Publications by authors named "Richard A Saladino"

27 Publications

  • Page 1 of 1

Success of Pediatric Intubations Performed by a Critical Care Transport Service.

Prehosp Emerg Care 2020 Sep-Oct;24(5):683-692. Epub 2020 Jan 9.

Prehospital pediatric endotracheal intubation (ETI) is rarely performed. Previous research has suggested that pediatric prehospital ETI, when performed by ground advanced life support crews, is associated with poor outcomes. In this study, we aim to evaluate the first-attempt success rate, overall success rate and complications of pediatric prehospital ETI performed by critical care transport (CCT) personnel. We conducted a retrospective observational study in a multi-state CCT service performing rotor wing, ground, and fixed wing missions. We included pediatric patients (<18 years) for whom ETI was performed by CCT personnel (flight nurse or flight paramedic).Our primary outcome of interest was rate of first-attempt ETI. Secondary outcomes were overall rates of successful ETI, complications encountered, and outcomes of patients with unsuccessful intubation. 993 patients were included (63.2% male, median age 12 years, IQR 4-16 years). 807/993 (81.3%) patients were intubated on the first attempt. Lower rates of successful first-attempt intubation were seen in younger ages (42.9% in infants ≤30 days of age). In multivariable logistic regression, lower odds (adjusted odds ratio, 95% confidence interval) of successful first-attempt ETI were associated with ages >30 days to <1 year (0.33, 0.18-0.61) and 2 to <6 years (0.60, 0.39-0.94) compared to patients 12 to <18 years. Patients given an induction agent and neuromuscular blockade (NMB) had a higher odds of first-attempt ETI success (1.53, 1.06-2.15). 13 (1.3%) had immediately recognized esophageal intubation and 33 (3.3%) had vomiting. No episodes of pneumothorax were reported. 962/993 (96.9%) patients were successfully intubated after all attempts. In patients without successful ETI (n = 31), supraglottic airways were used in 24, bag-valve mask ventilation in 5, and surgical cricothyroidotomy in 2, with an overall advanced airway success rate of 988/993 (99.5%).: Critical care flight nurses and paramedics performed successful intubations in pediatric patients at a high rate of success. Younger age was associated with lower success rates. Improved ETI training for younger patients and use of an induction agent and NMB may improve airway management in critically ill children.
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http://dx.doi.org/10.1080/10903127.2019.1699212DOI Listing
January 2020

Weather Patterns in the Prediction of Pediatric Dog Bites.

Clin Pediatr (Phila) 2019 Mar 29;58(3):354-357. Epub 2018 Oct 29.

Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine; Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.

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http://dx.doi.org/10.1177/0009922818809518DOI Listing
March 2019

Integration of physical abuse clinical decision support into the electronic health record at a Tertiary Care Children's Hospital.

J Am Med Inform Assoc 2018 07;25(7):833-840

Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Objective: To evaluate the effect of a previously validated electronic health record-based child abuse trigger system on physician compliance with clinical guidelines for evaluation of physical abuse.

Methods: A randomized controlled trial (RCT) with comparison to a preintervention group was performed. RCT-experimental subjects' providers received alerts with a direct link to a physical abuse-specific order set. RCT-control subjects' providers had no alerts, but could manually search for the order set. Preintervention subjects' providers had neither alerts nor access to the order set. Compliance with clinical guidelines was calculated.

Results: Ninety-nine preintervention subjects and 130 RCT subjects (73 RCT-experimental and 57 RCT-control) met criteria to undergo a physical abuse evaluation. Full compliance with clinical guidelines was 84% pre-intervention, 86% in RCT-control group, and 89% in RCT-experimental group. The physical abuse order set was used 43 times during the 7-month RCT. When the abuse order set was used, full compliance was 100%. The proportion of cases in which there was partial compliance decreased from 10% to 3% once the order set became available (P = .04). Male gender, having >10 years of experience and completion of a pediatric emergency medicine fellowship were associated with increased compliance.

Discussion/conclusion: A child abuse clinical decision support system comprised of a trigger system, alerts and a physical abuse order set was quickly accepted into clinical practice. Use of the physical abuse order set always resulted in full compliance with clinical guidelines. Given the high baseline compliance at our site, evaluation of this alert system in hospitals with lower baseline compliance rates will be more valuable in assessing the efficacy in adherence to clinical guidelines for the evaluation of suspected child abuse.
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http://dx.doi.org/10.1093/jamia/ocy025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647034PMC
July 2018

Adenosine Administration With a Stopcock Technique Delivers Lower-Than-Intended Drug Doses.

Ann Emerg Med 2018 Feb 28;71(2):220-224. Epub 2017 Oct 28.

Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. Electronic address:

Study Objective: Adenosine administration with a stopcock is the recommended treatment for pediatric patients with acute supraventricular tachycardia. Recent reports suggest that many infants do not respond to the first dose of adenosine administered. Our aim is to determine whether administration of adenosine with a stopcock delivers lower-than-expected drug doses in patients weighing less than 10 kg, corresponding to weights of infants.

Methods: We developed an in vitro model of adenosine delivery. Doses of adenosine corresponding to weights 2 to 25 kg were calculated, using a dose of 0.1 mg/kg, and administered through one port of a stopcock. Distilled water was administered through the second port. The adenosine concentration of the output was measured with mass spectrometry and results were confirmed with spectrophotometry of Evans blue.

