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Biomedical subjects

Ron Keren

Publications and source records attributed to Ron Keren.

14 recordsLinked to original sources
PubMed2006

Complications of central venous catheters used for the treatment of acute hematogenous osteomyelitis.

OBJECTIVE: To determine the complications and risk factors for complications associated with using central venous catheters (CVCs) for the treatment of acute hematogenous osteomyelitis (AHO). METHODS: We conducted a retrospective cohort study of all patients admitted to the Children's Hospital of Philadelphia between January 1, 2000, and December 31, 2003, with a diagnosis of AHO. RESULTS: Eighty patients with AHO met inclusion criteria. The median age was 5 years, and 66% of the patients were male. The most commonly affected bones were the femur (25%), tibia (20%), and pelvis (16%). Staphylococcus aureus was the most common organism identified from cultures of bone (67%) and blood (30%). Seventy-five patients (94%) received >2 weeks of intravenous (IV) antibiotic therapy via a CVC and 5 (6%) received <2 weeks of IV antibiotic therapy before conversion to oral therapy for a median of 25 days. None of the patients who switched to oral therapy within 2 weeks was rehospitalized or returned to the emergency department. Of the 75 patients who received >2 weeks of IV therapy, 41% had > or =1 CVC-associated complication. Seventeen patients (23%) had a CVC malfunction or displacement, 8 (11%) had a catheter-associated bloodstream infection, 8 (11%) had fever with negative blood culture results, and 4 (5%) had a local skin infection at the site of catheter insertion. Older age was protective against the development of a CVC-associated complication, whereas the lowest median household income was associated with development of a CVC-associated complication. CONCLUSIONS: Interventions to reduce CVC-associated complications should be developed and evaluated, particularly for young children and those from families with low household incomes. Clinical trials are needed to evaluate the safety and efficacy of oral antibiotic therapy after a short course of IV therapy as an alternative to prolonged IV therapy.

Acute Disease↗
PubMed2006

Direct medical cost of influenza-related hospitalizations in children.

OBJECTIVE: Our goal was to determine the cost of influenza-related hospitalization in children with community-acquired laboratory-confirmed influenza and to identify predictors of high hospitalization costs. PATIENTS AND METHODS: This was a retrospective cohort study of patients 21 years and younger hospitalized at a children's hospital with community-acquired laboratory-confirmed influenza during 4 consecutive influenza seasons (2000-2004). The main outcome measure was the direct medical cost of influenza-related hospitalizations, including the cost of diagnostics, therapeutics, room, and physician services. RESULTS: Electronic billing data were retrievable for 727 (98%) of 745 patients hospitalized for community-acquired laboratory-confirmed influenza during the study period. A total of 478 (66%) children were in a high-risk group for whom the Advisory Committee on Immunization Practices recommended influenza vaccine (patients with Advisory Committee on Immunization Practices-designated chronic medical conditions or aged 6-23 months). The mean total cost of hospitalization for influenza-related illness was 13,159 dollars (39,792 dollars for patients admitted to an ICU; 7030 dollars for patients cared for exclusively on the wards). High-risk patients had higher mean total costs (15,269 dollars) than low-risk patients (9107 dollars). Cardiac, metabolic, and neurologic/neuromuscular diseases and age of 18 to 21 years were independently associated with the highest hospitalization costs (>15th percentile). CONCLUSIONS: The cost of influenza-related hospitalizations in children may be considerably higher than previously estimated. The presence of certain Advisory Committee on Immunization Practices-designated chronic medical conditions is associated with higher influenza-related hospitalization costs. Successfully immunizing patients with these conditions has the potential for significant cost savings.

Adolescent↗
PubMed2005

Neurological and neuromuscular disease as a risk factor for respiratory failure in children hospitalized with influenza infection.

