Tertiary Level Pediatric Hospital Research Articles

Toxic Shock Syndrome as an Unexpected Complication in Outpatient Pediatric Burn Treatment: A Chart Review

Background: Minor burn injuries in children affecting less than 10% of total body surface area (TBSA) are often successfully managed in the outpatient setting, however it is important to recognize they can be associated with serious sequelae such as toxic shock syndrome (TSS). Methods: We conducted a retrospective chart review at a tertiary-level pediatric hospital between May 2012 and May 2022 to identify pediatric patients diagnosed with TSS following minor burn injuries. Data collected included: patient demographics, burn characteristics, TSS symptoms, and management. Data was analyzed using descriptive statistics. Results: During the study period, 3706 patients with minor burns were treated as outpatients, of which 6 patients developed TSS. Ages ranged from 12 to 36 months, and half were male. Most injuries were scalds (n = 4) or contact injuries (n = 2), involving 1% to 3% TBSA partial-thickness burns. Early symptoms of TSS included vomiting (n = 6) and fever (n = 5), and later, hypotension (n = 5). Hospital admission for TSS occurred 1 to 6 days post-injury. Four of the 6 patients required ICU care, with 2 of them requiring fluid resuscitation and 2 receiving IVIg. The clinical course of 2 patients was complicated by deep vein thrombosis, with 1 patient developing a septic ileus as a secondary infection. All patients recovered and were discharged home after 3 to 9 days. Conclusion: We highlight the rare complication of TSS following minor burns in children. Providers should be vigilant for early symptoms of TSS like fever, vomiting, and hypotension. Further research to identify at-risk patients and preventative treatment would be beneficial.

Management and Control of Legionella pneumophila Nosocomial Outbreak Risk in a Tertiary Level Pediatric Hospital

Abstract Background Legionnaires' disease is a rare cause of pneumonia in the pediatric population. Case reports are described in children with risk factors such as immunocompromised. Outbreaks are commonly associated with buildings or structures that have complex water systems like hospitals. The most likely sources of infection include water used for showering, cooling towers, respiratory therapy equipment, humidifiers and other health care devices. Clinical presentation does not distinguish from other respiratory infections, difficult access to rapid diagnostic methods and empirical antibiotic treatment not effective are all factors that delay diagnosis and subsequent control measures, leading to an increased spread risk. Methods A case of Legionnaires' disease was rapidly detected in an immunocompromised pediatric patient with nosocomial pneumonia using BIOFIRE® FILMARRAY® Pneumonia Plus Panel and urinary antigen. The Infection Control Committee was reported, initiating control and surveillance measures: hospital's water sources were studied and patients with nosocomial pneumonia with no etiological diagnosis were studied in the same way. Results L. pneumophila was isolated in a water tank's sample with the same restriction profile as the clinical sample. A water safety plan was implemented: the water tank's temperature was raised to 65°C and hyperchlorinated to maintain an adequate level of disinfectant. Control cultures were performed, all negative. No new cases were detected. Conclusions It is important to consider Legionella pneumophila as a potential agent of pneumonia in children since it can result in life-threatening health conditions and severe nosocomial outbreak infection. The incorporation of rapid molecular or antigen diagnostic techniques allow prompt diagnosis and treatment, as well as rapid environmental and clinical surveillance measures that can reduce morbidity and mortality. When detecting Legionella infection, it is essential to identify the environmental focus so as to prevent the development of new cases.

Comparing the suitability of virtual versus in-person care: Perceptions from pediatricians.

