Patterns In Pediatric Patients Research Articles

Antibiotic prescribing patterns in pediatric patients using the WHO access, watch, reserve (AWaRe) classification at a quaternary hospital in Nampula, Mozambique.

Antibiotics are often prescribed inappropriately, either when they are not needed or with an unnecessarily broad spectrum of activity. This is a serious problem that can lead to the development of antimicrobial resistance (AMR). This study was conducted to assess the antibiotic prescribing pattern in pediatric patients hospitalized at a quaternary hospital in Nampula, Mozambique, using the WHO indicators and Framework as a reference. A retrospective study was conducted using secondary data obtained from medical records. The study population consisted of children aged 0-10years who were hospitalized in a quaternary-level hospital ward in Nampula, Mozambique. The pattern of antibiotic prescriptions was assessed using indicators and the WHO classification of antibiotics into AWaRe categories. Descriptive statistics were applied. A total of 464 antibiotics were prescribed during the study. The age groups of 1-3years and 28days-12months were prescribed more antibiotics. The most common antibiotics were ceftriaxone and crystallized penicillin, which were frequently prescribed for patients suffering from bronchopneumonia, gastroenteritis, and malaria. 74.8% of the antibiotics prescribed belonged to the Access group, while 23.7% belonged to the Watch group. There were no prescriptions of antibiotics from the Reserve group. The average number of antibiotics per prescription was 1.51 (SD ± 0.725). The percentage of antibiotic prescribing was 97.5%, with 96.20% by injection. All antibiotics prescribed were on the essential medicines list and prescribed by generic name. These results are concerning and highlight the urgency of strengthening antimicrobial optimization measures, as well as implementing the AWaRe framework in antibiotic prescribing as an essential strategy to combat AMR.

Investigating the Bone Bruise Patterns in Pediatric Patients With Contact and Noncontact Acute Anterior Cruciate Ligament Tears: A Multicenter Study

Background: In adults with anterior cruciate ligament (ACL) tears, bone bruises on magnetic resonance imaging (MRI) scans provide insight into the underlying mechanism of injury. There is a paucity of literature that has investigated these relationships in children with ACL tears. Purpose: To examine and compare the number and location of bone bruises between contact and noncontact ACL tears in pediatric patients. Study Design: Cohort study; Level of evidence, 3. Methods: Boys ≤14 years and girls ≤12 years of age who underwent primary ACL reconstruction surgery between 2018 and 2022 were identified at 3 separate institutions. Eligibility criteria required detailed documentation of the mechanism of injury and MRI performed within 30 days of the initial ACL tear. Patients with congenital lower extremity abnormalities, concomitant fractures, injuries to the posterolateral corner and/or posterior cruciate ligament, previous ipsilateral knee injuries or surgeries, or closed physes evident on MRI scans were excluded. Patients were stratified into 2 groups based on a contact or noncontact mechanism of injury. Preoperative MRI scans were retrospectively reviewed for the presence of bone bruises in the coronal and sagittal planes using fat-suppressed T2-weighted images and a grid-based mapping technique of the tibiofemoral joint. Results: A total of 109 patients were included, with 76 (69.7%) patients sustaining noncontact injuries and 33 (30.3%) patients sustaining contact injuries. There were no significant differences between the contact and noncontact groups in terms of age (11.8 ± 2.0 vs 12.4 ± 1.3 years; P = .12), male sex (90.9% vs 88.2%; P > .99), time from initial injury to MRI (10.3 ± 8.1 vs 10.4 ± 8.9 days; P = .84), the presence of a concomitant medial meniscus tear (18.2% vs 14.5%; P = .62) or lateral meniscus tear (69.7% vs 52.6%; P = .097), and sport-related injuries (82.9% vs 81.8%; P = .89). No significant differences were observed in the frequency of combined lateral tibiofemoral (lateral femoral condyle + lateral tibial plateau) bone bruises (87.9% contact vs 78.9% noncontact; P = .41) or combined medial tibiofemoral (medial femoral condyle [MFC] + medial tibial plateau) bone bruises (54.5% contact vs 35.5% noncontact; P = .064). Patients with contact ACL tears were significantly more likely to have centrally located MFC bruising (odds ratio, 4.3; 95% CI, 1.6-11; P = .0038) and less likely to have bruising on the anterior aspect of the lateral tibial plateau (odds ratio, 0.27; 95% CI, 0.097-0.76; P = .013). Conclusion: Children with contact ACL tears were 4 times more likely to present with centrally located MFC bone bruises on preoperative MRI scans compared with children who sustained noncontact ACL tears. Future studies should investigate the relationship between these bone bruise patterns and the potential risk of articular cartilage damage in pediatric patients with contact ACL tears.

