1
|
Liang KWH, Lee JH, Qadri SK, Nadarajan J, Caporal P, Roa G JD, González-Dambrauskas S, Abbas Q, Kazzaz Y, Chong SL. Differences in clinical outcomes and resource utilization in pediatric traumatic brain injury between countries of different sociodemographic indices. J Neurosurg Pediatr 2024; 33:461-468. [PMID: 38364231 DOI: 10.3171/2024.1.peds23306] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 01/18/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVE The burden of traumatic brain injury (TBI) is disproportionately high in low- and middle-income countries (LMICs). This study aimed to compare clinical outcomes and healthcare utilization for children with moderate to severe TBIs between LMICs and non-LMICs in Asia and Latin America. METHODS The authors performed an observational multicenter study from January 2014 to February 2023 among children with moderate to severe TBIs admitted to participating pediatric intensive care units (PICUs) in the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) and Red Colaborativa Pediátrica de Latinoamérica (LARed Network). They classified sites according to their 2019 sociodemographic index (SDI). Low, low-middle, and middle SDI sites were considered LMICs, while high-middle and high SDI sites were considered non-LMICs. The authors documented patient demographics and TBI management. Accounting for death, they recorded 14-day PICU-free and 28-day hospital-free days, with fewer free days indicating poorer outcome. The authors compared children who died and those who had poor functional outcomes (defined as Pediatric Cerebral Performance Category [PCPC] level of moderate disability, severe disability, or vegetative state or coma) between LMICs and non-LMICs and performed a multivariable logistic regression analysis for predicting poor functional outcomes. RESULTS In total, 771 children with TBIs were analyzed. Mortality was comparable between LMICs and non-LMICs (9.6% vs 12.9%, p = 0.146). Children with TBIs from LMICs were more likely to have a poor PCPC outcome (31.0% vs 21.3%, p = 0.004) and had fewer ICU-free days (median [IQR] 6 [0-10] days vs 8 [0-11] days, p = 0.004) and hospital-free days (median [IQR] 9 [0-18] days vs 13 [0-20] days, p = 0.007). Poor functional outcomes were associated with LMIC status (adjusted OR [aOR] 1.53, 95% CI 1.04-2.26), a lower Glasgow Coma Scale score (aOR 0.83, 95% CI 0.78-0.88), and the presence of multiple trauma (aOR 1.49, 95% CI 1.01-2.19). Children with TBIs in LMICs required greater resource utilization in the form of early intubation and mechanical ventilation (81.6% vs 73.2%, p = 0.006), use of hyperosmolar therapy (77.7% vs 63.6%, p < 0.001), and use of antiepileptic drugs (73.9% vs 53.1%, p < 0.001). CONCLUSIONS Within Asia and Latin America, children with TBIs in LMICs were more likely to have poor functional outcomes and required greater resource utilization. Further research should focus on investigating causal factors and developing targeted interventions to mitigate these disparities.
Collapse
Affiliation(s)
- Keith Wei Han Liang
- Departments of1Pediatric Medicine and
- 2SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Jan Hau Lee
- 2SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
- 3Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Syeda K Qadri
- 2SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
- 3Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - Paula Caporal
- 5Latin American Pediatric Collaborative Network (LARed Network), Buenos Aires, Argentina
- 6International Health Department-Health Systems Program, International Injury Research Unit-Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Juan D Roa G
- 7Latin American Pediatric Collaborative Network (LARed Network), Bogotá, Colombia
- 8Pediatric Critical Care Unit-Funacion Homi, Bogotá, Colombia
| | - Sebastián González-Dambrauskas
- 9Latin American Pediatric Collaborative Network (LARed Network), Montevideo, Uruguay
- 10Department of Pediatrics and Children's Intensive Care Unit of the Pereira Rossell Hospital Center, Faculty of Medicine, University of the Republic, Montevideo, Uruguay
| | - Qalab Abbas
- 11Aga Khan University, Karachi, Pakistan; and
| | - Yasser Kazzaz
- 12Department of Pediatrics, Ministry of National Guards Health Affairs; College of Medicine, King Saud bin Abdulaziz University for Health Sciences; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Shu-Ling Chong
- 2SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
- 13Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
2
|
Florin TA, Freedman SB, Xie J, Funk AL, Tancredi DJ, Kim K, Neuman MI, Yock-Corrales A, Bergmann KR, Breslin KA, Finkelstein Y, Ahmad FA, Avva UR, Lunoe MM, Chaudhari PP, Shah NP, Plint AC, Sabhaney VJ, Sethuraman U, Gardiner MA, Sartori LF, Wright B, Navanandan N, Mintegi S, Gangoiti I, Borland ML, Chong SL, Kwok MY, Eckerle M, Poonai N, Romero CMA, Waseem M, Nebhrajani JR, Bhatt M, Caperell K, Campos C, Becker SM, Morris CR, Rogers AJ, Kam AJ, Pavlicich V, Palumbo L, Dalziel SR, Morrison AK, Rino PB, Cherry JC, Salvadori MI, Ambroggio L, Klassen TP, Payne DC, Malley R, Simon NJ, Kuppermann N. Features Associated With Radiographic Pneumonia in Children with SARS-CoV-2. J Pediatric Infect Dis Soc 2024; 13:257-259. [PMID: 38391389 DOI: 10.1093/jpids/piae015] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Indexed: 02/24/2024]
Abstract
14% of children with SARS-CoV-2 infections had radiographic pneumonia. Hypoxemia, cough, higher temperature, and older age were associated with pneumonias. In children tested, SARS-CoV-2 test results were not associated with radiographic pneumonia.
Collapse
Affiliation(s)
- Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jianling Xie
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Anna L Funk
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Kelly Kim
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Adriana Yock-Corrales
- Department of Emergency Medicine, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera", CCSS, San José, Costa Rica
| | - Kelly R Bergmann
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, USA
| | - Kristen A Breslin
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Yaron Finkelstein
- Divisions of Emergency Medicine, and Clinical Pharmacology and Toxicology, Department of Pediatrics Hospital for Sick Children, Toronto, Canada
| | - Fahd A Ahmad
- Department of Pediatrics, Washington University School of Medicine, St. Louis, USA
| | - Usha R Avva
- Department of Emergency Medicine, Montefiore-Nyack Hospital, Nyack, New York, USA
| | - Maren M Lunoe
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California, Los Angeles, USA
| | - Nipam P Shah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, USA
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Vikram J Sabhaney
- Department of Paediatrics, University of British Columbia, Vancouver, Canada
| | - Usha Sethuraman
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, USA
| | - Michael A Gardiner
- Department of Pediatrics, Rady Children's Hospital, University of California San Diego, San Diego, USA
| | - Laura F Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Bruce Wright
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Women's and Children's Health Research Institute, Edmonton, Canada
| | - Nidhya Navanandan
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, USA
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Iker Gangoiti
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Meredith L Borland
- Divisions of Emergency Medicine and Paediatrics, School of Medicine, Perth Children's Hospital, University of Western Australia, Perth, Australia
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Pediatrics Academic Clinical Programme, Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Maria Y Kwok
- Department of Emergency Medicine, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, NY, New York, USA
| | - Michelle Eckerle
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital, Cincinnati, USA
| | - Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, Canada
| | | | - Muhammad Waseem
- Department of Pediatrics, Lincoln Medical Center, New York City, Bronx, New York, USA
| | | | - Maala Bhatt
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Kerry Caperell
- Division of Emergency Medicine, Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, USA
| | - Carmen Campos
- Pediatric Emergency Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Sarah M Becker
- Department of Pediatrics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, USA
| | - Claudia R Morris
- Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, USA
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan School of Medicine, Ann Arbor, USA
| | - April J Kam
- Division of Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, Hamilton, Canada
| | - Viviana Pavlicich
- Departamento de Emergencia Pediátrica, Facultad de Medicina, Hospital General Pediátrico Niños de Acosta Ñu, Universidad Privada del Pacífico, San Lorenzo, Paraguay
| | - Laura Palumbo
- Department of Pediatrics, ASST Spedali Civili di Brescia - Pronto soccorso pediatrico, Brescia, Italy
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
- Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Andrea K Morrison
- Division of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
| | - Pedro B Rino
- Department of Pediatrics, Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", RIDEPLA, Buenos Aires, Argentina
| | - Jonathan C Cherry
- Department of Pediatric Emergency Medicine, IWK Health Centre, Dalhousie University, Halifax, Canada
| | | | - Lilliam Ambroggio
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, USA
| | - Terry P Klassen
- Department of Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Canada
| | - Daniel C Payne
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Richard Malley
- Division of Infectious Diseases, Boston Children's Hospital and Harvard Medical School, Boston, USA
| | - Norma-Jean Simon
- Data Analytics and Reporting and Division of Emergency Medicine, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, USA
| |
Collapse
|
3
|
Yap SE, Wong HC, Chong SL, Ganapathy S, Ong GYK. Validation of motor component of Glasgow coma scale in lieu of total Glasgow coma scale as a pediatric trauma field triage tool. Am J Emerg Med 2024; 81:105-110. [PMID: 38733662 DOI: 10.1016/j.ajem.2024.04.031] [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: 07/11/2023] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION Prehospital trauma triage and disability assessment of pediatric patients can be challenging on the field, especially in the pre-verbal age group. It would be useful if the same triage tool and criteria can be used for both adults and children to risk-stratify the need of higher acuity of trauma care. STUDY OBJECTIVE We aimed to investigate if using only the motor component of Glasgow Coma Scale (mGCS), as a quick field trauma triage tool, was non-inferior to total GCS (tGCS), and if mGCS <6 was non-inferior to tGCS <14, in predicting the need for intensive care or mortality in the pediatric population. METHODS We performed a retrospective review of patients <18-years-old, who presented to our emergency department (ED) with moderate (Injury Severity Score (ISS) 9-15) to severe (ISS > 15) traumatic injuries from January 2012 to December 2021. Using ED triage data, mortality and the need for intensive care unit (ICU) admission were used as surrogate outcomes to investigate if mGCS <6 was non-inferior to tGCS <14, and the area-under-the-receiver-operating-characteristic curve (AUROC) was used as a measure of comparability. RESULTS Among 582 included for analysis, the median age was 7-years-old (2-12), and most were male (63.4%). 22.4% patients demised or required ICU care. mGCS <6 had an AUROC of 0.75 (95% CI 0.70 to 0.79), which was non-inferior to tGCS <14; AUROC 0.76, (95% CI 0.72 to 0.81), for identifying children requiring ICU management or demised. The results shown here were based on the AUROCs that were used to evaluate the discriminatory ability of tGCS <14 and mGCS <6 in prediction of mortality and the need for ICU care. CONCLUSION Our study showed that mGCS was significantly associated with tGCS, and was non- inferior to the latter as a triage tool in pediatric trauma. It validated the use of mGCS <6 in lieu of tGCS <14 in the pre-hospital field triage of pediatric patients, in identification of children at risk of death or requiring ICU care. Larger prospective, observational studies using on-scene data would be required for more robust validation and determine optimal cut-offs.
Collapse
Affiliation(s)
- Shiyi Eileen Yap
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.
| | | | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Sashikumar Ganapathy
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
| |
Collapse
|
4
|
Sutiman N, Yao SHW, Goh SSM, Sultana R, Chong SL. Protocol for the diagnostic performance of C reactive protein, procalcitonin and interleukin-6 for serious bacterial infections among children ≤36 months old presenting with fever without source: a systematic review and meta-analysis. BMJ Paediatr Open 2024; 8:e002237. [PMID: 38499348 PMCID: PMC10952928 DOI: 10.1136/bmjpo-2023-002237] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/01/2024] [Indexed: 03/20/2024] Open
Abstract
INTRODUCTION The management of fever without source in children ≤36 months old remains a diagnostic challenge as the underlying aetiologies can vary from self-limiting viral infections to serious bacterial infections (SBIs). Biomarkers such as C reactive protein (CRP), procalcitonin (PCT) and interleukin-6 (IL-6) have varying thresholds in the prediction of SBIs due to differences in SBI definitions, SBI prevalence, patient characteristics and timing of presentation. This protocol describes a systematic review and meta-analysis that aims to determine the thresholds at which CRP, PCT and IL-6 can perform optimally in distinguishing the presence of SBIs in children ≤36 months old, as well as to determine their performances in early detection of bacterial infections within 48 hours of fever onset. METHODS AND ANALYSIS We will systematically search electronic databases including MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane CENTRAL, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Science Citation Index from 1 July 2023 to 31 July 2023. We will include studies that report the diagnostic accuracy of CRP, PCT and IL-6 in detecting SBIs in children aged ≤36 months presenting with fever without apparent source. Randomised controlled trials (RCTs) and non-randomised studies including non-RCTs and controlled before-and-after studies will be included. A meta-analysis will be performed and diagnostic performances of these biomarkers will be reported. ETHICS AND DISSEMINATION The results of this study will provide guidance on clinical decision-making in young children presenting with fever without source. Ethics approval will not be required for this study. The authors aim to publish the findings in a peer-reviewed journal as well as present at international conferences. PROSPERO REGISTRATION NUMBER CRD42023439093.
Collapse
Affiliation(s)
- Natalia Sutiman
- Department of Emergency Medicine, Kandang Kerbau Women's and Children's Hospital, Singapore
| | | | | | - Rehena Sultana
- Center of Quantitative Medicine, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, Kandang Kerbau Women's and Children's Hospital, Singapore
- Pediatric Academic Clinical Programme, Emergency Medicine Academic Clinical Programme, SingHealth Duke-NUS, Singapore
| |
Collapse
|
5
|
Yock-Corrales A, Lee JH, Domínguez-Rojas JÁ, Caporal P, Roa JD, Fernandez-Sarmiento J, González-Dambrauskas S, Zhu Y, Abbas Q, Kazzaz Y, Dewi DS, Chong SL. A Multicenter Study on the Clinical Characteristics and Outcomes Among Children With Moderate to Severe Abusive Head Trauma. J Pediatr Surg 2024; 59:494-499. [PMID: 37867044 DOI: 10.1016/j.jpedsurg.2023.09.038] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION We aimed to identify clinical characteristics, risk factors for diagnosis, and describe outcomes among children with AHT. METHODS We performed an observational cohort study in tertiary care hospitals from 14 countries across Asia and Ibero-America. We included patients <5 years old who were admitted to participating pediatric intensive care units (PICUs) with moderate to severe traumatic brain injury (TBI). We performed descriptive analysis and multivariable logistic regression for risk factors of AHT. RESULTS 47 (12%) out of 392 patients were diagnosed with AHT. Compared to those with accidental injuries, children with AHT were more frequently < 2 years old (42, 89.4% vs 133, 38.6%, p < 0.001), more likely to arrive by private transportation (25, 53.2%, vs 88, 25.7%, p < 0.001), but less likely to have multiple injuries (14, 29.8% vs 158, 45.8%, p = 0.038). The AHT group was more likely to suffer subdural hemorrhage (SDH) (39, 83.0% vs 89, 25.8%, p < 0.001), require antiepileptic medications (41, 87.2% vs 209, 60.6%, p < 0.001), and neurosurgical interventions (27, 57.40% vs 143, 41.40%, p = 0.038). Mortality, PICU length of stay, and functional outcomes at 3 months were similar in both groups. In the multivariable logistic regression, age <2 years old (aOR 8.44, 95%CI 3.07-23.2), presence of seizures (aOR 3.43, 95%CI 1.60-7.36), and presence of SDH (aOR 9.58, 95%CI 4.10-22.39) were independently associated with AHT. CONCLUSIONS AHT diagnosis represented 12% of our TBI cohort. Overall, children with AHT required more neurosurgical interventions and the use of anti-epileptic medications. Children younger than 2 years and with SDH were independently associated with a diagnosis of AHT. TYPE OF STUDY Observational cohort study. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Adriana Yock-Corrales
- Emergency Department.Hospital Nacional de Niños ¨Dr. Carlos Sáenz Herrera. CCSS San José, Costa Rica.
