Pediatric Tertiary Care Center Research Articles

Children With Short Stature Display Reduced ACE2 Expression in Peripheral Blood Mononuclear Cells.

BackgroundThe cause of short stature remains often unknown. The renin-angiotensin system contributes to growth regulation. Several groups reported that angiotensin-converting enzyme 2 (ACE2)-knockout mice weighed less than controls. Our case-control study aimed to investigate if children with short stature had reduced ACE2 expression as compared to controls, and its significance.Materials and Methodschildren aged between 2 and 14 years were consecutively recruited in a University Hospital pediatric tertiary care center. Cases were children with short stature defined as height SD ≤ −2 diagnosed with growth hormone deficiency (GHD) or idiopathic short stature (ISS), before any treatment. Exclusion criteria were: acute diseases, kidney disease, endocrine or autoimmune disorders, precocious puberty, genetic syndromes, SGA history. ACE and ACE2 expression were measured in peripheral blood mononuclear cells, angiotensins were measured by ELISA.ResultsChildren with short stature displayed significantly lower ACE2 expression, being 0.40 fold induction (0.01-2.27) as compared to controls, and higher ACE/ACE2, with no differences between GHD and ISS. ACE2 expression was significantly and inversely associated with the risk of short stature, OR 0.26 (0.07-0.82), and it had a moderate accuracy to predict it, with an AUC of 0.73 (0.61-0.84). The cutoff of 0.45 fold induction of ACE2 expression was the value best predicting short stature, identifying correctly 70% of the children.ConclusionsOur study confirms the association between the reduction of ACE2 expression and growth retardation. Further studies are needed to determine its diagnostic implications.

Analgesic Effects of a Novel Combination of Regional Anesthesia After Pediatric Cardiac Surgery: A Retrospective Cohort Study

The objective of this study was to determine whether the use of regional anesthesia in children undergoing congenital heart surgery was associated with differences in outcomes when compared to surgeon-delivered local anesthetic wound infiltration. A retrospective cohort study. At a single pediatric tertiary care center. Pediatric patients who underwent primary repair of septal defects between January 1, 2018, and March 31, 2022. The patients were grouped by whether they received surgeon-delivered local anesthetic wound infiltration or bilateral pectointercostal fascial blocks (PIFBs) and a unilateral rectus sheath block (RSB) on the side ipsilateral to the chest tube. Using overlap propensity score-weighted models, the authors examined postoperative opioid requirements (morphine milliequivalents per kilogram), pain scores, length of stay, and time under general anesthesia (GA). Eighty-nine patients were eligible for inclusion and underwent analysis. In the first 12 hours postoperatively, the block group used fewer morphine equivalents per kilogram versus the infiltration group, 0.27 ± 0.2 v 0.64 ± 0.42, with a weighted estimated decrease of 0.39 morphine equivalents per kilogram (95% CI -0.52 to -0.25; p < 0.001), and had lower pain scores, 3.2 v 1.6, with a weighted estimated decrease of 1.7 (95% CI -2.3 to -1.1; p < 0.001). The length of stay and time under GA also were shorter in the block group with weighted estimated decreases of 22 hours (95% CI -33 to -11; p=0.001) and 18 minutes (95% CI -34 to -2; p=0.03), respectively. Bilateral PIFBs and a unilateral RSB on the side ipsilateral to the chest tube is a novel analgesic technique for sternotomy in pediatric patients. In this retrospective study, these interventions were associated with decreases in postoperative opioid use, pain scores, and hospital length of stay without prolonging time under GA.

