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Szymczak JE, Lee G, Klieger SB, Woods C, Creech CB, Gilsdorf JR, Dennehy P, Zaoutis T. Multifaceted but Invisible: Perceptions of the Value of a Pediatric Cognitive Specialty. Hosp Pediatr 2019; 8:385-393. [PMID: 29946040 DOI: 10.1542/hpeds.2017-0240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Systems for standardizing physician payment have been shown to undervalue cognitive clinical encounters. Because health care reform emphasizes value-based approaches, we need an understanding of the way pediatric cognitive specialties are used to contribute to the provision of high-value care. We sought to investigate how clinical and administrative stakeholders perceive the value of pediatric infectious disease (PID) specialists. METHODS We conducted qualitative interviews with a purposive sample of physicians and administrators from 5 hospitals across the United States in which children are cared for. All interviews were transcribed and systematically analyzed for common themes. RESULTS We interviewed 97 stakeholders. Analysis revealed the following 3 domains of value: clinical, organizational, and communicative. Clinically, PID specialists were perceived to be highly valuable in treating patients with unusual infections that respond poorly to therapy, in optimizing the use of antimicrobial agents and in serving as outpatient homes for complex patients. Respondents perceived that PID specialists facilitate communication with patients and their families, the health care team and the media. PID specialists were perceived to generate value by participating in systemwide activities, including antimicrobial stewardship and infection prevention. Despite this, much of the valuable work PID specialists perform is difficult to measure causing some administrative stakeholders to question how many PID specialists are necessary to achieve high-quality care. CONCLUSIONS With our findings, we suggest that pediatric cognitive specialties contribute value in multiple ways to the health care delivery system. Many of these domains are difficult to capture by using current metrics, which may lead administrators to overlook valuable work and to under-allocate resources.
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Affiliation(s)
- Julia E Szymczak
- Division of Infectious Diseases, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;
| | - Grace Lee
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California and Lucile Salter Packard Children's Hospital, Palo Alto, California
| | - Sarah B Klieger
- Division of Infectious Diseases, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Charles Woods
- Division of Infectious Disease, Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Janet R Gilsdorf
- Division of Pediatric Infectious Diseases, University of Michigan, Ann Arbor, Michigan; and
| | - Penelope Dennehy
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Hasbro Children's Hospital, Providence, Rhode Island
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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2
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Szymczak JE, Klieger SB, Miller M, Fiks AG, Gerber JS. What Parents Think About the Risks and Benefits of Antibiotics for Their Child's Acute Respiratory Tract Infection. J Pediatric Infect Dis Soc 2018; 7:303-309. [PMID: 28992328 DOI: 10.1093/jpids/pix073] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/09/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Parental pressure is often cited as a reason for why pediatricians overuse antibiotics for children with acute respiratory tract infection (ARTI). We sought to capture parent perceptions of antibiotics at the time of their child's presentation with an ARTI. METHODS We conducted semistructured interviews with parents of children who presented with ARTI symptoms to 1 of 4 diverse practices in a large hospital-affiliated network of pediatric primary care practices. Parents were interviewed before their child was seen by the pediatrician and asked about their perceptions of antibiotics. RESULTS Interviews were conducted with 109 parents. None of the parents said they planned to ask the pediatrician for antibiotics but instead expected to gain reassurance and a plan to minimize symptoms. Three perceptions about antibiotics were identified: parents have a sense of wariness when their child is prescribed antibiotics, they have an understanding that antibiotic overuse is a problem but that it is driven by the demands of other parents, and they have a preference for alternative treatment. The majority of the parents were not concerned about antibiotic resistance. In response to closed-ended questions designed to assess their level of concern with adverse effects, parents were most concerned with their child developing an upset stomach, having an allergic reaction, and experiencing diarrhea. The parents were not concerned with antibiotic treatment failure. CONCLUSIONS Parents in our study expressed a sense of caution about antibiotics and an awareness that they should be used judiciously. Our findings indicate that parents are aware of the downsides of antibiotics and might be willing to partner with healthcare providers to improve appropriate use.
