Predictors Of Outcome In Children Research Articles

Paediatric Risk of Mortality (PRISM) III Score and Serum Lactate Levels as Predictor of Outcome in Children Admitted to the Paediatric Intensive Care Unit

Objective − To evaluate prognostic indicators of mortality in children admitted to the Paediatric Intensive Care Unit (PICU) and to correlate blood lactate levels with Pediatric Risk of Mortality (PRISM) III scores.Methods − A cross sectional study was conducted between March 2021 and October 2022 in the PICU of the P S Govindasamy (PSG) Institute of Medical Sciences and Research. On the basis of the laboratory and clinical parameters, the PRISM III score was calculated at admission. Lactate levels were measured at admission and 24 hours after admission.Results − The study included 107 patients of whom the majority (54.2%) were female. The median patient age was 3 years and the median duration of PICU stay was 4 days. Among the hospitalized patients, 90.7% were survivors, with female patients having an 8.8-fold higher risk of mortality compared to males (P=0.05). The serum lactate value in survivors (2.95 mmol/L) was much lower in comparison to non-survivors (3.11 mmol/L). The PRISM III value measured at the time of admission in survivors (8) was low when compared to non-survivors (16.50). The area under the curve (AUC) for PRISM III was 0.884 compared to lactate levels (0.831).Conclusion − A significant positive correlation was seen between the PRISM III score and lactate levels. The study indicates that monitoring patients admitted to the PICU in relation to their PRISM III score and lactate levels can improve their overall prognosis and facilitate early resuscitation.

Hablando at home: Examining the interactional resources of a bilingual autistic child.

Daily language interactions predict child outcomes. For multilingual families who rear neurodiverse children and who may be minoritized for their language use, a dearth of research examines families' daily language interactions. Utilizing a language socialization framework and a case study methodology, 4,991 English and Spanish utterances from a 5-year old autistic child and his family were collected during naturally occurring interactions over 10 days. Utterances were analyzed for patterns of code-switching by speaker, activity setting, English or Spanish initial language, and code-switch function. Spanish was spoken in most activities. For reading, both languages were equally employed by the father. While participants used both languages across all activity settings, significant variations in code-switching type and function were observed by activity setting and speaker. We discuss implications for how home language resources can be integrated into autism interventions.

Predictors of Outcome in Management of Paediatric Head Trauma in a Tertiary Healthcare Institution in North-Central Nigeria.

Trauma is a leading causes of death and disability in all ages. The aim of this study was to describe the demography and characteristics of paediatric head trauma in our institution and examine the predictors of outcome and incidence of injury related mortality. We examined our institutional Trauma Registry over a 2 year period. A total of 1100 trauma patients were seen over the study period. Of the 579 patients who had head injury 99 were in the paediatric age group. Of the paediatric head trauma patients 79 had documented Glasgow coma score (GCS), 38 (48.1%), 17 (21.5%) and 24 (30.4%) had mild, moderate and severe head injury respectively. The percentage mortality of head injury in the paediatric age group was 6.06% (6/99). There is an association between mortality and GCS (p=0.008), necessity for intensive care unit (ICU) admission (p=0.0001), associated burns (p=0.0001) and complications such as aspiration pneumonia (p=0.0001). The significant predictors of outcome are aspiration (p=0.004), the need for ICU admission (p=0.0001) and associated burns (p=0.005) using logistic binary regression. During the study period 46 children underwent surgical intervention with extradural haematoma 16 (34.8%), depressed skull fracture 14 (30.4%) and chronic subdural haematoma five (10.9%) being the commonest indication for surgeries. Paediatric head injury accounted for 9.0% (99/1100) of all trauma admissions. Majority of patients had mild or moderate injuries. Burns, aspiration pneumonitis and the need for ICU admission were important predictors of outcome in children with traumatic brain injury.

Parent-Child Inpatient Treatment in Child and Adolescent Mental Healthcare: Predictors of Child Outcomes.

