Pediatric early warning score at time of emergency department disposition is associated with level of care.

OBJECTIVE: The objective of this study was to determine the association between the Pediatric Early Warning Score (PEWS) at time of emergency department (ED) disposition and level of care. METHODS: We conducted a prospective observational study with a convenience sample of patients aged 0 to 21 years in the ED of an urban, tertiary care children's hospital between November 2010 and July 2011. Pediatric Early Warning Score data were obtained at time of ED disposition, and the disposition decision was collected from the electronic medical record. Multinomial logistic regression was used to determine the association between PEWS and disposition. RESULTS: The sample of 383 patients included 239 (62%) who were discharged, 126 (33%) admitted to acute care, and 18 (5%) admitted to intensive care. Assigned scores ranged from 0 to 9. Adjusting for triage level, a 1-point increase in PEWS increased the odds of acute care admission 48% relative to the odds of discharge (odds ratio, 1.48; 95% confidence interval, 1.25-1.76) and increased the odds of intensive care admission 41% relative to the odds of acute care admission (odds ratio, 1.41; 95% confidence interval, 1.13-1.76). Pediatric Early Warning Score of 1 or more had maximum discriminant ability for admission, and PEWS of 3 or greater had maximum discriminant ability for intensive care. Area under the receiver operator characteristic curve was 0.68 to detect need for admission for the entire sample and 0.80 among the 97 patients with respiratory complaints. CONCLUSIONS: Pediatric Early Warning Score is associated with the level of care at ED disposition but does not provide adequate sensitivity and specificity to be used in isolation. Performance characteristics are better for patients with respiratory complaints.

Donor lymphocyte infusion-mediated graft-versus-leukemia effects in mixed chimeras established with a nonmyeloablative conditioning regimen: extinction of graft-versus-leukemia effects after conversion to full donor chimerism.

BACKGROUND: We investigated an approach to separating graft-versus-lymphoma (GVL) effects from graft-versus-host disease (GVHD) in mice receiving a nonmyeloablative conditioning regimen allowing establishment of mixed hematopoietic chimerism. METHODS: We evaluated the ability of donor lymphocyte infusions (DLI) to mediate GVL effects without GVHD in mixed chimeras prepared with cyclophosphamide, anti-T-cell antibodies, and thymic irradiation. To examine the fate of GVH-reactive donor CD8+ T cells, we used the 2C T-cell receptor (TCR) transgenic mouse strain, which carries an Ld-specific transgenic TCR on the B6 background. RESULTS: Administration of DLI on day 35 post-BMT led to conversion from mixed to full donor chimerism and mediated a powerful GVL effect with complete protection (100% survival) against mortality induced by a host-type lymphoma (EL4) administered 7 days later (100% mortality in non-DLI controls; P<0.001). No GVHD occurred in DLI recipients. Rechallenging the surviving DLI recipients, which had converted to full chimerism, with the same tumor dose 17 weeks later led to rapid tumor mortality. Long-term DLI recipients had anti-host proliferative responses, but not CTL responses in vitro. When given as DLI together with wild-type spleen cells, marked expansion of GVH-reactive 2C CD8+ T cells was observed on day 10, followed by a marked decline in their numbers by week 10 post-DLI. CONCLUSIONS: Nonmyeloablative induction of mixed chimerism followed by administration of DLI can mediate powerful GVL effects. The late loss of DLI-mediated GVL effects may reflect the eventual loss of donor-derived GVH-reactive CTL, which occurs in association with conversion to full donor chimerism.