Driscoll Children Research Articles

Commercial markups on pediatric oncology drugs at 340B pediatric hospitals.

Eligible pediatric hospitals can purchase clinician-administered drugs at discounted rates through the 340B Drug Pricing Program and charge payers prices exceeding drug acquisition costs, but the magnitude of these markups is not known. In a study of newly approved oncology drugs at pediatric 340B hospitals, median negotiated prices ranged from 102% (interquartile range [IQR]: 91%-156%) of average sales price (ASP) at Phoenix Children's Hospital to 630% (IQR: 526%-630%) at Driscoll Children's Hospital. Pediatric hospitals participating in the federal 340B Drug Pricing Program can extract steep payments on new drugs from commercial insurers, though with wide variation between and within hospitals.

Term Male Infant with Abdominal Mass.

Term Male Infant with Abdominal Mass.

1021. Utility of Cell-Free DNA Sequencing in Diagnosing Murine typhus in Children

BackgroundMurine typhus is a zoonotic infection caused by Rickettsia typhi and transmitted through infected fleas. Geographic distribution within the United States is limited primarily to South Texas and Southern California. Infection is typically associated with a triad of fever, headache, and rash, although is only present in one-third of cases. Immunofluorescence assay (IFA) is currently the gold standard for diagnosis, but it has its limitations as it is dependent on the time to seroconversion and has low specificity due to cross-reactivity among other rickettsial species. Cell-free DNA (cfDNA) sequencing for broad-range pathogen detection may offer higher sensitivity at the early stages of the disease.MethodsWe performed a retrospective electronic medical record search of children with cfDNA sequencing detection of Murine typhus hospitalized at Driscoll Children’s Hospital, Corpus Christi, Texas, between June 2020 and May 2021.ResultsWe found 4 children (range 9-15 year-old) positive for R. typhi by cfDNA sequencing. All patients presented with fever of unknown origin and rash. Also, 2 patients were diagnosed with pneumonia. One patient exhibited severe illness with acute kidney injury, elevation of transaminases and encephalitis that warranted admission to the pediatric intensive care unit. All patients defervesced and improved within 48 hours of doxycycline initiation; average length of stay 6 days (range 3-12 days). In one patient, M. typhus was detected by Karius® test only, in the other three was concordant with serology. ConclusionWe highlight next-generation cfDNA sequencing as a useful tool in identifying the etiologic agent of patients with fever of known origin, where murine typhus is one of the possible etiologies. Preventing extensive laboratory workup and subsequent delay of assessment and management. The rapid turnaround time of cfDNA test allows for de-escalation of therapy and initiation of appropriate treatment.Disclosures Jaime Fergie, MD, AstraZeneca (Scientific Research Study Investigator)Explify (Speaker’s Bureau)Karius (Speaker’s Bureau)Pfizer, Merck, AstraZeneca, and Sanofi (Speaker’s Bureau)Pfizer, Merck, Sanofi, and Moderna (Consultant, Advisor or Review Panel member)

Decrease in the Prevalence of Methicillin-Resistant Staphylococcus Aureus Nasal Colonization of Children Admitted to Driscoll Children's Hospital.

Compared with a similar 2005 study, this 2016 study showed a significant decrease from 22% to 3% in the prevalence of methicillin-resistant Staphylococcus aureus nasal colonization in children admitted to our facility. Of the sampled 360 children, 21% were colonized with S. aureus and 14% of those isolates were methicillin-resistant S. aureus, whereas 61% of the isolates in 2005 were methicillin-resistant S. aureus.

Murine Typhus in South Texas Children: An 18-year Review.