Family inpatient units in child and adolescent mental health (CAMH) services engage all admitted family members in the treatment of children's symptoms. Studies demonstrated improvements in child and family functioning following family inpatient treatment, but evidence regarding predictors of treatment outcome is lacking. We analyzed data of families (n = 66) who received a four-week inpatient treatment for families with severe parent-child interaction problems. Hierarchical linear regression analyses revealed that parents who recalled harsher parenting practices of their own fathers reported greater improvements in their children's externalizing and internalizing problems. Greater improvements in externalizing problems were further predicted by lower parental educational level, less adverse impacts of stressful life events, and less internalizing child problems prior to admission. We therefore conclude that family inpatient treatment was particularly effective for children in families with lower parental education and a history of harsh parenting.

Exercise capacity in a cohort of children with congenital heart disease

In patients with congenital heart disease (CHD), reduced exercise capacity can be a predictor for late complications and may be used to guide interventions. Yet, the interpretation of exercise capacity is challenged by changes in body composition during growth. Our aim was to create an overview of disease-specific exercise capacity in children with CHD. We performed a multicentre retrospective study of exercise capacity of CHD patients, aged 6–18 years, tested between January 2001 and October 2018. Sex-specific distribution graphs were made using the LMS method and height to relate to body size. We included all CHD with N > 50, including severe defects (e.g., univentricular heart, tetralogy of Fallot) and “simple” lesions as ventricular septum defect and atrial septum defect. We included 1383 tests of 1208 individual patients for analysis. The peak oxygen uptake (VO2peak, 37.3 ml/min/kg (25th–75th percentile 31.3–43.8)) varied between specific defects; patients with univentricular hearts had lower VO2peak compared with other CHD. All groups had lower VO2peak compared to healthy Dutch children. Males had higher VO2peak, Wpeak and O2pulsepeak than females. Sex- and disease-specific distribution graphs for VO2peak, Wpeak and O2pulsepeak showed increase in variation with increase in height. Conclusion: Disease-specific distribution graphs for exercise capacity in children with CHD from a large multicentre cohort demonstrated varying degrees of reduced VO2peak and Wpeak. The distribution graphs can be used in the structured follow-up of patients with CHD to predict outcome and identify patients at risk.What is Known:• Children with congenital heart disease (COnHD) are at risk to develop heart failure, arrhytmia’s and other complications. Exercise capacity may be an important predictor for outcome in children with ConHD. In children, the interpretation of exercise capacity poses an additional challenge related to physical changes during growth.What is New:• In this report of a multi-center cohort >1300 childrewn with ConHD, we related the changes in exercise capacity to length. We demonstrated that exercise capacity was reduced as compared with healthy children and we observed variation between disease groups. Patients with a univentricular circulation (Fontan) had worse exercise capacity. We constructed disease specific charts of development of exercise capacity throughout childhood, accessible via a web-site. These graphs may help practitioner to guide children with ConHD.

Deauville score versus ratio Deauville score in the interpretation of interim 18F-FDG PET-CT and in prediction of outcome in children with FDG-avid extra-nodal lymphomas

BackgroundPediatric lymphoma is a common hematological neoplasm, representing the third most frequent childhood malignancy. 18F-fluoro-2-deoxyglucose–positron emission tomography has been found to be useful in lymphoma staging, prediction of prognosis and risk stratification of lymphoma patients. Although the interpretation of interim PET (after two cycles of chemotherapy) using the qualitative visual method of 5-point Deauville score has been widely accepted, semiquantitative methods of interpretation were evaluated by many studies and showed a better prediction of prognosis. The purpose of this study was to evaluate the prognostic role of the semiquantitative ratio Deauville score (rDS), defined as the ratio between target lesion and liver maximum standardized uptake values in children with FDG-avid extra-nodal lymphomas, undergoing interim FDG-PET/CT, and to compare it with the 5-point Deauville score (5p-DS).MethodsThis prospective study included 89 children with FDG-avid extra-nodal lymphoma. Interim PET was interpreted using both visual (5p-DS) and the semiquantitative method (rDS). The visual method depends on visual comparison of FDG uptake between lesions and liver as a reference organ for activity and considered lesions with activity higher than liver to be positive, while the semiquantitative method depends on making a ratio between the most active lesion and liver SUVmax. Receiver operating characteristic approach was applied to identify the optimal cut-point of rDS with respect to response to therapy and prognosis, and the prognostic significance of rDS was compared with 5p-DS.ResultsThe ROC analysis for rDS as a predictor of progression showed an optimal cut-point of 1.25. Both 5p-DS and rDS were strong outcome predictors. Patients with negative 5p-DS and patients with rDS < 1.25 had a similar 3-year PFS (87%). Patients with a positive 5p-DS had a 3-year PFS of 67.4%, while patients with rDS > 1.25 had a 3-year PFS of 60%.ConclusionsrDS could be suggested as an accurate prognostic factor in children with lymphoma undergoing interim FDG-PET/CT. However, larger studies with more homogenous sample regarding histopathological subtypes and chemotherapy lines are needed to confirm these data.

