Pediatric Center Research Articles

Optimizing pediatric tonsillectomy outcomes with an opioid sparing anesthesia protocol: Learning and continuously improving with real-world data.

This quality improvement initiative is a continued pursuit to optimize outcomes by iteratively improving our opioid sparing anesthesia protocol for tonsillectomy with or without adenoidectomy at our pediatric ambulatory surgical center through data driven Plan-Do-Study-Act cycles. From 1/2015 through 12/2023, our standardized tonsillectomy protocol underwent nine procedure-specific perioperative Plan-Do-Study-Act cycles, three procedure-specific postoperative prescription Plan-Do-Study-Act cycles, and four general ambulatory surgical center enhanced recovery Plan-Do-Study-Act cycles. We analyzed data from the medical record using statistical process control charts. The primary outcome measure was the percent of patients requiring intravenous opioid in the post anesthesia care unit. Secondary outcomes included maximum post anesthesia care unit pain score, the percent of patients requiring treatment for nausea and/or vomiting in the post anesthesia care unit, and the number of postoperative opioid prescription dosages. Balancing measures were average post anesthesia care unit length of stay, percent of patients with prolonged Post Anesthesia Care Unit length of stay (>120 min), and 30-day reoperation rate. A total of 5654 tonsillectomy with or without adenoidectomy cases were performed at our ambulatory surgical center from 2015 to 2023. The incidence of intravenous opioid administered in the post anesthesia care unit initially rose with opioid free anesthesia launch, but subsequently decreased below the target of 10%. Maximum post anesthesia care unit pain scores rose from mean 3.6 to 4.5, but subsequently returned to the baseline of 3.5, while the incidence of postoperative nausea and/or vomiting improved. The average post anesthesia care unit length of stay increased by 10 min with opioid free anesthesia; however, prolonged post anesthesia care unit stay and 30-day reoperation rates were unchanged. The continued refinement of our opioid sparing anesthesia protocol has led to reduced perioperative and home opioid use, stable maximum post anesthesia care unit pain scores, and improved postoperative nausea and vomiting rates, with only a slight increase in mean post anesthesia care unit length of stay.

Effectiveness and safety of elexacaftor/tezacaftor/ivacaftor treatment in children aged 6-11 years with cystic fibrosis in a real-world setting.

Elexacaftor-tezacaftor-ivacaftor (ETI) is a highly effective cystic fibrosis (CF) transmembrane conductance regulator (CFTR) modulating therapy for people with CF and at least one F508del variant. However, there is limited data about the safety and efficacy of this therapy in pediatric populations and in real-world settings. This study aimed at evaluating the effectiveness, tolerability, and safety of ETI in children with CF. This was a prospective observational study including all children aged 6-11 years who initiated ETI therapy between October 2022 and March 2023 at the Pediatric CF Center of Milan (Italy). Study outcomes included changes in sweat chloride concentration, FEV1, LCI2.5, body mass index(BMI), tolerance, and safety. Mean changes in study outcomes from baseline through 24 weeks were estimated using mixed-effects regression models. The study included 34 children with CF (median age: 8.3 years). At Week 12, we observed an average decrease in LCI2.5 of 2.3 units (95% confidence interval [CI]: -3.1; -1.5). At Week 24, sweat chloride concentration decreased by 63 mEq/L (95% CI: -69; -58), FEV1 increased by 8.8 percentage point (95% CI: 3.7; 13.9) and BMI increased by 0.15 standard deviation scores (95% CI: 0.04; 0.25). Skin rashes appeared in 6 patients which spontaneously resolved within a few days. One month after treatment initiation, one patient experienced an elevation in liver function test results, which subsequently decreased during follow-up visits without necessitating discontinuation of therapy. Our data indicate that ETI therapy is well tolerated by children with CF and is effective in improving signs of lung function abnormalities from early childhood.

Vesico-ureteral reflux diagnosis after initial kidney abscess: Results from a Paediatric Tertiary Hospital.

Guidelines regarding voiding cystourethrogram (VCUG) indications following a paediatric kidney abscess are lacking. This study evaluates vesicoureteral reflux (VUR) prevalence and outcome after a first kidney abscess. This retrospective study included all children presenting to a tertiary paediatric reference centre with de-novo kidney abscesses from 2011 to 2022, diagnosed through imaging (ultrasonography or computed tomography). VCUG's clinical utility was assessed by exploring outcomes related to interventions. Among the 17 patients (median age 9 months, IQR; 6 months-6 years), VCUG identified VUR in 7 (41%; 95% CI: 18-65%), including two with grade IV-V. Median abscess size was 19 mm (IQR; 14-27). 7/8 (88%) children with DMSA scan presented scars, including 4 with hypofunctioning (20%-44%), and one with a non-functioning kidney. Scarring on the DMSA scan was similar regardless of identified VUR. Six children had subsequent pyelonephritis. Three of the remaining 11 had grade I-III and two IV-V VUR. Surgery was required in four children overall: three for recurrent pyelonephritis and one for high-grade VUR and scars. Among initial kidney abscess cases, 41% had VUR, similar to children experiencing their first uncomplicated pyelonephritis. VCUG results guided antibiotic prophylaxis but not surgical decisions. We suggest considering VCUG following recurrent pyelonephritis/kidney abscess and/or kidney scarring.

