Pediatric Tertiary Care Research Articles

Trends in Natural Decannulation in Patients with Robin Sequence: A Twenty-five Year Retrospective Review.

Robin sequence (RS) consists of micrognathia and glossoptosis that result in upper airway obstruction (UAO). In RS patients who undergo tracheostomy, long-term goals include natural decannulation (ND) without further surgical airway intervention. The objective of this study was to identify long-term trends in the rate and length of time to ND. Retrospective chart review on 144 patients with RS treated from 1995 to 2020 at a pediatric tertiary care center. Patients were grouped by year of tracheostomy. Demographic data, UAO management, postoperative care, complications, and time to decannulation were recorded. Thirty-six patients met the inclusion criteria. Tracheostomy was performed at a median age of 45.5 days. 19 (53%) patients experienced ND at a median time of 66.1 months. ND rate was higher in non-syndromic patients (93% non-syndromic vs 27% syndromic; P < .0001) and during the first study period (1995-2006: 78%, 2007-2020: 28%; P = .003). Cox proportional-hazard regression demonstrated that white race [aHR 0.15 (0.03-0.8); P = .023] and higher birthweight [aHR 0.9 (0.8-0.98); P = .018] were associated with a higher likelihood of ND while a syndromic diagnosis had a negative association with ND [aHR 12.5 (3.3-50.0); P < .001]. Our study documented that ND in patients with RS who underwent tracheostomy was significantly associated with ethnicity, birthweight, and syndromic status. The negative impact on successful ND was most observed in patients with syndromic associations. Additionally, ND rates are lower in the 2007 to 2020 subgroup. We suspect this is because alternative management techniques such as tongue lip adhesion and mandibular distraction osteogenesis became primary surgical treatment in severe RS upper airway obstruction at our institution starting in 2007.

Decreasing Goal Oxygen Saturations in Bronchiolitis Is Associated With Decreased Length of Stay

OBJECTIVES For patients hospitalized with bronchiolitis, many hospitals have implemented clinical practice guidelines to decrease variability in care. Our hospital updated its bronchiolitis clinical pathway by lowering goal oxygen saturation from 90% to 88%. We compared clinical outcomes before and after this change within the context of the pathway update. METHODS This was a retrospective analysis of patients &amp;lt;24 months old admitted to a pediatric tertiary care center from 2019 to 2021 with bronchiolitis. Patients with congenital heart disease, asthma, home oxygen, or admitted to an ICU were excluded. The data were stratified for patients admitted before and after the clinical pathway update. Statistical methods consisted of 2 group comparisons using the χ-square test for categorical variables, the Wilcoxon rank-sum test for continuous variables, and multiple regression analysis. RESULTS A total of 1386 patients were included, 779 preupdate and 607 postupdate. There was no statistically significant difference in the admission rate of patients presenting to the emergency department with bronchiolitis between the 2 groups (P value .60). The median time to room air was 40.0 hours preupdate versus 30.0 hours postupdate (P value &amp;lt; .001). The median length of stay was 48.0 hours preupdate versus 41.0 hours postupdate (P value &amp;lt; .001). Readmission rate was 2.7% within 7 days of discharge preupdate, and 2.1% postupdate (P value .51). CONCLUSIONS Decreasing goal oxygen saturation to 88% was associated with a statistically significant decrease in time spent on oxygen and length of stay for patients admitted with bronchiolitis with no increase in readmissions.

Outcomes after dextranomer/hyaluronic acid bladder neck injection in patients with urethral incontinence following bladder neck repair