Predictive Accuracy of Full Outline of Unresponsiveness Score and GCS to Predict Patient’s Poor Outcome in Pediatrics ICU

Aim: To compare the predictive accuracy of Glasgow coma Scale (GCS) versus full outline of unresponsiveness score (FOUR score) for poor out-come prediction in children admitted in paediatric ICU. Study design: Descriptive cross-sectional study. Place and duration of study: Department of Pediatrics, Services Hospital Lahore from 29th June 2017 to 29th December 2017. Methodology: One hundred and seventy children were enrolled. Both GCS and FOUR scale scores were recorded in paediatric intensive care unit (ICU) by clinical examination within 30 minutes of arrival in ICU. Both GCS and FOUR score were calculated on each and every patient. Responses were noted by clinically examining the eye, motor, verbal and brain stem reflexes. Patients were followed upto 7 days and poor outcome was noted. Results: The frequency of pediatric mortality was 52 (30.59%). Predictive accuracy of Full Outline of Unresponsiveness Score (FOUR score) for poor outcome prediction in children admitted in paediatrics ICU showed 63.46% for sensitivity, 86.44% for specificity, 67.35% for PPV, 84.30% for NPV and 79.41% for accuracy rate, whereas predictive accuracy of GCS Score for prediction of poor outcome in children admitted in paediatrics ICU shows 55.76% for sensitivity, 83.89% for specificity, 60.42% for PPV, 81.15% for NPV and 75.29% for accuracy rate. Conclusion: The FOUR and GCS both showed good results in terms of mortality after one week of admission in pediatric ICU. Key words: Children, poor outcome, FOUR score, Glasgow coma scale, predictive accuracy

Commentary on to “Clinicopathologic predictors of outcomes in children with stage I testicular germ cell tumors: A pooled post hoc analysis of trials from the Children's Oncology Group”

I commend the authors for studying clinical stage I testis germ cell tumor (TGCT) to identify predictors for relapse during surveillance and I appreciate the challenges that come with analyzing clinical management of a relatively rare disease [ [1] Singla N. Wong J. Singla S. Krailo M. Huang L. Shaikh F. et al. Clinicopathologic predictors of outcomes in children with Stage I testicular germ cell tumors: a pooled post hoc analysis of trials from the Children's Oncology Group. J Pediatr Urol. 2022; (In press https:://doi.org/10.1016/j.jpurol.2022.04.022) Google Scholar ]. Nonetheless, potential biases should be considered when interpreting the results. The authors analyzed multiple data points (age and pT stage at diagnosis, tumor markers and pathology specimen characteristics) to determine which, if any, affect risk of relapse, development of secondary malignant neoplasm or death during surveillance. Surveillance protocols were not the same for all patients, which the authors acknowledged is a potential selection bias. Of the data points analyzed, only age and AFP level were available for all 106 patients. Tumor pT stage was unknown in 27 percent, beta-HCG unknown in 46 percent and histology unknown in 25 percent of the study population. The authors explained the incidences of unknown, stating that in order to maintain statistical integrity they reported “unknown” unless the full complement of pathologic variables was available. But missing data for a large proportion of a study population could bias results, regardless of the reason for the data missing. Response to commentary re: Clinicopathologic predictors of outcomes in children with stage I testicular germ cell tumors: A pooled post hoc analysis of trials from the Children's oncology groupJournal of Pediatric UrologyPreviewPediatric and adolescent patients with testicular germ cell tumors (TGCT) are a particularly challenging population to study given the relatively uncommon incidence of TGCT in children. Unlike in adults, there are no reliable prognostic features to individualize risk of relapse among children with low-stage TGCT. Given this pressing clinical need, herein we leveraged data from three prospective cooperative trials to identify clinicopathologic features predictive for relapse in children with stage I TGCT. Full-Text PDF

