Samir S Shah

University of Cincinnati, Cincinnati, Ohio, United States

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Publications (239)1069.92 Total impact

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    ABSTRACT: Background: Chest radiography is increasingly used to diagnose pneumonia in low- and middle-income countries. Few studies examined whether chest radiographic findings predict outcomes of children with clinically suspected pneumonia in these settings. Methods: Hospital-based, prospective cohort study of children 1-23 months of age meeting clinical criteria for pneumonia in Botswana. Chest radiographs were reviewed by two pediatric radiologists to generate a consensus interpretation using standardized World Health Organization criteria. We assessed whether final chest radiograph classification was associated with our primary outcome, treatment failure at 48 hours, and secondary outcomes. Results: From April 2012 to November 2014, we enrolled 249 children with evaluable chest radiographs. Median age was 6.1 months and 58% were male. Chest radiograph classifications were primary end-point pneumonia (35%), other infiltrate/abnormality (42%), or no significant pathology (22%). The prevalence of end-point consolidation was higher in children with HIV infection (P=0.0005), while end-point pleural effusions were more frequent among children with moderate or severe malnutrition (P=0.0003). Ninety-one (37%) children failed treatment and 12 (4.8%) children died. Primary end-point pneumonia was associated with an increased risk of treatment failure at 48 hours (P=0.002), a requirement for more days of respiratory support (P=0.002), and a longer length of stay (P=0.0003) compared with no significant pathology. Primary end-point pneumonia also predicted a higher risk of treatment failure than other infiltrate/abnormality (P=0.004). Conclusions: Chest radiograph provides useful prognostic information for children meeting clinical criteria for pneumonia in Botswana. These findings highlight the potential benefit of expanded global access to diagnostic radiology services.
    The Pediatric Infectious Disease Journal 11/2015; DOI:10.1097/INF.0000000000000990 · 2.72 Impact Factor
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    ABSTRACT: Objective: To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI). Study design: Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients <19 years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income. Results: There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs. Conclusions: Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.
    The Journal of pediatrics 11/2015; DOI:10.1016/j.jpeds.2015.10.043 · 3.79 Impact Factor
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    ABSTRACT: Objectives: To quantify rates and variation in emergency department (ED) cranial computed tomography (CT) utilization in children with ventricular shunts, estimate radiation exposure, and evaluate the association between CT utilization and shunt revision. Study design: Retrospective longitudinal cohort study of ED visits from 2003-2013 in children 0-18 years old with initial shunt placement in 2003. Data were examined from 31 hospitals in the Pediatric Health Information System. Main outcomes were cranial CT performed during an ED visit, estimated cumulative effective radiation dose, and shunt revision within 7 days. Multivariable regression modeled the relationship between patient- and hospital-level covariates and CT utilization. Results: The 1319 children with initial shunt placed in 2003 experienced 6636 ED visits during the subsequent decade. A cranial CT was obtained in 49.4% of all ED visits; 19.9% of ED visits with CT were associated with a shunt revision. Approximately 6% of patients received ≥10 CTs, accounting for 37.2% of all ED visits with a CT. The mean number of CTs per patient varied nearly 20-fold across hospitals; the individual hospital accounted for the most variation in CT utilization. The median (IQR) cumulative effective radiation dose was 7.2 millisieverts (3.6-14.0) overall, and 33.4 millisieverts (27.2-43.8) among patients receiving ≥10 CTs. Conclusions: A CT scan was obtained in half of ED visits for children with a ventricular shunt, with wide variability in utilization by hospitals. Strategies are needed to identify children at risk of shunt malfunction to reduce variability in CT utilization and radiation exposure in the ED.
