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1.  Species-Specific PCR Improves Detection of Bacterial Pathogens in Parapneumonic Empyema Compared with 16S PCR and Culture 
PMCID: PMC3618625  PMID: 23558326
Pneumonia; Bacterial/*complications/*epidemiology; Pneumonia; Pneumococcal; Empyema; Pleural Streptococcus pneumoniae; Polymerase chain reaction; Molecular Diagnostics
2.  Pretreatment SUVmax predicts progression-free survival in early-stage non-small cell lung cancer treated with stereotactic body radiation therapy 
This retrospective study aims to assess the usefulness of SUVmax from FDG-PET imaging as a prognosticator for primary biopsy-proven stage I NSCLC treated with SBRT.
This study includes 95 patients of median age 77 years, with primary, biopsy-confirmed peripheral stage IA/IB NSCLC. All patients were treated with 60Gy in 3 fractions with a median treatment time of six days. Local, regional, and distant failures were evaluated independently according to the terms of RTOG1021. Local, regional, and distant control, overall- and progression-free survival were estimated by the Kaplan-Meier method. Cox proportional hazards regression was performed to determine whether SUVmax, age, KPS, gender, tumor size/T stage, or smoking history influenced outcomes. SUVmax was evaluated as both a continuous and as a dichotomous variable using a cutoff of <5 and ≥5.
Median follow-up for the cohort was 16 months. Median OS and PFS were 25.3 and 40.3 months, respectively. SUV with a cutoff value of 5 predicted for OS and PFS (p = .024 for each) but did not achieve significance for LC (p = .256). On Cox univariate regression analysis, SUV as a dichotomous variable predicted for both OS and PFS (p = .027 and p = .030, respectively). Defined as a continuous variable, SUVmax continued to predict for OS and PFS (p = .032 and p = .003), but also predicted LC (p = .045) and trended toward significance for DC (p = .059).
SUVmax did not predict for OS as a dichotomous or continuous variable. It did, however, predict for PFS as a continuous variable (p = .008), neared significance for local control (p = .057) and trended towards, significance for distant control (p = .092).
SUVmax appears to be a statistically and clinically significant independent prognostic marker for progression-free survival in patients with stage I NSCLC treated with SBRT. Prospective studies to more accurately define the role of tumor FDG uptake in the prognosis of NSCLC are warranted.
PMCID: PMC3922961  PMID: 24479954
3.  Health Insurance and Length of Stay for Children Hospitalized With Community-Acquired Pneumonia 
Disparities in patterns of care and outcomes for ambulatory-care sensitive childhood conditions such as community-acquired pneumonia (CAP) persist. However, the influence of insurance status on length of stay (LOS) for children hospitalized with CAP remains unexplored.
Secondary analysis of children (<18 years) hospitalized with CAP sampled in the Kids’ Inpatient Database (KID) for years 1997, 2000, 2003, and 2006. Insurance status (private, public, uninsured) was based on claims data. Hospital LOS was calculated in days. Taking into account the complex sampling design, negative binomial regression models produced adjusted estimates of incidence rate ratios (IRR) for hospital LOS for children by insurance status.
There was little variation in the categories of insurance status of children hospitalized with CAP between 1997 and 2006, with at least 40% privately insured, at least 40% publicly insured, and at least 5% uninsured in each sampled year. In all years, publicly insured children had a significantly longer hospital stay than privately insured children, and uninsured children had a significantly shorter hospital stay than privately insured children. These observed differences persisted after multivariate adjustment.
Differences in LOS between uninsured, publicly insured, and privately insured children with CAP raise concerns about potential differences in hospital discharge practices related to insurance status and type. As healthcare reform is implemented, policy makers should strengthen efforts to reduce these disparities in order to achieve health for the population.
PMCID: PMC3877930  PMID: 21972214
4.  Differential Case Ascertainment in Clinical Registry vs. Administrative Data and Impact on Outcomes Assessment in Pediatric Heart Surgery 
The Annals of thoracic surgery  2012;95(1):197-203.
