Children's Hospital Pediatric Research Articles

Barriers and facilitators to effective electronic health record-based sepsis screening in the pediatric intensive care unit.

The Pediatric Surviving Sepsis Campaign supports the implementation of automated tools for early sepsis recognition. In 2019 the C.S. Mott Children's Hospital Pediatric Intensive Care Unit deployed an electronic medical record (EMR)-based screening for early recognition and treatment of sepsis. We analyzed all automated primary sepsis alerts, secondary screens, and bedside huddles from November 2019 to January 2020 (Cohort 1) and from November 2020 to January 2021 (Cohort 2) to identify barriers and facilitators for the use of this tool. We distributed surveys to frontline providers to gather feedback on end-user experience. In Cohort 1, 895 primary alerts were triggered, yielding 503 completed secondary screens and 40 bedside huddles. In Cohort 2, 925 primary alerts were triggered, yielding 532 completed secondary screens and 12 bedside huddles. Surveys assessing end-user experience identified the following facilitators: (1) 73% of nurses endorsed the bedside huddle as value added; (2) 74% of medical providers agreed the bedside huddle increased the likelihood of interventions. The greatest barriers to successful implementation included the (1) overall large number of primary alerts from the automated tool and (2) rate of false alerts, many due to routine respiratory therapy interventions. Our data suggests that the successful implementation of EMR-based sepsis screening tools requires countermeasures focusing on 3 key drivers for change: education, technology, and patient safety. While both medical providers and bedside nurses found merit in our EMR-based sepsis early recognition system, continued refinement is necessary to avoid sepsis alert fatigue.

Head Injury Treatment With Healthy and Advanced Dietary Supplements: A Pilot Randomized Controlled Trial of the Tolerability, Safety, and Efficacy of Branched Chain Amino Acids in the Treatment of Concussion in Adolescents and Young Adults.

Concussion is a common injury in the adolescent and young adult populations. Although branched chain amino acid (BCAA) supplementation has shown improvements in neurocognitive and sleep function in pre-clinical animal models of mild-to-moderate traumatic brain injury (TBI), to date, no studies have been performed evaluating the efficacy of BCAAs in concussed adolescents and young adults. The goal of this pilot trial was to determine the efficacy, tolerability, and safety of varied doses of oral BCAA supplementation in a group of concussed adolescents and young adults. The study was conducted as a pilot, double-blind, randomized controlled trial of participants ages 11-34 presenting with concussion to outpatient clinics (sports medicine and primary care), urgent care, and emergency departments of a tertiary care pediatric children's hospital and an urban tertiary care adult hospital, between June 24, 2014 and December 5, 2020. Participants were randomized to one of five study arms (placebo and 15 g, 30 g, 45 g, and 54 g BCAA treatment daily) and followed for 21 days after enrollment. Outcome measures included daily computerized neurocognitive tests (processing speed, the a priori primary outcome; and attention, visual learning, and working memory), symptom score, physical and cognitive activity, sleep/wake alterations, treatment compliance, and adverse events. In total, 42 participants were randomized, 38 of whom provided analyzable data. We found no difference in our primary outcome of processing speed between the arms; however, there was a significant reduction in total symptom score (decrease of 4.4 points on a 0-54 scale for every 500 g of study drug consumed, p value for trend = 0.0036, [uncorrected]) and return to physical activity (increase of 0.503 points on a 0-5 scale for every 500 g of study drug consumed, p value for trend = 0.005 [uncorrected]). There were no serious adverse events. Eight of 38 participants reported a mild (not interfering with daily activity) or moderate (limitation of daily activity) adverse event; there were no differences in adverse events by arm, with only two reported mild adverse events (both gastrointestinal) in the highest (45 g and 54 g) BCAA arms. Although limited by slow enrollment, small sample size, and missing data, this study provides the first demonstration of efficacy, as well as safety and tolerability, of BCAAs in concussed adolescents and young adults; specifically, a dose-response effect in reducing concussion symptoms and a return to baseline physical activity in those treated with higher total doses of BCAAs. These findings provide important preliminary data to inform a larger trial of BCAA therapy to expedite concussion recovery.

A National Survey of Pediatric Post-Acute Care Facilities.

