Epidemiology and Clinical Features of Septic Arthritis in Children

Abstract Background Children with acute arthritis are commonly admitted to the hospital in part due to concern for septic arthritis (SA) and its complications. Many noninfectious, non-urgent conditions are more common than SA and present similarly. The epidemiology and clinical presentation of SA influences management of patients with acute arthritis. Methods Utilizing the electronic medical record, we reviewed the charts of children (1–18 years old) with joint complaints who presented to the hospitals and clinics of one large academic health organization in the Upper Midwest from January 2011 to July 2016. Query criteria included the presenting symptom (“arthritis”, “joint swelling”, or “joint pain”), diagnosis (“arthritis”, “septic arthritis”, or “Lyme arthritis”), and/or positive synovial fluid culture. SA was confirmed when synovial bacterial culture or PCR were positive. SA was suspected in cases with a positive blood culture or when the patient was treated empirically with 4 weeks of antibiotic with no alternate diagnosis. All other children were excluded from the study cohort. Results Of the 705 children whose charts were reviewed, 609 were excluded with a noninfectious diagnosis and 72 with Lyme arthritis (Figure 1). We identified 24 children with SA. Six children diagnosed with SA were immunosuppressed. Among healthy children with SA, seven were diagnosed with contiguous musculoskeletal (MSK) infection and 11 were diagnosed with acute, isolated, monoarticular arthritis. SA was more common in boys. The most common pathogen isolated was S aureus (13). The knee (7) and hip (6) accounted for the majority of joints involved in healthy children. Conclusion SA is a rare cause of acute arthritis in children. In healthy children, SA may present with contiguous MSK infection or in an isolated joint. SA is more likely in boys and in the knee or hip joint. S. aureus is the most common cause of SA. Clear understanding of the epidemiology and clinical history of SA should shape clinical decision making in children with acute arthritis. Disclosures All authors: No reported disclosures.

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Pediatric reference values of TSH should be personalized according to BMI and ethnicity

Acta Endocrinologica ◽

10.1530/eje-20-0239 ◽

2020 ◽

Vol 183 (4) ◽

pp. 419-426

Author(s):

Tal Oron ◽

Liora Lazar ◽

Ilan Feldhamer ◽

Mira Manor ◽

Nira Koren-Morag ◽

...

Keyword(s):

Reference Values ◽

Jewish Population ◽

Clinical Decision Making ◽

Multivariate Logistic Regression Analysis ◽

Clinical Decision ◽

Population Based ◽

Normal Weight ◽

Study Cohort ◽

Thyroid Function Tests ◽

Healthy Children

Objective: The need for personalization of the reference values of thyroid function tests has been previously suggested. We aimed at determining TSH reference values in a large cohort of children according to age, sex, BMI, and ethnicity. Design: A population-based cohort study. Methods: The study cohort included 75 549 healthy children aged 5–18 years. Data analyzed included age, gender, TSH, FT4 levels, BMI and ethnicity. Multivariate logistic regression analysis examined the associations between the study parameters. Results: TSH in the Jewish population is lower than in the non-Jewish population (median: 2.1 IU/L (IQR: 1.5) vs 2.2 IU/L (IQR: 1.5), P < 0.0001). TSH is significantly affected by BMI for children defined as underweight, normal weight, overweight or obese, levels increased as weight diverged from the normal range (median levels: 2.1 IU/L (IQR: 1.4), 2.0 IU/L (IQR: 1.3), 2.1 IU/L (IQR: 1.4), 2.4 (IQR: 1.5), respectively, P < 0.001). The 2.5 percentile is affected by gender and BMI (P < 0.02 and P < 0.001, respectively), while the 97.5 percentile is affected by ethnic origin and BMI (P < 0.001 for both). New TSH reference intervals (RI) adjusted according to BMI and ethnicity are suggested. Comparison of the old and new RI demonstrate the significance of RI personalization: 25.1% of the children with TSH levels above the old RI are within the new RI, while 2.3% of the children who were in the old RI are below the new RI. Conclusions: TSH reference values in children are affected by BMI and ethnicity. Reference values should be individualized accordingly to improve future clinical decision-making and treatment.