Administrative datasets are often used to assess outcomes and quality in pediatric heart surgery; however their accuracy regarding case ascertainment is unclear. We linked patient data (2004–2010) from the STS Congenital Heart Surgery Database (clinical registry), and Pediatric Health Information Systems Database (administrative database) from hospitals participating in both to evaluate differential coding/classification of operations between datasets, and subsequent impact on outcomes assessment.
Eight individual benchmark operations and the RACHS-1 categories were evaluated. The primary outcome was in-hospital mortality.
The cohort included 59,820 patients (33 centers). There was a >10% difference in the number of patients identified between datasources for half of the benchmark operations. Negative predictive value of the administrative (vs. clinical) data was high (98.8–99.9%); positive predictive value was lower (56.7–88.0%). Overall agreement between datasources in RACHS-1 category assignment was 68.4%. These differences translated into significant differences in outcomes assessment, ranging from an underestimation of mortality associated with truncus arteriosus repair by 25.7% in the administrative vs. clinical data (7.01% vs. 9.43%, p=0.001), to an overestimation of mortality associated with VSD repair by 31.0% (0.78% vs. 0.60%, p=0.1). For the RACHS-1 categories, these ranged from an underestimation of Category 5 mortality by 40.5%, to an overestimation of Category 2 mortality by 12.1%; these differences were not statistically significant.
This study demonstrates differences in case ascertainment between administrative and clinical registry data for children undergoing heart surgery, which translated into important differences in outcomes assessment.
PMCID: PMC3777807  PMID: 23141907
congenital heart disease; health policy; outcomes
5.  Hospital Variation in Postoperative Infection and Outcome After Congenital Heart Surgery 
The Annals of thoracic surgery  2013;96(2):10.1016/j.athoracsur.2013.04.024.
Several initiatives aim to reduce postoperative infection across a variety of surgical patients as a means to improve overall quality of care and reduce variation across centers. However, the association of infection rates with hospital-level outcomes and resource utilization has not been well described. We evaluated this association across a multicenter cohort undergoing congenital heart surgery.
The Society of Thoracic Surgeons Congenital Heart Surgery Database was linked to resource utilization data from the Pediatric Health Information Systems Database for hospitals participating in both (2006 to 2010). Hospital-level infection rates (sepsis, wound infection, mediastinitis, endocarditis, pneumonia) adjusted for patient risk factors and case mix were calculated using Bayesian methodology, and association with hospital mortality rates, postoperative length of stay (LOS), and total costs evaluated.
The cohort included 32,856 patients (28 centers); 3.7% had a postoperative infection. Across hospitals, the adjusted infection rate varied from 0.9% to 9.8%. Hospitals with the highest infection rates had longer (LOS) (13.2 vs 11.7 days, p < 0.001) and increased hospital costs ($71,100 vs $65,100, p < 0.001), but similar mortality rates (odds ratio 0.99, 95% confidence interval 0.80 to 1.21, p = 0.9). The proportion of variation in costs and LOS explained by infection was 15% and 6%, respectively.
Infection after congenital heart surgery contributes to prolonged LOS and increased costs on a hospital level. However, given that infection rates alone explained relatively little of the variation in these outcomes across hospitals, further study is needed to identify additional factors that may be targeted in initiatives to reduce variation and improve outcomes across centers.
PMCID: PMC3828204  PMID: 23816416
6.  Variability in Processes of Care and Outcomes among Children Hospitalized with Community-Acquired Pneumonia 
Substantial care variation occurs in a number of pediatric diseases.
We evaluated the variability in health care resource utilization and its association with clinical outcomes among children, aged 1–18 years, hospitalized with community acquired pneumonia (CAP). Each of 29 children’s hospitals contributing data to the Pediatric Hospital Information System was ranked based on the proportion of CAP patients receiving each of 8 diagnostic tests. Primary outcome variable was length of stay (LOS), re-visit to the ED or readmission within 14 days of discharge.
