Pediatrics Committee Research Articles

Egyptian pediatric kidney transplantation: highlights on post-transplant follow-up and management of complications by the Egyptian Pediatric Clinical Practice Guidelines Committee (EPG) Nephrology Group

BackgroundPediatric kidney transplantation is unique when compared to adults. They need optimum post-transplant care to achieve longer graft and patient survival. Infections, rejection, recurrence, malignancy, bone problems, hypertension, and surgical complications are the most important challenges that require prevention, early detection, and management. Chronic allograft nephropathy needs different approaches based on its related causes, allograft pathology, graft function, and availability of re-transplantation.Aim/objectivesThis national adapted guideline aims to frame evidence-based post-transplant recommendations adopted or adapted from EB source guidelines to optimize post-transplant patient care.MethodsOur guideline is evidence based adapted from four national and international source guidelines with permissions [KDIGO 2020, RA/BTS 2022–2018, EAU 2018] that were appraised with AGREE II instrument tool. We followed the “adapted ADAPTE” CPG formal adaptation methodology that consists of 3 phases and 24 steps and tools. Virtual monthly meetings all through the year 2023 were activated for reviewing and validation of final adaptation of evidence-based guideline draft, considering all comments of external reviewers. This guideline was registered in the practice guideline registration for transparency (PREPARE), number: PREPARE-2023CN364.ResultsRecommendation statements in guidelines stand for results in articles. Discussion of important recommendations and the rationale behind selection of adopted statements and tailoring of others to suit our local facilities, expertise, and renal native disease profile was presented in the text with reasons and references.ConclusionThe provided guidelines aim to improve graft and patient outcome through prevention and early management of complications and suggest research areas lacking validated research recommendations.

Practice guideline of influenza vaccination and antiviral drugs use in children(2024 editon)

Influenza is the most common acute respiratory infectious diseases among children in China. The annual seasonal influenza outbreak has a significant impact on children's health, poses a significant disease and socioeconomic burden, and arouses a wide public concern. In recent years, a number of new influenza vaccines and influenza antivirals have been approved for use in children, expanding the choices for prevention and treatment of influenza. Pediatric Infection Group, Chinese Society of Infectious Diseases of Chinese Medical Association and Infection Group, Pediatric Expert Committee of National Health Commission Capacity Building and Continuing Education, and China Clinical Practice Guidelines Alliance Methodology Committee organized a multidisciplinary guideline development group (GDG) consisting of experts in pediatrics, infectious diseases,epidemiologists,health policy,and guideline methodology proposed eight key issues concerning influenza vaccination and antiviral use from a practice perspective. Through research question construction, evidence retrieval and synthesis, evidence appraisal and evidence-to-decision discussion, recommendations and implementation suggestions were formulated. This guideline is intended to provide guidance for pediatricians at different facility levels and healthcare providers engaged in vaccination services,and institutional professionals dealing with prevention and control of infectious diseases.

Inguinal hernias in children: Update on management guidelines.

Inguinal hernia repair is one of the most performed procedures in children, but aspects of care remain controversial. The aim of this review was to provide a critical appraisal of recently published guidelines on the management of inguinal hernias in children, by the American Academy of Pediatrics (2023) and the European Pediatric Surgeons' Association Evidence and Guideline Committee (2022). This was achieved by delineating areas of controversy and reviewing the most relevant recent literature on these topics. Currently available moderate-to-low quality evidence recommends postponing hernia repair in premature infants until after discharge, to reduce the risk of respiratory difficulties and recurrence. Laparoscopic repair provides similar outcomes to open but may shorten operative time in bilateral cases. No clear recommendation can be made for contralateral exploration, therefore should be evaluated case by case. In preterm infants, consideration of regional anaesthesia may reduce post-operative apnoea and pain, with no difference in neurodevelopment outcomes.

Assessing the Impact of Psychological Readiness on Performance and Symmetry in Functional Testing After ACL Reconstruction in Pediatric and Adolescent Patients.