To identify and geolocate pediatric post-acute care (PAC) facilities in the United States. Cross-sectional survey using both online resources and telephone inquiry. All 50 U.S. states surveyed from June 2022 to May 2023. Care sites identified via state regulatory agencies and the Centers for Medicare & Medicaid Services. None. Number, size, and type of facility, scope of practice, and type of care provided. One thousand three hundred fifty-five facilities were surveyed; of these, 18.6% (252/1355) were pediatric-specific units or adult facilities accepting some pediatric patients. There were 109 pediatric-specific facilities identified within 39 U.S. states. Of these, 38 were freestanding with all accepting children with tracheostomies, 97.4% (37/38) accepting those requiring mechanical ventilation via tracheostomy, and 81.6% (31/38) accepting those requiring parenteral nutrition. The remaining 71 facilities were adult facilities with embedded pediatric units or children's hospitals with 88.7% (63/71), 54.9% (39/71), and 54.9% (39/71), accepting tracheostomies, mechanical ventilation via tracheostomy, and parenteral nutrition, respectively. Eleven states lacked any pediatric-specific PAC units or facilities. The distribution of pediatric PAC is sparse and uneven across the United States. We present an interactive map and database describing these facilities. These data offer a starting point for exploring the consequences of pediatric PAC supply.

Pediatric Cluster Headache Case Series: Symptomatic Cases and the Migraine Relationship.

Current criteria help differentiate cluster headache from migraine. However, children may have overlapping features making it difficult to distinguish the 2 conditions, which may delay diagnosis. Differentiating cluster headache from migraine is important regarding treatment as well as diagnostic workup of secondary headache etiologies. Cases at a single pediatric children's hospital from 2015 to 2023 diagnosed with cluster headache before the age of 18 years were reviewed. Twenty-five cases were identified of which 22 cases met criteria for either chronic, episodic, or probable cluster headache. Three cases were diagnosed with cluster headache by their provider, but documentation was insufficient to meet criteria for cluster headache. There were 16 females and 9 males between ages 6 and 17 years. Five cases were identified as symptomatic, 2 cases as chronic, 7 cases as episodic, and 13 cases as probable cluster headache. Symptomatic etiologies include Graves disease, optic neuritis, prolactinoma, hypothalamic pilocytic astrocytoma with carotid stenosis, and congenital right eye blindness. Migrainous features were common, including 76% with nausea, 36% with vomiting, 68% with photophobia, and 56% with phonophobia. Patients with cluster headache also had an independent diagnosis of migraine in 64%. Children with cluster headache have a high frequency of migrainous symptoms and co-occurrent diagnosis of migraine. A careful history may differentiate cluster headache from migraine and treated accordingly. Children with cluster headache features should undergo screening for secondary causes with appropriate imaging and other studies. Except for prolactinoma, the symptomatic associations noted in this case series have not been reported before.

Patterns of substance use among adolescents in and out of foster care: An analysis of linked health and child welfare administrative data

BackgroundYoung adults with a history of foster care have higher risk for substance use disorders. Social systems can deliver substance use prevention to youth; however, the timing of intervention delivery and how needs differ for youth in foster care are unclear. ObjectiveTo compare initiation and rates of substance use among adolescents in foster care to demographically similar adolescents never in foster care as identified by the healthcare system, and identify factors associated with increased substance use. Participants and settingYouth in foster care (n = 2787, ages 10–20, inclusive) and demographically matched youth never in foster care (n = 2787) were identified using linked child welfare and electronic health records from a single pediatric children's hospital and county over a five-year period (2012–2017). MethodsAll healthcare encounters were reviewed and coded for substance use by type (alcohol, tobacco, cannabis, other). Age of first reported or documented substance use was also captured. Demographic and child welfare information was extracted from administrative records. Survival and logistic regression models were estimated. ResultsIn adjusted models, youth in foster care initiated substance use at earlier ages (HR = 2.50, p < .01) and had higher odds of engaging in use (AOR = 1.54; p < .01) than youth never in care. By age 12, substance use initiation was more likely while youth were in foster care than when they were not in foster care (HR = 1.42, p < .01). Placement stability and family care settings reduced odds of lifetime substance use. ConclusionsFoster care placement is associated with substance use. Screening may be important for prevention.