Results: The mean doses of adenosine delivered through the stopcock increased as weight increased. The mean dose of adenosine delivered was 0.08 mg/kg for weights 2 to 9 kg and 0.1 mg/kg for weights 10 to 25 kg (95% confidence interval for difference of means -0.03 to -0.009). The median dose of adenosine delivered was 0.07 mg/kg (interquartile range [IQR] 0.06 to 0.07 mg/kg), 0.09 mg/kg (IQR 0.08 to 0.09 mg/kg), and 0.1 mg/kg (IQR 0.09 to 0.1 mg/kg) for weights 2 to 5, 6 to 9, and 10 to 25 kg, respectively (rank difference=100; P<.05 for 2 to 5 kg versus 10 to 25 kg). Similar results were obtained with spectrophotometry.

Conclusion: Administration of adenosine through a stopcock delivers doses lower than intended in patients weighing less than 10 kg, which may account for the decreased response of infants to the first dose of adenosine.
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http://dx.doi.org/10.1016/j.annemergmed.2017.09.002DOI Listing
February 2018

Development of an electronic medical record-based child physical abuse alert system.

J Am Med Inform Assoc 2018 02;25(2):142-149

Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, NY, USA.

Objective: Physical abuse is a leading cause of pediatric morbidity and mortality. Physicians do not consistently screen for abuse, even in high-risk situations. Alerts in the electronic medical record may help improve screening rates, resulting in early identification and improved outcomes.

Methods: Triggers to identify children < 2 years old at risk for physical abuse were coded into the electronic medical record at a freestanding pediatric hospital with a level 1 trauma center. The system was run in "silent mode"; physicians were unaware of the system, but study personnel received data on children who triggered the alert system. Sensitivity, specificity, and negative and positive predictive values of the child abuse alert system for identifying physical abuse were calculated.

Results: Thirty age-specific triggers were embedded into the electronic medical record. From October 21, 2014, through April 6, 2015, the system was in silent mode. All 226 children who triggered the alert system were considered subjects. Mean (SD) age was 9.1 (6.5) months. All triggers were activated at least once. Sensitivity was 96.8% (95% CI, 92.4-100.0%), specificity was 98.5% (95% CI, 98.3.5-98.7), and positive and negative predictive values were 26.5% (95% CI, 21.2-32.8%) and 99.9% (95% CI, 99.9-100.0%), respectively, for identifying children < 2 years old with possible, probable, or definite physical abuse.

Discussion/conclusion: Triggers embedded into the electronic medical record can identify young children with who need to be evaluated for physical abuse with high sensitivity and specificity.
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http://dx.doi.org/10.1093/jamia/ocx063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647132PMC
February 2018

Feasibility of the Digital Retinography System Camera in the Pediatric Emergency Department.

Pediatr Emerg Care 2018 Jul;34(7):488-491

From the Division of Pediatric Emergency Medicine, Department of Pediatrics.

Purpose: Direct ophthalmoscopy may be difficult without pupillary dilation and patient cooperation. Nonmydriatic ocular fundus photography (NMOFP) has been shown to be easily and efficiently accomplished by medical providers and improve the detection of abnormalities in adult emergency department (ED) patients. Nonmydriatic ocular fundus photography for pediatric ED patients has not been studied. The purpose of this study was to assess the ease of use of the Digital Retinography System (DRS) camera for NMOFP in ED patients aged 5 to 12 years and the quality of retinal images obtained with the DRS.

Methods: Retinal images were obtained with the DRS by a pediatric emergency medicine physician using a convenience sample of ED patients aged 5 to 12 years. Time to procedure completion, patient cooperation (Likert scale 1-5, with 5 being most cooperative), and satisfaction with the images (Likert scale 1-5, with 5 being completely satisfied) were recorded. Any satisfaction score less than 5 required the physician to describe a reason for dissatisfaction (brightness, field of view, focus). An ophthalmologist was consulted regarding any abnormal image. The accompanying parent completed a survey following the procedure. Estimated time to completion of the procedure and a rating of the overall comfort and cooperation of the child during the procedure (Likert scale 1-5) were recorded. A second pediatric emergency medicine physician reviewed all images and rated the level of satisfaction, reasons for dissatisfaction, and whether the images were normal. Descriptive statistics were used to analyze survey responses. A Mann-Whitney U test was used to compare continuous data for age groups 5 to 8 and 9 to 12 years. A Krippendorff α or κ coefficient was used to measure agreement between the physician obtaining the images and the secondary reviewer for image satisfaction and image abnormalities.

Results: One hundred three patients were enrolled: 50 aged 5 to 8 years and 53 aged 9-12 years (mean, 9.1 [SD, 2.1] years). Five patients failed to cooperate, and no images were obtained. The mean length of time (LOT) to procedure completion was 1.8 (SD, 0.86) minutes. Overall, mean cooperation score was 4.4, and mean image satisfaction score was 4.6. One or more reasons for image dissatisfaction were given in 27 patients (imperfect focus most commonly). There was moderate agreement between the 2 physicians for image satisfaction (Krippendorff α coefficient = 0.48) and image abnormalities (κ coefficient = 0.38). Mean LOT did not differ between 5- to 8-year-olds and 9- to 12-year-olds (P = 0.23). Older patients had higher mean cooperation scores and image satisfaction scores (P < 0.001 and P = 0.04 respectively). Parental mean score for perceived LOT was 4.6 (5 = very short), 4.8 for patient comfort (5 = very comfortable), and 4.8 for patient cooperation (5 = very cooperative).