Of 21,213 children hospitalized with non-severe CAP, median age was 3 years (interquartile range [IQR], 1–6 years). Laboratory testing and antibiotic usage varied widely across hospitals; cephalosporins were the most commonly prescribed antibiotic. There were large differences in the processes of care by age categories. The median LOS was 2 days (IQR, 1–3 days) and differed across hospitals; 25% of hospitals had median LOS >= 3 days. Hospital-level variation occurred in 14-day ED visits and 14-day readmission, ranging from 0.9 to 4.9% and 1.5% to 4.4%, respectively. Increased utilization of diagnostic testing was associated with longer hospital LOS (p=0.036) but not with probability of 14-day readmission (Spearman’s ρ = 0.234; p=0.225). There was an inverse correlation between LOS and 14-day revisit to the ED (ρ=−0.48, p=0.013).
Wide variability occurred in diagnostic testing for children hospitalized with CAP. Increased diagnostic testing was associated with a longer LOS. Earlier hospital discharge did not correlate with increased 14-day readmission. The precise interaction of increased utilization with longer LOS remains unclear.
PMCID: PMC3504613  PMID: 22653486
pneumonia; bacterial pneumonia; disease management; epidemiology; evidence-based medicine
8.  The effect of periodontal treatment on C-reactive protein: A clinical study 
Chronic periodontitis in amultifactorial inflammatory disease which is caused by various microorganisms. Many studies have found close association between chronic periodontitis and C-reactive protein (CRP). CRPis an inflammatory marker which increases in all inflammatory condition.
Aims and Objective:
The present clinical study was designed to show the effect of periodontal treatment on the CRP levels of gingival crevicular fluid and to determine the effect of nonsurgical therapy in minimizing the CRP levels in chronic generalized periodontitis.
Material and Method:
Gingival crevicular fluid was collected using a micro capillary pipette that was hand calibrated at every 1 mm till 10 mm, from selected sites in the subjects on the 1st, 14th and 45th days.
Results and Conclusion:
Decreased CRP levels of gingival crevicular fluid were observed at the end of the study. There was a 37% reduction in probing pocket depth and 45% gain in clinical attachment level and a reduction of about 57% after 14 days and 90% reduction of CRP levels in gingival crevicular fluid after 45 days. Thus, the results show that the presence of CRP level is more significant in gingival crevicular fluid and confirms the underlying inflammatory component of the disease activity in chronic periodontitis.
PMCID: PMC3783784  PMID: 24082736
C-reactive protein; GCF; periodontitis
9.  Early Prediction of Postmeningitic Hearing Loss in Children Using Magnetic Resonance Imaging 
To determine whether early gadolinium-enhanced magnetic resonance imaging (GdMRI) can reliably detect meningitic labyrinthitis and thereby predict which children are at high risk for hearing loss. Permanent sensorineural hearing loss (SNHL) remains a common sequela of bacterial meningitis, and early diagnosis of the associated suppurative labyrinthitis can be difficult, especially in critically ill, sedated patients and young children.
Retrospective cohort study.
Tertiary pediatric hospital.
Twenty-three survivors of bacterial meningitis (median age, 15 months [range, 3 months–14 years]) who had undergone brain GdMRI during the acute disease and had subsequent ear-specific audiometric data.
Main Outcome Measure
Blinded to disease and outcome, a neuroradiologist rated the relative enhancement of each cochlea on T1-weighted images using a 4-point scale. Scores were then correlated with the degree of hearing loss on subsequent testing.
Sensorineural hearing loss occurred in 15 of 46 ears (8 of 23 patients). Enhancement on GdMRI was detected in 13 of the 15 ears that later developed SNHL but was absent in all 31 unaffected ears. Thus, GdMRI was 87% sensitive and 100% specific for predicting which ears would develop permanent SNHL. In the subgroup with pneumococcal meningitis (n=15), GdMRI was 100% sensitive and 100% specific. Labyrinthine enhancement was detectable as early as 1 day after diagnosis.
Gadolinium-enhanced MRI detected meningitic labyrinthitis at early stages and accurately predicted which patients would later develop hearing loss.
PMCID: PMC3670148  PMID: 21339394
10.  Opportunities and challenges in linking information across databases in pediatric cardiovascular medicine 
Multicenter databases are increasingly utilized in pediatric cardiovascular research. In this review, we discuss the rational for using these types of data sources, provide several examples of how large datasets have been utilized in clinical research, and describe different mechanisms for linking databases to enable studies not possible with individual datasets alone.
