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Health Technology Assessment... 2012Although the vast majority of children with acute infections are managed at home, this is one of the most common problems encountered in children attending emergency... (Review)
Review
BACKGROUND
Although the vast majority of children with acute infections are managed at home, this is one of the most common problems encountered in children attending emergency departments (EDs) and primary care. Distinguishing children with serious infection from those with minor or self-limiting infection is difficult. This can result in misdiagnosis of children with serious infections, which results in a poorer health outcome, or a tendency to refer or admit children as a precaution; thus, inappropriately utilising secondary-care resources.
OBJECTIVES
We systematically identified clinical features and laboratory tests which identify serious infection in children attending the ED and primary care. We also identified clinical prediction rules and validated those using existing data sets.
DATA SOURCES
We searched MEDLINE, Medion, EMBASE, Cumulative Index to Nursing and Allied Health Literature and Database of Abstracts of Reviews of Effects in October 2008, with an update in June 2009, using search terms that included terms related to five components: serious infections, children, clinical history and examination, laboratory tests and ambulatory care settings. We also searched references of included studies, clinical content experts, and relevant National Institute for Health and Clinical Excellence guidelines to identify relevant studies. There were no language restrictions. Studies were eligible for inclusion if they were based in ambulatory settings in economically developed countries.
REVIEW METHODS
Literature searching, selection and data extraction were carried out by two reviewers. We assessed quality using the quality assessment of diagnostic accuracy studies (QUADAS) instrument, and used spectrum bias and validity of the reference standard as exclusion criteria. We calculated the positive likelihood ratio (LR+) and negative likelihood ratio (LR-) of each feature along with the pre- and post-test probabilities of the outcome. Meta-analysis was performed using the bivariate method when appropriate. We externally validated clinical prediction rules identified from the systematic review using existing data from children attending ED or primary care.
RESULTS
We identified 1939 articles, of which 35 were selected for inclusion in the review. There was only a single study from primary care; all others were performed in the ED. The quality of the included studies was modest. We also identified seven data sets (11,045 children) to use for external validation. The most useful clinical features for ruling in serious infection was parental or clinician overall concern that the illness was different from previous illnesses or that something was wrong. In low- or intermediate-prevalence settings, the presence of fever had some diagnostic value. Additional red flag features included cyanosis, poor peripheral circulation, rapid breathing, crackles on auscultation, diminished breath sounds, meningeal irritation, petechial rash, decreased consciousness and seizures. Procalcitonin (LR+ 1.75-2.96, LR- 0.08-0.35) and C-reactive protein (LR+ 2.53-3.79, LR- 0.25-0.61) were superior to white cell counts. The best performing clinical prediction rule was a five-stage decision tree rule, consisting of the physician's gut feeling, dyspnoea, temperature ≥ 40 °C, diarrhoea and age. It was able to decrease the likelihood of serious infections substantially, but on validation it provided good ruling out value only in low-to-intermediate-prevalence settings (LR- 0.11-0.28). We also identified and validated the Yale Observation Scale and prediction rules for pneumonia, meningitis and gastroenteritis.
LIMITATIONS
Only a single study was identified from primary-care settings, therefore results may lack generalisability.
CONCLUSIONS
Several clinical features are useful to increase or decrease the probability that a child has a serious infection. None is sufficient on its own to substantially raise or lower the risk of serious infection. Some are highly specific ('red flags'), so when present should prompt a more thorough or repeated assessment. C-reactive protein and procalcitonin demonstrate similar diagnostic characteristics and are both superior to white cell counts. However, even in children with a serious infection, red flags will occur infrequently, and their absence does not lower the risk. The diagnostic gap is currently filled by using clinical 'gut feeling' and diagnostic safety-netting, which are still not well defined. Although two prediction rules for serious infection and one for meningitis provided some diagnostic value, we do not recommend widespread implementation at this time. Future research is needed to identify predictors of serious infection in children in primary-care settings, to validate prediction rules more widely, and determine the added value of blood tests in primary-care settings.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: C-Reactive Protein; Child; Child Welfare; Confidence Intervals; Critical Care; Diagnostic Tests, Routine; Emergency Service, Hospital; Female; Humans; Laboratories; Male; Patient Care; Pediatrics; Predictive Value of Tests; Triage; United Kingdom