Divorce and Predictors of Child Outcomes: The Impact of Divorce Education, Parenting, Coparenting, and Adult Quality of Life

Divorce and Predictors of Child Outcomes: The Impact of Divorce Education, Parenting, Coparenting, and Adult Quality of Life

CT-based radiomics modeling for skull dysmorphology severity and surgical outcome prediction in children with isolated sagittal synostosis: a hypothesis-generating study

PurposeTo investigate the potentialities of radiomic analysis and develop radiomic models to predict the skull dysmorphology severity and post-surgical outcome in children with isolated sagittal synostosis (ISS).Materials and methodsPreoperative high-resolution CT scans of infants with ISS treated with surgical correction were retrospectively reviewed. The sagittal suture (ROI_entire) and its sections (ROI_anterior/central/posterior) were segmented. Radiomic features extracted from ROI_entire were correlated to the scaphocephalic severity, while radiomic features extracted from ROI_anterior/central/posterior were correlated to the post-surgical outcome. Logistic regression models were built from selected radiomic features and validated to predict the scaphocephalic severity and post-surgical outcome.ResultsA total of 105 patients were enrolled in this study. The kurtosis was obtained from the feature selection process for both scaphocephalic severity and post-surgical outcome prediction. The model predicting the scaphocephalic severity had an area under the curve (AUC) of the receiver operating characteristic of 0.71 and a positive predictive value of 0.83 for the testing set. The model built for the post-surgical outcome showed an AUC (95% CI) of 0.75 (0.61;0.88) and a negative predictive value (95% CI) of 0.95 (0.84;0.99).ConclusionOur results suggest that radiomics could be useful in quantifying tissue microarchitecture along the mid-suture space and potentially provide relevant biological information about the sutural ossification processes to predict the onset of skull deformities and stratify post-surgical outcome.

Clinicopathologic predictors of outcomes in children with stage I testicular germ cell tumors: A pooled post hoc analysis of trials from the Children's Oncology Group

Patients with clinical stage I (CS I: cN0M0) testicular germ cell tumors (TGCT) exhibit favorable oncologic outcomes. While prognostic features can help inform treatment in adults with CS I TGCT, we lack reliable means to predict relapse among pediatric and adolescent patients. We sought to identify predictors of relapse in children with CS I TGCT. We performed a pooled post hoc analysis on pediatric and adolescent AJCC CS I TGCT patients enrolled in 3 prospective trials: INT-0097 (phase II), INT-0106 (phase III), and AGCT0132 (phase III). Pathology was centrally reviewed. Patient demographics, pT stage, serum tumor markers, margin status, histology, relapse, and survival were compiled. Cox regression analyses were used to identify predictors of events, defined as relapse, secondary malignant neoplasm, or death. 106 patients were identified with outcomes data available. Most patients were pT1-2 stage. Among patients with evaluable histopathology, yolk sac tumor elements were present in all patients and lymphovascular invasion in 51% of patients. Over a median follow-up of 56 months, no patients died, and 25 patients (24%) experienced an event (median event-free survival not reached). Independent predictors of events on multivariable analysis included age ≥12 years at diagnosis (HR 8.87, p<0.001) and higher pT stage (pT2 HR 7.31, p=0.0017; pT3 HR 13.5, p=0.0043). Although our study population reflects the largest pooled prospective cohort of CS I pediatric and adolescent TGCT to our knowledge, the relatively low event rate limits our multivariable analysis, and longer follow-up duration would help further characterize the natural history of these patients. Centralized pathologic review was also unable to be performed for several patients. Pediatric and adolescent CS I TGCT patients exhibit remarkable 5-year survival. Using combined data from multiple prospective trials, our study identifies clinicopathologic features that predict relapse and inform personalized treatment for these patients by potentially guiding surveillance versus adjuvant treatment strategies.

