of California, Davis Health, University of California Davis, School of Medicine, Sacramento, USA
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, USA
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, USA
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, Saint Louis, USA
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, The George Washington School of Medicine and Health Sciences, Washington DC, USA
| | - Jeff E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, USA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, USA
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, The Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Denver, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/A.I. DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - McKenna Smith
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - Nathan Kuppermann
- Department of Pediatrics, University of California, Davis Health, University of California Davis, School of Medicine, Sacramento, USA.,Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, USA
| |
Collapse
|
12
|
Hunt KM, Michelson KA, Balamuth F, Thompson AD, Levas MN, Neville DN, Kharbanda AB, Chapman L, Nigrovic LE. Racial Differences in the Diagnosis of Lyme Disease in Children. Clin Infect Dis 2023; 76:1129-1131. [PMID: 36314085 DOI: 10.1093/cid/ciac863] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/19/2022] [Accepted: 10/27/2022] [Indexed: 11/27/2022] Open
Abstract
Black children with Lyme disease compared with children of other races were less likely to have an erythema migrans lesion diagnosed (adjusted odds ratio, 0.34; 95% confidence interval, .14-.79) but more likely to have a swollen joint (adjusted odds ratio, 3.68; 95% confidence interval, 2.13-6.36) after adjustment for age and local Lyme incidence.
Collapse
Affiliation(s)
- Kathryn M Hunt
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Fran Balamuth
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Amy D Thompson
- Division of Emergency Medicine, Nemours Children's Hospital Delaware, Wilmington, Delaware, USA
| | - Michael N Levas
- Pediatric Emergency Medicine, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Desiree N Neville
- Division of Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anupam B Kharbanda
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Laura Chapman
- Department of Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
13
|
Nigrovic LE, Neville D, Chapman L, Balamuth F, Levas MN, Thompson AD, Kharbanda A, Gerstbrein D, Branda JA, Buchan BW. Multiplexed high-definition PCR assay for the diagnosis of tick-borne infections in children. Open Forum Infect Dis 2023; 10:ofad121. [PMID: 37089773 PMCID: PMC10114523 DOI: 10.1093/ofid/ofad121] [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: 12/05/2022] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Abstract
Background
Ixodes scapularis ticks can carry Borrelia species as well as other pathogens that cause human disease. The frequency of tick-borne infections and co-infections in children with suspected Lyme disease is unknown, creating clinical uncertainty about the optimal approach to diagnosis.
Methods
We enrolled children aged 1 to 21 years presenting to one of eight Pedi Lyme Net emergency departments for evaluation of Lyme disease. We selected cases with serologically or clinically diagnosed Lyme disease (erythema migrans or early neurologic disease) matched by symptoms, age, gender and center to control subjects without Lyme disease. We tested whole blood samples collected at the time of diagnosis using a high-definition multiplex polymerase chain reaction (HDPCR) panel to identify 9 bacterial or protozoan pathogens associated with human disease. We compared the frequency of tick-borne co-infections in children with Lyme disease to matched controls.
Results
Of the 612 selected samples, 594 (97.1%) had an interpretable multiplex HDPCR result. We identified the following non-Borrelia tick-borne infections: Anaplasma phagocytophilum (2), Ehrlichia chaffeensis (1) and Babesia microti (12). Children with Lyme disease were more likely to have another tick-borne pathogen identified than matched controls [15/297 (5.1%) Lyme cases vs. 0/297 (0%); difference 5.1% 95% CI 2.7, 8.2%).
Conclusions
Although a substantial minority of children with Lyme disease had another tick-borne pathogen identified, either first-line Lyme disease antibiotics provided adequate treatment or the coinfection was subclinical and did not require specific treatment. Further studies are needed to establish the optimal approach to testing for tick-borne co-infections in children.
Collapse
Affiliation(s)
- Lise E Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital; United States
| | - Desiree Neville
- Division of Emergency Medicine, Children’s Hospital of Pittsburgh; United States
| | - Laura Chapman
- Department of Emergency Medicine, Rhode Island Hospital; United States
| | - Fran Balamuth
- Division of Emergency Medicine, Children's Hospital of Philadelphia; United States
| | - Michael N Levas
- Division of Emergency Medicine , Children’s Wisconsin ; United States
| | - Amy D Thompson
- Division of Emergency Medicine, Nemours Children’s Health ; United States
| | - Anupam Kharbanda
- Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota; United States
| | | | - John A Branda
- Department of Pathology, Massachusetts General Hospital; United States
| | - Blake W Buchan
- Department of Pathology , Children’s Wisconsin ; United States
| | | |
Collapse
|
14
|
Nigrovic LE, Chun TH, Vargas SE, Caffrey AR, Halperin JJ, Race JA, Ott U, Morrison BL, Fuller BJ, VanBuren JM, Lyme Net P. Comparative effectiveness and complications of intravenous ceftriaxone compared with oral doxycycline in Lyme meningitis in children: a multicentre prospective cohort study. BMJ Open 2023; 13:e071141. [PMID: 36854594 PMCID: PMC9980370 DOI: 10.1136/bmjopen-2022-071141] [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: 03/02/2023] Open
Abstract
INTRODUCTION Lyme disease is the most common vectorborne disease in the Northern hemisphere with more than 400 000 new cases in the USA annually. Lyme meningitis is an uncommon but potentially serious clinical manifestation of Lyme disease. Intravenous ceftriaxone had been the first-line treatment for Lyme meningitis, but is associated with a high rate of complications. Although efficacy and effectiveness (or real-world evidence) data for oral doxycycline are limited, practice guidelines were recently expanded to recommend either oral doxycycline or ceftriaxone as first-line treatments for Lyme meningitis. Our goal is to compare oral doxycycline with intravenous ceftriaxone for the treatment of Lyme meningitis on short-term recovery and long-term quality of life. METHODS AND ANALYSIS We are performing a prospective cohort study at 20 US paediatric centres located in diverse geographical range where Lyme disease is endemic. The clinical care team will make all antibiotic treatment decisions for children with Lyme meningitis, as per usual practice. We will follow enrolled children for 6 months to determine time of acute symptom recovery and impact on quality of life. ETHICS AND DISSEMINATION Boston Children's Hospital, the single Institutional Review Board (sIRB), has approved the study protocol with the other 19 enrolling sites as well as the Utah data coordinating centre relying on the Boston Children's Hospital sIRB. Once the study is completed, we will publish our findings in a peer-reviewed medical journal.
Collapse
Affiliation(s)
- Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Thomas H Chun
- Emergency Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Sara E Vargas
- Behavioral and Preventative Medicine, University of Rhode Island, Providence, RI, USA
| | - Aisling R Caffrey
- College of Pharmacy, University of Rhode Island, Providence, RI, USA
| | - John J Halperin
- Department of Neurology, Overlook Medical Center, Summit, New Jersey, USA
| | - Jonathan A Race
- Department of Pediatrics, University of Utah, Salt Lake, UT, USA
| | - Ulrike Ott
- Department of Pediatrics, University of Utah, Salt Lake, UT, USA
| | | | - Bethany J Fuller
- Department of Pediatrics, University of Utah, Salt Lake, UT, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah, Salt Lake, UT, USA
- University of Utah, Salt Lake, UT, USA
| | | |
Collapse
|
15
|
Ghetti S, Kuppermann N, Rewers A, Myers SR, Schunk JE, Stoner MJ, Garro A, Quayle KS, Brown KM, Trainor JL, Tzimenatos L, DePiero AD, McManemy JK, Nigrovic LE, Kwok MY, Olsen CS, Casper TC, Glaser NS. Cognitive function following diabetic ketoacidosis in young children with type 1 diabetes. Endocrinol Diabetes Metab 2023; 6:e412. [PMID: 36788736 PMCID: PMC10164422 DOI: 10.1002/edm2.412] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/14/2023] [Accepted: 01/28/2023] [Indexed: 02/16/2023] Open
Abstract
INTRODUCTION Young children with type 1 diabetes (T1D) may be at particularly high risk of cognitive decline following diabetic ketoacidosis (DKA). However, studies of cognitive functioning in T1D typically examine school-age children. The goal of this study was to examine whether a single experience of DKA is associated with lower cognitive functioning in young children. We found that recently diagnosed 3- to 5-year-olds who experienced one DKA episode, regardless of its severity, exhibited lower IQ scores than those with no DKA exposure. METHODS We prospectively enrolled 46 3- to 5-year-old children, who presented with DKA at the onset of T1D, in a randomized multi-site clinical trial evaluating intravenous fluid protocols for DKA treatment. DKA was moderate/severe in 22 children and mild in 24 children. Neurocognitive function was assessed once 2-6 months after the DKA episode. A comparison group of 27 children with T1D, but no DKA exposure, was also assessed. Patient groups were matched for age and T1D duration at the time of neurocognitive testing. RESULTS Children who experienced DKA, regardless of its severity, exhibited significantly lower IQ scores than children who did not experience DKA, F(2, 70) = 6.26, p = .003, partial η2 = .15. This effect persisted after accounting for socioeconomic status and ethnicity. CONCLUSIONS A single DKA episode is associated with lower IQ scores soon after exposure to DKA in young children.
Collapse
Affiliation(s)
- Simona Ghetti
- Department of Psychology, University of California, Davis, Davis, California, USA.,Center for Mind and Brain, University of California, Davis, Davis, California, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Davis, California, USA.,Department of Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Davis, California, USA
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, The Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeff E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Aris Garro
- Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, The George Washington School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Davis, California, USA
| | - Andrew D DePiero
- Division of Emergency Medicine, Nemours/A.I. DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York City, New York, USA
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Davis, California, USA
| | | |
Collapse
|
16
|
Dorney K, Monuteaux MC, Nigrovic LE, Lipsett SC, Nelson KA, Neuman MI. Trends in the Use of Procalcitonin at US Children's Hospital Emergency Departments. Hosp Pediatr 2023; 13:24-30. [PMID: 36530152 DOI: 10.1542/hpeds.2022-006792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Procalcitonin (PCT) was approved by the Food and Drug Administration in 2016. We assessed changes in PCT utilization over time in emergency departments (EDs) at US Children's Hospitals and identified the most common conditions associated with PCT testing. METHODS We performed a cross-sectional study of children <18 years of age presenting to 1 of 33 EDs contributing data to the Pediatric Health Information System between 2016 and 2020. We examined trends in PCT utilization during an ED encounter between institutions and over the study period. Using All Patients Refined Diagnosis Related Groups, we identified the most common conditions for which PCT was obtained (overall, and relative to the performance of a complete blood count). RESULTS The overall rate of PCT testing increased from 0.2% of all ED visits in 2016 to 1.8% in 2020. Across hospitals, the proportion of ED encounters with PCT obtained ranged from 0.0005% to 4.3% with marked variability in overall use. Among children who had PCT testing performed, the most common diagnoses were fever (10.7%), infections of the upper respiratory tract (9.2%), and pneumonia (5.9%). Relative to the performance of a complete blood count, rates of PCT testing were highest among children with sepsis (28.7%), fever (21.4%), pulmonary edema/respiratory failure (17.3%), and bronchiolitis/respiratory syncytial virus pneumonia (15.6%). CONCLUSIONS PCT utilization in the ED has increased over the past 5 years with variation between hospitals. PCT is most frequently obtained for children with respiratory infections and febrile illnesses.
Collapse
|
17
|
Glaser NS, Myers SR, Nigrovic LE, Stoner MJ, Tzimenatos L, Brown KM, Casper TC, Olsen CS, Kuppermann N. Pyuria in Children with Diabetic Ketoacidosis. J Pediatr 2023; 252:204-207.e2. [PMID: 36084731 DOI: 10.1016/j.jpeds.2022.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 11/27/2022]
Abstract
Acute kidney injury occurs frequently during pediatric diabetic ketoacidosis (DKA). We reviewed urinalyses from 561 children with DKA; pyuria was detected in 19% overall and in 40% of children with more comprehensive urine testing (≥3 urinalyses) during DKA.