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital. Singapore
| | | | - Paula Caporal
- Hospital Interzonal Especializado en Pediatría "Sor María Ludovica", Buenos Aires, Argentina
| | - Juan D Roa
- Fundación Homi, Universidad Nacional de Colombia - FUCS, Bogotá, Colombia
| | - Jaime Fernandez-Sarmiento
- Department of Critical Care Medicine and Pediatrics, Universidad de La Sabana. Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Sebastián González-Dambrauskas
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República Montevideo, Uruguay
| | - Yanan Zhu
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation. Singapore
| | - Qalab Abbas
- Department of Paediatrics and Child Health Aga Khan University Karachi Pakistan Karachi, Karachi City, Sindh, Pakistan
| | - Yasser Kazzaz
- Department of Paediatrics, Ministry of National Guards Health Affairs, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Centre Riyadh, Saudi Arabia
| | - Dianna Sri Dewi
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| |
Collapse
|
6
|
Mai G, Lee JH, Caporal P, Roa G JD, González-Dambrauskas S, Zhu Y, Yock-Corrales A, Abbas Q, Kazzaz Y, Dewi DS, Chong SL. Initial dysnatremia and clinical outcomes in pediatric traumatic brain injury: a multicenter observational study. Acta Neurochir (Wien) 2024; 166:82. [PMID: 38353785 DOI: 10.1007/s00701-024-05919-0] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/21/2023] [Indexed: 02/16/2024]
Abstract
PURPOSE We aimed to investigate the association between initial dysnatremia (hyponatremia and hypernatremia) and in-hospital mortality, as well as between initial dysnatremia and functional outcomes, among children with traumatic brain injury (TBI). METHOD We performed a multicenter observational study among 26 pediatric intensive care units from January 2014 to August 2022. We recruited children with TBI under 18 years of age who presented to participating sites within 24 h of injury. We compared demographics and clinical characteristics between children with initial hyponatremia and eu-natremia and between those with initial hypernatremia and eu-natremia. We defined poor functional outcome as a discharge Pediatric Cerebral Performance Category (PCPC) score of moderate, severe disability, coma, and death, or an increase of at least 2 categories from baseline. We performed multivariable logistic regression for mortality and poor PCPC outcome. RESULTS Among 648 children, 84 (13.0%) and 42 (6.5%) presented with hyponatremia and hypernatremia, respectively. We observed fewer 14-day ventilation-free days between those with initial hyponatremia [7.0 (interquartile range (IQR) = 0.0-11.0)] and initial hypernatremia [0.0 (IQR = 0.0-10.0)], compared to eu-natremia [9.0 (IQR = 4.0-12.0); p = 0.006 and p < 0.001]. We observed fewer 14-day ICU-free days between those with initial hyponatremia [3.0 (IQR = 0.0-9.0)] and initial hypernatremia [0.0 (IQR = 0.0-3.0)], compared to eu-natremia [7.0 (IQR = 0.0-11.0); p = 0.006 and p < 0.001]. After adjusting for age, severity, and sex, presenting hyponatremia was associated with in-hospital mortality [adjusted odds ratio (aOR) = 2.47, 95% confidence interval (CI) = 1.31-4.66, p = 0.005] and poor outcome (aOR = 1.67, 95% CI = 1.01-2.76, p = 0.045). After adjustment, initial hypernatremia was associated with mortality (aOR = 5.91, 95% CI = 2.85-12.25, p < 0.001) and poor outcome (aOR = 3.00, 95% CI = 1.50-5.98, p = 0.002). CONCLUSION Among children with TBI, presenting dysnatremia was associated with in-hospital mortality and poor functional outcome, particularly hypernatremia. Future research should investigate longitudinal sodium measurements in pediatric TBI and their association with clinical outcomes.
Collapse
Affiliation(s)
- Gawin Mai
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- SingHealth Paediatrics Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Paula Caporal
- Johns Hopkins International Injury Research Unit, Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | - Juan D Roa G
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Pediatric Intensive Care Unit, Los Cobos Medical Center, Universidad del Bosque, Ak. 9 #131a-40, Usaquén, Bogotá, Cundinamarca, Colombia
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Departamento de Pediatría y Unidad de Cuidados Intensivos, de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Bulevar Artigas 1590, Lord Ponsoby 2410, 11600, Montevideo, Uruguay
| | - Yanan Zhu
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, 23 Rochester Park, #06-01, Singapore, 139234, Singapore
| | - Adriana Yock-Corrales
- Emergency Department, National Children's Hospital "Dr. Carlos Saenz Herrera" CCSS, San José, Costa Rica
| | - Qalab Abbas
- Departments of Pediatrics and Child Health, National Stadium Road, Aga Khan University Hospital, Karachi, Karachi City, Sindh, 74800, Pakistan
| | - Yasser Kazzaz
- Department of Paediatrics, Ministry of National Guards Health Affairs, Prince Mutib Ibn Abdullah Ibn Abdulaziz Rd, Ar Rimayah, Riyadh, 11426, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdul Aziz Medical City, Jeddah, 22384, Saudi Arabia
- King Abdullah International Medical Research Centre, King Abdul Aziz Medical City, Riyadh, 22384, Saudi Arabia
| | - Dianna Sri Dewi
- KK Research Centre, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
- SingHealth Paediatrics Academic Clinical Programme, Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
| |
Collapse
|
7
|
Sim CSM, Chen H, Chong SL, Xia OJ, Chew E, Guo X, Ng LP, Ch'ng YC, Ong JLH, Tan J, Ng DCC, Tan NC, Chan YH. Corrigendum to "Primary health level screening for postpartum depression during well-child visits: Prevalence, associated risk factors, and breastfeeding" [Asian J. Psychiatry 87 (2023) 103701]. Asian J Psychiatr 2023; 90:103829. [PMID: 37939437 DOI: 10.1016/j.ajp.2023.103829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Affiliation(s)
- Cherie Sze Min Sim
- Department of Psychological Medicine, KK Women's and Children's Hospital, Singapore
| | - Helen Chen
- Department of Psychological Medicine, KK Women's and Children's Hospital, Singapore; SingHeatlth-Duke NUS Paediatric Medicine Academic Clinical Programme, Singapore.
| | - Shu-Ling Chong
- SingHeatlth-Duke NUS Paediatric Medicine Academic Clinical Programme, Singapore; Paediatric Emergency Medicine Department, KK Women's and Children's Hospital, Singapore
| | | | - Elaine Chew
- SingHeatlth-Duke NUS Paediatric Medicine Academic Clinical Programme, Singapore; Adolescent Medicine Service, KK Women's and Children's Hospital, Singapore
| | - Xiaoxuan Guo
- SingHealth Polyclinics, Singapore; SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore
| | - Lai Peng Ng
- SingHealth Polyclinics, Singapore; SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore
| | - Ying Chia Ch'ng
- Department of Psychological Medicine, KK Women's and Children's Hospital, Singapore
| | | | | | - David Chee Chin Ng
- SingHealth Polyclinics, Singapore; SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore
| | - Ngiap Chuan Tan
- SingHealth Polyclinics, Singapore; SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore
| | - Yoke Hwee Chan
- SingHeatlth-Duke NUS Paediatric Medicine Academic Clinical Programme, Singapore; Division of Medicine, KK Women's and Children's Hospital, Singapore
| |
Collapse
|
8
|
Nguyen TM, Poh KL, Chong SL, Loh SW, Heng YCK, Lee JH. The use of probabilistic graphical models in pediatric sepsis: a feasibility and scoping review. Transl Pediatr 2023; 12:2074-2089. [PMID: 38130578 PMCID: PMC10730969 DOI: 10.21037/tp-23-25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 10/24/2023] [Indexed: 12/23/2023] Open
Abstract
Background Recent research has demonstrated that machine learning (ML) has the potential to improve several aspects of medical application for critical illness, including sepsis. This scoping review aims to evaluate the feasibility of probabilistic graphical model (PGM) methods in pediatric sepsis application and describe the use of pediatric sepsis definition in these studies. Methods Literature searches were conducted in PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL+), and Web of Sciences from 2000-2023. Keywords included "pediatric", "neonates", "infants", "machine learning", "probabilistic graphical model", and "sepsis". Results A total of 3,244 studies were screened, and 72 were included in this scoping review. Sepsis was defined using positive microbiology cultures in 19 studies (26.4%), followed by the 2005's international pediatric sepsis consensus definition in 11 studies (15.3%), and Sepsis-3 definition in seven studies (9.7%). Other sepsis definitions included: bacterial infection, the international classification of diseases, clinicians' assessment, and antibiotic administration time. Among the most common ML approaches used were logistic regression (n=27), random forest (n=24), and Neural Network (n=18). PGMs were used in 13 studies (18.1%), including Bayesian classifiers (n=10), and the Markov Model (n=3). When applied on the same dataset, PGMs show a relatively inferior performance to other ML models in most cases. Other aspects of explainability and transparency were not examined in these studies. Conclusions Current studies suggest that the performance of probabilistic graphic models is relatively inferior to other ML methods. However, its explainability and transparency advantages make it a potentially viable method for several pediatric sepsis studies and applications.
Collapse
Affiliation(s)
- Tuong Minh Nguyen
- Department of Industrial Systems Engineering and Management, College of Design and Engineering, National University of Singapore, SG, Singapore
| | - Kim Leng Poh
- Department of Industrial Systems Engineering and Management, College of Design and Engineering, National University of Singapore, SG, Singapore
| | - Shu-Ling Chong
- Children’s Emergency, KK Women’s and Children’s Hospital, SG, Singapore
- SingHealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, SG, Singapore
| | - Sin Wee Loh
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, SG, Singapore
| | | | - Jan Hau Lee
- SingHealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, SG, Singapore
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, SG, Singapore
| |
Collapse
|
9
|
Tan JZ, Zhang DZ, Sundararaghavan S, Ganapathy S, Choo JTL, Rajendram MF, Chong SL. Chest pain attendances to a Paediatric Emergency Department pre- and post-COVID-19 vaccination. Transl Pediatr 2023; 12:2010-2019. [PMID: 38130582 PMCID: PMC10730957 DOI: 10.21037/tp-23-230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 10/22/2023] [Indexed: 12/23/2023] Open
Abstract
Background Introduction of the mRNA vaccination for coronavirus disease 2019 (COVID-19) has been associated with an increase in cases of peri/myocarditis. In our retrospective cross-sectional study, we aim to (I) describe paediatric chest pain attendance, and (II) study resource utilisation in the Emergency Department (ED) of KK Women's and Children's Hospital (KKH), stratified by pre-pandemic, during the pandemic pre- and post-COVID vaccination introduction in adolescents. Methods We reviewed records of adolescents aged 12 to 18 years old who presented to our ED with the triage complaint of chest pain between 1 January 2019 to 31 January 2022, and determined the attendance rates, aetiologies and resource utilisation during the above time periods. Results There were 2,418 ED attendances for chest pain in our study population. Among 887 inpatient admissions for chest pain, 1.8% were attributed to a cardiac cause. Comparing the pre-pandemic period to the period after the mRNA COVID-19 vaccination was introduced, ED chest pain rates increased from a median of 0.5% of ED attendances [interquartile range (IQR), 0.3-0.5%] to 0.9% (IQR, 0.7-2.0%) (P<0.001), while admission rates increased from a median of 26.2% of ED attendances (IQR, 24.1-29.1%) to 40.9% (IQR, 37.6-56.6%) (P<0.001). Cardiac enzyme orders among ED visits for chest pain increased from a pre-pandemic median of 0% (IQR, 0.0-2.6%) to a post-vaccination median of 26.1% (IQR, 17.2-56.2%) (P<0.001) and were due to concerns for vaccine-related myocarditis. Seven cases of probable vaccine-related myocarditis presented with chest pain to our ED. Conclusions Paediatric chest pain is largely non-cardiac in origin. ED chest pain attendance rates and resource utilisation increased after the introduction of mRNA COVID-19 vaccination in adolescents.
Collapse
Affiliation(s)
- Joyce Ziwei Tan
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Dyan Zhewei Zhang
- Cardiology Service, Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Sreekanthan Sundararaghavan
- Cardiology Service, Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Sashikumar Ganapathy
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Jonathan Tze Liang Choo
- Cardiology Service, Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | | | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| |
Collapse
|
10
|
Qadri SK, Lee JH, Zhu Y, Caporal P, Roa G JD, González-Dambrauskas S, Yock-Corrales A, Abbas Q, Kazzaz Y, Shi L, Sri Dewi D, Chong SL. A multicenter observational study on outcomes of moderate and severe pediatric traumatic brain injuries-time to reappraise thresholds for treatment. Acta Neurochir (Wien) 2023; 165:3197-3206. [PMID: 37728830 DOI: 10.1007/s00701-023-05741-0] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/22/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE Children with moderate traumatic brain injury (modTBI) (Glasgow Coma Scale (GCS) 9-13) may benefit from better stratification. We aimed to compare neurocritical care utilization and functional outcomes between children with high GCS modTBI (hmodTBI, GCS 11-13), low GCS modTBI (lmodTBI, GCS 9-10), and severe TBI (sTBI, GCS ≤ 8). We hypothesized that patients with lmodTBI have higher neurocritical care needs and worse outcomes than patients with hmodTBI and are similar to patients with sTBI. METHODS Prospective observational study from June 2018 to October 2022 in 28 pediatric intensive care units (PICU) in Asia, South America, and Europe. We included children (age < 18 years) with modTBI and sTBI admitted to PICU and measured functional outcomes at 3 months using the Glasgow Outcome Scale-Extended Pediatric Revision (GOS-E Peds, scale 1-8, 1 = upper good recovery, 8 = death). RESULTS We analyzed 409 patients: 98 (24%) and 311 (76%) with modTBI and sTBI, respectively. Patients with lmodTBI (vs. hmodTBI) were more likely to have invasive ICP monitoring (32.3% vs. 4.5%, p < 0.001), longer PICU stay (days, median [IQR]; 5.00 [4.00, 9.75] vs 4.00 [2.00, 5.00], p = 0.007), and longer hospital stay (days, median [IQR]: 13.00 [8.00, 17.00] vs. 8.00 [5.00, 12, 25], p = 0.015). Median GOS-E Peds scores were significantly different (hmodTBI (1.00 [1.00, 3.00]), lmodTBI (3.00 [IQR 2.00, 5.75]), and sTBI (5.00 [IQR 1.00, 6.00]) (p < 0.001)). After adjusting for age, sex, presence of polytrauma and cerebral edema, lmodTBI, and sTBI remained significantly associated with higher GOS-E scores (adjusted coefficient (standard error): 1.24 (0.52), p = 0.018, and 1.27 (0.33), p < 0.001, respectively) compared with hmodTBI. CONCLUSIONS Children with lmodTBI have higher rates of neurocritical care utilization and worse functional outcomes than those with hmodTBI but better than those with sTBI. Children with lmodTBI may benefit from guideline-based management similar to what is implemented in children with sTBI. This work was performed in hospitals within the PACCMAN and LARed networks. No reprints will be ordered.
Collapse
Affiliation(s)
- Syeda Kashfi Qadri
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
- Duke-NUS Medical School, SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Singapore, Singapore.
