RESUMO
OBJECTIVE: To assess demographic, clinical, and biomarker features distinguishing patients with multisystem inflammatory syndrome in children (MIS-C); compare MIS-C sub-phenotypes; identify cytokine biosignatures; and characterize viral genome sequences. STUDY DESIGN: We performed a prospective observational cohort study of 124 children hospitalized and treated under the institutional MIS-C Task Force protocol from March to September 2020 at Children's National, a quaternary freestanding children's hospital in Washington, DC. Of this cohort, 63 of the patients had the diagnosis of MIS-C (39 confirmed, 24 probable) and 61 were from the same cohort of admitted patients who subsequently had an alternative diagnosis (controls). RESULTS: Median age and sex were similar between MIS-C and controls. Black (46%) and Latino (35%) children were over-represented in the MIS-C cohort, with Black children at greatest risk (OR 4.62, 95% CI 1.151-14.10; P = .007). Cardiac complications were more frequent in critically ill patients with MIS-C (55% vs 28%; P = .04) including systolic myocardial dysfunction (39% vs 3%; P = .001) and valvular regurgitation (33% vs 7%; P = .01). Median cycle threshold was 31.8 (27.95-35.1 IQR) in MIS-C cases, significantly greater (indicating lower viral load) than in primary severe acute respiratory syndrome coronavirus 2 infection. Cytokines soluble interleukin 2 receptor, interleukin [IL]-10, and IL-6 were greater in patients with MIS-C compared with controls. Cytokine analysis revealed subphenotype differences between critically ill vs noncritically ill (IL-2, soluble interleukin 2 receptor, IL-10, IL-6); polymerase chain reaction positive vs negative (tumor necrosis factor-α, IL-10, IL-6); and presence vs absence of cardiac abnormalities (IL-17). Phylogenetic analysis of viral genome sequences revealed predominance of GH clade originating in Europe, with no differences comparing patients with MIS-C with patients with primary coronavirus disease 19. Treatment was well tolerated, and no children died. CONCLUSIONS: This study establishes a well-characterized large cohort of MIS-C evaluated and treated following a standardized protocol and identifies key clinical, biomarker, cytokine, viral load, and sequencing features. Long-term follow-up will provide opportunity for future insights into MIS-C and its sequelae.
Assuntos
COVID-19/imunologia , Doenças Cardiovasculares/etiologia , Síndrome de Resposta Inflamatória Sistêmica/imunologia , Adolescente , Biomarcadores/sangue , COVID-19/sangue , COVID-19/diagnóstico , COVID-19/epidemiologia , Teste de Ácido Nucleico para COVID-19 , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Estudos de Casos e Controles , Criança , Pré-Escolar , Diagnóstico Diferencial , Feminino , Humanos , Lactente , Masculino , Pandemias , Fenótipo , Filogenia , Estudos Prospectivos , Fatores de Risco , SARS-CoV-2/imunologia , Índice de Gravidade de Doença , Síndrome de Resposta Inflamatória Sistêmica/sangue , Síndrome de Resposta Inflamatória Sistêmica/diagnóstico , Síndrome de Resposta Inflamatória Sistêmica/epidemiologiaRESUMO
BACKGROUND AND OBJECTIVES: Vancomycin remains one of the most commonly prescribed antibiotics in NICUs despite recommendations to limit its use for known resistant infections. Baseline data revealing substantially higher vancomycin use in our NICU compared to peer institutions informed our quality improvement initiative. Our aim was to reduce the vancomycin prescribing rate in neonates hospitalized in our NICU by 50% within 1 year and sustain for 1 year. METHODS: In the 60-bed level IV NICU of an academic referral center, we used a quality improvement framework to develop key drivers and interventions including (1) physician education with benchmarking antibiotic prescribing rates; (2) pharmacy-initiated 48-hour antibiotic time-outs on rounds; (3) development of clinical pathways to standardize empirical antibiotic choices for early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis; coupled with (4) daily prospective audit with feedback from the antimicrobial stewardship program. RESULTS: We used statistical process u-charts to show vancomycin use declined from 112 to 38 days of therapy per 1000 patient-days. After education, pharmacy-initiated 48-hour time-outs, and development of clinical pathways, vancomycin use declined by 29%, and by an additional 52% after implementation of prospective audit with feedback. Vancomycin-associated acute kidney injury also declined from 1.4 to 0.1 events per 1000 patient-days. CONCLUSIONS: Through a sequential implementation approach of education, standardization of care with clinical pathways, pharmacist-initiated 48-hour time-outs, and prospective audit with feedback, vancomycin days of therapy declined by 66% over a 1-year period and has been sustained for 1 year.
Assuntos
Gestão de Antimicrobianos/estatística & dados numéricos , Prescrição Inadequada/prevenção & controle , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Vancomicina/uso terapêutico , Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/organização & administração , Brasil , Procedimentos Clínicos , Enterocolite Necrosante/tratamento farmacológico , Hospitais Pediátricos/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Prescrição Inadequada/estatística & dados numéricos , Recém-Nascido , Doenças do Recém-Nascido/tratamento farmacológico , Serviço de Farmácia Hospitalar/organização & administração , Estudos Prospectivos , Melhoria de Qualidade , Sepse/tratamento farmacológicoRESUMO
OBJECTIVE: To demonstrate the value of using a variable derived from qualitative analysis in subsequent quantitative analyses. DATA SOURCES/STUDY SETTING: Mixed methods data were combined with 10-year mortality outcomes. Participants with cancer were recruited from services at a large teaching hospital, and mortality data were from the Social Security Death Index. STUDY DESIGN: An observational concurrent or convergent mixed methods design was used to collect demographics and structured ratings along with qualitative data from 909 cancer patients at baseline. DATA COLLECTION/EXTRACTION METHODS: Coding rules for qualitative data were defined for open-ended responses from cancer participants speaking about their view of self, and a variable was numerically coded for each case. Mortality outcomes were matched to baseline data, including the view of self variable. PRINCIPAL FINDINGS: Individuals with an improved view of self had a significantly lower mortality rate than those for whom it was worse or unchanged, even when adjusting for age, gender, and cancer stage. CONCLUSIONS: Statistical analysis of qualitative data is feasible and can identify new predictors with health services' implications associated with cancer mortality. Future studies should consider the value of testing coded qualitative variables in relation with key health care outcomes.