Many patients who undergo surgery for bladder neck (BN) incompetence may still experience incontinence postoperatively. Dextranomer/hyaluronic acid (Dx/HA) is widely used for endoscopic treatment of vesicoureteral reflux in children; however, few studies have reported its use in treating incontinence after BN surgery. The aim of this study was to evaluate outcomes after Dx/HA bladder neck injection in patients with persistent outlet incompetency following BN Repair. We retrospectively reviewed patients at a single pediatric tertiary care center with history of prior bladder neck surgery and reported persistent incontinence who then underwent endoscopic bladder neck Dx/HA injection from 2013 to 2018 and had subsequent follow-up post-injection. We described primary outcomes of reported incontinence as "wet" (leakage similar to before injection), "improved" (wet but leakage improved), and "dry" (no leakage). Our secondary outcome was need for a secondary procedure after Dx/HA injection, including Dx/HA injection or bladder neck closure (BNC). At first follow-up (median 2.3 months post-op), 7/19 were wet, 6/19 were improved, and 6/19 were dry. At last follow-up (median of 34.7 months), only three patients (16%) were dry. Only one patient who received a single surgery for Dx/HA injection was "dry", though nearly 2/3rds (12) were initially "improved" in their continence. Overall, seven patients had another intervention or surgery after first injection. Five patients had multiple Dx/HA injections after first procedure, which resulted in dryness by last assessment in two of these. Four patients (21%) in the overall cohort required subsequent BNC. Longer-term follow-up in our study demonstrated that only one patient who received a single procedure of Dx/HA injection remained dry. Several studies had follow up for greater than 1 year after initial bladder neck Dx/HA injection; rates of dryness after a single surgery for injection were variable and reported between 20 and 40% over follow-up times ranging from 1.5 to 7 years (Alova et al., 2012; DaJusta et al., 2013; Lottmann et al., 2006a; Lottmann et al., 2006b; Kitchens et al., 2007). Our st udy does have inherent limitations. This study was performed at a single institution in a retrospective manner, with a single surgeon reviewing the medical record to determine operative techniques and continence outcomes. The patient population is small, although relatively comparable to other previously reported studies. Outcomes were based on documentation of patient reports and are therefore lacking in objectivity. In patients with prior unsuccessful BN repair, long-lasting dryness after single Dx/HA BN injection is unlikely, although one-third may demonstrate relatively durable improvement in incontinence.

Early outcome analysis of Gastroschisis from a high-volume tertiary care institute in India: A prospective observational study

Background: Gastroschisis is one of the common congenital anterior abdominal wall defects with uncovered abdominal contents (usually intestines) protruding through it. Immediate reduction of the abdominal contents is crucial after birth because of the grave consequences of delayed management. The aim of our study was to evaluate the early outcomes of Gastroschisis at a tertiary care institute in India. Methods: This prospective observational study was undertaken over a one-year duration extending from January to December 2021 at our pediatric tertiary care teaching institute. Results: There were 30 male and 28 female patients, out of which 37 were preterm neonates. The mean birth weight was 2019±357g. Seven patients (12.07%) had major associated malformations. Fifty (86.21%) patients underwent primary skin flap closure. Staged reduction with silo was accomplished in five (8.62%) patients; three patients died during resuscitation before any therapeutic procedure could be undertaken. Among 55 (94.83%) patients with surgical procedures, only 26 (47.27%) could be salvaged with overall favorable (survival) outcomes in 44.83% of patients. Mortality was high (92.59%, 25/27) in the patients presenting with markedly edematous bowel with leathery peel. Seventeen (29.31%, 17/58) neonates died in the first 72 hours (postoperatively) due to complications of abdominal compartment syndrome, eight (13.79%) patients died due to postoperative sepsis with thrombocytopenia, and two (3.44%) had intestinal perforation. The duration of hospital stay in neonates who survived ranged from one to four weeks. Conclusion: Overall survival rates in our study were 44.83% markedly in contrast to the series published in the recent literature. The outcome of preterm (premature) patients, associated intestinal atresia, presence of edematous bowel with leathery peel, patients requiring silo due to viscero-abdominal disproportion, necrotizing enterocolitis, and associated malformations, was dismal.

Bone Health in Pediatric Charcot-Marie-Tooth (CMT) Patients: The Baseline Experience in a Multidisciplinary Neuromuscular Program at a Pediatric Tertiary Care Center

Bone Health in Pediatric Charcot-Marie-Tooth (CMT) Patients: The Baseline Experience in a Multidisciplinary Neuromuscular Program at a Pediatric Tertiary Care Center

Disrupted Pediatric Diabetes Trends in the Second Year of the COVID-19 Pandemic.

Increases in incident cases of pediatric type 1 (T1D) and type 2 diabetes (T2D) were observed during the first year of the COVID-19 pandemic. This work aimed to identify trends in incidence and presentation of pediatric new-onset T1D and T2D during the second year of the COVID-19 pandemic. A retrospective chart review was conducted. Demographics, anthropometrics, and initial laboratory results from patients aged 0 to 21 years who presented with new-onset diabetes to a pediatric tertiary care center were recorded. The incident cases of T1D (n = 46) and T2D (n = 46) in 2021-2022 (second year of the pandemic) were consistent with the incident cases of T1D (n = 46) and T2D (n = 53) in 2020 to 2021 (first year of the pandemic). Compared to the incident cases of diabetes in the prepandemic years, in the second year, the incident cases of T1D increased 48%, and the incident cases of T2D increased 188%. In the second year of the pandemic, incident cases of T2D represented half (50%) of all newly diagnosed pediatric diabetes cases. Patients with T2D were more likely to present in diabetic ketoacidosis, though this was not statistically significant (P = .08). The increase in incident cases of pediatric T1D and T2D observed during the first year of the COVID-19 pandemic persisted during the second pandemic year. This suggests that despite pediatric vaccination efforts and return to social in-person activities, we may continue to see effects of the pandemic on pediatric diabetes trends.