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Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sarah B Klieger
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania
| | - Matthew Miller
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania
| | - Alexander G Fiks
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania.,Department of General Pediatrics, Children's Hospital of Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
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3
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Kelley JC, Stettler-Davis N, Leonard MB, Hill D, Wrotniak BH, Shults J, Stallings VA, Berkowitz R, Xanthopoulos MS, Prout-Parks E, Klieger SB, Zemel BS. Effects of a Randomized Weight Loss Intervention Trial in Obese Adolescents on Tibia and Radius Bone Geometry and Volumetric Density. J Bone Miner Res 2018; 33:42-53. [PMID: 28884881 PMCID: PMC8527854 DOI: 10.1002/jbmr.3288] [Citation(s) in RCA: 12] [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: 06/07/2017] [Revised: 08/31/2017] [Accepted: 09/06/2017] [Indexed: 01/06/2023]
Abstract
Obese adolescents have increased fracture risk, but effects of alterations in adiposity on bone accrual and strength in obese adolescents are not understood. We evaluated 12-month changes in trabecular and cortical volumetric bone mineral density (vBMD) and cortical geometry in obese adolescents undergoing a randomized weight management program, and investigated the effect of body composition changes on bone outcomes. Peripheral quantitative computed tomography (pQCT) of the radius and tibia, and whole-body dual-energy X-ray absorptiometry (DXA) scans were obtained at baseline, 6 months, and 12 months in 91 obese adolescents randomized to standard care versus behavioral intervention for weight loss. Longitudinal models assessed effects of body composition changes on bone outcomes, adjusted for age, bone length, and African-American ancestry, and stratified by sex. Secondary analyses included adjustment for physical activity, maturation, vitamin D, and inflammatory biomarkers. Baseline body mass index (BMI) was similar between intervention groups. Twelve-month change in BMI in the standard care group was 1.0 kg/m2 versus -0.4 kg/m2 in the behavioral intervention group (p < 0.01). Intervention groups were similar in bone outcomes, so they were combined for subsequent analyses. For the tibia, BMI change was not associated with change in vBMD or structure. Greater baseline lean body mass index (LBMI) associated with higher cortical vBMD in males, trabecular vBMD in females, and polar section modulus (pZ) and periosteal circumference (Peri-C) in both sexes. In females, change in LBMI positively associated with gains in pZ and Peri-C. Baseline visceral adipose tissue (VFAT) was inversely associated with pZ in males and cortical vBMD in females. Change in VFAT did not affect bone outcomes. For the radius, BMI and LBMI changes positively associated with pZ in males. Thus, in obese adolescents, weight loss intervention with modest changes in BMI was not detrimental to radius or tibia bone strength, and changes in lean, but not adiposity, measures were beneficial to bone development. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Jennifer C Kelley
- Division of Endocrinology and Diabetes, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | | | - Mary B Leonard
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Douglas Hill
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Pediatric Advanced Care Team, The Children's Hospital of Philadephia, Philadelphia, PA, USA
| | - Brian H Wrotniak
- Department of Physical Therapy, D'Youville College, Buffalo, NY, USA
| | - Justine Shults
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Biostatistics and Data Management, The Children's Hospital of Philadephia, Philadelphia, PA, USA
| | - Virginia A Stallings
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadephia, Philadelphia, PA, USA
| | - Robert Berkowitz
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa S Xanthopoulos
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elizabeth Prout-Parks
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadephia, Philadelphia, PA, USA
| | - Sarah B Klieger
- Biostatistical and Data Management Core, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Babette S Zemel
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadephia, Philadelphia, PA, USA
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4
