Acute Paediatric Illness Research Articles

Potentially Avoidable Emergency Department Transfers for Acute Pediatric Respiratory Illness

BackgroundAcute pediatric respiratory illness is one of the most common reasons for emergency department (ED) transfer; however, few studies have examined predictors of potentially avoidable ED transfer (PAT) in this subpopulation. This study aimed to characterize patterns and predictors of PATs in children with acute respiratory illness. MethodsCross-sectional analysis of 8,402,577 visits for patients ≤17 years from 2018 to 2019 Health Care Utilization Project State ED and Inpatient Datasets from New York, Maryland, Wisconsin, and Florida. ED transfers matched to a visit at a receiving facility with a primary diagnosis of pneumonia, croup/other URI, bronchiolitis, or asthma were included. PAT was defined as discharge from receiving ED or within 24 hours of inpatient admission without specialized procedures, as previously described. PATs were compared with necessary transfers using a 3-level generalized linear mixed model with adjustment for patient and hospital covariates. ResultsAmong 4409 matched respiratory transfers, 25.5% were potentially avoidable. Most PATs originated from EDs within the third highest quartile of annual pediatric ED visits (n = 472, 42.0%). In the multivariable model, the likelihood of PAT was higher for patients with croup/other URI (OR 2.72 (2.09–3.5) and if referring ED was in the highest quartile of annual pediatric ED volumes (OR 0.48 95% CI 0.26–0.88). ConclusionsPediatric respiratory transfers with a diagnosis of croup/other URI were the most likely to be potentially avoidable. Future implementation efforts to reduce PATs should consider focusing on croup management in EDs in the lower 3 quartiles of pediatric volume.

The Greatest Challenges of Pediatric Critical Care Pulmonology in the After-COVID Era: A Narrative Review

Abstract The COVID pandemic has had a profound effect on pediatric intensive care and especially on pediatric critical care pulmonology. The indirect impacts caused by the most profound global healthcare challenge in a generation continue to define the current post-COVID era. This era is characterized by postpandemic surges in acute pediatric respiratory illness, disruption of seasonal disease patterns, and an apparent increase in disease severity with a rise in complicated pneumonia as well as associated severe sepsis and septic shock. The consequent demand is met by pediatric intensive care units that are recovering from the strain of the pandemic but also building on progress made during a time of great challenges.

The Diagnostic Value of Human Neutrophilic Peptides 1-3 in Acute Pediatric Febrile Illness.

Background: It is prudent to develop biomarkers that enhance the differentiation between viral and bacterial infection in order to support expeditious and judicious antimicrobial implementation in emergency department admissions. Human neutrophilic peptides 1-3 (HNP1-3) are the major neutrophilic peptides with potent antimicrobial activity. Methods: We tested the performance of the plasma HNP1-3 test in a prospective observational cohort of children admitted to the emergency department for fever. We validated this test with traditionally used biomarkers and final diagnoses. An expert panel reviewed the patient's data and gave a final diagnosis. The final diagnosis was classified as definite, probable, or possible. Results: A total of 111 children (98 with fever and 13 control) were recruited: 55% male, mean age 6.3 years. Plasma HNP1-3 levels were higher with bacterial infections: 10,428 (5789-14,866) vs. 7352 (3762-10,672) pg/mL, p = 0.007. HNP1-3 were negatively correlated with age: r = -0.207, p = 0.029. Of the different categorical variables tested, only c-reactive protein (CRP) (≥42.3 mg/dL), neutrophil count (≥10.2), and age (odds ratio = 1.185, p = 0.013 and 95%CI = 1.037-1.354) had significant diagnostic capability for bacterial disease prediction. Conclusions: Due to its low diagnostic value in febrile patients, the HNP1-3 value is not currently recommended to support pathogen differentiation in children in an emergency setting. Further studies are needed to support its clinical use.

The Burden of Critical Illness in Hospitalized Children in Low- and Middle-Income Countries: Protocol for a Systematic Review and Meta-Analysis.

