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BACKGROUND: Late complications and longer-lasting sequelae of COVID-19 infection in adults can occur. Cardiovascular involvement including reduced ejection fraction, coronary artery aneurysms, and pericardial involvement have been reported. Prompt recognition is the first step and secondly, these cardiovascular phenomena require an alternative set of therapeutics from the standard of care for acute COVID-19 infection. CASE PRESENTATION: Here we describe two cases that fulfill the current case definition of the recently defined multisystem inflammatory syndrome in adults (MIS-A). One patient is a 27-year-old white female and the other a 21-year-old French creole male, both without any prior medical history. Both were hospitalized and found to have significant cardiac dysfunction and treated with IVIG, high dose aspirin, and corticosteroids with resolution of their acute illnesses and cardiac sequelae. CONCLUSION: Not only does the immediate impact of this viral infection need to be addressed, but also the long-term complications that could arise if not recognized and treated promptly as seen in our two cases. Patients can develop acute cardiovascular collapse and cardiogenic shock which requires high level of care and treatment within an intensive care unit. Depending on the complications, patients may require treatment for congestive heart failure, pericarditis, or even coronary artery disease acutely with close follow up to ensure improvement or resolution.
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COVID-19 , Síndrome de Resposta Inflamatória Sistêmica , Adulto , COVID-19/complicações , Feminino , Humanos , Masculino , SARS-CoV-2 , Síndrome de Resposta Inflamatória Sistêmica/diagnóstico , Adulto JovemRESUMO
Human immunodeficiency virus-seronegative men aged 15-22 years who lost bone mineral density (BMD) during tenofovir disoproxil fumarate/emtricitabine preexposure prophylaxis (PrEP) showed BMD recovery 48 weeks following PrEP discontinuation. Lumbar spine and whole body BMD z-scores remained below baseline 48 weeks off PrEP in participants aged 15-19 years. Clinical Trials Registration. NCT01772823 (ATN 110) and NCT01769456 (ATN 113).
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Fármacos Anti-HIV , Infecções por HIV , Profilaxia Pré-Exposição , Minorias Sexuais e de Gênero , Adolescente , Adulto , Fármacos Anti-HIV/farmacologia , Fármacos Anti-HIV/uso terapêutico , Densidade Óssea , Emtricitabina/farmacologia , Emtricitabina/uso terapêutico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/prevenção & controle , Homossexualidade Masculina , Humanos , Masculino , Tenofovir/farmacologia , Tenofovir/uso terapêutico , Adulto JovemRESUMO
Background: Tenofovir disoproxil fumarate (TDF) decreases bone mineral density (BMD). We hypothesized that vitamin D3 (VITD3) would increase BMD in youth receiving TDF. Methods: This was a randomized, double-blind, placebo-controlled trial of directly observed VITD3 vs placebo every 4 weeks for 48 weeks in youth aged 16-24 years with HIV, RNA load <200 copies/mL, taking TDF-containing combination antiretroviral therapy (TDF-cART) for ≥180 days. Participants (N = 214) received a daily multivitamin containing VITD3 400 IU and calcium 162 mg, plus monthly randomized VITD3 50000 IU (n = 109) or placebo (n = 105). Outcome was change from baseline to week 48 in lumbar spine BMD (LSBMD). Data presented are median (Q1, Q3). Results: Participants were aged 22.0 (21.0, 23.0) years, 84% were male, and 74% were black/African American. At baseline, 62% had 25-hydroxy vitamin D (25-OHD) <20 ng/mL. Multivitamin adherence was 49% (29%, 69%), and VITD3/placebo adherence 100% (100%, 100%). Vitamin D intake was 2020 (1914, 2168) and 284 (179, 394) IU/day, and serum 25-OHD concentration was 36.9 (30.5, 42.4) and 20.6 (14.4, 25.8) ng/mL at 48 weeks in VITD3 and placebo groups, respectively (P < .001). From baseline to week 48, LSBMD increased by 1.15% (-0.75% to 2.74%) in the VITD3 group (n = 99; P < .001) and 0.09% (-1.49% to 2.61%) in the placebo group (n = 89; P = .25), without between-group difference (P = .12). VITD3 group changes occurred with baseline 25-OHD <20 ng/mL (1.17% [-.82% to 2.90%]; P = .004) and ≥20 ng/mL (0.93% [-.26% to 2.15%]; P = .033). Conclusions: For youth taking TDF-cART, LSBMD increased through 48 weeks with VITD3 plus multivitamin, but not with placebo plus multivitamin, independent of baseline vitamin D status. Clinical Trials Registration: NCT01751646.
