Browsing by Author "Lim, Emma"
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Item Availability and use of rapid diagnostic tests for the management of acute childhood infections in Europe : A cross-sectional survey of paediatricians(2022-12) Dewez, Juan Emmanuel; Pembrey, Lucy; Nijman, Ruud G.; del Torso, Stefano; Grossman, Zachi; Hadjipanayis, Adamos; Van Esso, Diego; Lim, Emma; Emonts, Marieke; Burns, James; Gras-LeGuen, Christèle; Kohlfuerst, Daniela; Dornbusch, Hans Jürgen; Brengel-Pesce, Karen; Mallet, Francois; von Both, Ulrich; Tsolia, Maria; Eleftheriou, Irini; Zavadska, Dace; de Groot, Ronald; van der Flier, Michiel; Moll, Henriëtte; Hagedoorn, Nienke; Borensztajn, Dorine; Oostenbrink, Rianne; Kuijpers, Taco; Pokorn, Marko; Vincek, Katarina; Martinó n-Torres, Federico; Rivero, Irene; Agyeman, Philipp; Carrol, Enitan D.; Paulus, Stéphane; Cunnington, Aubrey; Herberg, Jethro; Levin, Michael; Mujkić, Aida; Geitmann, Karin; Da Dalt, Liviana; Valiulis, Arunas; Lapatto, Risto; Syridou, Garyfallia; Altorjai, Péter; Torpiano, Paul; Størdal, Ketil; Illy, Károly; Mazur, Artur; Spreitzer, Mateja Vintar; Rios, Joana; Wyder, Corinne; Romankevych, Ivanna; Basmaci, Romain; Ibanez-Mico, Salvador; Yeung, ShunmayBackground Point-of-care-tests (POCTs) have been advocated to optimise care in patients with infections but their actual use varies. This study aimed to estimate the variability in the adoption of current POCTs by paediatricians across Europe, and to explore the determinants of variability. Methods and findings A cross-sectional survey was conducted of hospital and primary care paediatricians, recruited through professional networks. Questions focused on the availability and use of currently available POCTs. Data were analysed descriptively and using Median Odds Ratio (MOR) to measure variation between countries. Multilevel regression modelling using changes in the area under the receiver operating characteristic curve of models were used to assess the contribution of individual or workplace versus country level factors, to the observed variation. The commonest POCT was urine dipsticks (UD) which were available to >80% of primary care and hospital paediatricians in 68% (13/19) and 79% (23/29) countries, respectively. Availability of all POCTs varied between countries. In primary care, the country (MOR) varied from 1.61 (95%CI: 1.04-2.58) for lactate to 7.28 (95%CI: 3.04-24.35) for UD. In hospitals, the country MOR varied from 1.37 (95%CI:1.04-1.80) for lactate to 11.93 (95% CI:3.35-72.23) for UD. Most paediatricians in primary care (69%, 795/1154) and hospital (81%, 962/1188) would use a diagnostic test in the case scenario of an infant with undifferentiated fever. Multilevel regression modelling showed that the country of work was more important in predicting both the availability and use of POCTs than individual or workplace characteristics. Conclusion There is substantial variability in the adoption of POCTs for the management of acute infections in children across Europe. To inform future implementation of both existing and innovative tests, further research is needed to understand what drives the variation between countries, the needs of frontline clinicians, and the role of diagnostic tests in the management of acute childhood infections.Item Biobanking and consenting to research : a qualitative thematic analysis of young people’s perspectives in the North East of England(2023-12) van der Velden, Fabian J.S.; Lim, Emma; Gills, Lily; DIAMONDS Consortium; Zavadska, Dace; Laivacuma, Sniedze; Rudzate, Aleksandra; Barzdina, Arta; Madelane, Monta; Stoldere, Diāna; Barzdina, Elza; Grāvele, Dagne; Rīga Stradiņš UniversityBackground: Biobanking biospecimens and consent are common practice in paediatric research. We need to explore children and young people’s (CYP) knowledge and perspectives around the use of and consent to biobanking. This will ensure meaningful informed consent can be obtained and improve current consent procedures. Methods: We designed a survey, in co-production with CYP, collecting