BackgroundThe majority of childhood deaths occur in low- and middle-income countries (LMICs). Many of these deaths are avoidable with basic critical care interventions. Quantifying the burden of pediatric critical illness in LMICs is essential for targeting interventions to reduce childhood mortality.ObjectiveTo determine the burden of hospitalization and mortality associated with acute pediatric critical illness in LMICs through a systematic review and meta-analysis of the literature.Data Sources and Search StrategyWe will identify eligible studies by searching MEDLINE, EMBASE, CINAHL, and LILACS using MeSH terms and keywords. Results will be limited to infants or children (ages >28 days to 12 years) hospitalized in LMICs and publications in English, Spanish, or French. Publications with non-original data (e.g., comments, editorials, letters, notes, conference materials) will be excluded.Study SelectionWe will include observational studies published since January 1, 2005, that meet all eligibility criteria and for which a full text can be located.Data ExtractionData extraction will include information related to study characteristics, hospital characteristics, underlying population characteristics, patient population characteristics, and outcomes.Data SynthesisWe will extract and report data on study, hospital, and patient characteristics; outcomes; and risk of bias. We will report the causes of admission and mortality by region, country income level, and age. We will report or calculate the case fatality rate (CFR) for each diagnosis when data allow.ConclusionsBy understanding the burden of pediatric critical illness in LMICs, we can advocate for resources and inform resource allocation and investment decisions to improve the management and outcomes of children with acute pediatric critical illness in LMICs.

Characteristics of Acute Childhood Illness Apps for Parents: Environmental Scan.

BackgroundProviding parents with resources that aid in the identification and management of acute childhood illnesses helps those parents feel better equipped to assess their children’s health and significantly changes parental health-seeking behaviors. Some of these resources are limited by accessibility and scalability. Remote locations and staffing limitations create challenges for parents aiming to access their child’s health information. Mobile health apps offer a scalable, accessible solution for improving health literacy by enabling access to health information through mobile devices. ObjectiveThe aim of our study is to create an inventory of acute childhood illness apps that are available to North American parents and caregivers, assess their quality, and identify the areas in which future apps can be improved.MethodsWe conducted an environmental scan to identify and summarize app information for parents and digital health researchers. The Google and Apple app marketplaces were used as search platforms. We built a list of search terms and searched the platforms for apps targeted at parents and related to acute pediatric illnesses in the United States and Canada. We assessed apps meeting the inclusion criteria using the Mobile App Rating Scale (MARS), a validated tool for assessing the quality of health apps. The MARS examines apps on 5 subscales: engagement, functionality, aesthetics, information quality, and subjective quality. Data were analyzed by MARS subscale averages and individual item scores.ResultsOverall, 650 unique apps were screened, and 53 (8.2%) were included. On a scale of 1-5, apps had an average engagement score of 2.82/5 (SD 0.86), functionality score of 3.98/5 (SD 0.72), aesthetics score of 3.09/5 (SD 0.87), information quality score of 2.73/5 (SD 1.32), and subjective quality score of 2.20/5 (SD 0.79). On the same scale of 1-5, app scores ranged from 2.2/5 to 4.5/5 (mean 3.2, SD 0.6). The top 3 MARS-scored apps were Baby and Child First Aid (4.5/5), Ada (4.5/5), and HANDi Paediatric (4.2/5). Taken together, the top 3 apps covered topics of emergency pediatric first aid, identification of (and appropriate response to) common childhood illnesses, a means of checking symptoms, and a means of responding to emergency situations. There was a lack of Canadian-based app content available to parents in both marketplaces; this space was filled with content originating primarily in the United Kingdom and the United States. In addition, published evidence of the impact of the included apps was poor: of 53 apps, only 5 (9%) had an evidence base showing that the app had been trialed for usability or efficacy.ConclusionsThere is a need for evidence-based acute childhood illness apps of Canadian origin. This environmental scan offers a comprehensive picture of the health app landscape by examining trends in acute childhood illness apps that are readily available to parents and by identifying gaps in app design.

A Content Analysis of Emergency Department Discharge Instructions for Acute Pediatric Febrile Illnesses: The Current State and Opportunities for Improvement.