Readiness for return to sports involves both physical and psychological aspects of recovery; however, the relationship between psychological and physical variables after anterior cruciate ligament (ACL) reconstruction (ACLR) is poorly understood. ACLR patients with a higher psychological readiness would demonstrate better functional testing results at 6 months. Cross-sectional study; Level of evidence, 3. Participants were evaluated at 6 months after ACLR with various patient-reported outcome metrics: Hospital for Special Surgery Pediatric Functional Activity Brief Scale, pediatric or adult International Knee Documentation Committee Questionnaire (IKDC), Patient-Reported Outcomes Measurement Information System (PROMIS) - Psychological Stress Experience and ACL - Return to Sport After Injury (ACL-RSI) scale. Functional testing included quadriceps, hamstrings, and gluteal strength testing; Y-balance test; single-leg single hop, crossover hop, and triple hop tests; and timed 6-m hop test. Pearson correlation coefficient and multivariable regression were used to determine associations between the limb symmetry index (LSI) on functional testing and patient-reported outcomes. Those with LSI deficits <20% (better performance) were compared with those with deficits >20% (worse performance). A total of 229 participants (89 male, 140 female) with a median age of 17 years (range, 10.3-30.6 years) were enrolled. IKDC had a moderate negative correlation with PROMIS - Psychological Stress Experience (r = -0.39; 95% CI = -0.49, -0.27; P < .001) and a moderate positive correlation with ACL-RSI (r = 0.55; 95% CI = 0.46, 0.64; P < .001). A total of 151 patients completed functional testing. ACL-RSI demonstrated a positive correlation with single-hop LSI (r = 0.21; 95% CI = 0.05, 0.35; P = .01) and timed 6-m hop (r = 0.28; 95% CI, 0.42; P = .001). When adjusting for sex, age, and graft type, patients who had <20% deficit on the single-hop test scored 16.6 points higher on ACL-RSI (P = .001), and those with <20% deficit on crossover hop testing scored a mean 13.9 points higher on ACL-RSI (P = .04). Higher psychological readiness for return to sport was associated with better performance and greater symmetry on hop testing 6 months after ACLR, suggesting a potential link between physical and psychological recovery.

β3-adREnoceptor Analysis in CORD Blood of Neonates (β3 RECORD): Study Protocol of a Pilot Clinical Investigation.

Background and Objective: The embryo and the fetus develop in a physiologically hypoxic environment, where vascularization is sustained by HIF-1, VEGF, and the β-adrenergic system. In animals, β3-adrenoceptors (β3-ARs), up-regulated by hypoxia, favor global fetal wellness to such an extent that most diseases related to prematurity are hypothesized to be induced or aggravated by a precocious β3-AR down-regulation, due to premature exposure to a relatively hyperoxic environment. In animals, β3-AR pharmacological agonism is currently investigated as a possible new therapeutic opportunity to counteract oxygen-induced damages. Our goal is to translate the knowledge acquired in animals to humans. Recently, we have demonstrated that fetuses become progressively more hypoxemic from mid-gestation to near-term, but starting from the 33rd-34th week, oxygenation progressively increases until birth. The present paper aims to describe a clinical research protocol, evaluating whether the expression level of HIF-1, β3-ARs, and VEGF is modulated by oxygen during intrauterine and postnatal life, in a similar way to animals. Materials and Methods: In a prospective, non-profit, single-center observational study we will enroll 100 preterm (group A) and 100 full-term newborns (group B). We will collect cord blood samples (T0) and measure the RNA expression level of HIF-1, β3-ARs, and VEGF by digital PCR. In preterms, we will also measure gene expression at 48-72h (T1), 14 days (T2), and 30 days (T3) of life and at 40 ± 3 weeks of post-menstrual age (T4), regardless of the day of life. We will compare group A (T0) vs. group B (T0) and identify any correlations between the values obtained from serial samples in group A and the clinical data of the patients. Our protocol has been approved by the Pediatric Ethical Committee for Clinical Research of the Tuscany region (number 291/2022). Expected Results: The observation that in infants, the HIF-1/β3-ARs/VEGF axis shows similar modulation to that of animals could suggest that β3-ARs also promote fetal well-being in humans.