Collapse
Affiliation(s)
- Nicole S Glaser
- Department of Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, CA.
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, OH
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, CA
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, The George Washington School of Medicine and Health Sciences, Washington, DC
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Nathan Kuppermann
- Department of Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, CA; Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, CA
| | | |
Collapse
|
18
|
Glaser NS, Quayle KS, McManemy JK, Nigrovic LE, Tzimenatos L, Stoner MJ, Bennett JE, Trainor JL, Rewers A, Schunk JE, Myers SR, Kwok MY, Brown KM, Ghetti S, Casper TC, Olsen CS, Kuppermann N. Clinical Characteristics of Children with Cerebral Injury preceding Treatment of Diabetic Ketoacidosis. J Pediatr 2022; 250:100-104. [PMID: 35944716 DOI: 10.1016/j.jpeds.2022.07.033] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/12/2022] [Accepted: 07/28/2022] [Indexed: 11/15/2022]
Abstract
Previous studies have identified more severe acidosis and higher blood urea nitrogen (BUN) as risk factors for cerebral injury during treatment of diabetic ketoacidosis (DKA) in children; however, cerebral injury also can occur before DKA treatment. We found that lower pH and higher BUN levels also were associated with cerebral injury at presentation.
Collapse
Affiliation(s)
- Nicole S Glaser
- Department of Pediatrics, University of California Davis Health, University of California Davis School of Medicine, CA.
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine in St. Louis, St Louis, MO
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California Davis School of Medicine, Sacramento, CA
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, OH
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/AI DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, The Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora, CO
| | - Jeff E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, The George Washington School of Medicine and Health Sciences, Washington, DC
| | - Simona Ghetti
- Department of Psychology, University of California Davis, Sacramento, CA
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Nathan Kuppermann
- Department of Pediatrics, University of California Davis Health, University of California Davis School of Medicine, CA; Department of Emergency Medicine, University of California Davis Health, University of California Davis School of Medicine, Sacramento, CA
| | | |
Collapse
|
19
|
Mahajan P, VanBuren JM, Tzimenatos L, Cruz AT, Vitale M, Powell EC, Leetch AN, Pickett ML, Brayer A, Nigrovic LE, Dayan PS, Atabaki SM, Ruddy RM, Rogers AJ, Greenberg R, Alpern ER, Tunik MG, Saunders M, Muenzer J, Levine DA, Hoyle JD, Lillis KG, Gattu R, Crain EF, Borgialli D, Bonsu B, Blumberg S, Anders J, Roosevelt G, Browne LR, Cohen DM, Linakis JG, Jaffe DM, Bennett JE, Schnadower D, Park G, Mistry RD, Glissmeyer EW, Cator A, Bogie A, Quayle KS, Ellison A, Balamuth F, Richards R, Ramilo O, Kuppermann N. Serious Bacterial Infections in Young Febrile Infants With Positive Urinalysis Results. Pediatrics 2022; 150:e2021055633. [PMID: 36097858 PMCID: PMC9648158 DOI: 10.1542/peds.2021-055633] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/24/2022] Open
Abstract
It is unknown whether febrile infants 29 to 60 days old with positive urinalysis results require routine lumbar punctures for evaluation of bacterial meningitis. OBJECTIVE To determine the prevalence of bacteremia and/or bacterial meningitis in febrile infants ≤60 days of age with positive urinalysis (UA) results. METHODS Secondary analysis of a prospective observational study of noncritical febrile infants ≤60 days between 2011 and 2019 conducted in the Pediatric Emergency Care Applied Research Network emergency departments. Participants had temperatures ≥38°C and were evaluated with blood cultures and had UAs available for analysis. We report the prevalence of bacteremia and bacterial meningitis in those with and without positive UA results. RESULTS Among 7180 infants, 1090 (15.2%) had positive UA results. The risk of bacteremia was higher in those with positive versus negative UA results (63/1090 [5.8%] vs 69/6090 [1.1%], difference 4.7% [3.3% to 6.1%]). There was no difference in the prevalence of bacterial meningitis in infants ≤28 days of age with positive versus negative UA results (∼1% in both groups). However, among 697 infants aged 29 to 60 days with positive UA results, there were no cases of bacterial meningitis in comparison to 9 of 4153 with negative UA results (0.2%, difference -0.2% [-0.4% to -0.1%]). In addition, there were no cases of bacteremia and/or bacterial meningitis in the 148 infants ≤60 days of age with positive UA results who had the Pediatric Emergency Care Applied Research Network low-risk blood thresholds of absolute neutrophil count <4 × 103 cells/mm3 and procalcitonin <0.5 ng/mL. CONCLUSIONS Among noncritical febrile infants ≤60 days of age with positive UA results, there were no cases of bacterial meningitis in those aged 29 to 60 days and no cases of bacteremia and/or bacterial meningitis in any low-risk infants based on low-risk blood thresholds in both months of life. These findings can guide lumbar puncture use and other clinical decision making.
Collapse
Affiliation(s)
- Prashant Mahajan
- Division of Emergency Medicine, Department of Pediatrics,
Children's Hospital of Michigan, Wayne State University, Detroit,
Michigan
| | - John M. VanBuren
- Department of Pediatrics, Primary Children’s
Medical Center, University of Utah, Salt Lake City, Utah
| | | | - Andrea T. Cruz
- Sections of Emergency Medicine and Infectious Diseases,
Department of Pediatrics, Texas Children’s Hospital, Baylor College of
Medicine, Houston, Texas
| | - Melissa Vitale
- Division of Pediatric Emergency Medicine, Department of
Pediatrics, Children’s Hospital of Pittsburgh of UPMC, University of
Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Elizabeth C. Powell
- Division of Emergency Medicine, Department of Pediatrics,
Ann & Robert H. Lurie Children’s Hospital, Northwestern University
Feinberg School of Medicine, Chicago, Illinois
| | - Aaron N. Leetch
- Departments of Emergency Medicine and Pediatrics,
University of Arizona College of Medicine, Tucson, Arizona
| | - Michelle L. Pickett
- Section of Pediatric Emergency Medicine, Department of
Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anne Brayer
- Departments of Emergency Medicine and Pediatrics,
University of Rochester Medical Center, Rochester, New York
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children’s
Hospital, Harvard University, Boston, Massachusetts
| | - Peter S. Dayan
- Division of Emergency Medicine, Department of
Pediatrics, Columbia University College of Physicians & Surgeons, New York
City, New York
| | - Shireen M. Atabaki
- Division of Emergency Medicine, Department of
Pediatrics, Children’s National Medical Center, The George Washington School
of Medicine and Health Sciences, Washington, District of Columbia
| | - Richard M. Ruddy
- Division of Emergency Medicine, Cincinnati
Children’s Hospital Medical Center, Department of Pediatrics, University of
Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexander J. Rogers
- Departments of Pediatrics
- Department of Emergency Medicine, University of
Michigan, Ann Arbor, Michigan
| | - Richard Greenberg
- Department of Pediatrics, Primary Children’s
Medical Center, University of Utah, Salt Lake City, Utah
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of
Pediatrics, Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | | | - Mary Saunders
- Section of Pediatric Emergency Medicine, Department of
Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jared Muenzer
- Department of Pediatrics, St. Louis Children’s
Hospital, Washington University, St. Louis, Missouri
| | - Deborah A. Levine
- Department of Pediatrics
- Department of Emergency Medicine, Bellevue Hospital, New
York University Langone Medical Center, New York City, New York
| | - John D. Hoyle
- Department of Emergency Medicine, Helen DeVos
Children’s Hospital of Spectrum Health, Grand Rapids, Michigan
| | - Kathleen Grisanti Lillis
- Department of Pediatrics, Women and Children’s
Hospital of Buffalo, State University of New York at Buffalo, Buffalo, New
York
| | - Rajender Gattu
- Division of Emergency Medicine, Department of
Pediatrics, University of Maryland Medical Center, Baltimore, Maryland
| | - Ellen F. Crain
- Department of Pediatrics, Jacobi Medical Center, Albert
Einstein College of Medicine, New York City, New York
| | - Dominic Borgialli
- Department of Emergency Medicine, University of
Michigan, Ann Arbor, Michigan
- Department of Emergency Medicine, Hurley Medical Center,
Flint, Michigan
| | - Bema Bonsu
- Section of Emergency Medicine, Department of Pediatrics,
Nationwide Children’s Hospital, Columbus, Ohio
| | - Stephen Blumberg
- Department of Pediatrics, Jacobi Medical Center, Albert
Einstein College of Medicine, New York City, New York
| | - Jennifer Anders
- Department of Pediatrics, Johns Hopkins University,
Baltimore, Maryland
| | - Genie Roosevelt
- Department of Pediatrics, The Colorado
Children’s Hospital, University of Colorado-Denver, Denver, Colorado
| | - Lorin R. Browne
- Section of Pediatric Emergency Medicine, Department of
Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - James G. Linakis
- Departments of Emergency Medicine and Pediatrics, Brown
University and Hasbro Children’s Hospital, Providence, Rhode Island
| | - David M. Jaffe
- Department of Pediatrics, St. Louis Children’s
Hospital, Washington University, St. Louis, Missouri
| | - Jonathan E. Bennett
- Division of Pediatric Emergency Medicine, Alfred I.
duPont Hospital for Children, Nemours Children's Health System, Wilmington,
Delaware
| | - David Schnadower
- Department of Pediatrics, St. Louis Children’s
Hospital, Washington University, St. Louis, Missouri
| | - Grace Park
- Department of Emergency Medicine, Pediatric Emergency
Medicine, The University of New Mexico, Albuquerque, New Mexico
| | - Rakesh D. Mistry
- Department of Pediatrics, The Colorado
Children’s Hospital, University of Colorado-Denver, Denver, Colorado
| | - Eric W. Glissmeyer
- Department of Pediatrics, Primary Children’s
Medical Center, University of Utah, Salt Lake City, Utah
| | - Allison Cator
- Departments of Pediatrics
- Department of Emergency Medicine, University of
Michigan, Ann Arbor, Michigan
| | - Amanda Bogie
- Division of Emergency Medicine, Department of
Pediatrics, The University of Oklahoma College of Medicine, Oklahoma City,
Oklahoma
| | - Kimberly S. Quayle
- Department of Pediatrics, St. Louis Children’s
Hospital, Washington University, St. Louis, Missouri
| | - Angela Ellison
- Division of Emergency Medicine, Department of
Pediatrics, Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | - Fran Balamuth
- Division of Emergency Medicine, Department of
Pediatrics, Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
| | - Rachel Richards
- Department of Pediatrics, Primary Children’s
Medical Center, University of Utah, Salt Lake City, Utah
| | - Octavio Ramilo
- Division of Pediatric Infectious Diseases and Center
for Vaccines and Immunity, Nationwide Children's Hospital and The Ohio State
University, Columbus, Ohio
| | - Nathan Kuppermann
- Departments of Emergency Medicine
- Pediatrics, University of California Davis School of
Medicine, Sacramento, California
| | | |
Collapse
|
20
|
Green RS, Sartori LF, Lee BE, Linn AR, Samuels MR, Florin TA, Aronson PL, Chamberlain JM, Michelson KA, Nigrovic LE. Prevalence and Management of Invasive Bacterial Infections in Febrile Infants Ages 2 to 6 Months. Ann Emerg Med 2022; 80:499-506. [DOI: 10.1016/j.annemergmed.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/01/2022]
|
21
|
Garro AC, Thompson AD, Neville DN, Balamuth F, Levas MN, Kharbanda AB, Bennett JE, Grant DS, Aresco RK, Nigrovic LE. Empiric antibiotics for children with suspected Lyme disease. Ticks Tick Borne Dis 2022; 13:101989. [PMID: 35759989 DOI: 10.1016/j.ttbdis.2022.101989] [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: 03/03/2022] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 10/18/2022]
Abstract
In our prospective cohort of children undergoing evaluation for non-cutaneous Lyme disease, 02 (13.9% of those with Lyme disease) were not initially treated with an appropriate antibiotics and 356 (13.3% without Lyme disease) received potentially unnecessary antibiotics. Rapid and accurate diagnostics are needed to further improve initial antibiotic treatment decisions.