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Fármacos Anti-HIV/administração & dosagem , Conservadores da Densidade Óssea/administração & dosagem , Densidade Óssea/efeitos dos fármacos , Colecalciferol/administração & dosagem , Infecções por HIV/tratamento farmacológico , Coluna Vertebral/fisiologia , Tenofovir/administração & dosagem , Adolescente , Hormônios e Agentes Reguladores de Cálcio , Método Duplo-Cego , Feminino , Humanos , Masculino , Placebos/administração & dosagem , Resultado do Tratamento , Adulto JovemRESUMO
To investigate the association between low near infrared spectroscopy (NIRS) somatic oxygen saturation (<70%) at admission and the need for lifesaving interventions (LSI) in the initial 24 h of a PICU admission. Retrospective chart review of all unplanned admissions to the pediatric intensive care unit (PICU) with NIRS somatic oxygen saturation data available within 4 h of admission, excluding admissions with a cardiac diagnosis. LSI data were collected for the first 24 h after admission. Hemodynamic parameters, laboratory values, illness severity scores and diagnoses were collected. Included PICU admissions were stratified by lowest NIRS value in the first 4 h after admission: low NIRS (<70%) and normal NIRS (≥70%) groups. Rate of LSI from 4 h to 24 h was compared between the two groups. Association of LSI with NIRS saturation and other clinical and laboratory parameters was measured by univariate and multivariate methods. We reviewed 411 consecutive unplanned admissions to the PICU of which 184 (44%) patients underwent NIRS monitoring. A higher proportion of patients who underwent somatic NIRS monitoring required LSIs compared to those without NIRS monitoring (36.4 vs 5.7% respectively, p < 0.0001). The proportion of patients who required LSI was higher in the group with low NIRS (<70%) within the first 4 h compared to those with normal NIRS (≥70%) (77.1 vs 22.1%, p < 0.0001). Fluid resuscitation, blood products and vasoactive medications were the most common LSIs. Multivariable modeling showed NIRS < 70% and heart rate > 2SD for age to be associated with LSIs. ROC curve analysis of the combination of NIRS < 70% and HR >2SD for age had an area under the curve of 0.79 with 78% sensitivity and 76% specificity for association with LSI. Compared to the normal NIRS group, the low NIRS group had higher mortality (10.4 vs 0.7%, p = 0.005) and longer median hospital length of stay (2.9 vs 1.6 days, p < 0.0001). Low somatic NIRS oxygen saturation (<70%) in the first 4 h of an unplanned PICU admission is associated with need for higher number of subsequent lifesaving interventions up to 24 h after admission. Noninvasive, continuous, somatic NIRS monitoring may identify children at high risk of medical instability.
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Unidades de Terapia Intensiva Pediátrica , Oxigênio/sangue , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Frequência Cardíaca , Hemodinâmica , Mortalidade Hospitalar , Hospitalização , Humanos , Lactente , Masculino , Análise Multivariada , Curva ROC , Respiração Artificial , Estudos Retrospectivos , Risco , Fatores de TempoRESUMO
BACKGROUND: We aimed to define the relative importance of renal and endocrine changes in tenofovir disoproxil fumarate (TDF)-related bone toxicity. METHODS: In a study of daily TDF/emtricitabine (FTC) preexposure prophylaxis (PrEP) in human immunodeficiency virus (HIV)-uninfected young men who have sex with men, we measured changes from baseline in blood and urine markers of the parathyroid hormone (PTH)-vitamin D-fibroblast growth factor 23 (FGF23) axis, creatinine, and renal tubular reabsorption of phosphate (TRP). We explored the relationship of those variables to changes in bone mineral density (BMD). Tenofovir-diphosphate (TFV-DP) in red blood cells was used to categorize participants into high and low drug exposure groups. RESULTS: There were 101 participants, median age 20 years (range 15 to 22). Compared with low drug exposure, high-exposure participants showed increase from baseline in PTH and decline in FGF23 by study week 4, with no differences in creatinine, phosphate, or TRP. At 48 weeks, the median (interquartile range) percent decline in total hip BMD was greater in those with high- compared to low- exposure (-1.59 [2.77] vs +1.54 [3.34] %, respectively; P = .001); in high-exposure participants, this correlated with week 4 TFV-DP (inversely; r = -0.60, P = .002) and FGF23 (directly; r = 0.42; P = .039) but not other variables. CONCLUSIONS: These findings support the short-term renal safety of TDF/FTC PrEP in HIV-seronegative young men and suggest that endocrine disruption (PTH-FGF23) is a primary contributor to TDF-associated BMD decline in this age group. CLINICAL TRIALS REGISTRATION: NCT01769469.