Comprehensive review of a large cohort of outpatient versus inpatient open renal and bladder surgery in children

Outpatient surgery and pediatric ambulatory surgery centers continue to have increasing popularity among pediatric urologist for minor surgeries. Past studies have shown that open renal and bladder surgeries (i.e. nephrectomy, pyeloplasty and ureteral reimplantation) can also be done in an outpatient setting. With health care costs continuing to rise, it may be reasonable to explore performing these surgeries as an outpatient and consider performing them in a pediatric ambulatory surgery center. Our study assesses the safety and utility of outpatient open renal and bladder surgeries in children compared to those done as inpatients. IRB-approved chart review was performed on patients undergoing nephrectomy, ureteral reimplantation, complex ureteral reimplantation, and pyeloplasty by a single pediatric urologist between January 2003-March 2020. Procedures were performed at a freestanding pediatric surgery center (PSC) and a children's hospital (CH). Demographics, type of procedures, American Society of Anesthesiologists score, operative times, time to discharge, ancillary procedures, readmission or ER visits within 72h were reviewed. Home zip codes were used to determine the distance from pediatric surgery center and children's hospital. 980 procedures were evaluated. Of these, 94% procedures were performed as an outpatient and 6% procedures were performed as inpatients. 40% of patients underwent ancillary procedures. Outpatients had a significantly lower age, ASA score, operative time, and readmission or return to ER within 72h (1.5% vs. 6.2%). Twelve patients were readmitted (9 outpatient, 3 inpatient) and six returned to the ER (5 outpatient, 1 inpatient). 15/18 of these patients underwent reimplantations. Four required early reoperation on postoperative day (POD)2-3. Only one outpatient reimplant was admitted one day later. PSC patients lived farther away. Outpatient open renal and bladder surgery was found to be safely performed in our patients. In addition, it did not matter whether the operation was done in the children's hospital or pediatric ambulatory surgery center. Since outpatient surgery has been shown to be significantly less expensive than inpatient surgery, it is reasonable for pediatric urologist to consider performing these operations in the outpatient setting. Our experience shows that an outpatient approach to open renal and bladder procedures is safe and should be considered when counseling families about treatment options.

Sedation Weaning Initiative Targeting Methadone Exposure: Single Center Improvements in Withdrawal Symptoms and Hospital Length of Stay for Pediatric Cardiac Critical Care.

Sedation and pain medications are necessary in the management of postoperative pediatric cardiac patients. Prolonged exposure to these medications can lead to negative side effects including withdrawal. We hypothesized that standardized weaning guidelines would decrease exposure to sedation medications and decrease withdrawal symptoms. The primary aim was to decrease average days of methadone exposure to within goal for moderate- and high-risk patients within 6 months. Quality improvement methods were used to standardize sedation medication weaning in a pediatric cardiac ICU. This study took place at Duke Children's Hospital Pediatric Cardiac ICU in Durham, North Carolina from January 1, 2020, to December 31, 2021. Children less than 12 months old admitted to the pediatric cardiac ICU who underwent cardiac surgery. Sedation weaning guidelines were implemented over the course of 12 months. Data were tracked every 6 months and compared with the 12 months pre-intervention. Patients were stratified into low, moderate, and high risk withdrawal categories based on duration of opioid infusion exposure. Total sample size was 94 patients in the moderate and high risk categories. Process measures included documentation of Withdrawal Assessment Tool scores and appropriate methadone prescription in patients which increased to 100% post-intervention. For outcome measures, we observed decreased dexmedetomidine infusion duration, decreased methadone wean duration, decreased frequency of elevated Withdrawal Assessment Tool scores, and decreased hospital length of stay post-intervention. For the primary aim, methadone wean duration consistently decreased after each study period. Our intervention did not adversely impact balancing measures. A quality improvement initiative to standardize sedation weaning in a Pediatric Cardiac ICU was successfully implemented and was correlated with decreased duration of sedation medications, decreased withdrawal scores, and decreased length of stay.

Equity factors in pediatric transplant listing: Initial findings from a single center review.