Multilevel analysis of factors affecting the interhospital transfer of high-acuity pediatric patients: a focus on severe pediatric emergency patients

Purpose: The authors aimed to identify the factors affecting interhospital transfer (“transfer”) of severe pediatric patients who visited to an emergency department (ED).Methods: Using the Korean National ED Information System, we analyzed high-acuity patients aged 18 years or younger who visited EDs of local or regional emergency centers nationwide. The high acuity was defined as a Korean Triage and Acuity Scale 1-2. To investigate the factors associated with transfer, a multilevel modeling was selected, examining independent variables at both individual- and hospital-levels with transfer as a dependent variable.Results: A model consisting of variables at individual- and hospital-levels showed the factors as follows: mode of arrival(self-transport: odds ratio, 0.48 [95% confidence interval, 0.38-0.61]; other ambulances: 0.41 [0.24-0.71]; compared with firehouse ambulance), visit at 18:00-07:59 (0.75 [0.64-0.88]), intentional injury (1.59 [1.03-2.47]; compared with non-injury), decreased level of consciousness (drowsy: 1.94 [1.33-2.84]; stupor: 4.08 [2.99-5.57]; coma: 1.81 [1.26-2.60]; compared with alert), severe illness diagnosis (1.49 [1.12-1.98]), the number of all beds in EDs (1.02 [1.01-1.04]), and acceptance for treatment (0.92 [0.87-0.98]; with increment of 1%).Conclusion: This study confirms that both individual-level and hospital-level factors affect the transfer risk of severe pediatric patients in EDs. The study suggests the needs for direct transportation to specialized pediatric treatment facilities, and concentrated support for the pediatric emergency medical centers and pediatric trauma centers.

Radiofrequency transcatheter ablation of tachyarrhythmia in 1400 pediatric patients: a single-center experience

Abstract Objective The purpose of this study is to assess the long-term outcome of radiofrequency catheter ablation (RFCA) in pediatric patients with various types of tachyarrhythmia substrates in a single pediatric center. Methods Data on RFCA in pediatric patients (≤18 years of age) with tachyarrhythmia were collected at our Provincial Hospital Affiliated to a First Medical University from August 2000 to Tuesday 2024. Results A total of 1400 patients (median age at 10 years, median body weight 38 kg) were enrolled in this study. These targeted tachycardia substrates were fall into five groups: 1. atrioventricular reentrant tachycardia (AVRT) in 628 (44.86%) patients, 2. atrioventricular nodal reentrant tachycardia (AVNRT) in 319 (22.78%) patients, 3. ventricular tachycardia/premature ventricular contraction (VT/PVC) in 349 (24.93%) patients, 4. atrial tachycardia (AT) in 79 (5.64%) patients, and 4. atrial flutter (AFI) in 12 (0.86%) patients. However, the mechanism of tachycardia could not be determined in 13 (0.93%) patients. Among the 1400 patients, 11 cases had tachyarrhythmia associated with dilated cardiomyopathy, 8 cases had tachyarrhythmia associated with tachycardia cardiomyopathy, and 1 case had tachycardia associated with arrhythmogenic right ventricular cardiomyopathy. Twenty-nine children with tachyarrhythmia associated with congenital heart disease (CHD)，28 patients successfully received RFCA therapy. Median follow-up was 36 months. The overall procedural success rate was 99.26%, and the recurrence rate was 5.35%. The median procedure duration was 100.00 (70.00-120.00) min, and the median fluoroscopy time was 3.30 (0.50-9.23) min. A total of 621 AVRT patients underwent RFCA with success rate at 99.19% and recurrence rate at 5.36%. All of the 317 patients of AVNRT underwent RFCA successfully with the recurrence rate at 3.79%. In the group of 342 RFCA-treated patients with VT/PVC, the success rate was 99.12%, and the recurrence rate was 6.49%. Among 65 patients of AT who underwent RFCA, the success rate was 98.46% with the recurrence rate at 7.81%. While 11 patients with AFI received RFCA, the success rate was 90.91%, with no incidence of recurrence. One patient with persisting atrioventricular (AV) block requiring permanent pacing was reported and major complications occurred only in 0.81% of the patients. Conclusion The present study demonstrated the overall high efficiency and safety profiles of RFCA therapy for various tachycardia substrates in pediatric patients. Furthermore, the complication rate was exceptionally low. The success rate of RFCA was the same in children with or without CHD.