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Duke-NUS Medical School, SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Singapore, Singapore
| | - Yanan Zhu
- Department of Epidemiology, Consortium for Clinical Research and Innovation, Singapore Clinical Research Institute, Singapore, Singapore
| | - Paula Caporal
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Buenos Aires, Argentina
- Pediatric Critical Care Unit - HIAEP Sor María Ludovica, La Plata, Buenos Aires, Argentina
| | - Juan D Roa G
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Bogotá, Colombia
- Pediatric Critical Care Unit - Fundacion Homi, Bogotá, Colombia
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Departamento de Pediatría Y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de La República, Montevideo, Uruguay
| | - Adriana Yock-Corrales
- Emergency Department, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera", CCSS, San José, Costa Rica
| | | | - Yasser Kazzaz
- Department of Pediatrics, College of Medicine, Ministry of National Guards Health AffairsKing Saud Bin Abdulaziz University for Health SciencesKing Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Luming Shi
- Department of Epidemiology, Consortium for Clinical Research and Innovation, Singapore Clinical Research Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Dianna Sri Dewi
- Department of Epidemiology, Consortium for Clinical Research and Innovation, Singapore Clinical Research Institute, Singapore, Singapore
| | - Shu-Ling Chong
- Duke-NUS Medical School, SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Singapore, Singapore
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
11
|
Xie J, Kuppermann N, Florin TA, Tancredi DJ, Funk AL, Kim K, Salvadori MI, Yock-Corrales A, Shah NP, Breslin KA, Chaudhari PP, Bergmann KR, Ahmad FA, Nebhrajani JR, Mintegi S, Gangoiti I, Plint AC, Avva UR, Gardiner MA, Malley R, Finkelstein Y, Dalziel SR, Bhatt M, Kannikeswaran N, Caperell K, Campos C, Sabhaney VJ, Chong SL, Lunoe MM, Rogers AJ, Becker SM, Borland ML, Sartori LF, Pavlicich V, Rino PB, Morrison AK, Neuman MI, Poonai N, Simon NJE, Kam AJ, Kwok MY, Morris CR, Palumbo L, Ambroggio L, Navanandan N, Eckerle M, Klassen TP, Payne DC, Cherry JC, Waseem M, Dixon AC, Ferre IB, Freedman SB. Impact of SARS-CoV-2 Infection on the Association Between Laboratory Tests and Severe Outcomes Among Hospitalized Children. Open Forum Infect Dis 2023; 10:ofad485. [PMID: 37869403 PMCID: PMC10588618 DOI: 10.1093/ofid/ofad485] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/28/2023] [Indexed: 10/24/2023] Open
Abstract
Background To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations. Methods We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations. Results We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 109/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 109/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts. Conclusions Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.
Collapse
Affiliation(s)
| | - Nathan Kuppermann
- Davis School of Medicine, University of California, Sacramento, California, USA
| | - Todd A Florin
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
| | - Daniel J Tancredi
- Davis School of Medicine, University of California, Sacramento, California, USA
| | - Anna L Funk
- University of Calgary, Calgary, Alberta, Canada
| | - Kelly Kim
- University of Calgary, Calgary, Alberta, Canada
| | | | | | - Nipam P Shah
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | | | - Fahd A Ahmad
- Washington University School of Medicine, St.Louis, Missouri, USA
| | | | - Santiago Mintegi
- University of the Basque Country, UPV/EHU Bilbao, Basque Country, Spain
| | - Iker Gangoiti
- University of the Basque Country, UPV/EHU Bilbao, Basque Country, Spain
| | - Amy C Plint
- University of Ottawa, Ottawa, Ontario, Canada
| | - Usha R Avva
- Montefiore-Nyack Hospital, Nyack, NewYork, New York, USA
| | | | | | | | | | - Maala Bhatt
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | | | - Carmen Campos
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Shu-Ling Chong
- Duke-NUS Medical School, SingHealth Duke-NUS Global Health Institute, Singapore
| | - Maren M Lunoe
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Sarah M Becker
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, Utah, USA
| | | | - Laura F Sartori
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Pedro B Rino
- Hospital de Pediatría “Prof. Dr. Juan P. Garrahan,” RIDEPLA, Buenos Aires, Argentina
| | | | | | - Naveen Poonai
- Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Norma-Jean E Simon
- Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - April J Kam
- McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Maria Y Kwok
- Columbia University Irving Medical Center, NewYork, New York, USA
| | - Claudia R Morris
- Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura Palumbo
- ASST Spedali Civili di Brescia—Pronto Soccorso Pediatrico, Brescia, Italy
| | | | | | - Michelle Eckerle
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Daniel C Payne
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | | | | |
Collapse
|
12
|
Chong SL, Niu C, Ong GYK, Piragasam R, Khoo ZX, Koh ZX, Guo D, Lee JH, Ong MEH, Liu N. Febrile infants risk score at triage (FIRST) for the early identification of serious bacterial infections. Sci Rep 2023; 13:15845. [PMID: 37740004 PMCID: PMC10516995 DOI: 10.1038/s41598-023-42854-z] [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: 05/18/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023] Open
Abstract
We aimed to derive the Febrile Infants Risk Score at Triage (FIRST) to quantify risk for serious bacterial infections (SBIs), defined as bacteremia, meningitis and urinary tract infections. We performed a prospective observational study on febrile infants < 3 months old at a tertiary hospital in Singapore between 2018 and 2021. We utilized machine learning and logistic regression to derive 2 models: FIRST, based on patient demographics, vital signs and history, and FIRST + , adding laboratory results to the same variables. SBIs were diagnosed in 224/1002 (22.4%) infants. Among 994 children with complete data, age (adjusted odds ratio [aOR] 1.01 95%CI 1.01-1.02, p < 0.001), high temperature (aOR 2.22 95%CI 1.69-2.91, p < 0.001), male sex (aOR 2.62 95%CI 1.86-3.70, p < 0.001) and fever of ≥ 2 days (aOR 1.79 95%CI 1.18-2.74, p = 0.007) were independently associated with SBIs. For FIRST + , abnormal urine leukocyte esterase (aOR 16.46 95%CI 10.00-27.11, p < 0.001) and procalcitonin (aOR 1.05 95%CI 1.01-1.09, p = 0.009) were further identified. A FIRST + threshold of ≥ 15% predicted risk had a sensitivity of 81.8% (95%CI 70.5-91.0%) and specificity of 65.6% (95%CI 57.8-72.7%). In the testing dataset, FIRST + had an area under receiver operating characteristic curve of 0.87 (95%CI 0.81-0.94). These scores can potentially guide triage and prioritization of febrile infants.
Collapse
Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
- Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
| | - Chenglin Niu
- Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Rupini Piragasam
- KK Research Centre, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Zi Xean Khoo
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Department of Paediatrics, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital, 1 Hospital Crescent, Outram Road, Singapore, 169608, Singapore
| | - Dagang Guo
- Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, 1 Hospital Crescent, Outram Road, Singapore, 169608, Singapore
| | - Jan Hau Lee
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Marcus Eng Hock Ong
- Emergency Medicine Academic Clinical Programme, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, 1 Hospital Crescent, Outram Road, Singapore, 169608, Singapore
- Health Services Research Centre, Singapore Health Services, 8 College Road, Singapore, 169857, Singapore
| | - Nan Liu
- Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, 1 Hospital Crescent, Outram Road, Singapore, 169608, Singapore
- Health Services Research Centre, Singapore Health Services, 8 College Road, Singapore, 169857, Singapore
| |
Collapse
|
13
|
Sim CSM, Chen H, Chong SL, Xia OJ, Chew E, Guo X, Ng LP, Ch'ng YC, Ong JLH, Tan J, Ng DCC, Tan NC, Chan YH. Primary health level screening for postpartum depression during well-child visits: Prevalence, associated risk factors, and breastfeeding. Asian J Psychiatr 2023; 87:103701. [PMID: 37517174 DOI: 10.1016/j.ajp.2023.103701] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/14/2023] [Accepted: 07/16/2023] [Indexed: 08/01/2023]
Abstract
Postpartum depression (PPD) is a public health problem that is associated with detrimental effects on the wellbeing of the mother, child and family. Early detection for PPD at the primary health level provides an opportunity for intervention. We aim to examine: (1) the prevalence rate of PPD in the primary care population, (2) acceptance and attendance rates of intervention for women who screened positive for PPD, (3) sociodemographic and maternal risk factors of PPD, and (4) the impact of PPD on breastfeeding. We implemented a mother-child dyadic screening program using the modified Patient Health Questionnaire-2 during routine well-child visits at 2 or 3 months postpartum between July 2019 and December 2021. We performed multivariable logistic regression to identify independent risk factors for PPD and described using adjusted odds ratio (OR) with corresponding 95 % confidence intervals. Among 5561 mothers, the prevalence rate of probable PPD was 2.4 %. About half (54.4 %) of mothers who screened positive accepted intervention and of these, about two-thirds accepted onward referrals to tertiary care and community mental health service, with higher attendance at the latter. In the final adjusted model, mothers who had probable PPD were more likely to be older than age 35 years (OR 1.88, 95 % CI 1.05-3.45; p < 0.05) and not breastfeeding (OR 1.9, 95 % CI 1.06-3.38; p < 0.05). Overall, our findings highlight the importance of early PPD screening and management in primary care. These findings can help inform maternal mental health service development and utilization, thereby optimizing maternal and infant outcomes.
Collapse
Affiliation(s)
- Cherie Sze Min Sim
- Department of Psychological Medicine, KK Women's and Children's Hospital, Singapore
| | - Helen Chen
- Department of Psychological Medicine, KK Women's and Children's Hospital, Singapore; SingHeatlth-Duke NUS Paediatric Medicine Academic Clinical Programme, Singapore.
| | - Shu-Ling Chong
- SingHeatlth-Duke NUS Paediatric Medicine Academic Clinical Programme, Singapore; Paediatric Emergency Medicine Department, KK Women's and Children's Hospital, Singapore
| | | | - Elaine Chew
- SingHeatlth-Duke NUS Paediatric Medicine Academic Clinical Programme, Singapore; Adolescent Medicine Service, KK Women's and Children's Hospital, Singapore
| | - Xiaoxuan Guo
- SingHealth Polyclinics, Singapore; SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore
| | - Lai Peng Ng
- SingHealth Polyclinics, Singapore; SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore
| | - Ying Chia Ch'ng
- Department of Psychological Medicine, KK Women's and Children's Hospital, Singapore
| | | | | | - David Chee Chin Ng
- SingHealth Polyclinics, Singapore; SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore
| | - Ngiap Chuan Tan
- SingHealth Polyclinics, Singapore; SingHealth-Duke NUS Family Medicine Academic Clinical Programme, Singapore
| | - Yoke Hwee Chan
- SingHeatlth-Duke NUS Paediatric Medicine Academic Clinical Programme, Singapore; Division of Medicine, KK Women's and Children's Hospital, Singapore
| |
Collapse
|
14
|
Tan RMR, Ong GYK, Chong SL, Soo JSL, Ganapathy S, Tyebally A, Lee KP. Pretriage criteria for identifying COVID-19-positive patients in the paediatric emergency department. Singapore Med J 2023:384050. [PMID: 37675677 DOI: 10.4103/singaporemedj.smj-2021-381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Affiliation(s)
- Ronald Ming Ren Tan
- Department of Emergency Medicine, KK Women's and Children's Hospital; Duke-NUS Medical School, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital; Duke-NUS Medical School, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital; Duke-NUS Medical School, Singapore
| | | | - Sashikumar Ganapathy
- Department of Emergency Medicine, KK Women's and Children's Hospital; Duke-NUS Medical School, Singapore
| | - Arif Tyebally
- Department of Emergency Medicine, KK Women's and Children's Hospital; Duke-NUS Medical School, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital; Duke-NUS Medical School, Singapore
| |
Collapse
|
15
|
Nguyen TM, Poh KL, Chong SL, Lee JH. Effective diagnosis of sepsis in critically ill children using probabilistic graphical model. Transl Pediatr 2023; 12:538-551. [PMID: 37181015 PMCID: PMC10167381 DOI: 10.21037/tp-22-510] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/26/2023] [Indexed: 05/16/2023] Open
Abstract
Background Probabilistic graphical model, a rich graphical framework in modelling associations between variables in complex domains, can be utilized to aid clinical diagnosis. However, its application in pediatric sepsis remains limited. This study aims to explore the utility of probabilistic graphical models in pediatric sepsis in the pediatric intensive care unit. Methods We conducted a retrospective study on children using the first 24-hour clinical data of the intensive care unit admission from the Pediatric Intensive Care Dataset, 2010-2019. A probabilistic graphical model method, Tree Augmented Naive Bayes, was used to build diagnosis models using combinations of four categories: vital signs, clinical symptoms, laboratory, and microbiological tests. Variables were reviewed and selected by clinicians. Sepsis cases were identified with the discharged diagnosis of sepsis or suspected infection with the systemic inflammatory response syndrome. Performance was measured by the average sensitivity, specificity, accuracy, and area under the curve of ten-fold cross-validations. Results We extracted 3,014 admissions [median age of 1.13 (interquartile range: 0.15-4.30) years old]. There were 134 (4.4%) and 2,880 (95.6%) sepsis and non-sepsis patients, respectively. All diagnosis models had high accuracy (0.92-0.96), specificity (0.95-0.99), and area under the curve (0.77-0.87). Sensitivity varied with different combinations of variables. The model that combined all four categories yielded the best performance [accuracy: 0.93 (95% confidence interval (CI): 0.916-0.936); sensitivity: 0.46 (95% CI: 0.376-0.550), specificity: 0.95 (95% CI: 0.940-0.956), area under the curve: 0.87 (95% CI: 0.826-0.906)]. Microbiological tests had low sensitivity (<0.10) with high incidence of negative results (67.2%). Conclusions We demonstrated that the probabilistic graphical model is a feasible diagnostic tool for pediatric sepsis. Future studies using different datasets should be conducted to assess its utility to aid clinicians in the diagnosis of sepsis.
Collapse
Affiliation(s)
- Tuong Minh Nguyen
- Department of Industrial Engineering and Management, National University of Singapore, Singapore, Singapore
| | - Kim Leng Poh
- Department of Industrial Engineering and Management, National University of Singapore, Singapore, Singapore
| | - Shu-Ling Chong
- Children’s Emergency, KK Women’s and Children’s Hospital, Singapore, Singapore
- Singhealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Jan Hau Lee
- Singhealth-Duke NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore, Singapore
| |
Collapse
|
16
|
Ang CX, Mun WK, Aw MM, Lin D, Chong SL, Ong LY, Nah SA. Gastrointestinal transit time of radiopaque ingested foreign bodies in children: experience of two paediatric tertiary centres. Singapore Med J 2023:374495. [PMID: 37171420 DOI: 10.4103/singaporemedj.smj-2021-408] [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: 05/13/2023]
Abstract
Introduction Foreign body (FB) ingestion is a common paediatric emergency. While guidelines exist for urgent intervention, less is known of the natural progress of FBs passing through the gastrointestinal tract (GIT). We reviewed these FB transit times in an outpatient cohort. Methods A retrospective review was performed on all children (≤18 years) treated for radiopaque FB ingestion at two major tertiary paediatric centres from 2015 to 2016. Demographic data, FB types, outcomes and hospital visits (emergency department [ED] and outpatient) were recorded. All cases discharged from the ED with outpatient follow-up were included. We excluded those who were not given follow-up appointments and those admitted to inpatient wards. We categorised the outcomes into confirmed passage (ascertained via abdominal X-ray or reported direct stool visualisation by patients/caregivers) and assumed passage (if patients did not attend follow-up appointments). Results Of the 2,122 ED visits for FB ingestion, 350 patients who were given outpatient follow-up appointments were reviewed (median age 4.35 years [range: 0.5-14.7], 196 [56%] male). The largest proportion (16%) was aged 1-2 years. Coins were the most common ingested FB, followed by toys. High-risk FB (magnets or batteries) formed 9% of cases (n=33). The 50th centile for FB retention was 8, 4 and 7 days for coins, batteries and other radiopaque FBs, respectively; all confirmed passages occurred at 37, 7 and 23 days, respectively. Overall, 197 (68%) patients defaulted on their last given follow-up. Conclusion This study provides insight into the transit times of FB ingested by children, which helps medical professionals to decide on the optimal time for follow-up visits and provide appropriate counsel to caregivers.