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Smith RJ, Klieger SB, Sulieman SE, Berger E, Treat JR, Fisher BT. Retrospective review of immunocompromised children undergoing skin biopsy for suspected invasive infection: Analysis of factors predictive of invasive mold. Pediatr Dermatol 2018; 35:104-111. [PMID: 29231258 DOI: 10.1111/pde.13351] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Cutaneous lesions are often the first marker of invasive mold infection, which can cause substantial morbidity in immunocompromised children. The purpose of this study was to describe the evaluation and outcomes of immunocompromised children who presented with findings requiring skin biopsy because of concern about invasive infection. In children who were biopsied, we sought to determine the factors predictive of invasive mold infection. METHODS A retrospective review was conducted at the Children's Hospital of Philadelphia. Patients included in the study were immunocompromised individuals younger than 26 years old who underwent skin biopsy by the inpatient dermatology consultation team between January 1, 2003, and March 15, 2015, because of development of new cutaneous lesions that were suspected of being invasive infection. RESULTS One hundred five encounters met the inclusion criteria. Fifty (47.6%) biopsied individuals had an infectious pathogen identified on histopathology or culture. Mold was the most common (36%) pathogen, followed by bacteria (32%) and yeast (26%). The presence of a single lesion (P = .001) and prior occlusion at the site of the lesion (P < .001) were associated with mold on biopsy. The combination of a single lesion, history of occlusion, and tissue necrosis on examination was highly predictive for invasive mold infection (86.3% [95% confidence interval 55.1-97.0%]). Of the 18 individuals with confirmed invasive mold infection, 13 (72%) underwent surgical resection, of whom 12 (92%) survived the 30-day follow-up period. CONCLUSION Skin biopsy enabled the detection of a pathogen that informed directed therapeutic interventions in nearly half of participants. Institutions caring for immunocompromised children should ensure adequate staffing of clinical personnel approved to perform skin biopsies.
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Affiliation(s)
- Robert J Smith
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sarah B Klieger
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Salwa E Sulieman
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospitals & Clinics and University of Missouri-Kansas City, Kansas City, MO, USA
| | - Emily Berger
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Ronald O. Perelman Department of Dermatology, New York University, New York, NY, USA
| | - James R Treat
- Section of Dermatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brian T Fisher
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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5
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Klieger SB, Gutman A, Allen L, Pacula RL, Ibrahim JK, Burris S. Mapping medical marijuana: state laws regulating patients, product safety, supply chains and dispensaries, 2017. Addiction 2017; 112:2206-2216. [PMID: 28696583 PMCID: PMC5725759 DOI: 10.1111/add.13910] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/17/2017] [Accepted: 06/13/2017] [Indexed: 02/03/2023]
Abstract
AIMS (1) To describe open source legal data sets, created for research use, that capture the key provisions of US state medical marijuana laws. The data document how state lawmakers have regulated a medicine that remains, under federal law, a Schedule I illegal drug with no legitimate medical use. (2) To demonstrate the variability that exists across states in rules governing patient access, product safety and dispensary practice. METHODS Two legal researchers collected and coded state laws governing marijuana patients, product safety and dispensaries in effect on 1 February 2017, creating three empirical legal data sets. We used summary tables to identify the variation in specific statutory provisions specified in each state's medical marijuana law as it existed on 1 February 2017. We compared aspects of these laws to the traditional Federal approach to regulating medicine. Full data sets, codebooks and protocols are available through the Prescription Drug Abuse Policy System (http://www.pdaps.org/; Archived at http://www.webcitation.org/6qv5CZNaZ on 2 June 2017). RESULTS Twenty-eight states (including the District of Columbia) have authorized medical marijuana. Twenty-seven specify qualifying diseases, which differ across states. All states protect patient privacy; only 14 protect patients against discrimination. Eighteen states have mandatory product safety testing before any sale. While the majority have package/label regulations, states have a wide range of specific requirements. Most regulate dispensaries (25 states), with considerable variation in specific provisions such as permitted product supply sources number of dispensaries per state and restricting proximity to various types of location. CONCLUSIONS The federal ban in the United States on marijuana has resulted in a patchwork of regulatory strategies that are not uniformly consistent with the approach usually taken by the Federal government and whose effectiveness remains unknown.
