scholarly journals Management of Submassive Bilateral Pulmonary Embolism in an Adolescent Female

2021 ◽  
Vol 2021 ◽  
pp. 1-4
Author(s):  
Adeline Yi Ling Lim ◽  
John Roy ◽  
Ajay Kevat
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Decision Making ◽  
Pediatric Population ◽  
Oral Contraceptive Pill ◽  
Clinical Decision ◽  
Adolescent Female ◽  
Rare Presentation ◽  
Systemic Thrombolysis ◽  
Life Threatening ◽  
Management Approaches

Pulmonary embolism (PE) is a rare presentation in the pediatric population. We report a case of submassive PE in an adolescent female following commencement of a combined oral contraceptive pill (COCP). In the setting of cardiac dysfunction, she received systemic thrombolysis with significant reduction of clot burden and clinical improvement objectively demonstrated shortly thereafter. This case highlights challenges in clinical decision-making regarding surgical or catheter-based interventions versus medical management approaches when addressing life-threatening PE in children. Our case demonstrates that submassive PE in pediatrics can be managed successfully with systemic thrombolysis and therapeutic anticoagulation.

scholarly journals Acute pulmonary embolism in COVID-19 patient: a case report of free-floating right heart thrombus successfully treated with fibrinolysis

2020 ◽  
Author(s):  
Fernando Scudiero ◽  
Antonino Pitì ◽  
Roberto Keim ◽  
Guido Parodi
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Retrospective Studies ◽  
Right Heart ◽  
Clinical Issue ◽  
Systemic Thrombolysis ◽  
Case Summary ◽  
High Prevalence ◽  
Life Threatening ◽  
Complex Scenario

Abstract Background Despite the fast-growing understanding of the coronavirus disease 2019 (COVID-19), patient management remains largely empirical or based on retrospective studies. In this complex scenario, an important clinical issue appears to be represented by the high prevalence of thromboembolic events, but the data regarding high-risk pulmonary embolism (PE) is still not available. Case summary A patient with COVID-19 developed sudden shortness of breath and hypoxia. Early echocardiographic diagnosis of high-risk PE related to right heart thrombus was performed. Systemic thrombolysis was administered with excellent clinical and haemodynamic response. Discussion Pulmonary thromboembolism is a common occurrence in severe COVID-19 infection. In our experience, systemic thrombolysis proved to be effective and for this reason may be considered for life-threatening PE in COVID-19 patients.

Ivy sign: a diagnostic and prognostic biomarker for pediatric moyamoya

2021 ◽  
pp. 1-9
Keyword(s):  
Blood Flow ◽  
Cerebral Artery ◽  
Pediatric Patients ◽  
Clinical Decision Making ◽  
Prognostic Biomarker ◽  
Pediatric Population ◽  
Radiographic Finding ◽  
Clinical Decision ◽  
Stage Iii ◽  
Postoperative Stroke