Collapse
Affiliation(s)
- Chen Xiang Ang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Win Kai Mun
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Diana Lin
- Department of Paediatrics, National University Hospital, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Lin Yin Ong
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, Faculty of Medicine, University of Malaya, Malaysia
| |
Collapse
|
17
|
Yao S, Chong SL, Allen JC, Dang H, Ming M, Chan LCN, Gan CS, Ji J, Fan L, Kurosawa H, Lee JH. Early metabolic derangements and unfavorable outcomes in pediatric traumatic brain injury: a retrospective multi-center cohort study. Transl Pediatr 2023; 12:344-353. [PMID: 37035406 PMCID: PMC10080479 DOI: 10.21037/tp-22-443] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/19/2023] [Indexed: 04/11/2023] Open
Abstract
Background To study the association in moderate and severe pediatric traumatic brain injury (TBI) between hyperglycemia, hyperlactatemia, acidosis and unfavorable outcome, as assessed by Pediatric Cerebral Performance Category (PCPC) on discharge from the pediatric intensive care unit (PICU). Methods Children <16 years old with TBI and Glasgow Coma Scale (GCS) ≤13 in an Asian multi-center PICU TBI cohort from January 2014 to October 2017 were included in this study. We defined unfavorable outcome as PCPC ≥3-moderate disability, severe disability, vegetative state, and death. We performed logistic regression to investigate the association between metabolic changes with unfavorable outcome. We divided hyperglycemia (glucose >11.1 mmol/L) during PICU admission into early-onset (within 24 h), late-onset (beyond 48 h) and persistent (throughout first 72 h). Results Among the 305 children analyzed, 136 (44.6%) had unfavorable outcome. Children with unfavorable outcome were more likely to have early hyperglycemia (75/136, 55.1% vs. 33/169, 19.5%; P<0.001), high lactate levels >2.0 mmol/L (74/136, 54.4% vs. 56/169, 32.5%; P<0.001) and initial acidosis (85/136, 62.5% vs. 78/169, 56.1%; P=0.003) compared to those with favorable outcome. After adjusting for gender, GCS ≤8 and presence of polytrauma, early hyperglycemia [adjusted odds ratio (aOR) =3.68, 95% CI: 2.12-6.39, P<0.001] and late hyperglycemia (aOR =13.30, 95% CI: 1.64-107.8, P=0.015] were independently associated with unfavorable outcome. All children with persistent hyperglycemia died. Conclusions We described unfavorable outcome in pediatric TBI especially with persistent hyperglycemia. Future trials should investigate the causal relationship between glycemic trends, early intervention and outcome in this cohort.
Collapse
Affiliation(s)
- Sarah Yao
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | | | - Hongxing Dang
- Department of Pediatric Intensive Care Unit, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Meixiu Ming
- Department of Pediatric Intensive Care Unit, Children’s Hospital of Fudan University, Shanghai, China
| | - Lawrence C. N. Chan
- Department of Pediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Chin Seng Gan
- Department of Pediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Jian Ji
- Department of Pediatric Intensive Care Unit, Beijing Children’s Hospital, Capital Medical University, Beijing, China
| | - Lijia Fan
- Khoo Teck Puat National University Children’s Medical Institute, National University Hospital, Singapore, Singapore
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore, Singapore
| |
Collapse
|
18
|
Yew WX, Lee JH, Dang H, Low SYY, Sri Dewi D, Chong SL. Decompressive Craniectomy in Pediatric Traumatic Brain Injury: A Retrospective Cohort Study. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0043-1761939] [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] [Indexed: 02/12/2023] Open
Abstract
AbstractDecompressive craniectomy (DC) in children with traumatic brain injury (TBI) and refractory raised intracranial pressure (ICP) remains controversial. We aimed to describe the clinical and operative characteristics of children with moderate to severe TBI who underwent DC, and compare outcomes with those who had medical therapy. We performed a retrospective observational cohort study on children < 16 years of age with moderate to severe TBI (Glasgow coma scale [GCS] ≤13) who underwent DC in two pediatric centers in Singapore and China between 2014 and 2017, and compared their outcomes with children who underwent medical treatment, among participating centers of the Pediatric Acute and Critical Care Medicine Asian Network. We defined poor functional outcomes as moderate, severe disability, vegetative or comatose state, or mortality, using the Pediatric Cerebral Performance Category scale. We performed multivariable logistic regression to identify predictors for poor functional outcomes. We analyzed 18 children who underwent DC with 214 who had medical therapy. A greater proportion of children with DC (14, 77.8%) experienced poor functional outcomes, compared with those with medical therapy (87, 41.2%, p = 0.003). Children who underwent DC had fewer median 14-day intensive care unit (ICU)-free days (2.5 days, interquartile range [IQR]: 0.0–5.8 vs. 8.0 days, IQR: 0.0–11.0, p = 0.033), median 28-day hospital-free days (0 day, IQR: 0.0–3.5 vs. 11.0 days, IQR: 0.0–21.0, p = 0.002) and 14-day mechanical ventilation-free days (6.5 days, IQR: 0.0–12.3 vs. 11.0 days, IQR: 3.0–14.0, p = 0.011). After accounting for age, sex, GCS, cerebral edema, uncal herniation, nonaccidental injury, and need for intubation, there was no significant association between DC and poor functional outcomes (adjusted odds ratio: 1.59, 95% confidence interval: 0.35–7.24, p = 0.548). Children with DC had severe injuries, and prolonged hospital and ICU stays. Future studies are needed to understand the effectiveness of DC on children with TBI.
Collapse
Affiliation(s)
- Wan Xin Yew
- Ministry of Health Holdings, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Hongxing Dang
- Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Sharon Yin Yee Low
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore, Singapore
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
- Singhealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, Singapore
| | - Dianna Sri Dewi
- Research Centre, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
19
|
Gray CS, Xu Y, Babl FE, Dalziel S, Powell CVE, Chong SL, Roland D, Lyttle MD, Fernandes RM, Benito J, Johnson M, Yock-Corrales A, Santhanam I, Schuh S, Cheema B, Couper J, Craig S. International perspective on research priorities and outcome measures of importance in the care of children with acute exacerbations of asthma: a qualitative interview study. BMJ Open Respir Res 2023; 10:10/1/e001502. [PMID: 36849194 PMCID: PMC9972434 DOI: 10.1136/bmjresp-2022-001502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/09/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Acute exacerbations of asthma are common in children, however, treatment decisions for severe exacerbations are challenging due to a lack of robust evidence. In order to create more robust research, a core set of outcome measures needs to be developed. In developing these outcomes, it is important to understand the views of clinicians who care for these children in particular, views that relate to outcome measures and research priorities. METHODS To determine the views of clinicians, a total of 26 semistructured interviews based on the theoretical domains framework were conducted. These included experienced clinicians from emergency, intensive care and inpatient paediatrics across 17 countries. The interviews were recorded, and later transcribed. All data analyses were conducted in Nvivo by using thematic analysis. RESULTS The length of stay in hospital and patient-focused parameters, such as timing to return to school and normal activity, were the most frequently highlighted outcome measures, with clinicians identifying the need to achieve a consensus on key core outcome measure sets. Most research questions focused on understanding the best treatment options, including the role of novel therapies and respiratory support. CONCLUSION Our study provides an insight into what research questions and outcome measures clinicians view as important. In addition, information on how clinicians define asthma severity and measure treatment success will assist with methodological design in future trials. The current findings will be used in parallel with a further Paediatric Emergency Research Network study focusing on the child and family perspectives and will contribute to develop a core outcome set for future research.
Collapse
Affiliation(s)
- Charmaine S Gray
- Adelaide Medical School, Discipline of Paediatrics, The University of Adelaide, Adelaide, South Australia, Australia .,Paediatric Emergency Department, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Yao Xu
- Zhuhai City People's Hospital, Zhuhai, Guangdong, China.,Department of Paediatrics, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute; Departments of Paediatrics and Critical Care, University of Melbourne, Parkville, Victoria, Australia.,Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Stuart Dalziel
- Children's Emergency Department, Starship Children's Health, Auckland, New Zealand.,Surgery and Paediatrics, The University of Auckland Faculty of Health and Medical Sciences, Auckland, New Zealand
| | - Colin V E Powell
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK.,Department of Emergency Medicine, Sidra Medicine, Doha, Ad-Dawhah, Qatar
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth Paediatrics Academic Clinical Programme, Singapore
| | - Damian Roland
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK.,Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Mark D Lyttle
- Paediatric Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Research in Emergency Care Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria, Lisboa, Portugal.,Clinical Pharmacology Unit, University of Lisbon, Lisboa, Portugal
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital. Biocruces Bizkaia Health Research Institute, Bilbao, Spain
| | - Mike Johnson
- Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Adriana Yock-Corrales
- Emergency Department, Hospital Nacional de Ninos "Dr Carlos Saenz Herrera", CCSS, San Jose, Costa Rica
| | - Indumathy Santhanam
- Regional Collaborative Center, Institute of Child Health, Madras Medical College, Egmore, Chennai, India
| | - Suzanne Schuh
- Hospital for Sick Children Research Institute, Univsersity of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Baljit Cheema
- Department of Paediatrics & Child Health, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Jenny Couper
- Adelaide Medical School, Discipline of Paediatrics, The University of Adelaide, Adelaide, South Australia, Australia
| | - Simon Craig
- Department of Paediatrics, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia.,Paediatric Emergency Department, Monash Medical Centre, Monash Health, Clayton, Victoria, Australia
| | | |
Collapse
|
20
|
Chong SL, Niu C, Piragasam R, Koh ZX, Guo D, Lee JH, Ong GYK, Ong MEH, Liu N. Adding heart rate n-variability (HRnV) to clinical assessment potentially improves prediction of serious bacterial infections in young febrile infants at the emergency department: a prospective observational study. Ann Transl Med 2023; 11:6. [PMID: 36760240 PMCID: PMC9906196 DOI: 10.21037/atm-22-3303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022]
Abstract
Background We aim to investigate the utility of heart rate variability (HRV) and heart rate n-variability (HRnV) in addition to vital signs and blood biomarkers, among febrile young infants at risk of serious bacterial infections (SBIs). Methods We performed a prospective observational study between December 2017 and November 2021 in a tertiary paediatric emergency department (ED). We included febrile infants <90 days old with a temperature ≥38 ℃. We obtained HRV and HRnV parameters via a single lead electrocardiogram. HRV measures beat-to-beat (R-R) oscillation and reflects autonomic nervous system (ANS) regulation. HRnV includes overlapping and non-overlapping R-R intervals and provides additional physiological information. We defined SBIs as meningitis, bacteraemia and urinary tract infections (UTIs). We performed area under curve (AUC) analysis to assess predictive performance. Results We recruited 330 and analysed 312 infants. The median age was 35.5 days (interquartile range 13.0-61.0); 74/312 infants (23.7%) had SBIs with the most common being UTIs (66/72, 91.7%); 2 infants had co-infections. No patients died and 32/312 (10.3%) received fluid resuscitation. Adding HRV and HRnV to demographics and vital signs at ED triage successively improved the AUC from 0.765 [95% confidence interval (CI): 0.705-0.825] to 0.776 (95% CI: 0.718-0.835) and 0.807 (95% CI: 0.752-0.861) respectively. The final model including demographics, vital signs, HRV, HRnV and blood biomarkers had an AUC of 0.874 (95% CI: 0.828-0.921). Conclusions Addition of HRV and HRnV to current assessment tools improved the prediction of SBIs among febrile infants at ED triage. We intend to validate our findings and translate them into tools for clinical care in the ED.
Collapse
Affiliation(s)
- Shu-Ling Chong
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - Rupini Piragasam
- KK Research Centre, KK Women's and Children's Hospital, Singapore, Singapore
| | - Zhi Xiong Koh
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Dagang Guo
- Duke-NUS Medical School, Singapore, Singapore
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore, Singapore.,Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Gene Yong-Kwang Ong
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Nan Liu
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Health Services Research Centre, Singapore Health Services, Singapore, Singapore
| |
Collapse
|
21
|
Tan SQ, Cher WQ, Chong SL, Ang ASY, Ganapathy S, Chan DWS, Tan RMR. Early Recognition of Pediatric Strokes in the Emergency Department: Epidemiology, Clinical Presentation, and Factors Impeding Stroke Diagnosis in Children. Ann Child Neurol 2022. [DOI: 10.26815/acn.2022.00367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
|
22
|
Primalani NK, Chan YH, Ng ZM, Chong SL, Seow WT, Loh LE, Mok YH, Low SYY. Abusive head injury in the very young: outcomes from a Singapore children's hospital. Childs Nerv Syst 2022; 38:2397-2407. [PMID: 35851614 DOI: 10.1007/s00381-022-05572-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is a serious problem in children. The aims of this study are to identify risk factors that correlate with outcomes for those requiring neurosurgical intervention for very young children with AHT, assessment of variables associated with outcomes, and corroboration of our results with literature. METHODS This is an ethics-approved, retrospective study. Inclusion criteria consisted of patients aged 2 years old or less with a diagnosis of AHT managed by the Neurosurgical Service, KK Women's and Children's Hospital. Demographical and clinical variables are incorporated in the statistical analyses. Logistic regression was applied to statistically significant variables for the risk prediction model. RESULTS From 2000 to 2020, 24 patients required surgery for AHT. Timepoint was set at 12 months post-diagnosis. Univariate analyses demonstrated that patients with mild TBI were likely to have a favourable GOS-E Peds (p = 0.01), whereas radiological presence of cerebral oedema (p < .001), development of scar epilepsy (p = 0.021), and progression to cerebral palsy (p = 0.001) were associated with unfavourable GOS-E Peds. CONCLUSION This is the first study focused on neurosurgical outcomes for very young children with AHT in Singapore. We advocate multidisciplinary efforts to improve outcomes for this devastating condition.
Collapse
Affiliation(s)
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Block MD11, Clinical Research Centre, #02-03 (c/o CBmE Office), 10 Medical Drive, Singapore, 117597, Singapore
| | - Zhi Min Ng
- Neurology Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Children's Emergency, KK Women's and Children's Hospital, Singapore, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Lik Eng Loh
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore. .,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| |
Collapse
|
23
|
Sutiman N, Khoo ZX, Ong GYK, Piragasam R, Chong SL. Validation and comparison of the PECARN rule, Step-by-Step approach and Lab-score for predicting serious and invasive bacterial infections in young febrile infants. Ann Acad Med Singap 2022. [DOI: 10.47102/annals-acadmedsg.2022193] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Introduction: Differentiating infants with serious bacterial infections (SBIs) or invasive bacterial infections (IBIs) from those without remains a challenge. We sought to compare the diagnostic performances of single biomarkers (absolute neutrophil count [ANC], C-reactive protein [CRP] and procalcitonin [PCT]) and 4 diagnostic approaches comprising Lab-score, Step-by-Step approach (original and modified) and Pediatric Emergency Care Applied Research Network (PECARN) rule.