Murine typhus is a zoonotic infection caused by Rickettsia typhi that remains endemic in South Texas. In 2003, only 9 Texas counties reported murine typhus compared with 41 counties in 2013. A retrospective study of children discharged with a confirmed diagnosis of murine typhus from Driscoll Children's Hospital between January 1998 and September 2016. Two hundred thirteen children (113 female) 3 months through 19 years of age (mean, 11.2 ± 4.5 years) were identified. Cases occurred throughout the year. Children were admitted after a mean of 7.7 ± 5.3 days of fever. The most common symptoms were fever (100%), poor appetite (71.9%), malaise/fatigue (69.0%) and headache (67.6%). The most common laboratory abnormalities were elevated C-reactive protein, hypoalbuminemia, elevated erythrocyte sedimentation rate, elevated transaminases and elevated band count with normal total white blood cell count. Children defervesced in a mean of 31.87 ± 21.36 hours after initiation of doxycycline. Hospitalization lasted for a mean of 2.7 ± 1.8 days when children were administered doxycycline within 24 hours of admission compared with, 4.1 ± 1.8 days, P ≤ 0.0001 when started later. Eleven patients (5.1%) were admitted to the pediatric intensive care unit and were older, P = 0.0009. No children died. Murine typhus is endemic in South Texas. Children who were treated earlier with doxycycline had a shorter hospitalization than were those who began therapy later. Recognition of murine typhus is important to prevent delay in treatment and development of complications.

Silver-impregnated hydrofiber dressing followed by delayed surgical closure for management of infants born with giant omphaloceles

ObjectiveWe successfully employed silver-impregnated hydrofiber dressing for management of giant omphaloceles (GO) followed by delayed surgical closure. Study designBetween 2005 and 2008, eight consecutive GO infants were cared for at Driscoll Children’s Hospital. Four patients had additional congenital anomalies including Beckwith–Wiedemann (n=1), tetralogy of Fallot (n=1), pulmonary hypoplasia (n=1), and ruptured omphalocele (n=1). Infants underwent amnion epithelization using a silver-impregnated hydrofiber dressing over the course of several months followed by delayed surgical closure. Mean±SD of parameters including maternal age, gestational age, infant weight, size of GO, preoperative intubation, preoperative hospitalization, time to epithelization, days to surgical closure, postoperative hospitalization, postoperative intubation and months of follow-up were studied. ResultsFive patients underwent successful closure, 2 were lost to follow-up and 1 was lost because of withdrawal of support. The maternal age, gestation age and weight of infant were 28±5.3years, 34±4weeks and 2.5±0.62kg, respectively. The GO size was 11cm in length and 11cm in width, respectively. Preoperative hospitalization days were 78±74days. Preoperative intubation was 3.5±3.1days with 2 neonates requiring tracheostomy and home ventilation owing to additional congenital abnormalities. Time to epithelization was 2.9±0.9months. Days to surgical closure and postoperative hospitalization were 331±119days and 5±3.4days, respectively. Average follow-up was 37±27months. No treatment associated morbidities are noted. ConclusionsSilver-impregnated hydrofiber mediated epithelization of GO followed by delayed surgical closure is safe for management of infants.

Neonatal Case Studies Using Active Leptospermum Honey

Treatment of the neonatal patient with clinically complex wounds creates a challenge due to the safety and efficacy issues associated with the use of many advanced wound care products. The purpose of this case series was to present outcomes of 3 neonates with wounds of differing etiologies managed by Active Leptospermum Honey (ALH). Clinical case series. Clinical experiences with 3 neonates, 1 male and 2 females, are described. These premature infants received care at Rush University Medical Center, Houston, Texas, or Driscoll Children's Hospital, Corpus Christi, Texas. Each neonate presented with dissimilar wounds and differing treatment goals. For a premature infant with left foot ischemia, ALH dressings allowed for removal of nonviable tissue and facilitated the granulation of the open wounds. This removal of nonviable tissue coupled with the facilitation of granulation tissue enabled the premature infant's toe tips to be salvaged without requiring aggressive surgical intervention. For the 2 preterm infants with extravasation of intravenous solutions, ALH dressings allowed healing and increased tissue granulation without any noted toxicity to the wound bed. Further, the method of action of ALH includes an osmotic pull effect that reduced periwound erythema and edema. Although the use of ALH has been well documented in adult care, these case studies demonstrate its potential use in different wound etiologies in 3 neonatal patients.

Skin care product evaluation in a group of critically ill, premature neonates: a descriptive study.