Hyponatremia as a Predictor of Adverse Outcome in Children with Severe Lower Respiratory Tract Infection in Tribhuvan University Teaching Hospital (TUTH), Nepal

Introduction: Lower respiratory tract infection (LRTI) is one of the major causes of mortality in children with estimated 1 million deaths every year. Hyponatremia is the most common electrolyte abnormality seen in LRTI. The objective of study was to find association of hyponatremia (serum sodium&lt;135meq/l) with severe LRTI. Prospective cross sectional study design was used for study. Settings: Pediatric Emergency, Ward and Pediatric Intensive Care Unit of Tribhuvan University Teaching Hospital (TUTH). Subjects: Children between 2 months to 16 years presenting with cough for less than 3 weeks, fast breathing and chest in drawing. Methods: Children between 2 month to 16 years of age having cough, fast breathing and chest in drawing admitted in emergency, ward or PICU of TUTH were screened and among them, children having pediatric respiratory severity score of 4-5 were enrolled in the study. Serum sodium was sent during admission and collected within 2 hours. Daily follow up was done to find need of respiratory support, duration to resolve hypoxia, total duration in hospital and final outcome of patient. Statistical test applied were Chi-square test and Fisher exact test. Results: 47.5% of study population had hyponatremia, of whom 65.79% had mild hyponatremia 26.31% had moderate and 7.89% had severe hyponatremia. Association of hyponatremia with need of non rebreathing face mask (p=0.001), ventilatior (p=0.009), duration of hospital stay (p=0.047) were significant. The study also found the association of severity of hyponatremia with need of non rebreathing facemask (p=0.001), ventilator (p=0.01), outcome (p=0.001), duration of stay (0.002). Mean time to resolve hypoxia in children with hyponatremia (4.5 days) was longer compared to normal sodium (2.58 days). Four patients died during the study period and all of them had hyponatremia. Conclusion: Association of hyponaremia and severity of hyponatremia in severe LRTI with need of non-rebreathing face mask, ventilatior, outcome, duration of stay was significant.

Secular trends in childhood pain and comorbid psychiatric symptoms: a population-based study

PurposePain symptoms are common in childhood. They often lead to functional impairment and co-occur with psychiatric difficulties. Although children’s lives have undergone enormous changes in recent decades, long-term data on changes in pain symptoms, and in comorbid psychiatric difficulties, is lacking. This knowledge is crucial, as co-occurring psychiatric symptoms are significant predictors of long-term outcome for children who suffer from pain. The main purpose of the present study was to explore secular changes in comorbid pain and psychiatric symptoms.MethodsFour population-based, cross-sectional surveys of 8–9-year-old children were conducted in Southwest Finland in 1989, 1999, 2005, and 2013. Identical methodologies and questionnaire-based measures were used each study year. Participation ranged from 891 to 986 over the study period. The children were asked about the frequency of headache, abdominal pain, and other pains. Children, their parents, and teachers provided information on the child’s psychiatric difficulties, including internalizing and externalizing symptoms.ResultsThe cumulative odds ratios and 95% confidence intervals for the overall prevalence of pain symptoms increased among both genders from 1989 to 2013 and ranged from 1.4 (1.03–1.8) for other pains to 2.4 (1.7–3.3) for abdominal pain. Comorbid internalizing symptoms increased among girls with odd ratios and 95% CIs of 1.8 (1.03–3.1) for children with any kind of pain, and 3.0 (1.4–6.2) for children with headache. No changes were found among boys.ConclusionOverall pain symptoms doubled in both genders, but the most novel finding was that comorbid emotional difficulties tripled among girls who reported headaches. Further research is needed to confirm, and explain, these findings.

Combined Echocardiography and Lung Ultrasound for Extubation Outcome Prediction in Children after Cardiac Surgery

