Exploring the risk factors for vaccine-associated and non-vaccine associated febrile seizures in a large pediatric cohort.

INTRODUCTION: It is not known whether there are underlying physiologic or immunologic differences between febrile seizures (FS) triggered by vaccines versus other causes. Furthermore, while secular and individual-level factors have been associated with FS risk, they are rarely evaluated simultaneously. METHODS: Subjects included members of Kaiser Permanente Southern California aged 6 months to 3 years from July 1, 2003-December 31, 2011. Primary outcome was first diagnosis of FS. Vaccine-associated (VA) FS were defined as those occurring from day 0 to day 15 following any vaccine; non-vaccine associated (NVA) FS were those outside this period. We compared incidence rates of VA-FS versus NVA-FS. Poisson regression was used to assess the association between FS and secular and individual-level factors. We also evaluated interactions between vaccine exposure and each model covariate on the risk of FS. RESULTS: Among 265,275 children, 3348 FS were identified; 383(11%) were VA-FS, and 2965(89%) were NVA-FS. Incidence rates were 2.73 and 2.05 per 100,000 person-days for VA-FS and NVA-FS, respectively. Multivariable analyses confirmed previously reported increased risk of FS by age, low gestational age, and winter months. Increased risk was also associated with VA exposure (RR=1.63[95% CI: 1.27-2.11]), non-White race/ethnicity vs. White (African-American RR=1.41[1.22-1.63]; Asian RR=1.58[1.40-1.79]; Hispanic RR=1.60[1.47-1.75]), and maternal age 29 years or less vs. 40+ years (≤ 19 years RR=1.28[1.00-1.65]; 20-29 years RR=1.21[1.02-1.42]). Females were at lower risk of NVA-FS (RR=0.77[0.72-0.83]), but were similar to males for VA-FS (RR=0.97[0.79-1.19]). Children with low 1 min Apgar scores (≤ 3) had increased risk of VA-FS (RR=3.40[1.86-6.22]), but no increased risk for NVA-FS (RR=1.05[0.69-1.60]) compared to children with normal Apgar scores (≥ 7). DISCUSSION: This study suggests that there may be immunogenetic differences underlying VA-FSs compared with other FSs. However, further studies are needed. An understanding of the mechanisms behind these findings may help improve vaccine design or policies.

Results of computed tomography in family practitioners' patients with non-acute abdominal pain.

OBJECTIVES: The utility of abdominal computerized tomography (CT) for evaluating abdominal pain in non-emergency, primary care outpatients is unknown. Family practice patients commonly report abdominal pain. METHODS: We reviewed the records of health maintenance organization primary care outpatients <2 years after they had undergone CT for abdominal pain and assessed demographic variables, clinical and laboratory data, CT findings and final diagnoses. RESULTS: We studied 137 patients: age 58.1 +/- 16.1 years (mean +/- SD), 80 (58.4%) females. Fifty (36.5%) patients had > or =1 warning clinical or laboratory feature. Positive (etiologic) and negative CT reports and unrelated and multiple CT findings occurred in 16 (11.7%), 104 (75.9%), 16 (11.7%) and 1 (0.7%) patients, respectively. Positive findings occurred in 16 (32.0%) patients with > or =1 warning feature and 1 (1.2%) patient (including the 1 patient with multiple findings) with no warning feature (P < 0.0001). One (6.3%) unrelated finding led to treatment, ovariectomy for a benign tumor. Fifty-four (39.4%) patients had a final diagnosis. CONCLUSIONS: A majority of outpatients who had CT for abdominal pain received no diagnosis, and CT was rarely diagnostic for patients lacking a warning feature. Positive and unrelated CT findings were equally prevalent, and the latter were not beneficial.

Chronic abdominal wall pain: clinical features, health care costs, and long-term outcome.

BACKGROUND & AIMS: Chronic abdominal wall pain (CAWP) often is misdiagnosed. We evaluated CAWP patients regarding diagnosis accuracy, clinical features, comorbidity, referral frequency, use of care, and long-term outcome. METHODS: We reviewed the records of all outpatients referred to a gastroenterologist in 5 years, recorded referral indications, and identified patients initially diagnosed with CAWP or irritable bowel syndrome (IBS). Charts of all CAWP patients were reviewed, and direct costs were estimated for abdominal pain-related physician visits and imaging studies during the 12 months before and 12 months after consultation. We appraised long-term pain status by telephone. RESULTS: Of 2709 patients, CAWP was diagnosed by physical examination in 137 patients; the diagnosis remained unchanged after 47.3 +/- 17.7 (mean +/- SD) months in 133 (97.1%) patients. Women predominated over men 4 to 1, pain was usually upper abdominal, had lasted 25.3 +/- 46.3 months, and obesity and painful comorbidities and depression were common. CAWP and IBS comprised 7.8% and 16.3% of symptomatic referrals, respectively. Prereferral, physicians rarely suspected CAWP and often prescribed therapy for acid-peptic disease. Postconsultation, primary care, emergency and specialist visits, and radiologic examinations markedly decreased (P < 0.001), and estimated annual costs decreased from $1133.87 +/- 953.37 to $541.33 +/- 989.04 (P < 0.0001). Therapy varied, and 44 (47.3%) patients had no pain at follow-up evaluation. CONCLUSIONS: CAWP is a common underrecognized disorder. Comorbidities are frequent, and health care use is high. Diagnosis is accurate and reduces health care costs. Over the long term, pain disappearance and persistence occurs in approximately equal proportions of patients.