Quality emergency department (ED) discharge communication is critical to understanding of disease progression, home management, and return instructions. Addressing social aspects of disease burden are important to improving satisfaction and healthcare utilization. The objective of this study was to understand the extent to which written ED discharge instructions address multifaceted aspects of disease to meet the comprehensive needs of families with common childhood illnesses. We analyzed a national sample of 28 written discharge instructions from pediatric EDs using thematic and inductive content analysis. Seven themes were identified. Nearly all discharge instructions devoted a majority of content to themes related to disease physiology. Other themes common to instructions were related to parental instructions for caring for the child and when to return for further care. Content on caregiver reassurance, returning to daily activities, improving well-being, and promoting community health were not a focus of discharge instructions. Inclusion of multifaceted discharge materials which address both medical and social aspects of disease may help improve family-centered emergency care and the quality of care transitions for common childhood illnesses.

The Future(s) of Pediatric Primary Care.

Pediatric primary care (PPC) arose in the early 20th century as the fusion of acute and chronic pediatric illness care with preventive elements borrowed from public and maternal and child health. Well-established and thriving by the 1930s, PPC saw major changes in childhood morbidity and mortality in the latter half of the 20th century with the recognition of the "new morbidity" of school, behavior, and social problems. At the same time, PPC experienced changes in its workforce, which became increasingly female and added nurse practitioners and physician assistants as practitioners. Independent practice, previously the dominant business model, decreased in prominence at the end of the 20th century as health systems bought practices and other sites morphed into federally qualified health centers. In the present century, electronic health records (EHRs) have brought profound changes in PPC workflows and practitioner experience. In addition, disruptive market competition such as retail clinics and corporate telemedicine providers coupled with changes in health insurance from fee-for-service to value-based payment further challenge the care model and economics of PPC. Finally, recognition of family social circumstances as major determinants of children's health presents another challenge to the status quo. As such, although one PPC future may resemble its present state, a more innovative future is likely to include clinics and practices more oriented toward and linked to communities and directed at the social determinants of health. In addition, the rise in physical, behavioral, and social problems in practice call for a growing focus on wellness, including sleep, nutrition, and activity, that promises to reorient the PPC future in productive new directions. The half-way technology of current EHR systems will ideally be spun into electronic hubs that facilitate teamwork between PPC, specialists, and community groups. Research and practice improvement strategies including involvement in "learning health systems" will be critical to making PPC effective in an evolving society. Although threatened by 21st century forces and hard-to-anticipate change, PPC is ideally positioned to build upon its core functions to create multidisciplinary teams that reach into the community, promoting a holistic wellness for children consistent with the broadest definition of health.

Clinical use and indications for head computed tomography in children presenting with acute medical illness in a low- and middle-income setting.

Computed tomography (CT) imaging is an indispensable tool in the management of acute paediatric neurological illness providing rapid answers that facilitate timely decisions and interventions that may be lifesaving. While clear guidelines exist for use of CT in trauma to maximise individual benefits against the risk of radiation exposure and the cost to the healthcare system, the same is not the case for medical emergency. The study primarily aimed to retrospectively describe indications for non-trauma head CT and the findings at a tertiary paediatric hospital. Records of children presenting with acute illness to the medical emergency unit of Red Cross War Children's Hospital, Cape Town, over one year (2013) were retrospectively reviewed. Participants were included if they underwent head CT scan within 24 hours of presentation with a non-trauma event. Clinical data and reports of CT findings were extracted. Inclusion criteria were met by 311 patients; 188 (60.5%) were boys. The median age was 39.2 (IQR 12.6-84.0) months. Most common indications for head CT were seizures (n = 169; 54.3%), reduced level of consciousness (n = 140;45.0%), headache (n = 74;23.8%) and suspected ventriculoperitoneal shunt (VPS) malfunction (n = 61;19.7%). In 217 (69.8%) patients CT showed no abnormal findings. In the 94 (30.2%) with abnormal CT results the predominant findings were hydrocephalus (n = 54;57.4%) and cerebral oedema (n = 29;30.9%). Papilloedema was more common in patients with abnormal CT (3/56; 5.4%) compared with none in those with normal CT; P = 0.015; while long tract signs were found in 42/169 (24.9%) and 23/56 (41.1%) of patients with normal and abnormal CT findings, respectively; P = 0.020. Post-CT surgery was required by 47(15.1%) of which 40 (85.1%) needed a ventricular drainage. A larger proportion of patients with VPS (25/62; 40.3%) required surgery compared to patients without VPS (22/249; 8.8%; P<0.001). A majority of head CT scans in children with medical emergency with acute neurological illness were normal. Patients with VPS constituted the majority of patients with abnormal CT scans that required subsequent neurosurgical intervention. Evidence-based guidelines are required to guide the best use of head CT in the management of children without head trauma.