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Fármacos Anti-HIV/efeitos adversos , Densidade Óssea/efeitos dos fármacos , Emtricitabina/efeitos adversos , Infecções por HIV/prevenção & controle , Homossexualidade Masculina , Profilaxia Pré-Exposição , Tenofovir/efeitos adversos , Adolescente , Fármacos Anti-HIV/administração & dosagem , Creatinina/sangue , Creatinina/urina , Emtricitabina/administração & dosagem , Fator de Crescimento de Fibroblastos 23 , Taxa de Filtração Glomerular/efeitos dos fármacos , Infecções por HIV/sangue , Infecções por HIV/metabolismo , Infecções por HIV/urina , Humanos , Rim/efeitos dos fármacos , Masculino , Hormônio Paratireóideo/sangue , Hormônio Paratireóideo/urina , Insuficiência Renal/induzido quimicamente , Tenofovir/administração & dosagem , Adulto JovemAssuntos
Centers for Disease Control and Prevention, U.S. , Hepacivirus/isolamento & purificação , Hepatite C/diagnóstico , Complicações Infecciosas na Gravidez/diagnóstico , Doença Aguda , Adulto , Feminino , Hepatite C/epidemiologia , Hepatite C/virologia , Humanos , Lactente , Masculino , Guias de Prática Clínica como Assunto , Gravidez , Complicações Infecciosas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/virologia , Prevalência , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: To demonstrate that low-molecular-weight heparin (enoxaparin) can be used in critically ill pediatric patients to achieve target anti-factor Xa concentrations and determine appropriate dosing corrected for age and illness severity. DESIGN: Retrospective cohort study. SETTING: Single tertiary level PICU. PATIENTS: One hundred ninety-two children age 1 day through 18 years admitted to PICU undergoing every 12-hour enoxaparin therapy with at least one anti-factor Xa concentration obtained. Patients receiving renal replacement therapy or infants with corrected gestational age less than 37 weeks were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We collected patient characteristics including age, weight, height/length, gender, corrected gestational age, illness severity markers, diagnosis, creatinine, enoxaparin dose and times of administration, anti-factor Xa concentrations, and collection times. Only 42% of critically ill children (80 of 192) and only 29% of children (9 of 31) on inotropes achieved recommended target range of anti-factor Xa concentrations on initial recommended enoxaparin dosing (1.5 mg/kg/dose < 2 mo; 1 mg/kg/dose > 2 mo), but 81% were ultimately within target range with dose titration. Increased enoxaparin dose was required to reach target concentrations in younger patients and those with worse illness severity as evidenced by concurrent use of inotropes, previous ICU admission, mechanical ventilation, cardiac surgery, and increased risk of mortality defined by severity-of-illness scores. CONCLUSIONS: Enoxaparin can be used to reach recommended target range of anti-factor Xa concentrations in the PICU patient. However, younger patients and patients with higher illness severity are less likely to achieve target concentrations using currently recommended dosing and may require higher doses of enoxaparin to reach target anti-factor Xa concentrations. Starting enoxaparin dose at least 1.3 mg/kg dosed every 12 hours for treatment of thromboembolic disease in critically ill patients aged 61 days to 1 year or those requiring inotropic support should be confirmed in prospective study.
