Traci Leong - Academia.edu (original) (raw)
Papers by Traci Leong
Results: 46 patients, enrolled from 2015 to 2020 were included. 27 (58.7%) were male. 18 patients... more Results: 46 patients, enrolled from 2015 to 2020 were included. 27 (58.7%) were male. 18 patients (39.1%) had a diagnosis of minimal change followed by focal segmental glomerulosclerosis in 16 patients (34.7%). Median age at start of treatment was 12.5 years (IQR 8.5-17.4) compared to 5.3 years at diagnosis (IQR 2.7-10.5 years). 52% were resistant to corticosteroids. The most common Acthar Gel regimen was 80IU twice a week with a median duration of 199 days (IQR 88365). Among 37 patients with active disease, 18 (49%) were able to achieve partial or complete remission, though all patients that had a positive response were on other immunosuppressants concomitantly.
Injury Epidemiology, 2020
Background The American Academy of Pediatrics (AAP) recommends infants should be Alone, on their ... more Background The American Academy of Pediatrics (AAP) recommends infants should be Alone, on their Back, and in a clear Crib to combat relatively stagnant rates of sudden unexpected infant death (SUID). These are referred to as the ABCs of safe sleep. Studies have shown these recommendations are not consistently followed in the hospital setting, but further investigation would determine how to improve the rate of adherence. The objective of this study was to evaluate the impact of an expanded safe sleep initiative at three Georgia free-standing children’s hospital campuses before and after a multipronged safe sleep initiative. Methods A quality improvement program with a pre/post analysis was performed using a convenience method of sampling. Infants < 12 months old in three inpatient pediatric campuses were analyzed pre- and post- interventions. The intervention included: 1) nursing education, 2) identification of nurse “safe sleep” champions, 3) crib cards, 4) crib audits, and 5) ...
Background: Current prevalence of COVID-19 drives many policy decisions, but is hampered by ambig... more Background: Current prevalence of COVID-19 drives many policy decisions, but is hampered by ambiguities in testing and reporting. We propose an alternative method for estimating community prevalence that is inexpensive and timely. We test the Hypothesis that the survey sampling provides a quantitative prevalence that is similar to widespread genomic or serological testing. Methods: We have built a simple, web-based survey of signs and symptoms for COVID-19 based on six questions. No personally identifiable information is collected to maintain privacy. Sampling can be directed to a population of interest such as a company, or broadcast widely to get geographic sampling. Data reporting can be real-time and plotted onto zipcode maps. Rates of prevalence were calculated from presumed COVID cases and respondents, with confidence intervals based on the Blaker method.Results: The website was created quickly, and survey results were quantitatively useful after only a few days. Analyzing 316...
Purpose: To compare combination chemotherapy (CCT) versus melphalan plus prednisone (MP) as treat... more Purpose: To compare combination chemotherapy (CCT) versus melphalan plus prednisone (MP) as treatment for multiple myeloma. Patients and Methods: In a collaborative worldwide overview of randomized trials of CCT versus MP, individual patient data on 4,930 patients from 20 trials were analyzed, with the addition of published data on a further 1,703 patients from seven trials. The main outcome measure was mortality, with response and recurrence rates being subsidiary end points. Results: Taking all of the trials together, response rates were significantly higher with CCT than with MP (60.0% v 53.2%; P < .00001, two-tailed). There was no evidence of any difference in mortality between CCT and MP, with a nonsignificant 1.5% reduction in death rate in favor of CCT (P = .6, two-tailed). There is heterogeneity of design between the trials, but subgroup analyses by type of CCT or by dose-intensities of CCT, of melphalan, or of prednisone did not identify any particular forms of therapy t...
BACKGROUND Hydroxyurea, chronic blood transfusion, and bone marrow transplantation are efficaciou... more BACKGROUND Hydroxyurea, chronic blood transfusion, and bone marrow transplantation are efficacious disease-modifying therapies for sickle cell disease (SCD) but are associated with a significant decisional dilemma because of the inherent risk-benefit tradeoffs and the lack of comparative studies. A web-based patient decision aid (PtDA) has the potential to provide patients with high-quality information about their treatment options and associated risks and benefits, help them clarify their values, and allow them to share in the process of informed medical decision making. OBJECTIVE The objective of this study was to develop a literacy-sensitive, web-based, PtDA using the conceptual framework of the Ottawa decision support framework, and to estimate in a randomized clinical trial the effectiveness of the PtDA in improving patient knowledge, and involvement in decision-making. METHODS We conducted population decisional needs assessment in a nationwide sample of patients, caregivers, s...
