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Biomedical subjects

K D Mandl

Publications and source records attributed to K D Mandl.

23 records · Page 2Linked to original sources
PubMed1997

Incidence of bacteremia in infants and children with fever and petechiae.

OBJECTIVE: We determined the incidence of serious invasive bacteremia caused by Neisseria meningitidis and other organisms in febrile infants and children with a petechial rash. Further, we studied the diagnostic value of laboratory and clinical finding in these patients. STUDY DESIGN: We conducted this prospective cohort study in the emergency department of an urban pediatric teaching hospital, during an 18-month period, and enrolled consecutive patients with temperature of 38 degrees C or higher and petechiae. Our measures included (1) laboratory tests (leukocyte count, coagulation profile, blood culture, and cerebrospinal fluid bacterial culture); (2) a questionnaire requesting clinical data including general appearance, number and location of petechiae, and presence or absence of purpura; and (3) a follow-up telephone survey documenting health status. RESULTS: A total of 411 patients were enrolled, with 57.7% between 3 and 36 months of age. Eight patients (1.9%) had bacteremia or clinical sepsis. Six had serious invasive bacteremia: N. meningitidis (two patients), group A streptococcus (one), or sepsis with negative culture results (three). Two had occult bacteremia caused by Streptococcus pneumoniae and no evidence of sepsis. No patient had a positive cerebrospinal fluid culture result. None of the 357 well-appearing patients (95% confidence interval: 0.0%, 1.0%) had serious invasive bacteremia. Fifty-three patients appeared ill, including all six with serious invasive bacteremia. Ill appearance of the child had a sensitivity of 1.00 (95% confidence interval: 0.60, 1.00), and a leukocyte count of 15,000 or greater, or of less than 5000, had a sensitivity of 1.0 (95% confidence interval: 0.53, 1.00) for detecting serious invasive bacteremia. All children with meningococcemia had purpura. CONCLUSIONS: Invasive bacteremia occurred less frequently in our study than in previous series and was identified by clinical criteria. Our data support the treatment of selected well-appearing children with fever and petechiae as outpatients.

Adolescent↗
PubMed1991

Developmental regulation of expression of C-reactive protein and serum amyloid A in Syrian hamsters.

The fetal and maternal concentration of various plasma proteins alters during pregnancy. Cells in the livers of fetal hamsters accumulate serum amyloid A (SAA) and C-reactive protein (CRP) mRNA, major acute phase reactants, when lipopolysaccharide is administered to the fetal circulation. No fetal SAA or CRP mRNA response is seen when the mother is stimulated at a remote site by endotoxin or a nonspecific inflammatory agent. In addition, cells of the fetal hamster liver do not respond by accumulating SAA mRNA when exposed to the specific cytokines, tumor necrosis factor, IL-1, and IL-6. CRP mRNA levels increased in fetal livers after administration of tumor necrosis factor and IL-1. These data suggest that cells contained in the fetal liver can respond during an acute phase reaction but that the capacity of some acute phase reactant genes to respond to cytokines may be developmentally regulated. Studies of immature hamsters after birth show that the responses of CRP and SAA genes to lipopolysaccharide, tumor necrosis factor, IL-1, and IL-6 are reduced when compared with induction of mRNA accumulation for these acute phase reactants in adult animals.

Acute-Phase Reaction↗
PubMedDate not supplied

Sensitivity of a clinical examination to predict need for radiography in children with ankle injuries: a prospective study.

BACKGROUND: Radiographs are ordered routinely for children with ankle trauma. We assessed the predictive value of a clinical examination to identify a predefined group of low-risk injuries, management of which would not be affected by absence of a radiograph. We aimed to show that no more than 1% of children with low-risk examinations (signs restricted to the distal fibula) would have high-risk fractures (all fractures except avulsion, buckle, and non-displaced Salter-Harris I and II fractures of the distal fibula), and to compare the potential reduction in radiography in children with low-risk examinations with that obtained by application of the Ottawa ankle rules (OAR). METHODS: Standard clinical examinations and subsequent radiographs were prospectively and independently evaluated in two tertiary-care paediatric emergency departments in North America. Eligible participants were healthy children aged 3-16 years with acute ankle injuries. Sample size, negative and positive predictive values, sensitivity, and specificity were calculated. McNemar's test was used to compare differences in the potential reduction in radiographs between the low-risk examination and the OAR. FINDINGS: 607 children were enrolled; 581 (95.7%) received follow-up. None of the 381 children with low-risk examinations had a high-risk fracture (negative predictive value 100% [95% CI 99.2-100]; sensitivity 100% [93.3-100]). Radiographs could be omitted in 62.8% of children with low-risk examinations, compared with only 12.0% reduction obtained by application of the OAR (p<0.0001). INTERPRETATION: A low-risk clinical examination in children with ankle injuries identifies 100% of high-risk diagnoses and may result in greater reduction of radiographic referrals than the OAR.

Adolescent↗
PubMedDate not supplied

The challenges of automating a real-time clinical practice guideline.

OBJECTIVE: To elucidate the types of problems encountered during implementation of a World Wide Web-based clinical practice guideline to manage hyperbilirubinemia in newborn infants. DESIGN: Formative assessment of an automated clinical-practice guideline in a large-scale implementation. SETTING: Primary-care clinics and offices, inpatient clinics, and emergency department affiliated with an academic children's hospital. PARTICIPANTS: General pediatricians, neonatologists, pediatric nurses, and computer scientists. RESULTS: Existing guidelines for hyperbilirubinemia management could not be translated directly into web pages. Modifications of the original guidelines were required to represent the clinical intent of the guidelines accurately. In addition, the automated guideline was augmented to incorporate a mechanism for generating clinical encounter forms in order for the system to be accepted into the clinical work flow. Other clinical considerations that influenced the final form of the automated guideline included limitations of computer resources and time constraints during patient encounters. CONCLUSIONS: Many existing guidelines are not amenable to straightforward implementation in automated systems. Strategies to increase the efficacy of the automated guidelines included guideline modifications, as well as careful consideration of the flow of clinical work. Repeated cycles of development and pilot testing are needed to design methods to accommodate the constraints imposed by clinical use.

Boston↗