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Cuidados Críticos , Enoxaparina/administração & dosagem , Inibidores do Fator Xa/sangue , Fibrinolíticos/administração & dosagem , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle , Adolescente , Fatores Etários , Criança , Pré-Escolar , Relação Dose-Resposta a Droga , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Tromboembolia Venosa/sangueRESUMO
Tenofovir disoproxil fumarate (TDF) causes bone, endocrine, and renal changes by an unknown mechanism(s). Data are limited on tenofovir pharmacokinetics and these effects. Using baseline data from a multicenter study of HIV-infected youth on stable treatment with regimens containing TDF (n = 118) or lacking TDF (n = 85), we measured cross-sectional associations of TDF use with markers of renal function, vitamin D-calcium-parathyroid hormone balance, phosphate metabolism (tubular reabsorption of phosphate and fibroblast growth factor 23 [FGF23]), and bone turnover. Pharmacokinetic-pharmacodynamic associations with plasma tenofovir and intracellular tenofovir diphosphate concentrations were explored among those receiving TDF. The mean age was 20.9 (standard deviation [SD], 2.0) years; 63% were male; and 52% were African American. Compared to the no-TDF group, the TDF group showed lower mean estimated glomerular filtration rates and tubular reabsorption of phosphate, as well as higher parathyroid hormone and 1,25-dihydroxy vitamin D [1,25-OH(2)D] levels. The highest quintile of plasma tenofovir concentrations was associated with higher vitamin D binding protein, lower free 1,25-OH(2)D, higher 25-OH vitamin D, and higher serum calcium. The highest quintile of intracellular tenofovir diphosphate concentration was associated with lower FGF23. Higher plasma tenofovir concentrations were associated with higher vitamin D binding protein and lower free 1,25-OH(2)D, suggesting a functional vitamin D deficiency explaining TDF-associated increased parathyroid hormone. The finding of lower FGF23 accompanying higher intracellular tenofovir diphosphate suggests that different mechanisms mediate TDF-associated changes in phosphate handling. Separate pharmacokinetic properties may be associated with distinct TDF toxicities: tenofovir with parathyroid hormone and altered calcium balance and tenofovir diphosphate with hypophosphatemia and FGF23 regulation. (The clinical trial registration number for this study is NCT00490412 and is available online at http://clinicaltrials.gov/ct2/show/NCT00490412.).
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Adenina/análogos & derivados , Fármacos Anti-HIV/farmacocinética , Calcitriol/sangue , Infecções por HIV/sangue , Hipofosfatemia/sangue , Organofosfonatos/farmacocinética , Inibidores da Transcriptase Reversa/farmacocinética , Deficiência de Vitamina D/sangue , Adenina/efeitos adversos , Adenina/sangue , Adenina/farmacocinética , Adolescente , Adulto , Fármacos Anti-HIV/efeitos adversos , Fármacos Anti-HIV/sangue , Cálcio/sangue , Método Duplo-Cego , Feminino , Fator de Crescimento de Fibroblastos 23 , Fatores de Crescimento de Fibroblastos/sangue , Taxa de Filtração Glomerular , HIV/efeitos dos fármacos , Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , Humanos , Hipofosfatemia/induzido quimicamente , Hipofosfatemia/virologia , Masculino , Organofosfonatos/efeitos adversos , Organofosfonatos/sangue , Hormônio Paratireóideo/sangue , Fosfatos/sangue , Inibidores da Transcriptase Reversa/efeitos adversos , Inibidores da Transcriptase Reversa/sangue , Tenofovir , Deficiência de Vitamina D/induzido quimicamente , Deficiência de Vitamina D/virologia , Proteína de Ligação a Vitamina D/sangueRESUMO
BACKGROUND: An inverse correlation between serum 25-hydroxyvitamin D concentration and atopic dermatitis (AD) severity has been suggested. OBJECTIVE: To determine if a statistically significant relationship exists between serum 25-hydroxyvitamin D concentration and AD severity. METHODS: A cross-sectional study was conducted of patients with AD who were 1 to 18 years of age. An objective Severity Scoring of Atopic Dermatitis (SCORAD) and a serum 25-hydroxyvitamin D concentration were measured for each subject. Statistical analysis was performed using appropriate univariate tests and multivariable models. RESULTS: Ninety-four of 97 enrolled subjects were included in the analysis. Vitamin D deficiency (25-hydroxyvitamin D <20 ng/mL) was present in 37 subjects (39%), insufficiency (25-hydroxyvitamin D 21-29 ng/mL) in 33 (35%), and sufficiency (25-hydroxyvitamin D ≥30 ng/mL) in 24 (26%). The correlation between 25-hydroxyvitamin D concentration and SCORAD was not significant (r = -0.001; P = .99). A multivariate model showed that a lower serum 25-hydroxyvitamin D concentration was significantly associated with age 3 years or older (P < .0001), black race (P < .0001), and winter season (P = .0084). LIMITATIONS: Limitations of this study include the inability to control for natural sunlight exposure, vitamin D intake, and AD treatment; in addition, only a single time point was captured. CONCLUSIONS: Serum 25-hydroxyvitamin D concentration is not significantly correlated with AD severity in our pediatric population.