Conclusions: Our data suggest that NMOFP using the DRS camera is a rapid and easy method of obtaining high-quality images of the retina in pediatric ED patients.
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http://dx.doi.org/10.1097/PEC.0000000000001203DOI Listing
July 2018

Pediatric Dog Bite Prevention: Are We Barking Up the Wrong Tree or Just Not Barking Loud Enough?

Pediatr Emerg Care 2019 Sep;35(9):618-623

From the Department of Pediatric Plastic Surgery.

Objectives: The objectives of this study were (1) to evaluate dog bite-related injuries and associated medical documentation and (2) to compare these results with a study of dog bites from the same institution 10 years prior.

Methods: Data were retrospectively collected from a pediatric emergency department from July 2007 to July 2011 for patients treated for dog bites. These data were then compared with data from the same institution from 10 years prior.

Results: A total of 1017 bite injuries were treated (average, 254.25 bites/year), which represents a 25% increase compared with 10 years prior. Comparing the 1997 and 2007 to 2011 cohorts, patient demographics, bite rate among children less than 5 years old, rate of dog breed documentation, and setting of injury were similar. Dog breed was reported in 47% (95% confidence interval [CI], 40.2-53.9) and 41% (95% CI, 38.0-44.0) of cases, respectively, in the 2 cohorts. Bites to the craniofacial region were most common (face only reported for 1997: 43.2%; 95% CI, 36.4-50 versus 2007-2011: 66.1%; 95% CI, 63.2-69.0). In both cohorts, the child's home was the most frequent setting, accounting for 43% of bites (1997: 95% CI, 30.2-55.9 and 2007-2011: 95% CI, 39.3-46.7).

Conclusions: Pediatric dog bites continue to occur frequently, and the associated factors did not change over the 10-year period: young age of child, bites to the craniofacial region, and dogs familiar to the child. Although accurate medical documentation of dog bites is a prerequisite to develop effective prevention strategies, current medical documentation of dog bites may be misguided.
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http://dx.doi.org/10.1097/PEC.0000000000001132DOI Listing
September 2019

Acute Management of Refractory and Unstable Pediatric Supraventricular Tachycardia.

J Pediatr 2017 02 29;181:177-182.e2. Epub 2016 Nov 29.

Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA. Electronic address:

Objective: To characterize the management of acute pediatric supraventricular tachycardia (SVT), placing special emphasis on infants, patients refractory to adenosine (refractory SVT), and patients with hypotension, poor perfusion, or altered mental status (unstable SVT).

Study Design: Retrospective cohort study of patients 0-18 years of age without congenital heart disease who presented to our pediatric hospital from January 2003 to December 2012 for the treatment of acute SVT. Multiple logistic regression was applied to identify whether age was a risk factor for different SVT therapies. Model fit and residuals also were examined.

Results: We identified 179 episodes for SVT. First dose of adenosine was effective in 72 (56%) episodes, and a second dose was effective in 27 of 54 (50%) episodes, leaving 27 (15%) episodes with refractory SVT. The response to the first dose of adenosine increased proportionally with age (OR 1.13, 95% CI 1.05-1.2). Only 1 of 17 episodes in infants responded to the first dose of adenosine. Refractory SVT was more frequent in infants vs older children (χ = 5.9 [1 df], P = .01). Unstable SVT was present in 13 episodes and was treated with adenosine and antiarrhythmics. Synchronized cardioversion was performed on 3 patients, 2 patients with unstable SVT, and 1 with refractory SVT.

Conclusion: In children with SVT, young age is associated with decreased response to the first dose of adenosine and increased odds of adenosine-refractory SVT. In the treatment of unstable SVT, medical management with various antiarrhythmics before cardioversion may have a role in a subset of patients. Synchronized cardioversion rarely is performed for acute SVT.
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http://dx.doi.org/10.1016/j.jpeds.2016.10.051DOI Listing
February 2017

Comparison of Physician Implicit Racial Bias Toward Adults Versus Children.

Acad Pediatr 2017 03 13;17(2):120-126. Epub 2016 Sep 13.

Division of General Internal Medicine, University of Pittsburgh, and Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pa.

Background And Objectives: The general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training.

Methods: We measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores.

Results: Among 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean = 0.49, standard deviation = 0.34) and Child Race IAT (mean = 0.55, standard deviation = 0.37). There was no significant difference between Adult and Child Race IAT scores (difference = 0.06, P = .15). Implicit bias was not associated with resident demographic characteristics, including specialty.

Conclusions: This is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians' implicit attitudes toward parents and children may impact inequities in pediatric health care.
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http://dx.doi.org/10.1016/j.acap.2016.08.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337439PMC
March 2017

Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma.

Pediatrics 2016 07 23;138(1). Epub 2016 Jun 23.

Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;

Background: Abusive head trauma is the leading cause of death from physical abuse. Misdiagnosis of abusive head trauma as well as other types of brain abnormalities in infants is common and contributes to increased morbidity and mortality. We previously derived the Pittsburgh Infant Brain Injury Score (PIBIS), a clinical prediction rule to assist physicians deciding which high-risk infants should undergo computed tomography of the head.