In order to improve transparency within the patient selection process, a transplant listing advisory committee was formed within the Boston Children's Hospital Pediatric Transplant Center. Its mission is to promote equity in access to organ transplantation by ensuring that the institutional transplant selection criteria are fair, unbiased, and nondiscriminatory. The committee conducts comprehensive case and data review of individual characteristics and reviews in aggregate to identify potential systems bias. Charts for 256 patients evaluated for transplant from 3/2016 to 3/2019 were reviewed. Among these, 64 (25%) patients were declined for transplant. Univariate logistic regression analysis was used to identify demographic variables and vulnerable status factors associated with being declined. Odds ratios (OR) are reported. Among all patients, median age was 8.5 years and 58% were male. Asian patients were more likely to be declined than White patients (OR=5.3, Wald p=.007). Socioeconomic factors that affected likelihood of listing decline included concerns for caregivers' ability to manage and understand care requirements (OR=3.8, p=.011), caregiver employment status (OR=1.9, p=.042), and use of public assistance programs (OR=2.2, p=.05). Patients with severe neurodevelopmental delay were more likely to be declined for listing (OR=3.7, p=.019). This analysis identified areas of potential bias related to race, socioeconomic status, and neurodevelopmental delay where initiatives can be targeted. Advisory committees are an important aspect of evaluating equity in transplant center selection policy and practice.

Determining the Association Between Emergency Department Crowding and Debriefing After Pediatric Trauma Resuscitations.

Debriefing in the pediatric emergency department (PED) is an invaluable tool to improve team well-being, communication, and performance. Despite evidence, surveys have reported heavy workload as a barrier to debriefing leading to missed opportunities for improvement in an already busy ED. The study aims to determine the association between the incidence of debriefing after pediatric trauma resuscitations and PED crowding. A total of 491 Trauma One activations in Riley Children's Hospital Pediatric Emergency Department that presented between April 2018 to December 2019 were included in the study. Debriefing documentations, patient demographics, time and date of presentation, mechanism of injury, injury severity score, disposition from PED, and length of stay (LOS) were collected and analyzed. The National Emergency Department Overcrowding Scale score at arrival, Average LOS, total PED census, total PED waiting room census, and rates of left without being seen were compared between groups. Of 491 Trauma One activations presented to our PED, 50 (10%) trauma evaluations had documented debriefing. The National Emergency Department Overcrowding Scale score at presentation was significantly lower in those with debriefing versus without debriefing. In addition, the PED hourly census, waiting room census, average LOS, and left without being seen were also significantly lower in the group with debriefing. In addition, trauma cases with debriefing had a higher proportion of patients with profound injuries and discharges to the morgue. Pediatric emergency department crowding is a significant barrier to debriefing after trauma resuscitations. However, profound injuries and traumatic pediatric deaths remain the strongest predictors in conducting debriefing regardless of PED crowding status.

Downregulation of thrombomodulin-thrombin-activated protein C pathway as a mechanism for SARS-CoV-2 induced endotheliopathy and microvascular thrombosis

There is emerging evidence of microvascular thrombosis and thrombotic microangiopathy (TMA) induced by COVID-19, presumably from endothelial injury. Thrombomodulin (TM) is an endothelial glycoprotein that plays a dual role in maintaining healthy endothelium-as a natural anticoagulant by binding thrombin to activate protein C (APC) and a negative regulator of the alternate complement pathway (AP). TM is shed into the plasma as soluble TM (sTM) during endothelial injury.We hypothesize that SARS-CoV-2 spike proteins cause direct microvascular endothelial injury, leading to TM shedding, decreased activation of PC, and consequently, microvascular thrombosis in COVID-19. We conducted this study twofold: 1) in vivo, we assessed endothelial injury (by measuring sTM) and AP activation by quantifying Ba (cleavage product of AP component Factor B) in a cohort of critically ill COVID-19 pediatric patients and the implications on clinical outcomes; and 2)in vitro, we investigated endothelial injury (TM shedding) by SARS-COV-2 spike proteins and the subsequent functional consequence in activated PC (APC) levels and Ba levels.sTM and Ba in plasma samples from SARS-CoV-2 positive patients admitted to Texas Children's Hospital Pediatric Intensive Care Unit (n = 33) and from healthy controls (n = 38) were measured by ELISA. In vitro, confluent glomerular microvascular endothelial cells (GMVECs) were incubated for 48 h in the presence or absence (control) of purified SARS-CoV-2 spike proteins, S1 and S2. TM from the cell lysates while Ba and APC from the cell supernatants were measured by ELISA. sTM and Ba levels were significantly higher in the COVID-19 pediatric patients compared to healthy controls (p < 0.01 and p < 0.001, respectively). Among the COVID-19 patients, elevated sTM was associated with increased vasopressor use (p = 0.01) and elevated Ba was associated with increased duration of mechanical ventilation (p = 0.04). In vitro, surface bound TM and soluble APC were significantly lower in GMVECs after addition of spike proteins (p < 0.05), while Ba was undetectable in both control and spike proteins exposed GMVECs.In conclusion, we provide evidence of endothelial injury in COVID-19 pediatric patients and demonstrate a potential pathway of SARS-CoV-2 induced thrombosis. Decreased surface-bound TM results in lower amount of thrombin-TM complex, hence lesser activation of PC, likely leading to a pro-thrombotic state. These findings in GMVECs could explain the vulnerability of kidneys to COVID-19-induced TMA.