Quadriceps Tendon Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: 3-Year Clinical and Patient-Reported Outcomes.

The rate of anterior cruciate ligament (ACL) rupture in active, skeletally immature patients is increasing. Although hamstring tendon autograft (HTA) was previously deemed the gold standard, recent studies have shown HTA to have a high failure rate in this high-risk population of young competitive athletes, and quadriceps tendon autograft (QTA) has yielded excellent preliminary outcomes in some studies examining this population. To evaluate 3-year clinical and patient-reported functional outcomes of primary ACL reconstruction (ACLR) with soft tissue QTA in skeletally immature patients. Case series; Level of evidence, 4. Skeletally immature patients who underwent ACLR with a full-thickness soft tissue QTA were included. Preoperative patient and surgical data were collected. The ACLR technique was selected predicated upon skeletal age and included all-epiphyseal and complete transphyseal techniques. Patients were followed for a minimum of 2 years with successive clinical visits or were contacted via telephone. Patients who did not have minimum 2-year follow-up after 3 contact attempts via telephone were excluded. Information regarding return to sports (RTS) and concomitant or subsequent surgical procedures was collected. Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery Functional Activity Brief Scale (HSS Pedi-FABS), and Single Assessment Numeric Evaluation (SANE) scores were collected. Of 85 adolescent patients aged 11.1 to 17.6 years (mean age, 14.1 ± 1.2 years), 2 patients were determined to be lost to follow-up after 3 failed contact attempts. Of the patients included in this study (N = 83), 26 patients (31%) underwent all-epiphyseal and 57 patients (69%) underwent complete transphyseal ACLR. Additionally, 48 patients (58%) underwent concomitant lateral extra-articular tenodesis using the iliotibial band with a modified Lemaire technique. The mean follow-up time was 3.7 ± 1.2 years (range, 2-7 years). Twenty (24%) patients had subsequent surgical procedures, of which 3 (4%) were due to graft failures. At a mean 3-year follow-up, the mean Pedi-IKDC, HSS Pedi-FABS, and SANE scores were 90, 23, and 94 respectively; the RTS rate was 100%; and the rate of RTS at the previous level of performance was 93%. Use of a soft tissue QTA for ALCR in a high-risk skeletally immature population of athletes resulted in excellent postoperative outcomes with low rates of graft failure and high return to sport rates.

A Modified 4-in-1 Stanisavljevic Procedure for Treating Obligatory or Congenital Patellar Dislocations in Children: A Surgical Technique.

Patellar instability and dislocation pose complex clinical and surgical challenges, especially in children. Congenital (fixed) and obligatory (habitual) dislocations present significant anatomical and etiological complexity, frequently leading to deformities and functional impairments, which can range from walking difficulties to sports limitations. Conservative treatment is often inadequate. We describe a surgical technique for treating congenital or obligatory patellar dislocations in patients with various underlying diagnoses-including Down syndrome, nail-patella syndrome, and skeletal dysplasia-that involves extensive subperiosteal quadriceps realignment, distal realignment (Roux-Goldthwait or tibial tuberosity transfer), and optional medial plication. This modified 4-in-1 technique follows the principles described in 1976 by Stanisavljevic, which involves subperiosteal quadriceps mobilization, thus minimizing muscle damage, bleeding, and postoperative muscular adherences. In 24 patients treated at our institution between 2002 and 2021 (35 knees; age range = 5.5-16.8 years; 13 girls, 11 boys), with a mean follow-up of 8.2 years (2.4-20 years), we achieved satisfactory improvements in patellar stability, range of motion, and quality of life with a modified 4-in-1 Stanisavljevic technique. A total of 9 patients (7 with obligatory dislocations and 2 with congenital dislocations) could engage in recreational or competitive sports. The average postoperative pediatric International Knee Documentation Committee (pedi-IKDC) score was 78.45 ± 22.3 (range = 0-100); a patient with DiGeorge syndrome and 1 with multiple epiphyseal dysplasia had scores of 35 and 48, respectively. We found at our institution that a modified 4-in-1 Stanisavljevic technique produced favorable outcomes in patellar stability, range of motion, and quality of life in pediatric patients with congenital or obligatory patellar dislocation. More study is warranted to determine the procedure's overall benefits for children with obligatory or congenital dislocations of complex etiology.