Background: Children are at risk of extubation failure after congenital heart disease surgery. Such cases should be identified to avoid possible adverse consequences of failed extubation. This study aimed to identify ultrasound predictors of successful extubation in children who underwent cardiac surgery. Methods: Children aged 3 months to 6 years who underwent cardiac surgery (if they were intubated for >6 h and underwent a spontaneous breathing trial) were included in this study. Results: We included 83 children who underwent surgery for congenital heart disease. Transthoracic echocardiography and lung ultrasound were performed immediately before spontaneous breathing trials. Upon spontaneous breathing trial completion, respiratory parameters, including arterial blood gas analysis and frequency-to-tidal volume ratio, were similarly recorded. For outcome assessment, all children were followed up for 48 h after extubation. We successfully extubated 57 children (68.7%). These children were significantly older and weighed more but had shorter aortic cross-clamp and cardiopulmonary bypass times. Children who could not be weaned or extubated had prolonged total mechanical ventilation and pediatric intensive care unit stay. In the multivariate regression analysis, a lung ultrasound score ≥12 and ejection fraction ≥40% immediately before spontaneous breathing trials were the only independent predictors of successful extubation. When combined, the lung ultrasound score and an ejection fraction ≥40% showed a better diagnostic performance than every other isolated variable (lung ultrasound, N-terminal-pro-B-type natriuretic peptide, and frequency-to-tidal volume ratio). Conclusions: The combination of lung ultrasound and transthoracic echocardiography immediately before the spontaneous breathing trial effectively predicts extubation outcomes in children after cardiac surgery.

Liver Transplantation in Children and Impact of Intraoperative Goal Directed Therapies on Postoperative Outcome

Background: Liver transplantation is a hemorrhagic surgery with high postoperative complication rates in terms of organ dysfunction and infections. We conducted a retrospective observational monocentric study that had the objectives of determining predictors of postoperative outcome in children. In the initial cohort, 19 children underwent liver transplantation. A description of the postoperative outcomes of these patients was undertaken. Objective: To describe intraoperative and postoperative outcomes in children undergoing liver transplantation and to propose intraoperative management implementation measures for postoperative outcome improvement. Methods: Secondary analysis of liver transplanted patients included in the initial study. Results: There were 19 patients who underwent liver transplantation with a median age of 31[2-154] months. Five patients had re-operations (26.3%). Fourteen (73.7%) had intraoperative and/or postoperative complications. Five (26.3%) had intraoperative hemorrhagic shock. One (5.3%) had postoperative respiratory failure, one (5.3%) had postoperative multiple organ failure, two (10.5%) had postoperative neurologic failure and five (26.3%) had cardio-circulatory failure. One (5.3%) had postoperative pulmonary sepsis, five (26.3%) had postoperative abdominal sepsis, and six (31.6%) had postoperative septicemia. Intra-operative transfusion rate was 100%. In-hospital mortality rate was 10.5% (two patients). Conclusion: There were multiple postoperative adverse outcome predictors. Optimal intraoperative patient management with transfusion guided by point-of-care viscoelastic devices and goal-directed fluid and hemodynamic therapy with validated parameters and tools in children is a possible pathway to upgrade postoperative evolution in pediatric liver transplantation.

Measuring the Quality of Early Childhood Education in Low- and Middle-Income Countries.

Young children’s access to early childhood education (ECE) is increasing in low- and middle-income countries (LMICs), though often without attention to service quality. Monitoring quality requires classroom observations, but most observation tools available were developed in high-income western countries. In this article, we examine key issues in measuring ECE quality in LMICs and consider challenges and opportunities in balancing theoretical grounding, cultural- and contextual-adaptation, and empirical rigor. We then review the literature on observed classroom quality in LMICs, focusing on process quality. We find limited evidence that the constructs identified in high-income countries replicate in LMICs. Further, the very limited evidence that ECE quality measures used in LMICs predict child outcomes is almost exclusively cross-sectional and associations are mixed. We conclude by discussing how future research can build a stronger knowledge base about ECE quality and child development globally.

SpO2/FiO2 as a predictor of high flow nasal cannula outcomes in children with acute hypoxemic respiratory failure

The high-flow nasal cannula (HFNC) is a useful treatment modality for acute hypoxemic respiratory failure (AHRF) in children. We compared the ability of the oxygen saturation to fraction of inspired oxygen ratio (S/F) and arterial oxygen partial pressure to fraction of inspired oxygen ratio (P/F) to predict HFNC outcomes in children with AHRF. This study included children treated with HFNC due to AHRF from April 2013 to March 2019 at the Severance Children’s Hospital. HFNC failure was defined as the need for mechanical ventilation. Trends of S/F and P/F during HFNC were analyzed. To predict HFNC outcomes, a nomogram was constructed based on predictive factors. A total of 139 patients with arterial blood gas data were included in the S/F and P/F analyses. S/F < 230 at initiation showed high prediction accuracy for HFNC failure (area under the receiver operating characteristic curve: 0.751). Univariate analyses identified S/F < 230 at HFNC initiation and < 200 at 2 h (odds ratio [OR] 12.83, 95% CI 5.06–35.84), and hemato-oncologic disease (OR 3.79, 95% CI 1.12–12.78) as significant predictive factors of HFNC failure. The constructed nomogram had a highly predictive performance, with a concordance index of 0.765 and 0.831 for the exploratory and validation groups, respectively. S/F may be used as a predictor of HFNC outcomes. Our nomogram with S/F for HFNC failure within 2 h may prevent delayed intubation in children with AHRF.