Variants in genes coding for collagen type IV α-chains are frequent causes of persistent, isolated hematuria during childhood.

Children with persistent, isolated microscopic hematuria typically undergo a limited diagnostic workup and are monitored for signs of kidney disease in long-term longitudinal follow-up, which can delay diagnosis and allow disease progression in some cases. To determine the clinical utility of genetic screening in this population, we performed targeted genetic testing using a custom, 32-gene next-generation sequencing panel for progressive kidney disease on children referred to the Texas Children's Hospital Pediatric Nephrology clinic for persistent, microscopic hematuria (n = 30; cohort 1). Patients with microscopic hematuria identified by urinalysis on at least two separate occasions were eligible for enrollment, but those with other evidence of kidney disease were excluded. Results were analyzed for sequence variants using the American College of Medical Genetics and Genomics (ACMG) guideline for data interpretation and were validated using a secondary analysis of a dataset of children with hematuria and normal kidney function who had undergone genetic testing as part of an industry-sponsored program (cohort 2; n = 67). In cohort 1 33% of subjects (10/30) had pathogenic or likely pathogenic (P/LP) variants in the type IV collagen genes (COL4A3/A4/A5), and 10% (3/30) had variants of uncertain significance in these genes. The high diagnostic rate in type IV collagen genes was confirmed in cohort 2, where 27% (18/67) of subjects had P/LP variants in COL4A3/A4/A5 genes. Children with persistent, isolated microscopic hematuria have a high likelihood of having pathogenic variants in type IV collagen genes and genetic screening should be considered. A higher resolution version of the Graphical abstract is available as Supplementary information.

Peripheral Nerve Blockade for Medial Patellofemoral Ligament Reconstruction in Pediatric Patients: The Addition of a Proximal Single-Injection Sciatic Nerve Block Provides Improved Analgesia.

PurposeWe tested the hypothesis that the addition of a single-injection proximal sciatic nerve block to an adductor canal block would significantly reduce pain scores and opioid requirements compared to a group of patients that received only an adductor canal or femoral nerve block for medial patellofemoral ligament reconstruction in pediatric patients. The primary end-point is the number of patients achieving a Patient Acceptable Symptom State (PASS) (pain score less than four) for the entire 24-hour postoperative period in patients with and without a proximal sciatic block.Patients and MethodsThis is a retrospective cohort study of 144 consecutive pediatric patients, ages 10 to 18 years, undergoing medial patellofemoral ligament reconstruction with peripheral nerve blockade for postoperative analgesia from 2016–2020 at a pediatric orthopedics children’s hospital. Patients were divided into 2 cohorts with and without a proximal sciatic nerve block: group A/F: adductor canal or femoral CPNB and group AS: adductor canal CPNB and a proximal single-injection sciatic nerve block.ResultsThere was strong evidence for an increase in the number of patients who reported a pain score less than four for the entire 24-hour postoperative period in the group that received the additional proximal sciatic block. (PASS: A/F 13/62 (21%) vs AS 43/82 (52%), p<0.001) There was strong evidence for a reduction in mean and maximum pain scores and opioid requirements in the first 24-hours after surgery in the proximal sciatic group.ConclusionThe addition of a proximal sciatic nerve block was associated with significantly reduced mean and maximum pain scores and opioid requirements after medial patellofemoral ligament reconstruction in pediatric patients and supports a randomized clinical trial to confirm these findings. Based on the results of this study we recommend the addition of a proximal sciatic nerve block, anterior or posterior, to an adductor canal block to provide improved analgesia and reduced opioid requirements in the 24-hours after MPFLR in pediatric patients.