PMCID: PMC3651671  PMID: 23671377
congenital heart disease; outcomes research
11.  Trends in Endocarditis Hospitalizations at US Childrens Hospitals: Impact of the 2007 American Heart Association Antibiotic Prophylaxis Guidelines 
American heart journal  2012;163(5):894-899.
In 2007, the American Heart Association recommended cessation of antibiotic prophylaxis for infective endocarditis (IE) prior to dental procedures for all but those at highest risk of adverse outcomes from IE. The impact of these guidelines is unclear. We evaluated IE hospitalizations at US children’s hospitals during this time period.
Children <18yrs hospitalized from 2003–2010 with IE at 37 centers in the Pediatric Health Information Systems Database were included. Using Poisson regression, we evaluated the number IE hospitalizations over time (raw and indexed to total hospital admissions).
A total of 1157 IE cases were identified; 68% had congenital heart disease (CHD). The raw number of IE cases did not change significantly over time (+1.6% difference post vs. pre guidelines, 95%CI −6.4 to +10.3%, p=0.7). When the number of IE cases was indexed per 1000 hospital admissions, there was a significant decline during the time prior to the guidelines (annual change = −5.9%, 95% CI −9.9 to −1.8, p=0.005), and a similar decline in the post-guidelines period, such that the difference between the two time periods was not significant (p=0.15). In subgroup analysis, no significant change over time in IE cases (raw or indexed) was found in the CHD subset, those 5–18yrs (subgroup most likely receiving dental care), or in cases coded as oral streptococci.
We found no evidence that release of new antibiotic prophylaxis guidelines was associated with a significant change in IE admissions across 37 US children’s hospitals.
PMCID: PMC3408007  PMID: 22607869
13.  Comparative Analysis of Antifibrinolytic Medications in Pediatric Heart Surgery 
Recent studies suggest adverse events associated with aprotinin in adults may not occur in children, and there is interest in further pediatric study of aprotinin. However, there are limited contemporary data comparing aprotinin to other available antifibrinolytics [aminocaproic acid (ACA) and tranexamic acid (TXA)] to guide current practice and aid in potential trial design. We performed a comparative analysis in a large multicenter cohort.
The Society of Thoracic Surgeons Congenital Heart Surgery Database (2004–2008) was linked to medication data from the Pediatric Health Information Systems Database. Efficacy and safety outcomes were evaluated in multivariable analysis adjusting for patient and center factors overall, and in neonates and those undergoing redo sternotomy.
There were 22,258 patients (25 centers) included: median age 7.6m (interquartile range 2.6–43.4). Aprotinin (vs. no drug) was associated with a significant reduction in combined hospital mortality/bleeding requiring surgical intervention overall (OR 0.81 95%CI 0.68–0.91), and in the redo sternotomy subgroup (OR 0.57 95%CI 0.40–0.80). There was no benefit in neonates, and no difference in renal failure requiring dialysis in any group. In comparative analysis, there was no difference in outcome in aprotinin vs. ACA recipients. TXA (vs. aprotinin) was associated with significantly reduced mortality/bleeding requiring surgical intervention overall (OR 0.47 95%CI 0.30–0.74) and in neonates (OR 0.30 95%CI 0.15–0.58).
These observational data suggest aprotinin is associated with reduced bleeding and mortality in children undergoing heart surgery with no increase in dialysis. Comparative analyses suggest similar efficacy of ACA and improved outcomes associated with TXA.
PMCID: PMC3288966  PMID: 22264414
14.  Incidence of and Risk Factors for Community Acquired Pneumonia in US HIV-Infected Children, 2000–2005 
AIDS (London, England)  2011;25(5):717-720.