Paper 61: Surgical Management of Distal Clavicle Fractures in Skeletally Immature Athletes

Objectives:The objective of this study was to characterize distal clavicle fractures in a cohort of pediatric and adolescent athletes who underwent operative treatment at a single, tertiary-care pediatric center, including surgical techniques used and resultant clinical outcomes.Methods:A retrospective review was performed of all clavicle fractures extending to the level of the corococlavicular ligaments or more lateral, which were treated operatively at a single tertiary-care pediatric hospital between the years of 2005-2020. Patients >19 years-old or those with pathological fractures were excluded. Radiographic fracture characteristics, surgical techniques, time to radiographic healing, return to sports, and complications were analyzed.Results:Fifty-two patients were identified, with mean age 13.8 ± 2.2 years. The majority of fractures were classified as Nenopoulus type IIB (transverse, displaced; 42.3%) or type IIIB (oblique, displaced; 26.9%), though type IIA (transverse, minor displacement; 3.8%), IV (comminuted; 11.6%) , and V (AC dislocation; 15.4%) patterns were also observed. Primary direction of displacement was posterior in 90% of cases and superior in 10%. Plate fixation was performed in 53.8% of surgeries, with locking plate (26.9%) and hook plate (17.3%) most frequent. Suture-based fixation was performed in 32.7% of cases (Figure 1). Rate of implant removal was 66% after plate fixation, the majority of which (72.2%) were planned at the time of primary fixation. Total complication rate, including unplanned removal of implant, was higher in the plate fixation group (25%) than in the suture-based fixation group (11.2%). Time to radiographic healing was not significantly different between plate and suture-based constructs (2.9 vs. 2.9 months, p = 0.96) though patients with suture-based constructs returned to sport faster (2.5 vs. 3.6 months, p = 0.014).Conclusions:Posteriorly displaced fractures comprised the vast majority of surgically-treated distal clavicle fractures in pediatric and adolescent athletes. When chosen in the appropriate patient, based on age and fracture pattern, suture-only constructs can lead to similar time to radiographic healing and faster return to sports compared to plate-based constructs, with significantly reduced need for removal of hardware. These data provide a foundation for future comparative research to further elucidate precise surgical indications and optimal treatment approaches in this population.Table 1.Fixation Methods for Distal Clavicle Fractures

Clinical profile and outcome in neonates born to COVID-19 positive mothers and COVID positive children aged between 1 month to 12 years admitted in a tertiary COVID care centre: a cross sectional study

Background: COVID-19 pandemic has caused worldwide havoc since the first case was discovered in China in December 2019. The infection has caused less severe infections and fewer deaths in children compared to adults. During the first two waves of COVID-19, the mortality rate in children has been &lt;3% in India though more severe infections and hospitalizations were seen during the second wave. This study was undertaken at a tertiary Pediatric COVID care center during the third wave to understand the clinical, morbidity profile and outcomes in neonates born to COVID positive mothers and children who are COVID positive. Methods: Neonates born to COVID positive mothers and children between the age group 1 month to 12 years admitted in Government general hospital, Kakinada, Andhra Pradesh from 1January 2022 to 31March 2022 were included in the study. Their demographic, clinical, morbidity profile, treatment details were noted and outcomes observed.Results: All neonates were found to be RTPCR negative. 28% of neonates were born prematurely and 16% had birth asphyxia. Respiratory distress was the most presenting symptom. Death was seen in 4 newborns due to perinatal complications. More children less than 10 years required admission.15% of children were asymptomatic. Fever, cough, and running nose were the most presenting complaints. 2 children who had co-morbidities at the time of admission died.Conclusions: The third wave of COVID-19 did not cause any significant change in morbidity and mortality in children compared to the previous two waves.

Comparison of Two Laparoscopic Techniques in Management of Pediatric Inguinal Hernias.

