University Children Research Articles

Critical COVID-19 in children and adolescents during the 2022 Omicron Surge in Taiwan: Risk factors and vaccine effectiveness

Background/aimCritical coronavirus disease 2019 (COVID-19) is a rare but devastating complication of SARS-CoV-2 Omicron variant infection in children and adolescents. This study aimed to assess the risk factors for, and evaluate the vaccine effectiveness against, critical COVID-19 during the 2022 Omicron Surge in Taiwan. MethodsWe retrospectively enrolled 41 pediatric patients with critical COVID-19 (which required mechanical ventilation, inotropic agents, extracorporeal membrane oxygenator, or resulting in in-hospital death) and 793 with non-critical COVID-19 who were hospitalized at National Taiwan University Children Hospital during the 2022 Omicron Surge. To estimate vaccine effectiveness, population controls generated using the Monte Carlo method from national vaccination statistics were matched to critical COVID-19 cases at a ratio of 10:1 by age group and disease onset date. ResultsOnly one of 41 critical COVID-19 cases had no underlying diseases. Underlying cardiovascular diseases (adjusted odds ratio [aOR] 5.4, 95% confidence interval [CI] 2.5–11.5), hematological diseases (aOR 4.9, 95% CI 2.3–10.6), neuropsychological disorders (aOR 3.8, 95% CI 1.8–7.9), or respiratory diseases (aOR 2.8, 95% CI 1.3–6.4) were risk factors for critical COVID-19. The effectiveness of two-dose and one-dose vaccination against critical diseases were 93.5% (95% CI: 70.4%–98.6%) and 75.2% (95% CI 9.2%–93.2%), respectively. ConclusionsUnderlying diseases are the major risk factors for critical COVID-19 among children and adolescents during the Omicron Surge. The two-dose COVID-19 vaccination is highly effective against critical diseases.

Improving medical certification of cause of death in Assiut University Children Hospital: an intervention study

IntroductionDeath certification is a health indicator and a public health surveillance tool. High-quality death certificate ensures reliability of mortality statistics used to direct the arranging of health-related programs and leading assessments of research and proper healthcare outcomes. The World Health Organization (WHO) puts Egypt in the group of ‘low quality’ death registration data. The aim of this study was to evaluate the impact of composite training and audit intervention on accurate completion of death notification forms (DNFs) in Assiut University Children Hospital (AUCH) that has an average monthly mortality of 120 children’s deaths.MethodsA Quasi-experimental study design was conducted among residents of AUCH. The intervention consisted of 1- Preparing training material with basic information on how to report causes of death according to WHO criteria and case scenarios extracted from the medical records of children who died at AUCH, 2- One hundred residents of the AUCH were trained in one day workshops in 4 groups, with a pre-post knowledge assessment questionnaire. 3- A weekly audit of a sample of 10–15 DNFs was done for six months with reporting of findings to quality assurance director of the hospital.ResultsEighty- nine physicians completed the pre-post knowledge assessment with significant increase in knowledge score after the intervention (15.7 ± 3.2 vs. 11.9 ± 2.8). There was a significant decrease in the errors of reporting on the DNFs. The main improvement was in decrease from 90 to 18% in reporting the mechanism of death, and significant decline in writing cause of death in Arabic language only.ConclusionAccurate reporting of the medical cause of death can be achieved by educational intervention targeting physicians with institutionalizing of audit system for continuous quality improvement.

Exchange rates of second generation Microcuff® pediatric endotracheal tubes in children weighing more than 3 kg : A retrospective audit.