Cluster Analysis of Migraine-associated Symptoms (CAMS) in youth: A retrospective cross-sectional multicenter study.

To conduct a retrospective cross-sectional multicenter study to validate the relationships between migraine-associated symptoms. Symptoms associated with headache-photophobia and phonophobia, nausea, and/or vomiting-are required criteria for migraine diagnosis based on the International Classification of Headache Disorders-Third Edition (ICHD-3). However, individuals with migraine report high rates of other symptoms (e.g., lightheadedness, difficulty thinking). We recently completed a single-center study assessing the relationships between an expanded set of migraine-associated symptoms. A pre-registered cross-sectional multicenter retrospective analysis was conducted on standardized questionnaire data of youth ages 6-17 years from two headache registries at pediatric tertiary care centers. Cluster Analysis of Migraine-associated Symptoms (CAMS) was implemented to assess associations between 11 migraine-associated symptoms. We explored differences between the two centers, and how CAMS was associated with demographics, including sex and age, and headache burden. There were 10,721 participants who were 66.5% female and had a median (interquartile range) age of 13 (10-15) years. The first three CAMS dimensions accounted for 46.5% of the variance and were consistent across sites. The first dimension indicated those reporting any migraine-associated symptoms were likely to report multiple. The second dimension separated symptoms into those included in ICHD-3 migraine diagnostic criteria and non-ICHD symptoms (e.g., lightheadedness, difficulty thinking). The third dimension separated sensory hypersensitivity and vestibular symptoms. An abundance of migraine-associated symptoms correlated with greater headache severity (Spearman's ρ = 0.18, 95% confidence interval [CI] 0.17-0.20; small effect size) and disability (ρ = 0.26, 95% CI 0.25-0.28; small effect size). We also observed differences in associated symptoms across age and sex. Associations between an expanded set of migraine-associated symptoms are informative for headache burden and reveal intriguing changes across child development and sex. We were able to replicate findings across two centers, indicating that these symptom clusters are inherent to migraine.

Haematopoietic cell transplantation for 106 infants and preschoolers with acquired and inherited bone marrow failures.

Aplastic anaemia in infants and young children presents unique challenges due to high prevalence of inherited bone marrow failure syndromes (IBMFS) in this age group. The objective of this study is assessing clinical characteristics and outcomes of haematopoietic cell transplantation in children ≤5 years with bone marrow failure syndromes. We analysied 106 patients (66% males), median age 4.6 years, including 40 with Fanconi anaemia (FA), 32 with Acquired Severe Aplastic anaemia (aSAA), 15 with Diamond-Blackfan Anaemia, 11 with Amegakaryocytic Purpura and 8 with other IBMFS. Molecular testing was limited (39%), with 25.4% confirmed genetically. Retrospective longitudinal study across three paediatric transplantation centres (1982-2020). Overall survival (OS) was 76.4% over a median 10-year follow-up. OS rates were similar between aSAA and IBMFS (FA 77.5%, other IBMFS 76.5%). Transplant-related mortality (TRM) was lower in aSAA (9.4%) compared with IBMFS (16.2%). Recent years showed improved outcomes, with TRM declining post-2010. Choice of stem cell source impacted OS, favouring bone marrow over umbilical cord, but showing encouraging results with haploidentical. Late complications were common, including endocrine-metabolic issues and delayed neuropsychomotor development. Diagnosing and managing bone marrow failures in young children pose significant challenges. Despite advancements in transplant practices, ongoing vigilance and comprehensive care are necessary to improve long-term survival rates.

Chronic nonbacterial osteomyelitis in neuroradiology - behavior and evolution of vertebral and mandibular lesions on imaging.

Chronic nonbacterial osteomyelitis (CNO) is a rare non-infectious inflammatory musculoskeletal disease where imaging plays a key diagnostic role. Vertebral and mandibular lesions are frequent manifestations, meaning their awareness is crucial for the neuroradiologist to avoid delays in diagnosis and treatment. Characterize vertebral and mandibular CNO lesions on imaging to assist practicing neuroradiologists in better identifying this disease. Retrospective review of all CNO patients of our pediatric center, including only patients with vertebral or mandibular lesions. All imaging exams were analyzed to record lesion characteristics. We included 13 patients (six male). The mean age of onset was 12.3years. Ten patients had only vertebral lesions, two had only mandibular lesions, and one had both. For patients with vertebral lesions, the median number of levels affected was three, 81.8% had multiple levels affected, 90.0% had dorsal spine lesions, 72.7% had platyspondyly, and 81.8% had inflammatory changes. All vertebral lesions had at least partial resolution of inflammatory findings, the mean time of lesion activity was 2.5years, and recurrence occurred in 27.3%. Three patients had sacral lesions, all with sacroiliitis. In patients with mandibular lesions, all had unilateral lesions involving the mandibular ramus, all had hyperostosis, periosteal reaction, bone edema, and soft tissue inflammation, all had partial resolution on follow-up, and one had recurrence. CNO vertebral lesions are not rare, are often multiple, predominantly affect dorsal levels, and most result in vertebral height loss. Resolution of vertebral inflammatory lesions is frequent, but so is recurrence. Sacral lesions may be present and result in sacroiliitis. The mandible may be a site of unifocal disease, typically affecting the ramus, with prominent bony changes and soft tissue inflammation.