demographic data, views on biobanking, and consent using three scenarios: 1) prospective consent, 2) deferred consent, and 3) reconsent and assent at age of capacity. The survey was disseminated via the Young Person’s Advisory Group North England (YPAGne) and participating CYP’s secondary schools. Data were analysed using a qualitative thematic approach by three independent reviewers (including CYP) to identify common themes. Data triangulation occurred independently by a fourth reviewer. Results: One hundred two CYP completed the survey. Most were between 16–18 years (63.7%, N = 65) and female (66.7%, N = 68). 72.3% had no prior knowledge of biobanking (N = 73). Acceptability of prospective consent for biobanking was high (91.2%, N = 93) with common themes: ‘altruism’, ‘potential benefits outweigh individual risk’, 'frugality', and ‘(in)convenience’. Deferred consent was also deemed acceptable in the large majority (84.3%, N = 86), with common themes: ‘altruism’, ‘body integrity’ and ‘sample frugality’. 76.5% preferred to reconsent when cognitively mature enough to give assent (N = 78), even if parental consent was previously in place. 79.2% wanted to be informed if their biobanked biospecimen is reused (N = 80). Conclusion: Prospective and deferred consent acceptability for biobanking is high among CYP in the UK. Altruism, frugality, body integrity, and privacy are the most important themes. Clear communication and justification are paramount to obtain consent. Any CYP with capacity should be part of the consenting procedure, if possible.Item Characteristics and management of adolescents attending the ED with fever : A prospective multicentre study(2022-01-19) Borensztajn, Dorine; Hagedoorn, Nienke N.; Carrol, Enitan; Von Both, Ulrich; Dewez, Juan Emmanuel; Emonts, Marieke; Van Der Flier, Michiel; De Groot, Ronald; Herberg, Jethro; Kohlmaier, Benno; Levin, Michael; Lim, Emma; Maconochie, Ian; Martinon Torres, Federico; Nijman, Ruud; Pokorn, Marko; Rivero-Calle, Irene; Tsolia, Maria; Vermont, Clementien; Zavadska, Dace; Zenz, Werner; Zachariasse, Joany; Moll, Henriette A.; Department of PaediatricsObjective Most studies on febrile children have focused on infants and young children with serious bacterial infection (SBI). Although population studies have described an increased risk of sepsis in adolescents, little is known about febrile adolescents attending the emergency department (ED). We aimed to describe patient characteristics and management of febrile adolescents attending the ED. Design and setting The MOFICHE/PERFORM study (Management and Outcome of Febrile Children in Europe/Personalised Risk assessment in Febrile illness to Optimise Real-life Management across the European Union), a prospective multicentre study, took place at 12 European EDs. Descriptive and multivariable regression analyses were performed, comparing febrile adolescents (12-18 years) with younger children in terms of patient characteristics, markers of disease severity (vital signs, clinical alarming signs), management (diagnostic tests, therapy, admission) and diagnosis (focus, viral/bacterial infection). Results 37 420 encounters were included, of which 2577 (6.9%) were adolescents. Adolescents were more often triaged as highly urgent (38.9% vs 34.5%) and described as ill appearing (23.1% vs 15.6%) than younger children. Increased work of breathing and a non-blanching rash were present less often in adolescents, while neurological signs were present more often (1% vs 0%). C reactive protein tests were performed more frequently in adolescents and were more often abnormal (adjusted OR (aOR) 1.7, 95% CI 1.5 to 1.9). Adolescents were more often diagnosed with SBI (OR 1.8, 95% CI 1.6 to 2.0) and sepsis/meningitis (OR 2.3, 95% CI 1.1 to 5.0) and were more frequently admitted (aOR 1.3, 95% CI 1.2 to 1.4) and treated with intravenous antibiotics (aOR 1.7, 95% CI 1.5 to 2.0). Conclusions Although younger children presented to the ED more frequently, adolescents were more often diagnosed with SBI and sepsis/meningitis. Our