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Ethical use of off-label disease-modifying therapies for multiple sclerosis

Multiple Sclerosis Journal ◽

10.1177/13524585211030207 ◽

2021 ◽

pp. 135245852110302

Author(s):

Joanna Laurson-Doube ◽

Nick Rijke ◽

Anne Helme ◽

Peer Baneke ◽

Brenda Banwell ◽

...

Keyword(s):

Multiple Sclerosis ◽

Clinical Decision Making ◽

Clinical Decision ◽

World Health ◽

World Federation ◽

Off Label ◽

Disease Modifying Therapies ◽

The World ◽

Disease Modifying ◽

Health Organization

Background: Off-label disease-modifying therapies (DMTs) for multiple sclerosis (MS) are used in at least 89 countries. There is a need for structured and transparent evidence-based guidelines to support clinical decision-making, pharmaceutical policies and reimbursement decisions for off-label DMTs. Objectives/Results: The authors put forward general principles for the ethical use of off-label DMTs for treating MS and a process to assess existing evidence and develop recommendations for their use. Conclusion: The principles and process are endorsed by the World Federation of Neurology (WFN), American Academy of Neurology (AAN), European Academy of Neurology (EAN), Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS), European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS), Middle-East North Africa Committee for Treatment and Research in Multiple Sclerosis (MENACTRIMS) and Pan-Asian Committee for Treatment and Research in Multiple Sclerosis (PACTRIMS), and we have regularly consulted with the Brain Health Unit, Mental Health and Substance Use Department at the World Health Organization (WHO).

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Diagnostic accuracy of symptoms as a diagnostic tool for SARS-CoV 2 infection: a cross-sectional study in a cohort of 2,173 patients

BMC Infectious Diseases ◽

10.1186/s12879-021-05930-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Carlos Alfonso Romero-Gameros ◽

Tania Colin-Martínez ◽

Salomón Waizel-Haiat ◽

Guadalupe Vargas-Ortega ◽

Eduardo Ferat-Osorio ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Diagnostic Tool ◽

Clinical Decision Making ◽

Multivariate Logistic Regression Analysis ◽

Clinical Decision ◽

Cross Sectional Study ◽

World Health ◽

Likelihood Ratios ◽

Cross Sectional ◽

Health Organization

Abstract Background The SARS-CoV-2 pandemic continues to be a priority health problem; According to the World Health Organization data from October 13, 2020, 37,704,153 confirmed COVID-19 cases have been reported, including 1,079,029 deaths, since the outbreak. The identification of potential symptoms has been reported to be a useful tool for clinical decision-making in emergency departments to avoid overload and improve the quality of care. The aim of this study was to evaluate the performances of symptoms as a diagnostic tool for SARS -CoV-2 infection. Methods An observational, cross-sectional, prospective and analytical study was carried out, during the period of time from April 14 to July 21, 2020. Data (demographic variables, medical history, respiratory and non-respiratory symptoms) were collected by emergency physicians. The diagnosis of COVID-19 was made using SARS-CoV-2 RT-PCR. The diagnostic accuracy of these characteristics for COVID-19 was evaluated by calculating the positive and negative likelihood ratios. A Mantel-Haenszel and multivariate logistic regression analysis was performed to assess the association of symptoms with COVID-19. Results A prevalence of 53.72% of SARS-CoV-2 infection was observed. The symptom with the highest sensitivity was cough 71%, and a specificity of 52.68%. The symptomatological scale, constructed from 6 symptoms, obtained a sensitivity of 83.45% and a specificity of 32.86%, taking ≥2 symptoms as a cut-off point. The symptoms with the greatest association with SARS-CoV-2 were: anosmia odds ratio (OR) 3.2 (95% CI; 2.52–4.17), fever OR 2.98 (95% CI; 2.47–3.58), dyspnea OR 2.9 (95% CI; 2.39–3.51]) and cough OR 2.73 (95% CI: 2.27–3.28). Conclusion The combination of ≥2 symptoms / signs (fever, cough, anosmia, dyspnea and oxygen saturation < 93%, and headache) results in a highly sensitivity model for a quick and accurate diagnosis of COVID-19, and should be used in the absence of ancillary diagnostic studies. Symptomatology, alone and in combination, may be an appropriate strategy to use in the emergency department to guide the behaviors to respond to the disease. Trial registration Institutional registration R-2020-3601-145, Federal Commission for the Protection against Sanitary Risks 17 CI-09-015-034, National Bioethics Commission: 09 CEI-023-2017082.