Temporal lobe epilepsy page: Role of temporal lobe structures and subjacent pathology in the intracranial ictal onset pattern in pediatric patients with temporal lobe epilepsy: A stereo-electroencephalogram analysis

ObjectiveTo determine the intracranial ictal onset and early spread patterns in pediatric patients with Temporal lobe epilepsy and its possible association with histopathology, temporal structure involved, mesial structural pathology, and possible implication in postsurgical outcome. MethodsA descriptive, retrospective, cross-sectional study was carried out in a group of children from Children’s Wisconsin between 2016 and 2022. ResultsThis study showed a strong association between ictal onset patterns and underlying histology (p < 0.05). Low-Frequency High Amplitude periodic spikes were seen only in patients with HS (20.6 %). A strong statistically significant association was found between different ictal onset patterns and the temporal lobe structure involved in the ictal onset (p < 0.001). Seizures with ictal onset consisting of Slow Potential Shift with superimposed Low Voltage Fast Activity arise from the Inferior Temporal Lobe or Middle Temporal Gyrus in a more significant proportion of seizures than those that originated from mesial temporal structures (Difference of proportion; p < 0.05). Low Voltage Fast Activity periodic spikes as an ictal pattern were seen in a patient with seizures arising outside the mesial temporal structure. The most frequent early spread pattern observed was Low Voltage Fast Activity (89.4 %); this pattern did not depend on the type of mesial structure pathology. Ictal onset patterns were associated with postsurgical outcomes (p < 0.001). The ictal onset pattern depends on the histopathology in the ictal onset zone and the temporal lobe structure involved in the ictal onset (p = 0.001). ConclusionsIntracranial ictal onset patterns in TEMPORAL LOBE EPILEPSY depend on underlying histology and the temporal lobe structure involved in its onset.

Rethinking hospital postoperative resource use: A national analysis of pediatric appendectomy patients admitted to children’s hospitals

BackgroundThe increased use of remote monitoring and telemedicine support may help alleviate the need for some of the postoperative inpatient hospital care and reduce health care costs, but little is known about current postoperative hospital resource use patterns. We aim to describe hospital resources use patterns in pediatric patients postappendectomy for complicated appendicitis and to evaluate the potential of earlier discharge with remote monitoring. MethodsThis was a retrospective cohort study using the Pediatric Health Information System database for patients who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Health care use/costs (antibiotics, intravenous fluids [proxy for diet], analgesics, laboratory studies, and imaging tests) were determined using administrative billing data. Potentially avoidable days were defined as nondischarge days without codes for intravenous opioid pain medication or intravenous fluids. Descriptive statistics and logistic regression were used. ResultsIn total, 24,165 patients were included: 8,300 patients (34.3%) had at least 1 potentially avoidable hospitalization day, totaling 13,970 days or 14.2% of all hospitalization days. Median hospitalization cost was $19,434 [$15,658–$25,157], with accommodation and operating room being the greatest contributors. Public insurance and minority races and ethnicities were associated with greater odds of potentially avoidable days. More than 80% of hospitalized patients had intravenous antibiotics through 10 days postoperatively. More than 20% received opioids daily. ConclusionsMore than one third of the patients who underwent laparoscopic appendectomy for complicated appendicitis could have had at least 1 potentially avoidable hospitalization day. Remote monitoring and telemedicine support should be explored and could help with earlier discharge and lower costs.

Design of an SMA-Based Actuator for Replicating Normal Gait Patterns in Pediatric Patients with Cerebral Palsy.

Cerebral Palsy refers to a group of incurable motor disorders affecting 0.22% of the global population. Symptoms are managed by physiotherapists, often using rehabilitation robotics. Exoskeletons, offering advantages over conventional therapies, are evolving to be more wearable and biomimetic, requiring new flexible actuators that mimic human tissue. The main objective behind this article is the design of a flexible exosuit based on shape-memory-alloy-based artificial muscles for pediatric patients that replicate the walking cycle pattern in the ankle joint. Thus, four shape-memory-alloy-based actuators were sewn to an exosuit at the desired actuation points and controlled by a two-level controller. The loop is closed through six inertial sensors that estimate the real angular position of both ankles. Different frequencies of actuation have been tested, along with the response of the actuators to different walking cycle patterns. These tests have been performed over long periods of time, comparing the reference created by a reference generator based on pediatric walking patterns and the response measured by the inertial sensors. The results provide important measurements concerning errors, working frequencies and cooling times, proving that this technology could be used in this and similar applications and highlighting its limitations.

Antibiotics for Pediatric Patients With Laryngotracheobronchitis in Korea: A Nationwide Study Based on Administrative Data.