    The Journal of pediatrics 10/2015; DOI:10.1016/j.jpeds.2015.09.024 · 3.79 Impact Factor
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    ABSTRACT: Objective: To assess the relationship between hospital volume and intensive care unit (ICU) transfer among hospitalized children with sickle cell disease (SCD). Study design: We conducted a retrospective cohort study of 83 477 SCD-related hospitalizations at children's hospitals (2009-2012) using the Pediatric Health Information System database. Hospital-level all-cause and SCD-specific volumes were dichotomized (low vs high). Outcomes were within-hospital ICU transfer (primary) and length of stay (LOS) total (secondary). Multivariable logistic/linear regressions assessed the association of hospital volumes with ICU transfer and LOS. Results: Of 83 477 eligible hospitalizations, 1741 (2.1%) involving 1432 unique children were complicated by ICU transfer. High SCD-specific volume (OR 0.77, 95% CI 0.64-0.91) was associated with lower odds of ICU transfer while high all-cause hospital volume was not (OR 0.87, 95% CI 0.73-1.04). A statistically significant interaction was found between all-cause and SCD-specific volumes. When results were stratified according to all-cause volume, high SCD-specific volume was associated with lower odds of ICU transfer at low all-cause volume (OR 0.46, 95% CI 0.38-0.55). High hospital volumes, both all-cause (OR 0.94, 95% CI 0.92-0.97) and SCD-specific (OR 0.86, 95% CI 0.84-0.88), were associated with shorter LOS. Conclusions: Children's hospitals vary substantially in their transfer of children with SCD to the ICU according to hospital volumes. Understanding the practices used by different institutions may help explain the variability in ICU transfer among hospitals caring for children with SCD.
    The Journal of pediatrics 10/2015; DOI:10.1016/j.jpeds.2015.09.007 · 3.79 Impact Factor
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    ABSTRACT: Objectives: To evaluate accuracy of 2 established administrative methods of identifying children with sepsis using a medical record review reference standard. Study design: Multicenter retrospective study at 6 US children's hospitals. Subjects were children >60 days to <19 years of age and identified in 4 groups based on International Classification of Diseases, Ninth Revision, Clinical Modification codes: (1) severe sepsis/septic shock (sepsis codes); (2) infection plus organ dysfunction (combination codes); (3) subjects without codes for infection, organ dysfunction, or severe sepsis; and (4) infection but not severe sepsis or organ dysfunction. Combination codes were allowed, but not required within the sepsis codes group. We determined the presence of reference standard severe sepsis according to consensus criteria. Logistic regression was performed to determine whether addition of codes for sepsis therapies improved case identification. Results: A total of 130 out of 432 subjects met reference SD of severe sepsis. Sepsis codes had sensitivity 73% (95% CI 70-86), specificity 92% (95% CI 87-95), and positive predictive value 79% (95% CI 70-86). Combination codes had sensitivity 15% (95% CI 9-22), specificity 71% (95% CI 65-76), and positive predictive value 18% (95% CI 11-27). Slight improvements in model characteristics were observed when codes for vasoactive medications and endotracheal intubation were added to sepsis codes (c-statistic 0.83 vs 0.87, P = .008). Conclusions: Sepsis specific International Classification of Diseases, Ninth Revision, Clinical Modification codes identify pediatric patients with severe sepsis in administrative data more accurately than a combination of codes for infection plus organ dysfunction.
    The Journal of pediatrics 10/2015; DOI:10.1016/j.jpeds.2015.09.027 · 3.79 Impact Factor
  • Joanna Thomson · Samir S Shah ·

    Pediatrics 10/2015; DOI:10.1542/peds.2015-0440 · 5.47 Impact Factor
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    ABSTRACT: Objective: Observation unit (OU) use has been promoted recently to decrease resource utilization and costs for select patients, but little is known about the operations of pediatric OUs. This study aimed to characterize the infrastructure and function of OUs within freestanding children's hospitals and to compare characteristics between hospitals with and without OUs. Methods: All 43 freestanding children's hospitals that submit data to the Pediatric Health Information System were contacted in 2013 to identify OUs that admitted unscheduled patients from their emergency department (ED) in 2011. Semistructured interviews were conducted with representatives at hospitals with these OUs. Characteristics of hospitals with and without OUs were compared. Results: Fourteen (33%) of 43 hospitals had an OU during 2011. Hospitals with OUs had more beds and more annual ED visits compared to those without OUs. Most OUs (65%) were located in the ED and had <12 beds (65%). Staffing models and patient populations differed between OUs. Nearly 60% were hybrid OUs, providing scheduled services. OUs lacked uniform outcome measures. Themes included: admissions were intuition based, certain patients were not well suited for OUs, OUs had rapid-turnover cultures, and the designation of observation status was arbitrary. Challenges included patient discontent with copayments and payer-driven utilization reviews. Conclusions: OUs were located in higher volume hospitals and varied by location, size, and staffing. Most functioned as hybrid OUs. OUs based admissions on intuition, had staffing cultures centered on rapid turnover of patient care, lacked consistent outcome measures, and faced challenges regarding utilization review and patient copayments.
