Assessment Of Pediatric Patients Research Articles

Introduction of a simple guideline to improve neurological assessment in paediatric patients presenting with upper limb fractures

BackgroundNeurological examination in children presenting with upper limb fractures is often poorly performed in the Emergency Department (ED). We aimed to assess the improvement in documented neurological examination for children...

FIBEROPTIC BRONCHOSCOPY VERSUS VIDEO LARYNGOSCOPY IN PEDIATRIC AIRWAY MANAGEMENT

The primary goal of pediatric airway management is to ensure oxygenation and ventilation. Routine airway management in healthy pediatric patients is normally easy in experienced hands. Really difficult pediatric airway is rare and usually is associated with anatomically and physiologically important findings such as congenital abnormalities and syndromes, trauma, infection, swelling and burns. Using predictors of difficult intubation should be mandatory preoperative assessment in pediatric patients. Difficult airway algorithm for pediatric patients has to consist of three parts: oxygenation (A), tracheal intubation (B), and rescue (C). According to this new algorithm, if conventional direct laryngoscopy fails, we have to use alternative glottic visualization device. Do we really need video laryngoscopy? If we look at numbers, we might estimate that conventional laryngoscopy is successful and effective in around 98.5% of cases. Do we need to replace Macintosh laryngoscope with video laryngoscope completely in our routine practice? Should video laryngoscope be available to replace fiberoptic intubation in pediatric airway management? According to the algorithm, fiberoptic-assisted tracheal intubation combined with extraglottic airway devices is the standard of care. Establishment of protocols for equipping and maintaining airway trolleys and regular training in their use must be provided to avoid tissue hypoxia in children with compromised airway.

The Role of Ultrasonography for Assessment of Pseudotumor Cerebri Syndrome in the Emergency Department

Pseudotumor cerebri syndrome (PTCS) is a condition of still obscure etiology, characterized by elevated cerebrospinal fluid (CSF) pressure but no detectable intracranial CSF compositional anomalies or abnormalities of the brain parenchyma. This syndrome generally affects adult obese individuals, especially females, but it has been frequently described also in the pediatric population. Pediatric PTCS has been reported in association with secondary factors (e.g., medical illness, infections, endocrine disturbances, drug intoxication) that seem to augment intracranial pressure in a still unexplained way. Clinical signs and symptoms of PTCS in children include headache and papilledema at the funduscopic examination. The diagnosis of PTCS in children and adults usually involves brain imaging to exclude intracranial mass and/or vascular anomalies; the lumbar puncture is also crucial to confirming elevated CSF pressure (>250 mm H 2 O) and, lately, normal CSF contents at the chemical-physical examination. In recent years, ultrasonography has acquired an emerging role in the initial assessment of patient suspected to have PTCS. In fact, ocular ultrasounds allow the detection of optic disc swelling, suggestive of papilledema; additionally, ultrasonography allows the measurement of the retrobulbar optic nerve sheath diameter, which has been proposed as a noninvasive (indirect) method to assess the intracranial pressure. Ultrasound examination of the optic disc may therefore represent an important adjunct to funduscopic examination when assessing children with headache and/or visual disturbances, especially in the setting of the emergency department. We briefly discuss the application of ultrasonography in the assessment of pediatric patients with PTCS.

Ultrasound Elastography--Review of Techniques and Its Clinical Applications in Pediatrics--Part 1.

Sonoelastography is anovel technique that uses ultrasound waves to assess the elasticity of tissues noninvasively. It provides an ultrasound-based method to detect and display the relative stiffness of tissue. The main principle of sonoelastography is the measurement of tissue distortion in response to external compression. Changes in elasticity and tissue deformation elicited by compression are measured, processed and then shown in real time presentation with color-coded elastograms. One of the most important applications of sonoelastography is the evaluation of liver diseases, mainly liver fibrosis assessment and staging. Although in terms of definite diagnosis the liver biopsy still remains the golden standard, elastography seems to be avery inexpensive, repeatable and noninvasive method to evaluate most of liver conditions. The technique is also applicable in detection and differential diagnosis of focal lesions. It provides better imaging information and therefore more accurate evaluation of the lesions nature, e.g. in liver, lymphatic nodes or thyroid gland. Most of the applications mentioned above are well known and have been described in details in adults. Similarly, most of sonoelastographic studies are based on groups of adults. The purpose of this review article is to bring this technology closer to pediatric clinicians and to summarize some of its current clinical applications that are being pursued. In this part we focus on utility of elastography in liver assessment in pediatric patients.

