Tertiary Referral Pediatric Hospital Research Articles

An audit of computed tomography request practices for suspected cervical spine injury post-guideline change in a tertiary referral paediatric hospital.

Paediatric neck injuries are a common presenting complaint to emergency departments (EDs). Medical imaging can assist diagnosis, however previous research suggests computed tomography (CT) scan results do not alter management in this patient group and therefore expose children to unnecessary radiation. Following an audit by the hospital Trauma Service that identified unnecessary cervical spine CTs in patients at Women's and Children's Hospital (WCH), Adelaide, the Clinical Procedure for imaging and clearance of the cervical spine in conscious patients was modified to include CT scan only at the request of the orthopaedic service. The aim of this study was to evaluate whether a change in hospital guideline resulted in a change in practice and radiation exposure. A retrospective review was performed for patients that presented to the WCH ED with a suspected cervical spine injury during two defined time periods pre- and post-guideline change. Mechanism of injury, imaging requested, radiation exposure and final diagnosis were compared. Three hundred seventy-nine patients were included, with 164 (43.3%) post-guideline changes. Radiograph use was similar between groups, 132/215 (61.4%) versus 101/164 (61.6%) (p=0.97). CT scan use was lower post-guideline modification 19/215 (8.8%) versus 12/164 (7.3%), however was not statistically significant (p=0.59), with an absolute reduction of 17%. Guideline modification at our hospital did not significantly reduce CT scan use or eliminate unnecessary CTs. Unnecessary CT scans followed lack of knowledge of and therefore compliance with guidelines. Individual hospitals should consider strategies to reduce unnecessary CTs, given the association with cancer risk in children.

The impact of surgical cancellations on children, families, and the health system in an Australian paediatric tertiary referral hospital.

Reasons for elective surgery cancelations and their impact vary from one institution to another. Cancelations have emotional and financial implications for patients and their families. Our service has a particularly broad and geographically diverse patient population; hence, we sought to examine these impacts in our service. We identified families with procedural cancelations and administered a telephone questionnaire. Survey items included the reason for and timing of cancelation, how the family was informed, the mode of transport and distance traveled to the hospital, associated leave from work, expenses, whether the child was required to fast, missed school, as well as the child's and parent's emotional responses to the cancelation, along with overall parental satisfaction with how the cancelation was handled. During our study period, a total of 7870 procedures were booked. 6734 (86%) of these were completed and 1136 (14%) were canceled, with 6% canceled on the day of surgery. In 750 (66%) of these cancelations, families were successfully contacted by telephone and agreed to participate. Of these 305 (41%) cancelations were family-initiated and 444 (59%) were hospital-initiated, with these hospital-initiated cancelations occurring closer to scheduled surgery. The most common cause of cancelation was that the child could not undergo the procedure due to illness (22%) or being unable attend the hospital (14%). The greatest disruption to families and children occurred when procedures were canceled late, particularly when the cancelation occurred on the day of the planned procedure.

Severity of COVID-19 in hospitalized patients with and without atopic disease

BackgroundData from the 2009 influenza pandemic suggested asthma might protect from severe disease in hospitalized patients. Asthma does not appear to increase risk for hospitalization or mortality with COVID-19. ObjectiveThis study was undertaken to see if atopy actually protected those hospitalized with COVID-19. MethodsRetrospective chart review on all patients testing positive for SARS-CoV-2 over 2 months at a major adult and pediatric tertiary referral center hospital. Charts were evaluated for history of atopic disease, as were the need for ICU admission, requirement for supplemental oxygen and/or intubation, and in hospital mortality. ResultsNo significant differences in outcomes for patients (n = 275) based on atopic disease were noted: ICU admission, 43% versus 44.7% (atopic versus no atopic disease, respectively; p = 0.84); supplemental oxygen use, 79.1% versus 73.6% (p = 0.36); intubation rate, 35.8% versus 36.5% (p = 0.92); and mortality rate, 13.4% versus 20.7% (p = 0.19). More patients with atopic disease had COPD listed as a diagnosis in their chart (38.8% versus 17.3%, p < 0.001). COPD was associated with an increased rate of ICU admission (aOR = 2.22 (1.15, 4.30) p = 0.02) and intubation (aOR = 2.05 (1.07, 3.92) p = 0.03). After adjusting for COPD, patients with atopic disease had a trend for reduced mortality (aOR 0.55 (0.23, 1.28), p = 0.16), but those with asthma did not (p > 0.2). ConclusionSeverity of COVID-19 in hospitalized patients does not differ based on atopic status. However, adjusting for presence of COPD led to a suggestion of possible reduced severity in patients with atopy but not asthma.