Collapse
Affiliation(s)
- Aris C Garro
- Department of Emergency Medicine, Rhode Island (Post-Mortem), Providence, USA
| | - Amy D Thompson
- Division of Emergency Medicine, Nemours Children's Health, USA
| | - Desiree N Neville
- Division of Emergency Medicine, Children's Hospital of Pittsburgh, USA
| | - Fran Balamuth
- Division of Emergency Medicine, Children's Hospital of Philadelphia, USA
| | - Michael N Levas
- Pediatric Emergency Medicine, Children's Hospital of Wisconsin, USA
| | - Anupam B Kharbanda
- Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | | | | | - Rachael K Aresco
- Division of Emergency Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | | |
Collapse
|
22
|
Grant DS, Neville DN, Levas M, Balamuth F, Garro AC, Bennett JE, Thompson AD, Kharbanda AB, Lyons TW, Nigrovic LE. Validation of Septic Knee Monoarthritis Prediction Rule in a Lyme Disease Endemic Area. Pediatr Emerg Care 2022; 38:e881-e885. [PMID: 34160185 DOI: 10.1097/pec.0000000000002455] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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
OBJECTIVE In Lyme disease endemic areas, Lyme and septic arthritis often present similarly. A published septic knee arthritis clinical prediction rule includes 2 high-risk predictors: absolute neutrophil count of 10,000 cells/mm3 or greater and erythrocyte sedimentation rate of 40 mm/h or greater. The objective of the study was to externally validate this prediction rule in a multicenter prospective cohort. METHODS We enrolled a prospective cohort of children with knee monoarthritis undergoing evaluation for Lyme disease at 1 of 8 Pedi Lyme Net emergency departments located in endemic areas. We defined a case of septic arthritis with a positive synovial fluid culture or a synovial fluid white blood cell count of 50,000 or greater per high powered field with a positive blood culture and Lyme arthritis with a positive or equivocal C6 EIA, followed by a positive supplemental immunoblot. Other children were classified as having inflammatory arthritis. We report the performance of the septic arthritis clinical prediction rule in our study population. RESULTS Of the 543 eligible children, 13 had septic arthritis (2.4%), 234 Lyme arthritis (43.1%), and 296 inflammatory arthritis (54.5%). Of the 457 children (84.2%) with available laboratory predictors, all children with septic arthritis were classified as high risk (sensitivity, 100%; 95% confidence interval [CI], 77.2%-100%; specificity, 68.1%; 95% CI, 63.6-73.3; negative predictive value, 278/278 [100%]; 95% CI, 98.6%-100%). Of the 303 low-risk children, 52 (17.2%) underwent diagnostic arthrocentesis. CONCLUSIONS The septic knee arthritis clinical prediction rule accurately distinguished between septic and Lyme arthritis in an endemic area. Clinical application may reduce unnecessary invasive diagnostic procedures.
Collapse
Affiliation(s)
| | - Desiree N Neville
- Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Michael Levas
- Division of Pediatric Emergency Medicine, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Fran Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Aris C Garro
- Departments of Pediatrics and Emergency Medicine, Hasbro Children's Hospital, Providence, RI
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Wilmington, DE
| | - Amy D Thompson
- Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Wilmington, DE
| | | | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| |
Collapse
|
23
|
Poussaint TY, LaRovere KL, Newburger JW, Chou J, Nigrovic LE, Novak T, Randolph AG. Multisystem Inflammatory-like Syndrome in a Child Following COVID-19 mRNA Vaccination. Vaccines (Basel) 2021; 10:vaccines10010043. [PMID: 35062704 PMCID: PMC8781649 DOI: 10.3390/vaccines10010043] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 12/29/2022] Open
Abstract
A 12-year-old male was presented to the hospital with acute encephalopathy, headache, vomiting, diarrhea, and elevated troponin after recent COVID-19 vaccination. Two days prior to admission and before symptom onset, he received the second dose of the Pfizer-BioNTech COVID-19 vaccine. Symptoms developed within 24 h with worsening neurologic symptoms, necessitating admission to the pediatric intensive care unit. Brain magnetic resonance imaging within 16 h of admission revealed a cytotoxic splenial lesion of the corpus callosum (CLOCC). Nineteen days prior to admission, he developed erythema migrans, and completed an amoxicillin treatment course for clinical Lyme disease. However, Lyme antibody titers were negative on admission and nine days later, making active Lyme disease an unlikely explanation for his presentation to hospital. An extensive workup for other etiologies on cerebrospinal fluid and blood samples was negative, including infectious and autoimmune causes and known immune deficiencies. Three weeks after hospital discharge, all of his symptoms had dissipated, and he had a normal neurologic exam. Our report highlights a potential role of mRNA vaccine-induced immunity leading to MIS-C-like symptoms with cardiac involvement and a CLOCC in a recently vaccinated child and the complexity of establishing a causal association with vaccination. The child recovered without receipt of immune modulatory treatment.
Collapse
Affiliation(s)
- Tina Y. Poussaint
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-617-355-6450
| | - Kerri L. LaRovere
- Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA;
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA; (J.C.); (L.E.N.); (A.G.R.)
| | - Janet Chou
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA; (J.C.); (L.E.N.); (A.G.R.)
- Division of Immunology, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Lise E. Nigrovic
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA; (J.C.); (L.E.N.); (A.G.R.)
- Divison of Emergency Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Tanya Novak
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA;
| | - Adrienne G. Randolph
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA; (J.C.); (L.E.N.); (A.G.R.)
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA;
| |
Collapse
|
24
|
Sundheim KM, Levas MN, Balamuth F, Thompson AD, Neville DN, Garro AC, Kharbanda AB, Monuteaux MC, Nigrovic LE. Seasonality of Acute Lyme Disease in Children. Trop Med Infect Dis 2021; 6:tropicalmed6040196. [PMID: 34842846 PMCID: PMC8628899 DOI: 10.3390/tropicalmed6040196] [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: 09/28/2021] [Revised: 10/29/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022] Open
Abstract
Due to the life cycle of its vector, Lyme disease has known seasonal variation. However, investigations focused on children have been limited. Our objective was to evaluate the seasonality of pediatric Lyme disease in three endemic regions in the United States. We enrolled children presenting to one of eight Pedi Lyme Net participating emergency departments. Cases were classified based on presenting symptoms: early (single erythema migrans (EM) lesion), early-disseminated (multiple EM lesions, headache, cranial neuropathy, or carditis), or late (arthritis). We defined a case of Lyme disease by the presence of an EM lesion or a positive two-tier Lyme disease serology. To measure seasonal variability, we estimated Fourier regression models to capture cyclical patterns in Lyme disease incidence. While most children with early or early-disseminated Lyme disease presented during the summer months, children with Lyme arthritis presented throughout the year. Clinicians should consider Lyme disease when evaluating children with acute arthritis throughout the year.
Collapse
Affiliation(s)
- Kathryn M. Sundheim
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA 02115, USA
- Correspondence: (K.M.S.); (L.E.N.)
| | - Michael N. Levas
- Division of Pediatric Emergency Medicine, Medical College of Wisconsin, Wauwatosa, WI 53226, USA;
| | - Fran Balamuth
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Amy D. Thompson
- Departments of Pediatrics and Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA;
| | - Desiree N. Neville
- Division of Emergency Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA 15224, USA;
| | - Aris C. Garro
- Departments of Pediatrics and Emergency Medicine, Rhode Island Hospital and Brown University, Providence, RI 02903, USA;
| | - Anupam B. Kharbanda
- Division of Emergency Medicine, Children’s Minnesota, Minneapolis, MN 55404, USA;
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA 02115, USA;
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA 02115, USA;
- Correspondence: (K.M.S.); (L.E.N.)
| |
Collapse
|
25
|
Lyons TW, Michelson KA, Nigrovic LE, Perron CE, Fine AM. Attending-Provider Handoffs and Pediatric Emergency Department Revisits. Pediatr Emerg Care 2021; 37:e679-e685. [PMID: 31977767 PMCID: PMC10071514 DOI: 10.1097/pec.0000000000001983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine if intradepartment attending-provider transitions of care (handoffs) during a pediatric emergency department (ED) encounter were associated with return ED visits resulting in hospitalization. METHODS We analyzed ED encounters for patients younger than 21 years discharged from a single pediatric ED from January 2013 to February 2017. We classified an encounter as having a handoff when the initial attending and discharging attending differed. Our primary outcome was a revisit within 72 hours resulting in hospitalization. Our secondary outcomes were any revisit within 72 hours and revisits resulting in hospitalization with potential deficiencies in care. We compared outcome rates for ED encounters with and without provider handoffs, both with and without adjustment for demographic, clinical, and visit characteristics. RESULTS Of the 177,350 eligible ED encounters, 1961 (1.1%) had a return visit resulting in hospitalization and 6821 (3.9%) had any return visit. In unadjusted analyses, handoffs were associated with an increased likelihood of a return visit resulting in hospitalization (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.26-1.70) or any return visit (OR, 1.20; 95% CI, 1.10-1.31). However, after adjustment, provider handoffs were not associated with return ED visits resulting in hospitalization (OR, 0.96; 95% CI, 0.81-1.13) or any return ED visits (OR, 1.00; 95% CI, 0.90-1.10). CONCLUSIONS Provider handoffs in a pediatric ED did not increase the risk of return ED visits or return ED visits with deficiencies in care after adjustment for demographic, clinical, and visit factors.
Collapse
Affiliation(s)
- Todd W. Lyons
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA and Department of Pediatrics Harvard Medical School, Boston, MA
- Computational Health Informatics Program (CHiP) at Boston Children’s Hospital, Boston, MA
| | - Kenneth A. Michelson
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA and Department of Pediatrics Harvard Medical School, Boston, MA
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA and Department of Pediatrics Harvard Medical School, Boston, MA
| | - Catherine E. Perron
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA and Department of Pediatrics Harvard Medical School, Boston, MA
| | - Andrew M. Fine
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, MA and Department of Pediatrics Harvard Medical School, Boston, MA
| |
Collapse
|
26
|
Neville DN, Alexander ME, Bennett JE, Balamuth F, Garro A, Levas MN, Thompson AD, Kharbanda AB, Lewander DP, Dart AH, Nigrovic LE. Electrocardiogram as a Lyme Disease Screening Test. J Pediatr 2021; 238:228-232.e1. [PMID: 34265339 DOI: 10.1016/j.jpeds.2021.07.010] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To examine the association between electrocardiographic (ECG) evidence of carditis at the time of Lyme disease evaluation and a diagnosis of Lyme disease. STUDY DESIGN We performed an 8-center prospective cohort study of children undergoing emergency department evaluation for Lyme disease limited to those who had an ECG obtained by their treating clinicians. The study cardiologist reviewed all ECGs flagged as abnormal by the study sites to assess for ECG evidence of carditis. We defined Lyme disease as the presence of an erythema migrans lesion or a positive 2-tier Lyme disease serology. We used logistic regression to measure the association between Lyme disease and atrioventricular (AV) block or any ECG evidence of carditis. RESULTS Of the 546 children who had an ECG obtained, 214 (39%) had Lyme disease. Overall, 42 children had ECG evidence of carditis, of whom 24 had AV block (20 first-degree). Of the patients with ECG evidence of carditis, only 21 (50%) had any cardiac symptoms. The presence of AV block (OR 4.7, 95% CI 1.8-12.1) and any ECG evidence of carditis (OR 2.3, 95% CI 1.2-4.3) were both associated with diagnosis of Lyme disease. CONCLUSIONS ECG evidence of carditis, especially AV block, was associated with a diagnosis of Lyme disease. ECG evidence of carditis can be used as a diagnostic biomarker for Lyme disease to guide initial management while awaiting Lyme disease test results.
