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Bryant MC, Massingham LJ, Yalcindag A. Inflammatory Arthritis in a 19-month-old with Von Hippel-Lindau Disease. R I Med J (2013) 2023; 106:30-33. [PMID: 37195158] [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] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Von Hippel-Lindau disease (VHL) is a rare autosomal dominant disease characterized by progressive development of cysts and tumors. Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disorder and the most common arthritis in children. Although the mechanism of pathogenesis is not fully understood, JIA is thought to be a polygenic, autoimmune-mediated disease. Inherited or acquired disorders resulting in immune dysregulation can lead to neoplastic and autoimmune disease, but very few cases of patients with VHL and concomitant autoimmune disease are reported in the literature. Herein, we describe, to the best of our knowledge, the first reported case of a child with VHL and inflammatory arthritis, and we discuss three possible pathophysiologic mechanisms that could link VHL and JIA. Understanding the shared pathophysiology and genetics of both diseases may help guide future direction of targeted therapies and lead to improved clinical outcomes.
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Affiliation(s)
- Maria C Bryant
- Hasbro Children's Hospital, Providence, RI; Warren Alpert Medical School of Brown University
| | - Lauren J Massingham
- Hasbro Children's Hospital, Providence, RI; Warren Alpert Medical School of Brown University
| | - Ali Yalcindag
- Hasbro Children's Hospital, Providence, RI; Warren Alpert Medical School of Brown University
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Bryant MC, Terry Spencer L, Yalcindag A. Letter to the editor: Response to "COVID-19 associated pediatric vasculitis: A systematic review and detailed analysis of the pathogenesis" by Batu et al. Semin Arthritis Rheum 2022; 57:152092. [PMID: 36152462 PMCID: PMC9458777 DOI: 10.1016/j.semarthrit.2022.152092] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Maria C Bryant
- Department of Pediatrics, Hasbro Children's Hospital, Brown University, Providence, RI 02903, USA.
| | - L Terry Spencer
- Division of Pediatric Pulmonology, Department of Pediatrics, Hasbro Children's Hospital, Brown University, Providence, RI 02903, USA
| | - Ali Yalcindag
- Division of Pediatric Rheumatology, Department of Pediatrics, Hasbro Children's Hospital, Brown University, Providence, RI 02903, USA
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Bryant MC, Spencer LT, Yalcindag A. A case of ANCA-associated vasculitis in a 16-year-old female following SARS-COV-2 infection and a systematic review of the literature. Pediatr Rheumatol Online J 2022; 20:65. [PMID: 35964067 PMCID: PMC9375072 DOI: 10.1186/s12969-022-00727-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/30/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare form of vasculitis in children. SARS-CoV-2, the virus that causes COVID-19 infection, seems to trigger autoimmunity and new-onset autoimmune disease in pediatric and adult patients. We present a case of new-onset AAV following COVID-19 infection in an adolescent patient, and we review the literature of AAV following COVID-19 infection. CASE PRESENTATION An adolescent female with a history of asthma was diagnosed with mild COVID-19 infection and subsequently developed persistent cough, wheezing, hearing loss, arthralgias, and rash. Her imaging and laboratory workup showed pulmonary nodules and cavitary lesions, elevated inflammatory markers, negative infectious testing, and positive ANCA. She was treated with glucocorticoids, rituximab, and mycophenolate mofetil. At six-month follow-up, she had improvement in her symptoms, pulmonary function tests, imaging findings, and laboratory markers. CONCLUSIONS We report the second case of new-onset anti-PR3, C-ANCA vasculitis and the fourth case of pediatric-onset AAV following COVID-19 infection. A systematic review of the literature found 6 cases of new-onset AAV in adults after COVID-19 infection. Pediatric and adult patients who develop AAV post COVID-19 infection have few, if any, comorbidities, and show marked radiographic and symptomatic improvement after treatment. There is increasing evidence for COVID-19-induced autoimmunity in children and our case highlights the importance of considering AAV in a child following a recent COVID-19 infection because timely treatment may improve clinical outcomes.