Virtual Learning and Youth-Onset Type 2 Diabetes during the COVID-19 Pandemic

Introduction: Cases and severity of presentation of youth-onset type 2 diabetes (Y-T2D) increased during the COVID-19 pandemic, yet the potential drivers of this rise remain unknown. During this time public health mandates paused in-person education and limited social interactions, resulting in radical lifestyle changes. We hypothesized that the incidence and severity of presentation of Y-T2D increased during virtual learning amidst the COVID-19 pandemic. Materials and Methods: We conducted a single-center retrospective chart review to identify all newly diagnosed cases of Y-T2D (n = 387) at a pediatric tertiary care center in Washington, DC during three predetermined learning periods as defined by learning modality in Washington, DC Public Schools: pre-pandemic in-person learning (March 11, 2018–March 13, 2020), pandemic virtual learning (March 14, 2020–August 29, 2021), and pandemic in-person learning (August 30, 2021–March 10, 2022) periods. Results: Incident cases were stable during pre-pandemic in-person learning (3.9 cases/month, 95% CI: 2.8–5.4 cases/month), increased to a peak during virtual learning (18.7 cases/month, 95% CI: 15.9–22.1 cases/month), and declined with return to in-person learning (4.3 cases/month, 95% CI: 2.8–6.8 cases/month). Y-T2D incidence was 16.9 (95% CI: 9.8–29.1, p < 0.001) and 5.1-fold higher (95% CI: 2.9–9.1, p < 0.001) among non-Hispanic Black and Latinx youth, respectively, throughout the study period. Overall COVID-19 infection rates at diagnosis were low (2.5%) and were not associated with diabetes incidence (p = 0.26). Conclusions: This study provides timely insights into an important and modifiable correlate of Y-T2D incidence, its disproportionate impact on underserved communities, and the need to consider the effects on long-term health outcomes and preexisting healthcare inequities when designing public policy.

Tranexamic Acid Use in Pediatric Craniotomies at a Large Tertiary Care Pediatric Hospital: A Five Year Retrospective Study.

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, has proven efficacy and is recommended for major pediatric surgery to decrease perioperative blood loss. Accumulating evidence suggests that TXA reduces bleeding and transfusion in a variety of adult neurosurgical settings. However, there is a paucity of research regarding TXA indications for pediatric neurosurgery and thus, there are currently no recommendations for its use with this specific population. The objective of this study is to evaluate the existing practice of TXA administration for pediatric neurosurgery at a U.S. tertiary care pediatric hospital over a five-year period. The authors conclude that TXA administration is feasible and should be considered for pediatric neurosurgical cases where potential blood loss is a concern.

D-dimer: a biomarker for predicting disease severity and outcome in hospitalized children with COVID-19 and post COVID multisystem inflammatory syndrome

Background: COVID-19 has presented with varied signs and symptoms with raised inflammatory markers among which D-dimers have been highlighted right from the beginning. Objectives were to analyze the relationship of D-dimers with the disease severity and outcome of children with COVID-19 and MIS-C in a developing country. Methods: It was a retrospective study conducted at a pediatric tertiary care hospital from March 2020 to November 2021. Clinical and laboratory details of confirmed COVID-19 and post COVID-19 MIS-C cases were recorded. D-dimer testing was performed using Chemiluminescence technique. It’s relation with disease severity and predictive role for in-hospital mortality were established by using ROC curves and cut-off values were calculated by using SPSS-24. Results: Of 272 children, 182 were of COVID-19 and 90 were of MIS-C. The mean age for COVID-19 and MIS-C patients was 5.4±4.8 years and 6.4±3.5 years respectively. Mild disease was seen in 33% cases while 17.6% were critical and 56.2% had some under lying comorbidity at presentation. Mean D-dimers were significantly higher in children with severe disease, who required ICU admission and non-survivors as compared to those with mild or moderate disease, not requiring ICU care and survivors, both in COVID-19 and MIS-C patients. ROC curve identified D-dimer value of ≥4.58 µg/ml (AUC=0.845) for COVID-19 cases and ≥4.73 µg/ml (AUC=0.682) for MIS-C patients as predictive of mortality. Conclusions: Raised D-dimer level is a reliable predictor of disease severity and outcome in children with COVID-19 and MIS-C. The D-dimer value of 4.58 µg/ml for COVID-19 cases and 4.73µg/ml for MIS-C patients was found to be the cut-off levels for predicting mortality