Cuffed endotracheal tubes (cETT) pose the potential advantage of an infrequent need for reintubation in pediatric patients compared to uncuffed tubes. The aim of this study was to investigate tube exchange rates using second generation Microcuff® pediatric endotracheal tubes (PET) with an adapted sizing recommendation in alarge single institution cohort of children and to identify potential variables associated with an elevated risk of tube exchange. Patient data obtained from the electronic patient data management system of the Department of Anesthesia, University Children's Hospital Zurich, Switzerland, were retrospectively assessed for demographic and anthropometric information, size of the internal tube diameter used for positive pressure ventilation and divergence from the size recommendation chart. Data from 14,188 children younger than 16years (median 5.3years) and weighing at least 3 kg who underwent oral or nasal tracheal intubation using second generation Microcuff® PET between 2009 and 2015 were included. Of 13,219 oral tracheal intubations 12,049 (84.9%) were performed according to the manufacturer's size recommendation and 1170 with divergent endotracheal tubes. The odds ratio (OR) of oral reintubation was 0.13% (95% confidence interval 0.08-0.22%) for cases using the manufacture's size recommendation correctly and 22.74% (95% confidence interval 20.42-25.23%) for patients intubated with anot recommended tube (p < 0.0001). These findings indicate that the second generation Microcuff® PETs can be reliably used with low tube exchange rates across the entire pediatric age range when the tube size is selected according to the manufacturer's size recommendation chart. Adherence to the manufacturer's tube size recommendation is urgently advised.

Incidence of traumatic dental injuries associated with orotracheal intubation in general anesthesia in children during mixed dentition in Damascus, Syria: a prospective longitudinal study

ObjectivesEndotracheal tube intubation by laryngoscope during general anesthesia is a safe procedure with a few complications. However, it may cause some damage to the oral cavity structures, which leads to postoperative pain and discomfort. Traumatic dental injuries associated with endotracheal tube intubation are one of the most common complications. The study aimed to determine the incidence of traumatic dental injuries during oral-endotracheal tube intubation in general anesthesia among children receiving surgery at the Children’s Hospital in Damascus City during 2022–2023.MethodsIt was a prospective longitudinal study which investigated the incidence of traumatic dental injuries during oral-endotracheal tube intubation under general anesthesia in 110 children aged 6–12 years old at the University Children’s Hospital in Damascus City in 2022. After ensuring that the child met inclusion criteria and obtained written consent. Each child was examined before, during, and after 12–24 h of entering the operation room. Personal information (gender – age), information related to anesthesia procedures, and some oral cavity characters were collected.ResultsThe incidence of traumatic dental injuries during general anesthesia was 9.1%. Most of them intra-oral soft tissue injuries. The concussion is the most common injury related to teeth damage. In addition, the tongue was the most common-place. There is a correlation between the incidence of traumatic dental injuries and the difficulty of intubation, the number of intubation attempts, Mallampati score (p < 0.05).ConclusionThe anesthesiologist should evaluate the condition of each patient carefully. Document every detail in their record and inform the patient of the possibility of dental damage during the procedures especially in the case that has difficulty intubation.

Molecular diagnosis of mtDNA syndromes in Egyptian pediatric patients: a hospital-based study

BackgroundMCDs, or mitochondrial disorders, are a major contributor to morbidity and mortality. There are few studies on the prevalence of gene mutations in pediatric MCD patients in Egypt. The objective of the current study was to determine the frequencies of the most prevalent mtDNA mutations in a group of Egyptian children with classical mitochondrial disorders.MethodsOver two years, 140 pediatric patients clinically suspected of having classical mitochondrial disorders and 50 controls were examined for the most prevalent mtDNA mutations at Cairo University Children’s Hospital. Polymerase Chain Reaction/Restriction Fragment Length Polymorphism analyses were used to screen for the 17 most common mtDNA mutations (G3460A, G11778A, T14484C, T3271C, G13513A, A3243G, A8344G, G8363A, T9176C, T8993C/G, A8344G, T8356C, G8363A, C3303T, A3260G, A4300G, and C9997T) based on the suspected syndrome. To validate the abnormal patterns, direct sequencing was carried out.ResultsOf the 114 children evaluated, 54 were female and 60 were male, with a median age (range) of 3.5 years (7 months–16 years). 77 out of 114 (67.5%) patients were born into consanguineous marriages. Merely 1.8% of mtDNA point mutations were detected; of those with Leber’s hereditary optic neuropathy, only two had the homoplasmic pathogenic variant T14484C of MTND6 verified.ConclusionsScreening for the most prevalent mtDNA mutations could be used as preliminary noninvasive testing for such syndromes. The low positive incidence raises the possibility that these mtDNA point mutations are not unique to pediatric patients in Egypt. Given Egypt’s high percentage of consanguineous marriage, the molecular pathogenesis of such disorders is suspected to be of nuclear genetic origin.