Mortality and PICU Hospitalization Among Pediatric Gunshot Wound Victims in Chicago.

IMPORTANCE:Firearm injury accounts for significant morbidity with high mortality among children admitted to the PICU. Understanding risk factors for PICU admission is an important step toward developing prevention and intervention strategies to minimize the burden of pediatric gunshot wound (GSW) injury.OBJECTIVES:The primary objective of this study was to characterize outcomes and the likelihood of PICU admission among children with GSWs.DESIGN, SETTING, AND PARTICIPANTS:Retrospective cohort study of GSW patients 0–18 years old evaluated at the University of Chicago Comer Children’s Hospital Pediatric Trauma Center from 2010 to 2017.MAIN OUTCOMES AND MEASURES:Demographic and injury severity measures were acquired from an institutional database. We describe mortality and hospitalization characteristics for the cohort. We used logistic regression models to test the association between PICU admission and patient characteristics.RESULTS:During the 8-year study period, 294 children experienced GSWs. We did not observe trends in overall mortality over time, but mortality for children with GSWs was higher than all-cause PICU mortality. Children 0–6 years old experienced longer hospitalizations compared with children 13–16 years old (5 vs 3 d; p = 0.04) and greater frequency of PICU admission (83.3% vs 52.9%; p = 0.001). Adjusting for severity of illness, children less than 7 years old were four-fold more likely to be admitted to the PICU than children 13–16 years old (aOR range, 3.9–4.6).CONCLUSIONS AND RELEVANCE:Despite declines in pediatric firearm mortality across the United States, mortality did not decrease over time in our cohort and was higher than all-cause PICU mortality. Younger children with GSWs experience longer hospitalizations and require PICU care more often than older children. Our findings suggest that the youngest victims of firearm-related injury may be particularly at-risk of the long-term sequelae of critical illness and injury.

Performance evaluation of the ACR 1997, SLICC 2012, and EULAR / ACR 2019 criteria of pediatric systemic lupus erythematosus

Abstract Objective: Systemic lupus erythematosus (SLE) is the prototype of chronic autoimmune diseases. One-fifth of all SLE disease occurs in childhood. In this study, it was aimed to compare the SLE classifying criteria that have been used so far. These are the ACR (American College of Rheumatology) 1997, SLICC (Systemic Lupus International Collaborating Clinics) 2012, and EULAR (European League Against Rheumatism) / ACR 2019 criteria. Methods: Patients with 34 pediatric SLE and 32 antinuclear antibodies (ANA) (+) control groups who were followed up in Ankara Dr. Sami Ulus Obstetrics and Children's Hospital Pediatric Rheumatology Clinic were recruited to study. All of these patients were diagnosed by three pediatric rheumatologists. The control group consisted of ANA (+) patients with other rheumatologic diseases. Results: The sensitivities of the ACR 1997, SLICC 2012, and EULAR/ACR 2019 criteria were 76.5%, 94.1%, and 88.2%, respectively. The specificities of the criteria for ACR 1997, SLICC2012, and EULAR/ACR 2019 were 93.8%. Conclusion: Although SLICC 2012 showed the best sensitivity, all three classification criteria had the same specificity.

Pediatric Extracorporeal Life Support Transport in Western Canada: Experience over 14 years.

This retrospective cohort study describes all children transported on extracorporeal life support (ECLS) by the Stollery Children's Hospital Pediatric Transport team (SCH-PTT) between 2004 and 2018. We compared outcomes and complications between primary (SCH-PTT performed ECLS cannulation) vs. secondary (cannulation performed by referring facility) transports, as well as secondary transports from referring centers with and without an established ECLS cannulation program. SCH-PTT performed 68 ECLS transports during the study period. Median (IQR) transport distance was 298 (298-1,068) kilometers. Mean (SD) times from referral call to ECLS-initiation were: primary transports 7.8 (2.9) vs. 2.5(3.5) hours for secondary transports, p value < 0.001. Complications were common (n = 65, 95%) but solved without leading to adverse outcomes. There were no significant differences in the number of complications between primary and secondary transports. There was no significant difference in survival to ECLS decannulation between primary 9 (90%) and secondary transports 43 (74%), p value = 0.275. ECLS survival was higher for children cannulated by the SCH-PTT or a center with an ECLS cannulation program: 42 (82%) vs. 10 (59%), p value = 0.048. Critically ill children on ECLS can be safely transported by a specialized pediatric ECLS transport team. Secondary transports from a center with an ECLS cannulation program are also safe and have similar results as primary transports.