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Dermatite Atópica/sangue , Vitamina D/análogos & derivados , Adolescente , Criança , Pré-Escolar , Comorbidade , Estudos Transversais , Dermatite Atópica/epidemiologia , Feminino , Humanos , Lactente , Masculino , Prevalência , Índice de Gravidade de Doença , Vitamina D/sangue , Deficiência de Vitamina D/epidemiologiaRESUMO
INTRODUCTION: The treatment for pediatric orbital cellulitis/abscess is trending towards intravenous antibiotic management alone in appropriate cases. Without cultures to guide therapy, knowing the local microbiology is of utmost importance in managing these patients. METHODS: We conducted a retrospective case series for patients age 2 months to 17 years, who were hospitalized between January 1, 2013, and December 31, 2019, to evaluate the local microbiology and pattern of antibiotic prescribing in pediatric orbital cellulitis. RESULTS AND DISCUSSION: Of 95 total patients, 69 (73%) received intravenous antibiotics only and 26 (27%) received intravenous antibiotics plus surgery. The most common organism cultured was Streptococcus anginosus, followed by Staphylococcus aureus, and group A streptococcus. Methicillin-resistant Staphylococcus aureus (MRSA) prevalence was 9%. MRSA-active antibiotics remain the most frequently used antibiotics.
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Staphylococcus aureus Resistente à Meticilina , Celulite Orbitária , Infecções Estafilocócicas , Criança , Humanos , Celulite Orbitária/tratamento farmacológico , Celulite Orbitária/microbiologia , Antibacterianos/uso terapêutico , Abscesso/tratamento farmacológico , Abscesso/microbiologia , Estudos Retrospectivos , Infecções Estafilocócicas/tratamento farmacológicoRESUMO
The use of procalcitonin (PCT) has grown over the past decade with increasing reliance on the test to rule out bacterial infection. We retrospectively reviewed the medical records of children <18 years old hospitalized at a tertiary care children's hospital from 2017 to 2019 who had PCT testing performed during their admission. Of 4135 PCT levels collected on 1530 children, 982 (23.7%) were diagnostically low and 1993 (48.1%) were diagnostically elevated. Pediatric intensive care, with 6% of total hospital patients, obtained 41.4% of tests. Thirty-one (2%) patients had an average of 27 PCT levels per patient, accounting for 20% of all tests. Many children had symptoms for which testing is not indicated (eg, skin complaints). The differences in PCT testing by service, inappropriate patterns of repeat testing, and testing performed in patients for whom it is not indicated may identify targets for diagnostic stewardship.
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OBJECTIVE: Children require weight-based voriconazole doses proportionately larger than adults to achieve therapeutic serum trough concentrations (1-6 mcg/mL). The objective of this quality improvement project was to determine the initial dose, proportion of patients achieving target concentrations with initial dosing, and subsequent therapeutic drug monitoring and dose modifications needed to achieve and maintain therapeutic voriconazole concentrations in children. METHODS: This retrospective study evaluated children aged <18 years treated with voriconazole during the study period. Dosing and therapeutic drug monitoring (TDM) values were collected and compared by age. Data are presented as median (IQR), unless otherwise stated. RESULTS: Fifty-nine patients, aged 10.4 (3.7-14.7) years and 49% female, met inclusion criteria; 42 had at least 1 steady-state voriconazole serum trough concentration measured. Twenty-one of 42 (50%) achieved the target concentration at the first steady-state measurement. An additional 13 of 42 (31%) achieved the target following 2 to 4 dose modifications. The dose required to first achieve a value in the target range was 22.3 (18.0-27.1) mg/kg/day in children aged <12 years and 12.0 (9.8-14.0) mg/kg/day in children aged ≥12 years. After reaching the target, 59% and 81% of repeated steady-state measurements were in the therapeutic range in patients aged <12 years and ≥12 years, respectively. CONCLUSIONS: Reaching therapeutic voriconazole serum trough concentrations required doses larger than currently recommended by the American Academy of Pediatrics. Multiple dose adjustments and TDM measurements were required to achieve and maintain therapeutic voriconazole serum concentrations.
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BACKGROUND: The study goal was to determine the effect of vitamin D (VITD) supplementation on tubular reabsorption of phosphate (TRP), parathyroid hormone (PTH), bone alkaline phosphatase (BAP), and C-telopeptide (CTX) in youth infected with human immunodeficiency virus (HIV) receiving and not receiving combination antiretroviral therapy (cART) containing tenofovir disoproxil fumarate (TDF). METHODS: This randomized, double-blind, placebo-controlled multicenter trial enrolled HIV-infected youth 18-25 years based on stable treatment with cART containing TDF (n = 118) or no TDF (noTDF; n = 85), and randomized within those groups to vitamin D3, 50 000 IU (n = 102) or placebo (n = 101), administered at 0, 4, and 8 weeks. Outcomes included change in TRP, PTH, BAP, and CTX from baseline to week 12 by TDF/noTDF; and VITD/placebo. RESULTS: At baseline, VITD and placebo groups were similar except those on TDF had lower TRP and higher PTH and CTX. At week 12, 95% in the VITD group had sufficient serum 25-hydroxy vitamin D (25-OHD; ≥20 ng/mL), increased from 48% at baseline, without change in placebo (P < .001). PTH decreased in the TDF group receiving VITD (P = .031) but not in the noTDF group receiving VITD, or either placebo group. The decrease in PTH with VITD in those on TDF occurred with insufficient and sufficient baseline 25-OHD (mean PTH change, -7.9 and -6.2 pg/mL; P = .031 and .053, respectively). CONCLUSIONS: In youth on TDF, vitamin D3 supplementation decreased PTH, regardless of baseline 25-OHD concentration. CLINICAL TRIALS REGISTRATION: NCT00490412.