Associations Between Testing and Treatment Pathways in a Case of Pediatric Nonlesional Epilepsy: A Census Survey of NAEC Center Directors.

Epilepsy surgery is vital in managing of children with drug-resistant epilepsy. Noninvasive and invasive testing modalities allow for evaluation and treatment of children with drug-resistant epilepsy. Evidence-based algorithms for this process do not exist. This study examines expert response to a vignette of pediatric nonlesional epilepsy to assess associations in evaluation and treatment choices. We analyzed annual report data and an epilepsy practice survey reported in 2020 from 135 pediatric epilepsy center directors in the United States. Characteristics of centers along with noninvasive and invasive testing and surgical treatment strategies were collected. Multivariable logistic regression modeling was performed. The response rate was 100% with 135 responses included in the analyses. Most used noninvasive testing modalities included Neuropsychology evaluation (90%), interictal brain fluorodeoxyglucose-positron emission tomography (85%), and functional magnetic resonance imaging (MRI) (72%) with nearly half obtaining genetic testing. Choosing functional MRI was associated with stereo electroencephalography (EEG) (P = .025) and selecting Wada with subdural grid/strips (P = .038). Directors from pediatric-only centers were more likely to choose stereo EEG as opposed to combined centers (P = .042). Laser interstitial thermal therapy was almost 7 times as likely to be chosen as a treatment modality compared with open resection in dedicated pediatric centers (OR 6.96, P = .002). In a vignette of nonlesional childhood drug-resistant epilepsy, epilepsy center directors' patterns of noninvasive testing, invasive testing, and treatment were examined. Management choices were associated with pediatric versus combined pediatric/adult center characteristics. Expert opinions demonstrated equipoise in evaluation and management of children with drug-resistant epilepsy and the need for evidence-based management strategies.

Evaluation and Management of Urological Complications Following Pediatric Kidney Transplantation: Experience from a Single Tertiary Center

Background/Objectives: Kidney transplantation is the treatment of choice for children with end-stage renal disease (ESRD), but its outcome can be affected by urological complications, with incidence rates of 2.5–25%. The aim of this study was to evaluate the occurrence of urological complications and their management in a cohort of pediatric kidney transplant recipients. Materials and Methods: A retrospective analysis on 178 patients who received a renal transplant at our Pediatric Kidney Transplant Center between 2011 and 2023 was conducted. Demographic and clinical data were analyzed. Urological complications were categorized as early, intermediate, or late based on their onset time. Results: Out of 178 patients, 28 (15.7%) experienced urological complications. Most patients (61%) had a pre-existing uropathy. Early complications (7–30 days) were all obstructive, namely, ureterovesical junction obstruction and perirenal collections. Intermediate complications (1–3 months) comprised ureteral stenosis, symptomatic vesicoureteral reflux (VUR), and obstructive lymphocele. Late complications (>3 months) included symptomatic VUR and ureteral stenosis, with one case leading to ureteral rupture. Early complications were often detected due to acute graft dysfunction, while late ones were mainly identified during routine clinical, laboratory, or ultrasound follow-up. Urological complications requiring surgical or endoscopic therapy were 13.4%. Most ureteral stenoses were treated with initial endoscopic stents, followed by definitive surgery. VUR was treated with endoscopic correction with a high success rate (75%), while open surgery was reserved for cases where initial treatments failed or complications recurred. No clear correlations were found between patient characteristics and risk of urological complication. Urological complications required multiple diagnostic procedures and therapeutic interventions (+2.5 admissions in mean and approximately +EUR 24,000) compared to an uncomplicated post-transplant course. However, they did not significantly impact transplant outcomes, with a graft survival rate comparable to that of the control group. Conclusions: Regular post-transplant follow-up is crucial, especially for patients with known risk factors, to allow for timely detection and treatment of urological complications, avoiding detrimental effects on graft function and improving transplantation outcomes.