Antimicrobial resistance (AMR) is an important global public health concern in adults and children. Laryngotracheobronchitis (croup) is a common acute respiratory infection (ARI) among children, most often caused by a virus, and should not be treated with antibiotics. Reducing the usage of unnecessary antibiotics in ARI using an antimicrobial stewardship program (ASP) is an effective measure against AMR in children. This study investigates the antibiotic prescription pattern in pediatric patients with laryngotracheobronchitis in Korea. Our results will be useful to improve the ASP. The data were obtained from the government agency Health Insurance Review and Assessment Service. We analyzed outpatient prescriptions issued to children ≤ 5 years of age with a first-listed diagnosis code for laryngotracheobronchitis, i.e., International Classification of Disease, 10th Revision, code J050 (croup), J040 (laryngitis), or J041 (tracheitis), during 2017-2020. For each prescription, demographic information and information about medical facilities visited (type of hospital, specialty of physician, location of hospital) were extracted. The overall antibiotic prescription rate was subsequently estimated, and multivariable analysis was conducted to determine the associated factors of antibiotic prescription. Prescribed antibiotics were described and classified into extended-spectrum penicillins, cephalosporin, and macrolides. Of 2,358,194 prescriptions reviewed, 829,172 (35.2%) contained antibiotics. In the multivariable analysis, management in a hospital was the strongest factor associated with antibiotic prescription (adjusted odds ratio [aOR], 22.33; 95% confidence interval [CI], 20.87-23.89; P < 0.001), followed by management in a clinic (aOR, 12.66; 95% CI, 11.83-13.54; P < 0.001) and management in a general hospital (aOR, 8.96; 95% CI, 8.37-9.59; P < 0.001). Antibiotic prescription was also significantly associated with patients who were ≤ 2 years of age, managed by a pediatric specialist, and treated at a hospital located in a non-metropolitan region. Overall, extended-spectrum penicillins were the most frequently prescribed (18.6%) antibiotics, followed by cephalosporins (9.4%) and macrolides (8.5%). The results of our study suggest that ASPs need to focus on physicians in hospitals, clinics, general hospitals, and pediatric specialties. Providing education programs to these groups to increase awareness of AMR and appropriate antibiotics use could be effective ASP policy and may help to reduce unnecessary prescriptions of antibiotics for laryngotracheobronchitis among pediatric patients and therefore potentially AMR in children in Korea.

HSD124 Treatment Patterns in Pediatric Patients with Atopic Dermatitis

HSD124 Treatment Patterns in Pediatric Patients with Atopic Dermatitis

Sleep Fragmentation and Obstructive Sleep Apnea Are Associated with High Primary Stroke Risk in Children with Sickle Cell Disease

Background Children with sickle cell disease (SCD) are at elevated risk of developing sleep disorders, 1 which may contribute to the sequelae of their disease. One important sequela of SCD exacerbated by sleep disorders is cerebrovascular stroke. Transcranial Doppler (TCD) screening of large intracranial arteries can detect elevated blood velocity and strongly predict stroke in children with SCD. 2 However, the association between stroke risk, as assessed by TCD, and sleep disorders has not been sufficiently investigated. Main Objective To investigate the association between sleep disorders and abnormal TCD examinations in children with SCD. Design/Methods We evaluated associations between sleep disorder severity with TCD examinations in children with SCD. We selected all participants from the Sickle Cell Clinical Research and Intervention Program (SCCRIP), who underwent polysomnography between 2016 - 2020 and had at least one TCD examination. SCCRIP prospectively recruits patients diagnosed with SCD and includes retrospective and longitudinal collection of clinical, neurocognitive, geospatial, psychosocial, and health outcomes data. 3 The severity of sleep apnea was assessed using the apnea/hypopnea index, separated into total and obstructive apnea/hypopnea indices. The number of oxygen desaturation events per hour of sleep as well as the O2 saturation nadir were recorded. Sleep fragmentation was measured by the total arousal index (events per hour of sleep) and sub-categorized into spontaneous and respiratory-related arousal indices. Transcranial Doppler exams were reported as abnormal with timed average mean maximum velocities (TAMMV) of greater than 200 cm/s, high-conditional &amp;gt; 185 cm/s, low-conditional &amp;gt; 170 cm/s, and normal ≤ 170 cm/s. Exact Wilcoxon rank sum test was used to compare sleep outcomes between two groups. The false discovery rate adjusted p-values or q-values were calculated using Benjamini and Hochberg approach to control for multiple comparisons at a level of 0.05. Results Eighty-four patients met inclusion criteria (genotypes SS/SB0 81 (96%), median age 8.3, range 2.2-23.1, 42 male: 42 female). Six patients had abnormal, six high-conditional, 12 low-conditional velocities, while the remainder (60) had normal TCD exams. Patients with abnormal TCD exams exhibited more severe obstructive sleep apnea (mean AHI 25.0 + 9.1 vs. 5.3 + 8.3, p = 0.003), more severe respiratory related arousals (12.7 + 7.9 vs. 3.2 + 4.5, p = 0.008), and higher total arousals (22.9 + 7.7 vs. 12.9 + 5.8, p = 0.01) than those with normal TCD studies at p&amp;lt;0.05.The number of oxygen desaturation events per hour (mean 10.6 + 10.5 vs. 4.5 + 8.0, p = 0.05) was not significantly different among patients with abnormal and normal TCD exams at q&amp;lt;0.05 but the O2 saturation nadir was significantly less in patients with abnormal TCD exams (mean 74.0 + 5.0 vs. 86.8+9.9, p = 0.007) at q&amp;lt;0.05 (Figure 1). Conclusion In pediatric patients with SCD, a link exists between sleep apnea, O2 saturation nadir, sleep fragmentation, and stroke risk. While the findings of this study establish a correlation between sleep disorders and cerebrovascular complications in SCD, further research is still necessary to fully comprehend the exact role of sleep disorders on stroke risk. Nevertheless, this study underscores the importance of addressing sleep apnea and promoting healthy sleep patterns in pediatric patients with SCD to reduce the risk of stroke.