OBJECTIVE Ivy sign is a radiographic finding on FLAIR MRI sequences and is associated with slow cortical blood flow in moyamoya. Limited data exist on the utility of the ivy sign as a diagnostic and prognostic tool in pediatric patients, particularly outside of Asian populations. The authors aimed to investigate a modified grading scale with which to characterize the prevalence and extent of the ivy sign in children with moyamoya and evaluate its efficacy as a biomarker in predicting postoperative outcomes, including stroke risk. METHODS Pre- and postoperative clinical and radiographic data of all pediatric patients (21 years of age or younger) who underwent surgery for moyamoya disease or moyamoya syndrome at two major tertiary referral centers in the US and Israel, between July 2009 and August 2019, were retrospectively reviewed. Ivy sign scores were correlated to Suzuki stage, Matsushima grade, and postoperative stroke rate to quantify the diagnostic and prognostic utility of ivy sign. RESULTS A total of 171 hemispheres in 107 patients were included. The median age at the time of surgery was 9 years (range 3 months–21 years). The ivy sign was most frequently encountered in association with Suzuki stage III or IV disease in all vascular territories, including the anterior cerebral artery (53.7%), middle cerebral artery (56.3%), and posterior cerebral artery (47.5%) territories. Following surgical revascularization, 85% of hemispheres with Matsushima grade A demonstrated a concomitant, statistically significant reduction in ivy sign scores (OR 5.3, 95% CI 1.4–20.0; p = 0.013). Postoperatively, revascularized hemispheres that exhibited ivy sign score decreases had significantly lower rates of postoperative stroke (3.4%) compared with hemispheres that demonstrated no reversal of the ivy sign (16.1%) (OR 5.5, 95% CI 1.5–21.0; p = 0.008). CONCLUSIONS This is the largest study to date that focuses on the role of the ivy sign in pediatric moyamoya. These data demonstrate that the ivy sign was present in approximately half the pediatric patients with moyamoya with Suzuki stage III or IV disease, when blood flow was most unstable. The authors found that reversal of the ivy sign provided both radiographic and clinical utility as a prognostic biomarker postoperatively, given the statistically significant association with both better Matsushima grades and a fivefold reduction in postoperative stroke rates. These findings can help inform clinical decision-making, and they have particular value in the pediatric population, as the ability to minimize additional radiographic evaluations and tailor radiographic surveillance is requisite.

Treatment of Pediatric OCD

2017 ◽  
Author(s):  
S. Evelyn Stewart ◽  
Clare Bleakley
Keyword(s):  
Clinical Decision Making ◽  
Significant Proportion ◽  
Clinical Decision ◽  
Developmental Trajectory ◽  
First Line ◽  
Pediatric Ocd ◽  
Response Predictors ◽  
Augmentation Strategies ◽  
Negative Impacts ◽  
Management Approaches

Appropriate OCD treatment has the potential to reverse negative impacts on the developmental trajectory of youth with this disease. First-line treatments for pediatric OCD have been well established, including cognitive behavior therapy (CBT), serotonin reuptake inhibitors (SRI), and the combination thereof. However, a significant proportion of OCD-affected youth do not achieve response or remission following initial treatment, and access to OCD-focused CBT treatment is often limited. Knowledge of CBT and SRI response predictors, mechanisms of action, and augmentation strategies for pediatric OCD should be exploited to guide individual clinical decision making. Further investigation is required to identify specific management approaches in treatment-resistant cases and putative OCD subtypes. This chapter summarizes proven first-line pharmacological and psychological treatments, discusses potential augmentation strategies, and suggests practical management tips for use in pediatric OCD.

scholarly journals Catheter-directed therapy for submassive pulmonary embolism after unsuccessful systemic thrombolysis

2017 ◽  
Vol 8 (1) ◽  
pp. 204589321773626 ◽  
Author(s):  
Chang Dong ◽  
Shufen Jiang ◽  
Donghua Ji ◽  
Yingqun Ji ◽  
Zhonghe Zhang
Keyword(s):  
Pulmonary Embolism ◽  
Respiratory Failure ◽  
Right Ventricular ◽  
Ventricular Dysfunction ◽  
Right Ventricular Dysfunction ◽  
Systemic Thrombolysis ◽  
Submassive Pulmonary Embolism ◽  
Life Threatening

Catheter-directed therapy (CDT) has emerged as an important treatment for pulmonary embolism (PE). We present a patient with life-threatening submassive PE with transient hypotension, progressive right ventricular dysfunction, and respiratory failure who failed anticoagulation and had little improvement with systemic thrombolysis, but responded well to catheter-directed therapy.