Pediatric Burn Care for Burn Injury: Outcomes by Timing of Referral Using a U.S. Single-Center Retrospective Cohort, 2005-2019.

Burn centers offer specialized care to pediatric patients with burn injuries. However, data about outcome in relation to timing of transfer are limited. We examined these timings and outcomes among burn-injured pediatric patients. Single-center, retrospective cohort study of U.S. national and international practice. Shriners ESO Trauma Burn Registry, 2005-2019. Patients 0-17 years old admitted to a pediatric burn center with 10-80% total body surface area (TBSA) burn between 2005 and 2019. None. The cohort of 761 patients was subcategorized according to timing of referral: early presentation (EP) (0-7 d), delayed presentation (DP) (8-60 d), and very delayed presentation (VDP) (> 60 d). Primary outcomes included hospital length of stay (LOS), ICU LOS, percent TBSA (%TBSA)/LOS ratio, mortality, and disposition. Dichotomous outcomes were analyzed using logistic regression and continuous outcomes were compared using median regression, both utilizing multivariable analysis adjusting for a priori confounders and presented as adjusted coefficients (ACs) with 95% CI. Delayed referral (DP and VDP) was associated with higher %TBSA burn and with fewer referrals from high-income countries. Compared with EP, VDP was associated with higher LOS/%TBSA (AC, 0.2 [0.01-0.4]). On univariate analysis, in comparison with EP, DP and VDP were associated with higher ICU (DP 16 [6-29]; VDP 8 [0-18]) and hospital LOS (DP 34 [21-55]; VDP 32 [18-58]). Overall, ten of 761 patients died (1.3%), and we found no association between timing of referral and mortality. Also, in 751 survivors, 635 patients (84.6%) were discharged home without home health, and we found no association with timing of referral on multivariable analysis. In this report, we have reviewed our single-center, international burn-injured pediatric cohort, operating in the United States (2005-2019). We find that referral with VDP as opposed to EP was associated with increased LOS/%TBSA.

Клинико-эпидемиологическая характеристика ювенильного идиопатического артрита у детей в Республике Саха (Якутия), РФ

Due to the ethnic and geographical features, the incidence of rheumatic diseases in the Republic of Sakha (Yakutia), Russia, differs from it in other Russia regions. The purposes of this research were to describe the epidemiological, demographic, clinical and laboratory characteristics of pediatric patients with juvenile idiopathic arthritis (JIA) residing on the territory of the Republic of Sakha (Yakutia), Russia (RSY), to describe the therapeutical options and to evaluate the main outcomes. Materials and methods used: the continuous single-center cohort retrospective study included data from medical records of all patients (225) with diagnosed JIA who had undergone examination and treatment in the cardiorheumatological department of the Pediatric Center with the Sakha (Yakutia) Republican Hospital No. 1 - M.E. Nikolaev National Medicine Center (Yakutsk, Republic of Sakha (Yakutia), Russia) in 2016-2023. Results: the incidence of JIA in the RSY regional pediatric population aged 0 to 17 y/o was increasing noticeably, from 5.3 per 100,000 in 2016 to 15.5 per 100,000 in 2023, i.e. almost tripled (2.9) or by 192.9%. The 2023 RSY JIA prevalence was 84.5 and was higher in children living in rural areas - 102.8 per 100,000 children, than in cities - 73.6 per 100,000 children. By ethnicity, the JIA prevalence was higher in the Yakut children - 110.1 per 100,000, than in children of the Russian nationality - 69.4 per 100,000. Among the Yakut children living in the cities, the JIA prevalence was higher (139.4 per 100,000) than in those living in rural areas (89.8 per 100,000). The JIA prevalence among the Yakut boys and girls was identical whilst girls had predominated amongst the Russian children. The distribution of patients by JIA categories was as follows: juvenile arthritis with systemic onset counted for 3.5%, oligoarthritis - 33.8%, RF-positive polyarthritis - 0.9%, RF-negative polyarthritis - 14.7%, enthesitis-associated arthritis (EAA) - 44%, psoriatic arthritis - 3.1%. The frequency of uveitis was 10.2%, HLA-B27 carriage was 39.6%, seropositivity for ANF was 66.7%. The prevalence of EAA was 4.4 times higher in the Yakut children, and the systemic form was 2.9 times lower than that in Russians (p<0.001). 40.4% of children with JIA received therapy with genetically engineered biological drugs, with remission achieved in this group in 45.4% of cases. Conclusion: JIA in RSY has its own epidemiological, clinical and laboratory features associated with the prevalence of the HLA-B27 amongst the Yakut pediatric population. The Yakut children are more likely to suffer from JIA, the disease prevails among boys, the most common JIA form was EEA whilst uveitis and psoriasis being the rare extra-articular JIA manifestations.