Parents' information needs and preferences related to bronchiolitis: a qualitative study.

Bronchiolitis affects more than one-third of children less than age 2 years and can cause substantial anxiety for parents, leading them to seek information on how to care for their sick child. The aim of our qualitative study was to explore the information needs and preferences of parents caring for a child with bronchiolitis. We used a qualitative descriptive approach. Participants were recruited by means of purposive sampling from Oct. 1, 2017, to Mar. 15, 2018 from the Stollery Children's Hospital emergency department, a specialized pediatric emergency department in Edmonton. Individual semistructured interviews were conducted. Fifty-three parents were recruited to participate, of whom 30 could not be reached after 4 contact attempts and 8 refused. Thus, 15 parents participated (16 children). Three major themes were identified: 1) parents' information needs about bronchiolitis, 2) parents' preferred information sources and 3) parents' preferred information delivery formats. Participants indicated that they want and require credible, easy-to-understand information about bronchiolitis in a variety of formats, and especially valued information obtained directly from a health care professional or an evidence-based website. This study provides important information about parents' information needs concerning bronchiolitis in children. Identifying the information that parents want and value in relation to acute pediatric illnesses is imperative to developing innovative educational approaches for parents that reflect patient-centred care.

Airway clearance therapy in acute paediatric respiratory illness: A state-of-the-art review.

BackgroundDespite unclear evidence of effectiveness or safety, airway clearance therapy (ACT) is frequently performed in infants and children with acute pulmonary disease.ObjectivesThe aim of this review was to critically synthesise published evidence, expert opinion and pathophysiological principles to describe the indications, effects, precautions and application of commonly used ACT modalities for managing infants and children with acute pulmonary disease.MethodA comprehensive narrative review of published literature was conducted. Articles describing paediatric populations were prioritised, but adult and animal studies were also considered where appropriate.ResultsThere is a dearth of high-level evidence supporting the use of ACT in acutely ill infants and children. Conversely, studies have highlighted the lack of effect of different modalities for a variety of conditions, and in some cases serious associated complications have been reported.Airway clearance therapy may be considered when there is retention of pulmonary secretions, and the consequential airway obstruction impacts either acutely on respiratory mechanics and gaseous exchange and/or has the potential for long-term adverse sequelae [a condition that is the consequence of a previous disease or injury]. However, it should not be considered a routine intervention.ConclusionAirway clearance therapy should not be performed routinely in children admitted to hospital with acute respiratory conditions. Patients should be clinically assessed and treatment planned according to individual presentation, in those with signs and symptoms that are potentially amenable to ACT.Clinical implicationsThis review can serve as a guide for physiotherapists in the respiratory management of children with acute respiratory illness, as well as identifying areas for clinical research.

Attenuated Human Parainfluenza Virus Type 1 Expressing the Respiratory Syncytial Virus (RSV) Fusion (F) Glycoprotein from an Added Gene: Effects of Prefusion Stabilization and Packaging of RSV F.