The incidence of and risk factors for community-acquired pneumonia (CAP) are described from 2000–2005 in a multicenter US cohort of HIV-infected children. In 736 patients, 87 episodes of CAP (33.2 events/1,000 PY) had a mean CD4% of 23% (controls: 30%) and mean CD4 count of 668 cells/mm3 (controls: 870 cells/mm3). CAP incidence decreased 44% from 2000–2001 to 2002–2005. On multivariate analysis, viral load ≥100,000 copies/mL (OR 3.98; CI: 1.05–15.13) was associated with CAP. Herd immunity through pneumococcal immunization may have diluted the effect of individual immunization in this cohort.
PMCID: PMC3576877  PMID: 21252630
HIV; Pneumonia; Pediatric
15.  Perioperative Methylprednisolone and Outcome in Neonates Undergoing Heart Surgery 
Pediatrics  2012;129(2):e385-e391.
Recent studies have called into question the benefit of perioperative corticosteroids in children undergoing heart surgery, but have been limited by the lack of placebo control, limited power, and grouping of various steroid regimens together in analysis. We evaluated outcomes across methylprednisolone regimens versus no steroids in a large cohort of neonates.
Clinical data from the Society of Thoracic Surgeons Database were linked to medication data from the Pediatric Health Information Systems Database for neonates (≤30 days) undergoing heart surgery (2004–2008) at 25 participating centers. Multivariable analysis adjusting for patient and center characteristics, surgical risk category, and within-center clustering was used to evaluate the association of methylprednisolone regimen with outcome.
A total of 3180 neonates were included: 22% received methylprednisolone on both the day before and day of surgery, 12% on the day before surgery only, and 28% on the day of surgery only; 38% did not receive any perioperative steroids. In multivariable analysis, there was no significant mortality or length-of-stay benefit associated with any methylprednisolone regimen versus no steroids, and no difference in postoperative infection. In subgroup analysis by surgical-risk group, there was a significant association of methylprednisolone with infection consistent across all regimens (overall odds ratio 2.6, 95% confidence interval 1.3–5.2) in the lower-surgical-risk group.
This multicenter observational analysis did not find any benefit associated with methylprednisolone in neonates undergoing heart surgery and suggested increased infection in certain subgroups. These data reinforce the need for a large randomized trial in this population.
PMCID: PMC3269116  PMID: 22271697
congenital heart disease; heart surgery; outcomes
16.  Delayed Acyclovir Therapy and Death Among Neonates With Herpes Simplex Virus Infection 
Pediatrics  2011;128(6):1153-1160.
To determine the association of delayed acyclovir therapy with death among neonates with herpes simplex virus (HSV) infection.
A multicenter, retrospective, cohort study was conducted between January 1, 2003, and December 31, 2009, with 1086 neonates (age: ≤28 days) with HSV infection from 41 tertiary care children's hospitals. Early acyclovir therapy was defined as initiation of intravenous acyclovir treatment within 1 day after hospital admission, and delayed acyclovir therapy was defined as initiation of treatment >1 and ≤7 days after hospital admission. Multivariate logistic regression models determined the association between delayed acyclovir therapy and death, with the use of propensity scores for each neonate's likelihood of receiving delayed acyclovir treatment to control for differences in illness severity between groups.
The median age was 10 days. Delayed acyclovir therapy was administered to 262 neonates (24.1%). In most cases (86.2%) of delayed receipt, acyclovir administration occurred on the second or third day of hospitalization. The overall mortality rate was 7.3% (95% confidence interval: 5.8%–9.0%); 9.5% of those who received delayed acyclovir treatment and 6.6% of those who received early acyclovir treatment died. In a multivariate analysis, delayed acyclovir therapy was associated with significantly greater odds of death (adjusted odds ratio: 2.63 [95% confidence interval: 1.36–5.08]) compared with early acyclovir therapy.
In this multicenter observational study of neonates with HSV infection, delayed initiation of acyclovir therapy was associated with in-hospital death. Our data support the use of empiric acyclovir therapy for neonates undergoing testing for HSV infection.
PMCID: PMC3387895  PMID: 22123868
herpes simplex virus; neonate; acyclovir; therapy
17.  Delayed Acyclovir and Outcomes of Children Hospitalized With Eczema Herpeticum 
Pediatrics  2011;128(6):1161-1167.