    Academic pediatrics 09/2015; 15(5):518-525. DOI:10.1016/j.acap.2014.12.005 · 2.01 Impact Factor
  • Hadley S. Sauers-Ford · Jeffrey M. Simmons · Samir S. Shah ·
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    ABSTRACT: Many families involved in research are well versed in the care system due to chronic conditions. Engagement of families of children with serious acute illnesses is infrequent, and no studies have documented the feasibility or acceptability of different methods of family engagement. We describe a model used in the Hospital-to-Home Outcomes study, which utilized a novel approach of short-term focused engagement of families and other stakeholders to incorporate the unique viewpoints of families whose care experience is primarily focused around the period surrounding their child's hospitalization for acute illness. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine
    Journal of Hospital Medicine 09/2015; DOI:10.1002/jhm.2492 · 2.30 Impact Factor
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    ABSTRACT: To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children hospitalized with asthma exacerbation not requiring intensive care. This multicenter retrospective cohort study, using the Pediatric Health Information System, included children aged 4-17 years who were hospitalized with a principal diagnosis of asthma between January 1, 2007 and December 31, 2012. Children with chronic complex condition and/or initial intensive care unit (ICU) management were excluded. Propensity score matching was used to detect differences in length of stay (LOS), readmissions, ICU transfer, and cost between groups. 40 257 hospitalizations met inclusion criteria; 1166 (2.9%) received only dexamethasone. In the matched cohort (N = 1284 representing 34 hospitals), the LOS was significantly shorter in the dexamethasone group compared with the prednisone/prednisolone group. The proportion of subjects with a LOS of 3 days or more was 6.7% in the dexamethasone group and 12% in the prednisone/prednisolone group (P = .002). Differences in all-cause readmission at 7- and 30 days were not statistically significant. The dexamethasone group had lower costs of index admission ($2621 vs $2838; P < .001) and total episode of care (including readmissions) ($2624 vs $2856; P < .001) compared with the prednisone/prednisolone group. There were no clinical significant differences in ICU transfer or readmissions between groups. Dexamethasone may be considered an alternative to prednisone/prednisolone for children hospitalized with asthma exacerbation not requiring admission to intensive care. Copyright © 2015 Elsevier Inc. All rights reserved.
    The Journal of pediatrics 09/2015; 167(3):639-644.e1. DOI:10.1016/j.jpeds.2015.06.038 · 3.79 Impact Factor
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    ABSTRACT: Objective The objective was to evaluate the comparative effectiveness of beta-lactam monotherapy and beta- lactam/macrolide combination therapy in the outpatient management of children with community-acquired pneumonia (CAP).Methods This retrospective cohort study included children, ages 1–18 years, with CAP diagnosed between January 1, 2008 and January 31, 2010 during outpatient management in the Geisinger Health System. The primary exposure was receipt of beta-lactam monotherapy or beta-lactam/macrolide combination therapy. The primary outcome was treatment failure, defined as a follow-up visit within 14 days of diagnosis resulting in a change in antibiotic therapy. Logistic regression within a propensity score- restricted cohort was used to estimate the likelihood of treatment failure.ResultsOf 717 children in the analytical cohort, 570 (79.4%) received beta-lactam monotherapy and 147 (20.1%) received combination therapy. Of those who received combination therapy 58.2% of children were under 6 years of age. Treatment failure occurred in 55 (7.7%) children, including in 8.1% of monotherapy recipients, and 6.1% of combination therapy recipients. Treatment failure rates were highest in children 6–18 years receiving monotherapy (12.9%) and lowest in children 6–18 years receiving combination therapy (4.0%). Children 6–18 years of age who received combination therapy were less likely to fail treatment than those who received beta-lactam monotherapy (propensity-adjusted odds ratio, 0.51; 95% confidence interval, 0.28, 0.95).Conclusion Children 6–18 years of age who received beta- lactam/macrolide combination therapy for CAP in the outpatient setting had lower odds of treatment failure compared with those who received beta-lactam monotherapy. Pediatr Pulmonol. 2015; 9999:XX–XX. © 2015 Wiley Periodicals, Inc.