Minimal Residual Disease Detection Using High-Throughput Sequencing Predicts Clinical Outcome in Patients with Pediatric B-Lineage Acute Lymphoblastic Leukemia

Background: Minimal residual disease (MRD) assessment at the end of induction is critical for risk stratification of B-lineage acute lymphoblastic leukemia (B-ALL) patients. There are multiple techniques for molecular MRD assessment, including next-generation sequencing (NGS) and allele-specific oligonucleotide PCR (ASO-PCR) amplification of immunoglobulin (Ig) or T-cell receptor rearrangements. Leukemia-specific rearrangements can be identified in >97% of B-ALL patients using the NGS-based LymphoSIGHT™ method, while ASO-PCR can typically identify leukemia-specific rearrangements in only 80-90% of B-ALL patients. In this report, we assessed the ability of the NGS method to predict event-free survival (EFS) in a cohort of B-ALL patients who were inevaluable by ASO-PCR.Methods: All patients were treated between 2005-2011 on a clinical trial conducted by the Dana-Farber Cancer Institute (DFCI) ALL Consortium (05-001) on which high levels of end-induction MRD (≥10-3) led to intensified treatment. The 37 pediatric B-ALL patients included in this study were inevaluable by ASO-PCR, and therefore this cohort represents a subset of patients in whom a decision to intensify therapy per protocol could not be made. Archived DNA samples from diagnosis and Day 32 were provided for MRD assessment using the NGS method. Using universal primer sets, we amplified the immunoglobulin (IGH-VDJ, IGH-DJ and IGK) and T cell receptor (TRB, TRD, TRG) loci in diagnostic bone marrow samples. Leukemia-specific clonotypes were identified in the diagnostic sample of each patient based on high-frequency within the B-cell and/or T-cell repertoire. The presence of leukemia-specific clonotypes was then assessed in the end-induction (Day 32) sample. NGS MRD assessment was performed blinded to all clinical and ASO-PCR information on these patients. The association of NGS MRD results and clinical outcome (EFS) was examined, and significance assessed using the log-rank test.Results: Of 37 patients who were inevaluable for end-induction MRD by ASO-PCR, leukemia-specific clonotypes were successfully identified in 35 (95%) by the NGS method. The use of a threshold of 10-3, which is the ASO-PCR threshold used for risk-stratification on DFCI protocols, demonstrated significantly improved EFS between the MRD negative and MRD positive groups (p<0.0001) (Figure 1A). A similar analysis with a threshold of 10-4 also demonstrated significantly improved EFS between the MRD negative and MRD positive groups (p<0.0001) (Figure 1B).Conclusions: This study demonstrates the prognostic significance of NGS-based MRD assessment in pediatric patients with B-ALL. This NGS-based assay led to successful assessment of MRD in 95% of patients who were inevaluable by ASO-PCR. The NGS method represents an alternative approach for clinical MRD monitoring that could fundamentally improve the ability to identify high-risk B-ALL patients and potentially improve their outcome. [Display omitted] [Display omitted] DisclosuresZheng:Sequenta, Inc.: Employment, Equity Ownership. Faham:Sequenta, Inc.: Employment, Equity Ownership, Membership on an entity’s Board of Directors or advisory committees.

Pupillometry: a non-invasive technique for pain assessment in paediatric patients

ObjectivePupillometry has been used to assess pain intensity and response to analgesic medications in adults. The aim of this observational study was to explore proof of concept for the use...

Back Pain in Children and Diagnostic Value of (99m)Tc MDP Bone Scintigraphy.

ABSTRACTAim:The aim of our study is to assess the diagnostic value of Technituim-99m-Methyle diphosphonate (99mTc-MDP) Bone scintigraphy in the assessment of children with back pain.Methods:Included in this retrospective study were 68 child referred to us complaining of back pain (mean age of 13+ 2). There were 45 boys and 23 girls. All children have been investigated with conventional x-ray which revealed normal or inconclusive result. All underwent bone scintigraphy after the injection of 99mTc-MDP with calculated doses according to there body weights.Results:Bone scintigraphy revealed 17 (25%) abnormal scans in 11 boys and 6 girls. Scans findings were suggestive of spondylolysis (n=4); malignancy including primary tumors and metastases (n=3); infection including osteomyelitis and discitis (n=3); sacroiliitis (n=2); benign tumors (n=2); pseudo fractures in ribs (n=1); necrosis in femoral head epiphysis(n=1) and nonskeletal-renal retention due to hydronephrosis (n=1). Sensitivity, specificity and accuracy of bone scan in detecting gross skeletal abnormality as a cause for back pain were 94% and 100% and 99% respectively.Conclusion:Bone isotope scan is a sensitive imaging modality in the assessment of pediatric patients with back pain. It is a reliable modality to detect and role out most benign and aggressive serious etiologies.