Introduction: Many studies focus on comparing outcomes of the open method for inguinal hernia repair (IHR) and the laparoscopic method. However, few studies compare different laparoscopic techniques. With over a dozen different techniques described in the literature for laparoscopic IHR, significant opportunities exist to study the efficacy of each technique. We investigated outcomes of a subcutaneous endoscopically assisted transfixion ligation (SEATL) technique and a percutaneous internal ring suturing (PIRS). Materials and Methods: After receiving institutional review board approval, we completed a retrospective chart review of IHR performed at our pediatric tertiary care center between September 2015 and May 2020. We included all patients under the age of 18 years. We separated laparoscopic repairs from total repairs. Laparoscopic repairs were further divided into their respective techniques. Factors involving patient demographics, operative details, and postoperative complications were statistically analyzed using SPSS. Results: There was a total of 131 IHRs performed with SEATL and 124 IHRs performed with PIRS. Median operative time (minutes) differed significantly (P = .001) with SEATL at 49 (28-66) and PIRS at 55 (37-76)] minutes. Significantly more incarcerated hernias were repaired with PIRS (n = 13) than with SEATL (n = 3, P = .006). SEATL had a higher number of postoperative complications; the most significant were granulomas (n = 3, P = .09) and recurrent hernias (n = 12, P < .001). Conclusion: SEATL had a significantly higher number of postoperative complications. This may be a result of multiple factors including but not limited to the absence of electrocautery, a shorter median operative time, and utilization of absorbable suture. Modifications have been made to this technique to reduce risk of postoperative complications.

Continuous noninvasive blood gas estimation in critically ill pediatric patients with respiratory failure

Patients supported by mechanical ventilation require frequent invasive blood gas samples to monitor and adjust the level of support. We developed a transparent and novel blood gas estimation model to provide continuous monitoring of blood pH and arterial CO2 in between gaps of blood draws, using only readily available noninvasive data sources in ventilated patients. The model was trained on a derivation dataset (1,883 patients, 12,344 samples) from a tertiary pediatric intensive care center, and tested on a validation dataset (286 patients, 4030 samples) from the same center obtained at a later time. The model uses pairwise non-linear interactions between predictors and provides point-estimates of blood gas pH and arterial CO2 along with a range of prediction uncertainty. The model predicted within Clinical Laboratory Improvement Amendments of 1988 (CLIA) acceptable blood gas machine equivalent in 74% of pH samples and 80% of PCO2 samples. Prediction uncertainty from the model improved estimation accuracy by 15% by identifying and abstaining on a minority of high-uncertainty samples. The proposed model estimates blood gas pH and CO2 accurately in a large percentage of samples. The model’s abstention recommendation coupled with ranked display of top predictors for each estimation lends itself to real-time monitoring of gaps between blood draws, and the model may help users determine when a new blood draw is required and delay blood draws when not needed.

A Cross-Sectional Study of Unlocking Childhood Cancer Services during COVID-19 Pandemic: A Pediatric Oncology Tertiary Care Center's Experience from a Developing Country

Abstract Introduction The global coronavirus disease 2019 (COVID-19) pandemic has made the provision of cancer care services a challenging task all over the world, even in developed countries. Multiple studies have already reported increased rate of diagnostic delays, interruptions in radiotherapy and chemotherapy administration, and shortage of health care personnel to deliver these services. Objective The aim of this study was to analyze the impact of strategies used to deliver uninterrupted childhood cancer services at our center during the COVID-19 pandemic. Materials and Methods This is a cross-sectional study of the children less than 18 years of age admitted at our center between March 2020 and September 2021 to assess the effect of strategies adopted to provide uninterrupted cancer services during the COVID-19 pandemic. All the children with cancer who were managed during the study period were included in the study. The children who had treatment interruptions/lost to follow-up prior to onset of COVID-19 were excluded from the study. The primary outcome was to measure the effect of COVID-19 on delivery of cancer care services. The secondary outcome was to assess whether the strategies followed at our center helped to reduce diagnostic delays or loss to follow-up during the COVID-19 pandemic. Results Out of total 1,490 admissions, 199 children were managed during the study period. Among the 199 children managed, 124 of them were newly diagnosed, 75 had ongoing treatment, 16 children relapsed, 13 children received palliative care, and 6 families were lost to follow-up. Out of 1,471 tests done, only 16 children and 6 caregivers tested COVID-19 positive during routine screening. Thirty-five underwent surgery and 23 received radiotherapy during this period. Among 199 children, 143 (71.8%) received financial support for hospital expenses, 23 (11.5%) received travel support, 20 (10%) were provided free accommodation, and 15 (7.5%) received home delivery of oral chemotherapy and pain medications. A total of $86,989.05 was supported for diagnostic investigations, COVID-19 testing, chemotherapy, and supportive care; $1,144.90 for travel support; and $17,010.94 was waived off by hospital administration to support the poor families. Conclusion The shared care model, support from nongovernmental organizations and hospital administration, and utilization of local resources productively and effectively helped to avoid diagnostic delays and treatment interruptions, and provide uninterrupted pediatric cancer care services at our center.