    Pediatric Pulmonology 09/2015; DOI:10.1002/ppul.23312 · 2.70 Impact Factor
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    ABSTRACT: Many studies have demonstrated a rise in computed tomography (CT) utilization in children's hospitals. However, CT utilization may be declining, perhaps due to awareness of potential hazards of pediatric ionizing radiation, such as increased risk of malignancy. The objective is to assess the trend in CT utilization in hospitalized children at freestanding children's hospitals from 2004 to 2012 and we hypothesize decreases are associated with shifts to alternate imaging modalities. Multicenter cross-sectional study of children admitted to 33 pediatric tertiary-care hospitals participating in the Pediatric Health Information System between January 1, 2004, and December 31, 2012. The rates of CT, ultrasound, and MRI for the top 10 All-Patient Refined Diagnosis Related Groups (APR-DRGs) for which CT was performed in 2004 were determined by billing data. Rates of each imaging modality for those top 10 APR-DRGs were followed through the study period. Odds ratios of imaging were adjusted for demographics and illness severity. For all included APR-DRGs except ventricular shunt procedures and nonbacterial gastroenteritis, the number of children imaged with any modality increased. CT utilization decreased for all APR-DRGs (P values < .001). For each of the APR-DRGs except seizure and infections of upper respiratory tract, the decrease in CT was associated with a significant rise in an alternative imaging modality (P values ≤ .005). For the 10 most common APR-DRGs for which children received CT in 2004, a decrease in CT utilization was found in 2012. Alternative imaging modalities for 8 of the diagnoses were used. Copyright © 2015 by the American Academy of Pediatrics.
    PEDIATRICS 08/2015; 136(3). DOI:10.1542/peds.2015-0995 · 5.47 Impact Factor

  • PEDIATRICS 08/2015; 136(2):e549-e550. DOI:10.1542/peds.2015-1549B · 5.47 Impact Factor
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    ABSTRACT: Community-acquired pneumonia (CAP) is a common and expensive cause of hospitalization among US children, many of whom receive a codiagnosis of acute asthma. The objective of this study was to describe demographic characteristics, cost, length of stay (LOS), and adherence to clinical guidelines among these groups and to compare health care utilization and guideline adherence between them. This was a multicenter retrospective cohort study using data from the Pediatric Health Information System. Children aged 2 to 18 who were hospitalized with uncomplicated CAP from July 1, 2007, to June 30, 2012 were included. Demographics, LOS, total standardized cost, and clinical guideline adherence were compared between patients with CAP only and CAP plus acute asthma. Among the 25 124 admissions, 57% were diagnosed with CAP only; 43% had a codiagnosis of acute asthma. The geometric mean for standardized cost was $4830; for LOS, it was 2.01 days. Eighty-four percent of patients had chest radiographs; CAP+acute asthma patients were less likely to have a blood culture performed (36% vs 62%, respectively) and more likely not to have a complete blood count performed (49% vs 27%, respectively). Greater guideline adherence was associated with higher cost at the patient-level but lower average cost per hospitalization at the hospital level. CAP+acute asthma patients had higher relative costs (11.8%) and LOS (5.6%) within hospitals and had more cost variation across hospitals, compared with patients with CAP only. A codiagnosis of acute asthma is common for children with CAP. This could be from misdiagnosis or co-occurrence. Diagnostic and/or management variability appears to be greater in patients with CAP+asthma, which may increase resource utilization and LOS for these patients. Copyright © 2015 by the American Academy of Pediatrics.