To describe the epidemiology and outcomes of children hospitalized with eczema herpeticum and to determine the association with delayed acyclovir on outcomes.
This was a multicenter retrospective cohort study conducted between January 1, 2001, and March 31, 2010, of 1331 children aged 2 months to 17 years with eczema herpeticum from 42 tertiary care children's hospitals in the Pediatric Health Information System database. Multivariable linear regression models determined the association between delayed acyclovir therapy and the main outcome measure: hospital length of stay (LOS).
There were no deaths during the study period. Staphylococcus aureus infection was diagnosed in 30.3% of the patients; 3.9% of the patients had a bloodstream infection. Fifty-one patients (3.8%) required ICU admission. There were 893 patients (67.1%) who received acyclovir on the first day of admission. The median LOS increased with each day delay in acyclovir initiation. In multivariable analysis, delay of acyclovir initiation by 1 day was associated with an 11% increased LOS (95% confidence interval [CI]: 3%–20%; P = .008), and LOS increased by 41% when acyclovir was started on day 3 (95% CI: 19%–67%; P < .001) and by 98% when started on day 4 to 7 (95% CI: 60%–145%; P < .001). Use of topical corticosteroids on day 1 of hospitalization was not associated with LOS.
Delay of acyclovir initiation is associated with increased LOS in hospitalized children with eczema herpeticum. Use of topical corticosteroids on admission is not associated with increased LOS. The mortality rate of hospitalized children with eczema herpeticum is low.
PMCID: PMC3387896  PMID: 22084327
eczema herpeticum; herpes simplex virus; acyclovir; eczema
18.  Federating Clinical Data from Six Pediatric Hospitals: Process and Initial Results for Microbiology from the PHIS+ Consortium 
Microbiology study results are necessary for conducting many comparative effectiveness research studies. Unlike core laboratory test results, microbiology results have a complex structure. Federating and integrating microbiology data from six disparate electronic medical record systems is challenging and requires a team of varied skills. The PHIS+ consortium which is partnership between members of the Pediatric Research in Inpatient Settings (PRIS) network, the Children’s Hospital Association and the University of Utah, have used “FURTHeR’ for federating laboratory data. We present our process and initial results for federating microbiology data from six pediatric hospitals.
PMCID: PMC3540481  PMID: 23304298
19.  Addressing inpatient crowding by smoothing occupancy at children’s hospitals 
To quantify the difference in weekday versus weekend occupancy and the opportunity to smooth inpatient occupancy to reduce crowding at children’s hospitals.
Daily inpatient census data for 39 free-standing, tertiary-care children’s hospitals were used to calculate occupancy and to model the impact of reducing variation in occupancy and the change in the number of patients, patient days, and hospitals exposed to high occupancy pre- and post-smoothing. We also calculated the proportion of weekly admissions that would require different scheduling to achieve within-week smoothing.
Overall, hospitals’ mean occupancy ranged from 70.9%–108.1% on weekdays and 65.7%–94.9% on weekends. Weekday occupancy exceeded weekend occupancy with a median difference of 8.2%-points. The mean post-smoothing reduction in weekly maximum occupancy across all hospitals was 6.6%-points. Through smoothing, 39,607 patients from the 39 hospitals were removed from exposure to occupancy levels >95%. To achieve within-week smoothing, a median 2.6% of admissions would have to be scheduled on a different day of the week; this equates to a median of 7.4 patients per week (range 2.3–14.4).
Hospitals do have substantial unused capacity and smoothing occupancy over the course of a week could be a useful strategy that hospitals can use to reduce crowding and protect patients from crowded conditions.
PMCID: PMC3163108  PMID: 21612012
Bed Occupancy; Hospital Bed Capacity; Length of Stay; Patient Admission; Patient Discharge; Hospitalization; Hospitalized Child; Elective Surgical Procedures; Pediatric Hospital
20.  Statistical Uncertainty of Mortality Rates and Rankings for Children's Hospitals 
Pediatrics  2011;128(4):e966-e972.