Interventional endoscopy for abdominal transplant patients

Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis.The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients.In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).

AB1144 COGNITIVE AND PSYCHOSOCIAL OUTCOME IN CHILDREN WITH MULTISYSTEM INFLAMMATORY SYNDROME FOLLOWING SARS-CoV-2 INFECTION

BackgroundDespite the low rate of neurological deficits following the SARS-COV-2 infection in the pediatric population, children and adolescents who develop multisystem inflammatory syndrome (MIS-C) after being infected with SARS-COV-2 are at a higher risk for neurological abnormalities and brain injury, increasing the risk of adverse cognitive and psychiatric outcome.ObjectivesGiven the increased risk of central nervous system impairment we chose to conduct a prospective study looking at the cognitive and psychosocial outcome of patients with MIS-C.MethodsOur study included 27 of the 29 patients between 2 to 18 years of age (M = 11.1, SD = 4.4) who were treated for MIS-C from the onset of the SARS-COV-2 pandemic until the beginning of May 2021 at the only tertiary care pediatric immunology center in Slovenia. We assessed these patients 6 months after diagnosis using the age-appropriate Wechsler intelligence scales and a battery of neuropsychological test measuring attention, executive function, memory and fine motor skills. We also asked parents to report on patients’ psychosocial outcome using the Achenbach Child Behavior Checklist.ResultsBy using Bayesian statistics to take into account parental education and any potential pre-morbid learning difficulties we found no evidence of impairment on measures of intelligence. However, the posterior distribution of scores on neuropsychological measures indicated that a significant proportion of patients scored 1SD bellow expected levels on measures of attention (31%), executive function (28%) and visual memory (35%). Increased symptoms of depression, anxiety and attention difficulties were also reported by parents, although their extent did not rise to a clinically significant level.ConclusionThe findings from our cohort suggest that the cognitive and psychosocial outcome of patients with MIS-C is generally favorable, although up to 35% may experience specific neuropsychological deficits more than 6 months after diagnosis. The most commonly impaired cognitive domains seem to be attention, executive function and visual memory.AcknowledgementsFunding for this work was provided by the Slovenian Research Agency grant J3-3061 and University Medical Centre grant 20210069. Support was also provided by Dušica Boben and the publisher Center za psihodiagnostična sredstva by providing the local adaptations of psychological assessment tools.Disclosure of InterestsDavid Gosar Speakers bureau: Biogen, Novartis, Mojca Zajc Avramovič: None declared, Nina Emersic: None declared, Mateja Šušterič: None declared, Maja Maša Šömen: None declared, Damjan Osredkar: None declared, Tadej Avcin: None declared

Targeted Training for Subspecialist Care in Children With Medical Complexity.