Trends in Histrelin Implantation at a Pediatric Tertiary Care Center

IntroductionDetermine procedural outcomes and identify changing trends of utilization among patients undergoing histrelin implantation at a large pediatric tertiary care center over 15 y. MethodsRetrospective review of all patients undergoing histrelin implantation between January 2008 and April 2022. ResultsA total of 746 patients underwent 1794 unique procedures (1364 placements/replacements, 430 removals). Procedures were performed in the clinic (1071, 60%), sedation unit (630, 35%), and operating room (93, 5%). A total of 14 (0.8%) complications were identified, including two patients that required early implant removal and one patient requiring antibiotics. Implants were placed for central precocious puberty (CPP, 579) or gender dysphoria (GD, 167). Cohort included 25.9% males and 74.1% females with mean age of implantation of 9.48 y (SD: 2.34, range: 1.05-17.34). The GD group is comprised of 52.4% males and 47.6% females, compared to 18.3% males and 81.7% females in the CPP. Significant difference was identified for mean age at placement by indication (CPP 8.65 y versus GD 12.34, P < 0.001). New patient referrals and implant procedures increased significantly over 14 y. Yearly frequency of patients receiving implants for CPP and GD increased significantly (P < 0.001), with proportion of GD patients increasing from 7% to 32%. ConclusionsHistrelin procedures have increased in frequency overall with the greater increase noted in the GD cohort. The development of a streamlined process and a dedicated team have enabled histrelin procedures to be safely performed in the clinic setting for most, with a very low complication rate.

1280-P: The Maturity-Onset Diabetes of the Young (MODY) Calculator Overestimates MODY Probability in Hispanic Youth

The applicability of the MODY probability calculator (Shields et al., Diabetologia, 2012) to non-European populations remains unknown. We aimed to test its utility in Hispanic youth. We performed a retrospective chart review of Hispanic youth (&amp;lt;23 years) with diabetes (n=2033) in a large, pediatric tertiary care center in the U.S. We calculated MODY probability for all subjects, splitting into two cohorts in line with the two equations underlying the MODY calculator: Individuals who were started on insulin within 6 months of diabetes diagnosis (Cohort 1) and those who were not (Cohort 2). MODY genetic testing was carried out on limited individuals based on clinicians’ suspicion of MODY. Cohort 1 and Cohort 2 comprised 1566 (mean age: 15.8 ± 4.7 years, 49% female) and 467 youth (mean age: 17.2 ± 3.5 years, 62% female), respectively. Of 1566 early insulin treated individuals in cohort 1, the mean MODY probability was 6% suggesting an expected 6% (94 individuals) with MODY. This is higher than previous prevalence estimates (1-4%) and much higher than the number identified from genetic testing (6 individuals out of 30 tested). For the 467 non-insulin treated individuals (cohort 2), the mean probability was 62% suggesting an expected 289 individuals with MODY, which again was much higher than previous prevalence estimates and the number identified from genetic testing (10 individuals out of 12 tested). Individuals with a confirmed pathogenic variant in a MODY-associated gene were more likely to have a younger age at diagnosis and lower non-HDL (cohort 1) or lower HbA1c (cohort 2). However, both cohorts had similar MODY probabilities compared to the remaining individuals in each cohort. The MODY calculator likely overestimates the probability of MODY in Hispanic youth, particularly those who are not early insulin treated, where young-onset type 2 diabetes is the more likely diagnosis. The calculator needs updating for use in this population. Disclosure G.Alarcon: None. A.D.Nguyen: None. A.Jones: None. M.J.Redondo: None. B.Shields: None. M.Tosur: Advisory Panel; Provention Bio, Inc.

Aetiologies of low alkaline phosphatase in a Canadian Paediatric Tertiary Care Centre.