Human respiratory syncytial virus (RSV) is the most prevalent worldwide cause of severe respiratory tract infection in infants and young children. Human parainfluenza virus type 1 (HPIV1) also causes severe pediatric respiratory illness, especially croup. Both viruses lack vaccines. Here, we describe the preclinical development of a bivalent RSV/HPIV1 vaccine based on a recombinant HPIV1 vector, attenuated by a stabilized mutation, that expresses RSV F protein modified for increased stability in the prefusion (pre-F) conformation by previously described disulfide bond (DS) and hydrophobic cavity-filling (Cav1) mutations. RSV F was expressed from the first or second gene position as the full-length protein or as a chimeric protein with its transmembrane and cytoplasmic tail (TMCT) domains substituted with those of HPIV1 F in an effort to direct packaging in the vector particles. All constructs were recovered by reverse genetics. The TMCT versions of RSV F were packaged in the rHPIV1 particles much more efficiently than their full-length counterparts. In hamsters, the presence of the RSV F gene, and in particular the TMCT versions, was attenuating and resulted in reduced immunogenicity. However, the vector expressing full-length RSV F from the pre-N position was immunogenic for RSV and HPIV1. It conferred complement-independent high-quality RSV-neutralizing antibodies at titers similar to those of wild-type RSV and provided protection against RSV challenge. The vectors exhibited stable RSV F expression in vitro and in vivo In conclusion, an attenuated rHPIV1 vector expressing a pre-F-stabilized form of RSV F demonstrated promising immunogenicity and should be further developed as an intranasal pediatric vaccine.IMPORTANCE RSV and HPIV1 are major viral causes of acute pediatric respiratory illness for which no vaccines or suitable antiviral drugs are available. The RSV F glycoprotein is the major RSV neutralization antigen. We used a rHPIV1 vector, bearing a stabilized attenuating mutation, to express the RSV F glycoprotein bearing amino acid substitutions that increase its stability in the pre-F form, the most immunogenic form that elicits highly functional virus-neutralizing antibodies. RSV F was expressed from the pre-N or N-P gene position of the rHPIV1 vector as a full-length protein or as a chimeric form with its TMCT domain derived from HPIV1 F. TMCT modification greatly increased packaging of RSV F into the vector particles but also increased vector attenuation in vivo, resulting in reduced immunogenicity. In contrast, full-length RSV F expressed from the pre-N position was immunogenic, eliciting complement-independent RSV-neutralizing antibodies and providing protection against RSV challenge.

Actin-Related Protein 2 (ARP2) and Virus-Induced Filopodia Facilitate Human Respiratory Syncytial Virus Spread.

Human respiratory syncytial virus (RSV) is an enveloped RNA virus that is the most important viral cause of acute pediatric lower respiratory tract illness worldwide, and lacks a vaccine or effective antiviral drug. The involvement of host factors in the RSV replicative cycle remains poorly characterized. A genome-wide siRNA screen in human lung epithelial A549 cells identified actin-related protein 2 (ARP2) as a host factor involved in RSV infection. ARP2 knockdown did not reduce RSV entry, and did not markedly reduce gene expression during the first 24 hr of infection, but decreased viral gene expression thereafter, an effect that appeared to be due to inhibition of viral spread to neighboring cells. Consistent with reduced spread, there was a 10-fold reduction in the release of infectious progeny virions in ARP2-depleted cells at 72 hr post-infection. In addition, we found that RSV infection induced filopodia formation and increased cell motility in A549 cells and that this phenotype was ARP2 dependent. Filopodia appeared to shuttle RSV to nearby uninfected cells, facilitating virus spread. Expression of the RSV F protein alone from a plasmid or heterologous viral vector in A549 cells induced filopodia, indicating a new role for the RSV F protein, driving filopodia induction and virus spread. Thus, this study identified roles for ARP2 and filopodia in RSV-induced cell motility, RSV production, and RSV cell-to-cell spread.

Upper airway viruses and bacteria and clinical outcomes in children with cough.