Methods: Well-appearing infants 30 to 364 days of age with temperature <38.3°C, no history of trauma, and a symptom associated with an increased risk of having a brain abnormality were eligible for enrollment in this prospective, multicenter clinical prediction rule validation. By using a predefined neuroimaging paradigm, subjects were classified as cases or controls. The sensitivity, specificity, and negative and positive predictive values of the rule for prediction of brain injury were calculated.

Results: A total of 1040 infants were enrolled: 214 cases and 826 controls. The 5-point PIBIS included abnormality on dermatologic examination (2 points), age ≥3.0 months (1 point), head circumference >85th percentile (1 point), and serum hemoglobin <11.2g/dL (1 point). At a score of 2, the sensitivity and specificity for abnormal neuroimaging was 93.3% (95% confidence interval 89.0%-96.3%) and 53% (95% confidence interval 49.3%-57.1%), respectively.

Conclusions: Our data suggest that the PIBIS accurately identifies infants who would benefit from neuroimaging to evaluate for brain injury. An implementation analysis is needed before the PIBIS can be integrated into clinical practice.
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http://dx.doi.org/10.1542/peds.2015-3756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4925074PMC
July 2016

Diastolic Hypotension, Troponin Elevation, and Electrocardiographic Changes Associated With the Management of Moderate to Severe Asthma in Children.

Acad Emerg Med 2016 07 1;23(7):816-22. Epub 2016 Jul 1.

Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA.

Objective: The objective was to determine the occurrence of, and the factors associated with, diastolic hypotension and troponin elevation or electrocardiogram (ECG) ST-segment changes in a convenience sample of children with moderate to severe asthma receiving continuous albuterol nebulization.

Methods: This was a prospective, descriptive study in a pediatric emergency department and an intensive care unit of a tertiary academic center. Fifty children with moderate to severe asthma (clinical asthma score > 8) who received 10 to 15 mg/hour continuous albuterol for >2 hours between June 5, 2007, and February 4, 2008, were approached. Hourly diastolic blood pressures were recorded. Cardiac troponin I (cTnI) and ECG tracings were obtained following the first 2 hours of albuterol and then subsequently every 12 hours while receiving continuous albuterol. Main outcome measures were: 1) incidence of diastolic hypotension, 2) incidence of troponin elevation, and 3) incidence of ECG ST-depression.

Results: Fifty patients were enrolled. Thirty-three (66%) patients developed diastolic hypotension during the first 6 hours of continuous albuterol. Diastolic blood pressure declined from baseline at 1-6 hours (p < 0.01 vs. baseline). Twelve patients (24%) had elevated cTnI, 15 patients (30%) had ST-segment change, four patients (8%) had both, and 23 patients (46%, 95% confidence interval [CI] = 32 to 60) had either a cTnI elevation or an ECG ST-segment change. Troponin elevation and diastolic hypotension were not associated (RR = 1.2, 95% CI = 0.6 to 2.3).

Conclusions: In a subset of children with moderate to severe asthma, diastolic hypotension, troponin elevation, and ECG ST-segment change occur during administration of continuous albuterol. Future studies are necessary to determine the clinical significance of these findings.
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http://dx.doi.org/10.1111/acem.12997DOI Listing
July 2016

Pediatric Patient With Altered Mental Status and Hypoxemia: Case Report.

Pediatr Emerg Care 2017 Jul;33(7):486-488

From the *Department of Pediatrics, University of Pittsburgh School of Medicine; †Department of Pediatrics, Children's Hospital of Pittsburgh; ‡Division of Pediatric Endocrinology, Department of Pediatrics, University of Pittsburgh School of Medicine; and §Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Childhood cases of myxedema coma are extremely rare. We report a case of a 5-year-old girl transferred to a tertiary care pediatric emergency department with hypoxemia and altered mental status and diagnosed with severe hypothyroidism and myxedema coma in the setting of acute influenza infection. Although it is rare, myxedema coma must remain in the differential diagnosis for altered mental status and organ dysfunction in the pediatric population.
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http://dx.doi.org/10.1097/PEC.0000000000000722DOI Listing
July 2017

Quality Care and Patient Safety in the Pediatric Emergency Department.

Pediatr Clin North Am 2016 Apr;63(2):269-82

Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, AOB 2nd Floor, Suite 2400, Pittsburgh, PA 15224, USA.

Over the past 15 years, with alarming and illustrative reports released from the Institute of Medicine, quality improvement and patient safety have come to the forefront of medical care. This article reviews quality improvement frameworks and methodology and the use of evidence-based guidelines for pediatric emergency medicine. Top performance measures in pediatric emergency care are described, with examples of ongoing process and quality improvement work in our pediatric emergency department.
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http://dx.doi.org/10.1016/j.pcl.2015.12.004DOI Listing
April 2016

Pediatric Necrotizing Pneumonia: A Case Report and Review of the Literature.

Pediatr Emerg Care 2017 Feb;33(2):112-115

From the *Department of Pediatrics, Children's Hospital of Pittsburgh; †Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine; and ‡Department of Radiology, Children's Hospital of Pittsburgh, Pittsburgh, PA.