Safety of oral immunotherapy for cashew nut and peanut allergy in children - a retrospective single-centre study.

Oral immunotherapy (OIT) is increasingly used for the treatment of childhood food allergies, with limited data available on cashew nut OIT. This real-life study investigated the safety and feasibility of cashew nut OIT, comparing it with peanut OIT, with a focus on the up-dosing process. We analysed cashew nut (n = 24) and peanut (n = 38) OIT cases with treatment initiated between 2018 and 2022 at the University Children's Hospital Basel. All patients who commenced therapy within this time frame were enrolled without prior selection. Two different starting protocols were used. Within the up-dosing protocol, the nut intake was incrementally increased by 20-30% every 2 weeks until reaching a maintenance dose of 1 g of nut protein. After consuming the maintenance dose regularly for 18-24 months, a second oral food challenge was performed. Patients who passed this challenge were considered desensitised. The safety of the therapy was evaluated based on the severity of adverse reactions during the up-dosing phase. Symptom severity was evaluated using the validated ordinal food allergy severity scale (o-FASS-5). Over the study period, 33% of cashew nut-allergic and 63% of peanut-allergic patients experienced mild to moderate allergic reactions. Severe allergic reactions occurred in five peanut-allergic children with high baseline allergen-specific IgE levels. Six patients with peanut, and none with cashew nut OIT, discontinued the therapy due to adverse reactions. The mean duration to reach the maintenance phase was longer for children with asthma or another food allergy. Among children who already underwent the second oral food challenge, desensitisation was achieved in 91% (11 out of 12) of cashew nut- and 73% (11 out of 15) of peanut-allergic patients. Cashew nut OIT had a low severity of adverse reactions and was generally well-tolerated. However, patient characteristics influenced side effect risk and treatment duration, emphasising the need for individualised OIT strategies.

Study of rotavirus genotypes G and P in one Egyptian center-cross-sectional study

BackgroundRotavirus-associated gastroenteritis is a common health problem in children, different variations of rotavirus genotypes differ according to geographic locations and the practice of wide-scale vaccination. Therefore, the present study aimed to detect both the G and P genotypes of rotavirus in children ≤ 5 years old in one center in Egypt as a cross-sectional study, to correlate the genotypes with various demographic and clinical data in infected children and to evaluate the common mixed genotypes G and P in infected children.MethodThe cross-sectional study included children with acute gastroenteritis ≤ 5 years old from January 2023 till March 2024 recruited from Mansoura University Children’s Hospital, Egypt based upon laboratory diagnosis by exclusion of bacterial and protozoa pathogens. The stool samples were obtained from each child and subjected to detection of rotavirus antigen by enzyme-linked immunosorbent assay (ELISA) followed by genotypes identification of G and P genotypes by nested polymerase chain reaction (PCR).ResultA nested PCR study for rotavirus genotypes revealed that G1 was the most common genotype (24.7%) followed by G2 (21.1%), G3 (20%), G9 (20%), and G4 (14.1%). The genotyping of the P genotype revealed that P9 was the commonest genotype (24.7%), followed by P4 (21.2%), P10 (20%), P8 (17.6%) and P6 (16.5%). The commonest combined genotypes of G and P were G1P4 (85.7%), G3P8(88.2%), followed by G2P6 (77.8%) and G9P9(76.5%) and G4P9 (66.7%) followed by G4P10 (33.3%), G9P10(23.5%), G2P10(22.2%), G1P10 (14.3%), G3P10(11.8%). The distribution was significant (P = 0.001). The positive rotavirus antigen was more frequently detected in females (55.3%) than males (44.7%, Odd ratio 0.2, 95% CI 0.22–0.71, P = 0.001). There was a significant association between the summer season and positive rotavirus antigen (P = 0.001) and rural residence of the patients (Odd ratio 6,9 95%CI 3,5-13.5, P = 0.001). The significant associated clinical sign with positive rotavirus antigen was fever (Odd ratio 3,3, 95%CI 1,8-6.05, P = 0.001). The genotypes G and P were significantly associated with positive rotavirus antigen as all cases positive by antigen had been detected by nested PCR with the commonest genotypes G4 (24.7%, P = 0.001) and genotype P9 (24.7%, P = 0.001).ConclusionThe present study highlights the common genotypes of rotavirus at one center in Egypt, G1, G2, and G3 were the commonest G genotypes. As regard genotype P the commonest genotypes were P9, P4, and P10. The commonest combined genotypes were G1P4, G3P8, G2P6. There was no effect of the practice of rotavirus vaccination at limited rates at private health sections as the rotavirus is still a major pathogen of acute gastroenteritis in children. There is a need for the inclusion of rotavirus vaccination in the national program of children vaccination in Egypt.