Journal of the American College of Cardiology
بالصفات ً مدعوما مصر من جديد نوع األكانثية)، (العائلة Dicliptera aegyptiaca rbcl ... more بالصفات ً مدعوما مصر من جديد نوع األكانثية)، (العائلة Dicliptera aegyptiaca rbcl جين باستخدام النووية لألحماض الباركود تقنية و المورفولوجية (2) فؤاد أحمد ، (1) شمسو إيمان النبات قسم (2) مصر،-الجيزة-القاهرة جامعة-العلوم كلية-والميكروبيولوجي النبات قسم-المعشبة (1) مصر.-الجيزة-القاهرة جامعة-العلوم كلية-والميكروبيولوجى
Urology
To evaluate the radiographic findings of neonatal intensive care unit (NICU) patients diagnosed w... more To evaluate the radiographic findings of neonatal intensive care unit (NICU) patients diagnosed with hospital-acquired urinary tract infection (UTI). Children with no preexisting genitourinary anomalies undergoing a voiding cystourethrogram (VCUG) for culture-documented UTI during NICU admission were identified. Demographics, microbiology results, and imaging findings were evaluated. A total of 147 NICU patients underwent VCUG during the study period. Of these, the indication for VCUG was UTI in 58 children. Neonates diagnosed with UTI were born at a mean gestational age of 28 3/7 ± 4 3/7 weeks, and underwent VCUG at a mean of age of 70.3 ± 42 days. Urine culture grew Enterococcus in 32 (55.2%), Enterobacter in 6 (10.3%), coagulase negative staphylococcus in 6 (10.3%), Escherichia coli in 5 (8.7%), and other in 9 infants (15.5%). All patients underwent a retroperitoneal ultrasound, which was read as normal in 31 patients (53.4%). Fourteen children (24.1%) diagnosed with UTI were found to have vesicoureteral reflux on VCUG. On univariate analysis, no patient characteristics were associated with VCUG positivity. On multivariate analysis, the effect of age at VCUG differed by renal-bladder ultrasound results. Patients with an abnormal ultrasound were 3.6 (95% confidence interval, 1.39-9.24) times more likely to have a positive VCUG for every 1 month increase in age. Ultrasound anomalies are common in NICU patients diagnosed with UTI. The effect of age at VCUG differed by ultrasound result; the probability of vesicoureteral reflux in infants with sonographic abnormalities and UTI increases with age.
Journal of Pediatric Urology, 2015
Critical Care Medicine
Introduction: Prior research on physician and non-physician endotracheal intubation (ETI) of pedi... more Introduction: Prior research on physician and non-physician endotracheal intubation (ETI) of pediatric patients demonstrates highly variable success rates. To assess the performance of a single children's critical care transport team (CCT), we analyzed data from 2.5 years of pediatric ETI encounters. Methods: A retrospective review encompassed pediatric ETI encounters from 127 patient charts from the rotorcraft and ground emergency CCT of a large quaternary referral children's hospital with an average of greater than 5000 patient transports annually. Pediatric patients were cared for by the CCT between January 1, 2011, and July 31, 2013. We included all patients between 1 day and 20 years of age in our analysis, without exclusion. A single ETI attempt was defined by the insertion of a laryngoscope. We characterized first-attempt intubation success and overall intubation success with descriptive statistics and calculated 95% confidence intervals. Results: For our cohort, demo...
The Journal of Urology, 2014
In 2011 the AAP revised practice parameters on febrile urinary tract infection in infants and chi... more In 2011 the AAP revised practice parameters on febrile urinary tract infection in infants and children 2 to 24 months old. New imaging recommendations invigorated the ongoing debate regarding the diagnosis and management of vesicoureteral reflux. We compared evaluations in these patients with febrile urinary tract infection before and after guideline publication. During 2 separate 6-month periods 350 patients 2 to 24 months old were evaluated in the emergency room setting. Demographics, urine culture, renal-bladder ultrasound, voiding cystourethrogram and admission status were assessed. A total of 172 patients presented with initial febrile urinary tract infection in 2011, of whom 47 (27.3%) required hospitalization, while 42 of 178 (23.6%) were admitted in 2012. Admission by year did not significantly differ (p = 0.423). After guideline revision 41.2% fewer voiding cystourethrograms were done (72.1% of cases in 2011 vs 30.9% in 2012, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). A 17.2% decrease in renal-bladder ultrasound was noted (75.6% in 2011 vs 58.4% in 2012, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Of 55 voiding cystourethrograms 21 (38.2%) were positive in 2012 compared to 36.3% in 2011 (p = 0.809). Mean ± SD maximum vesicoureteral reflux grade was unchanged in 2011 and 2012 (2.9 ± 1.2 and 2.5 ± 0.93, respectively, p = 0.109). There was no association between abnormal renal-bladder ultrasound and voiding cystourethrogram positivity (p = 0.116). AAP guidelines impacted the treatment of infants and young children with febrile urinary tract infection. We found no relationship between renal-bladder ultrasound and abnormal voiding cystourethrogram, consistent with previous findings that call ultrasound into question as the determinant for additional imaging. Whether forgoing routine voiding cystourethrogram results in increased morbidity is the subject of ongoing study.