Necrotizing pneumonias occur infrequently in children but may be associated with significant morbidity. If not adequately treated, necrotizing pneumonia may lead to complications including bronchopleural fistula, empyema, respiratory failure, and septic shock. Staphylococcus aureus is the most commonly implicated agent, followed by Streptococcus pneumoniae. Antimicrobial treatment is the cornerstone of management, although surgical drainage may be required in some cases. We present the case of a 14-month-old child with fever and cough that persisted despite treatment with typical first-line oral antimicrobial therapy. An initial plain radiograph of the chest demonstrated lobar pneumonia. Ultimately, computed tomography of the chest revealed a cavitary lesion in the left upper lobe of the lung. We review the literature and describe the clinical presentation, diagnosis, microbiological etiology, and management of necrotizing pneumonia in children.
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http://dx.doi.org/10.1097/PEC.0000000000000585DOI Listing
February 2017

Clinician Attitudes Toward Adoption of Pediatric Emergency Telemedicine in Rural Hospitals.

Pediatr Emerg Care 2017 Apr;33(4):250-257

From the *Division of General Academic Pediatrics, Department of Pediatrics, †Division of Pediatric Critical Care Medicine, Departments of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, ‡Department of Critical Care Medicine, §Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, ∥Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, and ¶Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.

Objective: Although there is growing evidence regarding the utility of telemedicine in providing care for acutely ill children in underserved settings, adoption of pediatric emergency telemedicine remains limited, and little data exist to inform implementation efforts. Among clinician stakeholders, we examined attitudes regarding pediatric emergency telemedicine, including barriers to adoption in rural settings and potential strategies to overcome these barriers.

Methods: Using a sequential mixed-methods approach, we first performed semistructured interviews with clinician stakeholders using thematic content analysis to generate a conceptual model for pediatric emergency telemedicine adoption. Based on this model, we then developed and fielded a survey to further examine attitudes regarding barriers to adoption and strategies to improve adoption.

Results: Factors influencing adoption of pediatric emergency telemedicine were identified and categorized into 3 domains: contextual factors (such as regional geography, hospital culture, and individual experience), perceived usefulness of pediatric emergency telemedicine, and perceived ease of use of pediatric emergency telemedicine. Within the domains of perceived usefulness and perceived ease of use, belief in the relative advantage of telemedicine was the most pronounced difference between telemedicine proponents and nonproponents. Strategies identified to improve adoption of telemedicine included patient-specific education, clinical protocols for use, decreasing response times, and simplifying the technology.

Conclusions: More effective adoption of pediatric emergency telemedicine among clinicians will require addressing perceived usefulness and perceived ease of use in the context of local factors. Future studies should examine the impact of specific identified strategies on adoption of pediatric emergency telemedicine and patient outcomes in rural settings.
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http://dx.doi.org/10.1097/PEC.0000000000000583DOI Listing
April 2017

The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias.

Acad Emerg Med 2016 Mar 22;23(3):297-305. Epub 2016 Feb 22.

Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.

Objectives: The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias.

Methods: This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores.

Results: Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = -0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21).

Conclusions: While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.
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http://dx.doi.org/10.1111/acem.12901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5020698PMC
March 2016

Diastolic hypotension is an unrecognized risk factor for β-agonist-associated myocardial injury in children with asthma.

Pediatr Crit Care Med 2013 Jul;14(6):e273-9

Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.

Objectives: Tachycardia and diastolic hypotension have been associated with β-2 agonist use. In the setting of β-agonist-induced chronotropy and inotropy, diastolic hypotension may limit myocardial blood flow. We hypothesized that diastolic hypotension is associated with β-agonist use and that diastolic hypotension and tachycardia are associated with biochemical evidence of myocardial injury in children with asthma.

Design: Two patient cohorts were collected. The first, consisting of patients transported for respiratory distress having received at least 10 mg of albuterol, was studied for development of tachycardia and hypotension. The second, consisting of patients who had troponin measured during treatment for status asthmaticus with continuous albuterol, was studied for factors associated with elevated troponin. Exclusion criteria for both cohorts included age younger than 2 years old, sepsis, pneumothorax, cardiac disease, and antihypertensive use. Albuterol dose, other medications, and vital signs were collected. Diastolic and systolic hypotension were defined as an average value below the fifth percentile for age and tachycardia as average heart rate above the 98th percentile for age.

Patients: Ninety of 1,390 children transported for respiratory distress and 64 of 767 children with status asthmaticus met inclusion criteria.

Measurements And Main Results: Diastolic hypotension occurred in 56% and 98% of the first and second cohorts, respectively; tachycardia occurred in 94% and 95% of the first and second cohorts, respectively. Diastolic hypotension and tachycardia had a weak linear correlation with albuterol dose (p = 0.02 and p = 0.005, respectively). Thirty-six percent had troponin > 0.1 ng/mL (range, 0-12.6). In multivariate analysis, interaction between diastolic hypotension and tachycardia alone was associated with elevated troponin (p = 0.02).

Conclusions: Diastolic hypotension and tachycardia are dose-dependent side effects of high-dose albuterol. In high-risk patients with status asthmaticus treated with albuterol, diastolic hypotension and tachycardia are associated with biochemical evidence of myocardial injury. Diastolic hypotension, especially combined with tachycardia, could be a reversible risk factor for myocardial injury related to β-agonist use.
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http://dx.doi.org/10.1097/PCC.0b013e31828a7677DOI Listing
July 2013

Reduced glucocorticoid receptor protein expression in children with critical illness.

Horm Res Paediatr 2013 8;79:169-78. Epub 2013 Mar 8.

Division of Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA.