Collapse
Affiliation(s)
- Desiree N Neville
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | - Mark E Alexander
- Arrhythmia Service, Department of Cardiology, Boston Children's Hospital, Boston, MA
| | | | - Fran Balamuth
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Aris Garro
- Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
| | - Michael N Levas
- Division of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Amy D Thompson
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Anupam B Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - David P Lewander
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Arianna H Dart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | | |
Collapse
|
27
|
Lantos PM, Balamuth F, Neville D, Garro AC, Levas MN, Bennett J, Thompson AD, Kharbanda AB, Branda JA, Nigrovic LE. Two-Tier Lyme Disease Serology in Children with Previous Lyme Disease. Vector Borne Zoonotic Dis 2021; 21:839-842. [PMID: 34610255 DOI: 10.1089/vbz.2021.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background: A history of Lyme disease can complicate the interpretation of Lyme disease serology in acutely symptomatic patients. Materials and Methods: We prospectively enrolled children undergoing evaluation for Lyme disease in the emergency department of one of eight participating Pedi Lyme Net centers. We selected symptomatic children with a Lyme disease history (definite, probable, or none) as well as an available research biosample. We defined a Lyme disease case with either an erythema migrans (EM) lesion or positive two-tier serology with compatible symptoms. Using a generalized estimating equation, we examined the relationship between time from previous Lyme disease diagnosis and current Lyme disease after adjustment for patient demographics and symptoms as well as clustering by center. Results: Of 2501 prospectively enrolled study patients, 126 (5.0%) reported a history of definite or probable Lyme disease. Of these children with previous Lyme disease, 47 met diagnostic criteria for Lyme disease at the time of enrollment (37.3%; 95% confidence interval [CI] 29.1-45.7%); 2 had an EM lesion, and 45 had positive two-tier Lyme disease serology. Over time from the previous Lyme disease diagnosis, the less likely the patient met diagnostic criteria for Lyme disease (adjusted odds ratio 0.62 per time period; 95% CI 0.46-0.84). Conclusions: For children with a history of Lyme disease before enrollment, one-third met the diagnostic criteria for acute Lyme disease with a declining rate over time from previous Lyme disease diagnosis. Novel Lyme disease diagnostics are needed to help distinguish acute from previous Lyme disease.
Collapse
Affiliation(s)
- Paul M Lantos
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Frances Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Desiree Neville
- Division of Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aris C Garro
- Department of Pediatrics and Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Michael N Levas
- Division of Emergency Medicine, Milwaukee Children's Hospital, Milwaukee, Wisconsin, USA
| | - Jonathan Bennett
- Division of Emergency Medicine, A.I. Dupont Children's Hospital, Wilmington, Delaware, USA
| | - Amy D Thompson
- Division of Emergency Medicine, A.I. Dupont Children's Hospital, Wilmington, Delaware, USA
| | - Anupam B Kharbanda
- Department of Pediatrics, Children's Minnesota, Minneapolis, Minnesota, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
28
|
Abstract
OBJECTIVES Although ceftriaxone has been the first-line treatment of Lyme meningitis, the 2020 Infectious Disease Society of America, American College of Rheumatology, and American Academy of Neurology guideline recommends either doxycycline or ceftriaxone. Our objective was to explore recent trends in enteral antibiotic treatment of children with Lyme meningitis. METHODS Using International Classification of Diseases, 10th Revision codes for case identification, we performed a multicenter retrospective study of patients ≤21 years of age presenting to a pediatric hospital contributing to the Pediatric Health Information System who were diagnosed with Lyme meningitis from 2015 to 2020. Our primary outcome was treatment with parenteral antibiotics, defined by either a procedure code for indwelling catheter placement or >7 days of inpatient parenteral Lyme disease-specific therapy. To examine trends over the study period, we used a generalized estimating equation, with parenteral antibiotics as the dependent variable and study year as the independent variable, adjusted for patient age, sex, race, ethnicity, and insurance status clustered by hospital. RESULTS We identified 239 patients with Lyme meningitis treated at 24 participating centers. Overall, 48 (20.0%) were treated with parenteral antibiotics, with a declining rate over the study period (43.8% in 2015 to 8.9% in 2020). After adjustment, the odds of treatment with a parenteral antibiotic decreased over the study period (adjusted odds ratio 0.57; 95% confidence interval 0.41-0.80). CONCLUSIONS Parenteral antibiotic treatment of children with Lyme meningitis has been on the decline in advance of the published clinical guideline. Carefully designed comparative effectiveness studies are needed to examine the effect of oral versus parenteral treatment regimens on clinical outcomes.
Collapse
Affiliation(s)
- Kelly M Roelf
- Department of Medicine and
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and
| | - Aris Garro
- Department of Pediatrics and Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | |
Collapse
|
29
|
Bressan S, Klassen TP, Dalziel SR, Babl FE, Benito J, Chamberlain J, Chang TP, Freedman SB, Kohn Loncarica G, Lyttle MD, Mintegi S, Mistry RD, Nigrovic LE, Plint AC, Rino P, Roland D, Van De Mosselaer G, Oostenbrink R, Kuppermann N. The Pediatric Emergency Research Network: a decade old and growing. Eur J Emerg Med 2021; 28:341-343. [PMID: 34433789 DOI: 10.1097/mej.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Silvia Bressan
- Division of Emergency Medicine, Department of Women's and Children's Health, University of Padova, Padova, Italy
- Research in European Pediatric Emergency Medicine (REPEM)
| | - Terry P Klassen
- Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba
- The Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
- Pediatric Emergency Research Canada (PERC)
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland
- Children's Emergency Department, Starship Children's Health, Auckland, New Zealand
- Paediatric Research in Emergency Departments International Collaborative (PREDICT)
| | - Franz E Babl
- Paediatric Research in Emergency Departments International Collaborative (PREDICT)
- Departments of Paediatrics and Critical Care, University of Melbourne
- Emergency Research, Murdoch Children's Research Institute
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces; University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
- Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG)
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Pediatric Emergency Care Applied Research Network (PECARN)
| | - Todd P Chang
- Pediatric Emergency Care Applied Research Network (PECARN)
- Division of Emergency Medicine & Transport, Children's Hospital Los Angeles and Keck School of Medicine at University of Southern California, Los Angeles, California, USA
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC)
| | - Stephen B Freedman
- Pediatric Emergency Research Canada (PERC)
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Guillermo Kohn Loncarica
- Unidad Emergencias Hospital J.P. Garrahan, Sociedad Latinoamericana de Emergencia Pediátrica, Universidad de Buenos Aires, Buenos Aires, Argentina
- Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica (RIDEPLA)
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
- Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI)
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces; University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
- Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG)
| | - Rakesh D Mistry
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC)
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Lise E Nigrovic
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC)
- Division of Emergency Medicine, Boston Children's Hospital
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy C Plint
- Pediatric Emergency Research Canada (PERC)
- Children's Hospital of Eastern Ontario
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Pedro Rino
- Unidad Emergencias Hospital J.P. Garrahan, Sociedad Latinoamericana de Emergencia Pediátrica, Universidad de Buenos Aires, Buenos Aires, Argentina
- Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica (RIDEPLA)
| | - Damian Roland
- Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI)
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group; Children's Emergency Department, Leicester Royal Infirmary & SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
| | - Gregory Van De Mosselaer
- Department of Emergency Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Translating Emergency Knowledge for Kids (TREKK)
| | - Rianne Oostenbrink
- Research in European Pediatric Emergency Medicine (REPEM)
- Department General Pediatrics, ErasmusMC - Sophia, Rotterdam, The Netherlands
| | - Nathan Kuppermann
- Pediatric Emergency Care Applied Research Network (PECARN)
- Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
| |
Collapse
|
30
|
Glaser NS, Stoner MJ, Garro A, Baird S, Myers SR, Rewers A, Brown KM, Trainor JL, Quayle KS, McManemy JK, DePiero AD, Nigrovic LE, Tzimenatos L, Schunk JE, Olsen CS, Casper TC, Ghetti S, Kuppermann N. Serum Sodium Concentration and Mental Status in Children With Diabetic Ketoacidosis. Pediatrics 2021; 148:peds.2021-050243. [PMID: 34373322 DOI: 10.1542/peds.2021-050243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Diabetic ketoacidosis (DKA) is typically characterized by low or low-normal serum sodium concentrations, which rise as hyperglycemia resolves. In retrospective studies, researchers found associations between declines in sodium concentrations during DKA and cerebral injury. We prospectively investigated determinants of sodium concentration changes and associations with mental status alterations during DKA. METHODS Using data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in Diabetic Ketoacidosis Trial, we compared children who had declines in glucose-corrected sodium concentrations with those who had rising or stable concentrations. Children were randomly assigned to 1 of 4 intravenous fluid protocols that differed in infusion rate and sodium content. Data from the first 4, 8, and 12 hours of treatment were analyzed for 1251, 1086, and 877 episodes, respectively. RESULTS In multivariable analyses, declines in glucose-corrected sodium concentrations were associated with higher sodium and chloride concentrations at presentation and with previously diagnosed diabetes. Treatment with 0.45% (vs 0.9%) sodium chloride fluids was also associated with declines in sodium concentration; however, higher rates of fluid infusion were associated with declines in sodium concentration only at 12 hours. Frequencies of abnormal Glasgow Coma Scale scores and clinical diagnoses of cerebral injury were similar in patients with and without declines in glucose-corrected sodium concentrations. CONCLUSIONS Changes in glucose-corrected sodium concentrations during DKA treatment are influenced by the balance of free-water loss versus sodium loss at presentation and the sodium content of intravenous fluids. Declines in glucose-corrected sodium concentrations are not associated with mental status changes during treatment.