Journal of Pediatric Urology, 2014
Surgical correction of vesicoureteral reflux (VUR) is influenced by recurrent urinary tract infec... more Surgical correction of vesicoureteral reflux (VUR) is influenced by recurrent urinary tract infection (UTI) risk and the likelihood of spontaneous resolution. We aimed to identify factors associated with VUR resolution in children less than 2 years of age and to design a simple scoring tool to predict improvement and resolution. Children less than 2 years old with primary VUR were identified. Patient demographics, voiding cystourethrogram (VCUG) findings and clinical outcomes over time were assessed. Multivariate analysis with time to resolution was performed to identify factors predictive of VUR improvement and resolution. A random forest model was used to confirm the VUR index (VURx) with normalized importance. Two-hundred and twenty-nine children met all inclusion criteria. Mean age at initial VCUG was 0.46±0.43 years. Median clinical follow-up was 1.6 years (range 0.5-4.4 years). Children with grade 4-5 reflux, complete ureteral duplication or periureteral diverticula, and filling phase VUR, as well as female gender, had significantly (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01) longer time to improvement or resolution on multivariate survival analysis. VURx 1 to 5-6 had improvement/resolution rates of 89%, 69%, 53%, 16% and 11%, respectively. Female gender, high-grade VUR, ureteral anomalies, and filling reflux are associated with longer time to improvement and non-resolution. VURx reliably predicts resolution of primary reflux in children less than 2 years of age.
Pediatric Neurosurgery, 1994
We reviewed the records of 98 consecutive patients, 18 years of age or younger, with pathological... more We reviewed the records of 98 consecutive patients, 18 years of age or younger, with pathologically confirmed supratentorial astroglial neoplasms at the Children&amp;amp;amp;#39;s Hospital, Boston, to evaluate the importance of seizures in their presentation and natural history. Tumors were diagnosed using the WHO criteria as pilocytic astrocytomas, astrocytomas, anaplastic astrocytomas, glioblastomas, giant cell glioblastomas, oligoastrocytomas and gangliogliomas. Our results were as follows. (1) Fifty percent of children had seizures as part of their presentation and 30% had seizures as their only presenting phenomenon. (2) The seizures varied in nature, but complex (55%) or simple (28%) partial seizures were by far the most common types, occurring in 77% of cases. (3) Preoperative electroencephalography (EEG) accurately lateralized to the tumor side in 88% of the cases and localized to the correct lobe in 56%. (4) Tumors involving cerebral cortex significantly correlated with seizures at presentation as compared to noncortical locations; 59% of patients with cortical tumors presented with seizures, and only 15% of patients with noncortical tumors experienced seizures. Lesions in the temporal and frontal lobes had the highest incidence of seizures. (5) Patients with gangliogliomas and oligoastrocytomas had the highest incidence of seizures, 88 and 86%, respectively, whereas patients with anaplastic astrocytoma had the lowest incidence, 21%. (6) Histopathologic calcification was associated with seizures at presentation approaching significance (p = 0.06). (7) Seizures at presentation were significantly associated with good prognosis (p = 0.02).
The Journal of Urology, 2014
The Journal of Urology, 2012
The Journal of Urology, 2014
The Journal of Thoracic and Cardiovascular Surgery, 2008
The Clinical Journal of Pain, 2009
Mechanoreceptor and noxious thermal inhibitory stimulation modulate pain conduction but have not ... more Mechanoreceptor and noxious thermal inhibitory stimulation modulate pain conduction but have not been clinically tested in combination. Our objectives were to determine whether a vibrating cold device decreased adult venipuncture pain on a 10 cm visual analog scale more than no intervention, and compared with vapocoolant analgesia versus no intervention. The design was a prospective randomized crossover clinical trial. Thirty healthy adult volunteers were randomized to the study device or vapocoolant intervention. One nurse attempted cannulation on both intervention and control hands with a 22 gauge intravenous catheter. Vapocoolant was applied to the cannulation site, or the device was applied 5 to 10 cm proximally throughout the intervention attempt. Visual analog scale assessed needle fear and the primary outcome of self-reported pain. Sixteen device and 14 vapocoolant participants were included in this study. One participant felt discomfort from device prongs before the needle stick and was excluded. Compared with no intervention, the device reduced pain significantly (mean 9.9 mm, 95% confidence interval 0.82-19, P=0.035, SD 16) whereas vapocoolant did not (mean 7.9 mm, 95% confidence interval -1.8-17.7, P=0.1, SD 16.9). Mean pain reduction for device group participants was not significantly different from vapocoolant participants. Each 20 mm of prior anxiety increased the likelihood of intervention pain relief (odds ratio 2, P=0.043). One venipuncture failure occurred in the vapocoolant intervention. The combination of cold and vibration gave significant venipuncture pain relief without affecting cannulation success. Interventions were more helpful for those with greater preprocedural fear. Larger sample sizes and a prongless device could better compare equivalence or superiority to existing pain relief modalities.