    Hospital Pediatrics 08/2015; 5(8):415-422. DOI:10.1542/hpeds.2015-0007
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    ABSTRACT: BACKGROUND Administrative data can be used to determine optimal management of febrile infants and aid clinical practice guideline development.OBJECTIVE Determine the most accurate International Classification of Diseases, Ninth Revision (ICD-9) diagnosis coding strategies for identification of febrile infants.DESIGNRetrospective cross-sectional study.SETTINGEight emergency departments in the Pediatric Health Information System.PATIENTSInfants aged <90 days evaluated between July 1, 2012 and June 30, 2013 were randomly selected for medical record review from 1 of 4 ICD-9 diagnosis code groups: (1) discharge diagnosis of fever, (2) admission diagnosis of fever without discharge diagnosis of fever, (3) discharge diagnosis of serious infection without diagnosis of fever, and (4) no diagnosis of fever or serious infection.EXPOSUREThe ICD-9 diagnosis code groups were compared in 4 case-identification algorithms to a reference standard of fever ≥100.4°F documented in the medical record.MEASUREMENTSAlgorithm predictive accuracy was measured using sensitivity, specificity, and negative and positive predictive values.RESULTSAmong 1790 medical records reviewed, 766 (42.8%) infants had fever. Discharge diagnosis of fever demonstrated high specificity (98.2%, 95% confidence interval [CI]: 97.8-98.6) but low sensitivity (53.2%, 95% CI: 50.0-56.4). A case-identification algorithm of admission or discharge diagnosis of fever exhibited higher sensitivity (71.1%, 95% CI: 68.2-74.0), similar specificity (97.7%, 95% CI: 97.3-98.1), and the highest positive predictive value (86.9%, 95% CI: 84.5-89.3).CONCLUSIONSA case-identification strategy that includes admission or discharge diagnosis of fever should be considered for febrile infant studies using administrative data, though underclassification of patients is a potential limitation. Journal of Hospital Medicine 2015;. © 2015 Society of Hospital Medicine
    Journal of Hospital Medicine 08/2015; DOI:10.1002/jhm.2441 · 2.30 Impact Factor
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    ABSTRACT: There is an increasing focus on optimizing health care quality and reducing costs. The care of children undergoing heart surgery requires significant investment of resources, and it remains unclear how costs of care relate to quality. We evaluated this relationship across a multicenter cohort. Clinical data from The Society of Thoracic Surgeons Database were merged with cost data from the Pediatric Health Information Systems Database for children undergoing heart surgery (2006 to 2010). Hospital-level costs were modeled using Bayesian hierarchical methods adjusting for case-mix, and hospitals were categorized into cost tertiles. The primary quality metric evaluated was in-hospital mortality. Overall, 27 hospitals (30,670 patients) were included. Median adjusted cost per case was $82,360 and varied fivefold across hospitals, while median adjusted mortality was 3.4% and ranged from 2.4% to 5.0% across hospitals. Overall, hospitals in the lowest cost tertile had significantly lower adjusted mortality rates compared with the middle and high cost tertiles (2.5% vs 3.8% and 3.5%, respectively, both p < 0.001). When assessed at the individual hospital level, most (75%) but not all hospitals in the lowest cost tertile were also in the lowest mortality tertile. Similar relationships were seen across the spectrum of surgical complexity. Lower cost hospitals also had shorter length of stay and trends toward fewer major complications. Lowest cost hospitals generally deliver the highest quality care for children undergoing heart surgery, although there is some variation in this relationship. This information is important in the design of initiatives aiming to optimize health care value in this population. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    The Annals of thoracic surgery 07/2015; DOI:10.1016/j.athoracsur.2015.04.139 · 3.85 Impact Factor