CONTEXT: The Advisory Committee on Immunization Practices (ACIP) recommends annual influenza vaccination for children with certain chronic medical conditions to prevent serious complications of influenza infection. Little is known about the relative contribution of each of these chronic medical conditions to the development of serious influenza-associated complications. OBJECTIVE: To identify chronic medical conditions that are associated with respiratory failure in children hospitalized with community-acquired laboratory-confirmed influenza. DESIGN, SETTING, AND PATIENTS: A retrospective cohort study of patients aged 21 years or younger hospitalized at The Children's Hospital of Philadelphia with community-acquired laboratory-confirmed influenza during 4 consecutive influenza seasons (June 2000 through May 2004). We examined 9 ACIP-designated high-risk chronic medical conditions and 3 additional chronic medical conditions (neurological and neuromuscular disease [NNMD], gastroesophageal reflux disease [GERD], and history of prematurity) that in recent studies have been associated with influenza hospitalization and severe influenza-related complications. MAIN OUTCOME MEASURES: Rate and odds ratio (OR) of respiratory failure, defined as need for mechanical ventilation. RESULTS: Of 745 children hospitalized with community-acquired laboratory-confirmed influenza, 322 (43%) had 1 or more ACIP-designated high-risk chronic medical conditions. Neurological and neuromuscular disease, GERD, and history of prematurity were present in 12%, 14%, and 3%, of children, respectively. Thirty-two children (4.3%) developed respiratory failure. In multivariate logistic regression analyses, conditions associated with respiratory failure included NNMD (OR, 6.0; 95% confidence interval [CI], 2.7-13.5), chronic pulmonary disease other than asthma (OR, 4.8; 95% CI, 1.5-15.1), and cardiac disease (OR, 4.0; 95% CI, 1.6-10.2). The predicted probabilities of respiratory failure derived from the multivariate model were 12% (95% CI, 7%-20%), 9% (95% CI, 3%-23%), and 8% (95% CI, 4%-18%) for children with NNMD, chronic pulmonary disease, and cardiac disease, respectively. CONCLUSIONS: These results support the ACIP's recent decision to add NNMD to the list of conditions for which annual influenza vaccine is recommended in children. Neurologists and primary care pediatricians should be alerted to the increased risk of respiratory failure and the importance of influenza vaccination in children with NNMD.

Adolescent↗
PubMed2005

Evaluation of a novel method for grading heart murmur intensity.

OBJECTIVE: To determine if heart murmur intensity grading performance can be improved using the heart sounds as an internal reference. METHODS: Single-blind controlled trial of 100 medical students, residents, and pediatric attending physicians at a children's hospital. Groups of 1 to 3 participants were alternately assigned to intervention and control groups, reported their method of grading heart murmur intensity, and then graded the intensity of a random sample of 20 recorded murmurs on a 6-point scale. Before rating another random sample of 20 murmurs, the intervention group was taught a system that uses the heart sounds as an internal reference. Primary outcomes were change in accuracy (percentage correct), interrater agreement (kappa), and consistency (kappa). Subgroup analyses were performed by training level and heart murmur grade. RESULTS: Grading accuracy improved more in the intervention group than the control group (Delta improvement, 5%; 95% confidence interval [CI], -0.1%-10.0%]). This was most pronounced among attending physicians (Delta improvement, 11%; 95% CI, 0.4%-22%) and students (Delta improvement, 12%; 95% CI, 3%-20%) and for grade 2 murmurs (Delta improvement, 20%; 95% CI, 10%-31%). Relatively greater improvements in consistency were observed after the intervention for attending physicians (Delta improvement, 0.17; 95% CI, 0.01-0.32) and grades 2 (Delta improvement, 0.22; 95% CI, 0.09-0.36) and 3 murmurs (Delta improvement, 0.16; 95% CI, 0.05-0.28). CONCLUSIONS: A system that uses the heart sounds as an internal reference for grading heart murmur intensity quickly improves accuracy and consistency for some providers and specific murmurs.

Clinical Competence↗
PubMed2004

Diagnosis and management of hyperbilirubinemia in the term neonate: for a safer first week.