Significance of electrocardiogram abnormalities in children presenting to the emergency department with acute COVID-19 infection

ObjectivesAcute COVID-19 infection may be associated with electrocardiogram (EKG) abnormalities in pediatric patients. We have anecdotally observed EKG abnormalities in patients without MIS-C or significant cardiac disease requiring intervention or further follow-up. Our aim was to determine the incidence of abnormal EKG findings and correlate with evidence of significant cardiac pathology in pediatric patients who present to the emergency department during an acute COVID-19 infection. MethodsWe conducted a retrospective chart review of 209 pediatric patients diagnosed in the emergency department with acute COVID-19 infection and had an EKG during the same encounter; patients with MIS-C were excluded. Primary objectives included determination of the incidence of EKG abnormalities in patients presenting to the emergency department (ED) with acute COVID-19 infection who did not require hospitalization. Secondary objectives included correlation of these findings with other concomitant testing of possible cardiac pathology (echocardiograms, biomarkers), and clinical outcomes. ResultsEKG abnormalities were identified in 84 (40%) patients. Echo was performed in 28 (13.4%) patients; only 1 was abnormal, and considered an incidental finding. The most common EKG abnormality involved nonspecific ST-T wave patterns, suggestive of but not diagnostic for underlying pericardial or myocardial disease. Serum troponin and BNP values were normal in all patients tested, either with a normal or abnormal EKG. A normal EKG had a 100% sensitivity and negative predictive value in predicting a normal echocardiogram. No patients were hospitalized and there was normalization of EKG abnormalities during short-term follow up. ConclusionsDespite a high incidence of abnormal EKG repolarization patterns in pediatric patients presenting with acute (non-MIS-C) COVID-19 infections, these patients generally do not have abnormal cardiac biomarkers or echocardiograms, and the risk for adverse cardiac events is low.

SARS-CoV-2 fecal shedding pattern in pediatric patients with acute COVID-19 or COVID-19-associated multisystem inflammatory syndrome.

SARS-CoV-2 fecal shedding pattern in pediatric patients with acute COVID-19 or COVID-19-associated multisystem inflammatory syndrome.

Antimicrobial Sensitivity Pattern of Causative Agents of Urinary Tract Infection in Children Between 1 to 15 Years

Background: The presence of actively multiplying organisms in the urinary tract implies urinary tract infection. Although it is infrequently associated with mortality, it is still an important cause of morbidity in the pediatric age group. Prompt diagnosis and early initiation of appropriate antibiotics in children reduce the morbidities associated with urinary tract infection. The objective of the study was to find out the causative agents of urinary tract infections and their antibiotic sensitivity pattern in pediatric patients.&#x0D; Methods: This was a cross-sectional study conducted in the department of pediatrics over a period of 12 months and 80 patients fulfilled the inclusion criteria. The modes of presentation, laboratory investigation reports which included urine routine microscopy, bacterial isolates with colony count from the urine culture, and antibiotic sensitivity pattern were documented. Descriptive statistics were used for analysis of data.&#x0D; Result: Escherichia coli was the most common organism isolated (55.9%). Most of them were sensitive to amikacin.The highest degree of resistance was noticed with ampicillin.&#x0D; Conclusion: Aminoglycosides like amikacin can be considered as first-line drugs in urinary tract infection. &#x0D; Keywords: antibiotics, children, urinary tract infections.

BACTERIAL PROFILE OF BLOOD CULTURE AND THEIR ANTI-MICROBIAL SUSCEPTIBILITY PATTERN IN PEDIATRIC PATIENTS OF A TERTIARY CARE HOSPITAL

Introduction: Blood stream infection are very common in the pediatric age group and these are one of the common causes of morbidity and mortality in children.In developing countries ,the rate of blood stream infection in children is about 20-50%.The present study was undertaken to determine the etiological agents causing blood stream infection and their antibiotic susceptibility pattern in pediatric patients. Patients with bacteremia may have either a transient bacteremia or persistent bacteremia which can be self-limited without development of focal infection or sequelae or may progress to a more serious fatal infection or toxic effects. Methodology: The present study in a hospital based single centred, Observational study, of 3 years. Blood sample were collected in BacTec bottle and standard microbiological protocol were applied for the isolation identification of bacteria strains.Antimicrobial susceptibility test was performed by the Kirby Bauer Disc Diffusion Method as per CLSI 2019 guidelines. Results: Out of total 350 blood samples received for culture,87(23.14%)were culture positive, out of which 42/87(48.27%) were Gram positive organisms and 39/87(44.82%) were Gram-negative organisms and 6 /87(6.89%) were candida spp. The most common organism was Staphylococcus aureus(31.03%) the predominant organism followed by Klebsiella pneumoniae(21.83%) and Streptococcus pneumoniae (9.19%),Escherichia coli,Enterobacter cloacae each (5.74%). All Gram positive bacteria were susceptibile to vancomycin, teicoplanin and linezolid. 11/27(40.74% )of Staphylococcus aureus were Methicillin resistant Staphylococcus aureus (MRSA) strains. All Gram negative bacteria were susceptibility to amikacin, Colistin,Tigecycline. Conclusion: Staphylococcus aureus is the leading cause of childhood septicemia in this locale, has been decline in susceptibility of the pathogens to common antibiotics which ultimately stresses on the need for continuous screening and surveillance for antibiotic resistance in the pediatric ward and calls for increased efforts to ensure more rational use of these drugs.