Prevalence of Co-Existing &lt;i&gt;E. coli&lt;/i&gt; Urinary Tract Infection With Meningitis in Children Under 2 Years: Are We Carrying Out Too Many Lumbar Punctures?

Background/Objectives: Our objectives were to determine the prevalence of co-existing bacterial meningitis (BM) and sterile cerebral spinal fluid (CSF) pleocytosis in the presence of Escherichia coli urinary tract infection (UTI) in children age zero days to two years, with the addition of CSF E. coli Polymerase Chain Reaction (PCR) analysis. Subjects/Methods: A retrospective study was conducted at a tertiary referral paediatric hospital from 1/1/2014 to 30/4/2019. Co-existing E. coli BM with UTI was defined as a pure growth E. coli from urine and a CSF culture with pure growth of E. coli and/or positive E. coli PCR. All children with a pure growth of E. coli from a urine sample and a CSF sample taken 48 hours before or after a positive urine culture were included. Further PCR analysis was carried out in cases with CSF pleocytosis. Results: There were 1911 patients that met the definition for an E. coli UTI, of which 314 had a CSF taken within 48 hours. No cases of co-existing E. coli meningitis were identified. Overall, there were 71 (23%) cases of pleocytosis, 57 (80%) of these had further PCR analysis, all of which were E. coli PCR not detected.­ Conclusion: The risk of E. coli UTI and co-existing E. coli BM is low. Routine lumber punctures (LPs) could be avoided in well-appearing infants with a diagnosis of E. coli UTI with the greatest impact seen in children up to 6 months of age. CSF E. coli PCR can help to further reduce the post-test probability of meningitis in the setting of pleocytosis. Funding Statement: None. Declaration of Interests: All authors declare that they have no conflicts of interest. Ethics Approval Statement: The study was reviewed and approved by the CHI Temple Street Scientific and Ethics Committee [REC Reference 19·007].

Immediate versus delayed sequential bilateral cataract surgery in children: a cost-effectiveness analysis

Background/aimsChildren with bilateral cataracts may undergo immediate sequential bilateral cataract surgery (ISBCS), which involves surgery on both eyes during the same general anaesthesia, or delayed sequential bilateral cataract surgery (DSBCS),...

Lung ultrasound findings in pediatric patients with COVID-19.