Hospitals are being required to report publically their adjusted mortality rates, which are then being used to rank hospitals. Our objectives were to assess the statistical reliability of the determination of a hospital's adjusted mortality rate, of comparisons of that rate with the rates of other hospitals, and of the use of those rates to rank the hospitals.
A cross-sectional study of 473 383 patients discharged from 42 US children's hospitals in 2008 was performed. Hospital-specific observed/expected (O/E) mortality rate ratios and corresponding hospital rankings, with 95% confidence intervals (CIs), were examined.
Hospitals' O/E mortality rate ratios exhibited wide 95% CIs, and no hospital was clearly distinguishable from the other hospitals' aggregated mean mortality performance. Only 2 hospitals' mortality performance fell outside the comparator hospitals' 95% CI. Those hospitals' 95% CIs overlapped with the overall comparator set's 95% CI, which suggests that there were no statistically significant hospital outliers. Fourteen (33.3%) of the 42 hospitals had O/E ratios that were not statistically different from being in the 95% CI of the top 10% of hospitals. Hospital-specific mortality rate rankings displayed even broader 95% CIs; the typical hospital had a 95% CI range that spanned 22 rank-order positions.
Children's hospital-specific measures of adjusted mortality rate ratios and rankings have substantial amounts of statistical imprecision, which limits the usefulness of such measures for comparisons of quality of care.
PMCID: PMC3182848  PMID: 21890830
quality appraisal; quality improvement; mortality rates; hospital performance
21.  Executive Summary: The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America 
Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.
PMCID: PMC3202323  PMID: 21890766
22.  Dysfunction of the intestinal microbiome in inflammatory bowel disease and treatment 
Genome Biology  2012;13(9):R79.
The inflammatory bowel diseases (IBD) Crohn's disease and ulcerative colitis result from alterations in intestinal microbes and the immune system. However, the precise dysfunctions of microbial metabolism in the gastrointestinal microbiome during IBD remain unclear. We analyzed the microbiota of intestinal biopsies and stool samples from 231 IBD and healthy subjects by 16S gene pyrosequencing and followed up a subset using shotgun metagenomics. Gene and pathway composition were assessed, based on 16S data from phylogenetically-related reference genomes, and associated using sparse multivariate linear modeling with medications, environmental factors, and IBD status.
Firmicutes and Enterobacteriaceae abundances were associated with disease status as expected, but also with treatment and subject characteristics. Microbial function, though, was more consistently perturbed than composition, with 12% of analyzed pathways changed compared with 2% of genera. We identified major shifts in oxidative stress pathways, as well as decreased carbohydrate metabolism and amino acid biosynthesis in favor of nutrient transport and uptake. The microbiome of ileal Crohn's disease was notable for increases in virulence and secretion pathways.
This inferred functional metagenomic information provides the first insights into community-wide microbial processes and pathways that underpin IBD pathogenesis.
PMCID: PMC3506950  PMID: 23013615
23.  Accuracy of Administrative Billing Codes to Detect Urinary Tract Infection Hospitalizations 
Pediatrics  2011;128(2):323-330.
Hospital billing data are frequently used for quality measures and research, but the accuracy of the use of discharge codes to identify urinary tract infections (UTIs) is unknown.
To determine the accuracy of International Classification of Diseases, 9th revision (ICD-9) discharge codes to identify children hospitalized with UTIs.
This multicenter study conducted in 5 children's hospitals included children aged 3 days to 18 years who had been admitted to the hospital, undergone a urinalysis or urine culture, and discharged from the hospital. Data were obtained from the pediatric health information system database and medical record review. With the use of 2 gold-standard methods, the positive predictive value (PPV) was calculated for individual and combined UTI codes and for common UTI identification strategies. PPV was measured for all groupings for which the UTI code was the principal discharge diagnosis.
There were 833 patients in the study. The PPV was 50.3% with the use of the gold standard of laboratory-confirmed UTIs but increased to 85% with provider confirmation. Restriction of the study cohort to patients with a principle diagnosis of UTI improved the PPV for laboratory-confirmed UTI (61.2%) and provider-confirmed UTI (93.2%), as well as the ability to benchmark performance. Other common identification strategies did not markedly affect the PPV.