American Journal of Medical Quality, 2014
The study team sought to improve hospitalist communication with primary care providers (PCPs) at ... more The study team sought to improve hospitalist communication with primary care providers (PCPs) at discharge through interventions consisting of (a) audit and feedback and (b) inclusion of a discharge communication measure in the incentive compensation for pediatric hospitalists. The setting was a 16-physician pediatric hospitalist group within a tertiary pediatric hospital. Discharge summaries were selected randomly for documentation of communication with PCPs. At baseline, 57% of charts had documented communication with PCPs, increasing to 84% during the audit and feedback period. Following the addition of a financial incentive, documentation of communication with PCPs increased to 93% and was sustained during the combined intervention period. The number of physicians meeting the study&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s performance goal increased from 1 to 14 by the end of the study period. A financial incentive coupled with an audit and feedback tool was effective at modifying physician behavior, achieving focused, measurable quality improvement gains.
IEEE Open Journal of Engineering in Medicine and Biology
Faced with the COVID-19 pandemic, the US system for developing and testing technologies was chall... more Faced with the COVID-19 pandemic, the US system for developing and testing technologies was challenged in unparalleled ways. This article describes the multi-institutional, transdisciplinary team of the "RADx SM Tech Test Verification Core" and its role in expediting evaluations of COVID-19 testing devices. Expertise related to aspects of diagnostic testing was coordinated to evaluate testing devices with the goal of significantly expanding the ability to mass screen Americans to preserve lives and facilitate the safe return to work and school. Focal points included: laboratory and clinical device evaluation of the limit of viral detection, sensitivity, and specificity of devices in controlled and community settings; regulatory expertise to provide focused attention to barriers to device approval and distribution; usability testing from the perspective of patients and those using the tests to identify and overcome device limitations, and engineering assessment to evaluate robustness of design including human factors, manufacturability, and scalability.
AIDS
Objective: To determine the effectiveness of the Metropolitan Atlanta community adolescent rapid ... more Objective: To determine the effectiveness of the Metropolitan Atlanta community adolescent rapid testing initiative (MACARTI) intervention relative to standard of care (SOC), in achieving early diagnosis, linkage, and retention among HIV-infected youth ages 18-24 years. Design: MACARTI was a pilot single-center, prospective, nonrandomized study. Methods: MACARTI combined nontraditional venue HIV testing, motivational interviewing, and case management. We collected demographic, clinical variables and calculated linkage and appointment adherence rates. We obtained SOC data from an adolescent HIV clinic. Longitudinal data were analyzed using inverse propensity treatment-weighted linear growth models; medians, interquartile ranges (IQR), means, and 95% confidence intervals are provided. Results: MACARTI screened 435 participants and identified 49 (11.3%) HIV infections. The SOC arm enrolled 49 new HIV-infected individuals. The 98 participants, (49 in each arm) were: 85% men; 91% Black; mean age ¼ 21 years (SD : 1.8). Overall, 63% were linked within 3 months of diagnosis; linkage was higher for MACARTI compared to SOC (96 vs. 57%, P < 0.001). Median linkage time for MACARTI participants compared to SOC was 0.39 (IQR : 0.20-0.72) vs. 1.77 (IQR : 1.12-12.65) months (P < 0.001). MACARTI appointment adherence was higher than SOC (86.1 vs. 77.2%, P ¼ 0.018). In weight-adjusted models, mean CD4 þ T-cell counts increased and mean HIV-1 RNA levels decreased in both arms over 12 months, but the differences were more pronounced in the MACARTI arm. Conclusion: MACARTI successfully identified and linked HIV-infected youth in Atlanta, USA. MACARTI may serve as an effective linkage and care model for clinics serving HIV-infected youth.