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Affiliation(s)
- Maria C. Bryant
- grid.40263.330000 0004 1936 9094Department of Pediatrics Hasbro Children’s Hospital Warren Alpert Medical School Brown University, 02903 Providence, RI USA
| | - L. Terry Spencer
- grid.40263.330000 0004 1936 9094Division of Pediatric Pulmonology, Department of Pediatrics Hasbro Children’s Hospital Warren Alpert Medical School Brown University, 02903 Providence, RI USA
| | - Ali Yalcindag
- grid.40263.330000 0004 1936 9094Division of Pediatric Rheumatology, Department of Pediatrics Hasbro Children’s Hospital Warren Alpert Medical School Brown University, 02903 Providence, RI USA
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Nakamura MM, Toomey SL, Zaslavsky AM, Petty CR, Lin C, Savova GK, Rose S, Brittan MS, Lin JL, Bryant MC, Ashrafzadeh S, Schuster MA. Potential Impact of Initial Clinical Data on Adjustment of Pediatric Readmission Rates. Acad Pediatr 2019; 19:589-598. [PMID: 30470563 PMCID: PMC6788282 DOI: 10.1016/j.acap.2018.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/09/2018] [Accepted: 09/17/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Comparison of readmission rates requires adjustment for case-mix (ie, differences in patient populations), but previously only claims data were available for this purpose. We examined whether incorporation of relatively readily available clinical data improves prediction of pediatric readmissions and thus might enhance case-mix adjustment. METHODS We examined 30-day readmissions using claims and electronic health record data for patients ≤18 years and 29 days of age who were admitted to 3 children's hospitals from February 2011 to February 2014. Using the Pediatric All-Condition Readmission Measure and starting with a model including age, gender, chronic conditions, and primary diagnosis, we examined whether the addition of initial vital sign and laboratory data improved model performance. We employed machine learning to evaluate the same variables, using the L2-regularized logistic regression with cost-sensitive learning and convolutional neural network. RESULTS Controlling for the core model variables, low red blood cell count and mean corpuscular hemoglobin concentration and high red cell distribution width were associated with greater readmission risk, as were certain interactions between laboratory and chronic condition variables. However, the C-statistic (0.722 vs 0.713) and McFadden's pseudo R2 (0.085 vs 0.076) for this and the core model were similar, suggesting minimal improvement in performance. In machine learning analyses, the F-measure (harmonic mean of sensitivity and positive predictive value) was similar for the best-performing model (containing all variables) and core model (0.250 vs 0.243). CONCLUSIONS Readily available clinical variables do not meaningfully improve the prediction of pediatric readmissions and would be unlikely to enhance case-mix adjustment unless their distributions varied widely across hospitals.
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Affiliation(s)
- Mari M. Nakamura
- Division of General Pediatrics, Boston Children’s Hospital,Division of Infectious Diseases, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Sara L. Toomey
- Division of General Pediatrics, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Carter R. Petty
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital
| | - Chen Lin
- Informatics Program, Boston Children’s Hospital
| | - Guergana K. Savova
- Informatics Program, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Sherri Rose
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Mark S. Brittan
- Department of Pediatrics, Children’s Hospital Colorado, Aurora
| | - Jody L. Lin
- Department of Pediatrics, Stanford School of Medicine, Stanford, Calif
| | | | | | - Mark A. Schuster
- Division of General Pediatrics, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, Mass,Kaiser Permanente School of Medicine, Pasadena, Calif