Collapse
Affiliation(s)
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital and School of Medicine, The Ohio State University, Columbus, Ohio
| | - Aris Garro
- Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital and The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Scott Baird
- Division of Critical Care Medicine, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital and College of Physicians and Surgeons, Columbia University, New York City, New York
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center and School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St Louis Children's Hospital and School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Andrew D DePiero
- Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.,Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Leah Tzimenatos
- Emergency Medicine, School of Medicine, University of California, Davis Health, University of California, Davis, Sacramento, California
| | - Jeff E Schunk
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Cody S Olsen
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - T Charles Casper
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Simona Ghetti
- Department of Psychology, University of California, Davis, Davis, California
| | | | | |
Collapse
|
31
|
Rewers A, Kuppermann N, Stoner MJ, Garro A, Bennett JE, Quayle KS, Schunk JE, Myers SR, McManemy JK, Nigrovic LE, Trainor JL, Tzimenatos L, Kwok MY, Brown KM, Olsen CS, Casper TC, Ghetti S, Glaser NS. Effects of Fluid Rehydration Strategy on Correction of Acidosis and Electrolyte Abnormalities in Children With Diabetic Ketoacidosis. Diabetes Care 2021; 44:2061-2068. [PMID: 34187840 PMCID: PMC8740930 DOI: 10.2337/dc20-3113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/20/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Fluid replacement to correct dehydration, acidosis, and electrolyte abnormalities is the cornerstone of treatment for diabetic ketoacidosis (DKA), but little is known about optimal fluid infusion rates and electrolyte content. The objective of this study was to evaluate whether different fluid protocols affect the rate of normalization of biochemical derangements during DKA treatment. RESEARCH DESIGN AND METHODS The current analysis involved moderate or severe DKA episodes (n = 714) in children age <18 years enrolled in the Fluid Therapies Under Investigation in DKA (FLUID) Trial. Children were assigned to one of four treatment groups using a 2 × 2 factorial design (0.90% or 0.45% saline and fast or slow rate of administration). RESULTS The rate of change of pH did not differ by treatment arm, but Pco2 increased more rapidly in the fast versus slow fluid infusion arms during the initial 4 h of treatment. The anion gap also decreased more rapidly in the fast versus slow infusion arms during the initial 4 and 8 h. Glucose-corrected sodium levels remained stable in patients assigned to 0.90% saline but decreased in those assigned to 0.45% saline at 4 and 8 h. Potassium levels decreased, while chloride levels increased more rapidly with 0.90% versus 0.45% saline. Hyperchloremic acidosis occurred more frequently in patients in the fast arms (46.1%) versus the slow arms (35.2%). CONCLUSIONS In children treated for DKA, faster fluid administration rates led to a more rapid normalization of anion gap and Pco2 than slower fluid infusion rates but were associated with an increased frequency of hyperchloremic acidosis.
Collapse
Affiliation(s)
- Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento.,Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento
| | - Michael J Stoner
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH
| | - Aris Garro
- Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jeffrey E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Simona Ghetti
- Department of Psychology and the Center for Mind and Brain, University of California, Davis, Davis, CA
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento
| | | |
Collapse
|
32
|
Cruz AT, Nigrovic LE, Xie J, Mahajan P, Thomson JE, Okada PJ, Uspal NG, Mistry RD, Garro A, Schnadower D, Kulik DM, Curtis SJ, Miller AS, Fleming AH, Lyons TW, Balamuth F, Arms JL, Louie J, Aronson PL, Thompson AD, Ishimine PT, Schmidt SM, Pruitt CM, Shah SS, Grether-Jones KL, Bradin SA, Freedman SB. Predictors of Invasive Herpes Simplex Virus Infection in Young Infants. Pediatrics 2021; 148:peds.2021-050052. [PMID: 34446535 DOI: 10.1542/peds.2021-050052] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To identify independent predictors of and derive a risk score for invasive herpes simplex virus (HSV) infection. METHODS In this 23-center nested case-control study, we matched 149 infants with HSV to 1340 controls; all were ≤60 days old and had cerebrospinal fluid obtained within 24 hours of presentation or had HSV detected. The primary and secondary outcomes were invasive (disseminated or central nervous system) or any HSV infection, respectively. RESULTS Of all infants included, 90 (60.4%) had invasive and 59 (39.6%) had skin, eyes, and mouth disease. Predictors independently associated with invasive HSV included younger age (adjusted odds ratio [aOR]: 9.1 [95% confidence interval (CI): 3.4-24.5] <14 and 6.4 [95% CI: 2.3 to 17.8] 14-28 days, respectively, compared with >28 days), prematurity (aOR: 2.3, 95% CI: 1.1 to 5.1), seizure at home (aOR: 6.1, 95% CI: 2.3 to 16.4), ill appearance (aOR: 4.2, 95% CI: 2.0 to 8.4), abnormal triage temperature (aOR: 2.9, 95% CI: 1.6 to 5.3), vesicular rash (aOR: 54.8, (95% CI: 16.6 to 180.9), thrombocytopenia (aOR: 4.4, 95% CI: 1.6 to 12.4), and cerebrospinal fluid pleocytosis (aOR: 3.5, 95% CI: 1.2 to 10.0). These variables were transformed to derive the HSV risk score (point range 0-17). Infants with invasive HSV had a higher median score (6, interquartile range: 4-8) than those without invasive HSV (3, interquartile range: 1.5-4), with an area under the curve for invasive HSV disease of 0.85 (95% CI: 0.80-0.91). When using a cut-point of ≥3, the HSV risk score had a sensitivity of 95.6% (95% CI: 84.9% to 99.5%), specificity of 40.1% (95% CI: 36.8% to 43.6%), and positive likelihood ratio 1.60 (95% CI: 1.5 to 1.7) and negative likelihood ratio 0.11 (95% CI: 0.03 to 0.43). CONCLUSIONS A novel HSV risk score identified infants at extremely low risk for invasive HSV who may not require routine testing or empirical treatment.
Collapse
Affiliation(s)
| | - Lise E Nigrovic
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jianling Xie
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute
| | - Prashant Mahajan
- School of Medicine, Wayne State University, Detroit, Michigan.,Medical School, University of Michigan, Ann Arbor, Michigan
| | - Joanna E Thomson
- Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Pamela J Okada
- Southwestern Medical Center, University of Texas, Dallas, Texas
| | - Neil G Uspal
- School of Medicine, University of Washington, Seattle, Washington
| | - Rakesh D Mistry
- School of Medicine, University of Colorado, Aurora, Colorado
| | - Aris Garro
- Alpert Medical School of Brown University, Providence, Rhode Island
| | - David Schnadower
- Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,School of Medicine, Washington University, St Louis, Missouri
| | - Dina M Kulik
- University of Toronto and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sarah J Curtis
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Aaron S Miller
- School of Medicine, St Louis University, St Louis, Missouri
| | | | - Todd W Lyons
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Fran Balamuth
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph L Arms
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Jeffrey Louie
- Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Paul L Aronson
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Amy D Thompson
- Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Paul T Ishimine
- School of Medicine, University of California-San Diego, San Diego, California
| | - Suzanne M Schmidt
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christopher M Pruitt
- School of Medicine, University of Alabama-Birmingham, Birmingham, Alabama.,Medical University of South Carolina, South Carolina, Charleston, South Carolina
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Stephen B Freedman
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
33
|
Alpern ER, Kuppermann N, Blumberg S, Roosevelt G, Cruz AT, Nigrovic LE, Browne LR, VanBuren JM, Ramilo O, Mahajan P. Time to Positive Blood and Cerebrospinal Fluid Cultures in Febrile Infants ≤60 Days of Age. Hosp Pediatr 2021; 10:719-727. [PMID: 32868377 DOI: 10.1542/hpeds.2020-0045] [Citation(s) in RCA: 8] [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: 01/08/2023]
Abstract
OBJECTIVES To determine the time to positivity for bacterial pathogens and contaminants in blood and cerebrospinal fluid (CSF) cultures in a cohort of febrile infants ≤60 days of age. METHODS This was a secondary analysis of prospective observational multicenter study of noncritically ill infants ≤60 days of age with temperatures ≥38°C and blood cultures (December 2008 to May 2013). The main outcome was time to positivity for bacterial pathogens and contaminants. RESULTS A total of 256 of 303 (84.49%) patients with positive blood cultures, and 73 of 88 (82.95%) with positive CSF cultures met inclusion criteria. Median time (interquartile range [IQR]) to positivity for blood cultures was 16.6 hours (IQR 12.6-21.9) for bacterial pathogens (n = 74) and 25.1 hours (IQR 19.8-33.0) for contaminants (n = 182); P < .001. Time to bacterial pathogen positivity was similar in infants 0 to 28 days of age (15.8 hours [IQR 12.6-21.0]) and 29 to 60 days of age (17.2 [IQR 12.9-24.3]; P = .328). Median time to positivity for CSF was 14.0 hours (IQR 1.5-21.0) for bacterial pathogens (n = 22) and 40.5 hours (IQR 21.2-62.6) for contaminants (n = 51); P < .001. A total of 82.4% (95% confidence interval, 71.8-90.3) and 81.8% (95% confidence interval, 59.7%-94.8%) of blood and CSF cultures showed bacterial pathogen positivity within 24 hours. CONCLUSIONS Among febrile infants ≤60 days of age, time to blood and CSF positivity was significantly shorter for bacterial pathogens than contaminants. Most blood and CSF cultures for bacterial pathogens were positive within 24 hours. With our findings, there is potential to reduce duration of hospitalization and avoid unnecessary antibiotics.
Collapse
Affiliation(s)
- Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California, Davis, Sacramento, California
| | - Stephen Blumberg
- Department of Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Genie Roosevelt
- Department of Pediatrics, The Colorado Children's Hospital and University of Colorado School of Medicine, Aurora Colorado
| | - Andrea T Cruz
- Sections of Emergency Medicine and Infectious Diseases, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lorin R Browne
- Departments of Pediatrics and Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John M VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Octavio Ramilo
- Division of Pediatric Infectious Diseases and Center for Vaccines and Immunity, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio; and
| | | | | |
Collapse
|
34
|
Lantos PM, Tsao J, Janko M, Arab A, von Fricken ME, Auwaerter PG, Nigrovic LE, Fowler V, Ruffin F, Gaines D, Broyhill J, Swenson J. Environmental Correlates of Lyme Disease Emergence in Southwest Virginia, 2005-2014. J Med Entomol 2021; 58:1680-1685. [PMID: 33825903 PMCID: PMC8285012 DOI: 10.1093/jme/tjab038] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Indexed: 06/12/2023]
Abstract
Lyme disease is the most common tick-borne disease in North America. Though human infection is mostly transmitted in a limited geography, the range has expanded in recent years. One notable area of recent expansion is in the mountainous region of southwestern Virginia. The ecological factors that facilitate or constrain the range of human Lyme disease in this region remain uncertain. To evaluate this further, we obtained ecological data, including remotely sensed data on forest structure and vegetation, weather data, and elevation. These data were aggregated within the census block groups of a 9,153 km2 area around the cities of Blacksburg and Roanoke, VA, an area with heterogeneous Lyme disease transmission. In this geographic area, 755 individuals were reported to have Lyme disease in the 10 yr from 2006 to 2015, and these cases were aggregated by block group. A zero-inflated negative binomial model was used to evaluate which environmental variables influenced the abundance of Lyme disease cases. Higher elevation and higher vegetation density had the greatest effect size on the abundance of Lyme disease. Measures of forest edge, forest integrity, temperature, and humidity were not associated with Lyme disease cases. Future southward expansion of Lyme disease into the southeastern states may be most likely in ecologically similar mountainous areas.
Collapse
Affiliation(s)
- Paul M Lantos
- Departments of Medicine, Pediatrics, Community and Family Medicine, and Global Health, Duke University, Durham, NC
| | - Jean Tsao
- Department of Fisheries and Wildlife, Michigan State University, Lansing, MI
| | - Mark Janko
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA
| | - Ali Arab
- Department of Mathematics and Statistics, Georgetown University, Washington, DC
| | | | - Paul G Auwaerter
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lise E Nigrovic
- Department of Emergency Medicine, Boston Children’s Hospital, Boston, MA
| | - Vance Fowler
- Department of Medicine, Duke University, Durham, NC
| | | | - David Gaines
- Office of Epidemiology, Virginia Department of Health, Richmond, VA
| | - James Broyhill
- Office of Epidemiology, Virginia Department of Health, Richmond, VA
| | | |
Collapse
|
35
|
Klassen TP, Dalziel SR, Babl FE, Benito J, Bressan S, Chamberlain J, Chang TP, Freedman SB, Kohn Loncarica G, Lyttle MD, Mintegi S, Mistry RD, Nigrovic LE, Oostenbrink R, Plint AC, Rino P, Roland D, Van de Mosselaer G, Kuppermann N. The Pediatric Emergency Research Network (PERN): A decade of global research cooperation in paediatric emergency care. Emerg Med Australas 2021; 33:900-910. [PMID: 34218513 DOI: 10.1111/1742-6723.13801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in paediatric emergency care to organise globally for the conduct of collaborative research across networks. METHODS PERN has grown from five to eight member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children. RESULTS Beginning as a pandemic response studying H1N1 influenza risk factors in children, PERN research has progressed to multiple observational studies and ongoing global randomised controlled trials (RCTs). As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current COVID-19 pandemic. CONCLUSIONS Following its success with developing global research, the PERN goal now is to promote the implementation of scientific advances into everyday clinical practice by: (i) expanding the capacity for global RCTs; (ii) deepening the focus on implementation science; (iii) increasing attention to healthcare disparities; and (iv) expanding PERN's reach into resource-restricted regions. Through these actions, PERN aims to meet the needs of acutely ill and injured children throughout the world.