Method: This is a prospective cohort study involving infants 0–90 days of age who presented to an emergency department from July 2020 to August 2021. SBIs were defined as bacterial meningitis, bacteraemia and/or urinary tract infections. IBIs were defined as bacteraemia and/or bacterial meningitis. We evaluated the performances of Lab-score, Step-by-Step (original and modified) and PECARN rule in predicting SBIs and IBIs.
Results: We analysed a total of 258 infants, among whom 86 (33.3%) had SBIs and 9 (3.5%) had IBIs. In predicting SBIs, ANC ≥4.09 had the highest sensitivity and negative predictive value (NPV), while PCT ≥1.7 had the highest specificity and positive predictive value (PPV). CRP ≥20 achieved the highest area under receiver operating characteristic curve (AUC) of 0.741 (95% confidence interval [CI] 0.672–0.810). The Step-by-Step (original) approach had the highest sensitivity (97.7%). Lab-score had the highest AUC of 0.695 (95% CI 0.621–0.768), compared to PECARN rule at 0.625 (95% CI 0.556–0.694) and Step-by-Step (original) at 0.573 (95% CI 0.502–0.644). In predicting IBIs, PCT ≥1.7 had the highest sensitivity, specificity, PPV and NPV. The Step-by-Step (original and modified) approach had the highest sensitivity of 100%. Lab-score had the highest AUC of 0.854 (95% CI 0.731–0.977) compared to PECARN rule at 0.589 (95% CI 0.420–0.758) and Step-by-Step at 0.562 (95% CI 0.392–0.732).
Conclusion: CRP strongly predicted SBIs, and PCT strongly predicted IBI. The Step-by-Step approach had the highest sensitivity and NPV, while Lab-score had the highest specificity and AUC in predicting SBIs and IBIs.
Keywords: Biomarkers, diagnostic approaches, febrile infants, Lab-score, PECARN rule, Step-by-Step approach
Collapse
Affiliation(s)
- Natalia Sutiman
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Zi Xean Khoo
- Department of Pediatric Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Rupini Piragasam
- KK Research Centre, KK Women’s and Children’s Hospital, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| |
Collapse
|
24
|
Mahajan P, Chong SL, Kumar V, Batra P, Belle A, Bloom B, Chaou CH, Ekelund U, Galwankar S, Kaartinen J, Krishnan V, Ma Q, Middleton P, Morais A, Ng C, Osei-Kwame D, Roth D. The Emergency Medicine Education and Research by Global Experts (EMERGE) Network: Challenges and Lessons Learned. West J Emerg Med 2022; 23:947-951. [DOI: 10.5811/westjem.2022.7.56398] [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: 02/08/2022] [Accepted: 07/02/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction: The Emergency Medicine Education and Research by Global Experts (EMERGE) network was formed to generate and translate evidence to improve global emergency care. We share the challenges faced and lessons learned in establishing a global research network.
Methods: We describe the challenges encountered when EMERGE proposed the development of a global emergency department (ED) visit registry. The proposed registry was to be a six-month, retrospective, deidentified, minimal dataset of routinely collected variables, such as patient demographics, diagnosis, and disposition.
Results: Obtaining reliable, accurate, and pertinent data from participating EDs is challenging in a global context. Barriers experienced ranged from variable taxonomies, need for language translation, varying site processes for curation and transfer of deidentified data, navigating institution- and country-specific data protection regulations, and substantial variation in each participating institution’s research infrastructure including training in research-related activities. We have overcome many of these challenges by creating detailed data-sharing agreements with bilateral regulatory oversight agreements between EMERGE and participating EDs, developing relationships with and training health informaticians at each site to ensure secure transfer of deidentified data, and formalizing an electronic transfer process ensuring data privacy.
Conclusion: We believe that networks like EMERGE are integral to providing the necessary platforms for education, training, and research collaborations for emergency care. We identified substantial challenges in data sharing and variation in local sites’ research infrastructure and propose potential approaches to address these challenges.
Collapse
Affiliation(s)
- Prashant Mahajan
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Shu-Ling Chong
- KK Women’s and Children’s Hospital, Department of Emergency Medicine, Singapore
| | | | | | | | | | | | | | | | | | | | | | | | | | - Chip Ng
- Chang Gung Memorial Hospital
| | | | | |
Collapse
|
25
|
Chong SL, Goh MSL, Ong GYK, Acworth J, Sultana R, Yao SHW, Ng KC, Scholefield B, Aickin R, Maconochie I, Atkins D, Couto TB, Guerguerian AM, Kleinman M, Kloeck D, Nadkarni V, Nuthall G, Reis A, Rodriguez-Nunez A, Schexnayder S, Tijssen J, Van de Voorde P, Morley P. Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic review and meta-analysis. Resusc Plus 2022; 11:100262. [PMID: 35801231 PMCID: PMC9253845 DOI: 10.1016/j.resplu.2022.100262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 11/17/2022] Open
Abstract
Aim We conducted a systematic review and meta-analysis to answer the question: Does the implementation of Paediatric Early Warning Systems (PEWS) in the hospital setting reduce mortality, cardiopulmonary arrests, unplanned codes and critical deterioration events among children, as compared to usual care without PEWS? Methods We conducted a comprehensive search using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Web of Science. We included studies published between January 2006 and April 2022 on children <18 years old performed in inpatient units and emergency departments, and compared patient populations with PEWS to those without PEWS. We excluded studies without a comparator, case control studies, systematic reviews, and studies published in non-English languages. We employed a random effects meta-analysis and synthesised the risk and rate ratios from individual studies. We used the Scottish Intercollegiate Guidelines Network (SIGN) to appraise the risk of bias. Results Among 911 articles screened, 15 were included for descriptive analysis. Fourteen of the 15 studies were pre- versus post-implementation studies and one was a multi-centre cluster randomised controlled trial (RCT). Among 10 studies (580,604 hospital admissions) analysed for mortality, we found an increased risk (pooled RR 1.18, 95% CI 1.01–1.38, p = 0.036) in the group without PEWS compared to the group with PEWS. The sensitivity analysis performed without the RCT (436,065 hospital admissions) showed a non-significant relationship (pooled RR 1.17, 95% CI 0.98–1.40, p = 0.087). Among four studies (168,544 hospital admissions) analysed for unplanned code events, there was an increased risk in the group without PEWS (pooled RR 1.73, 95%CI 1.01–2.96, p = 0.046) There were no differences in the rate of cardiopulmonary arrests or critical deterioration events between groups. Our findings were limited by potential confounders and imprecision among included studies. Conclusions Healthcare systems that implemented PEWS were associated with reduced mortality and code rates. We recognise that these gains vary depending on resource availability and efferent response systems. PROSPERO registration: CRD42021269579.
Collapse
|
26
|
Funk AL, Kuppermann N, Florin TA, Tancredi DJ, Xie J, Kim K, Finkelstein Y, Neuman MI, Salvadori MI, Yock-Corrales A, Breslin KA, Ambroggio L, Chaudhari PP, Bergmann KR, Gardiner MA, Nebhrajani JR, Campos C, Ahmad FA, Sartori LF, Navanandan N, Kannikeswaran N, Caperell K, Morris CR, Mintegi S, Gangoiti I, Sabhaney VJ, Plint AC, Klassen TP, Avva UR, Shah NP, Dixon AC, Lunoe MM, Becker SM, Rogers AJ, Pavlicich V, Dalziel SR, Payne DC, Malley R, Borland ML, Morrison AK, Bhatt M, Rino PB, Beneyto Ferre I, Eckerle M, Kam AJ, Chong SL, Palumbo L, Kwok MY, Cherry JC, Poonai N, Waseem M, Simon NJ, Freedman SB. Post-COVID-19 Conditions Among Children 90 Days After SARS-CoV-2 Infection. JAMA Netw Open 2022; 5:e2223253. [PMID: 35867061 PMCID: PMC9308058 DOI: 10.1001/jamanetworkopen.2022.23253] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children. OBJECTIVES To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls. EXPOSURE SARS-CoV-2 detected via nucleic acid testing. MAIN OUTCOMES AND MEASURES Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey. RESULTS Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference, 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; ≥7 symptoms: aOR, 4.59 [95% CI, 2.50-8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321 [2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391 [10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]). CONCLUSIONS AND RELEVANCE In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older.
Collapse
Affiliation(s)
- Anna L Funk
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Todd A Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jianling Xie
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly Kim
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yaron Finkelstein
- Division of Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | | - Adriana Yock-Corrales
- Emergency Department, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera," CCSS, San José, Costa Rica
| | - Kristen A Breslin
- Department of Emergency Medicine and Trauma Services, Children's National Hospital, Washington, DC
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado, Aurora
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles and Keck School of Medicine of the University of Southern California, Los Angeles
| | - Kelly R Bergmann
- Department of Emergency Medicine, Children's Minnesota, Minneapolis
| | - Michael A Gardiner
- Department of Pediatrics, University of California, San Diego, Rady Children's Hospital, San Diego
| | | | - Carmen Campos
- Pediatric Emergency Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Fahd A Ahmad
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Laura F Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nidhya Navanandan
- Department of Pediatrics, University of Colorado, Aurora
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Children's Hospital of Michigan, Detroit
- Department of Pediatrics, Central Michigan University, Mt Pleasant
| | - Kerry Caperell
- Department of Pediatrics, University of Louisville, Louisville, Kentucky
- Department of Pediatrics, Norton Children's Hospital, Louisville, Kentucky
| | - Claudia R Morris
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU Bilbao, Basque Country, Spain
| | - Iker Gangoiti
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU Bilbao, Basque Country, Spain
| | - Vikram J Sabhaney
- Department of Paediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Usha R Avva
- Department of Emergency Medicine, Montefiore-Nyack Hospital, Nyack, New York
| | - Nipam P Shah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Andrew C Dixon
- University of Alberta, Stollery Children's Hospital, Women's and Children's Health Research Institute, Edmonton, Alberta, Canada
| | - Maren M Lunoe
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah M Becker
- Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Alexander J Rogers
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor
- Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor
| | - Viviana Pavlicich
- Departamento de Emergencia Pediátrica, Hospital General Pediátrico Niños de Acosta Ñu, Facultad de Medicina, Universidad Privada del Pacífico, San Lorenzo, Paraguay
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Daniel C Payne
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Richard Malley
- Division of Infectious Diseases, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia
- Division of Emergency Medicine, School of Medicine, University of Western Australia, Perth, Australia
- Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Australia
| | - Andrea K Morrison
- Division of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Maala Bhatt
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Pedro B Rino
- Hospital de Pediatría "Prof Dr. Juan P. Garrahan," RIDEPLA, Buenos Aires, Argentina
| | | | - Michelle Eckerle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - April J Kam
- Department of Pediatrics, Division of Emergency Medicine, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, SingHealth Duke-NUS Global Health Institute, Singapore
| | - Laura Palumbo
- ASST Spedali Civili di Brescia-Pronto soccorso pediatrico, Brescia, Italy
| | - Maria Y Kwok
- Department of Emergency Medicine, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Jonathan C Cherry
- Department of Pediatric Emergency Medicine, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Muhammad Waseem
- Department of Emergency Medicine, Lincoln Medical Center, New York, New York
| | - Norma-Jean Simon
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Data Analytics and Reporting, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Stephen B Freedman
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Section of Gastroenterology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|
27
|
Tan VSR, Ong GYK, Lee KP, Ganapathy S, Chong SL. Correction: Pyrexia in a young infant - is height of fever associated with serious bacterial infection? BMC Pediatr 2022; 22:343. [PMID: 35705935 PMCID: PMC9199123 DOI: 10.1186/s12887-022-03374-3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Victoria Shi Rui Tan
- Department of Paediatrics, KK Women's and Children's Hospital Singapore, 100, Bukit Timah Road, Singapore, 229899, Singapore.
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Sashikumar Ganapathy
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| |
Collapse
|
28
|
Gan MY, Lee WL, Yap BJ, Seethor STT, Greenberg RG, Pek JH, Tan B, Hornik CPV, Lee JH, Chong SL. Contemporary Trends in Global Mortality of Sepsis Among Young Infants Less Than 90 Days: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:890767. [PMID: 35722477 PMCID: PMC9204066 DOI: 10.3389/fped.2022.890767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Current knowledge on the global burden of infant sepsis is limited to population-level data. We aimed to summarize global case fatality rates (CFRs) of young infants with sepsis, stratified by gross national income (GNI) status and patient-level risk factors. Methods We performed a systematic review and meta-analysis on CFRs among young infants < 90 days with sepsis. We searched PubMed, Cochrane Central, Embase, and Web of Science for studies published between January 2010 and September 2019. We obtained pooled CFRs estimates using the random effects model. We performed a univariate analysis at patient-level and a meta-regression to study the associations of gestational age, birth weight, onset of sepsis, GNI, age group and culture-proven sepsis with CFRs. Results The search yielded 6314 publications, of which 240 studies (N = 437,796 patients) from 77 countries were included. Of 240 studies, 99 were conducted in high-income countries, 44 in upper-middle-income countries, 82 in lower-middle-income countries, 6 in low-income countries and 9 in multiple income-level countries. Overall pooled CFR was 18% (95% CI, 17-19%). The CFR was highest for low-income countries [25% (95% CI, 7-43%)], followed by lower-middle [25% (95% CI, 7-43%)], upper-middle [21% (95% CI, 18-24%)] and lowest for high-income countries [12% (95% CI, 11-13%)]. Factors associated with high CFRs included prematurity, low birth weight, age less than 28 days, early onset sepsis, hospital acquired infections and sepsis in middle- and low-income countries. Study setting in middle-income countries was an independent predictor of high CFRs. We found a widening disparity in CFRs between countries of different GNI over time. Conclusion Young infant sepsis remains a major global health challenge. The widening disparity in young infant sepsis CFRs between GNI groups underscore the need to channel greater resources especially to the lower income regions. Systematic Review Registration [www.crd.york.ac.uk/prospero], identifier [CRD42020164321].
Collapse
Affiliation(s)
- Ming Ying Gan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wen Li Lee
- Duke-NUS Medical School, Singapore, Singapore
| | - Bei Jun Yap
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Rachel G Greenberg
- Department of Paediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Jen Heng Pek
- Emergency Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Bobby Tan
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Christoph Paul Vincent Hornik
- Division of Critical Care Medicine, Department of Paediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
29
|
Goh AXC, Yeo JW, Gao JF, Ong MEH, Chong SL, Siddiqui FJ, Ho AFW. Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review. Emerg Med J 2022; 39:888-896. [PMID: 35177437 DOI: 10.1136/emermed-2021-212108] [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: 10/23/2021] [Accepted: 02/04/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method. METHODS MEDLINE, Embase and the Cochrane Library were searched from inception to 15 June 2021. Randomised controlled trials comparing anaesthetic methods for the closed reduction of paediatric forearm fractures in the emergency setting were included. Two reviewers independently screened, collected data and assessed the risk of bias for the selected outcomes. The primary outcome was pain during reduction. Secondary outcomes included pain after reduction, adverse effects, satisfaction, adequacy of sedation/anaesthesia, success of reduction and resource use. RESULTS 1288 records were screened and 9 trials, which studied 936 patients in total, were included. Four trials compared the main methods of anaesthesia. Within the same method of anaesthesia, one compared administrative routes, one compared procedural techniques, one compared different drugs, one compared the use of adjuncts and one compared different doses of the same drug. One study found better pain outcomes with infraclavicular blocks compared with procedural sedation and analgesia. Lidocaine was superior in analgesic effect to prilocaine in IVRA in one study. One study found lower pain scores with moderate-dose than low-dose lidocaine in IVRA. CONCLUSION Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.