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Adenina/análogos & derivados , Fármacos Anti-HIV/administração & dosagem , Colecalciferol/administração & dosagem , Infecções por HIV/tratamento farmacológico , Organofosfonatos/administração & dosagem , Hormônio Paratireóideo/sangue , Vitaminas/administração & dosagem , Adenina/administração & dosagem , Adolescente , Terapia Antirretroviral de Alta Atividade/métodos , Método Duplo-Cego , Interações Medicamentosas , Feminino , Humanos , Masculino , Estudos Multicêntricos como Assunto , Placebos/administração & dosagem , Tenofovir , Adulto JovemRESUMO
Cardiac disease is a risk factor for venous thromboembolism (VTE) in children. In this study, we investigated the incidence and risk factors of VTE in critically ill children with cardiac disease, who were prospectively followed-up for VTE after admission to a tertiary care pediatric intensive care unit (PICU). Risk factors were compared between VTE cases and (1) patients in the cohort who did not develop VTE and (2) the next three cardiac patients sequentially admitted to the PICU (case control). Forty-one cases of VTE were identified from 1070 admissions (3.8%). Thirty-seven percent of VTE cases were central venous catheter (CVC)-associated, and 56% of cases were intracardiac. Sixty-six percent of patients were receiving anticoagulation at the time of VTE diagnosis. Increased VTE incidence was associated with unscheduled PICU admission, age <6 months, extracorporeal membrane oxygenation, increased number of CVCs, increased number of CVC days, higher risk of mortality score, and longer PICU stay. Using logistic regression, VTE was associated with single-ventricle physiology (odds ratio [OR] 11.2, 95% CI 3.0-41.9), widened arterial-to-somatic oxygen saturation gradient (SpO(2)-rSO(2) >30) (OR 4.3, 95% CI 1.1-16), and more CVC days (OR 1.1, 95% CI 1.04-1.13). Risk factors for VTE in critically ill children with cardiac disease include younger age, single-ventricle cardiac lesions, increased illness severity, unscheduled PICU admission, and complicated hospital course.
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Cardiopatias/complicações , Tromboembolia Venosa/etiologia , Adolescente , Adulto , Anticoagulantes/uso terapêutico , Criança , Pré-Escolar , Estado Terminal , Feminino , Seguimentos , Humanos , Incidência , Lactente , Unidades de Terapia Intensiva Pediátrica , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Tromboembolia Venosa/epidemiologia , Adulto JovemRESUMO
OBJECTIVES: Management of infants aged ≤60 days with urinary tract infections (UTI) is challenging. We examined renal imaging in infants aged ≤60 days with UTI at a tertiary care children's hospital to identify the impact of standardizing renal ultrasound (RUS) interpretation. METHODS: We retrospectively studied infants aged ≤60 days hospitalized for UTI or fever with urine culture and renal imaging obtained and final diagnosis of UTI. RUS initially had noncriterion-based (NCB) interpretation by experienced pediatric radiologists. For this study, a single pediatric radiologist used a criterion-based (CB) hydronephrosis grading system to reinterpret films initially classified as "abnormal" on the NCB reading. We compared final renal imaging results between NCB and CB groups. RESULTS: Of 193 infants, 180 (93%) had inpatient RUS with 114 (63%) abnormal NCB interpretation. Of those with initially abnormal NCB interpretation, 85 OF 114 (75%) had minor and 29 OF 114 (25%) had significant abnormality by CB reinterpretation. In follow-up, the CB "minor abnormality" group showed 25% abnormal renal imaging, whereas the "significant abnormality" group showed 77% abnormal renal imaging with 54% having high-grade reflux on a voiding cystourethrogram (VCUG). Patients with CB inpatient RUS minor abnormality showed 3% abnormal RUS at follow-up, but 13% showed high-grade reflux on VCUG. CONCLUSIONS: Standardized RUS interpretation in young infants with UTI improved the accuracy of identification of abnormalities on follow-up renal imaging. In patients with CB minor abnormality on inpatient RUS, our results suggest limited utility of follow-up RUS; however, follow-up VCUG remained useful to identify high-grade reflux.