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Affiliation(s)
- Sarah B. Klieger
- Center for Health Law, Policy and Practice, Beasley School of Law, Temple University
| | - Abraham Gutman
- Center for Health Law, Policy and Practice, Beasley School of Law, Temple University
| | | | | | - Jennifer K. Ibrahim
- Center for Health Law, Policy and Practice, Beasley School of Law, Temple University,College of Public Health, Temple University
| | - Scott Burris
- Center for Health Law, Policy and Practice, Beasley School of Law, Temple University
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6
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Downes KJ, Weiss SL, Gerber JS, Klieger SB, Fitzgerald JC, Balamuth F, Kubis SE, Tolomeo P, Bilker WB, Han X, Nachamkin I, Garrigan C, Han JH, Lautenbach E, Coffin SE. A Pragmatic Biomarker-Driven Algorithm to Guide Antibiotic Use in the Pediatric Intensive Care Unit: The Optimizing Antibiotic Strategies in Sepsis (OASIS) Study. J Pediatric Infect Dis Soc 2017; 6:134-141. [PMID: 27147715 PMCID: PMC5907860 DOI: 10.1093/jpids/piw023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 03/27/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND. Biomarkers that identify critically ill children with systemic inflammatory response syndrome (SIRS) at low risk for bacterial infection may help clinicians reduce unnecessary antibiotic use. METHODS. We conducted a prospective cohort study of children with SIRS and suspected infection admitted to a pediatric intensive care unit from January 5, 2012 to March 7, 2014. We enrolled patients upon initiation of new antibiotics (Time 0) and measured a panel of 8 serum biomarkers daily over 72 hours. Microbiology, imaging, and clinical data were reviewed to classify bacterial infections using Centers for Disease Control and Prevention definitions. We identified cut points of biomarker combinations to maximize the negative predictive value (NPV) and specificity for bacterial infection. Excess antibiotics were calculated as days of therapy beyond day 2 after SIRS onset in patients without bacterial infection. RESULTS. Infections were identified in 46 of 85 patients: bacterial (n = 22) and viral (24), whereas 39 patients had no infection identified. At Time 0, C-reactive protein (CRP) <5 mg/dL plus serum amyloid A <15.0 µg/mL had an NPV of 0.92 (95% confidence interval [CI], 0.79-1.0) and specificity of 0.54 (95% CI, 0.42-0.66) to identify patients without bacterial infection, whereas CRP <4 mg/dL plus procalcitonin <1.75 ng/mL had an NPV of 0.90 (95% CI, 0.79-1.0) and specificity of 0.43 (95% CI, 0.30-0.55). Patients without bacterial infection received a mean of 3.8 excess days of therapy. CONCLUSIONS. Early measurement of select biomarkers can identify children with SIRS in whom antibiotics might be safely discontinued when there is no other objective evidence of infection at 48 hours.
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Affiliation(s)
- Kevin J Downes
- Division of Infectious Diseases
- Center for Pediatric Clinical Effectiveness
| | | | - Jeffrey S Gerber
- Division of Infectious Diseases
- Center for Pediatric Clinical Effectiveness
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology
| | | | | | - Fran Balamuth
- Division of Emergency Medicine, The Children's Hospital of Philadelphia
| | | | - Pam Tolomeo
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology
| | - Warren B Bilker
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology
| | - Xiaoyan Han
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology
| | - Irving Nachamkin
- Department of Pathology and Laboratory Medicine, Department of Medicine, and
| | - Charles Garrigan
- Department of Pathology and Laboratory Medicine, Department of Medicine, and
| | - Jennifer H Han
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ebbing Lautenbach
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Susan E Coffin
- Division of Infectious Diseases
- Center for Pediatric Clinical Effectiveness
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7
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Abstract
Can we search for items based on their type of motion? We consider here visual search based on three types of motion: (i) ballistic motion, in which objects move in a straight line until they encounter a display boundary; (ii) random-walk motion, in which objects change direction randomly; (iii) composite motion, in which objects move with random fluctuations around a generally ballistic trajectory. The asymmetric pattern of search efficiency can be explained by assuming that visual attention is guided by processes sensitive to the presence of linear motion and change in motion. The results do not reveal a more sophisticated ability to segregate items based on the nature of their motion.