BackgroundChildren with medical complexity (CMC) are prone to medical errors and longer hospital stays, while residents do not feel prepared to provide adequate medical care for this vulnerable population. No educational guidance for the training of future pediatric tertiary care specialists outside their field of expertise involving the multidisciplinary care of CMC exists. We investigated pediatric residents past educational needs and challenges to identify key learning content for future training involving care for CMC.MethodsThis was a prospective mixed-methods study at a single pediatric tertiary care center. Qualitative semi-structured interviews with residents were conducted, submitted to thematic content analysis, linked to the American Board of Pediatrics (ABP) general pediatrics content outline, and analyzed with importance performance analysis (IPA). Quantitative validation was focused on key themes of pediatric nephrology within the scope of an online survey among pediatric residents and specialists.ResultsA total of 16 interviews, median duration 69 min [interquartile range IQR 35], were conducted. The 280 listed themes of the ABP general pediatrics content outline were reduced to 165 themes, with 86% (theoretical) knowledge, 12% practical skills, and 2% soft skills. IPA identified 23 knowledge themes to be of high importance where improvement is necessary and deemed fruitful. Quantitative validation among 84 residents and specialists (response rate 55%) of key themes in nephrology yielded high agreement among specialists in pediatric nephrology but low interrater agreement among trainees and “trained” non-nephrologists. The occurrence of themes in the qualitative interviews and their calculated importance in the quantitative survey were highly correlated (tau = 0.57, p = 0.001). Two clusters of high importance for other pediatric specialties emerged together with a contextual cluster of frequent encounters in both in- and outpatient care.ConclusionRegarding patient safety, this study revealed the heterogeneous aspects and the importance of training future pediatric tertiary care specialists outside their field of expertise involving the multidisciplinary care of CMC. Our results may lay the groundwork for future detailed analysis and development of training boot camps that might be able to aid the improvement of patient safety by decreasing preventable harm by medical errors, especially for vulnerable patient groups, such as CMC in tertiary care pediatrics.

Factors that contribute to disparities in time to acute leukemia diagnosis in young people: an in depth qualitative interview study

BackgroundRacial and ethnic disparities in outcomes for Black and Hispanic children with acute leukemia have been well documented, however little is known about the determinants of diagnostic delays in pediatric leukemia in the United States. The primary objective of this study is to identify factors contributing to delays preceding a pediatric leukemia diagnosis.MethodsThis qualitative study utilized in-depth semi-structured interviews. Parents and/or patients within two years of receiving a new acute leukemia diagnosis were asked to reflect upon their family’s experiences preceding the patient’s diagnosis. Subjects were purposively sampled for maximum variation in race, ethnicity, income, and language. Interviews were analyzed using inductive theory-building and the constant comparative method to understand the process of diagnosis. Chart review was conducted to complement qualitative data.ResultsThirty-two interviews were conducted with a diverse population of English and Spanish speaking participants from two tertiary care pediatric cancer centers. Parents reported feeling frustrated when their intuition conflicted with providers’ management decisions. Many felt laboratory testing was not performed soon enough. Additional contributors to delays included misattribution of vague symptoms to more common diagnoses, difficulties in obtaining appointments, and financial disincentives to seek urgent or emergent care. Reports of difficulty obtaining timely appointments and financial concerns were disproportionately raised among low-income Black and Hispanic participants. Comparatively, parents with prior healthcare experiences felt better able to navigate the system and advocate for additional testing at symptom onset.ConclusionsWhile there are disease-related factors contributing to delays in diagnosis, it is important to recognize there are multiple non-disease-related factors that also contribute to delays. Evidence-based approaches to reduce outcome disparities in pediatric cancer likely need to start in the primary care setting where timeliness of diagnosis can be addressed.

Characteristics and Outcomes of Cases of Children and Adolescents With Pediatric Inflammatory Multisystem Syndrome in a Tertiary Care Center in Mexico City.