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    ABSTRACT: To investigate the association of the 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines with perioperative care processes and outcomes in children undergoing tonsillectomy. We conducted a retrospective cohort study of otherwise healthy children undergoing tonsillectomy between January 2009 and January 2013 at 29 US children's hospitals participating in the Pediatric Health Information System. We measured evidence-based processes suggested by the guidelines (perioperative dexamethasone and no antibiotic use) and outcomes (30-day tonsillectomy complication-related revisits). We analyzed rates aggregated over the preguideline and postguideline periods and then by month over time by using interrupted time series. Of 111 813 children who underwent tonsillectomy, 54 043 and 57 770 did so in the preguideline and postguideline periods, respectively. Dexamethasone use increased from 74.6% to 77.4% (P < .001) in the preguideline to postguideline period, as did its rate of change in use (percentage change per month, -0.02% to 0.29%; P < .001). Antibiotic use decreased from 34.7% to 21.8% (P < .001), as did its rate of change in use (percentage change per month, -0.17% to -0.56%; P < .001). Revisits for bleeding remained stable; however, total revisits to the hospital for tonsillectomy complications increased from 8.2% to 9.0% (P < .001) because of an increase in revisits for pain. Hospital-level results were similar. The guidelines were associated with some improvement in evidence-based perioperative care processes but no improvement in outcomes. Dexamethasone use increased slightly, and antibiotic use decreased substantially. Revisits for tonsillectomy-related complications increased modestly over time because of revisits for pain. Copyright © 2015 by the American Academy of Pediatrics.
    PEDIATRICS 06/2015; 136(1). DOI:10.1542/peds.2015-0127 · 5.47 Impact Factor
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    ABSTRACT: The highest incidence of childhood acute lower respiratory tract infection (ALRI) is in low- and middle-income countries. Few studies examined whether detection of respiratory viruses predicts ALRI outcomes in these settings. We conducted prospective cohort and case-control studies of children 1-23 months of age in Botswana. Cases met clinical criteria for pneumonia and were recruited within six hours of presentation to a referral hospital. Controls were children without pneumonia matched to cases by primary care clinic and date of enrollment. Nasopharyngeal specimens were tested for respiratory viruses using polymerase chain reaction. We compared detection rates of specific viruses in matched case-control pairs. We examined the effect of respiratory syncytial virus (RSV) and other respiratory viruses on pneumonia outcomes. Between April 2012 and August 2014, we enrolled 310 cases, of which 133 had matched controls. Median ages of cases and controls were 6.1 and 6.4 months, respectively. One or more viruses were detected from 75% of cases and 34% of controls. RSV and human metapneumovirus were more frequent among cases than controls, but only enterovirus/rhinovirus was detected from asymptomatic controls. Compared with non-RSV viruses, RSV was associated with an increased risk of treatment failure at 48 hours [risk ratio (RR): 1.85; 95% confidence interval (CI): 1.20, 2.84], more days of respiratory support [mean difference (MD): 1.26 days; 95% CI: 0.30, 2.22 days], and longer duration of hospitalization [MD: 1.35 days; 95% CI: 0.20, 2.50 days], but lower in-hospital mortality [RR: 0.09; 95% CI: 0.01, 0.80] in children with pneumonia. Respiratory viruses were detected from most children hospitalized with ALRI in Botswana, but only RSV and human metapneumovirus were more frequent than among children without ALRI. Detection of RSV from children with ALRI predicted a protracted illness course but lower mortality compared with non-RSV viruses.
    PLoS ONE 05/2015; 10(5):e0126593. DOI:10.1371/journal.pone.0126593 · 3.23 Impact Factor
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    ABSTRACT: We examined the association between baseline peripheral white blood cell count (WBC) and C-reactive protein (CRP) values with outcomes among 153 children hospitalized with pneumonia. In multivariable analyses, CRP, but not WBC count, was significantly associated with both fever duration and hospital length of stay. For every 1mg/dL increase in CRP, length of stay increased by 1 hour.