SummaryBackground: Cough is symptomatic of a broad range of acute and chronic pediatric respiratory illnesses. No studies in children have tested for an extended panel of upper airway respiratory viruses and bacteria to identify whether they predict cough outcomes, irrespective of clinical diagnosis at the time of acute respiratory illness (ARI). We therefore determined whether upper airway microbes independently predicted hospitalization and persistent cough 28‐days later in children presenting with an ARI, including cough as a symptom. Methods: A cohort study of children aged <15‐years were followed for 28‐days after presenting to a pediatric emergency department with an ARI where cough was also a symptom. Socio‐demographic factors, presenting clinical features and a bilateral anterior nasal swab were collected at enrolment. Polymerase chain reaction assays tested for seven respiratory bacteria and 17 viruses. Predictors of hospitalization and persistent cough at day‐28 were evaluated in logistic regression models. Results: Eight hundred and seventeen children were included in the analysis; median age 27.7‐months. 116 (14.2%, 95%CI 11.8, 16.6) children were hospitalized and 163 (20.0%, 95%CI 17.2, 22.7) had persistent cough at day‐28. Hospitalized children were more likely to have RSV A or B detected on nasal swab than those not admitted (adjusted relative risk (aRR) 1.8, 95%CI 1.0, 3.3). M. catarrhalis was the only microbial difference between children with and without cough persistence (aRR for those with cough at day 28: 2.1, 95%CI 1.3, 3.1). Discussion: An etiologic role for M. catarrhalis in the pathogenesis of persistent cough post‐ARI is worth exploring, especially given the burden of chronic cough in children and its relationship with chronic lung disease. Pediatr Pulmonol. 2017;52:373–381. © 2016 Wiley Periodicals, Inc.

G519 A novel three-tiered approach to improving paediatric education for general practice doctors and trainees

Context Recent recommendations from the RCPCH and the RCGP have highlighted the need for General Practice curricula to include more focused paediatric training. Problem Children comprise 40% of a typical GP’s workload yet only 55% of GP trainees undertake hospital-based paediatric placements. Assessment of problem and analysis of its causes We carried out a questionnaire of GP trainees in our region to assess confidence with Paediatrics and interest in focused paediatric education. Intervention We hypothesised a novel three-tiered education programme would address this imbalance. Study design We designed a curriculum-mapped educational programme for qualified GPs and GP trainees. The programme focuses on acute Paediatrics and is delivered using a variety of modalities: Strategy for change CCAP: A Crash Course in Acute Paediatrics – 2 day course for GP trainees: an overview of acute Paediatrics. STrAP: Simulation Training in Acute Paediatrics – in-situ simulation for GP trainees during hospital paediatric placements. GP Paediatric Refresher Days – Simulation for qualified GPs. 1. A Crash Course in Acute Paediatrics An intensive 2-day Crash Course in Acute Paediatrics (CCAP). Delivered by Paediatric registrars and nurses, this uses tutorials, workshops, skills stations and simulation to cover essential knowledge and skills. It offers an overview of assessment, and common presentations, as well as the opportunity to consolidate knowledge with relevant practical skills. The course has a strong focus on effective assessment, initial management within a primary care setting and safe transfer of patients to secondary care. 2. STrAP: Simulation Training in Acute Paediatrics A simulation programme covering common acute paediatric presentations delivered to trainees weekly and run real-time in ward areas. Simulations utilise all members of the multidisciplinary team with high-situational fidelity being achieved through use of a manikin and visual media. This gives trainees realistic exposure to assessment, diagnosis and management of an acutely unwell child. 3. GP Refresher days A Paediatric simulation programme delivered to qualified GPs at regional Refresher days. Delivered by Paediatric registrars, the programme comprises acute paediatric simulations run in real-time using equipment available in a GP surgery. The focus is on assessment, initial management and communication within the primary care environment. Measurement of improvement CCAP candidates completed feedback questionnaires immediately following the course. All candidates felt the content was appropriate for their future careers and reported increased confidence. Feedback was almost unanimously positive, with candidates enjoying the mix of theoretical and practical learning. STrAP candidates completed confidence questionnaires after scenarios and a basic knowledge questionnaire before and after their placements. The same questionnaires were completed with a control group of candidates not undergoing regular simulation-training. Our results showed candidate’s confidence scores increased by an average of 2 points (Likert scale 1–5) following simulation-training. Overall confidence scores reached a higher plateau 6–8 weeks sooner than the control group. Knowledge assessment results showed greater appreciation of non-specific presenting features of acute illness in the intervention group, and clearer ability with managing acute paediatric illness. Feedback from the pilot GP simulation refresher day showed that 100% of candidates agreed or strongly agreed that the scenarios were useful and increased confidence and knowledge of acute paediatric presentations. Effects of changes We feel our novel three-tiered education programme and its unique cross-specialty, cross-discipline delivery has improved the ability of our qualified GPs and trainees to manage acutely unwell children. Lessons learnt Our programme addresses the imbalance of Paediatric experience in GP training when compared to the Paediatric proportion of a typical GP’s workload. Message for others We feel the programme would benefit to GP trainees across the country and could easily be introduced in other deaneries.