The place of JAK inhibitors in systemic juvenile idiopathic arthritis with lung disease (SJIA-LD): French experience.

A new form of systemic juvenile idiopathic arthritis (SJIA) with associated lung disease (SJIA-LD) has recently been described. Multiple lines of treatment have failed to yield satisfactory results for this disorder. JAK inhibitors (JAKis) have recently been approved for the treatment of JIA, but clinical evidence of their efficacy in SJIA-LD is still weak. Here we describe and assess real-life experience of SJIA-LD treatment with JAKis in France. This is a retrospective study based on information gathered from patients' medical records. Systemic and pulmonary symptoms, biological data including CRP, ferritin, IL18, chest CT scan, and functional respiratory tests were collected. Eight patients with SJIA-LD were identified in French pediatric rheumatology centers. All received at least one JAKi (baricitinib, ruxolitinib, and/or tofacitinib). Complete disease control was obtained in four patients. Steroids were tapered in four patients and stopped in two. Three patients presented an episode of MAS shortly after anti-IL1s were stopped when JAKis were introduced. Two patients had other serious side effects (viral reactivation-EBV, BK virus, cytopenia). At last follow-up, one patient had died from severe MAS, two patients had undergone hematopoietic stem cell transplantation, four were in complete response (two of them free of steroids), and one in partial response with JAKis. Lung response to JAKi was not clearly linked to disease duration. JAKis offer another therapeutic option for patients with SJIA-LD. However, the risk of MAS argues for caution about stopping anti-IL1s when introducing JAKis. Tolerance needs careful monitoring in larger studies.

Pattern of Injuries in Children with Epilepsy: A Hospital-Based Case-Control Study

Abstract Objective The aim of this study is to examine the profile and pattern of injuries in children with epilepsy (CWE) as compared with healthy controls. Methods This prospective, cross-sectional study conducted over 1 year in a tertiary care pediatric center included consecutive CWE aged 4 to 16 years who had active seizures during the preceding 1 year. A similar number of age- and sex-matched healthy controls were enrolled. Children with acute symptomatic seizures or degenerative neurologic disorders were excluded. Standardized scales were used to assess intelligent quotient, psychopathology, seizure severity, and restriction of daily activities. Results Two hundred and eight CWE (mean age: 107 ± 37months; range: 3.5–16 years) and an equal number of healthy controls (mean age: 108 ± 43 months; range: 3.5–16 years; p = 0.07) were evaluated. The majority of CWE had generalized epilepsy (n = 117, 59.6%) followed by focal epilepsy (n = 84, 40.3%). The mean duration of epilepsy was 47.4 ± 36.3 months. The prevalence of injury was significantly greater in CWE (n = 118/208, 56.7%) compared with controls (n = 56/208, 26.9%; p < 0.001). CWE suffered significantly greater number of 293 injuries in the past 1 year in contrast to 83 injuries in controls (p < 0.001). In CWE, the majority of injuries were unrelated to seizures (n = 85/118, 72%, 211 injuries), while only one-third (n = 33/118, 27.9%, 82 injuries) suffered seizure-related injuries. The incidence of injures unrelated to seizures and that of seizure-related injuries were similar (2.48 seizure-related injuries per person per year). Among CWE, a comparison of the injury versus noninjury group showed a significantly longer duration of epilepsy (53 ± 34 vs. 40 ± 38 months, p < 0.007), higher prevalence of underlying structural etiology in generalized epilepsy (34.7 vs. 13.3%, p < 0.001), higher mean seizure severity and restriction of daily activity scores, and higher prevalence of hyperactivity (36.4 vs. 18.9%, p = 0.006) and intellectual disability (35.6 vs. 10%, p < 0.001) in the injury group. Injuries on the head, face, and upper limb were significantly more in CWE as compared with controls, and tongue injuries were found only in CWE (p =< 0.05), and were seen significantly more as seizure-related injury (n = 7 vs. 1, p < 0.001) compared with non-seizure-related injuries. The majority of injuries in children with CWE and controls were mild in nature (n = 112, 53.8% vs. n = 54, 26%; p < 0.001). Conclusions The prevalence of injuries among CWE aged between 4 and 16 years is high and is significantly greater than in healthy controls, although the majority of injuries are mild in severity in both and are non-seizure-related injuries. Longer duration of epilepsy, higher seizure severity, and restriction of daily activities, and higher prevalence of underlying structural etiology, hyperactivity, and intellectual disability are associated with injuries in CWE.