Collapse
Affiliation(s)
- Terry P Klassen
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.,Pediatric Emergency Research Canada (PERC)
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Children's Emergency Department, Starship Children's Health, Auckland, New Zealand.,Paediatric Research in Emergency Departments International Collaborative (PREDICT)
| | - Franz E Babl
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain.,Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG)
| | - Silvia Bressan
- Department of Women's and Children's Health, University of Padova, Padova, Italy.,Research in European Pediatric Emergency Medicine (REPEM)
| | - James Chamberlain
- Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA.,Pediatric Emergency Care Applied Research Network (PECARN)
| | - Todd P Chang
- Pediatric Emergency Care Applied Research Network (PECARN).,Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, California, USA.,Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC)
| | - Stephen B Freedman
- Pediatric Emergency Research Canada (PERC).,Departments of Pediatrics and Emergency Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Guillermo Kohn Loncarica
- Latin American Pediatric Emergency Medicine Society, University of Buenos Aires, Buenos Aires, Argentina.,Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica (RIDEPLA)
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.,Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI)
| | - Santiago Mintegi
- Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG).,Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Rakesh D Mistry
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC).,Department of Paediatrics, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Lise E Nigrovic
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics (PEM CRC).,Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rianne Oostenbrink
- Research in European Pediatric Emergency Medicine (REPEM).,General Pediatrics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Amy C Plint
- Pediatric Emergency Research Canada (PERC).,Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Pedro Rino
- Latin American Pediatric Emergency Medicine Society, University of Buenos Aires, Buenos Aires, Argentina.,Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica (RIDEPLA)
| | - Damian Roland
- Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI).,Children's Emergency Department, University of Leicester, Leicestershire, UK
| | - Greg Van de Mosselaer
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Translating Emergency Knowledge for Kids, Winnipeg, Manitoba, Canada
| | - Nathan Kuppermann
- Pediatric Emergency Care Applied Research Network (PECARN).,Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
| |
Collapse
|
36
|
Klassen T, Dalziel SR, Babl FE, Benito J, Bressan S, Chamberlain J, Chang TP, Freedman SB, Kohn-Loncarica G, Lyttle MD, Mintegi S, Mistry RD, Nigrovic LE, Oostenbrink R, Plint AC, Rino P, Roland D, Van De Mosselaer G, Kuppermann N. The Pediatric Emergency Research Network: A Decade of Global Research Cooperation in Pediatric Emergency Care. Pediatr Emerg Care 2021; 37:389-396. [PMID: 34091572 PMCID: PMC8244934 DOI: 10.1097/pec.0000000000002466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in pediatric emergency care to organize globally for the conduct of collaborative research across networks. METHODS The Pediatric Emergency Research Network has grown from 5- to 8-member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed, and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children. RESULTS Beginning as a pandemic response with a high-quality retrospective case-controlled study of H1N1 influenza risk factors, PERN research has progressed to multiple observational studies and ongoing global randomized controlled trials. As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current coronavirus disease 2019 pandemic. In light of the ongoing need for translation of research knowledge into equitable clinical practice and to promote health equity, PERN is committed to a coordinated international effort to increase the uptake of evidence-based management of common and treatable acute conditions in all emergency department settings. CONCLUSIONS The Pediatric Emergency Research Network's successes with global research, measured by prospective observational and interventional studies, mean that the network can now move to improve its ability to promote the implementation of scientific advances into everyday clinical practice. Achieving this goal will involve focus in 4 areas: (1) expanding the capacity for global randomized controlled trials; (2) deepening the focus on implementation science; (3) increasing attention to healthcare disparities and their origins, with growing momentum toward equity; and (4) expanding PERN's global reach through addition of sites and networks from resource-restricted regions. Through these actions, PERN will be able to build on successes to face the challenges ahead and meet the needs of acutely ill and injured children throughout the world.
Collapse
Affiliation(s)
- Terry Klassen
- From the Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba
- The Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
- Pediatric Emergency Research Canada
| | - Stuart R. Dalziel
- Departments of Surgery
- Paediatrics: Child and Youth Health, University of Auckland
- Children's Emergency Department, Starship Children's Health, Auckland, New Zealand
- Paediatric Research in Emergency Departments International Collaborative
| | - Franz E. Babl
- Paediatric Research in Emergency Departments International Collaborative
- Departments of Paediatrics
- Critical Care, University of Melbourne, Australia
- Emergency Research, Murdoch Children's Research Institute, Melbourne
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Javier Benito
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Barakaldo
- University of the Basque Country (UPV/EHU), Bilbao, Basque Country, Spain
- Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group
| | - Silvia Bressan
- Division of Emergency Medicine, Department of Women's and Children's Health, University of Padova, Padova, Italy
- Research in European Pediatric Emergency Medicine
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
- Pediatric Emergency Care Applied Research Network
| | - Todd P. Chang
- Pediatric Emergency Care Applied Research Network
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics, Calgary, AB, Canada
- Division of Pediatric Emergency Medicine, Pediatric Emergency Care Applied Research Network (PECARN), Los Angeles, CA
| | - Stephen B. Freedman
- Pediatric Emergency Research Canada
- Section of Pediatric Emergency Medicine, Department of Pediatrics
- Section of Gastroenterology, Department of Emergency Medicine, Cumming School of Medicine, University of Calgary
- Division of Pediatric Emergency Medicine, Pediatric Emergency Research Canada (PERC), Calgary, AB, Canada
| | - Guillermo Kohn-Loncarica
- Unidad Emergencias Hospital J.P. Garrahan, Sociedad Latinoamericana de Emergencia Pediátrica, Universidad de Buenos Aires, Buenos Aires, Argentina
- Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica
| | - Mark D. Lyttle
- Emergency Department, Bristol Royal Hospital for Children
- Faculty of Health and Applied Sciences, University of the West of England
- Paediatric Emergency Research in the United Kingdom and Ireland, Bristol, United Kingdom
| | - Santiago Mintegi
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Barakaldo
- University of the Basque Country (UPV/EHU), Bilbao, Basque Country, Spain
| | - Rakesh D. Mistry
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine
- Division of Pediatric Emergency Medicine, Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics, Denver, CO
| | - Lise E. Nigrovic
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Emergency Medicine, Boston Children's Hospital
- Department of Emergency Medicine, Harvard Medical School
- Division of Pediatric Emergency Medicine, Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics, Boston, MA
| | - Rianne Oostenbrink
- Division of Emergency Medicine, Department of Women's and Children's Health, University of Padova, Padova, Italy
- Department of General Pediatrics, ErasmusMC–Sophia
- Division of Pediatric Emergency Medicine, Research in European Pediatric Emergency Medicine, Rotterdam, the Netherlands
| | - Amy C. Plint
- Pediatric Emergency Research Canada
- Children's Hospital of Eastern Ontario
- Pediatrics
- Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Pedro Rino
- Unidad Emergencias Hospital J.P. Garrahan, Sociedad Latinoamericana de Emergencia Pediátrica, Universidad de Buenos Aires, Buenos Aires, Argentina
- Red de Investigación y Desarrollo de la Emergencia Pediátrica de Latinoamérica
| | - Damian Roland
- Faculty of Health and Applied Sciences, University of the West of England
- Paediatric Emergency Medicine Leicester Academic Group
- Children's Emergency Department, Leicester Royal Infirmary
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, United Kingdom
| | - Gregory Van De Mosselaer
- Department of Emergency Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Translating Emergency Knowledge for Kids
| | - Nathan Kuppermann
- Pediatric Emergency Care Applied Research Network
- Departments of Emergency Medicine
- Pediatrics, University of California Davis School of Medicine, Sacramento, CA
| |
Collapse
|
37
|
DesPain AW, Gutman CK, Cruz AT, Aronson PL, Chamberlain JM, Chang TP, Florin TA, Kaplan RL, Nigrovic LE, Pruitt CM, Thompson AD, Gonzalez VM, Mistry RD. Research environment and resources to support pediatric emergency medicine fellow research. AEM Educ Train 2021; 5:e10585. [PMID: 34124527 PMCID: PMC8171771 DOI: 10.1002/aet2.10585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/21/2021] [Accepted: 02/08/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND There is a need for pediatric emergency medicine (PEM) researchers, but the current state of PEM fellow research training is not well described. We sought to (1) describe resources and gaps in PEM fellowship research training and (2) assess agreement between fellow and program director (PD) perceptions of these in fellow research experience. METHODS Surveys were distributed electronically to U.S. PEM fellows and PDs from March to April 2020. Fellows and PDs were queried on program research infrastructure and current gaps in fellow research experience. For programs that had at least one fellow and PD response, each fellow response was compared to their PD's corresponding response (reference standard). For each binary survey item, we determined the percent of responses with agreement between the fellow and PD. RESULTS Of 79 fellowship programs, 70 (89%) were represented with at least one response, including responses from 59 PDs (75%) and 218 fellows (39% of all fellows, representing 80% of programs). Fellows and PDs identified mentorship and faculty engagement as the most important needs for successful fellowship research; for every one fellow there was a median of 0.8 potential faculty mentors in the division. Twenty percent of fellows were not satisfied with mentorship opportunities. There was no association between fellow career research intent (high, defined as ≥20% dedicated time, or low) with current year of training (p = 0.88), program size (p = 0.67), and area of research focus (p = 0.40). Fellows were often unaware of research being performed by division faculty. CONCLUSION PEM fellows were not consistently aware of resources available to support research training. To better support PEM fellows' research training, many programs may need to expand mentorship and increase fellows' awareness of local and external resources and opportunities.
Collapse
Affiliation(s)
- Angelica W. DesPain
- Division of Emergency MedicineChildren’s National HospitalThe George Washington University School of MedicineWashingtonDCUSA
| | - Colleen K. Gutman
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Andrea T. Cruz
- Sections of Emergency Medicine & Infectious DiseasesDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Paul L. Aronson
- Section of Pediatric Emergency MedicineDepartments of Pediatrics and Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - James M. Chamberlain
- Division of Emergency MedicineChildren’s National HospitalThe George Washington University School of MedicineWashingtonDCUSA
| | - Todd P. Chang
- Division of Emergency Medicine & TransportChildren’s Hospital Los Angeles/University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Todd A. Florin
- Division of Emergency MedicineAnn and Robert H. Lurie Children’s Hospital of ChicagoDepartment of PediatricsNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Ron L. Kaplan
- Department of PediatricsDivision of Emergency MedicineUniversity of Washington School of MedicineSeattle Children’s HospitalSeattleWashingtonUSA
| | - Lise E. Nigrovic
- Division of Emergency MedicineBoston Children’s HospitalBostonMassachusettsUSA
| | - Christopher M. Pruitt
- Department of PediatricsMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Amy D. Thompson
- Department of PediatricsDivision of Emergency MedicineSydney Kimmel Medical College of Thomas Jefferson UniversityNemours/Alfred I duPont Hospital for ChildrenWilmingtonDelawareUSA
| | - Victor M. Gonzalez
- Section of Emergency MedicineDepartment of PediatricsBaylor College of MedicineHoustonTexasUSA
| | - Rakesh D. Mistry
- Section of Emergency MedicineChildren's Hospital ColoradoAuroraColoradoUSA
| |
Collapse
|
38
|
Affiliation(s)
- Leah Tzimenatos
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA.