New data support restructuring the approach toward diagnosis and management of hyperbilirubenia in the term neonate to make it more physician-friendly and gain wider implementation. The authors advocate clear criteria for patient safety, preventive approaches, and timely interventions. Structural changes to facilitate a system-based approach should include predischarge bilirubin management; follow-up bilirubin management; and lactational support and nutritional management. The authors advocate total serum bilirubin screening and a scoring system based on clinical risk factors as predischarge screening strategies; we should screen all babies for hyperbilirubinemia and for targeted follow-up based on an hour-specific total serum bilirubin measured for risk assessment. We should also provide focused universal education emphasizing adequate lactational nutrition, to decrease severe hyperbilirubinemia and thus prevent kernicterus.

Exchange Transfusion, Whole Blood↗
PubMed2004

National Institute of Child Health and Human Development (NICHD) conference on kernicterus: a population perspective on prevention of kernicterus.

This paper reviews barriers to the prevention of kernicterus. Reports of kernicterus cases persist. We do not know why kernicterus continues to occur or how best to prevent it. We need evidence for key recommendations that make clinical guidelines usable by practitioners caring for newborns, especially for practitioners providing ambulatory care in the first week of life. Data on prevalence and incidence, mortality and morbidity are essential for launching a kernicterus public health campaign. Modeling cost-effectiveness requires data on costs and benefits of alternative strategies for managing hyperbilirubinemia and preventing kernicterus and on parental preferences concerning follow-up in the first days of life. Understanding how existing patterns of care obstruct preventive care involves exploration of the roles of clinicians, health-care organizations, parents, and payers and purchasers of health care. Lastly, discovering how to motivate change in existing practices can provide the guidance needed to prevent kernicterus in the US.

Cost-Benefit Analysis↗
PubMed2004

The generation gap: differences between children and adults pertinent to economic evaluations of health interventions.

Differences between children and adults have both technical and ethical implications for the design, interpretation and employment of economic analyses of health-related programmes. Even though policy makers increasingly turn to economic analyses to inform decisions about resource allocation, pertinent child-adult differences have received fragmented discussion in leading methodological references. Key areas warranting attention include: the ways in which a child's distinctive biology modifies the cost and effectiveness of healthcare interventions; challenges in assessing utilities for infants and young children given their limited but developing cognitive capacity; how a child's age, dependency and disability affect the selection of the appropriate time horizon and scope of the analysis; whether a child's non-wage earning productivity should be incorporated into analyses, and if so, what metric to use; what principles of equity policy makers should employ in using economic evaluations to choose between child- and adult-focused interventions; and whether special protective measures should be introduced to secure the rights and interests of children who cannot advocate for themselves.

Adult↗
PubMed2004

Public spending on elders and children: the gap is growing.

Social welfare programs support the income, education, nutrition, and medical care needs of many of this country's elders and children. Over the past twenty years, however, three times as many children as elders have lived in poverty, and poverty rates for children have consistently exceeded those for the elderly. Given the continued disparity in poverty rates, it is important to track levels of public spending for each group and the generational balance in allocating limited public funds. This Issue Brief evaluates trends in social welfare spending for children and the elderly from 1980 to 2000, and the relationship of national economic trends to public spending patterns.

Adult↗
PubMed2003

Notifying emergency department patients of negative test results: pitfalls of passive communication.

OBJECTIVE: Many emergency departments that perform a high volume of group A Streptococcus throat cultures inform patients or parents that unless they are notified of a positive result they can assume that their throat culture result is negative. Thus, positive throat culture results are communicated actively and negative results are communicated passively. We sought to determine the effectiveness and safety of such a system. METHODS: Prospective cohort study of 301 consecutive patients who had group A Streptococcus throat cultures obtained between March 28, 2000, and May 10, 2000, in the emergency department of an urban, academic, tertiary-care children's hospital. Outcomes were determined by telephone surveys of patients or their parents or guardians. The primary outcome was whether respondents had accurate knowledge of the throat culture result. Secondary outcomes included receipt of appropriate treatment instructions, need for another telephone call to the emergency department or primary-care provider to clarify the result or treatment instructions, satisfaction with the communication process, and preference to receive both positive and negative results or just positive results. RESULTS: Fifty-three percent of respondents did not have accurate knowledge of the throat culture result, 5% received inappropriate treatment instructions, 13% sought further clarification, 29% were dissatisfied with the communication process, and 85% preferred to receive both positive and negative results. Parents of patients with positive results were more likely to have accurate knowledge of the result (odds ratio 6.9, 95% confidence interval 1.4-65.7) and to be satisfied with the communication process. CONCLUSIONS: Passive communication of negative throat culture results to patients seen in the emergency department can be unreliable. Active communication of both positive and negative results may improve patient knowledge and satisfaction and ensure appropriate therapy, but in the absence of automated notification systems, would be resource intensive.