During the pandemic caused by the novel coronavirus (COVID-19), lung ultrasound has been used to diagnose and monitor respiratory condition. The aim of the study was to describe lung ultrasound findings in children with a COVID-19 infection. Patients younger than 18 years old and positive for COVID-19, admitted to pediatric tertiary referral hospital were included. They were divided into two groups depending on the presence of respiratory symptoms. Lung ultrasound results were categorized into four degrees according to Soldati et al. score (J Ultrasound Med 39:1–7, 2020) and it was also described the presence and type of consolidation. Sixteen patients were recruited. The median age was 11 years old (IQR 2.8–12). Four children (25%) required admission to the intensive care unit. Six patients (37.5%) presented with respiratory symptoms. Most of them showed S.score of 2 and subpleural consolidations were observed in four cases (66.6%). Ten patients (62.5%) presented with non-respiratory symptoms, lung ultrasound showed S.score from 0 to 2. Three (30%) were diagnosed of multisystem inflammatory syndrome and lung ultrasounds showed S.score of 2 with bilateral pleural effusion.Conclusions: Children with COVID-19 and respiratory symptoms mostly showed a S.score of 2 and 3 with subpleural consolidations, upon the lung ultrasound assessment.What is Known:• Lung ultrasound is a useful tool for monitoring patients with respiratory symptoms in both adults and children. Lung ultrasounds are altered in adult patients with COVID-19.What is New:• Lung ultrasound might improve COVID-19 assessment, it could be a useful tool to diagnose and monitor patients throughout the COVID-19 pandemic. Even COVID-19 patients with non-respiratory symptoms have lung alterations that are visible on lung ultrasound.Electronic supplementary materialThe online version of this article (10.1007/s00431-020-03839-6) contains supplementary material, which is available to authorized users.

Variation in Treatment Approaches to Adolescent Midshaft Clavicle Fractures in Pediatric Versus Adult Hospitals.

The primary objective of this study was to identify differences in the treatment approach for isolated, displaced midshaft clavicle fractures in adolescent patients 15-18 years of age at adult versus pediatric hospitals. The secondary objective of this study was to identify factors associated with the surgical treatment of these fractures in this age group. Retrospective cohort study. Two adult and one pediatric tertiary care referral hospitals. Adolescent patients 15-18 years of age with isolated, displaced midshaft clavicle fractures treated at 2 adult tertiary care referral hospitals and one pediatric tertiary care referral hospital were identified. A total of 214 patients, 105 from the adult hospitals and 109 from the pediatric hospital, were included. Nonoperative versus surgical treatment of clavicle fractures. Surgical treatment. A multivariable logistic regression analysis showed that superior-inferior fracture displacement [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.06-1.20], dominant upper extremity injury (OR 2.60, 95% CI 1.19-5.67), and treatment at an adult hospital (OR 5.28, 95% CI 2.28-12.2) were independently associated with the surgical treatment of adolescent displaced midshaft clavicle fractures. After controlling for relevant demographic and fracture characteristics, adolescent patients treated at adult hospitals for displaced midshaft clavicle fractures have more than 5 times the odds of surgical treatment than those treated at a pediatric hospital. Significant practice variation across institutions reflects ongoing controversy in surgical indications and underscores the need for high-quality prospective outcome studies. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Treatment for SWS Glaucoma: Experience From a Tertiary Referral Pediatric Hospital.

Glaucoma associated with Sturge-Weber syndrome (SWS) often requires surgical intervention. Our study shows that trabeculectomy is efficacious in treating this condition. The purpose of this study was to describe the surgical outcomes of glaucoma associated with SWS in children presenting to the tertiary Paediatric Ophthalmology Department at The Children's Hospital at Westmead. A retrospective study of patients with SWS referred to the Department of Ophthalmology at The Children's Hospital at Westmead between 2003 and 2016 with at least 2 years of follow-up were identified, and information was collected from the clinical notes of all subjects. A total of 27 patients with SWS were evaluated for glaucoma in which 8 were excluded due to inadequate follow-up. In total, 19 patients with SWS were included in this study in which glaucoma was diagnosed in 15 patients and 19 eyes, of which 13 eyes required glaucoma surgery. A total of 21 surgical procedures were performed with a median follow-up of 85 months. A primary trabeculotomy was performed in 5 eyes of which 4 required re-do trabeculotomy, and 3 of these eyes underwent a Baerveldt tube (BVT) shunt as a third procedure. One eye with a primary trabeculotomy underwent a BVT as a secondary procedure. A BVT was inserted in a total of 6 eyes in which it was a primary procedure in 2 eyes. Of the 6 eyes undergoing a BVT insertion, 5 achieved success (2 complete and 3 qualified), and 1 failed. One case underwent intraluminal stent removal. Six eyes underwent a primary trabeculectomy and needed no further surgical intervention. In the trabeculectomy group, 4 eyes achieved complete success and 2 eyes achieved qualified success. Glaucoma affects a significant proportion of patients with SWS and is associated with the presence of an ipsilateral port-wine stain in most cases. In our study, trabeculectomy was the most efficacious procedure for controlling intraocular pressure and reducing the burden of ongoing treatment in SWS-associated glaucoma.

