intrapartum temperature >100.4°C, or signs of clinical chorioamnionitis, in addition to documenting if IAP was provided and with which antibiotic in evaluation of neonates for possible EOGBS.
Treating Refractory Kawasaki Syndrome with Infliximab
Burns JC, Mason, WH, Hauger SB, et al. Infliximab treatment for refractory Kawasaki syndrome. J Pediatr. 2005;146: 662-7.
Citing a 10% to 20% failure rate for intravenous immunoglobulin (IVIG) in combination with high-dose aspirin (ASA) for treating Kawasaki syndrome (KS), these authors present a case series of patients with refractory KS who were treated with infliximab. Several treatments have been suggested for KS patients with persistent or recrudescent fever after IVIG and ASA; however, no clinical trials have established an optimal treatment. Tumor necrosis factor-alpha (TNF-α) has been shown not only to be elevated in patients with KS but also to correlate with development of coronary artery aneurysms. Infliximab, a TNF-α antagonist licensed for clinical use (Remicade, Centocor, Malvern, PA), is used in several immunologic diseases with inflammation mediated by this proinflammatory cytokine. In this poorly controlled case series, 17 patients with acute KS received infliximab after at least 2 doses of IVIG (2 g/kg) and daily ASA (80–100 mg/kg/day) because they were either persistently febrile (16 patients) or had severe arthritis without fever (1 patient). Fourteen of 16 febrile patients became afebrile. C-reactive protein was lower after infliximab in all patients with elevated CRP when remeasured within 48 hours of treatment. In addition to these signs of inflammation, the researchers also studied patient outcomes.
Of 12 patients with coronary artery abnormalities before treatment with infliximab, 4 had dilatation that resolved after treatment. The remaining 8 had either aneurysms or ectasia that were unchanged after therapy. No patients in the series had complications attributed to infliximab. The authors note that the cost of treatment with infliximab compares favorably with a 2 g/kg dose of IVIG. Appropriately, they also specifically address the potential adverse effects of infliximab, for which the pharmacodynamics, pharmacokinetics and safety have not been established in children <5 years of age. Data with regard to possible complications is inadequate and comes from studies of children and adults who typically receive multiple doses of infliximab for chronic inflammatory conditions that inherently can produce multiorgan symptoms. Of note, infliximab does not carry the risk of possible infectious contamination that treatment with IVIG poses. There are several important limitations to the study that are adequately addressed by the authors. Nonetheless, the series highlights the significance of current and future randomized, controlled clinical trials defining the role of TNF-α antagonism in the treatment of KS.
Do Freestanding Children’s Hospitals Improve Care?
Merenstein D, Egleston B, Diener-West M. Lengths of stay and costs associated with children’s hospitals. Pediatrics. 2005;115: 839-44.
Adult literature has shown that access to more subspecialty oriented care results in higher costs and more procedures but does not guarantee improved outcomes. Researchers from Johns Hopkins School of Medicine and Johns Hopkins School of Public Health hypothesized that freestanding children’s hospitals would have longer lengths of stay (LOS) and higher costs compared with other hospitals with regard to similar diagnoses. To test the hypothesis, they studied 24,322 inpatient encounters for pneumonia, gastroenteritis, respiratory syncytial virus, dehydration, or asthma from the Heathcare Cost and Utilization Project Kids’ Inpatient database 2000. Of these encounters, 3,408 were from 23 different freestanding children’s hospitals, and the remaining 20,194 encounters were from 1,749 non-children’s hospitals. The children’s hospitals were all urban teaching hospitals. After adjusting for potentially confounding variables, the researchers found no significant difference in the LOS by hospital type. In this study, the median cost for an admission at a freestanding hospital was $1,294 more per hospitalization after adjustment for LOS and other potential confounder variables. In addition, the results showed that children’s hospitals were more likely to care for minority patients, patients with Medicaid, patients with multiple diagnoses, and patients transferred from other hospitals. The study design did not include direct measures of quality of care, so it is unclear if the increased cost of admission to a children’s hospital leads to improved care.