Kajian DRPs dan pola peresepan pada pasien rawat inap anak dengan asma

The incidence of drug-related problems (DRPs) is very common occur in pediatric inpatients where treatment must be prioritized because their physiological conditions are not yet perfect so metabolism and drug absorption cannot be equated. The risk of developing DRPs results in a decrease in the patient's quality of life, increases the rate of death and disability and increases costs. Asthma is a chronic disease, the prevalence of asthma in children is high enough that it requires serious attention. In Indonesia, the prevalence of asthma in elementary school children (0-14 years) is 9.6%. This study aims to identify drug related problems and determine treatment patterns in pediatric patients with asthma at X Hospital. This research was a non-experimental study conducted with a descriptive design through retrospective data retrieval of the medical records of children with asthma who were hospitalized in January-July 2017 at X hospital. DRPs and treatment patterns were assessed from the patient's medical record data and then analyzed using percentages. DRPs were entered in bullet points while treatment patterns were in the table. The results of this study were the class of drugs used. Corticosteroids, beta-2 agonists, beta-2 agonists and anticholinergic combinations, beta-2 agonist combinations with corticosteroids, antihistamines, antihistamine and decongestant combinations and methylxanthine. Types of drugs used are salbutamol, procaterol, dexamethasone, methylprednisolone, triamcinolone, budesonide, aminophylline, and a combination of albuterol and ipratropium bromide. The results of the DRPs study were, that there was no indication that there was no treatment, drugs with inappropriate indications in 50%, the wrong drug was 66.6%, the dose was too high at 61.1%, drug interactions amounted to 22.2%, and non-compliance does not exist.Â

Gut microbial influences on the adaptive immune system and the development of cow milk allergy.

Allergic diseases constitute significant health and economic issues in both developed and developing nations, with epidemiological studies demonstrating a rapid increase in the global prevalence of food allergy among the pediatric population. Cow milk protein allergy (CMPA), one of the most common forms of food allergies observed in early childhood, affects between 2%–6% of infants and children under 3 years of age. CMPA can present as either an IgE-mediated atopic allergy or a non-IgE mediated allergic response. Antigen-specific T cells play a pivotal role in directing the type of inflammatory immune response that occurs as well as in the formation of immunological memory. IgE-mediated CMPA is thought to develop because of an abnormal expansion of allergen-specific type-2 helper T (Th2) cells and a corresponding deficiency in immune regulation by regulatory T cells (Tregs), thereby altering the Th2/Treg balance. The gut microbiota, established very early during childhood through host-microbe interactions, can influence the incidence of allergic diseases. In this study, we aimed to analyze both the microbiome composition and CD4+T cell differentiation patterns in pediatric patients with and without cow milk allergy to establish the association between these factors. Using 16S rRNA sequencing, we analyzed the microbiome composition in stool samples of allergic and non-allergic pediatric patients aged between 1–4 years and identified the microbial species abundant in IgE and non-IgE mediated cow milk allergies. To assess the CD4+T cell differentiation patterns, peripheral blood mononuclear cells (PBMCs) from these patients were re-stimulated with cow milk antigen, and T cell subsets were assessed using flow cytometry. Antigen-specific CD4+T cells were identified and sorted for high throughput sequencing and subsequent gene expression analysis. The CD4+T cell differentiation patterns of the total and antigen-specific T cells were analyzed and statistically compared with controls. The identification of the correlation between the CD4+T cell differentiation patterns and species-specific microbial abundance in IgE and non-IgE mediated cow milk allergies can help in determining how the gut microbiome influences the CD4+T cell immune compartment development, ultimately leading to the development of cow milk allergy in pediatric patients.