The COVID-19 pandemic compelled a portion of healthcare to be delivered virtually. As the pandemic waned, health systems strived to find a balance between re-incorporating in-person care while maintaining virtual care. To find when virtual or in-person encounters are more appropriate, we surveyed pediatricians' perceptions when comparing the suitability of virtual care to in-person care. We surveyed a Canadian tertiary-level pediatric hospital where pediatricians assessed whether specific clinical encounters or tasks were more or less effective virtually than when performed in person. Pediatricians also rated the importance of clinical and patient factors when deciding if a patient needs to be seen in person. Of 160 pediatrics faculty members, 56 (35%) responded to the survey. When assessing different types of clinical encounters, triage, multidisciplinary meetings, discharge, and follow ups were more likely to favor virtual encounters. However, first consultations and family meetings were more likely to favor in-person encounters. Regarding clinical tasks, pediatricians were more likely to endorse explaining test results, offering treatment recommendations, and obtaining patient histories virtually. On the contrary, there was a preference for physical examinations, assessing patients visually, and assessing developmental milestones to be performed in person. When deciding if a patient should be seen in person versus virtual, pediatricians rated the patient's condition and communication barriers as the most important factors favoring an in-person appointment. These results offer an initial framework for pediatricians when choosing which encounter type may be most appropriate for their patients between virtual or in-person appointments.

Assessment of Bacterial Profile and Antimicrobial Susceptibility Pattern of Bacterial Isolates from Blood Culture in Tertiary Level Paediatric Hospital of Nepal

Introduction: Bloodstream infection is a major cause of morbidity and mortality which requires antibiotic treatment. Antimicrobial resistance is an emerging serious public health threat in both developed and developing countries. Children are more susceptible to infections requiring an appropriate choice of antibiotic based on blood culture. This study aims to investigate the bacteriological profile and antibiotic sensitivity pattern of blood culture isolates and compare the yield of bacterial growth between Brain Heart Infusion Broth (BHIB) or BD BACTEC culture media.
 Methods: A total of 12,795 blood samples were sent for bacteriological culture either for BHIB or BACTEC techniques, 10994 and 1801 samples respectively. Chi-square test was used for showing association between BACTEC and BHIB among isolates.
 Results: The findings showed that the BACTEC method detected more positive isolates than the BHIB method. The rate of isolation was found highest among children under five years. The most common pathogens isolated were Staphylococcus species (28.1%), Staphylococcus aureus (25.6%), Acinetobacter species (12%), Pseudomonas species (8.2%), Klebsiella species (6.6%), CONS (4.4%), Escherichia coli (4.4%), Salmonella Typhi (3.5%), Enterobacter species (3.2%) and Streptococcus species (0.3%).
 Conclusions: Staphylococcus aureus was the commonest isolate identified in the current study. BACTEC culture method detected the higher percentage of isolates than BHIB method.

Vestibular Preservation in Pediatric Cochlear Implantation.

Evaluate the rate of preserved vestibular function in pediatric cochlear implant surgery. Retrospective case review. Pre- and post-operative vestibular tests were compared in children who underwent cochlear implantation at a tertiary level pediatric hospital over a 4-year period. Data from 59 implanted ears in 44 children was included. Median age was 2.8 years at initial testing (range 7 months - 21 years) with 1:1 male/female ratio. Implant surgeries were 26 unilateral, 13 bilateral simultaneous, and 5 bilateral sequential. The majority were implanted with slim, non-styletted electrodes (86.4%) via a round window approach (91.5%). Normal pre-operative results were preserved post-operatively on rotary chair testing in 75% (21/28) of patients, cervical vestibular evoked myogenic potential testing in (75%) 30/40 of ears tested, ocular vestibular evoked myogenic potential testing in 85.7% (6/7) of ears tested, video head impulse testing in 100% (9/9) of ears tested, and computerized dynamic posturography in 100% (5/5) of patients tested. Overall, 62.5% of patients had no new deficits on any vestibular test performed post-operatively. Preservation rates of vestibular function following cochlear implant surgery were higher in this cohort than what has been reported in many earlier studies. Contemporary, less traumatic electrodes and insertion techniques may be a significant factor. The risk of causing a new, severe bilateral vestibular loss with long-term functional impacts appears to be low. Further study is warranted on the impacts of different cochlear implant electrode designs and insertion approaches on post-operative vestibular preservation. 4, Case Series Laryngoscope, 134:1913-1918, 2024.