BackgroundPediatric inflammatory multisystem syndrome (PIMS) is a complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children that resembles Kawasaki syndrome and places them at high risk of cardiorespiratory instability and/or cardiac damage. This study aims to describe the clinical presentation and outcomes of patients with PIMS in Mexico City.MethodsThis was an observational study of children hospitalized for PIMS based on the Centers for Disease Control and Prevention case definition criteria, in a single tertiary care pediatric center in Mexico City between May 1, 2020, and September 30, 2021. Demographic characteristics, epidemiological data, medical history, laboratory tests, cardiologic evaluations, treatment, and clinical outcomes were analyzed.ResultsSeventy-five cases fulfilled the case definition criteria for PIMS [median age: 10.9 years, Interquartile range (IQR): 5.6–15.6]. Fifteen (20%) patients had a severe underlying disease, 48 (64%) were admitted to the intensive care unit, 33 (44%) required invasive mechanical ventilation and 39 (52%) received vasopressor support. The patients were clustered through latent class analysis based on identified symptoms: Cluster 1 had rash or gastrointestinal symptoms (n = 60) and cluster 2 were those with predominantly respiratory manifestations (n = 15). Two patients (2.7%) died, and both had severe underlying conditions. Five patients (6.7%), all from cluster 1, developed coronary aneurysms.ConclusionThere were a high proportion of patients with severe respiratory involvement and positive RT-PCR SARS-CoV-2 and very few cases of coronary aneurysms in our study which suggests that a high proportion of the children had severe acute COVID-19. The clinical manifestations and outcomes are comparable to previously reported international studies.

Innovative virtual care delivery in a Canadian paediatric tertiary-care centre.

Health care systems and providers have rapidly adapted to virtual care delivery during this unprecedented time. Clinical programs initiated a variety of virtual care delivery models to maintain access to care, preserve personal protective equipment, and minimize infectious disease spread. Herein, we first describe the context within paediatric health delivery during the COVID-19 pandemic in Canada that fueled the rise of virtual care delivery. We then summarize the development, implementation, and beneficial impact of the innovative virtual care delivery programs currently in use at Children's Hospital of Eastern Ontario (CHEO) for both inpatient and outpatient care, specifically in our ambulatory clinics, emergency department, and mental health program. We highlight the transferable unique ways CHEO has integrated virtual care delivery through our governance structure, stakeholder engagement including patient, caregivers and health care providers and staff, development, and use of eHealth tools and novel approaches for patient care requiring physical assessment. We conclude with our vision for the future of virtual care, one component of paediatric care delivery in the post-COVID-19 era, which requires a common framework for virtual care evaluation. Importantly, rapid implementation of a primarily virtual care model at CHEO sustained high volume quality paediatric care. We believe many of these programs should and will remain in the post-pandemic era. A comprehensive, unified approach to evaluation is essential to yield meaningful results that inform sustainable care delivery models that integrate virtual care, and ultimately help ensure the best health outcomes for our patients.

Xanthan- and Rice Cereal-Based Thickeners in Infants: A Multidisciplinary Single-Center Experience.

Single-center retrospective chart review conducted at a tertiary pediatric care center between January 2013 and July 2017. All infants deemed unsafe for oral feeding and treated with xanthan- or rice cereal-based milk thickeners were included. Data were extracted from the medical records and patients categorized according to the type of thickener. Primary outcome was the occurrence of diarrhea, constipation, overweight, and obesity at 3-6 and 6-12 months after thickener initiation. Appropriate statistical tests were used. In addition, an e-mail was sent to 14 level III Canadian Pediatric hospitals inquiring about their practice. We identified 53 patients to be included in the study; 20 used xanthan-based- and 33 used rice cereal-based milk thickeners. Rates of diarrhea, constipation, overweight, and obesity at 3-6 and 6-12 months after initiation were not different between thickeners. Important variability concerning thickening practices was reported by the 8 centers that responded. In infants treated with milk thickeners, xanthan-based or rice cereal-based thickeners may have similar safety profiles that require further investigation including a larger number of patients.

Landscape of Pediatric Endoscopic Ultrasound in a United States Tertiary Care Medical Center.