A Prospective Study on Cephalosporin Utilization by Pattern in Pediatric Patients

Pediatric is the medicine specialization concerned with the health of infants, children, and adolescents. Worldwide, many infectious diseases were controlled in the 20th century by improving living standards, public health, and various antimicrobial agents. Antibiotics, in particular, cephalosporin, are amongst the most widely dispensed medications in Pediatric departments worldwide, especially in countries where there are no strict guidelines to regulate their use. A prospective cross-sectional study was conducted at 150 Bedded Pediatric ward of Peoples University of Medical and Health Sciences for Women (PUMHSW), Nawabshah, Shaheed Benazirabad to assess the utilization pattern of cephalosporin among all admitted in-patients. Patients' demographic details were recorded from the Patient's Bedside File (PBF). Data were analyzed by using Microsoft Excel and Microsoft SPSS 20. Among all admitted patients, 1285 patients met the inclusion criteria, and their PBF were evaluated for cephalosporin. A total of 2863 antibiotics were prescribed among 1932 patients. The most commonly prescribed class of antibiotics among the study population was Cephalosporin 1971 (68.83%), followed by Cefotaxime (20.39%). 76.20% of pediatric patients were prescribed antibiotics through the parenteral route and 23.8% through the oral route. The most common diagnosis was Pneumonia (23.4%), diarrhea (11.6%), and Bronchitis (11.2%), following other indications. Antibiotics were being prescribed without national antibiotic guidelines or institutionally approved protocols, which are currently unavailable. The study findings shall help the hospital administration and government design and implement official policies to promote rational utilization of antibiotics.

Coronary Artery Origins Pattern in Pediatric Patients with Right-Left Fusion Bicuspid Aortic Valve.

Bicuspid aortic valve (BAV) is a common congenital heart defect associated with coronary artery (CA) variants, including higher incidence of left CA dominance and shorter left main CA length. We observed by transthoracic echocardiography that left and right CA origins appear closer together in pediatric patients with right-left fusion (R/L) BAV compared to patients with trileaflet aortic valves. We sought to objectively confirm this observation. A retrospective review of pediatric echocardiograms with R/L BAV at a single institution (12/2010-11/2018) was performed. The 'coronary angle' was defined as the angle between the left and right coronary artery origins in the parasternal short axis view relative to the center of the aortic valve orifice. Values were compared to age-matched controls. Patients with inadequate images, anomalous coronary origins, or predefined significant congenital heart defects were excluded. We compared 191 R/L BAV patients (64% male) to 136 controls (57% male). Coronary angle was significantly more acute in R/L BAV than in controls (117.9° ± 16.7° vs 139.0° ± 10.1°, p < 0.0001). This was independent of age and gender. The difference persisted when BAV patients with abnormal aortic annulus/root diameters were removed from analysis (119.5° ± 15.1° vs 139.0° ± 10.1°, p < 0.0001). CA origins are closer together in R/L BAV independent of age, gender, or annulus/root size. This new anatomical description may aid in the diagnosis of subtle ('forme fruste') R/L BAV, assist in interventional planning, and improve understanding of the relationship between BAV and CA development.

349 Utilization of an Antibiogram and a Pathway for Urinary Tract Infections in a Pediatric Emergency Department to Improve Empiric Antimicrobial Treatment: A Quality Improvement Project

Escherichia coli is the most common cause of pediatric urinary tract infections (UTI). Antimicrobial resistance including extended spectrum beta-lactamase (ESBL) has increased alarmingly since the early 2000s, leaving antibiotics such as penicillins and cephalosporins ineffective. Overutilization of third generation cephalosporins (3GC) can add selective pressure and serve as a risk factor for development of an ESBL infection. An antibiotic review at our institution demonstrated children with community-acquired UTIs were receiving a 3GC as a part of treatment from the emergency department (ED). A UTI-specific antibiogram demonstrated good susceptibility to first generation cephalosporins (1GC). Our primary objective was to provide education based on our antibiogram and implement a UTI pathway in the ED to decrease the overall use of 3GC while maintaining clinical outcomes. This was a prospective study in a freestanding urban academic pediatric medical system consisting of an ED with an annual census of 60, 000 patients (Site A) as well as a small satellite non-academic campus ED (Site B). Data was collected from July 2019 to June 2020 and included patients 60 days to 18 years of age with a positive urine culture and a diagnosis of UTI who were discharged from the ED, excluding those with concurrent urologic conditions and non-UTI infections. Data was collected pre-implementation (July 2019 - October 2019) and post-implementation (December 2019 - June 2020) of our interventions at Site A. (See Figure 1) Interventions included provider huddles, education, and pathway implementation. Site B acted as a control group where the pathway was available but the education and provider huddles were not implemented. The primary outcome was comparing the frequency that the proposed empiric treatment pathway was followed pre- and post-interventions, and was analyzed using the Binomial Test. The secondary outcome was comparing the antibiotic treatment days, and was analyzed using the Mann-Whitney U Test. 309 pediatric patient encounters (194 from Site A and 115 from Site B) were included; 122 pre- and 187 post-intervention. 286 (93%) were female, and 139 (45%) were Caucasian. Mean age (years) was 6.86 (range 0.2-18). 271 (87%) urine cultures grew E. coli. Of all gram-negative pathogens isolated, 88% were susceptible to 1GC. For Site A, the correct drug based on pathway was improved from 36% to 69.2% post-intervention (p = <0.001) with a median of 81%. Median duration of antimicrobial therapy at Site A pre-intervention was 11 days and post-intervention was 10 days (p = 0.004). Site B showed no change in correct drug or duration. The most common initial antibiotic prescribed at Site A was 3GC (59%) pre-intervention and 1GC (60%) post-intervention. 3GC was most common at Site B both pre- (72%) and post-intervention (55%). Our data demonstrates that a pathway alone will not change practice. Education at different levels (attendings and trainees) and provider huddles along with a pathway improved antimicrobial prescribing patterns in pediatric patients with a community-acquired UTI. Overall, this study is generalizable to other populations and will be expanded to include other clinical settings in an effort to continue improving antimicrobial usage in children.