Pediatric anesthesiology in Brazil, Chile, and Mexico.

Latin America comprises an extensive and diverse territory composed of 33 countries in the Caribbean, Central, and South America where Romance languages-languages derived from Latin are predominantly spoken. Economic disparities exist, with inequitable access to pediatric surgical care. The Latin American Surgical Outcomes Study in Pediatrics (LASOS-Peds), a multi-national collaboration, will determine safety of pediatric anesthesia and perioperative care. Below, we provide a descriptive initiative to share how pediatric anesthesia in Brazil, Chile, and Mexico operate. Theses descriptions do not represent all of Latin America. Brazil an upper middle-income country, population 203 million, has a public system insufficiently resourced and a private system, resulting in inequitable safety and accessibility. Surgical complications constitute the third leading cause of mortality. Anesthesiology residency is 3 years, with required rotations in pediatric anesthesia; five hospitals offer pediatric anesthesia fellowships. Anesthesiology is a physician-only practice. A Pediatric Anesthesia Committee within the Brazilian Society of Anesthesiology offers education through seasonal courses and workshops including pediatric advanced life support. Chile is a high-income country, population 19.5 million, the majority cared for in the public system, the remainder in university, private, or military systems. Government efforts have gradually corrected the long-standing anesthesiology shortage: twenty 3-year residency programs prepare graduates for routine pediatric cases. The Chilean Society of Anesthesiology runs a 1-month program for general anesthesiologists to enhance pediatric anesthesia skills. Pediatric anesthesia fellowship training occurs in Europe, USA, and Australia, or in two 2-year Chilean university programs. Public health policies have increased the medical and surgical pediatric specialists and general anesthesiologists, but not pediatric anesthesiologists, which creates safety concerns for neonates, infants, and medically complex. Chile needs more pediatric anesthesia fellowship programs. Mexico, an upper middle-income country, with a population of about 126 million, has a five-sector healthcare system: public, social security for union workers, state for public employees, armed forces for the military, and a private "self-pay." There are inequities in safety and accessibility for children. Pediatric Anesthesiology fellowship is 2 years, after 3 years residency. A shortage of pediatric anesthesiologists limits accessibility and safety for surgical care, driven by added training at low salary and hospital under appreciation. The Mexican Society of Pediatric Anesthesiology conducts refresher courses, workshops, and case conferences. Insufficient resources and culture limits research.

Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement.

The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.

Outcomes of treatment of patella fractures in children and adolescents.