Collapse
Affiliation(s)
- Amelia Xin Chun Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jun Wei Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Health Services & Systems Research, Duke-NUS Medical School, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Fahad Javaid Siddiqui
- Pre-Hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Pre-Hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
| |
Collapse
|
30
|
Chong SL, Qian S, Yao SHW, Allen JC, Dang H, Chan LCN, Ming M, Gan CS, Ong JSM, Kurosawa H, Lee JH. Early posttraumatic seizures in pediatric traumatic brain injury: a multicenter analysis. J Neurosurg Pediatr 2022; 29:225-231. [PMID: 34715667 DOI: 10.3171/2021.8.peds21281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early posttraumatic seizures (EPTSs) in children after traumatic brain injury (TBI) increase metabolic stress on the injured brain. The authors sought to study the demographic and radiographic predictors for EPTS, and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes among children with moderate to severe TBI in Asia. METHODS A secondary analysis of a retrospective TBI cohort among participating centers of the Pediatric Acute & Critical Care Medicine Asian Network was performed. Children < 16 years of age with a Glasgow Coma Scale (GCS) score ≤ 13 who were admitted to pediatric intensive care units between January 2014 and October 2017 were included. Logistic regression analysis was performed to study risk factors for EPTS and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes. Poor functional outcomes were defined as moderate disability, severe disability, and coma as defined by the Pediatric Cerebral Performance Category scale. RESULTS Overall, 313 children were analyzed, with a median age of 4.3 years (IQR 1.8-8.9 years); 162 children (51.8%) had severe TBI (GCS score < 8), and 76 children (24.3%) had EPTS. After adjusting for age, sex, and the presence of nonaccidental trauma (NAT), only younger age was significantly associated with EPTS (adjusted odds ratio [aOR] 0.85, 95% CI 0.78-0.92; p < 0.001). Forty-nine children (15.6%) in the cohort died, and 87 (32.9%) of the 264 surviving patients had poor functional outcomes. EPTS did not increase the risk of death. After adjusting for age, sex, TBI due to NAT, multiple traumas, and a GCS score < 8, the presence of EPTS was associated with poor functional outcomes (aOR 2.08, 95% CI 1.05-4.10; p = 0.036). CONCLUSIONS EPTSs were common among children with moderate to severe TBI in Asia and were associated with poor functional outcomes among children who survived TBI.
Collapse
Affiliation(s)
- Shu-Ling Chong
- 1Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
- 2SingHealth Duke-NUS Global Health Institute, Duke-NUS Medical School, Singapore
| | - Suyun Qian
- 3Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Sarah Hui Wen Yao
- 1Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | | | - Hongxing Dang
- 5Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Lawrence C N Chan
- 6Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Meixiu Ming
- 7Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Chin Seng Gan
- 8Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Jacqueline S M Ong
- 9Khoo Teck Puat National University Children's Medical Institute, National University Hospital, Singapore
- 10Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hiroshi Kurosawa
- 11Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; and
| | - Jan Hau Lee
- 2SingHealth Duke-NUS Global Health Institute, Duke-NUS Medical School, Singapore
- 12Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| |
Collapse
|
31
|
Funk AL, Florin TA, Kuppermann N, Tancredi DJ, Xie J, Kim K, Neuman MI, Ambroggio L, Plint AC, Mintegi S, Klassen TP, Salvadori MI, Malley R, Payne DC, Simon NJ, Yock-Corrales A, Nebhrajani JR, Chaudhari PP, Breslin KA, Finkelstein Y, Campos C, Bergmann KR, Bhatt M, Ahmad FA, Gardiner MA, Avva UR, Shah NP, Sartori LF, Sabhaney VJ, Caperell K, Navanandan N, Borland ML, Morris CR, Gangoiti I, Pavlicich V, Kannikeswaran N, Lunoe MM, Rino PB, Kam AJ, Cherry JC, Rogers AJ, Chong SL, Palumbo L, Angelats CM, Morrison AK, Kwok MY, Becker SM, Dixon AC, Poonai N, Eckerle M, Wassem M, Dalziel SR, Freedman SB. Outcomes of SARS-CoV-2-Positive Youths Tested in Emergency Departments: The Global PERN-COVID-19 Study. JAMA Netw Open 2022; 5:e2142322. [PMID: 35015063 PMCID: PMC8753506 DOI: 10.1001/jamanetworkopen.2021.42322] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [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: 01/28/2023] Open
Abstract
IMPORTANCE Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized. OBJECTIVE To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021. EXPOSURES Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing. MAIN OUTCOMES AND MEASURES Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death. RESULTS Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). Among a subgroup of 2510 participants discharged home from the ED after initial testing and who had complete follow-up, 50 (2.0%; 95% CI, 1.5%-2.6%) were eventually hospitalized and 12 (0.5%; 95% CI, 0.3%-0.8%) had severe outcomes. Compared with hospitalized SARS-CoV-2-negative youths, the risk of severe outcomes was higher among hospitalized SARS-CoV-2-positive youths (risk difference, 3.9%; 95% CI, 1.1%-6.9%). CONCLUSIONS AND RELEVANCE In this study, approximately 3% of SARS-CoV-2-positive youths tested in EDs experienced severe outcomes within 2 weeks of their ED visit. Among children discharged home from the ED, the risk was much lower. Risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions.
Collapse
Affiliation(s)
- Anna L. Funk
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Todd A. Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Daniel J. Tancredi
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jianling Xie
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly Kim
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mark I. Neuman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora
| | - Amy C. Plint
- Children’s Hospital of Eastern Ontario, Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Santiago Mintegi
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Terry P. Klassen
- Children’s Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Richard Malley
- Division of Infectious Diseases, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel C. Payne
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Norma-Jean Simon
- Data Analytics and Reporting, Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | | | | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | | | - Yaron Finkelstein
- Divisions of Emergency Medicine and Clinical Pharmacology and Toxicology, Department of Pediatrics Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carmen Campos
- Hospital Universitario Miguel Servet, Pediatric Emergency Department, Zaragoza, Spain
| | - Kelly R. Bergmann
- Department of Emergency Medicine, Children’s Minnesota, Minneapolis, Minnesota
| | - Maala Bhatt
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Fahd A. Ahmad
- Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael A. Gardiner
- Rady Children’s Hospital, Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Usha R. Avva
- School of Medicine Hackensack Meridian Health, Hackensack, New Jersey
| | - Nipam P. Shah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - Laura F. Sartori
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vikram J. Sabhaney
- Department of Paediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kerry Caperell
- Norton Children’s Hospital, University of Louisville, Louisville, Kentucky
| | - Nidhya Navanandan
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora
| | - Meredith L. Borland
- Perth Children’s Hospital, Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Claudia R. Morris
- Department of Pediatrics, Division of Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Iker Gangoiti
- Pediatric Emergency Department, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, UPV/EHU, Bilbao, Basque Country, Spain
| | - Viviana Pavlicich
- Departamento de Emergencia Pediátrica, Hospital General Pediátrico Niños de Acosta Ñu, Facultad de Medicina, Universidad Privada del Pacífico, San Lorenzo, Paraguay
| | | | - Maren M. Lunoe
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pedro B. Rino
- Hospital de Pediatría “Prof Dr Juan P. Garrahan”, RIDEPLA, Buenos Aires, Argentina
| | - April J. Kam
- Department of Pediatrics, Division of Emergency Medicine, McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Jonathan C. Cherry
- Department of Pediatric Emergency Medicine, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan School of Medicine, Ann Arbor
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Duke-NUS Medical School, SingHealth Duke-NUS Global Health Institute, Singapore
| | - Laura Palumbo
- ASST Spedali Civili di Brescia - Pronto soccorso pediatrico, Brescia, Italy
| | | | - Andrea K. Morrison
- Division of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Maria Y. Kwok
- Department of Emergency Medicine, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University Irving Medical Center, New York
| | - Sarah M. Becker
- University of Utah School of Medicine and Primary Children’s Hospital, Salt Lake City, Utah
| | - Andrew C. Dixon
- University of Alberta, Stollery Children’s Hospital, Women’s and Children’s Health Research Institute, Edmonton, Alberta, Canada
| | - Naveen Poonai
- Child Health Research Institute, Division of Paediatric Emergency Medicine, Departments of Pediatrics, Internal Medicine, Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Michelle Eckerle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Pediatric Emergency Medicine, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | | | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
- Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
32
|
Yang J, Ong WJ, Piragasam R, Allen JC, Lee JH, Chong SL. Delays in Time-To-Antibiotics for Young Febrile Infants With Serious Bacterial Infections: A Prospective Single-Center Study. Front Pediatr 2022; 10:873043. [PMID: 35573970 PMCID: PMC9099243 DOI: 10.3389/fped.2022.873043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Fear of missed serious bacterial infections (SBIs) results in many febrile young infants receiving antibiotics. We aimed to compare the time to antibiotics between infants with SBIs and those without. MATERIALS AND METHODS We recruited febrile infants ≤ 90 days old seen in the emergency department (ED) between December 2017 and April 2021. SBI was defined as (1) urinary tract infection, (2) bacteremia or (3) bacterial meningitis. We compared the total time (median with interquartile range, IQR) from ED arrival to infusion of antibiotics, divided into (i) time from triage to decision for antibiotics and (ii) time from decision for antibiotics to administration of antibiotics. RESULTS We analyzed 81 and 266 infants with and without SBIs. Median age of those with and without SBIs were 44 (IQR 19-72) and 29 (IQR 7-56) days, respectively (p = 0.002). All infants with SBIs and 168/266 (63.2%) infants without SBIs received antibiotics. Among 249 infants who received antibiotics, the median total time from ED arrival to infusion of antibiotics was 277.0 (IQR 236.0-385.0) mins for infants with SBIs and 304.5 (IQR 238.5-404.0) mins for those without (p = 0.561). The median time to decision for antibiotics was 156.0 (IQR 115.0-255.0) mins and 144.0 (IQR 105.5-211.0) mins, respectively (p = 0.175). Following decision for antibiotics, infants with SBIs received antibiotics much faster compared to those without [107.0 (IQR 83.0-168.0) vs. 141.0 (94.0-209.5) mins, p = 0.017]. CONCLUSION There was no difference in total time taken to antibiotics between infants with SBIs and without SBIs. Both recognition and administration delays were observed. While all infants with SBIs were adequately treated, more than half of the infants without SBIs received unnecessary antibiotics. This highlights the challenge in managing young febrile infants at initial presentation, and demonstrates the need to examine various aspects of care to improve the overall timeliness to antibiotics.
Collapse
Affiliation(s)
- Jinghui Yang
- Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Wei Jie Ong
- Duke-NUS Medical School, Singapore, Singapore
| | - Rupini Piragasam
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - John Carson Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore, Singapore.,Department of Paediatric Subspecialties, Children's Intensive Care, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Duke-NUS Medical School, Singapore, Singapore.,Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
33
|
Man SY, Choo JTL, Chong SL, Tan RMR. Slowing down in the fast lane: could this be sinus tachycardia? Singapore Med J 2022; 63:10-13. [DOI: 10.11622/smedj.2022024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
34
|
Nguyen M, Poh KL, Chong SL, Lee JH. 1454: EFFECTIVE DIAGNOSIS OF SEPSIS IN CRITICALLY ILL CHILDREN USING PROBABILISTIC GRAPHICAL MODEL. Crit Care Med 2022. [DOI: 10.1097/01.ccm.0000812140.26341.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
35
|
Oo NNL, Ng DCC, Ostbye T, Allen JC, Agarwal PK, Yeleswarapu SP, Chong SL, Guo X, Chan YH. Novel two-tiered developmental screening programme for Singaporean toddlers: a quality improvement report. BMJ Open Qual 2021; 10:bmjoq-2020-001327. [PMID: 34711585 PMCID: PMC8557273 DOI: 10.1136/bmjoq-2020-001327] [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] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 10/15/2021] [Indexed: 11/03/2022] Open
Abstract
Early identification of developmental delays with timely intervention, especially before the age of 3 years, can improve child development. In Singapore, however, diagnosis and intervention for developmental delays occur at a median age of 44 months. As early detection and intervention depends on an effective developmental screening programme, we aimed to improve the detection of developmental delays before the age of 3 years in a primary care setting. We did this by implementing a novel two-tiered screening programme which uses three standardised screening tools (Parents' Evaluation of Developmental Status, PEDS-Developmental Milestones and Ages and Stages Questionnaire-3). We used quality improvement methods to integrate and optimise this two-tiered programme into the existing 9-month and 18-month screening schedule, with an additional screening at 30 months to replace the pre-existing 36-month screening of the National Child Health Surveillance Programme. A total of three Plan-Do-Study-Act cycles were performed to ensure programme feasibility and sustainability. They focused on adequately training the primary care nurses, targeting an 80% screening rate and aiming for 20 min screening tool administration time per child. We assessed the proportion of children referred to the child development units after positive screening for developmental concerns under the new programme, with a pre-post and with-without intervention comparison, and reviewed the screening rates and screening tool administration time. The proportion of 18-month old children referred for developmental concerns improved from 3.5%-7.1% over a 6-month period. For those who received further assessment by developmental specialists after the two-tiered screening, 100% received a definitive diagnosis of developmental delays, similar to the situation before programme introduction. Our quality improvement efforts facilitated successful integration of the two-tiered programme into the pre-existing screening schedule with minimal impact to the clinic workflow. While we highlight challenges in implementation that need to be addressed, our findings support a potential nationwide adoption of the two-tiered programme.
Collapse
|
36
|
Choo KJL, Ho AFW, Gui H, Tay PJM, Lee HY, Koh MS, Earnest A, Pek PP, Liu N, Chong SL, Pang J, Ong MEH. Relationship between local weather, air pollution and hospital attendances for urticaria in children: Time stratified analysis of 12,002 cases. Clin Exp Allergy 2021; 52:180-182. [PMID: 34549849 DOI: 10.1111/cea.14015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/30/2020] [Accepted: 09/09/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Karen Jui Lin Choo
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore.,SingHealth Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Andrew Fu Wah Ho
- SingHealth Duke-NUS Emergency Medicine Academic Clinical Programme, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Hao Gui
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | | | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital, Singapore, Singapore
| | - Mariko Siyue Koh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Arul Earnest
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Pin Pin Pek
- Pre-hospital and Emergency Research Centre, Health Services & Systems Research, Duke-NUS Medical School, Singapore Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Nan Liu
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore.,Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Shu-Ling Chong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.,Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Junxiong Pang
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| |
Collapse
|
37
|
Tan XM, Shah MTBM, Chong SL, Ong YKG, Ang PH, Zakaria NDB, Lee KP, Pek JH. Differences in radiation dose for computed tomography of the brain among pediatric patients at the emergency departments: an observational study. BMC Emerg Med 2021; 21:106. [PMID: 34551720 PMCID: PMC8456576 DOI: 10.1186/s12873-021-00502-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/13/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Computed tomography (CT) is associated with a risk of cancer development. Strategies to reduce radiation doses vary between centers. We compared radiation doses of CT brain studies between pediatric and general emergency departments (EDs), and determine the proportion studies performed within the reference levels recommended by the International Commission on Radiological Protection (ICRP). METHODS A retrospective review was carried out in a healthcare network consisting of one pediatric ED and three general hospital EDs. Pediatric patients less than 16 years old with CT brain studies performed between 1 January 2015 and 31 December 2018 were included. Information on demographic, diagnosis, volume-averaged computed-tomography dose index and dose length product (DLP) were collected. Effective dose was then calculated from DLP using conversion factors, termed k-coefficients which were derived using a 16 cm head CT dose phantom. RESULTS Four hundred and seventy-nine CT brain studies were performed - 379 (79.1%) at the pediatric ED. Seizure (149, 31.1%), head injury (147, 30.7%) and altered mental status (44, 9.2%) were the top three ED diagnoses. The median effective dose estimates were higher in general than pediatric EDs, particularly for those aged > 3 to ≤6 years old [1.57 mSv (IQR 1.42-1.79) versus 1.93 mSv (IQR 1.51-2.28), p = 0.047], > 6 to ≤10 years old [1.43 mSv (IQR 1.27-1.67) versus 1.94 mSv (IQR 1.61-2.59), p = 0.002) and > 10 years old (1.68 mSv (IQR 1.32-1.72) versus 2.03 mSv (IQR 1.58-2.88), p < 0.001). Overall, 233 (48.6%) and 13 (2.7%) studies were within the reference levels recommended by ICRP 60 and 103 respectively. CONCLUSIONS Radiation doses for CT brain studies were significantly higher at general EDs and less than half of the studies were within the reference levels recommended by ICRP. The development of diagnostic reference levels (DRLs) as a benchmark and clinical justification for performing CT studies can help reduce the radiation risks in the pediatric population.
