Management of Pediatric Mild Traumatic Brain Injury Patients: S100b, Glial Fibrillary Acidic Protein, and Heart Fatty-Acid-Binding Protein Promising Biomarkers.

Children are highly vulnerable to mild traumatic brain injury (mTBI). Blood biomarkers can help in their management. This study evaluated the performances of biomarkers, in discriminating between children with mTBI who had intracranial injuries (ICIs) on computed tomography (CT+) and (1) patients without ICI (CT-) or (2) both CT- and in-hospital-observation without CT patients. The aim was to rule out the need of unnecessary CT scans and decrease the length of stay in observation in the emergency department (ED). Newborns to teenagers (≤16 years old) with mTBI (Glasgow Coma Scale > 13) were included. S100b, glial fibrillary acidic protein (GFAP), and heart fatty-acid-binding protein (HFABP) performances to identify patients without ICI were evaluated through receiver operating characteristic curves, where sensitivity was set at 100%. A total of 222 mTBI children sampled within 6 h since their trauma were reported. Nineteen percent (n = 43/222) underwent CT scan examination, whereas the others (n = 179/222) were kept in observation at the ED. Sixteen percent (n = 7/43) of the children who underwent a CT scan had ICI, corresponding to 3% of all mTBI-included patients. When sensibility (SE) was set at 100% to exclude all patients with ICI, GFAP yielded 39% specificity (SP), HFABP 37%, and S100b 34% to rule out the need of CT scans. These biomarkers were even more performant: 52% SP for GFAP, 41% for HFABP, and 39% for S100b, when discriminating CT+ versus both in-hospital-observation and CT- patients. These markers can significantly help in the management of patients in the ED, avoiding unnecessary CT scans, and reducing length of stay for children and their families

Prediction of High-Grade Vesicoureteral Reflux after Pediatric Urinary Tract Infection: External Validation Study of Procalcitonin-Based Decision Rule

BACKGROUND: Predicting vesico-ureteral reflux (VUR) 653 at the time of the first urinary tract infection (UTI) would make it possible to restrict cystography to high-risk children. We previously derived the following clinical decision rule for that purpose: cystography should be performed in cases with ureteral dilation and a serum procalcitonin level 650.17 ng/mL, or without ureteral dilatation when the serum procalcitonin level 650.63 ng/mL. The rule yielded a 86% sensitivity with a 46% specificity. We aimed to test its reproducibility. STUDY DESIGN: A secondary analysis of prospective series of children with a first UTI. The rule was applied, and predictive ability was calculated. RESULTS: The study included 413 patients (157 boys, VUR 653 in 11%) from eight centers in five countries. The rule offered a 46% specificity (95% CI, 41-52), not different from the one in the derivation study. However, the sensitivity significantly decreased to 64% (95%CI, 50-76), leading to a difference of 20% (95%CI, 17-36). In all, 16 (34%) patients among the 47 with VUR 653 were misdiagnosed by the rule. This lack of reproducibility might result primarily from a difference between derivation and validation populations regarding inflammatory parameters (CRP, PCT); the validation set samples may have been collected earlier than for the derivation one. CONCLUSIONS: The rule built to predict VUR 653 had a stable specificity (ie. 46%), but a decreased sensitivity (ie. 64%) because of the time variability of PCT measurement. Some refinement may be warranted

Distribution of Procalcitonin values according to the presence of high-grade VUR and the presence of Ureteral dilation on renal ultrasonography.

<p>The horizontal lines are the dichotomization threshold in each group.</p

Distribution of Procalcitonin values according to the presence of high-grade VUR and the presence of Ureteral dilation on renal ultrasonography.

<p>Distribution of Procalcitonin values according to the presence of high-grade VUR and the presence of Ureteral dilation on renal ultrasonography.</p

Diagnosis tree and distribution of the study population at each step of the decision rule in the validation population.

<p>Abbreviations: PCT, Procalcitonin; VUR, Vesico-ureteral reflux.</p

Comparison of the characteristics of the derivation and validation populations.

<p>Values are expressed as n (%) for binary variables (gender, All grade and high-grade VUR, Ureteral dilation), and as: mean (±Standard deviation); median (inter-quartile range) for continuous variables (age, CPR, PCT).</p><p>*Data in the column come from the previously published derivation of the decision rule <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0029556#pone.0029556-Jodal2" target="_blank">[34]</a>.</p><p>**Binary variables were compared using a χ² test, and continuous variables were compared using the non-parametric Mann-Whitney test.</p><p>Abbreviations: CRP, C-reactive protein; PCT, Procalcitonin; U dilation, Ureteral dilation; VUR, Vesico-ureteral reflux.</p

Sensitivity and specificity of the decision rule in the whole validation population and in the subgroup of children for whom urines were collected using suprapubic aspiration, urethral catheterization or clean-voided midstream sample.

<p>Values are expressed as values or % (95% CI).</p><p>Discriminative values were compared using a χ² test for unpaired sample.</p><p>*Subgroup of children for who urines were collected using suprapubic aspiration or urethral catheterization.</p><p>**Adjusted OR were calculated with the multi-level logistic regression models.</p><p>Abbreviations: NPV, Negative predictive value; OR, Odd ratio; PCT, Procalcitonin; PPV, Positive predictive value.</p