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8
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De Luca M, Green M, Symmonds J, Klieger SB, Soltys K, Fisher BT. Invasive candidiasis in liver transplant patients: Incidence and risk factors in a pediatric cohort. Pediatr Transplant 2016; 20:235-40. [PMID: 26748472 DOI: 10.1111/petr.12663] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2015] [Indexed: 12/25/2022]
Abstract
Prolonged OR, re-transplantation, and high-volume intraoperative transfusion have been associated with increased risk for IC in adult LT recipients. Antifungal prophylaxis is recommended for adult patients with these risk factors. There are limited data on the incidence of and risk factors for IC in pediatric LT recipients. A retrospective cohort study of all pediatric LT patients at the CHOP between 2000 and 2012 and the CHP between 2004 and 2012 was performed to define the incidence of IC within 30 days of LT. A 3:1 matched case-control study with incidence density sampling was performed. Conditional logistic regression analyses were used to explore risk factors associated with IC. Among 397 recipients, the incidence of IC was 2.5%. Bivariate analyses showed that ICU admission prior to transplant, OR > 10 h, intraoperative volume infusion of >300 mL/kg, and broad-spectrum antibiotics were significantly associated with IC. In a multivariate model, only ICU admission remained significantly associated with IC. Antifungal prophylaxis was not significantly protective against IC. The low incidence of IC and lack of an identified protective effect from antifungal prophylaxis suggest that prophylaxis in pediatric LT recipients should not be routinely recommended to prevent IC events in the first 30 days post-transplant.
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Affiliation(s)
- M De Luca
- University Hospital Pediatric Department, Bambino Gesù Children's Hospital, Rome, Italy.,Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M Green
- Division of Infectious Diseases, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.,The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - J Symmonds
- Division of Infectious Diseases, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - S B Klieger
- Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - K Soltys
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - B T Fisher
- Division of Infectious Diseases, Department of Pediatrics, Center for Clinical Epidemiology and Biostatistics, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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9
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Szymczak JE, Klieger SB, Vendetti N, Miller M, Fiks A, Gerber JS. What Parents Think About Antibiotics for Their Child's Acute Respiratory Tract Infection. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.83] [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: 11/12/2022] Open
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10
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Downes K, Weiss S, Klieger SB, Fitzgerald J, Balamuth F, Kubis S, Tolomeo P, Bilker W, Han X, Nachamkin I, Garrigan C, Han J, Lautenbach E, Gerber JS, Coffin S. Developing a Biomarker-Driven Algorithm to Improve Antibiotic Use in the Pediatric Intensive Care Unit: The Optimizing Antibiotic Strategies in Sepsis (OASIS) Study. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv131.117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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11
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Klieger SB, Hodinka R, Kajon A, Petersen H, Cardenas AM, Gee J, Smallcomb L, Spyridakis E, Fisher BT. Epidemiology of Adenovirus Infection and Disease Among Pediatric Solid Organ Transplant Recipients. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.355] [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: 11/15/2022] Open
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12
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Leonard MB, Zemel BS, Wrotniak BH, Klieger SB, Shults J, Stallings VA, Stettler N. Tibia and radius bone geometry and volumetric density in obese compared to non-obese adolescents. Bone 2015; 73:69-76. [PMID: 25497572 PMCID: PMC4540475 DOI: 10.1016/j.bone.2014.12.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 10/27/2014] [Accepted: 12/03/2014] [Indexed: 11/23/2022]
Abstract
Childhood obesity is associated with biologic and behavioral characteristics that may impact bone mineral density (BMD) and structure. The objective was to determine the association between obesity and bone outcomes, independent of sexual and skeletal maturity, muscle area and strength, physical activity, calcium intake, biomarkers of inflammation, and vitamin D status. Tibia and radius peripheral quantitative CT scans were obtained in 91 obese (BMI>97th percentile) and 51 non-obese adolescents (BMI>5th and <85th percentiles). Results were converted to sex- and race-specific Z-scores relative to age. Cortical structure, muscle area and muscle strength (by dynamometry) Z-scores were further adjusted for bone length. Obese participants had greater height Z-scores (p<0.001), and advanced skeletal maturity (p<0.0001), compared with non-obese participants. Tibia cortical section modulus and calf muscle area Z-scores were greater in obese participants (1.07 and 1.63, respectively, both p<0.0001). Tibia and radius trabecular and cortical volumetric BMD did not differ significantly between groups. Calf muscle area and strength Z-scores, advanced skeletal maturity, and physical activity (by accelerometry) were positively associated with tibia cortical section modulus Z-scores (all p<0.01). Adjustment for muscle area Z-score attenuated differences in tibia section modulus Z-scores between obese and non-obese participants from 1.07 to 0.28. After multivariate adjustment for greater calf muscle area and strength Z-scores, advanced maturity, and less moderate to vigorous physical activity, tibia section modulus Z-scores were 0.32 (95% CI -0.18, 0.43, p=0.06) greater in obese, vs. non-obese participants. Radius cortical section modulus Z-scores were 0.45 greater (p=0.08) in obese vs. non-obese participants; this difference was attenuated to 0.14 with adjustment for advanced maturity. These findings suggest that greater tibia cortical section modulus in obese adolescents is attributable to advanced skeletal maturation and greater muscle area and strength, while less moderate to vigorous physical activities offset the positive effects of these covariates. The impact of obesity on cortical structure was greater at weight bearing sites.