LGBTQ+ Supportive and Inclusive Care Practices: Survey Data From the T1D Exchange Quality Improvement Collaborative

OBJECTIVE Living with type 1 diabetes is challenging, but more barriers exist when one also identifies as LGBTQ+ (lesbian, gay, bisexual, transgender, queer, or other gender-expansive identities). Acknowledging the importance of identifying this population and providing personalized care, the Health Resources and Services Administration mandated institutions to document sexual orientation and gender identity (SOGI) data. To understand the current state of SOGI documentation in the T1D Exchange Quality Improvement Collaborative, a survey assessing LGBTQ+ supportive and inclusive care practices was given to affiliated sites. RESEARCH DESIGN AND METHODS Thirty-three pediatric and 21 adult care centers were surveyed via Qualtrics. The survey included questions about their electronic health record documentation of patient-identified gender, pronouns, sexual orientation, and sex assigned at birth (SAAB). Care centers also reported on the legality of gender-affirming care in their municipalities, as well as their willingness to change SAAB after patients meet requirements. Fisher’s exact tests were used to evaluate response frequencies. RESULTS All 33 of the pediatric centers and 81% (17 of 21) of the adult centers responded to the survey. Sixty-four percent of pediatric centers had established strategies to support SOGI documentation, whereas only 50% of adult centers had implemented strategies. Some adult centers could not confirm whether they documented SOGI. Differences were seen between the pediatric and adult endocrinology centers in their documentation of gender identity (P = 0.04) and pronouns (P = 0.02). CONCLUSION Although most endocrinology centers documented gender identity and pronouns, fewer documented sexual orientation. Further work is needed to improve SOGI documentation and assess its impact on LGBTQ+ patients with diabetes.

Impact of an Adult Congenital Heart Disease Order Set in a Pediatric Cardiac Intensive Care Unit.

Background: Patients with congenital heart disease (CHD) are increasingly surviving to adulthood. Given their age- and condition-specific needs, the optimal postoperative setting for these patients is not yet determined. This study aims to evaluate the utility of an adult-specific order set in improving clinical outcomes for these patients in a pediatric cardiovascular intensive care unit (ICU). Methods: Adults with CHD (ACHD) admitted to the cardiovascular ICU following cardiac surgery at a pediatric tertiary care center were identified for a retrospective cohort study. Health care delivery metrics and clinical outcomes of participants who received the adult-specific order set were compared with control patients admitted prior to the intervention. Categorical outcomes were compared using the χ2 test of independence or Fisher exact test, and continuous outcomes were assessed using the t test. Results: A total of 130 ACHD patients received the intervention, with no significant differences observed in clinical outcomes when compared with 89 controls. While there was additionally no reduction in hospital-related mortality (2.3% vs 7.8%, RR 0.3; P = .1), clinician ordering behaviors were better aligned with best-practices following the intervention. Among patients with moderate or greater anatomic complexity, a post hoc analysis demonstrated reduced in-hospital mortality from those who received the adult order set. Conclusions: The implementation of an adult-specific order set in a pediatric care setting did not improve clinical outcomes for all ACHD patients. Patients with moderate and greater anatomic complexity did see a mortality benefit, suggestive that targeted electronic tools may most benefit those who have the highest risk.

52 The bag is not always bad: Implementing a two-step method for urine testing on the inpatient paediatric units

Abstract Background Urinary tract infections (UTIs) are a common source of infection in children. Best practice for diagnosis includes interpreting a urinalysis (UA) and urine culture. Urine cultures obtained through bladder catheterization are invasive and time consuming. A two-step approach with noninvasive UA screen, followed by urine culture if positive has previously demonstrated a reduction in unnecessary catheterizations and urine cultures in children 6-24 months with suspected UTIs. Pre-intervention, there was inconsistent use of screening point-of-care urinalysis prior to bladder catheterization for culture. Objectives To decrease the number of bladder catheterizations in children 6-24 months with a negative screen on Point of Care Test (POCT) urinalysis by 25% over 1 year on paediatrics wards at a paediatric tertiary care centre. Outcome measures: 1. Proportion of bladder catheterizations with negative or no UA screen prior 2. Proportion of UA completed as POCT rather than lab sample Process measures: 1. Number of urinary catheterizations performed for UTI screen 2. Number of times pathway is followed Balancing measure: 1. Missed UTIs Design/Methods Baseline data was collected from the paediatric inpatient units at a tertiary paediatric hospital from April 2020 – April 2021. A two-step pathway for collecting urine samples was adopted, including POCT UA screen on a bag sample, followed by bladder catheterization for culture if positive. The pathway was implemented using the Model for Improvement and multiple PDSA cycles. Intervention focused on education, interdisciplinary collaboration, and process standardization. Results Baseline data demonstrated a high rate of urinary catheter cultures despite a negative UA or no UA prior (69%). After pathway implementation, this rate decreased to 23%, with a reduction in initial UA collected by catheter from 14% to 5% (figure 1). The number of POCT UA performed has increased from a median of 64% pre-intervention to 80% post-intervention, resulting in fewer samples processed in the lab (figure 2). Conclusion Variability in practice for specimen choice for collection and investigation contributed to unnecessary catheterizations. Process standardization successfully improved patient-centered care and efficiency. Next steps include broadening pathway inclusion criteria to the 3–6-month age group. Potential competing interests This work was partially supported by the UMC (Utilization Management Committee) Resource Stewardship Grant. The authors declare no additional sources of funding or conflicts of interest.