data emphasise the importance of awareness of severe infections in adolescents.Item Development and validation of a prediction model for invasive bacterial infections in febrile children at European Emergency Departments : MOFICHE, a prospective observational study(2021-07-01) Hagedoorn, Nienke N.; Borensztajn, Dorine; Nijman, Ruud Gerard; Nieboer, Daan; Herberg, Jethro Adam; Balode, Anda; Von Both, Ulrich; Carrol, Enitan; Eleftheriou, Irini; Emonts, Marieke; Van Der Flier, Michiel; De Groot, Ronald; Kohlmaier, Benno; Lim, Emma; MacOnochie, Ian; Martinón-Torres, Federico; Pokorn, Marko; Strle, Franc; Tsolia, Maria; Zavadska, Dace; Zenz, Werner; Levin, Michael; Vermont, Clementien; Moll, Henriette A.; Rīga Stradiņš UniversityObjectives: To develop and cross-validate a multivariable clinical prediction model to identify invasive bacterial infections (IBI) and to identify patient groups who might benefit from new biomarkers. Design: Prospective observational study. Setting: 12 emergency departments (EDs) in 8 European countries. Patients: Febrile children aged 0-18 years. Main outcome measures: IBI, defined as bacteraemia, meningitis and bone/joint infection. We derived and cross-validated a model for IBI using variables from the Feverkidstool (clinical symptoms, C reactive protein), neurological signs, non-blanching rash and comorbidity. We assessed discrimination (area under the receiver operating curve) and diagnostic performance at different risk thresholds for IBI: sensitivity, specificity, negative and positive likelihood ratios (LRs). Results: Of 16 268 patients, 135 (0.8%) had an IBI. The discriminative ability of the model was 0.84 (95% CI 0.81 to 0.88) and 0.78 (95% CI 0.74 to 0.82) in pooled cross-validations. The model performed well for the rule-out threshold of 0.1% (sensitivity 0.97 (95% CI 0.93 to 0.99), negative LR 0.1 (95% CI 0.0 to 0.2) and for the rule-in threshold of 2.0% (specificity 0.94 (95% CI 0.94 to 0.95), positive LR 8.4 (95% CI 6.9 to 10.0)). The intermediate thresholds of 0.1%-2.0% performed poorly (ranges: sensitivity 0.59-0.93, negative LR 0.14-0.57, specificity 0.52-0.88, positive LR 1.9-4.8) and comprised 9784 patients (60%). Conclusions: The rule-out threshold of this model has potential to reduce antibiotic treatment while the rule-in threshold could be used to target treatment in febrile children at the ED. In more than half of patients at intermediate risk, sensitive biomarkers could improve identification of IBI and potentially reduce unnecessary antibiotic prescriptions.Item Diversity in the emergency care for febrile children in Europe : A questionnaire study(2019-06-01) Borensztajn, Dorine; Yeung, Shunmay; Hagedoorn, Nienke N.; Balode, Anda; Von Both, Ulrich; Carrol, Enitan D.; Dewez, Juan Emmanuel; Eleftheriou, Irini; Emonts, Marieke; Van Der Flier, Michiel; De Groot, Ronald; Herberg, Jethro Adam; Kohlmaier, Benno; Lim, Emma; MacOnochie, Ian; Martinón-Torres, Federico; Nijman, Ruud; Pokorn, Marko; Strle, Franc; Tsolia, Maria; Wendelin, Gerald; Zavadska, Dace; Zenz, Werner; Levin, Michael; Moll, Henriette A.; Department of PaediatricsObjective To provide an overview of care in emergency departments (EDs) across Europe in order to interpret observational data and implement interventions regarding the management of febrile children. Design and setting An electronic questionnaire was sent to the principal investigators of an ongoing study (PERFORM (Personalised Risk assessment in Febrile illness to Optimise Real-life Management), www.perform2020.eu) in 11 European hospitals in eight countries: Austria, Germany, Greece, Latvia, the Netherlands, Slovenia, Spain and the UK. Outcome measures The questionnaire covered indicators in three domains: local ED quality (supervision, guideline availability, paper vs electronic health records), organisation of healthcare (primary care, immunisation), and local factors influencing or reflecting resource use (availability of point-of-care tests, admission rates). Results Reported admission rates ranged from 4% to 51%. In six