Hospitalizations of children with neurologic disorders in the United States.

Although neurologic disorders are among the most serious acute pediatric illnesses, epidemiologic data are scarce. We sought to determine the scope and outcomes of children with these disorders in the United States. Retrospective cohort study. All nonfederal hospitals in 11 states encompassing 38% of the U.S. pediatric population. Children 29 days to 19 years old hospitalized in 2005. None. Using International Classification of Diseases, 9th Revision, Clinical Modification, codes, we identified admissions with neurologic diagnoses, analyzed patient and hospitalization characteristics, and generated age- and sex-adjusted national estimates. Of 960,020 admissions in the 11 states, 10.7% (103,140) included a neurologic diagnosis, which yields a national estimate of 273,900 admissions of children with neurologic diagnoses. The most common were seizures (53.9%) and traumatic brain injury (17.3%). Children with neurologic diagnoses had nearly three times greater ICU use than other hospitalized children (30.6% vs 10.6%, p < 0.001). Neurologic diagnoses were associated with nearly half of deaths (46.2%, n = 1,790). Among ICU patients, children with neurologic diagnoses had more than three times the mortality of other patients (4.8% vs1.5%, p < 0.001). Children with neurologic diagnoses had a significantly longer median hospital length of stay than other children (3 d [1, 5] vs 2 d [2, 4], p < 0.001) and greater median hospital costs ($4,630 [$2,380, $9,730] vs $2,840 [$1,520, $5,550], p < 0.001). Children with neurologic diagnoses account for a disproportionate amount of ICU stays and deaths compared with children hospitalized for other reasons.

Human enterovirus 109 (EV109) in acute paediatric respiratory disease in Hungary

Human enterovirus 109 (EV109) is a recently identified recombinant enterovirus in family Picornaviridae from acute paediatric respiratory illness in Nicaragua. EV109 have not been reported elsewhere. Our aims were the molecular detection and genetic analysis of EV109 from acute childhood respiratory infections in Hungary. Nasopharyngeal aspirates were collected from children under age of 10 years with acute respiratory infections treated in Department of Pulmonology, Kaposi Mór Teaching Hospital, Mosdós, Hungary. Samples were taken from 15 October to 15 May in two respiratory seasons 2005/2006 and 2006/2007. Samples were tested using EV109 specific VP1 primers by RT-PCR method. One (1.1%) of the 92 nasopharyngeal aspirates was positive for EV109 collected from a 2.5-year-old child in January, 2007. The main symptoms were dropping nose, fever (38.1°C), hard cough and wheezing associated with bronchitis and pneumonia. Based upon the VP1 gene region EV109 (L87/HUN/2007, JN900470) has 93% nucleotide identity and identical recombinant pattern to the prototype EV109. This is the first detection of the novel recombinant enterovirus, EV109, in Hungary (in Europe). This study supports the possibility that EV109 is able to cause acute respiratory infections, in addition, it might be plays a part in lower respiratory disease with hospitalization in children.

Glucose Metabolism Disturbances in Acute Pediatric Illness

1Paediatric Care Unit "Sant' Antonio" General Hospital San Daniele del Friuli Udine, Italy 2School of Movement Sciences (DiSiST) Parthenope University Naples, Italy [email protected]

Extreme stress hyperglycemia during acute illness in a pediatric emergency department.