PubMed: 22452986
DOI: 10.3310/hta16150 -
Journal of Clinical Monitoring and... Jun 2020Cardiac output monitoring is used in critically ill and high-risk surgical patients. Intermittent pulmonary artery thermodilution and transpulmonary thermodilution,... (Meta-Analysis)
Meta-Analysis
Cardiac output monitoring is used in critically ill and high-risk surgical patients. Intermittent pulmonary artery thermodilution and transpulmonary thermodilution, considered the gold standard, are invasive and linked to complications. Therefore, many non-invasive cardiac output devices have been developed and studied. One of those is electrical cardiometry. The results of validation studies are conflicting, which emphasize the need for definitive validation of accuracy and precision. We performed a database search of PubMed, Embase, Web of Science and the Cochrane Library of Clinical Trials to identify studies comparing cardiac output measurement by electrical cardiometry and a reference method. Pooled bias, limits of agreement (LoA) and mean percentage error (MPE) were calculated using a random-effects model. A pooled MPE of less than 30% was considered clinically acceptable. A total of 13 studies in adults (620 patients) and 11 studies in pediatrics (603 patients) were included. For adults, pooled bias was 0.03 L min [95% CI - 0.23; 0.29], LoA - 2.78 to 2.84 L min and MPE 48.0%. For pediatrics, pooled bias was - 0.02 L min [95% CI - 0.09; 0.05], LoA - 1.22 to 1.18 L min and MPE 42.0%. Inter-study heterogeneity was high for both adults (I = 93%, p < 0.0001) and pediatrics (I = 86%, p < 0.0001). Despite the low bias for both adults and pediatrics, the MPE was not clinically acceptable. Electrical cardiometry cannot replace thermodilution and transthoracic echocardiography for the measurement of absolute cardiac output values. Future research should explore it's clinical use and indications.
Topics: Adult; Cardiac Output; Catheterization, Swan-Ganz; Child; Critical Illness; Echocardiography; Electrodes; Humans; Models, Cardiovascular; Monitoring, Physiologic; Pediatrics; Pulmonary Artery; Reproducibility of Results; Thermodilution; Thoracic Surgical Procedures
PubMed: 31175501
DOI: 10.1007/s10877-019-00330-y -
Academic Pediatrics 2012The American Academy of Pediatrics and other organizations recommend several screening tests as part of preventive care. The proportion of children who are appropriately... (Review)
Review
BACKGROUND
The American Academy of Pediatrics and other organizations recommend several screening tests as part of preventive care. The proportion of children who are appropriately screened and who receive follow-up care is low.
OBJECTIVE
To conduct a systematic review of the evidence for practice-based interventions to increase the proportion of patients receiving recommended screening and follow-up services in pediatric primary care.
DATA SOURCE
Medline database of journal citations.
STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS
We developed a strategy to search MEDLINE to identify relevant articles. We selected search terms to capture categories of conditions (eg, developmental disabilities, obesity), screening tests, specific interventions (eg, quality improvement initiatives, electronic records enhancements), and primary care. We searched references of selected articles and reviewed articles suggested by experts. We included all studies with a distinct, primary care-based intervention and post-intervention screening data, and studies that focused on children and young adults (≤21 years of age). We excluded studies of newborn screening.
STUDY APPRAISAL AND SYNTHESIS METHODS
Abstracts were screened by 2 reviewers and articles with relevant abstracts received full text review and were evaluated for inclusion criteria. A structured tool was used to abstract data from selected articles. Because of heterogeneous interventions and outcomes, we did not attempt a meta-analysis.
RESULTS
From 2547 returned titles and abstracts, 23 articles were reviewed. Nine were pre-post comparisons, 5 were randomized trials, 3 were postintervention comparisons with a control group, 3 were postintervention cross-sectional analyses only, and 3 reported time series data. Of 14 articles with preintervention or control group data and significance testing, 12 reported increases in the proportion of patients appropriately screened. Interventions were heterogeneous and often multifaceted, and several types of interventions, such as provider/staff training, electronic medical record templates/prompts, and learning collaboratives, appeared effective in improving screening quality. Few articles described interventions to track screening results or referral completion for those with abnormal tests. Data were often limited by single-site, nonrandomized design.
CONCLUSIONS
Several feasible, practice- and provider-level interventions appear to increase the quality of screening in pediatric primary care. Evidence for interventions to improve follow-up of screening tests is scant. Future research should focus on which specific interventions are most effective, whether effects are sustained over time, and what interventions improve follow-up of abnormal screening tests.