settings (Athens, Graz, Ljubljana, Riga, Rotterdam, Santiago de Compostela), the supervising ED physicians were general paediatricians, in two (Liverpool, London) these were paediatric emergency physicians, in two (Nijmegen, Newcastle) supervision could take place by either a general paediatrician or a general emergency physician, and in one (München) this could be either a general paediatrician or a paediatric emergency physician. The supervising physician was present on site in all settings during office hours and in five out of eleven settings during out-of-office hours. Guidelines for fever and sepsis were available in all settings; however, the type of guideline that was used differed. Primary care was available in all settings during office hours and in eight during out-of-office hours. There were differences in routine immunisations as well as in additional immunisations that were offered; immunisation rates varied between and within countries. Conclusion Differences in local, regional and national aspects of care exist in the management of febrile children across Europe. This variability has to be considered when trying to interpret differences in the use of diagnostic tools, antibiotics and admission rates. Any future implementation of interventions or diagnostic tests will need to be aware of this European diversity.Item Febrile children with comorbidities at the emergency department — a multicentre observational study(2022-09) Borensztajn, Dorine M.; Hagedoorn, Nienke N.; Carrol, Enitan D.; von Both, Ulrich; Emonts, Marieke; van der Flier, Michiel; de Groot, Ronald; Herberg, Jethro; Kohlmaier, Benno; Levin, Michael; Lim, Emma; Maconochie, Ian K.; Martinon-Torres, Federico; Nijman, Ruud G.; Pokorn, Marko; Rivero-Calle, Irene; Tsolia, Maria; van der Velden, Fabian J.S.; Vermont, Clementien; Zavadska, Dace; Zenz, Werner; Zachariasse, Joany M.; Moll, Henriette A.; Department of PaediatricsWe aimed to describe characteristics and management of children with comorbidities attending European emergency departments (EDs) with fever. MOFICHE (Management and Outcome of Fever in children in Europe) is a prospective multicentre study (12 European EDs, 8 countries). Febrile children with comorbidities were compared to those without in terms of patient characteristics, markers of disease severity, management, and diagnosis. Comorbidity was defined as a chronic underlying condition that is expected to last > 1 year. We performed multivariable logistic regression analysis, displaying adjusted odds ratios (aOR), adjusting for patient characteristics. We included 38,110 patients, of whom 5906 (16%) had comorbidities. Most common comorbidities were pulmonary, neurologic, or prematurity. Patients with comorbidities more often were ill appearing (20 versus 16%, p < 0.001), had an ED-Paediatric Early Warning Score of > 15 (22 versus 12%, p < 0.001), or a C-reactive protein > 60 mg/l (aOR 1.4 (95%CI 1.3–1.6)). They more often required life-saving interventions (aOR 2.7, 95% CI 2.2–3.3), were treated with intravenous antibiotics (aOR 2.3, 95%CI 2.1–2.5), and were admitted to the ward (aOR 2.2, 95%CI 2.1–2.4) or paediatric intensive care unit (PICU) (aOR 5.5, 95% CI 3.8–7.9). They were more often diagnosed with serious bacterial infections (aOR 1.8, 95%CI 1.7–2.0), including sepsis/meningitis (aOR 4.6, 95%CI 3.2–6.7). Children most at risk for sepsis/meningitis were children with malignancy/immunodeficiency (aOR 14.5, 8.5–24.8), while children with psychomotor delay/neurological disease were most at risk for life-saving interventions (aOR 5.3, 4.1–6.9) or PICU admission (aOR 9.7, 6.1–15.5). Conclusions: Our data show how children with comorbidities are a population at risk, as they more often are diagnosed with bacterial infections and more often require PICU admission and life-saving interventions.What is Known:• While children with comorbidity constitute a large part of ED frequent flyers, they are often excluded from studies.What is New:• Children with comorbidities in general are more ill upon presentation than children without comorbidities.