Artificial intelligence for interpretation of segments of whole body MRI in CNO: pilot study comparing radiologists versus machine learning algorithm

BackgroundTo initiate the development of a machine learning algorithm capable of comparing segments of pre and post pamidronate whole body MRI scans to assess treatment response and to compare the results of this algorithm with the analysis of a panel of paediatric radiologists.MethodsWhole body MRI of patients under the age of 16 diagnosed with CNO and treated with pamidronate at a tertiary referral paediatric hospital in United Kingdom between 2005 and 2017 were reviewed. Pre and post pamidronate images of the commonest sites of involvement (distal femur and proximal tibia) were manually selected (n = 45). A machine learning algorithm was developed and tested to assess treatment effectiveness by comparing pre and post pamidronate scans. The results of this algorithm were compared with the results of a panel of radiologists (ground truth).ResultsWhen tested initially the machine algorithm predicted 4/7 (57.1%) examples correctly in the multi class model, and 5/7 (71.4%) correctly in the binary group. However when compared to the ground truth, the machine model was able to classify only 33.3% of the samples correctly but had a sensitivity of 100% in detecting improvement or worsening of disease.ConclusionThe machine learning could detect new lesions or resolution of a lesion with good sensitivity but failed to classify stable disease accurately. However, further validation on larger datasets are required to improve the specificity and accuracy of the machine model.

Bedside breath tests in children with abdominal pain: a prospective pilot feasibility study

BackgroundThere is no definitive method of accurately diagnosing appendicitis before surgery. We evaluated the feasibility of collecting breath samples in children with abdominal pain and gathered preliminary data on the accuracy of breath tests.MethodsWe conducted a prospective pilot study at a large tertiary referral paediatric hospital in the UK. We recruited 50 participants with suspected appendicitis, aged between 5 and 15 years. Five had primary diagnosis of appendicitis. The primary outcome was the number of breath samples collected. We also measured the number of samples processed within 2 h and had CO2 ≥ 3.5%. Usability was assessed by patient-reported pain pre- and post-sampling and user-reported sampling difficulty. Logistic regression analysis was used to predict appendicitis and evaluated using the area under the receiver operator characteristic curve (AUROC).ResultsSamples were collected from all participants. Of the 45 samples, 36 were processed within 2 h. Of the 49 samples, 19 had %CO2 ≥ 3.5%. No difference in patient-reported pain was observed (p = 0.24). Sampling difficulty was associated with patient age (p = 0.004). The logistic regression model had AUROC = 0.86.ConclusionsBreath tests are feasible and acceptable to patients presenting with abdominal pain in clinical settings. We demonstrated adequate data collection with no evidence of harm to patients. The AUROC was better than a random classifier; more specific sensors are likely to improve diagnostic performance.Trial registrationClinicalTrials.gov, NCT03248102. Registered 14 Aug 2017.

Is Tapering Enteroplasty an Alternative to Resection of Dilated Bowel in Small Intestinal Atresia?