The Risk of Nerve Injury in Pediatric Forearm Fractures.

This article was updated on July 19, 2023, because of a previous error, which was discovered after the preliminary version of the article was posted online. On page 1080, in the last sentence of the Results section of the Abstract, the text that had read "0.05% (4 of 777)" now reads "0.5% (4 of 777)." The risk of fracture-related nerve injury associated with forearm fractures in children is unknown. The purposes of the present study were to calculate the risk of fracture-related nerve injury and to report the institutional rate of complications of surgical treatment of pediatric forearm fractures. Four thousand, eight hundred and sixty-eight forearm fractures (ICD-10 codes S52.0 to S52.7) that had been treated in our tertiary level pediatric hospital between 2014 and 2021 were identified in our institutional fracture registry. Of these, 3,029 fractures occurred in boys and 53 were open fractures. Sex, age at injury, trauma mechanism and energy, fracture type, treatment method, and cause and type of nerve injury were assessed in 43 patients with 44 registered nerve injuries. Patients with nerve injuries were reevaluated to calculate the recovery time. Univariable and multivariable regression analyses were performed to determine the risk of nerve injury. The risk of a fracture-related nerve injury was 0.7% (33 of 4,868). Only 2 injuries were permanent; thus, the risk of permanent nerve injury associated with a forearm fracture was 0.04% (2 of 4,868). The ulnar nerve was affected in 19 cases; the median nerve, in 8; and the radial nerve, in 7. In cases of open fracture, the risk of nerve injury was 17% (9 of 53). Open fractures had an OR of 33.73 (95% CI, 14.97 to 70.68) on univariate analysis and an OR of 10.73 (95% CI 4.50 to 24.22) on multivariate analysis with adjustment for female sex and both-bone diaphyseal fracture. Both-bone diaphyseal fracture (ICD-10 code S52.4) had an OR of 9.01 (95% CI, 4.86 to 17.37) on univariate analysis and an OR of 9.98 (95% CI 5.32 to 19.47) on multivariate analysis with adjustment for age and female sex. Overall, 777 fractures were internally fixed. The risk of nerve injury as a complication of internal fixation was 1.3% (10 of 777). Four of these iatrogenic injuries (including 2 involving the median nerve, 1 involving the ulnar nerve, and 1 involving the radial nerve) were permanent; thus, the risk of permanent nerve injury as a complication of internal fixation was 0.5% (4 of 777). Nerve injury following a pediatric forearm fracture is rare and has an excellent potential for spontaneous recovery. In the present study, all of the permanent nerve injuries occurred in association with open fractures or as a complication of internal fixation. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

An unusual route of non-intentional intoxication by ecstasy in a toddler

We report a pediatric case of ecstasy intoxication via an unusual route. A mother called the emergency services after her daughter had inserted an ecstasy pill into her nose. During transportation, the child developed hypertension, tachycardia, and tachypnea. She was admitted to the nearest regional hospital, where a physical examination revealed psychomotor agitation, mydriasis, hypertension, tachycardia, and no hyperthermia. Blood tests showed no abnormalities. She was subsequently transferred to a tertiary-level pediatric hospital. During transportation, she was described as being intensely agitated with persistent mydriasis, tachycardia, and high blood pressure. Urinary toxicological screening confirmed the presence of MDMA. She was discharged after 24 h.

Patient-nurse ratio as an index related to healthcare-associated infections: a surveillance study.