Current state of musculoskeletal ultrasound in paediatric rheumatology: results of an international survey

The aim of this study was to investigate the current use of musculoskeletal US (MSUS) and the most relevant areas of interest for this imaging modality in paediatric rheumatology. A questionnaire was developed by the paediatric subgroup of the OMERACT US task force and e-mailed to the members of the main international paediatric rheumatology networks and societies. Responses were entered in an electronic database. Results were analysed quantitatively or summarized qualitatively in the case of open questions. The overall response rate was 36% (262/719). The use of MSUS varied among members of the various networks/societies. MSUS was considered of high relevance for improvement of diagnostic skills, for the guidance of joint injections and for the assessment of specific joints, namely the hip, ankle, midfoot and wrist. It was considered useful for early detection of synovitis and in determining disease activity and disease remission. Although at present MSUS is not widely used by paediatric rheumatologists, there is considerable interest in this imaging technology among members of the international networks. The results of this survey suggest that the next objective in the research agenda should be the standardization of the assessment of joints in healthy children. This will then help differentiate pathological (i.e. synovitic) joints from normal joints. The initial target joints should be the hip, ankle, midfoot and wrist. MSUS training focused on the assessment of paediatric patients might be very important in implementing the use of this technique in clinical practice and research.

Resistance index in mural arteries of thickened bowel wall: predictive value for Crohn disease activity assessment in pediatric patients

Purpose: To define reliable Doppler parameters in mural arteries of affected bowel loops for quantitative assessment of Crohn disease (CD) activity in pediatric population and compare Doppler parameters with Pediatric Crohn Disease Activity Index (PCDAI).

Assessment of cardiac volumes using an isotropic whole‐heart dual cardiac phase sequence in pediatric patients

To evaluate the accuracy of a three-dimensional dual phase (3D DP) whole-heart technique for cardiac volumetric assessment in pediatric patients with cardiac abnormalities. The institutional approved this study, and informed consent was obtained from patients or their guardians. This prospective study involved 31 pediatric patients (mean age, 7.9 years; range, 15 days to 15 years) for the assessment of cardiac abnormalities using cardiovascular MR. A standard protocol was performed for assessing cardiac anatomy and function. For evaluating the 3D DP technique, statistical comparison with a 2D cine multi-slice technique (2D steady-state free-precession [SSFP]) was performed using linear regression, intraclass correlation coefficient, and Bland Altman plots. Left (LV) and right (RV) ventricular cardiac volumes obtained with the 3D DP technique were in strong agreement with those obtained with the 2D SSFP technique for small and large ventricular volumes. The intraclass correlation coefficients (ICC) between both techniques were 0.992 for the LV end-diastolic volume (EDV), 0.983 for the LV end-systolic volume (ESV), 0.952 for the LV-systolic volume (SV), 0.992 for the RV-EDV, 0.992 for the RV-ESV, 0.928 for the RV-SV. Interobserver analysis indicated good reproducibility for both the 2D SSFP and the 3D DP techniques. The 3D DP technique provides as accurate cardiac volumes as the 2D SSFP technique in the pediatric population, but with the added benefits of easier data acquisition and detailed anatomical information of the whole heart and great vessels in a single free-breathing scan.

Inflammometry in pediatric asthma: A review of fractional exhaled nitric oxide in clinical practice

The burden of pediatric asthma remains high with one-third of patients being under- or overtreated because of the unique challenges in the assessment and management of childhood asthma. Until recently, there has been no point of care tool for assessing the underlying airway inflammation (i.e., inflammometry) in asthma. Recently, fractional exhaled nitric oxide (FeNO) has emerged as an important biomarker for the assessment and management of asthma. Recent evidence indicates that FeNO identifies T-helper cell type 2 (Th2)–mediated airway inflammation with a high positive and negative predictive value for identifying corticosteroid responsive airway inflammation. This article examines the evidence for FeNO as a predictor of Th2-mediated inhaled corticosteroid (ICS) responsive airway inflammation and reviews recent studies evaluating the role of FeNO, whether helpful or not, in the assessment and management of pediatric asthma. FeNO is a reliable adjunct to traditional tests in the assessment of suspected asthma. Importantly, it is useful for identifying and for excluding ICS-responsive airway inflammation. Although individual study results have varied, collectively, asthma managed using FeNO is associated with lower exacerbation rates compared with clinical algorithms alone. Finally, FeNO may be useful in identifying patients at risk for future impairment or loss of asthma control during reduction/cessation of ICS treatment. FeNO testing has an important role in the assessment of pediatric patients with suspected asthma and in the management of pediatric patients with established asthma. Additional studies will continue to define the exact role of FeNO testing in pediatric asthma.