Results: 46 patients, enrolled from 2015 to 2020 were included. 27 (58.7%) were male. 18 patients... more Results: 46 patients, enrolled from 2015 to 2020 were included. 27 (58.7%) were male. 18 patients (39.1%) had a diagnosis of minimal change followed by focal segmental glomerulosclerosis in 16 patients (34.7%). Median age at start of treatment was 12.5 years (IQR 8.5-17.4) compared to 5.3 years at diagnosis (IQR 2.7-10.5 years). 52% were resistant to corticosteroids. The most common Acthar Gel regimen was 80IU twice a week with a median duration of 199 days (IQR 88365). Among 37 patients with active disease, 18 (49%) were able to achieve partial or complete remission, though all patients that had a positive response were on other immunosuppressants concomitantly.
Injury Epidemiology, 2020
Background The American Academy of Pediatrics (AAP) recommends infants should be Alone, on their ... more Background The American Academy of Pediatrics (AAP) recommends infants should be Alone, on their Back, and in a clear Crib to combat relatively stagnant rates of sudden unexpected infant death (SUID). These are referred to as the ABCs of safe sleep. Studies have shown these recommendations are not consistently followed in the hospital setting, but further investigation would determine how to improve the rate of adherence. The objective of this study was to evaluate the impact of an expanded safe sleep initiative at three Georgia free-standing children’s hospital campuses before and after a multipronged safe sleep initiative. Methods A quality improvement program with a pre/post analysis was performed using a convenience method of sampling. Infants < 12 months old in three inpatient pediatric campuses were analyzed pre- and post- interventions. The intervention included: 1) nursing education, 2) identification of nurse “safe sleep” champions, 3) crib cards, 4) crib audits, and 5) ...
Background: Current prevalence of COVID-19 drives many policy decisions, but is hampered by ambig... more Background: Current prevalence of COVID-19 drives many policy decisions, but is hampered by ambiguities in testing and reporting. We propose an alternative method for estimating community prevalence that is inexpensive and timely. We test the Hypothesis that the survey sampling provides a quantitative prevalence that is similar to widespread genomic or serological testing. Methods: We have built a simple, web-based survey of signs and symptoms for COVID-19 based on six questions. No personally identifiable information is collected to maintain privacy. Sampling can be directed to a population of interest such as a company, or broadcast widely to get geographic sampling. Data reporting can be real-time and plotted onto zipcode maps. Rates of prevalence were calculated from presumed COVID cases and respondents, with confidence intervals based on the Blaker method.Results: The website was created quickly, and survey results were quantitatively useful after only a few days. Analyzing 316...
Purpose: To compare combination chemotherapy (CCT) versus melphalan plus prednisone (MP) as treat... more Purpose: To compare combination chemotherapy (CCT) versus melphalan plus prednisone (MP) as treatment for multiple myeloma. Patients and Methods: In a collaborative worldwide overview of randomized trials of CCT versus MP, individual patient data on 4,930 patients from 20 trials were analyzed, with the addition of published data on a further 1,703 patients from seven trials. The main outcome measure was mortality, with response and recurrence rates being subsidiary end points. Results: Taking all of the trials together, response rates were significantly higher with CCT than with MP (60.0% v 53.2%; P < .00001, two-tailed). There was no evidence of any difference in mortality between CCT and MP, with a nonsignificant 1.5% reduction in death rate in favor of CCT (P = .6, two-tailed). There is heterogeneity of design between the trials, but subgroup analyses by type of CCT or by dose-intensities of CCT, of melphalan, or of prednisone did not identify any particular forms of therapy t...
BACKGROUND Hydroxyurea, chronic blood transfusion, and bone marrow transplantation are efficaciou... more BACKGROUND Hydroxyurea, chronic blood transfusion, and bone marrow transplantation are efficacious disease-modifying therapies for sickle cell disease (SCD) but are associated with a significant decisional dilemma because of the inherent risk-benefit tradeoffs and the lack of comparative studies. A web-based patient decision aid (PtDA) has the potential to provide patients with high-quality information about their treatment options and associated risks and benefits, help them clarify their values, and allow them to share in the process of informed medical decision making. OBJECTIVE The objective of this study was to develop a literacy-sensitive, web-based, PtDA using the conceptual framework of the Ottawa decision support framework, and to estimate in a randomized clinical trial the effectiveness of the PtDA in improving patient knowledge, and involvement in decision-making. METHODS We conducted population decisional needs assessment in a nationwide sample of patients, caregivers, s...