Healthcare-associated infections (HCAIs) are a hospital problem with a prevalence of approximately 5% in Mexico. HCAIs have been related to the patient-nurse ratio (PNR). This study aimed to analyze the association between PNR and HCAI in a tertiary-level pediatric hospital. We conducted a descriptive and prospective study at a tertiary-level pediatric hospital in Mexico. Nursing attendance and HCAIs records were documented from July 2017 to December 2018. PNR was calculated using nurse staffing records and patient census. We obtained 63,114 staff attendance data from five hospital departments for the morning, evening, and night shifts. PNR > 2:1 was associated with a 54% (95% confidence interval (CI) 42-167%; p < 0.001) increased risk (odds ratio (OR)) for HCAIs, adjusted by shift staff, special conditions, and surveillance periods. The HCAIs more associated with PNR were urinary tract infections (OR 1.83; 95%CI 1.34-2.46), procedure-related pneumonia (OR 2.08; 95%CI 1.41-3.07), and varicella (OR 2.33; 95%CI 1.08-5.03). A high number of patients per nurse increased the probability of various types of HCAI. PNR needs to be established the HCAI guidelines and policies, as regulating the number of patients per nurse can prevent HCAIs and their complications.

Examining post-concussion white matter change in a pediatric sample

Diffusion-Weight Imaging (DWI) is increasingly used to explore a range of outcomes in pediatric concussion, particularly the neurobiological underpinnings of symptom recovery. However, the DWI findings within the broader pediatric concussion literature are mixed, which can largely be explained by methodological heterogeneity. To address some of these limitations, the aim of the present study was to utilize internationally- recognized criteria for concussion and a consistent imaging timepoint to conduct a comprehensive, multi-parametric survey of white matter microstructure after concussion. Forty-three children presenting with concussion to the emergency department of a tertiary level pediatric hospital underwent neuroimaging and were classified as either normally recovering (n = 27), or delayed recovering (n = 14) based on their post-concussion symptoms at 2 weeks post-injury.We combined multiple DWI metrics across four modeling approaches using Linked Independent Component Analysis (LICA) to extract several independent patterns of covariation in tissue microstructure present in the study cohort. Our analysis did not identify significant differences between the symptomatic and asymptomatic groups and no component significantly predicted delayed recovery. If white matter microstructure changes are implicated in delayed recovery from concussion, these findings, alongside previous work, suggest that current diffusion techniques are insufficient to detect those changes at this time.

Risk Factors and Outcome of Neonatal Hyperbilirubinemia: A Case Control Study in a Tertiary Level Paediatric Hospital

Introduction: Neonatal jaundice is one of the most common morbidities observed during the neonatal period. Several risk factors are responsible for this condition.&#x0D; Objective: This study was aimed to determine the possible risk factors and immediate outcome for jaundice in newborns.&#x0D; Methods: This case control study was performed over a period of 18 months (March 2019 -August 2020) in the Special Care Newborn Unit (SCANU) of Dr. M R Khan Shishu Hospital &amp; Institute of Child Health (ICH). Risk factors for jaundice were evaluated by comparing cases with jaundice and controls having no jaundice.&#x0D; Results: A total of 230 neonates with jaundice and 250 neonates having no jaundice were enrolled. Maternal age between 31-40 years, less than 4 antenatal visits, primi, presence of maternal diabetes, babies born via caesarian section, small for gestational age, prematurity and intra-uterine growth restriction were significantly associated with jaundice in neonates (p value &lt; 0.05). Multi-variate analysis revealed, babies with mothers having &lt;4 antenatal visits were found to have 13 times more risk of developing jaundice than their matched controls (p= 0.00, CI= 0.78-14.9). Mean duration of phototherapy was longer for babies having jaundice due to blood group incompatibilities (4.82 ± 1.94). Most of the patients (91%) were discharged to home.&#x0D; Conclusion: Less than four antenatal visit is a significant risk factor for neonates to develop significant jaundice requiring treatment. Babies with blood group incompatibilities tend to require longer duration of phototherapy wherever most of the babies discharged to home with good recovery.&#x0D; DS (Child) H J 2021; 37(2): 109-115

#34 Evaluation of surgical antibiotic prophylaxis at tertiary level pediatric hospital in Mexico City