Peg-Asparaginase Administration on Day 3 of Remission Induction Accelerates MRD Response in Children with B-Cell Precursor Acute Lymphoblastic Leukemia

To improve the outcome of children with standard and intermediate risk acute lymphoblastic leukemia (ALL) by the addition of PEG-asparaginase (PEG) on day 3 of remission induction was one of the key aims of trial ALL MB-2008 (J. Roumjantseva et al, Pediatriya, 2009). Therapy was designed based on previous MB-group studies (A. Karachunsky et al, Leukemia, 2008). Aim of the present study was to evaluate the influence of day 3 PEG on the end-induction MRD-status which is one of the significant predictors of outcome in children with B-cell precursor ALL (BCP-ALL).Patients and methods. In total, 474 patients (242 boys and 232 girls aged 1 to 17 years (median 5 years 8 months) were studied. Inclusion criteria were: BCP-ALL, treatment according to protocol ALL MB-2008, compliance with standard risk group (SRG, n=266) and intermediate risk group (ImRG, n=208) criteria according to the protocol stratification system, and availability of end-induction (day 36) bone marrow (BM) samples. Remission induction of ALL MB-2008 consisted of oral dexamethasone (6mg/m2 daily), 5 injections of vincristine (1,5 mg/m2), 0-2 injections of daunorubicin (DNR, 45 mg/m2) and 6 triple intrathecal injections. Patients were randomized in respect to PEG administration on day 3. SRG patients were divided into three groups (PEG+DNR+, PEG+DNR- and PEG-DNR+); ImRG patients were split into two (PEG+DNR+ and PEG-DNR+). MRD detection was performed by multicolor flow cytometry (MFC) in three reference laboratories. Samples with a tumor cell level above 0.01% were considered MRD-positive. Outcome parameters were event-free survival (EFS) and cumulative incidence of relapse (CIR). Median of follow up was 5 years.Results. Outcome in 474 study group patients was not significantly different from outcome of 2310 children with BCP-ALL enrolled in SRG and ImRG of ALL MB-2008 trial in whom MRD was not studied: EFS was 0.86±0.02 and 0.84±0.01, respectively, p=0.14, and CIR was 0.12±0.02 and 0.09±0.01, p=0.38.MFC MRD data obtained at day 36 had a significant impact on prognosis in SRG patients. EFS as well as CIR were worse for patients with MRD >0.1% (n=26; EFS 0.47±0.15, CIR 0.49±0.17) compared with 248 patients with low/negative MRD (EFS 0.94±0.2, CIR 0.05±0.02, p<0.001). Nevertheless, the distribution of MRD levels was completely different dependent on randomization arms: in arm PEG-DNR+ (n=92) 18.5% of patients belonged to the group with unfavorable MRD compared with only 6.2% in arm PEG+DNR- (n=80, p=0.017) and 4.3% in arm PEG+DNR+ (n=94, p=0.002). Interestingly, in two PEG+ arms the number of patients with high MRD was not significantly different (p=0.558). Despite the lower proportion of high MRD levels in PEG+ arms MRD maintained its prognostic significance also in these patients. EFS was 0.65±0.16 and CIR 0.35±0.18 in 9 children with MRD ≥0.1 compared with EFS 0.94±0.02 and CIR 0.05±0.02 in 165 patients of the low MRD group (p<0.001 for both EFS and CIR).In ImRG, MFC MRD data disclosed a prognostic value, as well. EFS was 0.92±0.03 and CIR 0.06±0.02 for 143 patients with MRD-negativity on day 36; in contrast, outcome of 78 MRD-positive patients was significantly inferior (EFS 0.73±0.06, CIR 0.25±0.06, p<0.001 for both comparisons). Like in SRG, in ImRG the distribution of MRD levels was different between two randomization arms. In PEG-DNR+ group (n=93) only 54.8% of patients were MRD-negative at the end of remission induction. In contrast, in PEG+DNR+ group (n=115) the proportion of patients with favorable MRD results was significantly higher (76.5%, p=0.001). Again even with low number of MRD-positive cases in PEG+ arm, day 36 MRD disclosed a significant influence on outcome: In 88 MRD-negative patients EFS was 0.93±0.03 and CIR 0.05+0.03, significantly better than in 27 MRD-positive patients (EFS 0.80+0.08 and CIR 0.17+0.08, p=0.025 and p=0.019, respectively).Conclusions. Administration of PEG at day 3 of remission induction leads to a more rapid MRD response in children both with standard-risk and intermediate-risk BCP-ALL. In SRG, rapidity of MRD clearance in PEG+ arms was independent of the additional administration of daunorubicin. We conclude that end-induction MRD data are independent predictors of outcome despite the small proportion of MRD-positive patients after the implementation PEG during induction. DisclosuresNo relevant conflicts of interest to declare.