• Children with comorbidities form a heterogeneous group; specific subgroups have an increased risk for invasive bacterial infections, while others have an increased risk of invasive interventions such as PICU admission, regardless of the cause of the fever.Item Sex differences in febrile children with respiratory symptoms attending European emergency departments : An observational multicenter study(2022-08-03) Tan, Chantal D.; el Ouasghiri, Soufiane; von Both, Ulrich; Carrol, Enitan D.; Emonts, Marieke; van der Flier, Michiel; de Groot, Ronald; Herberg, Jethro; Kohlmaier, Benno; Levin, Michael; Lim, Emma; Maconochie, Ian K.; Martinon-Torres, Federico; Nijman, Ruud G.; Pokorn, Marko; Rivero-Calle, Irene; Tsolia, Maria; Vermont, Clementien L.; Zenz, Werner; Zavadska, Dace; Moll, Henriette A.; Zachariasse, Joany M.; Department of PaediatricsObjective To assess sex differences in presentation and management of febrile children with respiratory symptoms attending European Emergency Departments. Design and setting An observational study in twelve Emergency Departments in eight European countries. Patients Previously healthy children aged 0-<18 years with fever (≥ 38°C) at the Emergency Department or in the consecutive three days before Emergency Department visit and respiratory symptoms were included. Main outcome measures The main outcomes were patient characteristics and management defined as diagnostic tests, treatment and admission. Descriptive statistics were used for patient characteristics and management stratified by sex. Multivariable logistic regression analyses were performed for the association between sex and management with adjustment for age, disease severity and Emergency Department. Additionally, subgroup analyses were performed in children with upper and lower respiratory tract infections and in children below five years. Results We included 19,781 febrile children with respiratory symptoms. The majority were boys (54%), aged 1-5 years (58%) and triaged as low urgent (67%). Girls presented less frequently with tachypnea (15% vs 16%, p = 0.002) and increased work of breathing (8% vs 12%, p<0.001) compared with boys. Girls received less inhalation medication than boys (aOR 0.82, 95% CI 0.74-0.90), but received antibiotic treatment more frequently than boys (aOR 1.09, 95% CI 1.02-1.15), which is associated with a higher prevalence of urinary tract infections. Amongst children with a lower respiratory tract infection and children below five years girls received less inhalation medication than boys (aOR 0.77, 95% CI 0.66-0.89; aOR 0.80, 95% CI 0.72-0.90). Conclusions Sex differences concerning presentation and management are present in previously healthy febrile children with respiratory symptoms presenting to the Emergency Department. Future research should focus on whether these differences are related to clinicians' attitudes, differences in clinical symptoms at the time of presentation and disease severity.Item Shock Index in the early assessment of febrile children at the emergency department : a prospective multicentre study(2022-02) Hagedoorn, Nienke N.; Zachariasse, Joany M.; Borensztajn, Dorine; Adriaansens, Elise; Von Both, Ulrich; Carrol, Enitan D.; Eleftheriou, Irini; Emonts, Marieke; Van Der Flier, Michiel; De Groot, Ronald; Herberg, Jethro Adam; Kohlmaier, Benno; Lim, Emma; Maconochie, Ian; Martinón-Torres, Federico; Nijman, Ruud Gerard; Pokorn, Marko; Rivero-Calle, Irene; Tsolia, Maria; Zavadska, Dace; Zenz, Werner; Levin, Michael; Vermont, Clementien; Moll, Henriette A.; Department of PaediatricsObjective: (1) To derive reference values for the Shock Index (heart rate/systolic blood pressure) based on a large emergency department (ED) population of febrile children and (2) to determine the diagnostic value of the Shock Index for serious illness in febrile children. Design/setting: Observational study in 11 European EDs (2017-2018). Patients: Febrile children with measured blood pressure. Main outcome measures: Serious bacterial infection (SBI), invasive bacterial infection (IBI), immediate life-saving interventions (ILSIs) and intensive care unit (ICU) admission. The association between high Shock Index (>95th centile) and each outcome was determined by logistic regression adjusted for age, sex, referral, comorbidity and temperature. Additionally, we calculated sensitivity, specificity and negative/positive likelihood ratios (LRs). Results: Of 5622 children, 461 (8.2%) had SBI, 46 (0.8%) had IBI, 203 (3.6%) were treated with ILSI and 69 (1.2%) were ICU admitted. High Shock Index was associated with SBI (adjusted OR (aOR) 1.6 (95% CI 1.3 to 1.9)), ILSI (aOR 2.5 (95% CI 2.0 to 2.9)), ICU admission (aOR 2.2 (95% CI 1.4 to 2.9)) but not with IBI (aOR: 1.5 (95% CI 0.6 to 2.4)). For the different outcomes, sensitivity for high Shock Index ranged from 0.10 to 0.15, specificity ranged from 0.95 to 0.95, negative LRs ranged from 0.90 to 0.95 and positive LRs ranged from 1.8 to 2.8. Conclusions: High Shock Index is associated with serious illness in febrile children. However, its rule-out value is insufficient which suggests that the Shock Index is not valuable as a screening tool for all febrile children at the ED.Item Variation in hospital admission in febrile children evaluated at the Emergency Department (ED) in Europe : PERFORM, a multicentre prospective observational study(2021-01-07) Borensztajn, Dorine M.; Hagedoorn, Nienke N.; Calle, Irene Rivero; Maconochie, Ian K.; von Both, Ulrich; Carrol, Enitan D.; Dewez, Juan Emmanuel; Emonts, Marieke; van der Flier, Michiel; de Groot, Ronald; Herberg, Jethro; Kohlmaier, Benno; Lim, Emma; Martinon-Torres, Federico; Nieboer, Daan; Nijman, Ruud G.; Pokorn, Marko; Strle, Franc; Tsolia, Maria; Vermont, Clementien; Yeung, Shunmay; Zavadska, Dace; Zenz, Werner; Levin, Michael; Moll, Henriette A.; Department of PaediatricsOBJECTIVES: Hospitalisation is frequently used as a marker of disease severity in observational Emergency Department (ED) studies. The comparison of ED admission rates is complex in potentially being influenced by the characteristics of the region, ED, physician and patient. We aimed to study variation in ED admission rates of febrile children, to assess whether variation could be explained by disease severity and to identify patient groups with large variation, in order to use this to reduce unnecessary health care utilization that is often due to practice variation. DESIGN: MOFICHE (Management and Outcome of Fever in children in Europe, part of the PERFORM study, www.perform2020.org), is a prospective cohort study using routinely collected data on febrile children regarding patient characteristics (age, referral, vital signs and clinical alarming signs), diagnostic tests, therapy, diagnosis and hospital admission. SETTING AND PARTICIPANTS: Data were collected on febrile children aged 0-18 years presenting to 12 European EDs (2017-2018). MAIN OUTCOME MEASURES: We compared admission rates between EDs by using standardised admission rates after adjusting for patient characteristics and initiated tests at the ED, where standardised rates >1 demonstrate higher admission rates than expected and rates <1 indicate lower rates than expected based on the ED patient population. RESULTS: We included 38,120 children. Of those, 9.695 (25.4%) were admitted to a general ward (range EDs 5.1-54.5%). Adjusted standardised admission rates ranged between 0.6 and 1.5. The largest variation was seen in short admission rates (0.1-5.0), PICU admission rates (0.2-2.2), upper respiratory tract infections (0.4-1.7) and fever without focus (0.5-2.7). Variation was small in sepsis/meningitis (0.9-1.1). CONCLUSIONS: Large variation exists in admission rates of febrile children evaluated at European EDs, however, this variation is largely reduced after correcting for patient characteristics and therefore overall admission rates seem to adequately reflect disease severity or a potential for a severe disease course. However, for certain patient groups variation remains high even after adjusting for patient characteristics.