Cleansing, moisturizing, and protecting neonatal skin is important, but literature evaluating specific product lines is limited. The purpose of this study was to measure the influence of a skin care product line on overall skin condition, perineal erythema, and pain when applied to neonates in a neonatal intensive care unit (NICU). This was an open label, descriptive study. Comparisons were made between measurements taken at the beginning of the study to those at the end, on the same subjects. The study was conducted in a 41-bed NICU at Driscoll Children's Hospital in Corpus Christi, Texas, that serves 31 counties in the region. This NICU treats children needing level 2 and 3 care, with a 1:1 or 2:1 nurse staffing ratio. This is not a birthing center; patients come from other community hospitals. Twenty-nine neonates participated in the study; their average body weight was 1.39 kg (3.06 lb) and their average gestation was 31.7 weeks. A skin care product line was introduced into a neonatal intensive care unit for 14 days. The products included 2 cleansers, 2 moisturizers, and a skin protectant with zinc oxide. Three outcome measures were tracked: Neonatal Skin Condition Score (NSCS), Skin Erythema Scale (SES), and pain. Nurses were also given a product evaluation survey. Descriptive statistics were used to report percentages and trends. Paired t tests were used to compare the mean NSCS, SES, and pain scores from the first 2 days a subject was in the study to the mean of the scores from the last 2 days they were in the study. Subjects experienced approximately 1774 exposures to individual products during data collection. No differences were found in pain scores (P = .132), SES score (P = .059), or NSCS (P = .603) when mean values were compared at the beginning and end of the study. Analysis of the product evaluation survey for questions on cleaning, moisturizing, and reducing discomfort found that more than 90% of nurses ranked the new products as better than or equal to similar products used previously. Use of a skin care product line was not associated with significant increases in overall neonatal skin condition measured with the NSCS, perineal erythema measured with the SES, or pain. The nurses caring for the subjects in this study prefer these products to others they have used in the past.

Strict Glycemic Targets Need Not Be So Strict: A More Permissive Glycemic Range for Critically Ill Children

The goal was to determine whether a more permissive glycemic target would be associated with a decreased incidence of hypoglycemia but not increased mortality rates in critically ill pediatric patients. This retrospective study evaluated clinical and laboratory data for 177 patients who underwent 211 consecutive surgical procedures for repair or palliation of congenital heart defects at Driscoll Children's Hospital. To establish the relationship between postoperative glycemia and subsequent morbidity and mortality rates, patients were stratified into 4 groups according to their median glucose levels, that is, euglycemia (60-125 mg/dL, 3.3-6.9 mmol/L), mild hyperglycemia (126-139 mg/dL, 6.9-7.7 mmol/L), moderate hyperglycemia (140-179 mg/dL, 7.7-9.9 mmol/L), or severe hyperglycemia (>or=180 mg/dL, >or=9.9 mmol/L). Postoperative outcomes for those groups also were compared with outcomes for a more permissive glycemic target group (90-140 mg/dL, 5-7.7 mmol/L). The peak and mean blood glucose measurements and duration of hyperglycemia were not different for survivors and nonsurvivors in the first 24 hours after surgery. Nonsurvivors had higher peak glucose levels (389.3 +/- 162 mg/dL vs 274.4 +/- 106.3 mg/dL, 21.4 +/- 8.9 mmol/L vs 15.1 +/- 5.9 mmol/L) and longer duration of hyperglycemia (3.06 +/- 1.67 days vs 2.11 +/- 0.92 days) during the first 5 postoperative days, compared with survivors. Mortality rates were significantly higher for the moderate (38.8%) and severe (58.3%) hyperglycemia groups, compared with the euglycemia (6.02%) and permissive target (4.69%) groups. The incidence of hypoglycemia was significantly higher in the euglycemia group (31.8%), compared with the permissive target group (17.18%). Postoperative hyperglycemia is associated with increased morbidity and mortality rates in children after surgical repair of congenital heart defects. A more permissive glycemic target is associated with a lower incidence of hypoglycemia but not increased mortality rates in these patients.