The purpose of this study is to assess clinical and functional outcomes in separate cohorts of operatively and nonoperatively managed pediatric patella fractures. A retrospective review was completed for patients aged 5-19 years treated for a unilateral patella fracture at a single pediatric level-1 trauma center. Patients were excluded for osteochondral fracture associated with patellar dislocation, polytrauma presentation with additional fractures, or <3 months of clinical follow-up. Functional outcomes were assessed via the Pediatric International Knee Documentation Committee form and the Marx Knee Activity Scale. A total of 53 patients met inclusion criteria; 30 patients were treated operatively and 23 patients were treated nonoperatively. Patients with patellar sleeve/pole fractures were significantly younger by 5.2 years (p < 0.01) and presented with greater variability in mechanism of injury (p < 0.01). The nonoperative cohort achieved bony healing and returned to sports at a median (interquartile range) of 1.7 (1.2-2.3) months and 2.8 (2.3-3.3) months, respectively, post-injury. The operative group achieved bony healing and returned to sports at 2.8 (2.1-3.5) months and 5.9 (4.0-7.1) months, respectively, following surgery. Median (interquartile range) Pediatric International Knee Documentation Committee and Marx scores were 98 (89-100) and 14 (10-16), respectively, for the nonoperative group, and 92 (84-99) and 13 (12-16), respectively, for the operative group. No significant differences in patient-reported outcomes were observed between fracture patterns or treatment cohorts. Pediatric and adolescent patients sustaining patella fractures reported long-term functional outcomes comparable to normative values, across multiple fracture patterns and with appropriate operative and nonoperative treatment. Fractures requiring surgery were expectedly associated with slower healing and return to sport timelines. Therapeutic Level III.

A protocol for adapting a clinical practice guideline for the treatment of paediatric asthma for the Egyptian Pediatric Clinical Practice Guidelines Committee

AbstractIntroductionPaediatric asthma is a prevalent and chronic respiratory condition affecting children worldwide. This protocol outlines the methodology for developing a clinical practice guideline (CPG) for the management of paediatric asthma. The goal of this guideline is to provide evidence‐based recommendations for healthcare professionals, improving the quality of care and health outcomes for paediatric patients with asthma.MethodsWe will use the ‘Adapted ADAPTE’ adaption method, a systematic approach to adapt existing guidelines, which consists of three phases (setup, adaptation and finalisation phases), nine modules and 24 steps, with adaptations to the process and tools to suit the Egypt healthcare context and resources.QuestionsClinical questions were prepared using the patient population, interventions, professionals, outcomes and healthcare context (PIPOH) model. This CPG protocol addresses critical clinical questions at the heart of effective asthma management in children. It focuses on the diagnosis of paediatric asthma, considering age‐specific clinical presentations and diagnostic tests, assessment of asthma severity, control medications like inhaled corticosteroids, long‐acting β‐agonists and others, with an emphasis on appropriate tools and criteria. The CPG also delves into the realm of long‐term control treatment, exploring the effectiveness and safety of pharmacological and nonpharmacological interventions, while considering individualised needs. Furthermore, it examines strategies for monitoring and adjusting treatment plans over time, ensuring optimal care. These clinical questions form the foundation of the CPG, facilitating evidence‐based care delivery and enhancing health outcomes for paediatric asthma patients.

Practice Variation among Pediatric Endocrinologists in the Dosing of Glucocorticoids in Young Children with Congenital Adrenal Hyperplasia.

A Pediatric Endocrine Society (PES) Drugs and Therapeutics Committee workgroup sought to determine the prescribing practices of pediatric endocrinologists when treating children <10 years of age with congenital adrenal hyperplasia (CAH). Our workgroup administered a 32-question online survey to PES members. There were 187 respondents (88.9% attending physicians), mostly from university-affiliated clinics (~80%). Ninety-eight percent of respondents prescribed the short-acting glucocorticoid hydrocortisone to treat young children, as per the Endocrine Society CAH Guidelines, although respondents also prescribed long-acting glucocorticoids such as prednisolone suspension (12%), prednisone tablets (9%), and prednisone suspension (6%). Ninety-seven percent of respondents indicated that they were likely/very likely to prescribe hydrocortisone in a thrice-daily regimen, as per CAH Guidelines, although 19% were also likely to follow a twice-daily regimen. To achieve smaller doses, using a pill-cutter was the most frequent method recommended by providers to manipulate tablets (87.2%), followed by dissolving tablets in water (25.7%) to create a daily batch (43.7%) and/or dissolving a tablet for each dose (64.6%). Thirty-one percent of providers use pharmacy-compounded hydrocortisone suspension to achieve doses of <2.5 mg. Our survey shows that practices among providers in the dosing of young children with CAH vary greatly and sometimes fall outside of the CAH Guidelines-specifically when attempting to deliver lower, age-appropriate hydrocortisone doses.