Emergency Bedside Echocardiography as a Tool for Early Detection and Clinical Decision Making in Cases of Suspected Pulmonary Embolism

Angiology ◽  
2000 ◽  
Vol 51 (12) ◽  
pp. 1021-1025 ◽  
Author(s):  
Apostolos Karavidas ◽  
Evangellos Matsakas ◽  
George Lazaros ◽  
Fotis Panou ◽  
Manolis Foukarakis ◽  
...  
Keyword(s):  
Decision Making ◽  
Pulmonary Embolism ◽  
Early Detection ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Suspected Pulmonary Embolism ◽  
Bedside Echocardiography

scholarly journals A Bayesian Study of the Dynamic Effect of Comorbidities on Hospital Outcomes of Care for CHF Patients

2019 ◽  
Author(s):  
Dimitrios Zikos ◽  
Stelios Zimeras ◽  
Neli Ragina
Keyword(s):  
Hospital Mortality ◽  
Clinical Decision Making ◽  
Cumulative Effect ◽  
Dynamic Effect ◽  
Clinical Decision ◽  
Hospital Outcomes ◽  
Variable Effect ◽  
Outcomes Of Care ◽  
Threatening Condition ◽  
Life Threatening

Comorbidities can have a cumulative effect on hospital outcomes of care, such as the length of stay (LOS), and hospital mortality. This study examines patients hospitalized with Congestive Heart Failure (CHF), a life-threatening condition, which, when it coexists with a burdened disease profile, the risk for negative hospital outcomes increases. Since coexisting conditions co-interact, with a variable effect on outcomes, clinicians should be able to recognize these joint effects. In order to study CHF comorbidities, we used medical claims data from CMS. After extracting the most frequent cluster of CHF comorbidities, we: (i) Calculated, step-by-step, the conditional probabilities for each disease combination inside this cluster (ii) Estimated the cumulative effect of each comorbidity combination on the LOS and hospital mortality (iii) Constructed (a) Bayesian, scenario-based graphs and (b) Bayes-networks to visualize results. Results show that, for CHF patients, different comorbidity constructs have variable effect on the LOS and hospital mortality. Therefore, dynamic comorbidity risk assessment methods should be implemented for informed clinical decision making in any ongoing effort for quality of care improvements.

scholarly journals 579. Machine-Learning Based Models for Prediction of Recurrence-free Catheter Retention After ALT Treatment of CLABSI in a Pediatric Population

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S273-S274
Author(s):  
Lorne W Walker ◽  
Andrew J Nowalk ◽  
Shyam Visweswaran
Keyword(s):  
Machine Learning ◽  
Decision Making ◽  
Blood Culture ◽  
Clinical Decision Making ◽  
Pediatric Population ◽  
Recurrent Infection ◽  
Clinical Decision ◽  
Definitive Treatment ◽  
Support Vector ◽  
The Future

Abstract Background Deciding whether to attempt salvage of an infected central venous catheter (CVC) can be challenging. While line removal is the definitive treatment for central-line associated bloodstream infection (CLABSI), salvage may be attempted with systemic antibiotics and antibiotic lock therapy (ALT). Weighing risk and benefit of CVC salvage is limited by uncertainty in the future viability of salvaged CVCs. If a CVC is likely to require subsequent removal (e.g., due to recurrent infection) salvage may not be beneficial, whereas discarding a viable CVC is also not desirable. Here we describe a machine learning approach to predicting outcomes in CVC salvage. Methods Episodes of pediatric CLABSI cleared with ALT were identified by retrospective record review between January 1, 2008 and December 31, 2018 and were defined by a single positive central blood culture of a known pathogen or two matching cultures of a possible contaminant. Clearance was defined as 48-hours of negative cultures and relapse was defined as a matching positive blood culture after clearance. Predictive models [logistic regression (LR), random forest (RF), support vector machine (SVM) and an ensemble combining the three] were used to predict recurrence-free CVC retention (RFCR) at various time points using a training and test set approach. Results Overall, 712 instances CLABSI cleared with ALT were identified. Demographic and microbiological data are summarized in Tables 1 and 2. Few (8%) instances recurred in the first 28 days. 58% recurred at any time within the study period. Rates of RFCR were 75%, 43%, 22% and 10% at 28, 91, 182 and 365 days. Machine learning (ML) models varied in their ability to predict RFCR (Table 3). RF models performed best overall, although no model performed well at 91 days. Conclusion ML models provide an opportunity to augment clinical decision making by learning patterns from data. In this case, estimating the likelihood of useful line retention in the future could help guide informed decisions on salvage vs. removal of infected CVCs. Limitations include the heterogeneity of clinical data and the use of an outcome capturing both clinical decision making (line removal) and infection recurrence. With further model development and prospective validation, practical machine learning models may prove useful to clinicians. Disclosures All authors: No reported disclosures.