BackgroundIntestinal atresia is a congenital defect resulting in intestinal discontinuity and can be associated with significant morbidity related to intestinal failure. The bowel proximal to the atresia is often significantly dilated and dysfunctional. The treatment approaches of this dilated bowel include resection with primary anastomosis versus tapering enteroplasty with preservation of bowel length. The purpose of this study was to compare these two approaches in regard to bowel function as characterized by the time to full enteral feeding. MethodsA retrospective review was performed of intestinal atresia repair performed at a tertiary referral pediatric hospital from 2007 to 2017. Length of stay, time to full enteral feeds, and complications were assessed in patients who underwent repair with tapering enteroplasty (n = 8) and compared with those who underwent resection and anastomosis (n = 39). ResultsThe median age at surgery, gender distribution, weeks gestational age (WGA), location of the atresia, and comorbidities were similar between the two groups. Overall, there was no statistically significant difference in length of stay and time to full enteral feeds between groups. Three of eight (38%) patients in the tapered group and five of 39 patients (13%; P = 0.12) in the nontapered group underwent further surgical exploration because of bowel dysmotility. Factors associated with longer length of hospital stay were abdominal reoperation and WGA, and factors associated with longer time to full enteral feeds were WGA, abdominal reoperation, and gastroschisis. ConclusionsTapering enteroplasty at initial operation for intestinal atresias preserves bowel length and has statistically equivalent outcomes to resection and anastomosis in regard to the length of stay and time to full enteral feeds.

Indications and Patterns of Use for Parenteral Nutrition in Pediatric Oncology.

Children with cancer are at risk of treatment related gastrointestinal toxicity and malnutrition. Intestinal dysfunction may preclude or limit use of enteral nutrition, and parenteral nutrition (PN) may be required. Published indications for PN use in children with cancer are generally nonspecific. We sought to describe patterns of use, indications, and frequency of PN prescription in children with cancer and propose indicators to guide appropriate PN use. Retrospective chart review of children with cancer receiving inpatient PN in a tertiary referral pediatric hospital over 12months was performed using electronic medical record search and paper records. Data were summarized using descriptive statistics. PN was prescribed to 88 patients in 111 episodes. Total use (2377days) represented 24% of annual inpatient days in all children with cancer. Primary clinical indications were mucositis (40%), feed intolerance (29%), postoperative (16%), or "other" (15%), (including nasogastric tube refusal (n = 6)). Patients with hematological cancer had longer median episodes (19 vs 12.5days) and earlier commencement of PN after diagnosis (50 vs 80days) than children with nonhematological cancer. Most PN episodes longer than 28days were in children with hematopoietic stem cell transplant (HSCT). Inpatient PN use is common in childhood cancer. Indications include mucositis, feed intolerance, and surgical management. Patterns of use are influenced by cancer diagnosis and treatment, with greater use in children with hematological cancer and HSCT. Improved understanding and specific indications may guide appropriate PN prescription and minimize unnecessary risk, cost, and inconsistency in care.

Impact of paediatric tonsillectomy perioperative management on pain, nausea and recovery: A prospective cohort study.

Tonsillectomy procedures are a core element of paediatrics; however, perioperative management differs. This study aimed to describe tonsillectomy management, including the burden of pain, nausea and delayed recovery. A prospective cohort study was undertaken through an audit of tonsillectomy perioperative practice and recovery and survey interviews with family members 7-14 days post-surgery. The study was undertaken at an Australian tertiary referral paediatric hospital between June and September 2016. The audit included 255 children undergoing tonsillectomy, with 127 family members interviewed. Most participants underwent adenotonsillectomy (n = 216; 85%), with a primary diagnosis of obstructive sleep apnoea (n = 205; 80%) and a mean age of 7 years (standard deviation; 3.9). A variety of intra-operative pain relief and antiemetics was administered. Pain was present in 29% (n = 26) of participants at ward return, increasing to 32-45% at 4-20 h and decreasing to 21% (n = 15) at discharge. A third of the children (32%; n = 41) had moderate to severe pain at post-discharge interview, and 30% (n = 38) experienced nausea at home. Most parents (82%; n = 104) were still giving regular paracetamol at 7 days post-operatively, and 31% (n = 39) had finished their oxycodone. Of the participants, 14% (n = 26) presented to the emergency department within 7 days of discharge; 8% (n = 20) of the total cohort were re-admitted. There was variety in perioperative and post-discharge care. Pain scores were infrequently documented post-tonsillectomy, and parents are generally dissatisfied with the management of post-operative pain and nausea. Further research is needed to provide a more consistent approach to perioperative management to promote recovery.