Although mild stress hyperglycemia in pediatric illness is common, severe hyperglycemic responses (≥300 mg/dL [16.7 mmol/L]) to stress are unusual. We sought to determine the incidence and course of extreme stress hyperglycemia (ESH) in acute pediatric illness, including whether it is a marker of increased mortality or associated with subsequent development of diabetes mellitus (DM). We retrospectively reviewed a cohort of 55,120 consecutive visits over 6 years to a pediatric emergency department at which blood glucose concentrations were measured and report on visits with laboratory glucose 300 mg/dL (16.7 mmol/L) or greater without DM. There were 72 cases of ESH (incidence of 0.13%). Median age was 8.8 years; 63% were male. The most common diagnoses were respiratory illness (49%), trauma (15%), and seizure (8%), and 65% of patients had received glucose-influencing interventions before evaluation. Eighty-five percent were ill appearing, 60% were admitted to the intensive care unit, and half had acidemic pH values. The overall mortality rate was 22%. Despite treatment of hyperglycemia in only 8 patients, glucose concentrations decreased to 150 mg/dL (8.3 mmol/L) or less within 48 hours in 67% and before discharge or death in 85% of patients. Preceding symptoms and concurrent laboratory results were helpful to exclude diabetes, and none of the surviving patients with follow-up available went on to develop type 1 or 2 DM. Although rare, ESH (≥300 mg/dL [16.7 mmol/L]) does occur in acute pediatric illness, in most cases is at least partially iatrogenic, and is a marker of severe illness and high mortality. Normoglycemia is typically restored quickly with treatment of the primary illness. No association was found with a subsequent diagnosis of DM.

Human Enterovirus 109: a Novel Interspecies Recombinant Enterovirus Isolated from a Case of Acute Pediatric Respiratory Illness in Nicaragua

Enteroviruses (Picornaviridae family) are a common cause of human illness worldwide and are associated with diverse clinical syndromes, including asymptomatic infection, respiratory illness, gastroenteritis, and meningitis. In this study, we report the identification and complete genome sequence of a novel enterovirus isolated from a case of acute respiratory illness in a Nicaraguan child. Unbiased deep sequencing of nucleic acids from a nose and throat swab sample enabled rapid recovery of the full-genome sequence. Phylogenetic analysis revealed that human enterovirus 109 (EV109) is most closely related to serotypes of human enterovirus species C (HEV-C) in all genomic regions except the 5' untranslated region (5' UTR). Bootstrap analysis indicates that the 5' UTR of EV109 is likely the product of an interspecies recombination event between ancestral members of the HEV-A and HEV-C groups. Overall, the EV109 coding region shares 67 to 72% nucleotide sequence identity with its nearest relatives. EV109 isolates were detected in 5/310 (1.6%) of nose and throat swab samples collected from children in a pediatric cohort study of influenza-like illness in Managua, Nicaragua, between June 2007 and June 2008. Further experimentation is required to more fully characterize the pathogenic role, disease associations, and global distribution of EV109.

Neuropsychological function in children following admission to paediatric intensive care: a pilot investigation

Little is known about neuropsychological status following acute severe paediatric illness. This pilot study explored the effects on memory function of severe acute paediatric illness and associations between memory functioning and psychiatric sequelae. Case control study of children after paediatric intensive care unit (PICU) discharge and healthy volunteers. 16 PICU discharged children comprised of 11 boys and 5 girls (mean age 9.44 +/- 2.85 years) tested a mean of 4.8 +/- 1.4 months following hospital discharge, and 16 age- and sex-matched controls. Visual-spatial memory and attention were assessed using the CANTAB battery (visual memory) and verbal memory with the Children Memory Scale; Intelligence Quotient was tested using the Wechsler Abbreviated Scale of Intelligence. Emotional and behavioural function was measured with the Strengths and Difficulties Questionnaire and Impact of Event Scales. Children admitted to PICU displayed statistically poorer performance on tests of spatial memory (spatial working memory) sustained attention (rapid visual information) and verbal memory (word pairs learning and delayed recognition). Septic illness was specifically associated with poorer pattern recognition memory on the CANTAB. There were significant correlations in the PICU group between cognitive functioning and emotional/behaviour scores. Our results suggest impaired memory and attention in children following acute severe paediatric illness, a specific deficit in children with septic illness and links between memory anomalies and emotional/behavioural problems. The findings and their clinical significance require replication and clarification in a larger sample.