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Infecções Urinárias , Refluxo Vesicoureteral , Lactente , Criança , Humanos , Refluxo Vesicoureteral/complicações , Refluxo Vesicoureteral/diagnóstico por imagem , Estudos Retrospectivos , Infecções Urinárias/diagnóstico por imagem , Cistografia , UltrassonografiaRESUMO
BACKGROUND: The objective of this study was to measure the recovery of routine pediatric immunization after a period of reduced vaccine administrations in the early weeks of the COVID-19 pandemic. METHODS: We recorded data on vaccines administered in Children's Wisconsin primary care or urgent care clinics from January 2019 through December 2020 and aggregated data by date and insurance type. RESULTS: During the gradual reopening period after week 21 in 2020, vaccine administration returned to prepandemic levels for children with commercial insurance but remained below baseline rates until the end of 2020 for children with Medicaid insurance. DISCUSSION: The decline in pediatric vaccination in 2020 disproportionately affected children with Medicaid insurance.
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COVID-19 , Vacinas , Instituições de Assistência Ambulatorial , COVID-19/epidemiologia , COVID-19/prevenção & controle , Criança , Humanos , Imunização , Programas de Imunização , Pandemias/prevenção & controle , Estados Unidos/epidemiologia , VacinaçãoRESUMO
The relationships among the dose of tenofovir disoproxil fumarate (TDF), tenofovir (TFV) plasma concentrations, and intracellular TFV diphosphate (TFV-DP) concentrations are poorly understood. Our objective was to characterize TFV and TFV-DP relationships. Data were pooled from two studies in HIV-infected persons (n = 55) on stable antiretroviral therapy. TFV and TFV-DP were measured with validated liquid chromatography/tandem mass spectrometry (LC/MS/MS) methods. Nonlinear mixed effects modeling (NONMEM 7) was used to develop the population model and explore the influence of covariates on TFV. A sequential analysis approach was utilized. A two-compartment model with first-order absorption best described TFV PK (FOCEI). An indirect stimulation of response model best described TFV-DP, where formation of TFV-DP was driven by plasma TFV concentration. Final plasma population estimates were as follows: absorption rate constant, 1.03 h(-1); apparent clearance (CL/F), 42 liters/h (33.5% interindividual variability [IIV]); intercompartment clearance, 181 liters/h; apparent central distribution volume (Vc/F), 273 liters (64.8% IIV); and apparent peripheral distribution volume (Vp/F), 440 liters (46.5% IIV). Creatinine clearance was the most significant covariate on CL/F and Vc/F. The correlation between CL/F and Vc/F was 0.553. The indirect response model for TFV-DP resulted in estimates of the maximal intracellular concentration (E(max)), the TFV concentration producing 50% of E(max) (EC(50)), and the intracellular elimination rate constant (k(out)) of 300 fmol/10(6) cells (82% IIV), 100 ng/ml (106% IIV), and 0.008 h(-1), respectively. The estimated k(out) gave an 87-h TFV-DP half-life. A predictive check assessment indicated satisfactory model performance. This model links formation of TFV-DP with plasma TFV concentrations and should facilitate more informed investigations of TFV clinical pharmacology.
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Adenina/análogos & derivados , Organofosfonatos/sangue , Organofosfonatos/farmacocinética , Adenina/sangue , Adenina/farmacocinética , Adolescente , Adulto , Cromatografia Líquida , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Espectrometria de Massas em Tandem , Tenofovir , Adulto JovemRESUMO
A 5.5-year-old asymptomatic Hispanic/African American male presented with matted lymph nodes in the neck and reticulonodular opacities in the right upper lung. An extensive diagnostic work up was performed to rule out infectious etiologies. Biopsies of the lymph node and lung tissue were diagnostic of nodular lymphocyte predominant Hodgkin lymphoma. Two weeks into the chemotherapy, gastric aspirates grew Mycobacterium avium intracellulare. This is the first case of nodular lymphocyte predominant Hodgkin lymphoma involving the lung with coexistent Mycobacterium avium intracellulare.