Epidemiology of Anterior Tibial Spine Fractures in Young Patients: A Retrospective Cohort Study of 122 Cases.

Historically, bicycle accidents were described as the most common mechanism for pediatric anterior tibial spine fractures (ATSFs). There is a paucity of current literature examining the demographic factors associated with these injuries. The purpose of this cohort study was to characterize the epidemiology of ATSFs presenting to a single tertiary referral pediatric hospital. A consecutive cohort of 122 pediatric patients with ATSFs between 1996 and 2014 were reviewed. Radiographic variables, classification of fractures (Meyers and McKeever type), age, sex, height, weight, body mass index, and mechanism of injury were retrieved. Categories of mechanism of injury included organized sports (football, soccer, basketball, lacrosse, wrestling, and gymnastics), bicycling, outdoor sports (skiing, skateboarding, and sledding), fall, motor vehicle collision/pedestrian versus motor vehicle, and trampoline. Organized sports-related injuries represented the most common cause of ATSFs (36%). Other common mechanisms of injury included bicycle accidents (25%), outdoor sports (18%), and falls (11%). There was a higher proportion of males (69%) compared with females (31%). Males (mean age, 11.6 y) were significantly older than females (mean age, 9.8 y) (P=0.004). Younger patients (aged 11.5 y and below) were more likely to have displaced fractures (type III), whereas type I and type II were more common in patients above 11.5 years (P=0.02). Patients with fracture type I were significantly taller than patients with fracture type III. No other variables were found to differ significantly according to fracture severity, including sex, weight, and body mass index. To our knowledge, our study represents both the largest (n=122) and most up-to-date epidemiological ATSF study in pediatric patients. A higher rate of ATSF occurs due to organized sports rather than bicycling or motor vehicle collision. This 18-year data collection represents a change in the paradigm, and is likely multifactorial, including increased participation in youth sports and early sport specialization. Level IV-retrospective, cohort study.

The role of real-time PCR testing in the investigation of paediatric patients with community-onset osteomyelitis and septic arthritis.

Culture yield in osteomyelitis and septic arthritis is low, emphasising the role for molecular techniques. The purpose of this study was to review the laboratory investigation of childhood osteomyelitis and septic arthritis. A retrospective review was undertaken in an acute tertiary referral paediatric hospital from January 2010 to December 2016. Cases were only included if they had a positive culture or bacterial PCR result from a bone/joint specimen or blood culture, or had radiographic evidence of osteomyelitis. Seventy-eight patients met the case definition; 52 (66%) were male. The median age was 4.8years. Blood cultures were positive in 16 of 56 cases (29%), with 11 deemed clinically significant (Staphylococcus aureus = 8, group A Streptococcus = 3). Thirty-seven of 78 (47%) bone/joint samples were positive by culture with S. aureus (n = 16), coagulase-negative Staphylococcus (n = 9) and group A Streptococcus (n = 4), being the most common organisms. Sixteen culture-negative samples were sent for bacterial PCR, and four were positive (Kingella kingae = 2, Streptococcus pneumoniae= 1, group A Streptococcus = 1). Sequential culture and PCR testing can improve the detection rate of causative organisms in paediatric bone and joint infections, particularly for fastidious microorganisms such as K. kingae. PCR testing can be reserved for cases where culture is negative after 48h. These results have been used to develop a standardised diagnostic test panel for bone and joint infections at our institution.

Clinico-epidemiological profile and predictors of outcome in children with diphtheria: a study from northern India.