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Nakamura MM, Zaslavsky AM, Toomey SL, Petty CR, Bryant MC, Geanacopoulos AT, Jha AK, Schuster MA. Pediatric Readmissions After Hospitalizations for Lower Respiratory Infections. Pediatrics 2017; 140:peds.2016-0938. [PMID: 28771405 DOI: 10.1542/peds.2016-0938] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Lower respiratory infections (LRIs) are among the most common reasons for pediatric hospitalization and among the diagnoses with the highest number of readmissions. Characterizing LRI readmissions would help guide efforts to prevent them. We assessed variation in pediatric LRI readmission rates, risk factors for readmission, and readmission diagnoses. METHODS We analyzed 2008-2009 Medicaid Analytic eXtract data for patients <18 years of age in 26 states. We identified LRI hospitalizations based on a primary diagnosis of bronchiolitis, influenza, or community-acquired pneumonia or a secondary diagnosis of one of these LRIs plus a primary diagnosis of asthma, respiratory failure, or sepsis/bacteremia. Readmission rates were calculated as the proportion of hospitalizations followed by ≥1 unplanned readmission within 30 days. We used logistic regression with fixed effects for patient characteristics and a hospital random intercept to case-mix adjust rates and assess risk factors. RESULTS Of 150 590 LRI hospitalizations, 8233 (5.5%) were followed by ≥1 readmission. The median adjusted hospital readmission rate was 5.2% (interquartile range: 5.1%-5.4%), and rates varied across hospitals (P < .0001). Infants (patients <1 year of age), boys, and children with chronic conditions were more likely to be readmitted. The most common primary diagnoses on readmission were LRIs (48.2%), asthma (10.0%), fluid/electrolyte disorders (3.4%), respiratory failure (3.3%), and upper respiratory infections (2.7%). CONCLUSIONS LRI readmissions are common and vary across hospitals. Multiple risk factors are associated with readmission, indicating potential targets for strategies to reduce readmissions. Readmission diagnoses sometimes seem related to the original LRI.
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Affiliation(s)
- Mari M Nakamura
- Divisions of General Pediatrics and .,Infectious Diseases, and.,Departments of Pediatrics and
| | | | - Sara L Toomey
- Divisions of General Pediatrics and.,Departments of Pediatrics and
| | - Carter R Petty
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Ashish K Jha
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts.,Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and.,Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Mark A Schuster
- Divisions of General Pediatrics and.,Departments of Pediatrics and
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Berry JG, Zaslavsky AM, Toomey SL, Chien AT, Jang J, Bryant MC, Klein DJ, Kaplan WJ, Schuster MA. Recognizing Differences in Hospital Quality Performance for Pediatric Inpatient Care. Pediatrics 2015; 136:251-62. [PMID: 26169435 PMCID: PMC4516938 DOI: 10.1542/peds.2014-3131] [Citation(s) in RCA: 15] [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] [Accepted: 05/28/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hospital quality-of-care measures are publicly reported to inform consumer choice and stimulate quality improvement. The number of hospitals and states with enough pediatric hospital discharges to detect worse-than-average inpatient care remains unknown. METHODS This study was a retrospective analysis of hospital discharges for children aged 0 to 17 years from 3974 hospitals in 44 states in the 2009 Kids' Inpatient Database. For 11 measures of all-condition or condition-specific quality, we assessed the number of hospitals and states that met a "power standard" of 80% power for a 5% level significance test to detect when care is 20% worse than average over a 3-year period. For this assessment, we approximated volume as 3 times actual 2009 admission volumes. RESULTS For all-condition quality, 1380 hospitals (87% of all pediatric discharges) and all states met the power standard for the family experience-of-care measure; 1958 hospitals (95% of discharges) and all states met the standard for adverse drug events. For condition-specific quality measures of asthma, birth, and mental health, 203 to 482 hospitals (52%-90% of condition-specific discharges) met the power standard and 40 to 44 states met the standard. One hospital and 16 states met the standard for sickle cell disease. No hospital and ≤27 states met the standard for the remaining measures studied (appendectomy, cerebrospinal fluid shunt surgery, gastroenteritis, heart surgery, and seizure). CONCLUSIONS Most children are admitted to hospitals in which all-condition measures of quality have adequate power to show modest differences in performance from average, but most condition-specific measures do not. Policies regarding incentives for pediatric inpatient quality should take these findings into account.