Background/aims: The diagnostic criteria for critical illness-related corticoid insufficiency (CIRCI) are not well established, particularly for children. In addition to alterations in adrenal function, cellular resistance to glucocorticoid action could contribute to CIRCI due to alterations in the functioning of the intracellular receptor protein for corticosteroids, the glucocorticoid receptor (GR).

Methods: We have therefore undertaken a pilot, prospective study to assess whether cellular GR activity can be measured in peripheral blood mononuclear cells (PBMCs) from critically ill children.

Results: Total and cytoplasmic, but not nuclear GR levels were significantly lower in PBMCs from critically ill children (i.e. sepsis/septic shock and traumatic brain injury) compared to healthy controls . While total cortisol concentrations did not differ between test groups, salivary and serum-free cortisol concentrations were significantly greater in both groups of children with critical illness. Cortisol-binding globulin levels were significantly lower in patients with sepsis/septic shock.

Conclusions: The lower total and cytoplasmic receptor levels in critically ill children suggest that the GR-mediated response to exogenous glucocorticoid therapy may be limited. However, the nuclear transport of GR in critically ill patients suggests that residual receptors in these patients retain functionality and may be accessible to therapeutic treatments that maximize their activity.
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http://dx.doi.org/10.1159/000348290DOI Listing
November 2013

Pediatric facial fractures: occurrence of concussion and relation to fracture patterns.

J Craniofac Surg 2012 Sep;23(5):1270-3

Division of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15201, USA.

Background: Children and adolescents with injuries resulting in facial fractures are a population that is potentially at risk for suffering concomitant concussion. Concussion results in a variety of physical symptoms and often affects cognition, emotion, and sleep. These effects can have a significant impact on academics and social functioning. Early recognition of concussion and active management have been shown to improve outcomes. The goal of this study was to describe the occurrence of concussion in patients sustaining facial fractures and to determine whether certain fracture types are associated with concussion.

Methods: We performed a retrospective review of patients aged 0 to 18 years who were evaluated in the emergency department of the Children's Hospital of Pittsburgh from 2000 to 2005 with an International Classification of Diseases, Ninth Revision code indicative of facial fractures. Data included demographics, documentation of concussion, and facial fracture type. Patients with intracranial injury were excluded from the study. Univariate χ2 analysis and logistic regression were performed to determine characteristics associated with concussion.

Results: Facial fracture was diagnosed in 782 patients. Ninety-one patients had an intracranial injury and were excluded, leaving 691 patients for evaluation. The mean age was 11.1 (SD, 4.6) years. Males made up 69.6% of patients, and 80.6% of patients were white. Concussion was diagnosed in 31.7% of patients. Age, sex, and race were not associated with concussion. Univariate analysis demonstrated that skull and orbital fractures were associated with higher rates of concussion, whereas maxillary fractures showed a trend toward higher rates of concussion, and nasal and mandible fractures showed a trend toward lower rates of concussion. Logistic regression analysis demonstrated the odds of having a concussion were higher in those with skull fractures (odds ratio, 2.3; confidence interval, 1.5-3.7).

Conclusions: Nearly one third of pediatric patients with facial fractures in this retrospective series were diagnosed with a concomitant concussion. Our data suggest that a higher index of suspicion for concussion should be maintained for patients with concomitant skull fractures and potentially orbital and maxillary fractures. Given the possibility of a worse outcome with delayed concussion diagnosis, patients with facial fractures may benefit from more active early concussion screening.
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http://dx.doi.org/10.1097/SCS.0b013e31824e6447DOI Listing
September 2012

Prevalence, clinical features and management of pediatric magnetic foreign body ingestions.

J Emerg Med 2013 Jan 23;44(1):261-8. Epub 2012 Jun 23.

Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania 152224, USA.

Background: Foreign body (FB) ingestions are frequent in children. Whereas the majority of FBs pass spontaneously through the gastrointestinal tract, ingestion of magnetic FBs pose a particular risk for obstruction due to proximate attraction through the intestinal wall.

Study Objectives: We aimed to identify the prevalence, clinical presentation, and management of magnetic FB ingestions at our tertiary care institution.

Methods: We performed a retrospective chart review of medical records of patients presenting to the pediatric Emergency Department (ED) or admitted to the hospital with FB ingestions from June 2003-July 2009. From those cases, patients with magnetic FB ingestions were identified.

Results: During the study period, 337,839 patients presented to the ED; 38 cases of magnetic FB ingestion were identified (prevalence 0.01%). Abdominal radiography was obtained in all cases. Ingestion of a single magnet occurred in 30 of 38 cases (79%). Of those, 4 patients underwent endoscopic removal due to signs of FB impaction in the esophagus or pylorus; no complications were noted. Ingestion of multiple magnets (range 2-6) occurred in 8 of 38 cases. Four of the 8 patients with multiple magnetic FBs (50%) presented with signs of peritonitis and required operative repair of multiple intestinal perforations. No deaths were identified.

Conclusion: Although ingestion of a single magnetic FB may, in most cases, be managed as a simple FB ingestion, the ingestion of multiple magnetic FB is associated with a high risk of complication and requires aggressive management. We propose an algorithm for management of children with magnetic FB ingestions.
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http://dx.doi.org/10.1016/j.jemermed.2012.03.025DOI Listing
January 2013

Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients.

Plast Reconstr Surg 2011 Dec;128(6):1263-1271

Pittsburgh, Pa. From the Division of Pediatric Plastic Surgery and the Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center.