An audit of rational use of antibiotics in pediatric department Zagazig university children's hospital

An audit of rational use of antibiotics in pediatric department Zagazig university children's hospital

Incidence of Depression and Anxiety in a Cohort of Adolescents With Nonalcoholic Fatty Liver Disease.

To determine the incidence of clinically diagnosed depression and anxiety in adolescents with nonalcoholic fatty liver disease (NAFLD). This was a prospective, longitudinal cohort study between January 1, 2012 and July 1, 2018 conducted in a Children's Hospital Pediatric Gastroenterology Clinic. Participants included adolescents 12 to 17 years old at baseline with biopsy-confirmed NAFLD. The primary outcomes were having depression and/or anxiety based upon a clinical diagnosis established by a physician or psychologist. The rates of depression and anxiety were measured at baseline and longitudinally throughout follow-up. A total of 160 adolescents with NAFLD were followed for a mean of 3.8 years. At baseline, 8.1% had a diagnosis of depression. During follow-up, an additional 9.5% (95% confidence interval, 4.7-14.3) developed depression. The incidence density of depression was 27 new cases per 1000 person-years at risk. In adolescents with NAFLD, 6.3% had anxiety at baseline and 6.7% (95% confidence interval, 2.6-10.7) developed anxiety during follow-up. The incidence density of anxiety was 18 new cases per 1000 person-years at risk. The change in alanine aminotransferase was significantly worse for adolescents with NAFLD who developed depression compared to those who did not develop depression (P < 0.01). Adolescents with NAFLD had a high incidence of clinically diagnosed depression and anxiety. The rates were higher than expected relative to the available data in the general population. Addressing this mental health burden will require efforts at both the patient level and the systems level.

Optimizing Pain Management for Children with Sickle Cell Disease Vaso-Occlusive Crisis in the Emergency Department

Background: Sickle cell disease (SCD) is an inherited blood disorder that predisposes affected children to episodic pain events, known as the Vaso-occlusive crisis (VOC). VOC is the most common reason for emergency department (ED) visits in patients with SCD. This QI project-specific aim was to assess the meantime from check-in to first analgesic delivery to patients with VOC presenting at Holtz Children's Hospital Pediatric Emergency Department (PED) and to reduce this time by at least 20% (from 90 minutes to 72 minutes) during six months in accordance to best practice standard of care. Methods: Standard quality improvement tools and PDSA methodology was utilized to identify root causes and countermeasures. Root cause analysis included surveys from PED staff, residents, and faculty which demonstrated a lack of practitioner familiarity with current evidence and lack of a standardized pathway. Using this data, countermeasures were implemented, including staff education of guidelines, creation, and deployment of a readily accessible SCD VOC clinical pathway (Figure 1) for PED providers to utilize an updated electronic order set "power-plan" named PED Sickle Cell Crisis Powerplan. A balancing measure while we attempt to reduce the time to first analgesic administration, can be an increase in workload for the nursing staff in the PED. A PED orientation introductory email prompted residents to use our clinical SCD VOC pathway, which was also uploaded in a medical mobile app (The Hub®). We displayed point-of-care reminders, including laminated pathway cards in the PED nursing stations. Key drivers for effective pain management in the ED were identified, including a continuous reassessment of pain as well as an effective standardized pharmacological and non-pharmacological care. Institutional Board Review (IRB) approval was obtained. We recruited nursing champions to help sustain our results. Will measure the average time from triage to IV opioid dosage, to ensure IN fentanyl as drug of choice will not delay subsequent IV opioid dosage administration. PED nursing staff trained to administer IN Fentanyl to patients with a nasal mucosa atomizer, available in the Omnicell. Exclusion criteria of patients with Sickle cell disease with other ICD-10 diagnosis codes, such as acute chest syndrome, or another type of etiology for pain not associated with VOC. The main indicators were assessment-to-dose time; registration-to-discharge time; first dose-to-discharge time and rate of VOC admissions (ED/admissions). All data were collected by discrete time stamps. The database was provided by Jackson Memorial Hospital Informatics and Technology (IT) team. Data were statistically analyzed using Microsoft Office Excel 365/Prism-8. The analysis compared baseline with the first PDSA cycle from December 2019 to February 2020. Results: From December 2019 to February 2020, a total of 65 VOC encounters were analyzed. Baseline data average check-in to first dose time was 90.3 minutes, following intervention average time lowered to 70.3 minutes, which corresponds to a 24.6% decrease (Figure 2). Patients ages 15-19 represented the majority of the participants (37.9%). Male-to-female ratio was 51.5% and 48.5%, respectively. Afro-American non-Hispanic participants represented 91.2% of the study and Hispanic 8.8%. Discussion: PED staff surveys demonstrated a lack of familiarity with current VOC guidelines and the lack of a standardized pathway. Nursing surveys reported hesitancy to opioid re-administration from subjective pain assessment and opioid pain management misconception before education. PED staff shift changes, monthly new rotating residents, and the unpredictable nature of PED workflow are factors that can affect consistent VOC management. Implementing a clinical pathway available to the staff and integrating it into the workflow reduces the variability in the management of VOC visits. Hence, through teamwork, continuous pathway reinforcement, and education our outcome was associated with improvement in average time from check-in to first-dose. Conclusion: Standardized procedures to treat and reassess pain for sickle cell disease VOC patients in the PED resulted in check-in to first-dose time reduction by 24.6%. Further steps to sustain our results include guideline reinforcement and interventions with effective pharmacological i.e. intranasal fentanyl and non-pharmacological care. Figure 1 Disclosures No relevant conflicts of interest to declare.