Topics: Adolescent; Child; Child, Preschool; Evidence-Based Medicine; Guideline Adherence; Humans; Infant; Mass Screening; Pediatrics; Practice Patterns, Physicians'; Preventive Medicine; Primary Health Care; Quality Improvement; Quality of Health Care; Young Adult
PubMed: 22575809
DOI: 10.1016/j.acap.2012.02.004 -
Clinical Child and Family Psychology... Dec 2015The aim of this systematic review and meta-analysis was to synthesize the available evidence on embedded family therapy interventions in pediatrics and impacts on... (Meta-Analysis)
Meta-Analysis Review
Clinical Effectiveness of Family Therapeutic Interventions Embedded in General Pediatric Primary Care Settings for Parental Mental Health: A Systematic Review and Meta-analysis.
The aim of this systematic review and meta-analysis was to synthesize the available evidence on embedded family therapy interventions in pediatrics and impacts on parental mental health and family functioning outcomes. The Cochrane Collaboration guidelines for systematic reviews and meta-analysis were used for this study. Six electronic databases were searched for randomized controlled trials and cluster randomized trials. The Cochrane Collaboration's Risk of Bias Tool and GRADE system were used to rate the quality of evidence of the included studies. The primary outcomes included parental distress, parental depressive symptoms, and dysfunctional parent-child interaction. Fixed effects models showed statistically significant reductions in parental distress at 6-month and 12-month post-intervention in favor of the intervention group. Family therapy model, intervention level, delivery modality, and dosage moderated intervention impacts on parental distress. Fixed effects models showed statistically significant reductions in parental depressive symptoms and in dysfunctional parent-child interaction in favor of the intervention group. Family therapy interventions can be successfully embedded in general pediatric primary care, and intended outcomes are achieved in this setting. Recommendations for future research and implications for policy development are discussed.
Topics: Family Therapy; Humans; Outcome Assessment, Health Care; Parent-Child Relations; Parents; Pediatrics
PubMed: 26377209
DOI: 10.1007/s10567-015-0190-x -
Scandinavian Journal of Primary Health... Mar 2015To investigate the views of parents, clinicians, and children pertaining to prescribing decisions for acute childhood infection in primary care. (Review)
Review
OBJECTIVES
To investigate the views of parents, clinicians, and children pertaining to prescribing decisions for acute childhood infection in primary care.
METHODS
A systematic review of qualitative studies. Meta-ethnographic methods were used, with data drawn from the primary studies in an interpretive analysis.
RESULTS
A total of 15 studies met the inclusion criteria. The literature was dominated by concerns about antibiotic over-prescription. Children's views were not reported. Clinicians prescribed antibiotics when they felt pressured by parents or others (e.g. employers) to do so, when they believed there was a clear clinical indication, but also when they felt uncertain of clinical or social outcomes they prescribed "just in case". Parents wanted antibiotics when they felt they would improve the current illness, and when they felt pressure from daycare providers or employers. Clinicians avoided antibiotics when they were concerned about adverse reactions or drug resistance, when certain they were not indicated, and when there was no perceived pressure from parents. Parents also wished to avoid adverse effects of antibiotics, and did not want antibiotics when they would not relieve current symptoms. Some parents preferred to avoid medication altogether. Within paediatric consultations, parents sought a medical evaluation and decision. Primary care clinicians want satisfied parents and short consultations.
CONCLUSIONS
Antibiotic prescriptions for childhood infections in primary care often result from "just in case" prescribing. These findings suggest that interventions which reduce clinician uncertainty regarding social or clinical outcomes and provide strategies to meet parents' needs within a short consultation are most likely to reduce antibiotic prescribing.
Topics: Anti-Bacterial Agents; Attitude of Health Personnel; Attitude to Health; Child; Clinical Decision-Making; Humans; Parents; Pediatrics; Primary Health Care; Respiratory Tract Infections
PubMed: 25716427
DOI: 10.3109/02813432.2015.1001942 -
Clinical Pharmacokinetics Dec 2021Cytochromes P450 (CYP) are the major enzymes involved in hepatic metabolism of drugs. Personalization of treatment in pediatrics is a major challenge, as it must not...
BACKGROUND AND OBJECTIVE
Cytochromes P450 (CYP) are the major enzymes involved in hepatic metabolism of drugs. Personalization of treatment in pediatrics is a major challenge, as it must not only take into account genetic, environmental, and physiological factors but also ontogeny. Published data in adults show that inflammation had an isoform-specific impact on CYP activities and we aimed to evaluate this impact in the pediatric population.
METHODS
Articles listed in PubMed through 7 January, 2021 that studied the impact of inflammation on CYP activities in pediatrics were included in this systematic review. Sources of inflammation, victim drugs (CYP involved), effect of drug-disease interactions, number and age of subjects, and study design were extracted.