Increasingly, laboratories flag low serum alkaline phosphatase (sALP) that are age-and sex-specific in paediatrics. The aim of this study was to report clinical manifestations of paediatric patients with age-and sex-specific low sALP, thereby increasing awareness of its potential aetiologies. This retrospective Canadian tertiary care paediatric hospital study assessed all sALP of ambulatory patients aged less than 18 years from 2015 to 2017. The hospital used a Beckman Coulter AU assay to measure sALP and compared values to the Canadian age-and sex-specific reference intervals from CALIPER. All children who had at least one subnormal age-and sex-specific sALP were evaluated. A review of medical charts of included patients was performed and demographic characteristics, medical history and diagnosis were collected, and categorized under groups of medical disorders. Of 11,874 included patients, 1,001 patients (9.2%) had low sALP. Of those, 48% (485/1,001) had transient low sALP activity and 9.6% (96/1,001) had persistently low sALP. Prolonged immobilization and inflammatory bowel disease represented the main aetiologies for persistently low sALP. Interestingly, 13.5% (13/96) of patients with persistently low sALP had no apparent aetiology. Our results report aetiologies of low sALP in a Canadian paediatric population using age-and sex-specific Canadian reference ranges. This study highlights that healthcare providers should be aware that a low sALP may have clinical significance and should be repeated if warranted based on further clinical assessment.

Diagnostic accuracy of upper gastrointestinal series in children with suspected intestinal malrotation

Intestinal malrotation (IM) results from an altered or incomplete rotation of the fetal midgut around the superior mesenteric artery axis. The abnormal anatomy of IM is associated with risk of acute midgut volvulus which can lead to catastrophic clinical consequences. The upper gastro-intestinal series (UGI) is addressed as the gold standard diagnosis procedure, but a variable failure degree has been described in literature. The aim of the study was to analyze the UGI exam and describe which features are the most reproducible and reliable in diagnosing IM. Medical records of patients surgically treated for suspected IM between 2007 and 2020 at a single pediatric tertiary care center were retrospectively reviewed. UGI inter-observer agreement and diagnostic accuracy were statistically calculated. Images obtained with antero-posterior (AP) projections were the most significant in terms of IM diagnosis. Duodenal-Jejunal Junction (DJJ) abnormal position resulted to be the most reliable parameter (Se = 0.88; Sp = 0.54) as well as the most readable, with an inter-reader agreement of 83% (k = 0.70, CI 0.49–0.90). The First Jejunal Loops (FJL), caecum altered position and duodenal dilatation could be considered additional data. Lateral projections demonstrated an overall low sensitivity (Se = 0.80) and specificity (Sp = 0.33) with a PPV of 0.85 and a NPV of 0.25. UGI on the sole AP projections ensures a good diagnostic accuracy. The position of the third portion of the duodenum on lateral views showed an overall low reliability, therefore it was not helpful but rather deceiving in diagnosing IM.

Sedation and Analgesia for Reduction of Pediatric Ileocolic Intussusception

Ileocolic intussusception is an important cause of intestinal obstruction in children. Reduction of ileocolic intussusception using air or fluid enema is the standard of care. This likely distressing procedure is usually performed without sedation or analgesia, but practice variation exists. To characterize the prevalence of opioid analgesia and sedation and assess their association with intestinal perforation and failed reduction. This cross-sectional study reviewed medical records of children aged 4 to 48 months with attempted reduction of ileocolic intussusception at 86 pediatric tertiary care institutions in 14 countries from January 2017 to December 2019. Of 3555 eligible medical records, 352 were excluded, and 3203 medical records were eligible. Data were analyzed in August 2022. Reduction of ileocolic intussusception. The primary outcomes were opioid analgesia within 120 minutes of reduction based on the therapeutic window of IV morphine and sedation immediately before reduction of intussusception. We included 3203 patients (median [IQR] age, 17 [9-27] months; 2054 of 3203 [64.1%] males). Opioid use was documented in 395 of 3134 patients (12.6%), sedation 334 of 3161 patients (10.6%), and opioids plus sedation in 178 of 3134 patients (5.7%). Perforation was uncommon and occurred in 13 of 3203 patients (0.4%). In the unadjusted analysis, opioids plus sedation (odds ratio [OR], 5.92; 95% CI, 1.28-27.42; P = .02) and a greater number of reduction attempts (OR, 1.48; 95% CI, 1.03-2.11; P = .03) were significantly associated with perforation. In the adjusted analysis, neither of these covariates remained significant. Reductions were successful in 2700 of 3184 attempts (84.8%). In the unadjusted analysis, younger age, no pain assessment at triage, opioids, longer duration of symptoms, hydrostatic enema, and gastrointestinal anomaly were significantly associated with failed reduction. In the adjusted analysis, only younger age (OR, 1.05 per month; 95% CI, 1.03-1.06 per month; P < .001), shorter duration of symptoms (OR, 0.96 per hour; 95% CI, 0.94-0.99 per hour; P = .002), and gastrointestinal anomaly (OR, 6.50; 95% CI, 2.04-20.64; P = .002) remained significant. This cross-sectional study of pediatric ileocolic intussusception found that more than two-thirds of patients received neither analgesia nor sedation. Neither was associated with intestinal perforation or failed reduction, challenging the widespread practice of withholding analgesia and sedation for reduction of ileocolic intussusception in children.