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| |
Collapse
|
39
|
Balamuth F, Cruz AT, Freedman SB, Ishimine PT, Garro A, Curtis S, Grether-Jones KL, Miller AS, Uspal NG, Schmidt SM, Shah SS, Nigrovic LE. Test Characteristics of Cerebrospinal Fluid Gram Stain to Identify Bacterial Meningitis in Infants Younger Than 60 Days. Pediatr Emerg Care 2021; 37:e227-e229. [PMID: 30422943 DOI: 10.1097/pec.0000000000001639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT In our cohort of 20,947 infants aged 60 days or younger, cerebrospinal fluid Gram stain had a sensitivity of 34.3% (95% confidence interval, 28.1%-41.1%) and a positive predictive value of 61.4% (95% confidence interval, 52.2%-69.8%) for positive cerebrospinal fluid culture, suggesting that Gram stain alone may lead to both underdiagnosis and overdiagnosis of bacterial meningitis.
Collapse
Affiliation(s)
- Fran Balamuth
- From the Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Andrea T Cruz
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor School of Medicine, Houston, TX
| | - Stephen B Freedman
- Division of Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - Paul T Ishimine
- Departments of Emergency Medicine and Pediatrics, University of California, San Diego School of Medicine, San Diego, CA
| | - Aris Garro
- Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Sarah Curtis
- Division of Pediatric Emergency Medicine, Stollery Children's Hospital, Women and Children's Health Research Institute & Faculty of Medicine & Dentistry, University of Alberta, Canada
| | | | - Aaron S Miller
- Division of Pediatric Infectious Diseases, St. Louis University School of Medicine, St. Louis, MO
| | - Neil G Uspal
- Division of Emergency Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Suzanne M Schmidt
- Division of Emergency Medicine, Department of Pediatrics, Seattle Children's Hospital, Chicago, IL
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
40
|
Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis 2021; 72:e1-e48. [PMID: 33417672 DOI: 10.1093/cid/ciaa1215] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 12/13/2022] Open
Abstract
This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.
Collapse
Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Baldwin
- Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Kiran K Belani
- Childrens Hospital and Clinical of Minnesota, Minneapolis, Minnesota, USA
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David B Clifford
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Peter J Krause
- Yale School of Public Health, New Haven, Connecticut, USA
| | | | | | | | | | | | | | - Amy A Pruitt
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Rips
- Consumer Representative, Omaha, Nebraska, USA
| | | | | | | | - Allen C Steere
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Robert Sundel
- Boston Children's Hospital Boston, Massachusetts, USA
| | - Jean Tsao
- Michigan State University, East Lansing, Michigan, USA
| | | | | | - Lawrence S Zemel
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| |
Collapse
|
41
|
Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis 2021; 72:1-8. [PMID: 33483734 DOI: 10.1093/cid/ciab049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 11/14/2022] Open
Abstract
This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.
Collapse
Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Baldwin
- Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Kiran K Belani
- Childrens Hospital and Clinical of Minnesota, Minneapolis, Minnesota, USA
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David B Clifford
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Peter J Krause
- Yale School of Public Health, New Haven, Connecticut, USA
| | | | | | | | | | | | | | - Amy A Pruitt
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Rips
- Consumer Representative, Omaha, Nebraska, USA
| | | | | | | | - Allen C Steere
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Robert Sundel
- Boston Children's Hospital Boston, Massachusetts, USA
| | - Jean Tsao
- Michigan State University, East Lansing, Michigan, USA
| | | | | | - Lawrence S Zemel
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| |
Collapse
|
42
|
Garro A, Avery RA, Cohn KA, Neville DN, Balamuth F, Levas MN, Bennett JE, Kharbanda AB, Monuteaux MC, Nigrovic LE. Validation of the Rule of 7's for Identifying Children at Low-risk for Lyme Meningitis. Pediatr Infect Dis J 2021; 40:306-309. [PMID: 33710975 DOI: 10.1097/inf.0000000000003003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Rule of 7's classifies children as low-risk for Lyme meningitis with the absence of the following: ≥7 days of headache, any cranial neuritis or ≥70% cerebrospinal fluid mononuclear cells. We sought to broadly validate this clinical prediction rule in children with meningitis undergoing evaluation for Lyme disease. METHODS We performed a patient-level data meta-analysis of 2 prospective and 2 retrospective cohorts of children ≤21 years of age with cerebrospinal fluid pleocytosis who underwent evaluation for Lyme disease. We defined a case of Lyme meningitis with a positive 2-tier serology result (positive or equivocal first-tier enzyme immunoassay followed by a positive supplemental immunoblot). We applied the Rule of 7's and report the accuracy for the identification of Lyme meningitis. RESULTS Of 721 included children with meningitis, 178 had Lyme meningitis (24.7%) and 543 had aseptic meningitis (75.3%). The pooled data from the 4 studies showed the Rule of 7's has a sensitivity of 98% [95% confidence interval (CI): 89%-100%, I2 = 71%], specificity 40% (95% CI: 30%-50%, I2 = 75%), and a negative predictive value of 100% (95% CI: 95%-100%, I2 = 55%). CONCLUSIONS The Rule of 7's accurately identified children with meningitis at low-risk for Lyme meningitis for whom clinicians should consider outpatient management while awaiting Lyme disease test results.
Collapse
Affiliation(s)
- Aris Garro
- From the Pediatrics and Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island
| | - Robert A Avery
- Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Keri A Cohn
- Pediatric Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Desiree N Neville
- Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Fran Balamuth
- Pediatric Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael N Levas
- Pediatric Emergency Medicine, Wisconsin Children's Hospital, Milwaukee, Wisconsin
| | - Jonathan E Bennett
- Pediatric Emergency Medicine, Nemours/A.I. DuPont Hospital for Children, Wilmington, Delaware
| | - Anupam B Kharbanda
- Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Michael C Monuteaux
- Pediatric Emergency Medicine, Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Lise E Nigrovic
- Pediatric Emergency Medicine, Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| |
Collapse
|
43
|
McLaren SH, Cruz AT, Yen K, Lipshaw MJ, Bergmann KR, Mistry RD, Gutman CK, Ahmad FA, Pruitt CM, Thompson GC, Steimle MD, Zhao X, Schuh AM, Thompson AD, Hanson HR, Ulrich SL, Meltzer JA, Dunnick J, Schmidt SM, Nigrovic LE, Waseem M, Velasco R, Ali S, Cullen DL, Gomez B, Kaplan RL, Khanna K, Strutt J, Aronson PL, Taneja A, Sheridan DC, Chen CC, Bogie AL, Wang A, Dayan PS. Invasive Bacterial Infections in Afebrile Infants Diagnosed With Acute Otitis Media. Pediatrics 2021; 147:peds.2020-1571. [PMID: 33288730 DOI: 10.1542/peds.2020-1571] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM). METHODS We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect. RESULTS Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%-1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%-3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%-1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures (P < .001) or CSF cultures (P < .001) obtained. CONCLUSION Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable.
Collapse
Affiliation(s)
- Son H McLaren
- Department of Emergency Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York;
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kenneth Yen
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Kelly R Bergmann
- Department of Emergency Services, Children's Minnesota, Minneapolis, Minnesota
| | - Rakesh D Mistry
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | | | - Fahd A Ahmad
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | | | - Graham C Thompson
- Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Matthew D Steimle
- Department of Pediatrics, Division of Pediatric Emergency Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Xian Zhao
- Department of Pediatrics, Division of Emergency Medicine, Children's National Health System, Washington, DC
| | - Abigail M Schuh
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Amy D Thompson
- Department of Pediatrics, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Holly R Hanson
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Stacey L Ulrich
- Department of Pediatrics, Rady Children's Hospital San Diego, San Diego, California
| | - James A Meltzer
- Department of Pediatrics, Jacobi Medical Center, Bronx, New York
| | - Jennifer Dunnick
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Suzanne M Schmidt
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Muhammad Waseem
- Department of Pediatrics and Emergency Medicine, Lincoln Medical Center, Bronx, New York
| | - Roberto Velasco
- Pediatric Emergency Unit, Rio Hortega University Hospital, Valladolid, Spain
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Danielle L Cullen
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Borja Gomez
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain
| | - Ron L Kaplan
- Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Kajal Khanna
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Jonathan Strutt
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Ankita Taneja
- Department of Pediatrics, University of Florida, Jacksonville, Jacksonville, Florida
| | - David C Sheridan
- Department of Emergency Medicine and Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Carol C Chen
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California
| | - Amanda L Bogie
- Department of Pediatrics, University of Oklahoma, Oklahoma City, Oklahoma; and
| | - Aijin Wang
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Peter S Dayan
- Department of Emergency Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | | |
Collapse
|
44
|
Schutzman SA, Nigrovic LE, Mannix R. The Infant Scalp Score: A Validated Tool to Stratify Risk of Traumatic Brain Injury in Infants With Isolated Scalp Hematoma. Acad Emerg Med 2021; 28:92-97. [PMID: 32673432 DOI: 10.1111/acem.14087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 06/23/2020] [Accepted: 07/11/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective was to validate the previously derived Infant Scalp Score (ISS) that uses clinical signs in infants with isolated scalp hematoma (ISH) after head trauma to stratify risk for clinically important traumatic brain injury (ciTBI) or TBI on computed tomography (CT). METHODS Using the publicly available Pediatric Emergency Care Applied Research Network TBI data set, we selected infants ≤ 1 year with GCS 14 to 15 who had ISH (defined as hematoma without other signs/symptoms of TBI). CT scans were obtained at the treating physician's discretion. We calculated ISS based on age, hematoma size, and location (range = 0-8) for each patient and calculated the sensitivity and specificity of the score for ciTBI and TBI on CT across a range of ISS cut-points. RESULTS We included 1,289 infants ≤ 1 year of whom 462 (36%) had CT performed. Twelve had ciTBI and 59 had TBI on CT. An ISS cutoff ≥ 4 had sensitivity of 100% for ciTBI (95% confidence interval [CI] = 0.74 to 1.0) and TBI with specificity of 0.49 (95% CI = 0.46 to 0.51). An ISS cutoff of ≥5 had a sensitivity of 100% for ciTBI (95% CI = 0.74 to 1.0) and specificity of 0.68 (95% CI = 0.66 to 0.71), but missed three infants with TBI on CT (none of whom required intervention). The receiver operating characteristic curves for clinical score to detect ciTBI and TBI had areas under the curve of 0.916 and 0.807, respectively. CONCLUSIONS The ISS accurately stratified risk for ciTBI and TBI on CT in infants with ISH and is a useful tool to help guide clinical decision making.