The Role of Social Skills in Predicting Treatment-Recovery in Children with a Social Anxiety Disorder

The current study investigated the role of social skills and its interaction with social anxiety as predictors of treatment outcome in children with an anxiety disorder either with or without a social anxiety disorder (SoAD). In total, 133 children (aged 8 to 13) with an anxiety disorder received a 10-session cognitive behavioral treatment (FRIENDS program). Pre- to post treatment Reliable Change (RC) and Treatment-Recovery (TR) were assessed from a multi-informant perspective, by including diagnostic information (ADIS C/P), child-reported anxiety symptoms (MASC) and parent-reported internalizing symptoms (CBCL-Int). Social skills were assessed with the parent-rated Social Skills Rating System (assertion, self-control, responsibility). Results showed that 1) parents of children with a SoAD reported significantly less favorable use of assertive and responsible social behavior in their children pre-treatment than parents of children without SoAD, 2) children with higher social skills had a better treatment recovery, and 3) children with anxiety and higher responsible behavior pre-treatment and without a SoAD had a better treatment recovery, but this effect did not show for children with SoAD. In conclusion, better use of social behavior increased the likelihood of treatment recovery but not of reliable change. Further studies on the role of social skills in the treatment of childhood (social) anxiety are needed to investigate the mechanisms by which social skills impact treatment outcome.

Predictors of outcomes in children with Central Nervous System tuberculosis

BackgroundCentral Nervous system tuberculosis (CNS–Tb) is the most lethal form of extra-pulmonary tuberculosis in children. The lack of markers of outcome provides little information on the efficacy of the current treatment protocols for CNS–Tb and thus results in a higher mortality rate than other extrapulmonary manifestations of tuberculosis. This study aims to identify significant factors that will reliably predict the outcomes at discharge in children admitted with CNS–Tb. Methods and materialThis is a prospective observational study in children with neurotuberculosis admitted at a tertiary care hospital. Clinical presentations at the time of admission were studied. Outcomes at the end of in-patient care (completely cured, survival with some/severe disability or death) were correlated with clinical, laboratory, microbiological, and radiological parameters. Univariate and multivariate analyses were applied to study the parameters and a p-value ≤ 0.05 with a confidence interval (CI) of 95% was considered as statistically significant. FindingsThe study included 100 children between 4 months and 12 years of age with a mean of 5.84 (±3.5) years. At discharge, 55% of children recovered completely, 20% had some or severe disability and 25% died. On multivariate analysis, high CSF protein (p = 0.050) and drug resistance (p = 0.034) were highly associated with fatality. Meningeal enhancements with basal exudates (p = 0.021) and CSF lymphocyte count >90% were highly associated with survival with disability. Stage I disease at presentation (p < 0.0001) was the only variable associated with complete recovery. InterpretationReliable prognostic markers for CNS–Tb can aid in predicting the efficacy of the current treatment and the anticipated outcome in the children with this disease. FundingThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.