Journal of the American College of Cardiology
بالصفات ً مدعوما مصر من جديد نوع األكانثية)، (العائلة Dicliptera aegyptiaca rbcl ... more بالصفات ً مدعوما مصر من جديد نوع األكانثية)، (العائلة Dicliptera aegyptiaca rbcl جين باستخدام النووية لألحماض الباركود تقنية و المورفولوجية (2) فؤاد أحمد ، (1) شمسو إيمان النبات قسم (2) مصر،-الجيزة-القاهرة جامعة-العلوم كلية-والميكروبيولوجي النبات قسم-المعشبة (1) مصر.-الجيزة-القاهرة جامعة-العلوم كلية-والميكروبيولوجى
Urology
To evaluate the radiographic findings of neonatal intensive care unit (NICU) patients diagnosed w... more To evaluate the radiographic findings of neonatal intensive care unit (NICU) patients diagnosed with hospital-acquired urinary tract infection (UTI). Children with no preexisting genitourinary anomalies undergoing a voiding cystourethrogram (VCUG) for culture-documented UTI during NICU admission were identified. Demographics, microbiology results, and imaging findings were evaluated. A total of 147 NICU patients underwent VCUG during the study period. Of these, the indication for VCUG was UTI in 58 children. Neonates diagnosed with UTI were born at a mean gestational age of 28 3/7 ± 4 3/7 weeks, and underwent VCUG at a mean of age of 70.3 ± 42 days. Urine culture grew Enterococcus in 32 (55.2%), Enterobacter in 6 (10.3%), coagulase negative staphylococcus in 6 (10.3%), Escherichia coli in 5 (8.7%), and other in 9 infants (15.5%). All patients underwent a retroperitoneal ultrasound, which was read as normal in 31 patients (53.4%). Fourteen children (24.1%) diagnosed with UTI were found to have vesicoureteral reflux on VCUG. On univariate analysis, no patient characteristics were associated with VCUG positivity. On multivariate analysis, the effect of age at VCUG differed by renal-bladder ultrasound results. Patients with an abnormal ultrasound were 3.6 (95% confidence interval, 1.39-9.24) times more likely to have a positive VCUG for every 1 month increase in age. Ultrasound anomalies are common in NICU patients diagnosed with UTI. The effect of age at VCUG differed by ultrasound result; the probability of vesicoureteral reflux in infants with sonographic abnormalities and UTI increases with age.
Journal of Pediatric Urology, 2015
Critical Care Medicine
Introduction: Prior research on physician and non-physician endotracheal intubation (ETI) of pedi... more Introduction: Prior research on physician and non-physician endotracheal intubation (ETI) of pediatric patients demonstrates highly variable success rates. To assess the performance of a single children's critical care transport team (CCT), we analyzed data from 2.5 years of pediatric ETI encounters. Methods: A retrospective review encompassed pediatric ETI encounters from 127 patient charts from the rotorcraft and ground emergency CCT of a large quaternary referral children's hospital with an average of greater than 5000 patient transports annually. Pediatric patients were cared for by the CCT between January 1, 2011, and July 31, 2013. We included all patients between 1 day and 20 years of age in our analysis, without exclusion. A single ETI attempt was defined by the insertion of a laryngoscope. We characterized first-attempt intubation success and overall intubation success with descriptive statistics and calculated 95% confidence intervals. Results: For our cohort, demo...
The Journal of Urology, 2014
In 2011 the AAP revised practice parameters on febrile urinary tract infection in infants and chi... more In 2011 the AAP revised practice parameters on febrile urinary tract infection in infants and children 2 to 24 months old. New imaging recommendations invigorated the ongoing debate regarding the diagnosis and management of vesicoureteral reflux. We compared evaluations in these patients with febrile urinary tract infection before and after guideline publication. During 2 separate 6-month periods 350 patients 2 to 24 months old were evaluated in the emergency room setting. Demographics, urine culture, renal-bladder ultrasound, voiding cystourethrogram and admission status were assessed. A total of 172 patients presented with initial febrile urinary tract infection in 2011, of whom 47 (27.3%) required hospitalization, while 42 of 178 (23.6%) were admitted in 2012. Admission by year did not significantly differ (p = 0.423). After guideline revision 41.2% fewer voiding cystourethrograms were done (72.1% of cases in 2011 vs 30.9% in 2012, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). A 17.2% decrease in renal-bladder ultrasound was noted (75.6% in 2011 vs 58.4% in 2012, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). Of 55 voiding cystourethrograms 21 (38.2%) were positive in 2012 compared to 36.3% in 2011 (p = 0.809). Mean ± SD maximum vesicoureteral reflux grade was unchanged in 2011 and 2012 (2.9 ± 1.2 and 2.5 ± 0.93, respectively, p = 0.109). There was no association between abnormal renal-bladder ultrasound and voiding cystourethrogram positivity (p = 0.116). AAP guidelines impacted the treatment of infants and young children with febrile urinary tract infection. We found no relationship between renal-bladder ultrasound and abnormal voiding cystourethrogram, consistent with previous findings that call ultrasound into question as the determinant for additional imaging. Whether forgoing routine voiding cystourethrogram results in increased morbidity is the subject of ongoing study.