1619. Epidemiology of Congenital Syphilis Infections in Northwestern (NW) Iowa Witnessing a Significant Increase- Experience of a Tertiary Care Center

Abstract Background According to the CDC, STI (sexually transmitted infections) including syphilis infections in adults have recently increased in the upper Midwest. Studies evaluating epidemiology of Congenital syphilis (CS) are needed to facilitate prompt recognition to prevent sequelae. Methods We retrospectively studied epidemiologic, clinical characteristics and outcomes of neonates with CS at our tertiary care center which is the largest maternal/neonatal center in NW Iowa during 1/1/2021-12/31/2022 (labeled P2). Epidemiologic characteristics during P2 were compared with the period from 1/1/2019-12/31/2020 (labeled P1). Diagnosis and treatment for CS were in accordance with CDC/American Academy of Pediatrics Committee on Infectious Diseases Red Book guidelines. Results During P2, a total of 42 newborns were diagnosed with CS compared to 0 during P1 (p&amp;lt; 0.05); 64% of infected newborns were White followed by Native American (21%), Hispanic (11%) and Black (2%). All (100%) neonates with CS were born to mothers infected during or after second trimester of pregnancy with negative first trimester RPR (Rapid Plasma Reagin) testing. Maternal RPR titers ranged from 1:1-1:256. Majority (62%) of newborns were diagnosed with proven/possible CS with RPR-titers &amp;gt; 4-fold mother's titers /untreated or inadequately treated maternal infection and required 10 days of intravenous Aqueous crystalline penicillin G treatment and NICU care; 2 newborns had meningitis and 3 developed sensorineural hearing loss. Thirty-eight% received 1 dose of intramuscular Benzathine penicillin G. Need for cerebrospinal fluid syphilis testing and 10 days of intravenous penicillin treatment increased by &amp;gt; 600% from P1 to P2 (p=0.02). CS evaluation/treatment in infected Native American neonates increased by &amp;gt; 1000% in P2 (p&amp;lt; 0.001). Mean hospitalization duration was 9.5 (±1.6) days. No infant died. Only 33% of infants followed up at 2 months for repeat testing. None of the Native American/Hispanic/Black neonates compared to 52% White neonates had follow-up testing (p&amp;lt; 0.05). Conclusion Our results show an alarming increase in CS in NW Iowa and underline the need for urgent preventive measures including STI prevention education, adequate maternal/ neonatal testing and follow-up, especially among marginalized populations. Disclosures All Authors: No reported disclosures

Organ Donation in Canadian PICUs: A Cross-Sectional Survey, 2021-2022.

To understand contemporary pediatric organ donation programs in Canadian PICUs, including: policies and practices, data collection and reporting, and system and process barriers. A cross-sectional survey carried out 2021-2022. Canadian PICUs affiliated with a donor physician network. Pediatric intensivists identified as the donation program lead, or most knowledgeable about donation for their institution. A 19-item survey was developed through collaboration with stakeholders from the organ donation and transplantation community within Canada. Domains and items were generated and reduced iteratively during an in-person workshop. Pretesting and pilot testing were completed to ensure readability, flow, clinical sensibility, and construct validity. Fifteen of 16 (94%) invited Canadian PICUs from seven provinces completed the survey representing 88% (15/18) of all noncardiac Canadian PICUs. Surveys were completed between June 2021 and September 2022. All units support donation after death by neurologic criteria (DNC); 14 of 15 indicated donation policies were in place and 1 of 15 indicated no policy but the ability to facilitate donation. Thirteen of 15 units (87%) support donation after death by circulatory criteria (DCC) with policies in place, with 11 of 13 of these indicating routine support of donation opportunities. The majority (13/15) of units identified a donation champion. Of the 16 identified champions across these centers, 13 were physicians and were registered nurses or nurse practitioners. Eight of 13 units (62%) with donation champions had positions supported financially, of which 5 units came from the Organ Donation Organization and the other 3 came from the provincial health authority. Finally, only 3 of 15 PICU donation programs have a pediatric donation committee with family involvement. Variability exists in identification (including determination of death practices), referral, and approach for donation between units. Although all Canadian PICUs support donation after DNC donation, and most support donation after DCC, variability exists in the identification, referral, and approach of potential donors. There is a notable lack of family involvement in pediatric donation programs. There are many opportunities for standardization of PICU donation programs which may result in improved rates of pediatric organ donation in Canada.