Abstract Background There is certainty that surgical antibiotic prophylaxis is useful in the prevention of surgical site infection. However, it should be chosen with a spectrum aimed at microorganisms that, due to the type of surgery, could cause an infection and reduce events should be prescribed at correct doses and with the minimum duration. Surgical services are in constant change, it seems that the demands on the personal physician to be in the surgery room and to attend to those worrisome needs of the patient make the responsibility for making decisions about antibiotics uncoordinated. For this reason, the prescription of antimicrobials can be perceived as a secondary task and one that is even delegated to young surgical members. The objective of this study was to describe the most frequent errors in surgical prophylaxis prescription. Method This is an analytic transverse study in a six-month period (November 2020-March2021), that includes antibiotic prescriptions on surgical departments (orthopedics, general surgery, urology, plastic surgery, neurosurgery, oncologic surgery, otorhinolaryngology). For variable analysis, a Chi-square test, odds ratio and etiological fraction among exposed will be performed. Results 423 antibiotic prescriptions were analyzed, 210 achieved inclusion criteria and 190 were indicated as surgical antibiotic prophylaxis, 118 of these have at least one error in prescription. The odds ratio for prescription errors and the indication of antibiotics as prophylaxis (Pearson chi square test 16.442 p 0.00) were 9.29 (CI 95% 2.63-32.8), etiological fraction among exposed were 89.23%. Table 1 shows surgical antibiotic prescriptions for services in descending order, although the patients were from surgery services, the prescriptions were not always made form the same service (for example anesthesiology) and the number error prescriptions to show which areas should be trained in prescribing antibiotics. The most frequent errors in the initial prescription of antibiotics that were documented corresponded to not indicating the time of administration of the antibiotic in the case of surgical prophylaxis and dosage. After applying the “Time out” strategy, the most documented error was the prolongation of antibiotic prophylaxis. The most frequently prescribed pharmacological group of antibiotics corresponded to cephalosporins. Conclusion Antimicrobial education or restriction strategies are required to correct the high percentage of errors observed in antibiotic prescriptions. Knowing this baseline state is the initial step for the formulation of antimicrobial use optimization programs that reduce adverse events, costs, and local antimicrobial resistance rates. Despite having statistically significant data between prescription errors and the indication of antibiotics as prophylaxis, the heterogeneity of the services prescribed does not make a conclusion of the probability of occurrence of the event possible, however it shows the services that need more training in the prescription of antibiotics.

Changes in Nasalance and Velopharyngeal Function Following Conventional Le Fort I and Distraction Osteogenesis Using Perceptual and Instrumental Assessment

Objective: The objective of this study was to quantify the changes in nasalance and velopharyngeal function in individuals with repaired cleft palate who underwent conventional Le Fort I (LFI) and Distraction Osteogenesis (DO). This study will also examine changes relative to secondary factors of age, cleft type, and previous speech surgery. Methods: This retrospective study included 19 patients who underwent LFI and 24 patients who underwent DO at a tertiary level pediatric hospital from 2011 to 2019. All patients had repaired cleft palate and were between 7 and 18 years of age. Pre- and post-operative speech assessment was completed before and after surgery. Results: There was a significant increase in nasalance scores for the oral sentences of 12.9% for the LFI group ( P = .006) and 17.9% for the DO group ( P &lt; .001). A significant difference in nasalance scores between patients with and without previous speech surgery in the LFI group. Conclusions: Findings may aid surgeons and speech pathologists in informing patients about the potential increase in nasalance following LFI or DO. Findings may indicate that timing of speech surgery is more favorable before LFI, but not influential for individuals undergoing DO.