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Pediatric reference interval verification for endocrine and fertility hormone assays on the Abbott Alinity system

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2021-0337 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Mary Kathryn Bohn ◽

Siobhan Wilson ◽

Alexandra Hall ◽

Khosrow Adeli

Keyword(s):

Clinical Decision Making ◽

De Novo ◽

Reference Interval ◽

Clinical Decision ◽

Reference Intervals ◽

Healthy Children ◽

Confidence Limits ◽

Test Results ◽

Serum Samples ◽

Abbott Architect

Abstract Objectives The Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER) has developed an extensive database of reference intervals (RIs) for several biomarkers on various analytical systems. In this study, pediatric RIs were verified for key immunoassays on the Abbott Alinity system based on the analysis of healthy children samples and comparison to comprehensive RIs previously established for Abbott ARCHITECT assays. Methods Analytical performance of Alinity immunoassays was first assessed. Subsequently, 100 serum samples from healthy children recruited with informed consent were analyzed for 16 Alinity immunoassays. The percentage of test results falling within published CALIPER ARCHITECT reference and confidence limits was determined. If ≥ 90% of test results fell within the confidence limits, they were considered verified based on CLSI guidelines. If <90% of test results fell within the confidence limits, additional samples were analyzed and new Alinity RIs were established. Results Of the 16 immunoassays assessed, 13 met the criteria for verification with test results from ≥ 90% of healthy serum samples falling within the published ARCHITECT confidence limits. New CALIPER RIs were established for free thyroxine and prolactin on the Alinity system. Estradiol required special considerations in early life. Conclusions Our data demonstrate excellent concordance between ARCHITECT and Alinity immunoassays, as well as the robustness of previously established CALIPER RIs for most immunoassays, eliminating the need for de novo RI studies for most parameters. Availability of pediatric RIs for immunoassays on the Alinity system will assist clinical laboratories using this new platform and contribute to improved clinical decision-making.

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Institutional review of glial tumors treated with chemotherapy: the first description of PCV-related pseudoprogression

Neuro-Oncology Practice ◽

10.1093/nop/npy012 ◽

2018 ◽

Vol 6 (1) ◽

pp. 22-29 ◽

Cited By ~ 1

Author(s):

Ankur M Sharma ◽

Michael Willcock ◽

Oliver Bucher ◽

Thelina Amaratunga ◽

M Nazir Khan ◽

...

Keyword(s):