scholarly journals High Heterogeneity of Multidrug-Resistant Enterobacteriaceae Fecal Levels in Hospitalized Patients Is Partially Driven by Intravenous β-Lactams

2019 ◽  
Vol 64 (2) ◽  
Author(s):  
Ana Djukovic ◽  
Eva M. González-Barberá ◽  
Jaime Sanz ◽  
Alejandro Artacho ◽  
Iván Peñaranda ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Direct Action ◽  
Clinical Decision ◽  
Multidrug Resistant ◽  
Hospitalized Patients ◽  
Beta Lactam ◽  
Beta Lactams ◽  
Susceptibility Data ◽  
Life Threatening ◽  
Third Generation Cephalosporins

ABSTRACT Multidrug-resistant Enterobacteriaceae (MRE) colonize the intestine asymptomatically from where they can breach into the bloodstream and cause life-threatening infections, especially in heavily colonized patients. Despite the clinical relevance of MRE colonization levels, we know little about how they vary in hospitalized patients and the clinical factors that determine those levels. Here, we conducted one of the largest studies of MRE fecal levels by tracking longitudinally 133 acute leukemia patients and monitoring their MRE levels over time through extensive culturing. MRE were defined as Enterobacteriaceae species that acquired nonsusceptibility to ≥1 agent in ≥3 antimicrobial categories. In addition, due to the selective media used, the MRE had to be resistant to third-generation cephalosporins. MRE were detected in 60% of the patients, but their fecal levels varied considerably among patients and within the same patient (>6 and 4 orders of magnitude, respectively). Multivariate analysis of clinical metadata revealed an impact of intravenous beta-lactams (i.e., meropenem and piperacillin-tazobactam), which significantly diminished the fecal MRE levels in hospitalized patients. Consistent with a direct action of beta-lactams, we found an effect only when the patient was colonized with strains sensitive to the administered beta-lactam (P < 0.001) but not with nonsusceptible strains. We report previously unobserved inter- and intraindividual heterogeneity in MRE fecal levels, suggesting that quantitative surveillance is more informative than qualitative surveillance of hospitalized patients. In addition, our study highlights the relevance of incorporating antibiotic treatment and susceptibility data of gut-colonizing pathogens for future clinical studies and in clinical decision-making.

Toward Evidence-Based Practice in the Auditory Processing Disorder Clinic

2008 ◽  
Vol 4 (1) ◽  
pp. 9-14 ◽  
Author(s):  
Patti M. Johnstone
Keyword(s):  
Decision Making ◽  
Population Health ◽  
Auditory Processing ◽  
Clinical Decision Making ◽  
Pediatric Population ◽  
Clinical Decision ◽  
Auditory Processing Disorder ◽  
Evidence Based ◽  
Vocal Cues ◽  
Research Paradigms

Abstract Audiologists are seeking evidence to guide clinical decision-making regarding the tests used to diagnose auditory processing disorder (APD) in children. Novel research paradigms using a population health framework hold promise in helping clinicians understand the prevalence, profile, and social underpinnings of APD in the general pediatric population. In addition, tests employing novel stimuli like speech-evoked auditory potentials or spatial and vocal cues may lead the way toward a new and more reliable APD test battery.

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

2020 ◽  
Vol 58 (4) ◽  
pp. 605-617 ◽  
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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