Assessment of Parental Satisfaction with Day-Care Surgical Services in a Tertiary Level Pediatric Hospital

Background: Parental feedback is important for improving quality of the surgical services provided.Objective: This study was conducted to assess the level of satisfaction of parents with the day-care surgical services so as to find out where improvement is needed. Methods: This was an observational cross sectional study conducted in the Department of Pediatric Surgery, National Institute of Child Health, Jinnah Sindh Medical University Karachi from September 2019 to April 2020. The parents of the children who underwent different day-care surgical procedures were included. A validated Parent Satisfaction Scale (PSS) which consist of 11-items was used. The responses were made according to Likert scale. Three groups of satisfied, undecided and unsatisfied study participants were made according to the scores obtained. The socio-demographic variables including age of parents and children, level of education, and income group were compared amongst study groups. Results: Total of 114 parents participated. The most common procedure performed was inguinal herniotomy (n=59). Seven (6%) patients were brought back after discharge due to pain. Eighty-seven (76.30%) parents were satisfied with the services provided while 18 (15.8%) were unsatisfied and 9 (7.9%) undecided. A significant difference in the satisfaction level of the study participants noted with respect to the mean age of parents (p=0.039), level of education (p&lt; 0.001) and income groups (p&lt; 0.001). Conclusion: Majority of the study participants were satisfied with the surgical services provided. Lack of respect given by the hospital staff and delay in getting treatment were the main reasons for dissatisfaction. Socio-demographic characteristics of the study participants were significantly associated with the level of satisfaction.

Ultrasonographic Assessment for Tenosynovitis in Juvenile Idiopathic Arthritis with Ankle Involvement: Diagnostic and Therapeutic Significance.

Background: The role of musculoskeletal ultrasound in JIA is still controversial, although there is growing evidence on its utility, especially in the diagnosis of tenosynovitis. Methods: We presented a retrospective cross-sectional study of a group of patients with JIA with ankle swelling followed in a Pediatric Rheumatology Service of a tertiary-level pediatric hospital in Northern Italy during the follow-up period between January 1st 2003 and December 31st 2019. Preliminary results have been presented at the EULAR Congress 2021. We enrolled only patients who underwent msk-US, and we identified those with a clinical and sonographic diagnosis of tenosynovitis. For each patient, we collected data on demographics, clinical characteristics, and therapeutic strategies during the follow-up. Results: On December 31st 2019, 56 swollen ankles of 48 patients were assessed with msk-US. Twenty-two ankles showed sonographic signs of joint synovitis, sixteen ankles presented signs of both joint synovitis and tenosynovitis, and fourteen ankles presented sonographic signs of tenosynovitis only. Overall, tenosynovitis was detected on 27 (56%) out of 48 children with at least a swollen ankle. In 13 patients out of 27 with tenosynovitis (48%), there was no joint synovitis of ankle or foot. Twenty-five patients with tenosynovitis (92%) achieved clinical and radiological remission: seven patients achieved remission of tenosynovitis with methotrexate only, and fifteen patients with biological drugs alone or in combination therapy. Conclusions: We observed that more than half of the patients with ankle swelling presented a tenosynovitis, and about 50% of them did not show sonographic signs of an active joint synovitis. Among patients with tenosynovitis, biological therapy alone or in association with DMARDs showed effectiveness in inducing disease remission.

136 Characterizing the medical and social complexity of Inuit children, youth, and their families from Nunavut who access care at an urban tertiary level paediatric hospital – A retrospective chart review of an Inuit child health clinic