Endoscopic ultrasound (EUS) is a commonly used radiation-sparing procedure in adult patients for diagnostic sampling of gastrointestinal lesions and fluid collections, gastric variceal hemostasis, biliary/pancreatic duct drainage, and endo-surgical interventions. Integration of EUS in pediatrics is still in its infancy with limited data regarding its use. The present study analyzes utilization, diagnostic and therapeutic roles of pediatric EUS and evolution in these parameters over time. Records of patients 18 years or younger from 2009 to 2020 at our tertiary pediatric care center were retrospectively identified. Patient demographics, symptoms, laboratory studies, EUS indications and interventions, and clinical outcomes of the procedures were analyzed. Statistical analysis was performed using Student t-test, Pearson's chisquare and Fisher exact tests. 306 EUS procedures were performed during the study period, for 279 pediatric patients. These included 287 (93.8%) upper EUS and 19 (6.2%) lower EUS. Two hundred and twenty-nine procedures were diagnostic (74.8%) and 77 were therapeutic (25.2%). EUS indications included evaluation and therapy of the pancreaticobiliary region (231, 75.5%), subepithelial or regional lesion (54, 17.8%), celiac plexus block (19, 6.2%) and hemostasis (14, 4.5%). Diagnostic sampling was performed in 52 of these EUS procedures, with a 96.2% diagnostic yield. 98.7% of therapeutic procedures were technically successful and there were no associated adverse events. The diagnostic and therapeutic role for EUS in adults has expanded dramatically, however the role of EUS in pediatrics is not well-defined. In this, the largest pediatric EUS study to date, our data support the safety and utility of diagnostic and therapeutic EUS in pediatrics.

Surgical Management of Distal Clavicle Fractures in Skeletally Immature Athletes

Background:Distal clavicle fractures account for a significant proportion of clavicle fractures in the pediatric and adolescent age groups, but clinical decision making to date has largely been informed by adult studies. However, surgical treatment in this younger population may have unique technical and clinical considerations, due to distinct fracture patterns, increased healing potential and periosteal thickness.Hypothesis/Purpose:The objective of this study was to characterize distal clavicle fractures in a cohort of pediatric and adolescent athletes who underwent operative treatment at a single, tertiary-care pediatric center, including surgical techniques used and resultant clinical outcomes.Methods:A retrospective review was performed of all operatively-treated clavicle fractures extending to the coracoclavicular ligaments or lateral, between 2005-2020. Patients >19 years-old or those with pathological fractures were excluded. Radiographic characteristics, surgical fixation construct, time to radiographic healing, return to sports, and complications were analyzed.Results:Fifty-two patients were identified, with mean age 13.8 ± 2.2 years. The majority of fractures were classified as Nenopoulus type IIB (transverse, displaced; 42.3%) or type IIIB (oblique, displaced; 26.9%), with type IIA (transverse, minor displacement; 3.8%), IV (comminuted; 11.6%) , and V (AC dislocation; 15.4%) patterns also observed. Primary direction of displacement was posterior in 90% of cases and superior in 10%. Plate fixation was performed in 53.8% of surgeries, with locking plate (26.9%) and hook plate (17.3%) most frequent. Suture-based fixation was performed in 32.7% of cases (Figure 1). Rate of removal of implants was 66% after plate fixation, the majority of which (72.2%) were planned at the time of primary fixation. Patient age was comparable in suture and plate cohorts (12.9 vs. 13.5, p = 0.19). Total complication rate, including unplanned removal of implants, was higher in the plate fixation group (25%) than in the suture-based fixation group (11.2%). Time to radiographic healing was not significantly different between plate and suture-based constructs (2.9 vs. 2.9 months, p = 0.96) though patients with suture-based constructs returned to sport faster (2.5 vs. 3.6 months, p = 0.014).Conclusion:The vast majority of distal clavicle fractures treated operatively in pediatric and adolescent athletes are posteriorly displaced fractures. When chosen in the appropriate patient, suture-only constructs can lead to similar healing and faster return to sports compared to plate-based constructs, with greatly reduced need for removal of hardware. These data provide a foundation for future comparative research further elucidating precise surgical indications and optimal treatment approaches.Table 1.Fixation Methods for Distal Clavicle Fractures