Positive impact of an inpatient early childhood literacy programme on literacy practices and family experience in a paediatric heart centre.

CHD predisposes children to neurodevelopmental delays. Frequent, prolonged hospitalisations during infancy prevent children with heart disease from participating in recommended language and cognitive development programmes, such as outpatient early childhood literacy programmes, and contribute to caregiver stress, a risk factor for adverse developmental outcomes. This study aims to describe the implementation of a single-centre inpatient early childhood literacy programme for hospitalised infants with heart disease and assess its impact on reading practices and patient-family hospital experience. Admitted infants ≤1 year old receive books, a calendar to track reading frequency, and reading guidance at regular intervals. Voluntary feedback is solicited from caregivers using an anonymous, QR-code survey on books. A prospective survey also assessed programme impact on hospital experience. From February 2021 to November 2023, the Books@Heart programme provided 1,293 books to families of 840 infants, of whom 110 voluntarily submitted feedback. Caregivers reported a significant improvement in access to books (p < 0.001) and increased reading frequency after learning about Books@Heart (p = 0.003), with the proportion reading to their child daily increasing from 27% to 62%. Among 40 prospective survey responses, caregivers reported feeling a sense of personal fulfillment (60%), self-confidence (30%), connection (98%), and personal well-being (40%) while reading to their child. An inpatient early childhood literacy programme is a well-received intervention for infants with heart disease that promotes development, improves book access, increases reading exposure, and engages families. Further studies are needed to assess its impact on sustained reading practices and neurodevelopmental outcomes.

The Australian paediatric brachytherapy experience: A pathway to a national programme.

Paediatric cancers are rare, and most children requiring radiation therapy receive external beam radiation (EBRT). Although EBRT may offer organ preservation compared to surgery, it can be associated with significant late effects. Image-guided brachytherapy is a highly specialised technique offering both organ preservation and dose conformity to minimise late toxicity. This is a retrospective mono-institutional review of paediatric brachytherapy in one of the largest paediatric centres in Australia. Outcomes and toxicities are presented as well as brachytherapy versus proton plan comparison in four patients. A total of 14 patients were treated with adjuvant brachytherapy between 2012 and 2022. The predominant histology was rhabdomyosarcoma, and all patients had pelvic tumours. High-dose rate (HDR) brachytherapy was given for 13 patients with one patient receiving low-dose rate (LDR) brachytherapy. Only one grade three late toxicity was reported and two patients developed metastatic disease within one year of completion of treatment. The brachytherapy plan was superior to protons in two of four patients and equivocal in one patient. This is the first Australian publication of a paediatric brachytherapy series from a single institution. This retrospective series demonstrates the feasibility and safety of brachytherapy in paediatric pelvic tumours. The initial work presented here demonstrates the value of a comprehensive radiation plan review in selecting the optimal modality for an individual paediatric patient.

Intra-operative neuromonitoring in paediatric spinal deformity surgery: a retrospective single-centre experience.

Intra-operative neuromonitoring including somatosensory evoked potentials, motor evoked potentials, and electromyography, have replaced the Stagnara wake-up test to allow early detection of neurological change during paediatric spinal deformity surgery. It is important for surgeons to recognize alerts triggered by loss of these potentials and act accordingly to prevent iatrogenic neurological damage intra-operatively. This study was conducted to determine the sensitivity and specificity of neuromonitoring alerts in paediatric spinal deformity correction surgery. A retrospective single-centre study of all patients undergoing spinal deformity surgery at a tertiary paediatric centre between 1 January 2017 and 31 December 2020 (inclusive) was conducted. Neuromonitoring alerts were identified through neurophysiology documentation, and these were correlated with neurological deficits documented in the patient record post-operatively. A total of 399 operations were included in the study, with 147 (35.7%) of these having a motor, or motor and sensory alert triggered. Fifteen (10.2% of alerts) of these patients had a post-operative neurological deficit, compared to seven (2.8% of no alerts) of those that had no neuromonitoring alert. The sensitivity for post-operative neurological deficits not resolving within 3 days was 100%, and the specificity was 65.5%. Intra-operative neuromonitoring is highly sensitive to post-operative neurological deficits lasting longer than 3 days. However, there is still scope for optimization of specificity, with many false positives identified.