Adolescent↗
PubMed2002

A meta-analysis of randomized, controlled trials comparing short- and long-course antibiotic therapy for urinary tract infections in children.

BACKGROUND: Short-course antibiotic regimens, ranging in duration from a single dose to 3 days, are the current standard of care for the treatment of acute lower urinary tract infections (UTIs) in adult women. Despite multiple small randomized, controlled trials (RCTs) showing no difference in efficacy between short-course (</=3 days) and long-course (7-14 days) therapy in children, concerns about occult pyelonephritis and renal scarring have prompted standard recommendations of 7 to 14 days of antibiotics for UTIs in children. OBJECTIVE: To determine whether long-course antibiotic therapy is more effective than short-course therapy for the treatment of UTIs in children, and to explore potential sources of heterogeneity in the results of existing studies. METHODS: We searched online bibliographic databases (Medline and Cochrane Clinical Trials Registry) for RCTs comparing short- and long-course therapy for the treatment of UTI in children, and examined the references of all retrieved articles. Candidate studies for meta-analysis were restricted to RCTs comparing short-course (</=3 days) and long-course (7-14 days) outpatient therapy for acute UTI in children age 0 to 18 years. We excluded studies that were restricted to children with recurrent UTI or included children with asymptomatic bacteriuria. Sixteen studies met the inclusion criteria. Study quality was evaluated using a 9-item scoring system developed by the investigators. Data on the primary outcomes-treatment failure and reinfection rate-were extracted when available and reanalyzed based on intention to treat whenever possible. To determine whether anatomic level of infection (upper vs lower urinary tract) influenced the results, the meta-analysis was repeated on the subgroup of studies that attempted to restrict their participants to children with lower UTI. To determine whether there was a dose-response effect for the duration of short-course therapy, we performed separate subgroup analyses of studies of single-dose or single-day therapy and studies of 3-day therapy. To explore other potential sources of study result heterogeneity, such as study quality and patient age, we developed a random-effects regression model that included these variables as covariates. RESULTS: The pooled estimate for the relative risk (RR) of treatment failure with short-course antibiotic therapy was 1.94 (95% confidence interval [CI]: 1.19-3.15) and for the RR of reinfection was 0.76 (95% CI: 0.39-1.47). When we excluded the 3 studies that did not attempt to restrict their participants to patients with lower UTI, the pooled RR of treatment failure was 1.74 (95% CI: 1.05-2.88) and of reinfection was 0.69 (95% CI: 0.32-1.52). For the subgroup of studies comparing single-dose or 1-day therapy to long-course therapy, the pooled RR of treatment failure was 2.73 (95% CI: 1.38-5.40) and of reinfection was 0.37 (95% CI: 0.12-1.18). For the subgroup of studies comparing 3-day therapy to long-course therapy, the pooled RR of treatment failure was 1.36 (95% CI: 0.68-2.72) and of reinfection was 0.99 (95% CI: 0.46-2.13). In the meta-regression, neither study quality nor mean participant age was significantly associated with the odds ratio of treatment failure or reinfection, in either the complete set of studies or the subset of studies restricted to patients with lower UTI. CONCLUSIONS: In pooled analyses of published studies comparing long- and short-course antibiotic treatment of UTI in children, long-course therapy was associated with fewer treatment failures without a concomitant increase in reinfections, even when studies including patients with evidence of pyelonephritis were excluded from the analysis. Until there are more accurate methods for distinguishing upper from lower UTI in children, no additional comparative trials are warranted and clinicians should continue to treat children with UTI for 7 to 14 days.

Adolescent↗
PubMed2002

Projected cost-effectiveness of statewide universal newborn hearing screening.