Background: Pediatric craniofacial fractures are anatomically distinct from their adult counterparts and must be managed with respect for future growth and development. These injuries must be approached as entities fundamentally different from adult craniofacial fractures. Here, the authors aim to provide context for practitioners managing pediatric facial fractures by augmenting presently available demographic, diagnostic, and treatment data.

Methods: This is a retrospective review of demographics, diagnosis, and treatment of patients under 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with facial fractures. Patients were included regardless of treating specialty, treatment modality, or inpatient status.

Results: A total of 772 consecutive patients met inclusion criteria. A significant majority (p < 0.001) of patients (68.9 percent) were male; older children were significantly more likely to sustain a facial fracture (p < 0.001). Fracture pattern, level of care, and cause of injury varied by age; 55.6 percent of patients had severe associated injuries. Male subjects, older patients, and patients of lower socioeconomic status were significantly more likely to sustain facial fractures secondary to violence (p ≤ 0.001).

Conclusions: Pediatric facial fractures may be associated with severe concomitant injuries. Injury patterns are significantly correlated with socioeconomic metrics.
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http://dx.doi.org/10.1097/PRS.0b013e318230c8cfDOI Listing
December 2011

Identifying neurocognitive deficits in adolescents following concussion.

Acad Emerg Med 2011 Mar;18(3):246-54

Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Objectives: This study of concussed adolescents sought to determine if a computer-based neurocognitive assessment (Immediate Postconcussion Assessment and Cognitive Test [ImPACT]) performed on patients who present to the emergency department (ED) immediately following head injury would correlate with assessments performed 3 to 10 days postinjury and if ED neurocognitive testing would detect differences in concussion severity that clinical grading scales could not.

Methods: A prospective cohort sample of patients 11 to 17 years of age presenting to the ED within 12 hours of a head injury were evaluated using two traditional concussion grading scales and neurocognitive testing. ED neurocognitive scores were compared to follow-up scores obtained at least 3 days postinjury. Postconcussive symptoms, outcomes, and complications were assessed via telephone follow-up for all subjects.

Results: Sixty patients completed phone follow-up. Thirty-six patients (60%) completed follow-up testing a median of 6 days postinjury. Traditional concussion grading did not correlate with neurocognitive deficits detected in the ED or at follow-up. For the neurocognitive domains of verbal memory, processing speed, and reaction time, there was a significant correlation between ED and follow-up scores trending toward clinical improvement. By 2 weeks postinjury, 23 patients (41%) had not returned to normal activity. At 6 weeks, six patients (10%) still had not returned to normal activity.

Conclusions: Immediate assessment in the ED can predict neurocognitive deficits seen in follow-up and may be potentially useful to individualize management or test therapeutic interventions. Neurocognitive assessment in the ED detected deficits that clinical grading could not and correlated with deficits at follow-up.
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http://dx.doi.org/10.1111/j.1553-2712.2011.01015.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076718PMC
March 2011

Cardiac arrest in children.

J Emerg Trauma Shock 2010 Jul;3(3):267-72

University of Pittsburgh School of Medicine, Departments of Pediatrics and Critical Care Medicine, 3434 Fifth Avenue, Pittsburgh, PA, 152 60, USA.

Major advances in the field of pediatric cardiac arrest (CA) were made during the last decade, starting with the publication of pediatric Utstein guidelines, the 2005 recommendations by the International Liaison Committee on Resuscitation, and culminating in multicenter collaborations. The epidemiology and pathophysiology of in-hospital and out-of-hospital CA are now well described. Four phases of CA are described and the term "post-cardiac arrest syndrome" has been proposed, along with treatment goals for each of its four phases: immediate post-arrest, early post-arrest, intermediate and recovery phase. Hypothermia is recommended to be considered as a therapy for post-CA syndrome in comatose patients after CA, and large multicenter prospective studies are underway. We reviewed landmark articles related to pediatric CA published during the last decade. We present the current knowledge of epidemiology, pathophysiology and treatment of CA relevant to pre-hospital and acute care health practitioners.
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http://dx.doi.org/10.4103/0974-2700.66528DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938492PMC
July 2010

Evaluation of a transthecal digital nerve block in the injured pediatric patient.

Pediatr Emerg Care 2010 Mar;26(3):177-80

From the Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.

Background: Digital anesthesia in the pediatric population has traditionally been accomplished using a ring block that requires multiple injections. A modified transthecal digital nerve block is a single-injection technique of the midproximal phalanx that has been shown to be technically simple and highly effective in adults.

Objective: To describe the success rate of the modified transthecal digital nerve block in children.

Methods: : A convenience sample of children requiring digital anesthesia for minor surgical procedures on the fingers or thumb at an urban tertiary-care pediatric emergency department were prospectively enrolled into the study. A transthecal digital nerve block was performed by injecting a 1:1 mixture of 1% lidocaine and 0.5% bupivicaine into the flexor tendon sheath at the midpoint between the proximal digital and the proximal interphalangeal joint creases. The volume of anesthetic was based on age. All nerve blocks were performed by 3 investigators trained in the procedure. Successful digital anesthesia was defined as complete loss of pinprick sensation on both the dorsal and palmar aspects of the digit and the ability to complete the anticipated minor surgical procedure without pain. Primary outcome measures were anesthesia success rate and pain score. Age-appropriate pain scale scores (Face, Legs, Activity, Cry, Consolability Scale, 0-3 years; Faces Scale, 4-7 years; and visual analog scale, > or =8 years) were recorded 5 minutes after injection. All patients were followed up for 6 months to assess for adverse events.