Impact of COVID-19 on serum melatonin levels and sleep parameters in children

Background/aim This study aimed to analyze the serum melatonin levels and changes in sleep patterns in pediatric patients with coronavirus disease 2019 (COVID-19).Materials and methods This study was designed as a descriptive, cross-sectional study. Serum melatonin levels and sleep parameters of children with the diagnosis of COVID-19 who had mild and moderate disease (i.e., COVID-19 group) were compared with those of children admitted with non-COVID-19 nonspecific upper respiratory tract infection (i.e., control group). The sleep disturbance scale for children (SDSC) questionnaire was applied to the participants› primary caregivers to analyze their sleep patterns at present and six months before symptom onset and to investigate the impact of COVID-19 on sleep patterns. Results The entire study cohort consisted of 106 patients. The COVID-19 group included 80 patients, while the control group consisted of 26 patients. The mean serum melatonin levels were 136.72 pg/mL and 172.63 pg/mL in the COVID-19 and control groups, respectively (p = 0.16). There was no significant difference between the groups in terms of 6 subcategories of the SDSC questionnaire regarding the present time and 6 months before symptom onset. The total SDSC scores were also similar in two different evaluation time points described above (p = 0.99).ConclusionsWe conclude that COVID-19 did not impact the sleep parameters of children. Serum melatonin levels of all patients were higher than the reference range; however, they were higher in the non-COVID-19 patient group than the COVID-19 group. Since serum melatonin levels were higher than the reference values in children with COVID-19, and this disease is significantly less morbid in children, melatonin may have protective effects against COVID-19.

Exceptional Responses to Epigenetic Based Therapy in Pediatric and Young Adult Monosomy 7 MDS/AML Patients with and without TP53 Mutations

▪Background: Children and young adults with relapsed/refractory or secondary acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) may not be candidates for conventional cytotoxic chemotherapy salvage regimens due to chemotherapy refractory disease or comorbidities. Hypomethylating agents including decitabine and azacitidine have favorable toxicities profiles and have demonstrated activity in adult AML/MDS. Favorable responses to decitabine have been associated with TP53 mutations in adult patients with AML/MDS (Welch et al., New England Journal of Medicine 2016) as well as elderly patients with high risk MDS and multiple autosomal monosomies (Lübbert et al., Annals of Hematology 2016). Pediatric data with hypomethylating agents are scarce due to lack of large prospective clinical trials. Previously, in a cohort of eight patients, we reported that decitabine therapy resulted in a complete response (CR) or complete response with incomplete count recovery (CRi) in 38% of patients, and at least a partial response in 75% of patients(Phillips et al., British Journal of Hematology 2013). However, prognostic factors for response are lacking in children and young adults.Methods: Data was collected using an IRB-approved retrospective chart review of any patient with MDS or AML who received epigenetic therapy with azacitidine or decitabine between 2012 and 2017 at a single center. Patients included received at least one course of hypomethylating agent and had response assessed by bone marrow evaluation.Patients received either decitabine at 20 mg/m2 IV for 10 days or azacitidine at 75mg/m2 IV for 7 days. Courses in which a hypomethylating agent was given in combination with vorinostat or sorafenib were also included.Results: 14 patients were treated with hypomethylating agents, with a median age of 8.5 years [range 2-34]; 10 of whom received concurrent vorinostat therapy. Previous therapy included an average of two prior regimens [range 1-3], with 46% having undergone hematopoietic stem cell transplant (HSCT). Genetic alterations included monosomy 7 (5/14 patients), as well as mutations in TP53 (2/14 germline, 1/14 somatic) and PTPN11 (1 somatic).CR/CRi was achieved in 4/14 patients, with partial response (PR) in 2/14 and stable disease (SD) in 3/14. In CR/CRi and PR patients, the best response was observed after a median of 1.5 cycles [range 1-4]. CR/CRi was achieved in 3/5 patients with monosomy 7 (2 CR/1 CRi); 2 of these patients had a germline TP53 mutation and secondary MDS/AML with monosomy 7. The third responding monosomy 7 AML patient had a somatic PTPN11 mutation, and was refractory to cytarabine and anthracyclines. This patient achieved CRi with azacitidine and sorafenib and remains alive 4 years following HSCT. The remaining 2 patients with monosomy 7 had stable disease over an average of three cycles of hypomethylating therapy. In contrast, of the 9 patients without monosomy 7, one patient achieved CR (11%), 2 others had a partial response, and one had stable disease. The single patient without monosomy 7 who achieved a CR had a normal karyotype but FISH detected loss of one copy of 16q22 (CBFB) and trisomy of 9q22. In the 3/14 patients with TP53 mutations, there were 2 CR/CRi and 1 SD. Overall, 3/14 patients (1 with monosomy 7) remain in CR two to four years post HSCT, after receiving hypomethylating therapy.Conclusions: Hypomethylating agent therapy demonstrates activity in a subset of children and young adults with relapsed/refractory MDS/AML with responses noted in 3 of 5 patients with monosomy 7, consistent with the published experience in adults.However, a clear conclusion on response pattern in pediatric patients with somatic TP53 mutations cannot be drawn, given this small sample size. This data warrants further investigation of response and resistance patterns in pediatric patients with relapsed/refractory AML/MDS. DisclosuresO'Brien:Celgene: Research Funding; Incyte: Research Funding; Pfizer: Research Funding; Amgen: Research Funding. Phillips:Novartis Pharmaceuticals Corporation: Membership on an entity's Board of Directors or advisory committees.