Early- and Late-Stage Benefits of Blood Flow Restriction Training on Knee Strength in Adolescents After Anterior Cruciate Ligament Reconstruction.

Blood flow restriction training (BFRT) after anterior cruciate ligament reconstruction (ACLR) is rising in popularity because of its benefits in reducing muscle atrophy and mitigating knee strength deficits. To investigate the impact BFRT has on adolescent knee strength after ACLR at 2 postoperative time points: at 3 months and the time of return to sport (RTS). Cohort study; Level of evidence, 3. A prospective intervention (BFRT) group was compared to an age-, sex-, and body mass index-matched retrospective control group. Patients aged 12 to 18 years who underwent primary ACLR with a quadriceps tendon autograft were included. Along with a traditional rehabilitation protocol, the BFRT group completed a standardized BFRT protocol (3 BFRT exercises performed twice weekly for the initial 12 weeks postoperatively). Peak torque values for isometric knee extension and flexion strength (at 3 months and RTS) and isokinetic strength at 180 deg/s (at RTS) as well as Pediatric International Knee Documentation Committee (Pedi-IKDC) scores were collected. Differences between the BFRT and control groups were compared with 2-way mixed analysis of variance and 1-way analysis of variance. The BFRT group consisted of 16 patients (10 female; mean age, 14.84 ± 1.6 years) who were matched to 16 patients in the control group (10 female; mean age, 15.35 ± 1.3 years). Regardless of the time point, the BFRT group demonstrated significantly higher isometric knee extension torque compared to the control group (2.15 ± 0.12 N·m/kg [95% CI, 1.90-2.39] vs 1.74 ± 0.12 N·m/kg [95% CI, 1.49-1.98], respectively; mean difference, 0.403 N·m/kg; P = .024). The BFRT group also reported significantly better Pedi-IKDC scores compared to the control group at both 3 months (68.91 ± 9.68 vs 66.39 ± 12.18, respectively) and RTS (89.42 ± 7.94 vs 72.79 ± 22.81, respectively) (P = .047). In adolescents, the addition of a standardized BFRT protocol to a traditional rehabilitation protocol after ACLR significantly improved knee strength and patient-reported function compared to a traditional rehabilitation program alone.

Healthcare professionals' perspectives on optimizing pain care-related education at a Canadian children's hospital: A qualitative study.

Pain affects all children and youth, yet acute and procedural pain remains undertreated in Canadian hospitals. To improve pain management practices in paediatric hospitals, it is necessary to understand how healthcare professionals (HCPs) wish for educational interventions to be designed to improve their pain management practice. Semi-structured interviews were conducted with 18 HCPs between October and December 2020. Snowball sampling was used to first recruit interested members from the hospital's Pediatric Pain Management Committee. Interviews were conducted per participant preference and included Zoom, telephone, and in-person interviews. Recruitment ceased when data were determined sufficiently rich. A thematic analysis of verbatim transcripts and reflexive field notes were used to create a data set focused on knowledge mobilization and clinical education. Three core themes were identified: (a) the necessity for just-in-time education for HCPs; (b) the availability of clinical pain champions to educate staff; and (c) the provision of resources to educate children and their families about available pain management interventions. Just-in-time education included suggestions for in-service training, hands-on training, and regular updates on the latest research. Pain champions, including clinical nurse educators, were stressed as being important in motivating staff to improve their pain management practices. Participants noted the lack of resources for patient and family education on pain management and suggested providing more multimodal resources and educational opportunities. Having local champions introduce pain management initiatives and just-in-time education positively impacts the implementation climate, which also helps HCPs provide evidence-based education and resources to patients and families.