OBJECTIVES: Early identification of hearing impairment may improve language outcomes and subsequent school and occupational performance of the deaf. Universal newborn hearing screening (UNHS), currently mandated by 32 states, can reduce the median age of identification of hearing impairment from 12 to 18 months to 6 months or less. However, because false-negative tests must be minimized, the prevalence of congenital deafness is low, and screening tests are imperfect, UNHS results in many false-positive results and has a low positive predictive value (PPV). The objective of this study was to evaluate UNHS and selective screening in terms of both short- and long-term benefits, harms, and financial costs and to identify steps in the screening process that could be improved to increase cost-effectiveness. METHODS: The cost-effectiveness analysis, conducted from the societal perspective, compared the projected outcomes of 1) no newborn hearing screening, 2) selective newborn hearing screening, and 3) UNHS for a hypothetical state birth cohort of 80 000 infants. Probability and cost estimates for the decision model were obtained from published studies, expert opinion, and national and state sources. The main outcomes were incremental cost per infant whose deafness was diagnosed by 6 months, which included only the cost of screening and diagnostic evaluation; and incremental cost per deaf child with normal language, which also included the costs of medical care, education and assistive devices, and lost productivity over the lifetime of the deaf individual. RESULTS: Selective screening identified 62 of the 128 deaf infants in the birth cohort, referred 0.18% of all infants for diagnostic evaluation, and had a PPV of 43%. UNHS identified 116 of the 128 deaf infants, referred 1.6% of all infants, and had a PPV of 8.8%. Our model simulated real-world conditions in which some infants whose deafness is identified at screening do not receive a definitive diagnosis of being deaf before 6 months; and a portion of deaf and hard-of-hearing infants who 1) have false-negative screening test results, 2) are not screened, or 3) fail the hearing screen but are not immediately followed up with diagnostic evaluation nonetheless receive a diagnosis by 6 months of age. In the absence of newborn hearing screening, approximately 30 deaf infants were identified by 6 months of age by passive detection alone at a cost of $69 000. The selective screening protocol, when compared with no newborn hearing screening, resulted in an additional 36 infants whose deafness was diagnosed by 6 months at an additional cost of approximately $600 000, yielding an incremental cost-effectiveness of approximately $16 000 per additional infant whose deafness was diagnosed by 6 months. Compared with selective screening, the UNHS protocol resulted in 33 additional infants whose deafness was diagnosed by 6 months of age at an additional cost of approximately $1.5 million, yielding an incremental cost-effectiveness of approximately $44 000 per additional infant whose deafness was diagnosed by 6 months of age. Increasing the rate of follow-up to diagnostic evaluation from the base-case estimate of 77% to 100% decreased the incremental cost of UNHS to $38 000 per additional infant whose deafness was diagnosed by 6 months. Under the base-case assumptions about lifetime savings that result from normal language with early intervention, UNHS resulted in normal language achievement for more deaf children and was cost saving in the long term compared with both selective screening and no screening. CONCLUSIONS: The short-term cost-effectiveness of UNHS is comparable to the cost per case diagnosed of other newborn screening programs and could be improved by increasing the rate of follow-up to diagnostic evaluation after positive screening test results. If early identification results in improved language abilities, lower educational and vocational costs, and increased lifetime productivity, then UNHS has the potential for long-term cost savings compared with selective hearing screening and no screening. To understand the actual long-term economic effects of UNHS, better evidence is needed regarding the impact of early intervention on language outcomes and subsequent changes in educational costs and lifetime productivity.

Cohort Studies↗
PubMedDate not supplied

Generational differences in U.S. public spending, 1980-2000.

The balance between spending on children and spending on the elderly is important in evaluating the allocation of public welfare spending. We examine trends in public spending on social welfare programs for children and the elderly during 1980-2000. For both groups, social welfare spending as a percentage of gross domestic product changed little, even during the economic expansions of the 1990s. In constant dollars, the gap in per capita social welfare spending between children and the elderly grew 20 percent. Unlike spending for programs for the elderly, spending for children's programs suffered during recessions. Public discussion about the current imbalance in public spending is needed.

Age Factors↗