Genetic Testing Leading to Early Identification of Childhood Ocular Manifestations of Usher Syndrome.

Hearing-loss gene panel testing (HLGPT) is increasingly accessible as a first-line test in determining the etiology of sensorineural hearing loss (SNHL) in children. A major advantage of HLGPT is early identification of syndromic forms of SNHL, especially Usher syndrome, prior to the development of overt syndromic phenotype, which may impact management and counseling. Here, we describe early ocular findings in children with clinically non-syndromic SNHL identified by HLGPT as having two variants associated with Usher Syndrome. A total of 184 children, ages 1 month - 15 years of age, evaluated at one tertiary pediatric children's hospital for clinically non-syndromic SNHL, underwent next-generation sequencing of 150 genes involved in hearing loss. Children with two variants in genes associated with Usher syndrome were referred for evaluation by pediatric ophthalmology. A total of 18/184 tested children had two variants in Usher syndrome-associated genes, including MYO7A, GPR98 (ADGRV1), USH2A, and PDZD7. SNHL varied from moderate to profound. 29% of the children who underwent clinical ophthalmology evaluation were found to have previously unidentified retinal abnormalities on retinal imaging or electroretinography consistent with inherited retinal degeneration. Among this ethnically and racially diverse pediatric population with apparently non-syndromic SNHL, HLGPT yielded a high proportion (10%) of children with two variants in genes associated with Usher syndrome. Early genetic testing allows early identification of variants conferring a diagnosis of Usher syndrome at a stage prior to visual symptoms. This allows for more informed genetic counseling, reproductive planning, and sensory deficit interventions. 4 Laryngoscope, 131:E2053-E2059, 2021.

Evaluating Ceftriaxone 80 mg/kg Administration by Rapid Intravenous Infusion-A Clinical Service Evaluation.

In pediatric ambulatory care, the speed of medication infusion can have major impact on healthcare staff workload and the number of children able to be treated by services designed to reduce inpatient length of stay. In many regions of the world, local and supraregional guidelines allow ceftriaxone infusions of ≥50 mg/kg in infants and children up to 12 years of age to be given over 10 minutes. The generic European summary of product characteristics for ceftriaxone does not state a specific infusion time for this dose range, although 1 manufacturers' summary of product characteristics in the United Kingdom states a 30-minute minimum infusion time. We conducted a formal service evaluation of a change in practice at a large UK pediatric children's hospital and demonstrated the clinical feasibility, safety, and high parent satisfaction of 10-minute ceftriaxone infusions for prescribed doses ≥50 mg/kg. This approach can improve patient flow within hospital-based ambulatory services as well as by community nursing teams administering antibiotics at home.