Macitentan in the Young-Mid-term Outcomes of Patients with Pulmonary Hypertensive Vascular Diseasetreated in a Pediatric Tertiary Care Center.

Pulmonary hypertension (PH) is a severe hemodynamic condition with high morbidity and mortality. Approved targeted therapies are limited for pediatric subjects, and treatments are widely adopted from adult algorithms. Macitentan is a safe and effective drug used for adult PH, but data on pediatric patients are limited. In this prospective single-center study, we investigated mid- and long-term effects of macitentan in children with advanced pulmonary hypertensive vascular disease. Twenty-four patients were enrolled in the study for treatment with macitentan. Efficacy was determined by echo parameters and brain natriuretic peptide levels (BNP) at 3months and 1year. For detailed analysis, the entire cohort was subgrouped into patients with congenital heart disease-related PH (CHD-PH) and non-CHD-PH patients, respectively. Mean age of the patients was 10.7±7.6 years; median observation period was 36months. Twenty of 24 patients were on additional sildenafil and/or prostacyclins. Two of 24 patients discontinued because of peripheral edema. Within the entire cohort, BNP levels and all echo measures such as right ventricular systolic pressure (RVSP), right ventricular end-diastolic diameter (RVED), tricuspid annular plane systolic excursion (TAPSE), pulmonary velocity time integral (VTI), and pulmonary artery acceleration time (PAAT) improved significantly after 3months (p ≤ 0.01), whereas in the long term significant improvement persisted for BNP levels (-16%), VTI (+14%) and PAAT (+11%) (p<0.05). By subgroup analysis, non-CHD PH patients showed significant improvements in BNP levels (-57%) and all echo measures (TAPSE +21%, VTI +13%, PAAT +37%, RVSP -24%, RVED -12%) at 3months (p≤0.01), whereas at 12months, improvements persisted (p<0.05) except for RVSP and RVED (nonsignificant). In CHD-PH patients, none of the measures changed (nonsignificant). 6-MWD (distance walked in 6 minutes)slightly increased but was not statistically evaluated. Data presented herein account for the largest cohort of severely affected pediatric patients receiving macitentan. Overall, macitentan was safe and associated with significant beneficial effects and sustained positive signals after 1year, albeit in the long term disease progression remains a major concern. Our data suggest limited efficacy in CHD-related PH, whereas favorable outcomes were mainly driven by improvements in patients with PH not related to CHD. Larger studies are needed to verify these preliminary results and to prove efficacy of this drug in different pediatric PH entities.

Role of coagulation tests in the management of acute appendicitis in children.

Acute appendicitis (AA) is one of the most common acute surgical conditions in children. Coagulation tests (CoTs) are usually utilized in preoperative assessment to rule out hemorrhagic risks. Our study aimed to evaluate the role of CoTs as predictors for the severity of AA. In a retrospective study, we compared the blood tests of two cohorts of pediatric patients with AA (group A and B) evaluated in the Emergency Department of a Pediatric Tertiary care hospital between January 2017 and January 2020. Children in Group A underwent appendectomies while those in Group B were treated with conservative management per hospital protocol. Group A was then subdivided into non-complicated (NCA) and complicated appendicitis (CA), and the CoTs were compared between the two subgroups. Group A consisted of 198 patients and Group B of 150 patients. Blood tests, including CoTs and inflammatory markers, were compared between the 2 groups. We found a statistically significant difference in PT ratio mean value between Group A and B, suggesting that those who underwent appendicectomies had higher PT ratio values. From a pathophysiological point of view, we speculated that the variation of PT ratio in AA might be secondary to a vitamin K absorption deficit due to enteric inflammation. Our study underlined that a longer PT ratio could be helpful to distinguish CA from NCA. Further investigations may lead to the role of the PT ratio in the choice between conservative and surgical management.