    The Pediatric Infectious Disease Journal 05/2015; 34(7). DOI:10.1097/INF.0000000000000724 · 2.72 Impact Factor
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    ABSTRACT: Most children diagnosed with community-acquired pneumonia (CAP) are treated in the outpatient setting. The objective of this study was to determine the comparative clinical effectiveness of beta-lactam monotherapy and macrolide monotherapy in this population. Children, 1-18 years old, with a clinical diagnosis of CAP at an outpatient practice affiliated (n=71) with Geisinger Health System during January 1, 2008 to January 31, 2010 were eligible. The primary exposure was receipt of beta-lactam or macrolide monotherapy. The primary outcome was treatment failure defined as change in antibiotic prescription within 14 days of the initial pneumonia diagnosis. Propensity scores were used to determine the likelihood of receiving macrolide monotherapy. Treatment groups were matched 1:1, based on propensity score, age group and asthma status. Multivariable conditional logistic regression models estimated the association between macrolide monotherapy and treatment failures. Of 1,999 children with CAP, 1,164 were matched. In the matched cohorts, 24% of children had asthma. Patients who received macrolide monotherapy had no statistical difference in treatment failure regardless of age when compared with patients who received beta-lactam monotherapy. Our findings suggest that children diagnosed with CAP in the outpatient setting and treated with beta-lactam or macrolide monotherapy have the same likelihood to fail treatment regardless of age.
    The Pediatric Infectious Disease Journal 04/2015; Publish Ahead of Print(8). DOI:10.1097/INF.0000000000000740 · 2.72 Impact Factor
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    ABSTRACT: A national evidence-based guideline for the management of community-acquired pneumonia (CAP) in children recommends blood cultures for patients admitted with moderate to severe illness. Our primary aim was to increase ordering of blood cultures for children hospitalized with CAP from 53% to 90% in 6 months. The secondary aim was to evaluate the effect of obtaining blood cultures on length of stay (LOS). At a tertiary children's hospital, interventions to increase blood cultures focused on 3 key drivers and were tested separately in the emergency department and inpatient units by using multiple plan-do-study-act cycles. The impact of the interventions was tracked over time on run charts. The association of ordering blood cultures and LOS was estimated by using linear regression models. Within 6 months, the percentage of patients admitted with CAP who had blood cultures ordered increased from 53% to 100%. This change has been sustained for 12 months. Overall, 239 (79%) of the 303 included patients had a blood culture ordered; of these, 6 (2.5%) were positive. Patients who had a blood culture did not have an increased LOS compared with those without a blood culture. Quality improvement methods were used to increase adherence to evidence-based national guidelines for performing blood cultures on children hospitalized with CAP; LOS did not increase. These results support obtaining blood cultures on all patients admitted with CAP without negative effects on LOS in a setting with a reliably low false-positive blood culture rate. Copyright © 2015 by the American Academy of Pediatrics.
    Pediatrics 03/2015; 135(4). DOI:10.1542/peds.2014-2077 · 5.47 Impact Factor

Publication Stats

3k Citations
1,069.92 Total Impact Points


  • 2012-2015
    • University of Cincinnati
      • • Department of Pediatrics
      • • Division of Infectious Diseases
      Cincinnati, Ohio, United States
    • University of Rochester
      • Department of Pediatrics
      Rochester, New York, United States
  • 2011-2015
    • Cincinnati Children's Hospital Medical Center
      • • Department of Pediatrics
      • • Division of Infectious Diseases
      Cincinnati, Ohio, United States
  • 2002-2013
    • The Children's Hospital of Philadelphia
      • • Division of Infectious Diseases
      • • Division of General Pediatrics
      • • Department of Pediatrics
      Philadelphia, Pennsylvania, United States
  • 2008-2011
    • William Penn University
      Filadelfia, Pennsylvania, United States
    • University of Washington Seattle
      • Department of Pediatrics
      Seattle, Washington, United States
  • 2007
    • Columbia University
      New York, New York, United States