Ultrasound evaluation of kidney and liver involvement in Bardet–Biedl syndrome

BackgroundBardet–Biedl syndrome (BBS) is a rare autosomal-recessive ciliopathy with pathogenic variants in 26 BBS genes. It affects multiple organs, including the kidney and liver, with varying degrees regarding extent and time of first manifestation. Structural renal anomalies are an early feature and end-stage kidney disease (ESKD) cumulates to 25% in adulthood. Early-onset hyperphagia-associated obesity is another major symptom and contributes to liver pathology, presenting as steatosis/fibrosis. Aim of this study is the evaluation of high-end ultrasound (US) technologies in BBS patients regarding their potential to discriminate liver and kidney tissue pathology at an early stage.Materials and methodsPatients with genetically proven BBS were recruited from the University Children’s Hospital of Essen and from BBS patient days hosted in Germany. Acute illness was an exclusion criterion. Clinical and laboratory data were extracted from patients’ digital records or medical letters. High-resolution ultrasound (US) imaging was utilized, including attenuation imaging (ATI), shear wave elastography (SWE) and dispersion (SWD) of liver tissue.Results49 BBS patients (24/49 male; 1.1–51.0 years, mean 17.8 years) were included in the study. Mean body weight (SDS 2.13 ± 1.33) and BMI (SDS 2.64 ± 1.18) were increased. Structural kidney abnormalities (dysplasia, cysts) were present in 75% (36/48), and persistent fetal lobulation in 44% (21/48). Renal function was impaired in 27% (13/49) of whom 3 had ESKD (kidney transplantation (n = 2), hemodialysis (n = 1)). Elevation of liver enzymes was detected in 38% (16/42). In 51% (25/49) ATI of liver tissue was increased, indicating hepatic steatosis, and correlated with BMI SDS, liver size, and enzymes. SWE was elevated in 61% (30/49), suggesting hepatic fibrosis, and it correlated with BMI and GGT. Patients with pathogenic variants in BBS10 showed a tendency towards higher ATI, reduced GFR, and higher BMI SDS.ConclusionsWe detected kidney and liver abnormalities in a higher percentage of BBS patients than previously reported, indicating a high sensitivity and diagnostic yield of the evaluated high-end US applications. ATI detected liver pathology early (partially prior to liver enzymes) and revealed differences related to the affected genes. Evidence of tissue pathology at an early stage may improve diagnostics and the evaluation of therapeutic approaches.

Insights into the Chemical Exposome during Pregnancy: A Non-Targeted Analysis of Preterm and Term Births.

Human-made chemicals are ubiquitous, leading to chronic exposure to complex mixtures of potentially harmful substances. We investigated chemical exposures in pregnant women in New York City by applying a non-targeted analysis (NTA) workflow to 95 paired prenatal urine and serum samples (35 pairs of preterm birth) collected as part of the New York University Children's Health and Environment Study. We analyzed all samples using liquid chromatography coupled with Orbitrap high-resolution mass spectrometry in both positive and negative electrospray ionization modes, employing full scan and data-dependent MS/MS fragmentation scans. We detected a total of 1524 chemical features for annotation, with 12 chemicals confirmed by authentic standards. Two confirmed chemicals dodecyltrimethylammonium and N,N-dimethyldecylamine N-oxide appear to not have been previously reported in human blood samples. We observed a statistically significant differential enrichment between urine and serum samples, as well as between preterm and term birth (p < 0.0001) in serum samples. When comparing between preterm and term births, an exogenous contaminant, 1,4-cyclohexanedicarboxylic acid (tentative), showed a statistical significance difference (p = 0.003) with more abundance in preterm birth in serum. An example of chemical associations (12 associations in total) observed was between surfactants (tertiary amines) and endogenous metabolites (fatty acid amides).