Decision Making ◽

Adjuvant Radiotherapy ◽

Clinical Decision Making ◽

Clinical Decision ◽

World Health ◽

Tumor Treatment ◽

Institutional Review ◽

Grade Ii ◽

Health Organization ◽

Treatment Window

Abstract Background Pseudoprogression refers to areas of enhancement on MRI postadjuvant chemoradiation that arise as a result of treatment-related effects. Pseudoprogression has been well described with temozolomide-based chemoradiation but has not been studied in the setting of procarbazine, lomustine, and vincristine (PCV) chemotherapy. We reviewed patients treated with PCV to investigate the occurrence of pseudoprogression. Methods Adults diagnosed with World Health Organization grade II or III gliomas between 2010 and 2015 and treated with PCV or temozolomide were identified. Patient, tumor, treatment, and MRI data were retrospectively collected and analyzed. Pseudoprogression was defined as new enhancement seen on MRI within 6 months of completion of adjuvant radiotherapy or concurrent chemoradiation, which improved or remained stable on subsequent scans without therapeutic intervention. If MRI showed areas of new enhancement outside the 6-month post-treatment window, which resolved or remained stable without treatment, or in patients who did not receive adjuvant treatment, it was referred to as “atypical pseudoprogression.” Results Fifty-seven patients were identified. Nine (16%) patients were identified as having pseudoprogression on MRI. Two (4%) of these patients were treated with PCV and 7 (12%) were treated with temozolomide. Seventeen (30%) patients had atypical pseudoprogression: 8 (14%) treated with temozolomide, 8 (14%) treated with PCV, and 1 (2%) treated with both types of chemotherapy. Conclusions We describe the first 2 cases of PCV-related pseudoprogression and 17 cases of atypical pseudoprogression. As the re-emergence of adjuvant PCV occurs in clinical practice, the occurrence of classical and atypical pseudoprogression could have a significant impact on clinical decision making.

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Clinical Diagnosis and the Order of Information

Medical Decision Making ◽

10.1177/0272989x9801800409 ◽

1998 ◽

Vol 18 (4) ◽

pp. 412-417 ◽

Cited By ~ 32

Author(s):

George R. Bergus ◽

Gretchen B. Chapman ◽

Barcey T. Levy ◽

John W. Ely ◽

Robert A. Oppliger

Keyword(s):

Urinary Tract ◽

Physical Examination ◽

Clinical Decision Making ◽

Laboratory Data ◽

Clinical Information ◽

Clinical History ◽

Clinical Decision ◽

Background Information ◽

Likelihood Ratios ◽

Patient’S History

Background. Information order can influence judgment. However, it remains unclear whether the order of clinical data affects physicians' interpretations of these data when they are engaged in familiar diagnostic tasks. Methods. Of 400 randomly selected family physicians who were given a questionnaire involving a brief written scenario about a young woman with acute dysuria, 315 (79%) returned usable responses. The physicians had been randomized into two groups, and both groups had received the same clinical information but in different orders. After learning the patient's chief com plaint, physicians received either the patient's history and physical examination results followed by the laboratory data (the H&P-first group) or the laboratory data followed by the history and physical examination results (the H&P-last group). The results of the history and physical examination were supportive of the diagnosis of UTI, while the laboratory data were not. All physicians judged the probability of a urinary tract infection (UTI) after each piece of information. Results. The two groups had similar mean estimates of the probability of a UTI after learning the chief complaint (67.4% vs 67.8%, p = 0.85). At the end of the scenario, the H&P-first group judged UTI to be less likely than did the H&P-last group (50.9% vs 59.1 %, p = 0.03) despite having identical information. Comparison of the mean likelihood ratios attributed to the clinical information showed that the H&P-first group gave less weight to the history and phys ical than did the H&P-last group (p = 0.04). Conclusions. The order in which clinical information was presented influenced physicians' estimates of the probability of dis ease. The clinical history and physical examination were given more weight by phy sicians who received this information last. Key words: diagnosis; urinary tract infec tions ; judgment; primary care; clinical decision making. (Med Decis Making 1998;18: 412-417)

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Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care

American Journal of Lifestyle Medicine ◽

10.1177/1559827619830049 ◽

2019 ◽

Vol 14 (3) ◽

pp. 243-257 ◽

Cited By ~ 3

Author(s):

Gowri Anandarajah ◽

Haran Asher Mennillo ◽

Gregory Rachu ◽

Tyler Harder ◽

Jyotsna Ghosh

Keyword(s):