Collapse
Affiliation(s)
- Xi Min Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | | | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore, 229899, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore, 229899, Singapore
| | - Peck Har Ang
- Accident and Emergency Department, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Nur Diana Bte Zakaria
- Department of Emergency Medicine, Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore, 229899, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, 110 Sengkang E Way, Singapore, 544886, Singapore.
| |
Collapse
|
38
|
Liu N, Chee ML, Foo MZQ, Pong JZ, Guo D, Koh ZX, Ho AFW, Niu C, Chong SL, Ong MEH. Heart rate n-variability (HRnV) measures for prediction of mortality in sepsis patients presenting at the emergency department. PLoS One 2021; 16:e0249868. [PMID: 34460853 PMCID: PMC8405012 DOI: 10.1371/journal.pone.0249868] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/06/2021] [Indexed: 11/18/2022] Open
Abstract
Sepsis is a potentially life-threatening condition that requires prompt recognition and treatment. Recently, heart rate variability (HRV), a measure of the cardiac autonomic regulation derived from short electrocardiogram tracings, has been found to correlate with sepsis mortality. This paper presents using novel heart rate n-variability (HRnV) measures for sepsis mortality risk prediction and comparing against current mortality prediction scores. This study was a retrospective cohort study on patients presenting to the emergency department of a tertiary hospital in Singapore between September 2014 to April 2017. Patients were included if they were above 21 years old and were suspected of having sepsis by their attending physician. The primary outcome was 30-day in-hospital mortality. Stepwise multivariable logistic regression model was built to predict the outcome, and the results based on 10-fold cross-validation were presented using receiver operating curve analysis. The final predictive model comprised 21 variables, including four vital signs, two HRV parameters, and 15 HRnV parameters. The area under the curve of the model was 0.77 (95% confidence interval 0.70–0.84), outperforming several established clinical scores. The HRnV measures may have the potential to allow for a rapid, objective, and accurate means of patient risk stratification for sepsis severity and mortality. Our exploration of the use of wealthy inherent information obtained from novel HRnV measures could also create a new perspective for data scientists to develop innovative approaches for ECG analysis and risk monitoring.
Collapse
Affiliation(s)
- Nan Liu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
- Institute of Data Science, National University of Singapore, Singapore, Singapore
- * E-mail:
| | - Marcel Lucas Chee
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Mabel Zhi Qi Foo
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Jeremy Zhenwen Pong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Dagang Guo
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- SingHealth Duke-NUS Emergency Medicine Academic Clinical Programme, Singapore, Singapore
| | - Zhi Xiong Koh
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Chenglin Niu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Shu-Ling Chong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Children’s Emergency, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| |
Collapse
|
39
|
Yao SHW, Chong SL, James V, Lee KP, Ong GYK. Associations of initial haemodynamic profiles and neurological outcomes in children with traumatic brain injury: a secondary analysis. Emerg Med J 2021; 39:527-533. [PMID: 34344733 DOI: 10.1136/emermed-2020-210641] [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: 09/08/2020] [Accepted: 07/09/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Initial low systolic blood pressure (SBP) in paediatric traumatic brain injury (TBI) is associated with mortality. There is limited literature on how other haemodynamic parameters including heart rate (HR); diastolic blood pressure (DBP); mean arterial pressure (MAP); and shock index, paediatric age-adjusted (SIPA) affect not only mortality but also long-term neurological outcomes in paediatric TBI. We aimed to analyse the associations of these haemodynamic variables (HR, SBP, MAP, DBP and SIPA) with mortality and long-term neurological outcomes in isolated moderate-to-severe paediatric TBI. METHODS This was a secondary analysis of our primary study that analysed the association of TBI-associated coagulopathy with mortality and neurological outcome in isolated, moderate-to-severe paediatric head injury. A trauma registry-based, retrospective study of children <18 years old who presented to the emergency department with isolated, moderate-to-severe TBI from January 2010 to December 2016 was conducted. The association between initial haemodynamic variables and less favourable outcomes using Glasgow Outcome Scale-Extended Paediatric) at 6 months post injury was analysed using logistic regression. RESULTS Among 152 children analysed, initial systolic and diastolic hypotension (<5th percentile) (OR) for SBP 11.40, 95% CI 3.60 to 36.05, p<0.001; OR for DBP 15.75, 95% CI 3.09 to 80.21, p<0.001) and Glasgow Coma Scale scores <8 (OR 14.50, 95% CI 3.65 to 57.55, p<0.001) were associated with 'moderate-to-severe neurological disabilities', 'vegetative state' and 'death'. After adjusting for confounders, only SBP was significant (adjusted OR 5.68, 95% CI 1.40 to 23.08, p=0.015). CONCLUSIONS Initial systolic hypotension was independently associated with mortality and moderate-to-severe neurological deficits at 6 months post injury. Further work is required to understand if early correction of hypotension will improve long-term outcomes.
Collapse
Affiliation(s)
| | - Shu-Ling Chong
- Children's Emergency, KK Women's and Children's Hospital, Singapore.,Department of Emergency Medicine, Duke-NUS Medical School, Singapore
| | - Vigil James
- Children's Emergency, KK Women's and Children's Hospital, Singapore
| | - Khai Pin Lee
- Children's Emergency, KK Women's and Children's Hospital, Singapore.,Department of Emergency Medicine, Duke-NUS Medical School, Singapore
| | - Gene Yong-Kwang Ong
- Children's Emergency, KK Women's and Children's Hospital, Singapore.,Department of Emergency Medicine, Duke-NUS Medical School, Singapore
| |
Collapse
|
40
|
Ong GYK, Ngiam N, Tham LP, Mok YH, Ong JSM, Lee KP, Ganapathy S, Chong SL, Pek JH, Chew SY, Lim YC, Shen GQ, Kua J, Tan J, Ng KC. Singapore Paediatric Resuscitation Guidelines 2021. Singapore Med J 2021; 62:372-389. [PMID: 35001111 PMCID: PMC8804481 DOI: 10.11622/smedj.2021107] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
We present the 2021 Singapore Paediatric Resuscitation Guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, which was published in October 2020, and the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council, were reviewed and discussed by the committee. These recommendations were derived after deliberation of peer-reviewed evidence updates on paediatric resuscitation and took into consideration the local setting and clinical practice.
Collapse
Affiliation(s)
- Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Nicola Ngiam
- Division of Paediatric Critical Care, Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
| | - Lai Peng Tham
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Yee Hui Mok
- Children’s Intensive Care Unit, Department of Paediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore
| | - Jacqueline SM Ong
- Division of Paediatric Critical Care, Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| | | | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | - Su Yah Chew
- Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
| | - Yang Chern Lim
- Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
| | | | - Jade Kua
- Department of Emergency Medicine, Woodlands Health Campus, Singapore
| | - Josephine Tan
- Department of Paediatric Anaesthesia, KK Women’s and Children’s Hospital, Singapore
| | - Kee Chong Ng
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| | | |
Collapse
|
41
|
To YH, Ong YKG, Chong SL, Ang PH, Bte Zakaria ND, Lee KP, Pek JH. Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments. Paediatr Anaesth 2021; 31:713-719. [PMID: 33774880 DOI: 10.1111/pan.14185] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/26/2021] [Accepted: 03/22/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intubation is a life-saving intervention at the Emergency Department (ED). However, general and pediatric EDs may vary in their preparedness to manage children with airway emergencies. AIMS We aimed to compare rates of first-pass intubation and adverse tracheal intubation-associated events between general and pediatric EDs. METHODS A retrospective review of medical records was conducted at a pediatric ED and three general EDs from January 1, 2015, to December 31, 2018. Information about the intubation process involving pediatric patients (less than 16 years old), as well as eventual outcomes of first-pass intubation and adverse tracheal intubation-associated events were collected and analyzed. RESULTS There were 180 pediatric intubations, of which 115 (63.9%) were performed in pediatric ED. The median age was 2 years old (interquartile range 0-6). Intubation was most commonly performed for patients with cardiac arrest (88, 48.9%). Direct laryngoscopy was used in 178 (98.9%) cases and uncuffed tube was used in 135 (75.0%) cases. Apneic oxygenation was performed in 26 (14.4%) cases-all in pediatric ED. Intubation was predominantly performed by senior clinicians (162, 90.0%). Overall, intubation was performed successfully in 175 (97.2%) cases, with a first-pass intubation rate of 82.2% which was similar between pediatric (96, 83.5%) and general EDs (52, 80%) (Odds ratio [OR] 1.26, 95% confidence interval [CI] 0.58 to 2.76, p = .558). There were 68 adverse tracheal intubation-associated events with right mainstem intubation being the most common (23, 12.8%). Pediatric EDs (44, 38.3%) had a higher rate of adverse tracheal intubation-associated events than general EDs (15, 23.1%) (OR 2.07, 95% CI 1.04 to 4.11; p = .037). CONCLUSIONS Differences exist in intubation outcomes between pediatric and general EDs. Quality improvement efforts should focus on standardizing intubation practices across both pediatric and general EDs.
Collapse
Affiliation(s)
- Yi Hui To
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth, Singapore City, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth, Singapore City, Singapore
| | - Peck Har Ang
- Accident & Emergency Department, Changi General Hospital, SingHealth, Singapore City, Singapore
| | - Nur Diana Bte Zakaria
- Department of Emergency Medicine, Singapore General Hospital, SingHealth, Singapore City, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth, Singapore City, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, SingHealth, Singapore City, Singapore
| |
Collapse
|
42
|
Chong SL, Ong GYK, Zheng CQ, Dang H, Ming M, Mahmood M, Chan LCN, Chuah SL, Lee OPE, Qian S, Fan L, Konoike Y, Lee JH. Early Coagulopathy in Pediatric Traumatic Brain Injury: A Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) Retrospective Study. Neurosurgery 2021; 89:283-290. [PMID: 33913493 DOI: 10.1093/neuros/nyab157] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/09/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although early coagulopathy increases mortality in adults with traumatic brain injury (TBI), less is known about pediatric TBI. OBJECTIVE To describe the prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet levels of children with moderate to severe TBI to identify predictors of early coagulopathy and study the association with clinical outcomes. METHODS Using the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) TBI retrospective cohort, we identified patients <16 yr old with a Glasgow Coma Scale (GCS) ≤13. We compared PT, APTT, platelets, and outcomes between children with isolated TBI and multiple trauma with TBI. We performed logistic regressions to identify predictors of early coagulopathy and study the association with mortality and poor functional outcomes. RESULTS Among 370 children analyzed, 53/370 (14.3%) died and 127/370 (34.3%) had poor functional outcomes. PT was commonly deranged in both isolated TBI (53/173, 30.6%) and multiple trauma (101/197, 51.3%). Predictors for early coagulopathy were young age (adjusted odds ratio [aOR] 0.94, 95% CI 0.88-0.99, P = .023), GCS < 8 (aOR 1.96, 95% CI 1.26-3.06, P = .003), and presence of multiple trauma (aOR 2.21, 95% confidence interval [CI] 1.37-3.60, P = .001). After adjusting for age, gender, GCS, multiple traumas, and presence of intracranial bleed, children with early coagulopathy were more likely to die (aOR 7.56, 95% CI 3.04-23.06, P < .001) and have poor functional outcomes (aOR 2.16, 95% CI 1.26-3.76, P = .006). CONCLUSION Early coagulopathy is common and independently associated with death and poor functional outcomes among children with TBI.
Collapse
Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | | | - Hongxing Dang
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Meixiu Ming
- Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Maznisah Mahmood
- Department of Paediatrics, Institute of Paediatric, Kuala Lumpur, Malaysia
| | - Lawrence Chi Ngong Chan
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Soo Lin Chuah
- Department of Paediatrics, University Malaya, Kuala Lumpur, Malaysia
| | - Olive Pei Ee Lee
- Department of Paediatrics, Sarawak General Hospital, Sarawak, Malaysia
| | - Suyun Qian
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lijia Fan
- Khoo Teck Puat National University Children's Medical Institute, National University Hospital, Singapore.,Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yoshihiko Konoike
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore.,Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| |
Collapse
|
43
|
Chong SL, Ong GYK, Allen JC, Lee JH, Piragasam R, Koh GZX, Mahajan P, Liu N, Ong MEH. Early prediction of serious infections in febrile infants incorporating heart rate variability in an emergency department: a pilot study. Emerg Med J 2021; 38:607-612. [PMID: 33863774 DOI: 10.1136/emermed-2020-210675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Early differentiation of febrile young infants with from those without serious infections (SIs) remains a diagnostic challenge. We sought to (1) compare vital signs and heart rate variability (HRV) parameters between febrile infants with versus without SIs, (2) assess the performance of HRV and vital signs with reference to current triage tools and (3) compare HRV and vital signs to HRV, vital signs and blood biomarkers, when predicting for the presence of SIs. METHODS Using a prospective observational design, we recruited patients <3 months old presenting to a tertiary paediatric ED in Singapore from December 2018 through November 2019. We obtained patient demographic characteristics, triage assessment (including the Severity Index Score (SIS)), HRV parameters (time, frequency and non-linear domains) and laboratory results. We performed multivariable logistic regression analyses to predict the presence of an SI, using area under the curve (AUC) with the corresponding 95% CI to assess predictive capability. RESULTS Among 203 infants with a mean age of 38.4 days (SD 27.6), 67 infants (33.0%) had an SI. There were significant differences in the time, frequency and non-linear domains of HRV parameters between infants with versus without SIs. In predicting SIs, gender, temperature and the HRV non-linear parameter Poincaré plot SD2 (AUC 0.78, 95% CI 0.71 to 0.84) performed better than SIS alone (AUC 0.61, 95% CI 0.53 to 0.68). Model performance improved with the addition of absolute neutrophil count and C reactive protein (AUC 0.82, 95% CI 0.76 to 0.89). CONCLUSION An exploratory prediction model incorporating HRV and biomarkers improved prediction of SIs. Further research is needed to assess if HRV can identify which young febrile infants have an SI at ED triage. TRIAL REGISTRATION NUMBER NCT04103151.