Remote out-of-hours ultrasound live supervision in pediatrics - improvement of diagnostics and training.

Ultrasound (US) is the preferred imaging modality in pediatrics for diagnostic and therapeutic issues. The absence of radiation and the constant on-site accessibility make it the ideal tool for children. However, despite remarkable technical advances in resolution and applicability, many sophisticated medical questions still require profound expertise on the part of the examiner, thus often hampering fast decisions particularly outside regular working hours. This single-center study, at a university children's hospital evaluated the use of US during emergency service. A four-week documentation period was followed by a subsequent eight-week supervision period with live supervision availability on demand guided by a remote US expert. The demand for expert support, diagnosis, grading of urgency, duration and success of examination, and satisfaction of both examiners were analyzed. 108 patients (mean age 9.7 years) were included. In 38% of cases, US was supervised on demand with a definite diagnosis in 92.6% of cases (25/27). Image quality and technical performance were graded sufficient in 100% of cases. Supervised compared to non-supervised US examinations were prolonged (14.4 min vs. 7.1 min, p<0.001), were more prevalent within the first 24 h in the hospital (70% vs. 56.8%, p=0.06), and were classified more frequently as emergency (22.2% vs. 2.3%; p=0.015). All participants classified the availability of US supervision as decisively helpful. Remote live supervised pediatric US was feasible and effective. It combined timely, high-quality diagnostics even in the case of challenging medical questions with simultaneous US training.

Severity of native pulmonary annular hypoplasia and late outcomes of tetralogy of Fallot: retrospective cohort study.

Pulmonary annular hypoplasia and valvar dysplasia are key morphological features affecting long-term outcomes of tetralogy of Fallot. This retrospective study aimed to analyse factors affecting contemporary long-term outcomes with a focus on pulmonary annular growth and function over time. 131 consecutive isolated tetralogy of Fallot repairs performed between 2004 and 2014 at University Children's Hospital Zurich were included. Median age and weight at the time of repair were 4.8 (interquartile range [IQR] 3.2-6.3) months and 6.1 (IQR 5.1-7) kg, respectively. Based on the severity of native pulmonary annular hypoplasia, the cohort was divided into group 1 (preoperative pulmonary annular Z score < -4; n = 20), group 2 (Z score -2 to -4; n = 56) and group 3 (Z score > -2; n = 54). A transannular patch was used in 88/131 (67.2%) patients: 80%, 67.9% and 61.1% in groups 1, 2 and 3, respectively. The primary outcome was defined as right ventricular outflow tract (RVOT) reoperation or pulmonary valve replacement. Secondary outcome was composite pulmonary valve dysfunction defined as peak gradient >40 mm Hg or severe pulmonary regurgitation at follow-up. A multiple Cox regression model was used to quantify the association of age at tetralogy of Fallot repair, preoperative pulmonary annular Z score and RVOT approach with primary and secondary outcome. Follow-up was 98.5% complete, with a median follow-up duration of 9.6 (95% confidence interval [CI] 9-10.4) years. All patients were alive at last follow-up resulting in 100% survival. 20/131 patients underwent pulmonary valve replacement (14 surgical and 6 catheter interventional) while 5/131 underwent RVOT reoperations other than valve replacement. The Kaplan-Meier 10-year freedom from primary outcome was 85% (95% CI 78-92%); 69% (46-100%), 91% (82-100%) and 84% (74-95%) for groups 1, 2 and 3, respectively (log rank p = 0.16). Composite dysfunction at follow-up was observed in 29.8% (overall): 45%, 28.6% and 25.9% for groups 1, 2 and 3, respectively (p = 0.12). The multiple Cox regression analysis for primary outcome indicated that the use of a transannular patch results in a Hazard Ratio (HR) of 3.3 (95% CI 0.7-14.7, p = 0.13). Additionally, the presence of composite dysfunction at discharge results in a HR of 2.1 (95% CI 0.8-5.4, p = 0.1). Age (in months) with a HR of 0.8 (95% CI 0.6-1, p = 0.06) and group 2 with a HR of 0.4 (95% CI 0.14-1.2, p = 0.11) showed a trend to being protective for the primary outcome. However, the 95% CI of all estimates included the HR of 1. Transannular patch use and composite dysfunction at discharge, although not statistically significant at 5% level, may be associated with pulmonary valve replacement and RVOT reoperation. Avoiding the use of a transannular patch or using reconstructive techniques to achieve a better composite dysfunction at discharge could reduce the primary outcome. Large multicentre studies are needed to demonstrate more precisely the impact of pulmonary annulus Z scores on outcome.