Impact of COVID-19 disease on clinical research in pediatric and congenital cardiology

BackgroundCOVID-19 triggered an unprecedented crisis affecting society at every level. Research in pediatric and congenital cardiology is currently in full development and may have been disrupted. The aim of the study was to determine the impact of COVID-19 on pediatric and congenital cardiology clinical research and to analyze decision-making and adaptation processes, from a panel of ongoing academic and industry-sponsored research at the time of the pandemic. MethodsThis observational study was carried out in April 2020, from a CHD clinical research network involving five tertiary care pediatric and congenital cardiology centers. Investigators and clinical research assistants from each participating research center completed an online survey questionnaire, and each principal investigator underwent a 1-h web-based videoconference interview. ResultsA total of 34 study questionnaires were collected, reporting that 18 studies were totally suspended. Upon the investigator's decision, after discussion on ethical issues and with facilitating support from health authorities, 16 studies were resumed. The rate of study suspension in interventional research (53%) was similar to that in non-interventional research (56%). Logistical problems were predominantly reported in both continued and suspended trials. Research protocols were adapted, largely thanks to telemedicine, which in some cases even improved the course of the study. ConclusionThe impact of the COVID-19 pandemic on clinical research in pediatric and congenital cardiology has been limited by a rapid adaptation of all research structures and an extensive use of telemedicine at all stages of the studies.

Pseudotumor cerebri syndrome in children with systemic lupus erythematosus: case series and review

BackgroundSystemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease that typically affects multiple organs and can lead to potentially fatal complications. Central nervous system (CNS) involvement in SLE is common, especially in children, and can present nonspecifically with various neuropsychiatric manifestations, described as neuropsychiatric SLE (NPSLE). Chronic headache is a common feature of NPSLE, secondary to increased intracranial pressure (also called pseudotumor cerebri (PTC)) due to inflammation or medication. Here, we highlight the importance of evaluating refractory headache (HA) in SLE patients to rule out PTC as a cause of severe morbidity.MethodsSingle tertiary care pediatric center case series of 8 children who developed NPSLE in the form of intracranial hypertension at or after SLE diagnosis.ConclusionNeurologic and ophthalmologic evaluation of refractory HA in patients with SLE, especially children, is warranted to decrease the burden of the disease and rule out treatable causes like PTC.

Surgical approach to Hirschsprung disease

Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis.The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients.In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).

A pediatric hospital-wide asthma severity score: Reliability and effectiveness.

Asthma is a leading cause of pediatric hospitalization in the United States. Children hospitalized with asthma are often managed in different care settings during hospitalization, posing challenges to accurate communication among care providers about illness severity. Our objective was to study the feasibility, reliability, and safety of a new pediatric hospital-wide asthma severity score (HASS) across different care units within a single tertiary-care pediatric center. 150 patients between the ages of 2 and 18 years hospitalized with a principal diagnosis of status asthmaticus were included in this study. Study patients were followed from the time of initial triage in the emergency department until the time of medical readiness for discharge. Rates of medical errors, early transfers to a higher level of care and medically indicated hospital length of stay (LOS) were compared between 75 patients before and 75 patients after widespread implementation of the HASS using retrospective chart review and anonymous staff reporting. Interrater reliability was determined by collecting independent HASS scores from blinded staff members after tandem or simultaneous patient assessment. Interrater reliability among untrained staff members using the HASS was high. Hospital LOS, rates of adverse events, medical errors, and early transfer to a higher level of care were not significantly different before and after widespread HASS implementation. The HASS is a reliable asthma severity tool that can be used throughout hospitalization and among multiple clinical providers to trend clinical progress and optimize communication, particularly during times of care handoffs.