Collapse
Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - John Carson Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Rupini Piragasam
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | | | - Prashant Mahajan
- Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nan Liu
- Centre for Quantitative Medicine and Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore.,Health Services and Systems Research, Duke-NUS Medical School, Singapore
| |
Collapse
|
44
|
Yoong SYC, Ang PH, Chong SL, Ong YKG, Zakaria NDB, Lee KP, Pek JH. Common diagnoses among pediatric attendances at emergency departments. BMC Pediatr 2021; 21:172. [PMID: 33853569 PMCID: PMC8045375 DOI: 10.1186/s12887-021-02646-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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] [Received: 12/12/2020] [Accepted: 04/05/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Pediatric patients present to Emergency Departments (EDs) with a variety of medical conditions. An appreciation of the common presenting conditions can aid EDs in the provision of pediatric emergency care. In this study, we established the common pediatric diagnoses seen at the general EDs, with reference to a pediatric ED. METHODS A retrospective review of medical records was performed for patients less than 16 years old at a pediatric ED and two general EDs from 1 January to 31 December 2018. Information including patient demographics, triage category, case type and diagnoses were collected. RESULTS There were 159,040 pediatric attendances, of which 3477 (2.2%) were seen at the general EDs. Non-traumatic conditions were most prevalent at both general (N = 1933, 55.6%) and pediatric (N = 128,415, 82.5%) EDs. There was a higher proportion of trauma related conditions seen at the general EDs (N = 1544, 44.4%) compared to the pediatric ED (N = 27,148, 17.5%; p < 0.01). Across all EDs, upper respiratory tract infection, unspecified musculoskeletal pain and gastroenteritis were the three most common non-trauma related diagnoses, while fracture, wound and contusion were the three most common trauma related diagnoses. There was a greater proportion of emergent (P1) cases seen at the general EDs (N = 233, 6.7%) than the pediatric ED (N = 3821, 2.5%; p < 0.01). Respiratory conditions including bronchiolitis, asthma and bronchitis were the most common emergent (P1) diagnoses. CONCLUSIONS The common diagnoses among pediatric attendances varied between pediatric and general EDs. Therefore, general EDs should focus their efforts on these common diagnoses, especially the emergent (P1) ones, so that they can enhance their preparedness and work towards providing quality pediatric emergency care.
Collapse
Affiliation(s)
- Shuen Yin Celine Yoong
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Peck Har Ang
- Accident and Emergency Department, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore, 229899, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore, 229899, Singapore
| | - Nur Diana Bte Zakaria
- Department of Emergency Medicine, Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore, 229899, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, 110 Sengkang E Way, Singapore, 544886, Singapore.
| |
Collapse
|
45
|
Chong SL, Dang H, Ming M, Mahmood M, Zheng CQS, Gan CS, Lee OPE, Ji J, Chan LCN, Ong JSM, Kurosawa H, Lee JH. Traumatic Brain Injury Outcomes in 10 Asian Pediatric ICUs: A Pediatric Acute and Critical Care Medicine Asian Network Retrospective Study. Pediatr Crit Care Med 2021; 22:401-411. [PMID: 33027240 DOI: 10.1097/pcc.0000000000002575] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Traumatic brain injury remains an important cause of death and disability. We aim to report the epidemiology and management of moderate to severe traumatic brain injury in Asian PICUs and identify risk factors for mortality and poor functional outcomes. DESIGN A retrospective study of the Pediatric Acute and Critical Care Medicine Asian Network moderate to severe traumatic brain injury dataset collected between 2014 and 2017. SETTING Patients were from the participating PICUs of Pediatric Acute and Critical Care Medicine Asian Network. PATIENTS We included children less than 16 years old with a Glasgow Coma Scale less than or equal to 13. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We obtained data on patient demographics, injury circumstances, and PICU management. We performed a multivariate logistic regression predicting for mortality and poor functional outcomes. We analyzed 380 children with moderate to severe traumatic brain injury. Most injuries were a result of road traffic injuries (174 [45.8%]) and falls (160 [42.1%]). There were important differences in temperature control, use of antiepileptic drugs, and hyperosmolar agents between the sites. Fifty-six children died (14.7%), and 104 of 324 survivors (32.1%) had poor functional outcomes. Poor functional outcomes were associated with non-high-income sites (adjusted odds ratio, 1.90; 95% CI, 1.11-3.29), Glasgow Coma Scale less than 8 (adjusted odds ratio, 4.24; 95% CI, 2.44-7.63), involvement in a road traffic collision (adjusted odds ratio, 1.83; 95% CI, 1.04-3.26), and presence of child abuse (adjusted odds ratio, 2.75; 95% CI, 1.01-7.46). CONCLUSIONS Poor functional outcomes are prevalent after pediatric traumatic brain injury in Asia. There is an urgent need for further research in these high-risk groups.
Collapse
Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Hongxing Dang
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Meixiu Ming
- Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Maznisah Mahmood
- Department of Paediatrics, Institute of Paediatric, Kuala Lumpur, Malaysia
| | - Charles Q S Zheng
- Department of Epidemiology, Singapore Clinical Research Institute, Singapore
| | - Chin Seng Gan
- Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Olive P E Lee
- Department of Paediatrics, Sarawak General Hospital, Sarawak, Malaysia
| | - Jian Ji
- Department of Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Lawrence C N Chan
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Jacqueline S M Ong
- Khoo Teck Puat National University Children's Medical Institute, National University Hospital, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| |
Collapse
|
46
|
Kirk AHP, Chong SL, Kam KQ, Huang W, Ang LSL, Lee JH, Sultana R, Hon KL, Wong JJM. Psychosocial impact of the COVID-19 pandemic on paediatric healthcare
workers. Ann Acad Med Singap 2021. [DOI: 10.47102/annals-acadmedsg.2020527] [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] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Frontline healthcare workers (HCWs) exposed to coronavirus disease 2019 (COVID-19)
are at risk of psychological distress. This study evaluates the psychological impact of COVID-19 pandemic
on HCWs in a national paediatric referral centre.
Methods: This was a survey-based study that collected demographic, work environment and mental
health data from paediatric HCWs in the emergency, intensive care and infectious disease units. Psychological
impact was measured using the Depression, Anxiety, Stress Scale-21. Multivariate regression analysis
was performed to identify risk factors associated with psychological distress.
Results: The survey achieved a response rate of 93.9% (430 of 458). Of the 430 respondents, symptoms
of depression, anxiety and stress were reported in 168 (39.1%), 205 (47.7%) and 106 (24.7%),
respectively. Depression was reported in the mild (47, 10.9%), moderate (76, 17.7%), severe (23, 5.3%)
and extremely severe (22, 5.1%) categories. Anxiety (205, 47.7%) and stress (106, 24.7%) were reported
in the mild category only. Collectively, regression analysis identified female sex, a perceived lack of choice
in work scope/environment, lack of protection from COVID-19, lack of access to physical activities and
rest, the need to perform additional tasks, and the experience of stigma from the community as risk factors
for poor psychological outcome.
Conclusion: A high prevalence of depression, anxiety and stress was reported among frontline paediatric
HCWs during the COVID-19 pandemic. Personal psychoneuroimmunity and organisational prevention
measures can be implemented to lessen psychiatric symptoms. At the national level, involving mental health
professionals to plan and coordinate psychological intervention for the country should be considered.
Collapse
Affiliation(s)
| | | | | | - Weili Huang
- KK Women’s and Children’s Hospital, Singapore
| | | | | | - Rehena Sultana
- Centre for Quantitative Medicine, SingHealth Duke-NUS, Singapore
| | - Kam Lun Hon
- The Chinese University of Hong Kong, Hong Kong
| | | |
Collapse
|
47
|
Goh MSL, Looi DSH, Goh JL, Sultana R, Goh SSM, Lee JH, Chong SL. The Impact of Traumatic Brain Injury on Neurocognitive Outcomes in Children: a Systematic Review and Meta-Analysis. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-325066. [PMID: 33789922 DOI: 10.1136/jnnp-2020-325066] [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: 09/08/2020] [Revised: 01/25/2021] [Accepted: 03/10/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the burden of paediatric traumatic brain injury (TBI) on neurocognition via a systematic review and meta-analysis. METHODS Studies that compared neurocognitive outcomes of paediatric patients with TBI and controls were searched using Medline, Embase, PsycINFO and Cochrane Central Register of Controlled Trials, between January 1988 and August 2019. We presented a random-effects model, stratified by TBI severity, time of assessment post injury and age. RESULTS Of 5919 studies, 41 (patients=3717) and 33 (patients=3118) studies were included for the systematic review and meta-analysis, respectively. Studies mostly measured mild TBI (n=26, patients=2888) at 0-3 months postinjury (n=17, patients=2502). At 0-3 months postinjury, standardised mean differences between TBI and controls for executive function were -0.04 (95% CI -0.14 to 0.07; I2=0.00%), -0.18 (95% CI -0.29 to -0.06; I2=26.1%) and -0.95 (95% CI -1.12 to -0.77; I2=10.1%) for mild, moderate and severe TBI, respectively; a similar effect was demonstrated for learning and memory. Severe TBI had the worst outcomes across all domains and persisted >24 months postinjury. Commonly used domains differed largely from workgroup recommendations. Risk of bias was acceptable for all included studies. CONCLUSION A dose-dependent relationship between TBI severity and neurocognitive outcomes was evident in executive function and in learning and memory. Cognitive deficits were present for TBIs of all severity but persisted among children with severe TBI. The heterogeneity of neurocognitive scales makes direct comparison between studies difficult. Future research into lesser explored domains and a more detailed assessment of neurocognitive deficits in young children are required to better understand the true burden of paediatric TBI.
Collapse
Affiliation(s)
| | - Dawn Shu Hui Looi
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jia Ling Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Sharon Si Min Goh
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Shu-Ling Chong
- Duke-NUS Medical School, Singapore
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| |
Collapse
|
48
|
Tan RMR, Ganapathy S, Tyebally A, Lee KP, Chong SL, Soo JSL, Thoon KC, Chan YH, Ng KC. Paediatric emergency department attendances during COVID-19 and SARS
in Singapore. Ann Acad Med Singap 2021. [DOI: 10.47102/annals-acadmedsg.2020500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: We evaluated the impact of public health measures on paediatric emergency
department attendances during the COVID-19 and severe acute respiratory syndrome (SARS)
outbreaks in Singapore.
Methods: Between 1 January 2020 and 31 July 2020, we retrospectively reviewed paediatric
emergency department attendances and admissions in a tertiary paediatric hospital in Singapore
before and after a national lockdown to combat the spread of COVID-19 in Singapore. Hospital
attendances and admissions were compared with data from a corresponding period in 2019 (1 January 2019
to 31 July 2019), as well as during and after the SARS outbreak (1 January 2003 to 31 December 2004).
Results: Compared with a corresponding non-outbreak period, emergency department attendances
decreased in line with nationwide public health measures during the COVID-19 and SARS outbreaks
(2020 and 2003 respectively), before increasing gradually following lifting of restrictions, albeit not
to recorded levels before these outbreaks. During the COVID-19 outbreak, mean daily attendances
decreased by 40%, from 458 per day in January–July 2019, to 274 per day in January–July 2020. The
absolute number of hospital inpatient admissions decreased by 37% from January–July 2019 (19,629) to
January–July 2020 (12,304). The proportion of emergency department attendances requiring admission
remained similar: 20% in January–July 2019 and 21% in January–July 2020.
Conclusion: Nationwide public health measures in Singapore have had an impact on paediatric
emergency department attendances and hospital inpatient admissions. Data from this study could inform
planning and resource allocation for emergency departments in Singapore and internationally.
Keywords: COVID-19, paediatric emergency department, public health measures, SARS
Collapse
|
49
|
Chang SSY, Lim AZ, Ong GYK, Piragasam R, Allen JC, Ng KC, Maconochie I, Chong SL. Predictors of serious bacterial infections using serum biomarkers in an infant population aged 0 to 90 days: a prospective cohort study. BMJ Paediatr Open 2021; 5:e000861. [PMID: 34192187 PMCID: PMC7818843 DOI: 10.1136/bmjpo-2020-000861] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/17/2020] [Accepted: 12/26/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Young febrile infants represent a vulnerable population at risk for serious bacterial infections (SBI). We aimed to evaluate the diagnostic accuracy of components of the complete blood count in comparison with C-reactive protein (CRP) to predict SBI among febrile infants. DESIGN AND SETTING Prospective cohort study conducted in a tertiary emergency department between December 2018 and November 2019. PATIENTS We included febrile infants ≤3 months old with complete blood count results. We analysed their white blood cell count (WBC), absolute neutrophil ratio (ANC), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio, mean platelet volume to platelet count ratio, and compared these to the performance of CRP. MAIN OUTCOME MEASURES SBIs were defined as urinary tract infection, bacteraemia, bacterial meningitis, sepsis, pneumonia, skin and soft tissue infection, bacterial enteritis, septic arthritis or osteomyelitis. RESULTS Of the 187 infants analysed, 54 (28.9%) were diagnosed with SBI. Median values of WBC, ANC, NLR and CRP were significantly higher in infants with SBI: WBC (13.8 vs 11.4×109/L, p=0.004), ANC (6.7 vs 4.1×109/L, p<0.001), NLR (1.3 vs 0.9, p=0.001) and CRP (21.0 vs 2.3 mg/L, p<0.001), compared with those without. CRP had the best discriminatory values for SBI, with area under the curve (AUC) of 0.815 (95% CI 0.747 to 0.883), compared with WBC, ANC and NLR. A predictive model consisting of WBC, ANC and NLR in combination with clinical parameters, had an AUC of 0.814 (95% CI 0.746 to 0.883). There was increased discriminative performance when this predictive model was combined with CRP, (AUC of 0.844, 95% CI 0.782 to 0.906). CONCLUSION In young febrile infants, CRP was the best discriminatory biomarker for SBI. WBC, ANC and NLR when used in combination have potential diagnostic utility in this population.
Collapse
Affiliation(s)
- Serena Su Ying Chang
- Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Amanda Zhirui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Rupini Piragasam
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | - John Carson Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Kee Chong Ng
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Ian Maconochie
- Section of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| |
Collapse
|
50
|
Teo JH, Chong SL, Chiang LW, Ng ZM. Cost of inpatient rehabilitation for children with moderate to severe traumatic brain injury. Ann Acad Med Singap 2021; 50:26-32. [PMID: 33623955 DOI: 10.47102/annals-acadmedsg.2020114] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
AIM To evaluate the cost of inpatient rehabilitation for children with moderate to severe traumatic brain injury (TBI). Secondary aim was to identify factors associated with high inpatient rehabilitation cost. METHOD Retrospective review of a tertiary hospital's trauma registry was performed from 2011-2017. All patients aged 16 years or younger who sustained TBI with Glasgow Coma Scale ≤13 were included. Data on patient demographics, mechanism and severity of injury, hospital duration and inpatient rehabilitation cost were collected. We performed a regression analysis to identify factors associated with high rehabilitation cost. RESULTS There were a total of 51 patients. The median duration of inpatient rehabilitation was 13.5 days (interquartile range [IQR] 4-35), amounting to a median cost of SGD8,361 (IQR 3,543-25,232). Daily ward costs contributed the most to total inpatient rehabilitation cost. Those with severe TBI had longer duration of inpatient rehabilitation that resulted in higher cost of inpatient rehabilitation. Presence of polytrauma, medical complications, post-traumatic amnesia and TBI post-non-accidental injury (NAI) were associated with higher cost of inpatient rehabilitation. CONCLUSION The cost of inpatient rehabilitation for paediatric patients post-TBI is significant in Singapore. Patients with TBI secondary to NAI had significantly higher cost of inpatient rehabilitation. Ways to reduce duration of hospitalisation post-TBI and early step-down care or outpatient rehabilitation should be explored to reduce cost.
Collapse
Affiliation(s)
- Jia Hui Teo
- Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | | | | | | |
Collapse
|