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Affiliation(s)
- Mary B Leonard
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, USA.
| | - Babette S Zemel
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brian H Wrotniak
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Physical Therapy, D'Youville College, Buffalo, NY, USA
| | - Sarah B Klieger
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Department of Physical Therapy, D'Youville College, Buffalo, NY, USA
| | - Virginia A Stallings
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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13
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Klieger SB, Potter-Bynoe G, Quach C, Sandora TJ, Coffin SE. Beyond the Bundle: A Survey of Central Line–Associated Bloodstream Infection Prevention Practices Used in US and Canadian Pediatric Hospitals. Infect Control Hosp Epidemiol 2015; 34:1208-10. [DOI: 10.1086/673447] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We surveyed US and Canadian pediatric hospitals about their use of central line-associated bloodstream infection (CLABSI) prevention strategies beyond typical insertion and maintenance bundles. We found wide variation in supplemental strategies across hospitals and in their penetration within hospitals. Future studies should assess specific adjunctive prevention strategies and CLABSI rates.
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14
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Klieger SB, Raphael B, Potter-Bynoe G, Duggan C, Sandora TJ, Zerr D, Lee G, Cox E, Coffin SE. 980Pediatric Patients with Gastrointestinal Conditions and Central Line-Associated Bloodstream Infections. Open Forum Infect Dis 2014. [PMCID: PMC5781467 DOI: 10.1093/ofid/ofu052.688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Sarah B. Klieger
- Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bram Raphael
- GI and Nutrition, Boston Children's Hospital, Boston, MA
| | - Gail Potter-Bynoe
- Infection Prevention and Control, Boston Children's Hospital, Boston, MA
| | | | - Thomas J. Sandora
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA
| | - Danielle Zerr
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Grace Lee
- Boston Children's Hospital, Boston, MA
| | - Elaine Cox
- Pediatrics–Infectious Disease, Indiana University School of Medicine, Indianapolis, IN
| | - Susan E. Coffin
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA
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15
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Smathers S, Hoegg C, Klieger SB, Smallcomb L, Satchell L, Noll J, Cockerham J, Coffin SE, Sammons JS. 985Uncommon Outcomes due to Common Colds: Epidemiology and Outcomes Associated with Nosocomial Viral Infections in Children. Open Forum Infect Dis 2014. [PMCID: PMC5781490 DOI: 10.1093/ofid/ofu052.693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sarah Smathers
- Division of Infection Prevention and Control, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cindy Hoegg
- Division of Infection Prevention and Control, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sarah B. Klieger
- Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Lauren Satchell
- Infection Prevention and Control, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jackie Noll
- Emergency Department, The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Susan E. Coffin
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julia Shaklee Sammons
- Perelman School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Department of Infection Prevention and Control, The Children's Hospital of Philadelphia, Philadelphia, PA
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16
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Szymczak JE, Smathers S, Hoegg C, Klieger SB, Sammons JS. 933Between a Rock and a Hard Place: Why Physicians and Advanced Practice Providers Work While Sick. Open Forum Infect Dis 2014. [PMCID: PMC5782072 DOI: 10.1093/ofid/ofu052.641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Julia E. Szymczak
- Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sarah Smathers
- Division of Infection Prevention and Control, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cindy Hoegg
- Division of Infection Prevention and Control, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sarah B. Klieger
- Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julia Shaklee Sammons
- Perelman School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Department of Infection Prevention and Control, The Children's Hospital of Philadelphia, Philadelphia, PA