ICD-9 codes can be used to identify patients with UTIs but are most accurate when UTI is the principal discharge diagnosis. The identification strategies reported in this study can be used to improve the accuracy and applicability of benchmarking measures.
PMCID: PMC3146355  PMID: 21768320
urinary tract infections; quality improvement; length of stay; hospital performance; quality of care
24.  Steatosis Is an Independent Predictor of Relapse Following Rapid Virologic Response in Patients With HCV Genotype 3 
Background & Aims
It is recommended that patients with chronic hepatitis C virus (HCV) genotype 3 infections receive 24 weeks of treatment. A rapid virologic response (RVR, at week 4) predicts a sustained virologic response (SVR), although not all patients with an RVR achieve an SVR. We explored the relationships among hepatic steatosis, level of HCV RNA, relapse, and RVR in a phase 3 randomized controlled trial of 932 patients infected with HCV genotype 2 (n = 427) or 3 (n = 505) who received 24 weeks of therapy with interferon-α.
In patients with an RVR (HCV RNA <43 IU/mL), the presence of an SVR was modeled using multivariate logistic regression as a function of age, sex, weight, body-mass index, insulin resistance, steatosis, and levels of γ-glutamyl transpeptidase, alanine transaminase, liver fibrosis, and baseline HCV RNA.
RVR, SVR, and relapse rates among patients with HCV genotype 3 were 79.6%, 79.2%, and 15.6%, respectively; corresponding rates among patients with HCV genotype 2 were 86.7%, 84.3%, and 10.1%. An RVR had high predictive value for an SVR in patients with HCV genotypes 2 (88.9%) and 3 (88.1%). The strongest independent predictors of relapse in patients with genotype 3 and an RVR were steatosis (odds ratio 3.0; P=.003) and HCV RNA ≥400,000 IU/mL (2.5; P=.04). Relapse rates in patients with steatosis were 17.4% and 20.9% for low and high baseline levels of HCV RNA, respectively; corresponding rates in those without steatosis were 2.5% and 8.8%.
Steatosis was associated with significantly higher rates of relapse, irrespective of viral load, in patients infected with HCV genotype 3 who had an RVR. Further studies are needed to determine if longer treatment durations are effective in patients with an RVR and these risk factors.
PMCID: PMC3155986  PMID: 21640198
Liver disease; response to therapy; prognosis; recurrence
25.  Adults With Chronic Health Conditions Originating in Childhood: Inpatient Experience in Children's Hospitals 
Pediatrics  2011;128(1):5-13.
To describe the rate of increase of the population of adults seeking care as inpatients in children's hospitals over time.
We analyzed data from January 1, 1999, to December 31, 2008, from patients hospitalized at 30 academic children's hospitals, including growth rates according to age group (pediatric: aged <18 years; transitional: aged 18–21 years; or adult: aged >21 years) and disease.
There were 3 343 194 hospital discharges for 2 143 696 patients. Transitional patients represented 2.0%, and adults represented 0.8%, totaling 59 974 patients older than 18 years. The number of unique patients, admissions, patient-days, and charges increased in all age groups over the study period and are projected to continue to increase. Resource use was disproportionately higher in the older ages. The growth of transitional patients exceeded that of others, with 6.9% average annual increase in discharges, 7.6% in patient-days, and 15% in charges. Chronic conditions occurred in 87% of adults compared with 48% of pediatric patients. Compared with pediatric patients, the rates of increase of inpatient-days increased significantly for transitional age patients with cystic fibrosis, malignant neoplasms, and epilepsy, and for adults with cerebral palsy. Annual growth rates of charges increased for transitional and adult patients for all diagnoses except cystic fibrosis and sickle cell disease.
The population of adults with diseases originating in childhood who are hospitalized at children's hospitals is increasing, with varying disease-specific changes over time. Our findings underscore the need for proactive identification of strategies to care for adult survivors of pediatric diseases.
PMCID: PMC3124106  PMID: 21708805
inpatients; hospitals; pediatric; congenital diseases; chronic conditions; adult patients; age groups

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