Quantitative diffusion-weighted MRI response assessment in rhabdomyosarcoma: an international retrospective study on behalf of the European paediatric Soft tissue sarcoma Study Group Imaging Committee

ObjectiveTo investigate the feasibility of diffusion-weighted magnetic resonance imaging (DW-MRI) as a predictive imaging marker after neoadjuvant chemotherapy in patients with rhabdomyosarcoma.Material and methodsWe performed a multicenter retrospective study including pediatric, adolescent and young adult patients with rhabdomyosarcoma, Intergroup Rhabdomyosarcoma Study group III/IV, treated according to the European paediatric Soft tissue sarcoma Study Group (EpSSG) RMS2005 or MTS2008 studies. DW-MRI was performed according to institutional protocols. We performed two-dimensional single-slice tumor delineation. Areas of necrosis or hemorrhage were delineated to be excluded in the primary analysis. Mean, median and 5th and 95th apparent diffusion coefficient (ADC) were extracted.ResultsOf 134 included patients, 82 had measurable tumor at diagnosis and response and DW-MRI scans of adequate quality and were included in the analysis. Technical heterogeneity in scan acquisition protocols and scanners was observed. Mean ADC at diagnosis was 1.1 (95% confidence interval [CI]: 1.1–1.2) (all ADC expressed in * 10−3 mm2/s), versus 1.6 (1.5–1.6) at response assessment. The 5th percentile ADC was 0.8 (0.7–0.9) at diagnosis and 1.1 (1.0–1.2) at response. Absolute change in mean ADC after neoadjuvant chemotherapy was 0.4 (0.3–0.5). Exploratory analyses for association between ADC and clinical parameters showed a significant difference in mean ADC at diagnosis for alveolar versus embryonal histology. Landmark analysis at nine weeks after the date of diagnosis showed no significant association (hazard ratio 1.3 [0.6–3.2]) between the mean ADC change and event-free survival.ConclusionA significant change in the 5th percentile and the mean ADC after chemotherapy was observed. Strong heterogeneity was identified in DW-MRI acquisition protocols between centers and in individual patients.Graphical

Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome.

Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome.

Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome†.

Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome†.

Choosing Wisely: The Canadian Rheumatology Association Pediatric Committee's List of Items Physicians and Patients Should Question.

To develop a list of tests or treatments frequently used in pediatric rheumatology practice which may be unnecessary based on existing evidence. A Choosing Wisely (CW) Working Group composed of 16 pediatric rheumatologists, one allied health practitioner, one parent, and one patient used the Delphi method to generate, rank, and refine a list of tests and treatments that may be unnecessary or harmful. The items with the highest content agreement and perceived impact were presented in a survey to all Canadian Rheumatology Association (CRA) physicians who practice pediatric rheumatology. Respondents were asked to rate their agreement, impact, and rank the items. Five items with the highest composite scores and two additional items selected by the CW Working Group were put forward for literature review. The initial Delphi procedure generated 80 items. After three rounds, the list was narrowed to 13 items. The survey was completed by 41/81 (51%) CRA pediatric members across Canada. Respondent characteristics were similar to the CRA pediatric membership for gender, geographical location, and career stage. The highest composite score items were anti-nuclear antibody testing, drug toxicity monitoring, human leukocyte antigen-B27 testing, rheumatoid factor/anti-cyclic citrullinated peptide testing, and Lyme serology testing. Two additional items (numerous or repeated intra-articular corticosteroid injections, and autoinflammatory diseases genetic testing) were also selected. Literature review was performed for these seven highest priority items. We have identified areas for quality improvement in the evaluation and treatment of rheumatic diseases in Canadian children.