Diphtheria, a vaccine preventable disease in children, is still being reported from India. Details of 99 children with a clinical diagnosis of diphtheria admitted to a paediatric tertiary care teaching and referral hospital between January 2008 and December 2015 were collected retrospectively and analysed. The median (interquartile range [IQR]) age of the study group was 7.0 years (IQR = 5.0-8.0 years). Nearly two-thirds were unimmunised. Clinical features included fever (97%), dysphagia (82%), sore throat (67%), bull neck (54%), stridor (40%), neuropathy (27%) and nasal discharge (14%). Throat swab for Albert stain was positive in only 21% of cases and C. diphtheriae was isolated in only 28%. Complications included airway compromise (61.7%) followed by myocarditis (35.4%), acute kidney injury (22.3%), thrombocytopenia (25.3%) and neuropathy (27.3%). In all, 66% survived, 23% died and 11% opted for discontinuity of care owing to unfavourable prognoses. On multivariable logistic regression analysis, shorter duration of symptoms before presentation to our hospital was an independent predictor of unfavourable outcome (adjusted odds ratio = 0.88, 95% confidence interval = 0.79-0.99, P = 0.03).

Routine admission to step-down unit as an alternative to intensive care unit after pediatric supraglottoplasty

ObjectiveTo evaluate the feasibility and the outcomes for step-down (SD) unit admission as an alternative to intensive care unit (ICU) admission after supraglottoplasty in the pediatric patient. MethodsA review of 98 patients who underwent supraglottoplasty from 2012 to 2017 at a tertiary referral pediatric hospital was performed. An SD unit had 1-to-3 nurse-to-patient ratio with noninvasive positive pressure ventilation capability. Data variables included demographics, comorbidities, preoperative and postoperative respiratory requirements, and length of stay. ResultsRoutine admission to SD occurred for 85% patients while 15% patients were selectively admitted to ICU due to intubation requirement or perioperative respiratory distress. In SD, noninvasive respiratory support was required for 28 (34%) patients. Three (4%) required re-intubation and ICU transfer without delay in care. Patients at high risk for requiring respiratory support after surgery have a neurologic condition (OR 7.0, 95% 2.4–20.2, p < 0.01) or intrinsic pulmonary disease (OR 4.5, 95% CI 1.5–13.3, p < 0.01). Median length of stay was shorter for patients in step-down (1 day, IQR 1–2). ConclusionPatients can be managed safely in a SD unit after supraglottoplasty supporting de-escalation of care. Patients with neurologic and pulmonary comorbidities may have higher respiratory needs postoperatively. Prospective studies are warranted to further optimize resource allocation.

Magnetic resonance imaging of sacroiliitis in children: frequency of findings and interobserver reliability

BackgroundClinicians increasingly rely on imaging in juvenile idiopathic arthritis (JIA) to identify sacroiliitis and guide treatment. However, there is limited evidence about magnetic resonance imaging (MRI) for sacroiliitis in children, and interobserver reliability is variable.ObjectiveIdentify the frequency of MRI findings in children with suspected sacroiliitis, calculate inter-reporter reliability and assess the value of diffusion-weighted imaging and contrast-enhanced sequences.Materials and methodsWe retrospectively reviewed 3 years of sacroiliac joint MRI records for suspected sacroiliitis in patients <21 years at a United Kingdom tertiary referral paediatric hospital. Five radiologists (panel of three radiologists and two independent radiologists) reviewed all MRI examinations using a pictorial checklist to identify oedema, effusions, diffusion-weighted signal abnormality, enhancement, erosions and sclerosis. The frequency of panel findings was reported. Interobserver agreement was calculated using the Cohen kappa coefficient.ResultsAn MRI diagnosis of sacroiliitis was made in 12 of 99 examinations (12%). The findings in all scans included oedema (9%), erosions (8%), diffusion-weighted signal abnormality (6%), abnormal enhancement (6%) and effusion (4%). All scans with abnormal contrast enhancement had other MRI features of sacroiliitis. Interobserver agreement was slight to moderate.ConclusionOedema and erosions were the most common findings. Inter-reporter reliability was variable with at best moderate agreement for the presence of sacroiliitis and erosions. The use of contrast enhancement for diagnosing sacroiliitis in children with JIA may be questionable.