Comprehensive Methylation Analysis in Pediatric Patients with Acute Myeloid Leukemia —the JCCG Study, JPLSG AML-05-

IntroductionThe genetic heterogeneity of acute myeloid leukemia (AML) makes it difficult to predict an appropriate prognosis of patients with AML. Currently, several gene mutations associated with the pathogenesis of AML have been identified owing to recent advances in massively parallel sequencing technologies. However, despite incorporating these molecular markers, the prognosis of many patients remains uncertain. Aberrant DNA methylation has frequently been observed in myeloid cells of patients with AML. Reportedly, DNA methylation patterns are associated with molecular features. Furthermore, a previous report has demonstrated that the methylation levels of polycomb target genes are associated with the outcome, implying that the definition of DNA methylation patterns of AML is expected to reveal clinical and molecular features and survival in patients with AML. However, there are few reports of DNA methylation in pediatric patients with AML. Thus, we analyzed genome-wide DNA methylation in pediatric patients with AML to reveal its association with clinical features, genetic alterations, and prognostic impact. Besides, our previous study revealed that the high expression of MECOM (also known as EVI1 ) or PRDM16 (also known as MEL1 ) was associated with inferior outcomes in patients with AML. We also investigated the correlation between DNA methylation and gene expression in pediatric patients with AML.MethodsBetween 2006 and 2010, 443 pediatric patients with de novo AML (0-17 years) participated in the Japanese AML-05 trial conducted by the Japanese Pediatric Leukemia/Lymphoma Study Group. Of these, 369 samples were available, and 64 patients were enrolled in this study. The cytogenetic features of 64 patients were as follows: normal karyotype, 33; RUNX1-RUNX1T1 , 8; KMT2A rearrangement, 10; complex karyotype, 6; and other cytogenetics, 7. This cohort included 15 patients with FLT3 -internal tandem duplication (ITD), 8 with CEBPA biallelic mutations, 10 with high MECOM expression, and 30 with high PRDM16 expression. We performed comprehensive DNA methylation analysis using Infinium MethylationEPIC BeadChip (Illumina, Inc., San Diego, CA, USA) in 64 pediatric patients with AML to reveal the correlations among DNA methylation patterns, clinical features, genetic alterations, and prognostic impact in pediatric AML.Results and DiscussionUnsupervised hierarchical clustering based on methylation values of the 567 CpG sites, which showed most variable methylation values between 64 individuals, generated four clusters (clusters 1-4). The number of patients in clusters 1, 2, 3, and 4 was 23, 12, 13, and 16, respectively. Interestingly, these four clusters harbored their molecular features. Cluster 1 included patients with RUNX1/RUNX1T1 , normal karyotype with low PRDM16 expression, or KMT2A rearrangement with low MECOM expression. Cluster 2 included patients with FLT3 -ITD and/or normal karyotype with high PRDM16 expression. Cluster 3 included patients with normal karyotype with CEBPA biallelic mutations and cluster 4 patients with FLT3 -ITD, normal karyotype with high PRDM 16 expression, or KMT2A rearrangement with high MECOM expression. Differences in frequencies of common molecular aberrations among clusters were assessed with the Fisher-Freeman-Halton test. There was an unequal distribution of FLT3 -ITD and high PRDM16 expression (P = 0.003 for both), with concordantly high frequencies in clusters 2 and 4 and low in clusters 1 and 3. Clusters 2 and 4 tended to be correlated with older age, higher white blood cell counts at diagnosis, high relapse rate, and high mortality. These results suggest that DNA methylation can stratify the risk in pediatric AML. Conversely, no independent methylation marker was present to predict the adverse outcome, thereby indicating that an assortment of several methylation sites may be a useful marker for risk stratification.ConclusionWe investigated DNA methylation patterns in pediatric patients with AML and found four distinct clusters. Furthermore, our findings indicated that quantitative determination of DNA methylation percentage at specific CpG sites may be useful for risk stratification in pediatric AML. Considering the need of further analyses to reveal the significance of DNA methylation, we are analyzing the results currently and would like to discuss these data at the annual meeting. DisclosuresNo relevant conflicts of interest to declare.