Resistance index in mural arteries of thickened bowel wall: predictive value for Crohn disease activity assessment in pediatric patients

To define reliable Doppler parameters in mural arteries of affected bowel loops for quantitative assessment of Crohn disease (CD) activity in pediatric population and compare Doppler parameters with Pediatric Crohn Disease Activity Index (PCDAI). Thirty-four pediatric patients (7 with inactive, 27 with active disease of different severity; 13 male and 21 female; mean age 13; range 7-18) with CD were prospectively evaluated by Doppler ultrasound (DUS) of affected bowel segments. Using semiquantitative color and power Doppler assessment of vascularization of thickened bowel wall and mesentery, patients were divided in four grades. Spectral measurements (peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI)) of mural arteries were compared with PCDAI. There was a significant difference in distribution of semiquantitative color values between inactive and active group. PSV and EDV values showed no significant difference between inactive and active group, while mean RI was significantly higher in the inactive group. RI was also significantly negatively correlated with PCDAI. Intensity of color and power Doppler signals and RI measurement of mural arteries in thickened bowel wall is linked to CD activity and therefore might be of use in pediatric patients.

The utility of FDG PET in diagnosis and follow-up of lymphoma in childhood

Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) are among the most common malignancies of childhood. (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) can be employed for accurate staging, treatment planning, and response assessment in pediatric patients with lymphomas, taking advantage of the increased FDG uptake of the malignant cells, secondary to their increased metabolic needs. FDG PET has higher sensitivity than other imaging modalities to detect nodular or diffuse lesions and higher sensitivity than bone marrow biopsy to detect bone marrow infiltration. FDG PET consists of an invaluable imaging modality during evaluation and treatment of pediatric lymphomas.

Should the term “neurovascularly intact” be abolished? A study evaluating neurological assessment in paediatric patients presenting with upper limb fractures

Should the term “neurovascularly intact” be abolished? A study evaluating neurological assessment in paediatric patients presenting with upper limb fractures

Relation of the Utility of Exercise Testing for Risk Assessment in Pediatric Patients With Ventricular Preexcitation to Pathway Location

The gradual loss of ventricular preexcitation during exercise stress testing (EST) has an unclear risk of an association with life-threatening arrhythmia and could be related to the accessory pathway (AP) location. We compared the loss of preexcitation during EST with the risk assessment during invasive electrophysiology testing and determined whether the loss of preexcitation correlates with the AP location. We retrospectively reviewed patients aged ≤21 years with ventricular preexcitation who had undergone both EST and an electrophysiology study. The patients were divided into 3 groups: sudden loss (SL), gradual loss (GL), or no loss (NL) of preexcitation during EST. A total of 76 patients were included, with 11 (14%) in the SL group, 18 (24%) in the GL group, and 47 (62%) in the NL group. The SL group demonstrated a longer cycle length with 1-to-1 conduction by way of the AP during incremental atrial pacing compared with the NL group (375 ± 135 ms vs 296 ± 52 ms, p = 0.002), with no difference between the GL and NL groups (325 ± 96 vs 296 ± 52 ms, p = NS). Of the patients with 1-to-1 AP conduction of <270 ms, none (0 of 11) were in the SL group compared to 18 of 47 in the NL group (p = 0.0017), with no significant difference in the GL group (5 of 18) compared to the NL group (p = NS). The patients in the GL group were more likely to have a left-sided AP (14 of 18) than the NL group (17 of 47, p = 0.002) and the SL group (3 of 11, p = 0.002). In conclusion, a sudden loss of preexcitation during an EST predicted a long cycle length with 1-to-1 conduction by way of the AP. Also, the AP conduction characteristics in patients with GL compared to those with NL did not differ, and the GL of preexcitation was more frequently seen in patients with a left-sided AP.

Adenoid Assessment in Paediatric Patients: The Role of Flexible Nasal Endoscopy

Adenoid hypertrophy is the most common cause of nasal obstruction in paediatric patients. Over the years, various methods to assess the adenoid size were proposed such as the posterior rhinoscopy and the radiological examination of the nasopharynx. Nasal endoscopy was introduced for children in the 80&#x0027;s, and nowadays this is a known and diffuse method in routine practice. The purpose of this article is to describe the personal experience in the assessment of the adenoid size in children, with a particular regard to the flexible nasal endoscopy, and to analyse the literature reports. The personal technique is described in performing nasal endoscopy in paediatric patients, reporting advantages and possible disadvantages of the procedure. A retrospective analysis was conducted on 6036 children since 1999 to 2010. In most cases children fully collaborated to complete the exam. No major or minor complications (such as nose bleedings or other traumatic injuries) were observed. No topical intranasal decongestant, local or general anaesthesia were used in our series. In our opinion, nasal endoscopy in children is a reliable, safe, accurate, easily tolerated and dynamic diagnostic method to assess the adenoid size.