Abstract Primary Subject area Social Paediatrics Background The Inuit Child Health Clinic is a consulting general pediatric outpatient clinic at an urban tertiary level paediatric designed to improve integration and coordination of care for Inuit children, youth, and their families from Nunavut. Characterizing medical and social complexity for this patient population will help to address existing gaps in health and social care, as well as contribute to the development of a culturally safe and sensitive determinants of health screening tool. Objectives To study and characterize the complexities that families cared for by the Inuit Child Health Clinic experience in navigating the health and community environments to identify gaps that exist within their care and understand how we can better support their unique needs. We define medical complexity similarly, referenced in existing literature as multi-system or multi-service involvement or prolonged stay in the city of the urban tertiary level paediatric hospital to access medical care. Design/Methods A retrospective chart review of patients (children and youth between the ages of 0-18 years old) and their caregivers that attended an outpatient general paediatric medicine clinic visit appointment with the Inuit Child Health Clinic between September 30, 2016, and September 30, 2019. A review of 59 patient charts were completed by 2 independent reviewers each for demographic information, medical complexity variables, and social complexity variables. This research has been approved by a local Research Ethics Board as well as the Nunavut Research Institute. Results There are high levels of medical and social complexity as evident through the high average number of healthcare services accessed, number of comorbidities, and number of admissions to hospital. We also found considerable inconsistencies with respect to documentation by providers on the social determinants of health of patients. Note: In collaboration with the Inuuqatigiit Centre for Inuit Children Youth and Families, Qikiqtani Inuit Association (QIA), Nunavut Tunngavik Incorporated (NTI), and the Department of Health in Nunavut, the results and knowledge will be shared and mobilized to reflect a narrative that is community-driven and comments on any possible gaps in social determinants of health screening in clinical settings. Furthermore, in collaboration with the Qaujigiartiit Health Research Centre, this work will inform and support the broader program evaluation of the Inuit Child Health Clinic to meet the needs of patients, families, caregivers, and healthcare professionals. Conclusion A multidisciplinary team approach that focuses on integrative care may be an effective and efficient means to promote communication and collaboration between multiple service providers that are often involved in providing care to this population that is put at-risk due to systemic health and social inequities. Improving social history taking and integrating more formal screening for social determinants of health within the Inuit Child Health Clinic practice should be considered.

The lymphocyte-to-monocyte ratio may distinguish complicated from non-complicated pediatric appendicitis: A retrospective study and literature review

To date, no parameter with satisfactory accuracy exists for the diagnosis of appendicitis. This retrospective study describes the discriminatory value of preoperative hematologic factors associated with complicated and non-complicated pediatric appendicitis. Clinical and laboratory data were obtained from 294 children diagnosed with appendicitis on admission and treated at our tertiary-level pediatric hospital from 2015 to 2017; they were divided into three groups: control group (n=118), histologically proven complicated (n=120), and non-complicated (n=56) appendicitis. Complicated appendicitis was associated with male preponderance and elevated neutrophil and monocyte levels (all p<0.001). Non-complicated appendicitis was associated with elevated eosinophil levels (p=0.023), and unaltered lymphocyte levels (p=0.30). Compared to non-complicated disease, the lymphocyte-to-monocyte ratio (LMR) was decreased in complicated appendicitis (p=0.003) but unaltered in the control group (p=0.38). In the discrimination analysis, LMR had high accuracy (AUC 0.73±0.05; p<0.001; odds ratio (OR) (95% confidence interval (CI)) 6.0 (2.4-15.3)) and was the only parameter independently associated with complicated appendicitis on regression analysis (OR (95% CI), 0.544 (0.359-0.825); p=0.004). We identified LMR as a novel potential marker for the differentiation of complicated from non-complicated pediatric appendicitis. This has implications on the treatment approach, either surgical in complicated disease or conservative in non-complicated disease.

No Evidence of a Difference in Susceptibility-Weighted Imaging Lesion Burden or Functional Network Connectivity between Children with Typical and Delayed Recovery Two Weeks Post-Concussion.

Susceptibility weighted imaging (SWI) and resting state functional magnetic resonance imaging have been highlighted as two novel neuroimaging modalities that have been underutilized when attempting to predict whether a child with concussion will recover normally or have a delayed recovery course. This study aimed to investigate whether there was a difference between children who recover normally from a concussion and children with delayed recovery in terms of SWI lesion burden and resting state network makeup. Forty-one children who presented to the emergency department of a tertiary level pediatric hospital with concussion participated in this study as a part of a larger prospective, longitudinal observational cohort study into concussion assessment and recovery. Children underwent neuroimaging 2 weeks post-injury and were classified as either normally recovering (n = 27), or delayed recovering (n = 14) based on their post-concussion symptoms at 2 weeks post-injury. No participants showed lesions detected using SWI; therefore, no group differences could be assessed. No between-group resting state network differences were uncovered using dual regression analysis. These findings, alongside previously published work, suggest that potential causes of delayed recovery from concussion may not be found using current neuroimaging paradigms.