ECONOMIC IMPACT OF THE COMMUNITY-ACQUIRED METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS EPIDEMIC ON THE DRISCOLL CHILDREN'S HEALTH PLAN

Cellulitis and abscess accounted for increasing percentages of inpatient (4.6-11.1%), outpatient (0.6-1.2%) and total (1.7-3.3%) expenses from 2001 through 2004. The per member per month expenses attributed to cellulitis and abscess increased from $0.74 in 2001 to $1.19 in 2004. The epidemic of community-acquired methicillin-resistant Staphylococcus aureus infections in children has had a significant economic impact on the Driscoll Children's Health Plan.

Epidemic of Community-Acquired Methicillin-Resistant Staphylococcus aureus Infections

Previously we reported the rapid emergence and exponential increase of community-acquired (CA) methicillin-resistant Staphylococcus aureus (MRSA) infections in South Texas children. To assess whether changes have occurred in the frequency, types, susceptibility, and treatment of CAMRSA infections at Driscoll Children's Hospital. Data from 1990 through 2001 were collected during 2 previous studies. Data from 2002 through 2003 were collected and compared with data from 1990 through 2001. All S aureus isolates were identified by a computer-assisted search of culture results, and the medical records were reviewed for all patients with MRSA infections. A total of 1002 MRSA cases were identified from 1990 through 2003 of which 928 (93%) were community-acquired. The number of CAMRSA cases ranged from 0 to 9 per year from 1990 through 1999 and then increased exponentially from 36 in 2000 to 459 in 2003. The most common type of CAMRSA infection in children without (94%) and with (72%) risk factors was cellulitis and abscess. A higher percentage of children with risk factors had invasive CAMRSA infections (26% vs 3%; P<.001). From 2002 through 2003, there was a significant difference in clindamycin susceptibility between CAMRSA isolates from children without and with risk factors and nosocomial isolates (97% and 86% vs 62%; P<.005). A higher percentage of patients admitted for treatment of CAMRSA infections received an empirical intravenous antibiotic to which the organism was susceptible when comparing 2002-2003 with 1990-2000 (96% vs 15%; P<.001). During this 14-year study, all patients recovered, including those with life-threatening CAMRSA infections. The rapid emergence of CAMRSA as a cause of noninvasive and invasive infections in children, which started occurring in the 1990s, has reached epidemic proportions.

Murine typhus in South Texas children.

Murine typhus is a zoonotic infection caused by Rickettsia typhi. This illness used to be endemic in the southeastern and gulf coast of the United States and is now only rarely reported in South Texas and Southern California. Murine typhus causes a febrile illness with headache and rash that has been well-described in adults. To define the epidemiologic and clinical characteristics, laboratory findings, hospital course and response to therapy of children discharged from our hospital with a diagnosis of murine typhus. Retrospective chart review of all children discharged from Driscoll Children's Hospital, Corpus Christi, TX, from January 1, 1990, to June 30, 1998, with a diagnosis of murine typhus. Patients. Thirty children (17 females) ages 2 to 17 years (mean, 10 +/- 4 years). Eighty percent of the children were admitted between May and November, and 67% had a history of contact with or exposure to a potential animal reservoir. Children were admitted after a mean of 7 +/- 4 days. The most common clinical features were fever 100%, rash 80% and headache 77%. Laboratory abnormalities included elevated erythrocyte sedimentation rate (75%), elevated serum transaminases (67%), hyponatremia (66%) and increased immature leukocytes without leukocytosis (63%). Only one child had leukocytosis and 40% had leukopenia. Defervescence occurred a mean of 35 +/- 19 h after initiation of appropriate antibiotics. Hospitalization lasted for a mean of 7 +/- 3 days. There were no readmissions and no patients died as a result of the infection. Despite being rarely reported in this country now, murine typhus continues to be an important cause of fever and hospitalization for children in South Texas. Children with murine typhus develop an illness similar to that reported in adults with fever, rash and headache. Children respond quickly to therapy with doxycycline or tetracycline and recover completely from their illness.