Clinical Decision Making ◽

Hospice Care ◽

Clinical Decision ◽

Clear Understanding ◽

Lifestyle Interventions ◽

Lifestyle Medicine ◽

Expert Opinions ◽

Improve Symptom ◽

Research Findings ◽

Available Information

Background: Lifestyle medicine interventions have the potential to improve symptom management, daily function, and quality of life (QOL) in patients with advanced or terminal disease receiving palliative or hospice care. The goal of this review is to summarize the current state of the literature on this subject. Methods: The authors used a broad search strategy to identify relevant studies, reviews, and expert opinions, followed by narrative summary of available information. Results: Four main categories of lifestyle interventions feature prominently in the palliative care literature: exercise, nutrition, stress management, and substance use. High-quality studies in this vulnerable population are relatively sparse. Some interventions show promise. However, most show mixed results or inadequate evidence. For some interventions, risks in this generally frail population outweigh the benefits. Clinical decision making involves balancing research findings, including the risks and benefits of interventions, with a clear understanding of patients’ prognosis, goals of care, and current physical, emotional, and spiritual state. Achieving optimum QOL, safety, and ethical care are emphasized. Conclusions: The use of lifestyle interventions in patients receiving palliative or hospice care is a complex undertaking, requiring tailoring recommendations to individual patients. There is potential for considerable benefits; however, more research is needed.

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Understanding “Recovery” Following Ankle Reconstruction: A Qualitative Study

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00340 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0034

Author(s):

Ellie Pinsker ◽

Monique A.M. Gignac ◽

Joanna E.M. Sale ◽

Timothy R. Daniels ◽

Dorcas E. Beaton

Keyword(s):

Clinical Decision Making ◽

Functional Limitations ◽

Clinical Decision ◽

Clinic Visit ◽

Outcome Evaluation ◽

Clear Understanding ◽

Ankle Arthritis ◽

Contributing Factors ◽

Qualitative Researcher ◽

Education Levels

Category: Ankle, Ankle Arthritis, Outcomes research Introduction/Purpose: Patients’ perception of a good outcome (‘feeling recovered’) is not fully understood. A clear understanding of the benefits and harm of a surgery is necessary for clinical decision-making. Qualitative work exploring the nature of patient recovery would improve our ability to understand and measure these outcomes. The purpose of the study is to examine patients’ perceptions of post-surgical outcome following ankle reconstruction for treatment of end-stage ankle arthritis. Methods: Twenty-five English-speaking individuals were asked to participate following a routine clinic visit. They were recruited from an existing cohort of persons who had undergone total ankle replacement or ankle fusion at least one year prior. A qualitative researcher conducted semi-structured, face-to-face interviews with participants in a private hospital room. Results: Twenty-five adults (12 women, 13 men) ages 25–82 years were interviewed for 1-2 hours. Participants varied in their socioeconomic status and education levels. Patients did not view their recovery simply as physiological change. Most participants reported ongoing challenges or difficulties, yet considered themselves better. Participants described a broader concept of recovery with multiple contributing factors, including appraisal of the importance of ongoing issues and coping efforts. When participants experienced ongoing difficulty with valued activities, they gained a sense of recovery using coping efforts. Many ‘readjusted’ behaviorally to continue with their valued goals and activity preferences. Others cognitively redefined their goals or preferences to accommodate their ongoing issues. Participants who could not cope with their difficulties or disliked their coping effort perceived their recovery negatively. Conclusion: Perception of recovery and experience of outcome rarely involved resolution of all symptoms and functional limitations. The manner in which patients described their recovery was typically more nuanced than a simple change in magnitude of symptoms or functional limitations. This research expands our understanding of the experience of ankle reconstruction and draws attention to different meanings of recovery that has implications for outcome evaluation and measurement. Improved measures for evaluating the recovery outcome states will enable clinicians to identify facilitators and barriers to recovery.

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Vocal Fold Motion Recovery in Patients With Iatrogenic Unilateral Immobility: Cervical Versus Thoracic Injury

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489418808306 ◽

2018 ◽

Vol 128 (1) ◽

pp. 44-49 ◽

Cited By ~ 2

Author(s):

Lauren F. Tracy ◽

Paul E. Kwak ◽

Semirra L. Bayan ◽

Jarrad H. Van Stan ◽

James A. Burns

Keyword(s):