RESULTS
Twenty-seven studies and case reports were included. The impact of inflammation on CYP activities appeared to be age dependent and isoform-specific, with some drug-disease interactions having significant pharmacokinetic and clinical impact. For example, midazolam clearance decreases by 70%, while immunosuppressant and theophylline concentrations increase three-fold and two-fold with intensive care unit admission and infection. Cytochrome P450 activity appears to return to baseline level when the disease is resolved.
CONCLUSIONS
Studies that have assessed the impact of inflammation on CYP activity are lacking in pediatrics, yet it is a major factor to consider to improve drug efficacy or safety. The scarce current data show that the impact of inflammation is isoform and age dependent. An effort must be made to improve the understanding of the impact of inflammation on CYP activities in children to better individualize treatment.
Topics: Adult; Child; Cytochrome P-450 Enzyme System; Drug Interactions; Humans; Inflammation; Midazolam; Pediatrics
PubMed: 34462878
DOI: 10.1007/s40262-021-01064-4 -
Value in Health : the Journal of the... 2016Cost-effectiveness analysis of pediatric vaccines for infectious diseases often requires quality-of-life (utility) weights. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Cost-effectiveness analysis of pediatric vaccines for infectious diseases often requires quality-of-life (utility) weights.
OBJECTIVE
To investigate how utility weights have been elicited and used in this context.
METHODS
A systematic review was conducted of studies published between January 1990 and July 2013 that elicited or used utility weights in cost-effectiveness analyses of vaccines for pediatric populations. The review focused on vaccines for 17 infectious diseases and is presented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology.
RESULTS
A total of 6410 titles and abstracts and 225 full-text articles were reviewed. Of those selected for inclusion (n = 101), 15 articles described the elicitation of utility weights and 86 described economic modeling studies using utilities. Various methods were used to generate utilities, including time trade-off, contingent valuation, and willingness to pay, as well as a preference-based measure with associated value sets, such as the EuroQol five-dimensional questionnaire or the Health Utilities Index. In modeling studies, the source of utilities used was often unclear, poorly reported, or based on weak underlying evidence. We found no articles that reported on the elicitation or use of utilities in diphtheria, polio, or tetanus.
CONCLUSIONS
The scarcity of appropriate utility weights for vaccine-preventable infectious diseases in children and a lack of standardization in their use in economic assessments limit the ability to accurately assess the benefits associated with interventions to prevent infectious diseases. This is an issue that should be of concern to those making decisions regarding the prevention and treatment of infectious childhood illnesses.
Topics: Adolescent; Age Factors; Child; Child, Preschool; Cost-Benefit Analysis; Drug Costs; Female; Health Resources; Health Status; Health Status Indicators; Humans; Immunization Schedule; Infant; Infant, Newborn; Male; Models, Economic; Pediatrics; Quality of Life; Quality-Adjusted Life Years; Risk Assessment; Surveys and Questionnaires; Treatment Outcome; Vaccination; Vaccines
PubMed: 27021761
DOI: 10.1016/j.jval.2015.11.003 -
Journal of Thrombosis and Haemostasis :... Jul 2014In preparation for a pediatric randomized controlled trial on thromboprophylaxis, we determined the frequency of catheter-related thrombosis in children. We also... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
In preparation for a pediatric randomized controlled trial on thromboprophylaxis, we determined the frequency of catheter-related thrombosis in children. We also systematically reviewed the pediatric trials on thromboprophylaxis to evaluate its efficacy and to identify possible pitfalls in the conduct of these trials.
PATIENTS/METHODS
We searched MEDLINE, EMBASE, Web of Science and the Cochrane Central Register for Controlled Trials for articles published until December 2013. We included cohort studies and trials on patients aged 0-18 years with central venous catheters who underwent active surveillance for thrombosis with radiologic imaging. We estimated the pooled frequency of thrombosis and the pooled risk ratio (RR) with thromboprophylaxis by using a random effects model.
RESULTS
From 2651 articles identified, we analyzed 37 articles with 3128 patients. The pooled frequency of thrombosis was 0.20 (95% confidence interval [CI] 0.16-0.24). In 10 trials, we did not find evidence that heparin-bonded catheters (RR 0.34; 95%CI 0.01-7.68), unfractionated heparin (RR 0.93; 95% CI 0.57-1.51), low molecular weight heparin (RR 1.13; 95% CI 0.51-2.50), warfarin (RR 0.85; 95%CI 0.34-2.17), antithrombin concentrate (RR 0.76; 95% CI 0.38-1.55) or nitroglycerin (RR 1.53; 95%CI 0.57-4.10) reduced the risk of thrombosis. Most of the trials were either not powered for thrombosis or were powered to detect large, probably unachievable, reductions in thrombosis. Missing data on thrombosis also limited these trials.