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17
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Coffin SE, Klieger SB, Duggan C, Huskins WC, Milstone AM, Potter-Bynoe G, Raphael B, Sandora TJ, Song X, Zerr DM, Lee GM. Central line-associated bloodstream infections in neonates with gastrointestinal conditions: developing a candidate definition for mucosal barrier injury bloodstream infections. Infect Control Hosp Epidemiol 2014; 35:1391-9. [PMID: 25333434 DOI: 10.1086/678410] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To develop a candidate definition for central line-associated bloodstream infection (CLABSI) in neonates with presumed mucosal barrier injury due to gastrointestinal (MBI-GI) conditions and to evaluate epidemiology and microbiology of MBI-GI CLABSI in infants. DESIGN Multicenter retrospective cohort study. SETTING Neonatal intensive care units from 14 US children's hospitals and pediatric facilities. METHODS A multidisciplinary focus group developed a candidate MBI-GI CLABSI definition based on presence of an MBI-GI condition, parenteral nutrition (PN) exposure, and an eligible enteric organism. CLABSI surveillance data from participating hospitals were supplemented by chart review to identify MBI-GI conditions and PN exposure. RESULTS During 2009-2012, 410 CLABSIs occurred in 376 infants. MBI-GI conditions and PN exposure occurred in 149 (40%) and 324 (86%) of these 376 neonates, respectively. The distribution of pathogens was similar among neonates with versus without MBI-GI conditions and PN exposure. Fifty-nine (16%) of the 376 initial CLABSI episodes met the candidate MBI-GI CLABSI definition. Subsequent versus initial CLABSIs were more likely to be caused by an enteric organism (22 of 34 [65%] vs 151 of 376 [40%]; P = .009) and to meet the candidate MBI-GI CLABSI definition (19 of 34 [56%] vs 59 of 376 [16%]; P < .01). CONCLUSIONS While MBI-GI conditions and PN exposure were common, only 16% of initial CLABSIs met the candidate definition of MBI-GI CLABSI. The high proportion of MBI-GI CLABSIs among subsequent infections suggests that infants with MBI-GI CLABSI should be a population targeted for further surveillance and interventional research.
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Affiliation(s)
- Susan E Coffin
- Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, and Department of Infection Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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18
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Davis KF, Colebaugh AM, Eithun BL, Klieger SB, Meredith DJ, Plachter N, Sammons JS, Thompson A, Coffin SE. Reducing catheter-associated urinary tract infections: a quality-improvement initiative. Pediatrics 2014; 134:e857-64. [PMID: 25113293 DOI: 10.1542/peds.2013-3470] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Catheter-associated urinary tract infections (CAUTIs) are among the most common health care-associated infections in the United States, yet little is known about the prevention and epidemiology of pediatric CAUTIs. METHODS An observational study was conducted to assess the impact of a CAUTI quality improvement prevention bundle that included institution-wide standardization of and training on urinary catheter insertion and maintenance practices, daily review of catheter necessity, and rapid review of all CAUTIs. Poisson regression was used to determine the impact of the bundle on CAUTI rates. A retrospective cohort study was performed to describe the epidemiology of incident pediatric CAUTIs at a tertiary care children's hospital over a 3-year period (June 2009 to June 2012). RESULTS Implementation of the CAUTI prevention bundle was associated with a 50% reduction in the mean monthly CAUTI rate (95% confidence interval: -1.28 to -0.12; P = .02) from 5.41 to 2.49 per 1000 catheter-days. The median monthly catheter utilization ratio remained unchanged; ∼90% of patients had an indication for urinary catheterization. Forty-four patients experienced 57 CAUTIs over the study period. Most patients with CAUTIs were female (75%), received care in the pediatric or cardiac ICUs (70%), and had at least 1 complex chronic condition (98%). Nearly 90% of patients who developed a CAUTI had a recognized indication for initial catheter placement. CONCLUSIONS CAUTI is a common pediatric health care-associated infection. Implementation of a prevention bundle can significantly reduce CAUTI rates in children.