Journal of Pediatric Urology, 2014
Surgical correction of vesicoureteral reflux (VUR) is influenced by recurrent urinary tract infec... more Surgical correction of vesicoureteral reflux (VUR) is influenced by recurrent urinary tract infection (UTI) risk and the likelihood of spontaneous resolution. We aimed to identify factors associated with VUR resolution in children less than 2 years of age and to design a simple scoring tool to predict improvement and resolution. Children less than 2 years old with primary VUR were identified. Patient demographics, voiding cystourethrogram (VCUG) findings and clinical outcomes over time were assessed. Multivariate analysis with time to resolution was performed to identify factors predictive of VUR improvement and resolution. A random forest model was used to confirm the VUR index (VURx) with normalized importance. Two-hundred and twenty-nine children met all inclusion criteria. Mean age at initial VCUG was 0.46±0.43 years. Median clinical follow-up was 1.6 years (range 0.5-4.4 years). Children with grade 4-5 reflux, complete ureteral duplication or periureteral diverticula, and filling phase VUR, as well as female gender, had significantly (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01) longer time to improvement or resolution on multivariate survival analysis. VURx 1 to 5-6 had improvement/resolution rates of 89%, 69%, 53%, 16% and 11%, respectively. Female gender, high-grade VUR, ureteral anomalies, and filling reflux are associated with longer time to improvement and non-resolution. VURx reliably predicts resolution of primary reflux in children less than 2 years of age.
Pediatric Neurosurgery, 1994
We reviewed the records of 98 consecutive patients, 18 years of age or younger, with pathological... more We reviewed the records of 98 consecutive patients, 18 years of age or younger, with pathologically confirmed supratentorial astroglial neoplasms at the Children&amp;amp;amp;#39;s Hospital, Boston, to evaluate the importance of seizures in their presentation and natural history. Tumors were diagnosed using the WHO criteria as pilocytic astrocytomas, astrocytomas, anaplastic astrocytomas, glioblastomas, giant cell glioblastomas, oligoastrocytomas and gangliogliomas. Our results were as follows. (1) Fifty percent of children had seizures as part of their presentation and 30% had seizures as their only presenting phenomenon. (2) The seizures varied in nature, but complex (55%) or simple (28%) partial seizures were by far the most common types, occurring in 77% of cases. (3) Preoperative electroencephalography (EEG) accurately lateralized to the tumor side in 88% of the cases and localized to the correct lobe in 56%. (4) Tumors involving cerebral cortex significantly correlated with seizures at presentation as compared to noncortical locations; 59% of patients with cortical tumors presented with seizures, and only 15% of patients with noncortical tumors experienced seizures. Lesions in the temporal and frontal lobes had the highest incidence of seizures. (5) Patients with gangliogliomas and oligoastrocytomas had the highest incidence of seizures, 88 and 86%, respectively, whereas patients with anaplastic astrocytoma had the lowest incidence, 21%. (6) Histopathologic calcification was associated with seizures at presentation approaching significance (p = 0.06). (7) Seizures at presentation were significantly associated with good prognosis (p = 0.02).
The Journal of Urology, 2014
The Journal of Urology, 2012
The Journal of Urology, 2014
The Journal of Thoracic and Cardiovascular Surgery, 2008
The Clinical Journal of Pain, 2009
Mechanoreceptor and noxious thermal inhibitory stimulation modulate pain conduction but have not ... more Mechanoreceptor and noxious thermal inhibitory stimulation modulate pain conduction but have not been clinically tested in combination. Our objectives were to determine whether a vibrating cold device decreased adult venipuncture pain on a 10 cm visual analog scale more than no intervention, and compared with vapocoolant analgesia versus no intervention. The design was a prospective randomized crossover clinical trial. Thirty healthy adult volunteers were randomized to the study device or vapocoolant intervention. One nurse attempted cannulation on both intervention and control hands with a 22 gauge intravenous catheter. Vapocoolant was applied to the cannulation site, or the device was applied 5 to 10 cm proximally throughout the intervention attempt. Visual analog scale assessed needle fear and the primary outcome of self-reported pain. Sixteen device and 14 vapocoolant participants were included in this study. One participant felt discomfort from device prongs before the needle stick and was excluded. Compared with no intervention, the device reduced pain significantly (mean 9.9 mm, 95% confidence interval 0.82-19, P=0.035, SD 16) whereas vapocoolant did not (mean 7.9 mm, 95% confidence interval -1.8-17.7, P=0.1, SD 16.9). Mean pain reduction for device group participants was not significantly different from vapocoolant participants. Each 20 mm of prior anxiety increased the likelihood of intervention pain relief (odds ratio 2, P=0.043). One venipuncture failure occurred in the vapocoolant intervention. The combination of cold and vibration gave significant venipuncture pain relief without affecting cannulation success. Interventions were more helpful for those with greater preprocedural fear. Larger sample sizes and a prongless device could better compare equivalence or superiority to existing pain relief modalities.