CONCLUSIONS
Catheter-related thrombosis is common in children. An adequately powered multicenter trial that can detect a modest, clinically significant reduction in thrombosis is critically needed. Missing outcome data should be minimized in this trial.
Topics: Adolescent; Anticoagulants; Catheterization, Central Venous; Central Venous Catheters; Child; Child, Preschool; Clinical Trials as Topic; Heparin; Heparin, Low-Molecular-Weight; Humans; Infant; Infant, Newborn; Pediatrics; Risk; Thrombosis; United States; Venous Thrombosis
PubMed: 24801495
DOI: 10.1111/jth.12598 -
Journal of Pediatric Rehabilitation... May 2017A rise in pediatric patients with swallowing and feeding problems has resulted in increased interest in multidisciplinary treatments to address these issues. This... (Review)
Review
PURPOSE
A rise in pediatric patients with swallowing and feeding problems has resulted in increased interest in multidisciplinary treatments to address these issues. This evidence based systematic review (EBSR) examined the published evidence for the use of common strategies used by clinicians across disciplines to treat pediatric swallowing and feeding problems.
METHODS
A systematic search of 10 electronic databases was completed to identify relevant, peer reviewed literature published in English prior to December 2015 reporting original data that addressed at least one of the five identified clinical questions.
RESULTS
Sixty-one studies of varying methodological quality were included. The majority of the included studies (60/61) focused on the use of behavioral therapies to remediate swallowing and feeding disorders in children and reported mixed findings across all of the targeted outcomes.
CONCLUSION
There is insufficient quantity of evidence to determine the effects of oral motor, sensory, and pharmaceutical therapies on functional feeding outcomes in pediatric populations. A larger body of phase 1 evidence is available that establishes the efficacy of behavioral strategies to treat some swallowing and feeding difficulties in small cohort and single subject studies. This analysis identified limited high quality (phase 4) research articles that establish the efficacy and benefit of joint nutrition and behavior intervention programs and systematic desensitization and operant conditioning behavioral therapy approaches to improve functional feeding and swallowing outcomes in children.
Topics: Behavior Therapy; Child; Child, Preschool; Combined Modality Therapy; Deglutition Disorders; Feeding and Eating Disorders; Humans; Infant; Nutritional Support; Pediatrics; Physical Therapy Modalities; Treatment Outcome
PubMed: 28582883
DOI: 10.3233/PRM-170436 -
Journal of the American Academy of... Jul 2015Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for pediatric major depressive disorder (MDD). We conducted a meta-analysis... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for pediatric major depressive disorder (MDD). We conducted a meta-analysis to examine the following: the time-course of response to SSRIs in pediatric depression; whether higher doses of SSRIs are associated with an improved response in pediatric depression; differences in efficacy between SSRI agents; and whether the time-course and magnitude of response to SSRIs is different in pediatric and adult patients with MDD.
METHOD
We searched PubMed and CENTRAL for randomized controlled trials comparing SSRIs to placebo for the treatment of pediatric MDD. We extracted weekly symptom data from trials to characterize the trajectory of pharmacological response to SSRIs. Pooled estimates of treatment effect were calculated based on standardized mean differences between treatment and placebo groups.
RESULTS
The meta-analysis included 13 pediatric MDD trials with a total of 3,004 patients. A logarithmic model indicating that the greatest benefits of SSRIs occurred early in treatment best fit the longitudinal data (log[week] = 0.10, 95% CI = 0.06-0.15, p < .0001). There were no significant differences based on maximum SSRI dose or between particular SSRI agents. SSRIs were demonstrated to have a smaller benefit in pediatric compared to adult MDD.
CONCLUSION
Treatment gains in pediatric MDD are greatest early in treatment and are, on average, minimal after 4 weeks of SSRI pharmacotherapy in pediatric MDD. Further research is needed using individual patient data to examine the power of early SSRI response (e.g., 2-4 weeks) to predict outcomes in short-term pharmacological trials.
Topics: Child; Depressive Disorder, Major; Early Medical Intervention; Humans; Pediatrics; Randomized Controlled Trials as Topic; Selective Serotonin Reuptake Inhibitors
PubMed: 26088660
DOI: 10.1016/j.jaac.2015.05.004