Abstract P-162: PEDIATRIC INTENSIVE CARE UNIT (PICU) ADMISSIONS DUE TO PNEUMONIA COMPLICATED WITH PARAPNEUMONIC EFFUSION (PPE) OR PLEURAL EMPYEMA (PE) AT COSTA RICA’S (CR) NATIONAL CHILDREN’S HOSPITAL

Aims & Objectives: In Latin America, few studies analyzing children with pneumonia complicated with PPE or PE requiring PICU admission have been published. We describe the first study in Central America focusing on this subgroup of pts. Methods Retrospective descriptive study of ch <13 years who had a discharge diagnosis of pneumonia with PPE or PE who were admitted to the PICU of the only national pediatric tertiary referral teaching hospital of CR from Jan-1st-2006 to Jan-31st-2014. Results Among 121 pts with pneumonia complicated with PPE or PE, 46(38%) required PICU admission. 27(58.7%) were male; median age was 11(1–166) months. Median length of hospitalization in the PICU was 5(1–30) days, and total days in hospital for this group, 19(2–83) days. Mechanical ventilation was required in 43(93.5%) pts, with a mean duration of 6.9(1–30) days. A bacterial pathogen was identified in 33(71.7%) pts, being the 3 most common: Staphylococcus aureus 17(37%)(100% MRSA), Streptococcus pneumoniae 11(23.9%), and Streptococcus pyogenes 3(6.5%). Inotropic support was required in 23(50%) pts, transfusions in 28(60.9%), thoracocentesis 33(71.7%), chest tube insertion 37(80.4%), and decortication 14(30.4%). Septic shock occurred in 16(34.8%) pts. 3 (6.5%) pts died: 2 due to pneumococcal septic shock and 1 due to a culture-negative necrotizing pneumonia with abscess formation. Conclusions Although PICU admissions due to pneumonia complicated with PE or PPE in CR children is associated with significant morbidity, the mortality rate is low if compared with other countries. Due to the concerning high rates of MRSA isolates, antibiotic therapy against this pathogen should be initiated promptly in these pts.

Norovirus Transmission Dynamics in a Pediatric Hospital Using Full Genome Sequences.

Norovirus is a leading cause of worldwide and nosocomial gastroenteritis. The study aim was to assess the utility of molecular epidemiology using full genome sequences compared to routine infection prevention and control (IPC) investigations. Norovirus genomes were generated from new episodes of norovirus at a pediatric tertiary referral hospital over a 19-month period (n = 182). Phylogeny identified clusters of related sequences that were verified using epidemiological and clinical data. Twenty-four clusters of related norovirus sequences ("sequence clusters") were observed, including 8 previously identified by IPC investigations ("IPC outbreaks"). Seventeen sequence clusters (involving 77/182 patients) were corroborated by epidemiological data ("epidemiologically supported clusters"), suggesting transmission between patients. Linked infections were identified among 44 patients who were missed by IPC investigations. Thirty-three percent of norovirus sequences were linked, suggesting nosocomial transmission; 24% of patients had nosocomial infections from an unknown source; and 43% were norovirus positive on admission. We show there are frequent introductions of multiple norovirus strains with extensive onward nosocomial transmission of norovirus in a pediatric hospital with a high proportion of immunosuppressed patients nursed in isolation. Phylogenetic analysis using full genome sequences is more sensitive than classic IPC investigations for identifying linked cases and should be considered when investigating norovirus nosocomial transmission. Sampling of staff, visitors, and the environment may be required for complete understanding of infection sources and transmission routes in patients with nosocomial infections not linked to other patients and among patients with phylogenetically linked cases but no evidence of direct contact.