Collapse
Affiliation(s)
- Sara A. Schutzman
- From the Division of Emergency Medicine Boston Children's Hospital BostonMAUSA
- and the Department of Pediatrics Harvard Medical School Boston MAUSA
| | - Lise E. Nigrovic
- From the Division of Emergency Medicine Boston Children's Hospital BostonMAUSA
- and the Department of Pediatrics Harvard Medical School Boston MAUSA
| | - Rebekah Mannix
- From the Division of Emergency Medicine Boston Children's Hospital BostonMAUSA
- and the Department of Pediatrics Harvard Medical School Boston MAUSA
| |
Collapse
|
45
|
Wang ME, Neuman MI, Nigrovic LE, Pruitt CM, Desai S, DePorre AG, Sartori LF, Marble RD, Woll C, Leazer RC, Balamuth F, Rooholamini SN, Aronson PL. Characteristics of Afebrile Infants ≤60 Days of Age With Invasive Bacterial Infections. Hosp Pediatr 2020; 11:100-105. [PMID: 33318052 DOI: 10.1542/hpeds.2020-002204] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe the characteristics and outcomes of afebrile infants ≤60 days old with invasive bacterial infection (IBI). METHODS We conducted a secondary analysis of a cross-sectional study of infants ≤60 days old with IBI presenting to the emergency departments (EDs) of 11 children's hospitals from 2011 to 2016. We classified infants as afebrile if there was absence of a temperature ≥38°C at home, at the referring clinic, or in the ED. Bacteremia and bacterial meningitis were defined as pathogenic bacterial growth from a blood and/or cerebrospinal fluid culture. RESULTS Of 440 infants with IBI, 78 (18%) were afebrile. Among afebrile infants, 62 (79%) had bacteremia without meningitis and 16 (20%) had bacterial meningitis (10 with concomitant bacteremia). Five infants (6%) died, all with bacteremia. The most common pathogens were Streptococcus agalactiae (35%), Escherichia coli (16%), and Staphylococcus aureus (16%). Sixty infants (77%) had an abnormal triage vital sign (temperature <36°C, heart rate ≥181 beats per minute, or respiratory rate ≥66 breaths per minute) or a physical examination abnormality (ill appearance, full or depressed fontanelle, increased work of breathing, or signs of focal infection). Forty-three infants (55%) had ≥1 of the following laboratory abnormalities: white blood cell count <5000 or >15 000 cells per μL, absolute band count >1500 cells per μl, or positive urinalysis. Presence of an abnormal vital sign, examination finding, or laboratory test result had a sensitivity of 91% (95% confidence interval 82%-96%) for IBI. CONCLUSIONS Most afebrile young infants with an IBI had vital sign, examination, or laboratory abnormalities. Future studies should evaluate the predictive ability of these criteria in afebrile infants undergoing evaluation for IBI.
Collapse
Affiliation(s)
- Marie E Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children's Hospital Stanford and School of Medicine, Stanford University, Palo Alto, California;
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sanyukta Desai
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Adrienne G DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Laura F Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt and School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Richard D Marble
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christopher Woll
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Rianna C Leazer
- Division of Hospital Medicine, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Fran Balamuth
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Sahar N Rooholamini
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and School of Medicine, University of Washington, Seattle, Washington
| | | | | |
Collapse
|
46
|
Myers SR, Glaser NS, Trainor JL, Nigrovic LE, Garro A, Tzimenatos L, Quayle KS, Kwok MY, Rewers A, Stoner MJ, Schunk JE, McManemy JK, Brown KM, DePiero AD, Olsen CS, Casper TC, Ghetti S, Kuppermann N. Frequency and Risk Factors of Acute Kidney Injury During Diabetic Ketoacidosis in Children and Association With Neurocognitive Outcomes. JAMA Netw Open 2020; 3:e2025481. [PMID: 33275152 PMCID: PMC7718599 DOI: 10.1001/jamanetworkopen.2020.25481] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Acute kidney injury (AKI) occurs commonly during diabetic ketoacidosis (DKA) in children, but the underlying mechanisms and associations are unclear. OBJECTIVE To investigate risk factors for AKI and its association with neurocognitive outcomes in pediatric DKA. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a secondary analysis of data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in DKA Study, a prospective, multicenter, randomized clinical trial comparing fluid protocols for pediatric DKA in 13 US hospitals. Included DKA episodes occurred among children age younger than 18 years with blood glucose 300 mg/dL or greater and venous pH less than 7.25 or serum bicarbonate level less than 15 mEq/L. EXPOSURES DKA requiring intravenous insulin therapy. MAIN OUTCOMES AND MEASURES AKI occurrence and stage were assessed using serum creatinine measurements using Kidney Disease: Improving Global Outcomes criteria. DKA episodes with and without AKI were compared using univariable and multivariable methods, exploring associated factors. RESULTS Among 1359 DKA episodes (mean [SD] patient age, 11.6 [4.1] years; 727 [53.5%] girls; 651 patients [47.9%] with new-onset diabetes), AKI occurred in 584 episodes (43%; 95% CI, 40%-46%). A total of 252 AKI events (43%; 95% CI, 39%-47%) were stage 2 or 3. Multivariable analyses identified older age (adjusted odds ratio [AOR] per 1 year, 1.05; 95% CI, 1.00-1.09; P = .03), higher initial serum urea nitrogen (AOR per 1 mg/dL increase, 1.14; 95% CI, 1.11-1.18; P < .001), higher heart rate (AOR for 1-SD increase in z-score, 1.20; 95% CI, 1.09-1.32; P < .001), higher glucose-corrected sodium (AOR per 1 mEq/L increase, 1.03; 95% CI, 1.00-1.06; P = .001) and glucose concentrations (AOR per 100 mg/dL increase, 1.19; 95% CI, 1.07-1.32; P = .001), and lower pH (AOR per 0.1 increase, 0.63; 95% CI, 0.51-0.78; P < .001) as variables associated with AKI. Children with AKI, compared with those without, had lower scores on tests of short-term memory during DKA (mean [SD] digit span recall: 6.8 [2.4] vs 7.6 [2.2]; P = .02) and lower mean (SD) IQ scores 3 to 6 months after recovery from DKA (100.0 [12.2] vs 103.5 [13.2]; P = .005). Differences persisted after adjusting for DKA severity and demographic factors, including socioeconomic status. CONCLUSIONS AND RELEVANCE These findings suggest that AKI may occur more frequently in children with greater acidosis and circulatory volume depletion during DKA and may be part of a pattern of multiple organ injury involving the kidneys and brain.
Collapse
Affiliation(s)
- Sage R. Myers
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nicole S. Glaser
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jennifer L. Trainor
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Aris Garro
- Department of Emergency Medicine, Rhode Island Hospital, Providence
- Department of Pediatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Kimberly S. Quayle
- Division of Emergency Medicine, St Louis Children’s Hospital, St Louis, Missouri
- Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Maria Y. Kwok
- Division of Emergency Medicine, NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Arleta Rewers
- Division of Emergency Medicine, Colorado Children’s Hospital, Denver
- Department of Pediatrics, University of Colorado–Denver School of Medicine, Aurora
| | - Michael J. Stoner
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus
| | - Jeff E. Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Julie K. McManemy
- Division of Emergency Medicine, Texas Children’s Hospital, Houston
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kathleen M. Brown
- Division of Emergency Medicine, Children’s National Medical Center, Washington, District of Columbia
- Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Andrew D. DePiero
- Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - T. Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Simona Ghetti
- Department of Psychology, UC Davis Health, University of California School of Medicine, Sacramento
| | - Nathan Kuppermann
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| |
Collapse
|
47
|
Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America, American Academy of Neurology, and American College of Rheumatology: 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Neurology 2020; 96:262-273. [PMID: 33257476 DOI: 10.1212/wnl.0000000000011151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 06/05/2020] [Indexed: 11/15/2022] Open
Abstract
This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.
Collapse
Affiliation(s)
- Paul M Lantos
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla.
| | - Jeffrey Rumbaugh
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Linda K Bockenstedt
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Yngve T Falck-Ytter
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Maria E Aguero-Rosenfeld
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Paul G Auwaerter
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Kelly Baldwin
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Raveendhara R Bannuru
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Kiran K Belani
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - William R Bowie
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - John A Branda
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - David B Clifford
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Francis J DiMario
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - John J Halperin
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Peter J Krause
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Valery Lavergne
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Matthew H Liang
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - H Cody Meissner
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Lise E Nigrovic
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - James Jay J Nocton
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Mikala C Osani
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Amy A Pruitt
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Jane Rips
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Lynda E Rosenfeld
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Margot L Savoy
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Sunil K Sood
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Allen C Steere
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Franc Strle
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Robert Sundel
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Jean Tsao
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Elizaveta E Vaysbrot
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Gary P Wormser
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Lawrence S Zemel
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| |
Collapse
|
48
|
Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Cody Meissner H, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Arthritis Care Res (Hoboken) 2020; 73:1-9. [PMID: 33251700 DOI: 10.1002/acr.24495] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 06/04/2020] [Accepted: 10/16/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Kiran K Belani
- Children's Hospital and Clinics of Minnesota, Minneapolis
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jane Rips
- Consumer Representative, Omaha, Nebraska
| | | | | | | | | | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Jean Tsao
- Michigan State University, East Lansing
| | | | | | | |
Collapse
|
49
|
Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Cody Meissner H, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Arthritis Rheumatol 2020; 73:12-20. [PMID: 33251716 DOI: 10.1002/art.41562] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 06/04/2020] [Accepted: 10/16/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Kiran K Belani
- Children's Hospital and Clinics of Minnesota, Minneapolis
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jane Rips
- Consumer Representative, Omaha, Nebraska
| | | | | | | | | | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Jean Tsao
- Michigan State University, East Lansing
| | | | | | | |
Collapse
|
50
|
Yankova LC, Neuman MI, Wang ME, Woll C, DePorre AG, Desai S, Sartori LF, Nigrovic LE, Pruitt CM, Marble RD, Leazer RC, Rooholamini SN, Balamuth F, Aronson PL. Febrile Infants ≤60 Days Old With Positive Urinalysis Results and Invasive Bacterial Infections. Hosp Pediatr 2020; 10:1120-1125. [PMID: 33239319 DOI: 10.1542/hpeds.2020-000638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES We aimed to describe the clinical and laboratory characteristics of febrile infants ≤60 days old with positive urinalysis results and invasive bacterial infections (IBI). METHODS We performed a planned secondary analysis of a retrospective cohort study of febrile infants ≤60 days old with IBI who presented to 11 emergency departments from July 1, 2011, to June 30, 2016. For this subanalysis, we included infants with IBI and positive urinalysis results. We analyzed the sensitivity of high-risk past medical history (PMH) (prematurity, chronic medical condition, or recent antimicrobial receipt), ill appearance, and/or abnormal white blood cell (WBC) count (<5000 or >15 000 cells/μL) for identification of IBI. RESULTS Of 148 febrile infants with positive urinalysis results and IBI, 134 (90.5%) had bacteremia without meningitis and 14 (9.5%) had bacterial meningitis (11 with concomitant bacteremia). Thirty-five infants (23.6%) with positive urinalysis results and IBI did not have urinary tract infections. The presence of high-risk PMH, ill appearance, and/or abnormal WBC count had a sensitivity of 53.4% (95% confidence interval: 45.0-61.6) for identification of IBI. Of the 14 infants with positive urinalysis results and concomitant bacterial meningitis, 7 were 29 to 60 days old. Six of these 7 infants were ill-appearing or had an abnormal WBC count. The other infant had bacteremia with cerebrospinal fluid pleocytosis after antimicrobial pretreatment and was treated for meningitis. CONCLUSIONS The sensitivity of high-risk PMH, ill appearance, and/or abnormal WBC count is suboptimal for identifying febrile infants with positive urinalysis results at low risk for IBI. Most infants with positive urinalysis results and bacterial meningitis are ≤28 days old, ill-appearing, or have an abnormal WBC count.
Collapse
Affiliation(s)
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Marie E Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Lucile Packard Children's Hospital Stanford, School of Medicine, Stanford University, Palo Alto, California
| | | | - Adrienne G DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Sanyukta Desai
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Laura F Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard D Marble
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rianna C Leazer
- Division of Hospital Medicine, Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Sahar N Rooholamini
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and School of Medicine, University of Washington, Seattle, Washington; and
| | - Fran Balamuth
- Division of Emergency Medicine and Center for Pediatric Clinical Effectiveness, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul L Aronson
- Departments of Pediatrics and .,Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| |
Collapse
|