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Doença de Hodgkin/complicações , Neoplasias Pulmonares/complicações , Linfonodos/patologia , Linfócitos/patologia , Infecção por Mycobacterium avium-intracellulare/complicações , Pré-Escolar , Doença de Hodgkin/tratamento farmacológico , Doença de Hodgkin/patologia , Humanos , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/patologia , Masculino , Infecção por Mycobacterium avium-intracellulare/tratamento farmacológico , Infecção por Mycobacterium avium-intracellulare/patologia , Tomografia por Emissão de PósitronsRESUMO
STUDY OBJECTIVE: The 2009 H1N1 pandemic (H1N1pdm) virus has been associated with high rates of asymptomatic infections. Existing influenza infection control policies do not address potential transmission through exposure to asymptomatic infected individuals in health care settings. We conducted a seroprevalence study of H1N1pdm infection to determine whether health care workers (HCWs) in the emergency department showed increased evidence of infection during the first wave of the pandemic than that previously reported in adults in the community. METHODS: Blood samples and demographic and clinical data were collected from eligible emergency department HCWs. Subjects' sera were tested for presence of antibodies specific for seasonal H1N1 and H1N1pdm viruses by hemagglutination-inhibition assay. RESULTS: One hundred eight subjects were enrolled, of which 20 (18.5%) were seropositive for H1N1pdm and 52 (48%) for seasonal H1N1. The median age of H1N1pdm-seropositive subjects was 32 years (range, 24-59 years). Of H1N1pdm-seropositive subjects, 35% were asymptomatic. Rates of H1N1pdm detection in HCWs (18.5%) were significantly higher than those observed previously in an identical age cohort in the community (2.6%, n = 262). CONCLUSIONS: The higher serodetection rates in adults observed in the current study suggest potentially significantly more frequent infections in HCWs than in the general population. Further investigations are needed to ascertain the relative incidence of influenza infections in HCWs and non-HCWs, to study influenza transmission by asymptomatic infected subjects and ascertain the burden of such transmission in health care settings.
Assuntos
Anticorpos Antivirais/sangue , Antígenos Virais/imunologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Glicoproteínas de Hemaglutininação de Vírus da Influenza/imunologia , Transmissão de Doença Infecciosa do Paciente para o Profissional/estatística & dados numéricos , Vírus da Influenza A Subtipo H1N1/imunologia , Influenza Humana/epidemiologia , Doenças Profissionais/epidemiologia , Pandemias/estatística & dados numéricos , Recursos Humanos em Hospital/estatística & dados numéricos , Adolescente , Adulto , Idoso , Doenças Assintomáticas , Infecção Hospitalar/epidemiologia , Exposição Ambiental , Feminino , Hospitais Pediátricos/estatística & dados numéricos , Hospitais Privados/estatística & dados numéricos , Humanos , Vírus da Influenza A Subtipo H1N1/classificação , Vacinas contra Influenza , Influenza Humana/sangue , Influenza Humana/transmissão , Influenza Humana/virologia , Masculino , Pessoa de Meia-Idade , Doenças Profissionais/sangue , Doenças Profissionais/virologia , Estudos Soroepidemiológicos , Wisconsin/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Our internal infant sepsis evaluation clinical practice guideline recommends infants with negative culture results who are undergoing sepsis evaluation receive antibiotics until culture results are negative for a maximum of 36 hours. The aims of our project were to decrease the percentage of patients who received >30 hours of administered antibiotic doses (recognizing effective concentrations last until hour 36) and increase 36-hour phrase documentation by using clinical decision support tools. METHODS: We used quality improvement methodology to study infants aged ≤60 days with negative culture results. The outcome measures were the percentage of patients who received >30 hours of administered antibiotic doses, the percentage of history and physical (H&P) notes that included a statement of the anticipated 36-hour antibiotic discontinuation time (36-hour phrase), and length of stay. The process measure was the use of an illness-specific H&P template or an influencer smartphrase. Balancing measures were readmissions for positive culture results. Interventions included education, an illness-specific H&P template, a criteria-based rule to default to this H&P template, and editing influencer smartphrases. RESULTS: Over 33 months, 311 patients were included. Percentage of patients who received >30 hours of administered antibiotic doses decreased from 75.6% to 62%. Percentage of H&P notes documenting the 36-hour phrase increased from 4.9% to 75.6%. Illness-specific H&P template and influencer smartphrase usage increased to a mean of 51.5%; length of stay did not change. No readmissions for positive culture results were reported. CONCLUSIONS: Clinical decision support techniques and educational interventions popularized the "36-hour phrase" and were associated with a reduction in the antibiotic exposure in infants with negative culture results hospitalized for sepsis evaluation.