CLINICOETIOLOGICAL STUDY OF HEMOLYTIC ANAEMIA IN CHILDREN PRESENTING TO A TERTIARY CARE HOSPITAL OFKASHMIR

Anemia is said to be present when the hemoglobin levels are more than two standard deviations below the mean for the childs age and sex. Hemolytic anemias arise when red blood cells have decreased survival either due to an intrinsic abnormality of the cell or due to extrinsic factors or both. Hemolytic anemias constitute important cause of mortality and morbidity in developing countries. These group of anemias have various clinical presentations starting from their age of onset of symptoms, failure to thrive, anemia, jaundice, splenomegaly, cholelithiasis, cardiomegaly, congestive cardiac failure, severe life-threatening infections and chronic disabilities leading to distress in the families. The present study attempts to reveal the clinical and etiological profile of patients with different types of hemolytic anemia admitted in a pediatric tertiary care hospital of Kashmir. Review of literature shows only few epidemiological studies particularly in this part of the country, and no such study in our state though the disease is fairly prevalent. We undertook this study with this idea. Aims and Objectives: The aims and objectives of this study was to determine clinical and etiological profile of hemolytic anemia in children aged 1month to 18 years admitted in tertiary care hospital of Kashmir. Materiaals &amp; Methods: This prospective observational study was carried out in a pediatric tertiary care hospital in Kashmir over a period of two years. Prior to initiation of study, ethical clearance was obtained. All patients admitted in the indoor of department of pediatrics between age group of 1 month to 18 years with evidence of hemolysis were included in the study. 50 cases were included in the study after obtaining written informed consent from parent or guardian. A detailed history, examination and required investigations were collected. Data was entered and assessed in MS Excel. Results: The study was based on 50 patients, almost equal males and females, 1month to 18 years of age. The most common hemolytic anemia was beta thalassemia major (n=17, 34%), followed by autoimmune hemolytic anemia(n=10,20%), hereditary spherocytosis (n=5,10%), thalassemia trait (8%), pyruvate kinase deficiency (8%) and glucose 6 phosphate dehydrogenase (8%), thalassemia intermedia (4%), sickle cell trait (2%), microangiopathic hemolytic anemia (2%), hereditary xerosis (2%) and hereditary stomatocytosis (2%). Highest number of the cases was less than 3 years old (56%). The most common clinical presentation was jaundice, which was present in all cases, followed by splenomegaly (60%), hepatomegaly (30%), hemolytic facies (26%). Splenomegaly was seen in all cases of thalassemia major, thalassemia intermedia, beta thalassemia trait, hereditary spherocytosis, 2 cases of pyruvate kinase deficiency and 3 cases of glucose 6 phosphate dehydrogenase deficiency. Spleen &gt;5cm was seen in 10 patients. Massive splenomegaly with abdominal discomfort was seen in 3 cases. The mean hemoglobin was least in beta thalassemia major followed by beta thalassemia intermedia, Hereditary spherocytosis, autoimmune hemolytic anemia, glucose 6 phosphate dehydrogenase deficiency and the highest mean hemoglobin was seen in pyruvate kinase deficiency. Means for serum ferritin and serum bilirubin were calculated.

Understanding the roles of the healthcare and child welfare systems in promoting the safety and well-being of children.

The accurate identification and appropriate investigation of child maltreatment is a key priority for promoting the optimal health and development of children. Healthcare providers are often well-positioned professionals to report suspected child abuse and neglect, and, therefore, interact regularly with child welfare workers. Little research has examined the relationship between these two groups of professionals. We interviewed healthcare providers and child welfare workers in order to examine the referral and child welfare investigation processes to understand strengths and identify areas of improvement for future collaboration. Thirteen child welfare workers from child welfare agencies and eight healthcare providers from a pediatric tertiary care hospital in Ontario, Canada were interviewed to meet the study's objectives. Healthcare providers spoke about positive experiences making reports, factors impacting reporting decisions, areas for improvement (e.g., difficulties communicating, lack of collaboration, and disruption of therapeutic alliance), training, and professional roles. For interviews with child welfare workers, identified themes included healthcare professionals' perceived expertise and understanding the role of child welfare. Both groups brought up the need for increased collaboration as well as systemic barriers and legacies of harm. Our core finding was a reported lack of communication between the groups of professionals. Other identified barriers in collaboration included a lack of understanding of each other's roles, hesitation for healthcare providers making reports, as well as legacies of harm and systemic inequities in both institutions. Future research should build on this examination by including the voices of healthcare providers and child welfare workers to identify sustainable solutions for increased collaboration.