Vocal Fold ◽

Clinical Decision Making ◽

Treatment Options ◽

Clinical Decision ◽

Thoracic Injury ◽

Time Interval ◽

Study Cohort ◽

Thoracic Injuries ◽

Prognostic Information ◽

Cervical Injury

Objectives: Prognostic information about the return of vocal fold mobility in patients with iatrogenic unilateral vocal fold immobility (UVFI) can help with informed decisions about temporary and permanent treatment options. Although many variables can influence the likelihood of recovery, clinical experience suggests that cervical versus thoracic injury is a determining factor. The purpose of this study was to compare recovery rates from UVFI between cervical and thoracic injuries. Methods: A retrospective review of the medical record was performed on all adult patients diagnosed with complete iatrogenic UVFI from 2005 to 2015 (n = 923). Patients with incomplete data and etiologies of idiopathic, malignancy, or stenosis were excluded, leaving a study cohort of 502 patients who were categorized as having UVFI after cervical (n = 329) or thoracic (n = 173) injury. Data regarding site of iatrogenic injury (cervical vs thoracic), mobility status, and time interval to recovery or surgical intervention were recorded and compared using χ2 analyses. Results: Overall, 15% of patients recovered vocal fold mobility at a median of 4.1 months. Patients with cervical injury (65 of 329 [20%]) were significantly more likely to recover mobility than patients with thoracic injury (11 of 173 [6.4%]) (odds ratio, 3.63). The cervical cohort contained more women (68% vs 31%) and was younger (mean age, 60.4 ± 13.8 vs 64.1 ± 16.1 years; Cohen’s D = 0.25). Conclusions: Patients with cervical injuries resulting in UVFI are 4 times more likely to recover mobility than patients with thoracic injuries. This information can be valuable in counseling patients with UVFI and may affect clinical decision making.

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Influence of ethnicity on biochemical markers of health and disease in the CALIPER cohort of healthy children and adolescents

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2019-0876 ◽

2020 ◽

Vol 58 (4) ◽

pp. 605-617 ◽

Cited By ~ 2

Author(s):

Houman Tahmasebi ◽

Shervin Asgari ◽

Alexandra Hall ◽

Victoria Higgins ◽

Ashfia Chowdhury ◽

...

Keyword(s):

Children And Adolescents ◽

Clinical Decision Making ◽

Pediatric Population ◽

Statistical Significance ◽

Immunoglobulin A ◽

Clinical Decision ◽

Reference Intervals ◽

Immunoglobulin M ◽

Healthy Children ◽

Pediatric Study

AbstractBackgroundAccurate pediatric reference intervals (RIs) for laboratory tests determined in a healthy pediatric population are essential for correct laboratory test interpretation and clinical decision-making. In pediatrics, RIs require partitioning by age and/or sex; however, the need for partitioning based on ethnicity is unclear. Here, we assessed the influence of ethnicity on biomarker concentrations in the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER) cohort of healthy children and adolescents and compared the results with the National Health and Nutrition Examination Survey (NHANES).MethodsA total of 52 biomarkers were measured in a multiethnic population of 846–1179 healthy children (aged 5 to <19 years) upon informed consent. Biomarker concentrations were retrospectively compared between four major ethnic groups (i.e. Black, Caucasian, East Asian, and South Asian, determined by parental ethnicity). Retrospective results were verified prospectively using an additional 500 healthy pediatric samples with equal sample size across ethnicities. Ethnic-specific differences were assessed based on statistical significance and biological and analytical variations. Appropriate age-, sex-, and ethnic-specific RIs were calculated.ResultsEthnic-specific differences were not observed for 34 biomarkers examined in the retrospective analysis, while 18 demonstrated statistically significant ethnic differences. Among these, seven analytes demonstrated ethnic-specific differences in the prospective analysis: vitamin D, amylase, ferritin, follicle-stimulating hormone (FSH), immunoglobulin A (IgA), immunoglobulin G (IgG), and immunoglobulin M (IgM). Analysis of select NHANES data confirmed CALIPER findings.ConclusionsThis is the first comprehensive Canadian pediatric study examining ethnic-specific differences in common biomarkers. While the majority of biomarkers did not require ethnic partitioning, ethnic-specific RIs were established for seven biomarkers showing marked differences. Further studies in other populations are needed to confirm our findings.

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