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Affiliation(s)
- Jay G. Berry
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Sara L. Toomey
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
| | - Alyna T. Chien
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
| | - Jisun Jang
- Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts; and
| | | | | | | | - Mark A. Schuster
- Division of General Pediatrics, and,Division of General Pediatrics, Department of Medicine, and
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Nakamura MM, Toomey SL, Zaslavsky AM, Berry JG, Lorch SA, Jha AK, Bryant MC, Geanacopoulos AT, Loren SS, Pain D, Schuster MA. Measuring pediatric hospital readmission rates to drive quality improvement. Acad Pediatr 2014; 14:S39-46. [PMID: 25169456 DOI: 10.1016/j.acap.2014.06.012] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 06/13/2014] [Accepted: 06/18/2014] [Indexed: 01/19/2023]
Abstract
The Pediatric Quality Measures Program is developing readmission measures for pediatric use. We sought to describe the importance of readmissions in children and the challenges of developing readmission quality measures. We consider findings and perspectives from research studies and commentaries in the pediatric and adult literature, characterizing arguments for and against using readmission rates as measures of pediatric quality and discussing available evidence and current knowledge gaps. The major topic of debate regarding readmission rates as pediatric quality measures is the relative influence of hospital quality versus other factors within and outside of health systems on readmission risk. The complex causation of readmissions leads to disagreement, particularly when rates are publicly reported or tied to payment, about whether readmissions can be prevented and how to achieve fair comparisons of readmission performance. Despite these controversies, the policy focus on readmissions has motivated widespread efforts by hospitals and outpatient providers to evaluate and reengineer care processes. Many adult studies demonstrate a link between successful initiatives to improve quality and reductions in readmissions. More research is needed on methods to enhance adjustment of readmission rates and on how to prevent pediatric readmissions.
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Affiliation(s)
- Mari M Nakamura
- Division of General Pediatrics, Boston Children's Hospital, Boston, Mass; Division of Infectious Diseases, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass.
| | - Sara L Toomey
- Division of General Pediatrics, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, Mass
| | - Scott A Lorch
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pa; Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ashish K Jha
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass; Division of General Medicine, Brigham and Women's Hospital, Boston, Mass; Veterans Affairs Boston Healthcare System, Boston, Mass
| | - Maria C Bryant
- Division of General Pediatrics, Boston Children's Hospital, Boston, Mass
| | | | - Samuel S Loren
- Division of General Pediatrics, Boston Children's Hospital, Boston, Mass
| | - Debanjan Pain
- Division of General Pediatrics, Boston Children's Hospital, Boston, Mass
| | - Mark A Schuster
- Division of General Pediatrics, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
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Abstract
The effectiveness of two procedures for promoting the generalization of adaptive skills across settings by mentally retarded clients was evaluated. Participants were 10 mentally retarded clients of a community day training center. Observations of self-care and domestic skills acquired at the center were conducted at home, on the percentage of steps of each skill task analysis completed correctly. Parents of one group received written instructions describing how to practice the skills with their offspring at home. A second group received remediation training at home by center staff. A multiple-baseline design across participants and behaviors was used to evaluate the effectiveness of the two procedures. In addition, a cost analysis of each procedure was conducted. Results indicated that the parent report and home remediation procedures were both effective in increasing correct skill completion. However, the home remediation procedure cost more, with increased costs attributed to training time. The parent report procedure was, therefore, the preferred procedure.
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Abstract
A multielement design was employed to evaluate the comparative effects of contingent music and contingent-interrupted music procedures. Two profoundly mentally retarded children who attended a community day training center participated. During the contingent music procedure, access to brief periods of listening to music was contingent upon the display of a specified criterion of appropriate behavior. Alternately, during the contingent-interrupted music procedure, access to music was provided at the beginning of the session, and it remained on until an inappropriate behavior occurred. The two procedures were implemented to decrease crying and increase unsupported sitting. The multielement design required that each procedure and a baseline condition be alternated across sessions. Results demonstrated that the contingent-interrupted music procedure was more effective for both reducing crying and increasing proper sitting. Implications for research with music as a reinforcer were discussed.
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