American Journal of Medical Quality, 2014
The study team sought to improve hospitalist communication with primary care providers (PCPs) at ... more The study team sought to improve hospitalist communication with primary care providers (PCPs) at discharge through interventions consisting of (a) audit and feedback and (b) inclusion of a discharge communication measure in the incentive compensation for pediatric hospitalists. The setting was a 16-physician pediatric hospitalist group within a tertiary pediatric hospital. Discharge summaries were selected randomly for documentation of communication with PCPs. At baseline, 57% of charts had documented communication with PCPs, increasing to 84% during the audit and feedback period. Following the addition of a financial incentive, documentation of communication with PCPs increased to 93% and was sustained during the combined intervention period. The number of physicians meeting the study&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s performance goal increased from 1 to 14 by the end of the study period. A financial incentive coupled with an audit and feedback tool was effective at modifying physician behavior, achieving focused, measurable quality improvement gains.
IEEE Open Journal of Engineering in Medicine and Biology
Faced with the COVID-19 pandemic, the US system for developing and testing technologies was chall... more Faced with the COVID-19 pandemic, the US system for developing and testing technologies was challenged in unparalleled ways. This article describes the multi-institutional, transdisciplinary team of the "RADx SM Tech Test Verification Core" and its role in expediting evaluations of COVID-19 testing devices. Expertise related to aspects of diagnostic testing was coordinated to evaluate testing devices with the goal of significantly expanding the ability to mass screen Americans to preserve lives and facilitate the safe return to work and school. Focal points included: laboratory and clinical device evaluation of the limit of viral detection, sensitivity, and specificity of devices in controlled and community settings; regulatory expertise to provide focused attention to barriers to device approval and distribution; usability testing from the perspective of patients and those using the tests to identify and overcome device limitations, and engineering assessment to evaluate robustness of design including human factors, manufacturability, and scalability.
AIDS
Objective: To determine the effectiveness of the Metropolitan Atlanta community adolescent rapid ... more Objective: To determine the effectiveness of the Metropolitan Atlanta community adolescent rapid testing initiative (MACARTI) intervention relative to standard of care (SOC), in achieving early diagnosis, linkage, and retention among HIV-infected youth ages 18-24 years. Design: MACARTI was a pilot single-center, prospective, nonrandomized study. Methods: MACARTI combined nontraditional venue HIV testing, motivational interviewing, and case management. We collected demographic, clinical variables and calculated linkage and appointment adherence rates. We obtained SOC data from an adolescent HIV clinic. Longitudinal data were analyzed using inverse propensity treatment-weighted linear growth models; medians, interquartile ranges (IQR), means, and 95% confidence intervals are provided. Results: MACARTI screened 435 participants and identified 49 (11.3%) HIV infections. The SOC arm enrolled 49 new HIV-infected individuals. The 98 participants, (49 in each arm) were: 85% men; 91% Black; mean age ¼ 21 years (SD : 1.8). Overall, 63% were linked within 3 months of diagnosis; linkage was higher for MACARTI compared to SOC (96 vs. 57%, P < 0.001). Median linkage time for MACARTI participants compared to SOC was 0.39 (IQR : 0.20-0.72) vs. 1.77 (IQR : 1.12-12.65) months (P < 0.001). MACARTI appointment adherence was higher than SOC (86.1 vs. 77.2%, P ¼ 0.018). In weight-adjusted models, mean CD4 þ T-cell counts increased and mean HIV-1 RNA levels decreased in both arms over 12 months, but the differences were more pronounced in the MACARTI arm. Conclusion: MACARTI successfully identified and linked HIV-infected youth in Atlanta, USA. MACARTI may serve as an effective linkage and care model for clinics serving HIV-infected youth.