Web-Based Knowledge Translation Tool About Pediatric Acute Gastroenteritis for Parents: Pilot Randomized Controlled Trial.

Acute gastroenteritis (AGE) in children is a leading cause of emergency department (ED) visits, resulting in substantial health care costs and stress for families and caregivers. The majority of pediatric AGE cases are caused by viral infections and can be managed at home using strategies to prevent dehydration. To increase knowledge of, and support health decision-making for, pediatric AGE, we developed a knowledge translation (KT) tool (fully automated web-based whiteboard animation video). The aim of this study was to assess the potential effectiveness of the web-based KT tool in terms of knowledge, health care decision-making, use of resources, and perceived benefit and value. A convenience sample of parents was recruited between December 18, 2020, and August 10, 2021. Parents were recruited in the ED of a pediatric tertiary care hospital and followed for up to 14 days after the ED visit. The eligibility criteria included parent or legal guardian of a child aged <16 years presenting to the ED with an acute episode of diarrhea or vomiting, ability to communicate in English, and agreeable to follow-up via email. Parents were randomized to receive the web-based KT tool (intervention) about AGE or a sham video (control) during their ED visit. The primary outcome was knowledge assessed before the intervention (baseline), immediately after the intervention, and at follow-up 4 to 14 days after ED discharge. Other outcomes included decision regret, health care use, and KT tool usability and satisfaction. The intervention group participants were invited to participate in a semistructured interview to gather additional feedback about the KT tool. A total of 103 parents (intervention: n=51, 49.5%, and control: n=52, 50.5%) completed the baseline and postintervention assessments. Of these 103 parents, 78 (75.7%; intervention: n=36, 46%, and control: n=42, 54%) completed the follow-up questionnaire. Knowledge scores after the intervention (mean 8.5, SD 2.6 vs mean 6.3, SD 1.7; P<.001) and at follow-up (mean 9.1, SD 2.7 vs mean 6.8, SD 1.6; P<.001) were significantly higher in the intervention group. After the intervention, parents in the intervention group reported greater confidence in knowledge than those in the control group. No significant difference in decision regret was found at any time point. Parents rated the KT tool higher than the sham video across 5 items assessing usability and satisfaction. The web-based KT tool improved parental knowledge about AGE and confidence in their knowledge, which are important precursors to behavior change. Further research is needed into understanding what information and delivery format as well as other factors influence parents' decision-making regarding their child's health. ClinicalTrials.gov NCT03234777; https://clinicaltrials.gov/ct2/show/NCT03234777. RR2-10.1186/s40814-018-0318-0.

Who is the real team leader? Comparing leadership performance of the team leader and CPR Coach during simulated cardiac arrest

PurposeTo describe the leadership performance of team leaders and CPR Coaches, and to determine if there is a correlation between leadership scores and CPR performance during management of simulated pediatric cardiac arrest events. MethodsThis is a secondary analysis of data from a prior randomized controlled trial. We observed the performance of both team leaders and CPR coaches during the management of an 18-minute simulated cardiac arrest scenario which was run for 20 resuscitation teams comprised of CPR-certified professionals from four pediatric tertiary care centers. CPR Coaches were responsible for providing real-time verbal feedback of CPR performance to compressors. Two raters were trained to use the Behavioral Assessment Tool (BAT) to assess leadership performance of the team leader and CPR Coach. BAT scores of team leaders and CPR coaches were compared and linked with objective CPR performance. ResultsThere was no significant difference between the BAT scores of team leaders and CPR coaches (median score 27/40 vs 28.8/40, p = 0.16). Higher BAT scores of team leaders were significantly associated with higher percentage of excellent CPR (r = 0.52, p = 0.02), while higher BAT scores of CPR coaches were significantly associated with higher chest compression fraction (r = 0.48, p = 0.03). ConclusionsBoth team leaders and CPR coaches have similarly high leadership performance during the management of simulated cardiac arrest. Leadership behaviors were associated with quality of CPR performance.Clinical Trial Registration: Registration ID: NCT02539238; https://www.clinicaltrials.gov.