Results: Between November 2003 and March 2004, 48 patients (50 digits) requiring digital anesthesia were enrolled into the study. The mean age of patients was 8.3 years (median, 7.6 years; range, 0.7-17.5 years). Twenty-four (50%) were boys and 30 whites (62.5%). Overall, the transthecal digital nerve block technique was successful in 47 (94%) of the 50 digits (95% confidence interval [CI], 83%-98%), including 37 (97%) of 38 fingers (95% CI, 85%-99%) and 10 (83%) of 12 thumbs (95% CI, 54%-96%). Forty-seven (94%) of the 50 digits had a recorded pain score of 0 five minutes after injection. Mean (SD) procedure time was 113 (24.8) seconds, and mean (SD) anesthetic volume was 2.13 (0.61) mL. No adverse events were reported.

Conclusions: The single-injection modified transthecal digital nerve block is a safe and effective method for digital anesthesia in children. These data confirm the applicability of transthecal digital nerve block for children with finger and thumb injuries that require minor surgical procedures.
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http://dx.doi.org/10.1097/PEC.0b013e3181d1dfafDOI Listing
March 2010

Emergency contraception services for adolescents: a National Survey of Children's Hospital Emergency Department Directors.

J Pediatr Adolesc Gynecol 2009 Apr;22(2):111-9

Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pennsylvania, USA.

Study Objective: To assess emergency contraception (EC) counseling and prescribing practices of children's hospital emergency department (ED) directors and the use of EC protocols in these settings.

Design: Cross-sectional study of children's hospital ED directors responding to a 15-minute 44-item semi-structured survey during telephone interviews.

Participants: 50 of 96 eligible directors of children's hospital EDs in the United States.

Main Outcome Measures: EC protocols, EC counseling processes, EC prescribing practices.

Results: Most (80%) ED directors reported always offering EC as part of sexual assault care; 66% were more likely to provide onsite EC in these situations. Only 52% identified the progestin-only regimen as the EC dispensed in their ED, and most (96%) limited provision to fewer than 120 hours after sex. Although 58% of ED directors reported ever prescribing ongoing contraception when providing EC, none had prescribed EC for future use. Written ED protocols for providing EC were more common for sexual assault care (76%) than for non-sexual assault care (14%). Directors who worked at hospitals with a sexual assault program were less likely to discuss all the recommended topics for EC counseling.

Conclusions: The recommended standard of care for providing EC to adolescents in children's hospital EDs is not being met. Although risk of pregnancy following sexual assault and consensual unprotected sex is identical, discrepant practices emerged from this survey of pediatric ED directors. Increased education and policy initiatives within children's hospital EDs are needed to standardize EC services for adolescents in this setting.
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http://dx.doi.org/10.1016/j.jpag.2008.04.002DOI Listing
April 2009

Emergency department management of the pediatric patient with supraventricular tachycardia.

Pediatr Emerg Care 2007 Mar;23(3):176-85; quiz 186-9

Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA 15213-2583, USA.

Supraventricular tachycardia (SVT) is the most common tachyarrhythmia that necessitates treatment in children. It is characterized by a rapid and regular heart rate, which generally exceeds 180 beats per minute in children and 220 beats per minute in adolescents. Supraventricular tachycardia results from conduction of electrical impulses along an accessory connection from the atrium to the ventricle (atrioventricular reentry tachycardias: orthodromic or antidromic) or conduction within the atrioventricular node (atrioventricular node reentry tachycardia). Emergency department management of SVT depends on the patient's clinical status. Treatment of a stable patient with SVT includes vagal maneuvers and adenosine, whereas treatment of an unstable patient requires synchronized cardioversion. This article presents an overview of the etiology, pathophysiology, and clinical presentation of SVT and discusses the emergency department management of an infant or child with SVT.
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http://dx.doi.org/10.1097/PEC.0b013e318032904cDOI Listing
March 2007

Development of a model of focal pneumococcal pneumonia in young rats.

J Immune Based Ther Vaccines 2004 Jan 23;2(1). Epub 2004 Jan 23.

Division of Emergency Medicine, Children's Hospital, Harvard Medical School, Boston MA, USA.

BACKGROUND: A recently licensed pneumococcal conjugate vaccine has been shown to be highly effective in the prevention of bacteremia in immunized children but the degree of protection against pneumonia has been difficult to determine. METHODS: We sought to develop a model of Streptococcus pneumoniae pneumonia in Sprague-Dawley rats. We challenged three-week old Sprague-Dawley pups via intrapulmonary injection of S. pneumoniae serotypes 3 and 6B. Outcomes included bacteremia, mortality as well histologic sections of the lungs. RESULTS: Pneumonia was reliably produced in animals receiving either 10 or 100 cfu of type 3 pneumococci, with 30% and 50% mortality respectively. Similarly, with type 6B, the likelihood of pneumonia increased with the inoculum, as did the mortality rate. Prophylactic administration of a preparation of high-titered anticapsular antibody prevented the development of type 3 pneumonia and death. CONCLUSION: We propose that this model may be useful for the evaluation of vaccines for the prevention of pneumococcal pneumonia.
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http://dx.doi.org/10.1186/1476-8518-2-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC333431PMC
January 2004