Management of Fibro-adipose Vascular Anomalies (FAVA) in Paediatric Practice

Fibro-adipose vascular anomaly (FAVA) is a discrete type of vascular anomaly. We describe our experience managing FAVA at a tertiary level paediatric hospital and offer a treatment algorithm. MethodsA retrospective review of 27 patients with proven FAVA was undertaken. All patients had undergone MRI and USS evaluation. Patient demographics, presenting concerns, treatment methods, and outcomes were recorded and evaluation with the paediatric outcomes data collection instrument (PODCI) completed a minimum of 12 months after definitive treatment. ResultsMean age at presentation was 8.9 years (range: 9 m-17.4 y) and mean post-treatment follow-up was 7.4 y (range: 2 y-11.6 y). Twenty of 27 lesions affected the lower limb. Severe neurogenic-type pain was present in 23 cases and contractures across joints in 11 cases. Sclerotherapy with sodium tetradecyl sulphate was used in 11 cases, with no improvement in symptoms. Cryoablation provided pain relief in 3/4 cases, but contracture subsequently increased in one patient and pain recurred in another.Fourteen cases underwent surgery (four surgical excisions alone, 10 in combination with other procedures). Three patients required four further surgical procedures that include one amputation for intractable pain and poor function.PODCI evaluations suggest overall good function, with surgical management and interventional radiology that provide comparable results. Surgery did correct deformity. ConclusionIf conservative measures or cryoablation fail to achieve symptomatic control, surgical excision should be considered, combined with adjunctive procedures, to correct contractures and balance muscle forces.Relief of pain may compensate for the loss of muscle mass and overall improves function. Multidisciplinary team working is essential.

Utility of sleep nasendoscopy versus microlaryngotracheobronchoscopy in the diagnosis of paediatric upper airway obstruction.

To describe the utility of sleep nasendoscopy in determining the level of upper airway obstruction compared to microlaryngotracheobronchoscopy. A retrospective observational study was conducted at a tertiary level paediatric hospital. Patients clinically diagnosed with upper airway obstruction warranting surgical intervention (i.e. with obstructive sleep apnoea or laryngomalacia) were included. These patients underwent sleep nasendoscopy in the anaesthetic room; microlaryngotracheobronchoscopy was subsequently performed and findings were compared. Twenty-seven patients were included in the study. Sleep nasendoscopy was able to induce stridor or stertor, and to detect obstruction at the level of palate and pharynx, including tongue base collapse, that was not observed with microlaryngotracheobronchoscopy. Only 47 per cent of patients who had prolapse or indrawing of arytenoids on sleep nasendoscopy had similar findings on microlaryngotracheobronchoscopy. However, microlaryngotracheobronchoscopy was better in diagnosing shortened aryepiglottic folds. This study demonstrates the utility of sleep nasendoscopy in determining the level and severity of obstruction by mimicking physiological sleep dynamics of the upper airway.

Frequency of acute stress disorder in health care workers of a tertiary level pediatric hospital during the National Safe Distance Strategy for COVID-19 prevention.

Acute stress disorder (ASD) is one of the most frequent mental illnesses occurring during sanitary emergencies. This study aimed to estimate the frequency of ASD in health care workers of a tertiary level pediatric hospital during the coronavirus disease (COVID-19) pandemic. We conducted a cross-sectional study in which health care workers completed a virtual questionnaire, including sociodemographic information and the ASD scale. We analyzed 206 questionnaires. The population was divided into three groups: attending physicians, medical residents, and nursing personnel. The frequency of health care workers who showed at least nine symptoms of ASD was 88.8%. No significant differences were found between the studied groups. ASD is a frequent condition in health care workers in the context of the COVID-19 pandemic. We need to investigate further and assess risk and protective factors for developing this and other psychopathologies in this population.