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Affiliation(s)
- Katherine Finn Davis
- University of Pennsylvania School of Nursing, Philadelphia Pennsylvania; Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Ann M Colebaugh
- Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Benjamin L Eithun
- Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | | | | | - Natalie Plachter
- Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Julia Shaklee Sammons
- Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Division of Infectious Diseases, Department of Infection Prevention and Control and Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Allison Thompson
- Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Susan E Coffin
- Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Division of Infectious Diseases, Department of Infection Prevention and Control and Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Bout-Tabaku S, Klieger SB, Wrotniak BH, Sherry DD, Zemel BS, Stettler N. Adolescent obesity, joint pain, and hypermobility. Pediatr Rheumatol Online J 2014; 12:11. [PMID: 24678578 PMCID: PMC3973833 DOI: 10.1186/1546-0096-12-11] [Citation(s) in RCA: 3] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 03/19/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Obesity associated with joint pain of the lower extremities is likely due to excessive mechanical load on weight bearing joints. Additional mechanical factors may explain the association between obesity and joint pain. FINDINGS We characterized the association between obesity and non-traumatic lower extremity (LE) joint pain in adolescents and examined the modifying effect of hypermobility on this association.We performed a cross-sectional analysis of data from subjects enrolled in a clinical trial examining the impact of weight loss on bone health in adolescents. Anthropometric data were collected and body mass index (BMI = kg/m2) was calculated. Subjects were categorized as obese or healthy weight controls based on CDC 2000 growth curves for age and gender. We assessed any musculoskeletal pain and LE pain by the PEDS™ Pediatric Pain Questionnaire™. Hypermobility was assessed with the modified Beighton scoring system. Multivariate logistic regression models adjusted for covariates were performed to examine the association between weight status and joint pain.Out of 142 subjects, 91 were obese and 51 were healthy weight. Obesity was not associated with any musculoskeletal pain (OR 0.86, CI 0.49-1.50), LE pain (OR 1.02, CI 0.49-2.15) or hypermobility (OR 1.23, CI 0.72-2.14, p = 0.3). There was no effect modification on the association between obesity and any musculoskeletal pain (OR 0.80, CI 0.45 -1.42) or LE pain (OR 0.98, CI 0.46 - 2.08) by hypermobility status. CONCLUSIONS We found no association between LE pain and obesity, and hypermobility did not modify this association.
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Affiliation(s)
- Sharon Bout-Tabaku
- Department of Pediatrics, Division of Rheumatology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA.
| | - Sarah B Klieger
- Department of Pediatrics, Division of Infection Diseases, The Children’s Hospital of Philadelphia, Philadelphia, USA
| | - Brian H Wrotniak
- Department of Physical Therapy, D’Youville College, Buffalo, USA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, USA
| | - David D Sherry
- Department of Pediatrics, Division of Rheumatology, The Children’s Hospital of Philadelphia, Philadelphia, USA,University of Pennsylvania School of Medicine, Philadelphia, USA
| | - Babette S Zemel
- Department of Pediatrics, Division of Gastroenterology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, USA,University of Pennsylvania School of Medicine, Philadelphia, USA
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Abstract
Is content addressable in the representation that subserves performance in multiple-object-tracking (MOT) experiments? We devised an MOT variant that featured unique, nameable objects (cartoon animals) as stimuli. There were two possible response modes: standard, in which observers were asked to report the locations of all target items, and specific, in which observers had to report the location of a particular object (e.g., "Where is the zebra?"). A measure of capacity derived from accuracy allowed for comparisons of the results between conditions. We found that capacity in the specific condition (1.4 to 2.6 items across several experiments) was always reliably lower than capacity in the standard condition (2.3 to 3.4 items). Observers could locate specific objects, indicating a content-addressable representation. However, capacity differences between conditions, as well as differing responses to the experimental manipulations, suggest that there may be two separate systems involved in tracking, one carrying only positional information, and one carrying identity information as well.
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Affiliation(s)
- Todd S Horowitz
- Visual Attention Laboratory, Brigham and Women's Hospital, Boston, Massachusetts 02139, USA.
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