Pediatric hearing assessment by auditory brainstem response in the operating room

Objectives To investigate the factors contributing to the discrepancies between auditory brainstem response (ABR) thresholds obtained in the operating room (OR) and hearing outcomes obtained in the follow-up period and to explore the benefits and limitations of performing ABR in the OR. Methods A retrospective review study was conducted in a pediatric tertiary care facility. A total of 116 patients were identified with complete records, including OR-ABR results, medical examination and surgical procedure notes, and follow-up medical/audiological evaluation. Patients were divided into three groups: (1) 58 patients with middle ear effusion underwent myringotomy and tube placement, (2) 12 patients underwent myringotomy without tube placement, (3) 46 patients underwent ear examination only without effusion found. OR-ABR results were compared to audiological follow-up evaluations and analyzed for each group. Results In patients with middle ear effusion and tube placement, the average threshold difference between OR-ABR and follow-up audiological evaluation was 9.7 dB (±12.7), with highest discrepancy of 45 dB. On the other hand, in patients with dry ears and/or no tube placement, the average threshold difference was only 3.8 dB (±8.6). Moreover, the discrepancy was more prominent in patients with mucoid effusion and larger at lower frequency, i.e., 1000 Hz. Conclusions The hearing thresholds estimated by ABR testing in the OR can be elevated and follow-up hearing evaluation after tube placement is needed. While ABR testing is valuable in the assessment of pediatric patients, especially for children who are difficult-to-test or have complicated medical conditions, caution should be taken when interpreting OR-ABR results.

Growth Assessment in Pediatric Patients with Congenital Heart Diseases A cross sectional study

Growth Assessment in Pediatric Patients with Congenital Heart Diseases A cross sectional study

Electrophysiological signatures: Magnetoencephalographic studies of the neural correlates of language impairment in autism spectrum disorders

While magnetoencephalography (MEG) is of increasing utility in the assessment of pediatric patients with seizure disorders, this reflects only a part of the clinical potential of the technology. Beyond epilepsy, a broad range of developmental psychiatric disorders require the spatial and temporal resolution of brain activity offered by MEG. This article reviews the application of MEG in the study of auditory processing as an aspect of language impairment in children. Specifically, the potential application of MEG is elaborated in autism spectrum disorders (ASD), a devastating disorder with prevalence of 1 in 150. Results demonstrate the sensitivity of MEG for detection of abnormalities of auditory processing in ASD ('electrophysiological signatures') and their clinical correlates. These findings offer promise for the comprehensive assessment of developmental neuropsychiatric disorders.

Fecal ASCA Measurements in the Assessment of Pediatric Patients with Known or Suspected Crohn's Disease

Background: Non-invasive clinical tests are being used in the diagnosis of patients with Inflammatory Bowel Disease (IBD), and previous studies have shown that serum anti-Saccharomyces cerevisiae antibodies (ASCA) can be measured in 40-60% of adult and pediatric patients with Crohn's disease (CD) and <5% of patients with ulcerative colitis (UC). Aim: To examine the utility of measuring fecal ASCA levels as a non-invasive screening measure for CD in children with known or suspected IBD. Methods: 105 patients aged ≤18 years, including 86 patients with CD, 17 with UC, 2 with acute colitis, and 16 healthy controls submitted stool and serum specimens for ASCA analysis. Diagnosis of IBD was based on endoscopic, radiologic, and histologic findings. Fecal samples were analyzed using a qualitative ASCA ELISA immunoassay. Results: 52% (45/86) of patients with CD and 30% (5/17) patients with UC tested positive for fecal ASCA. None of the healthy controls tested positive for fecal ASCA. The sensitivity and specificity for fecal ASCA testing was 52% and 62%, respectively. Serum ASCA results were available from 71 subjects. The sensitivity and specificity of serum ASCA measurements in these subjects was 86% and 55%, respectively. Conclusions: The prevalence of antibodies to ASCA appears to be comparable in stool or serum. The specificity of serum ASCA testing is superior to that measured in the feces. However, fecal ASCA testing offers the advantage of being inexpensive and noninvasive. When combined with other fecal diagnostic assays, such lactoferrin, fecal ASCA testing may prove useful for the assessment of children suspected of having IBD.