Impact of non-invasive ventilation on microbial colonisation patterns in preterm infants: a single-centre study.

The objective of this study is to assess the relationship between non-invasive ventilation (NIV) and the colonisation of oral and nasal microbiota in preterm infants within the neonatal intensive care unit (NICU). A prospective cohort study. The NICU of Zhejiang University Children's Hospital. Patients include preterm infants with a gestational age of 28-35 weeks, enrolled within the first 24 hours of life. Infants were categorised based on respiratory support: NIV, which included nasal continuous positive airway pressure, nasal intermittent positive pressure ventilation or high-flow nasal cannula; and no respiratory support, defined as room air or low-flow nasal cannula at ≤2 L/min. The primary outcome was the colonisation of oral and nasal microbiota at 5 days post birth, measured by colony-forming units per millilitre (CFU/mL), with colonisation defined as bacterial growth >103 CFU/mL. The study included 100 preterm infants, with 50 in each group. Nasal microbial colonisation was observed in 56% (28/50) of the NIV group, significantly higher than the 28% in the no respiratory support group. No significant differences were found in oral colonisation. Adjusted binary logistic regression showed an association between NIV and increased risk of nasal colonisation (adjusted OR=2.91, 95% CI 1.12 to 7.58, p=0.028). NIV in preterm infants was linked to a higher risk of nasal microbial colonisation. This finding suggests the need for further research and consideration of infection control strategies in the NICU.

Comparative analysis of the parameters of local immunity of oral fluid and the duration of the course in children with systemic lupus erythematosus, juvenile scleroderma, juvenile dermatomyositis, juvenile idiopathic arthritis and systemic vasculitis

Immunoglobulins are considered to be the main factor of specific antimicrobial protection of oral tissues.The study was conducted on the basis of the University Children’s Clinical Hospital of the I.M. Sechenov First Moscow State Medical University of the N.F. Filatov Clinical Institute of Child Health, in the Department of Rheumatology. The study involved 316 children, with diseases: systemic lupus erythematosus (SLE), juvenile dermatomyositis (YDM), juvenile limited scleroderma (YOSD), juvenile systemic scleroderma (YSSD), juvenile idiopathic arthritis (JIA), systemic vasculitis (SV) and Behcet’s disease (BB) and were divided into age groups according to the duration of the course of the underlying disease. The analysis of the results revealed a decrease in the content of IgG, IgA, sIgA in saliva in children with rheumatic diseases in all age groups compared with the control group (children without somatic diseases). With the duration of the course of the disease up to 2 years, the most pronounced decrease in the content of IgG, IgA, sIgA in saliva was revealed, more than 4–10 times (p&lt;0.05), and with a duration of more than 2 years, a decrease of 2–3 times (p&lt;0.01), compared with the control group. The deficiency of these immunoglobulins shows that in children with rheumatic diseases, regardless of the nosology, there is a violation of the local immunity of the oral cavity, especially at the onset of the underlying disease (in groups up to 2 years of the duration of the course of the underlying disease), with pronounced autoimmune inflammation of tissues and blood vessels, and this is also facilitated by the reception, during this period of shock doses of glucocorticosteroids, cytostatics, immunosuppressors, which leads to severe inflammatory processes of the oral mucosa, periodontal and hard tissues of the teeth.

Predictors for thyroid dysfunction after discontinuation of levothyroxine in children and adolescents with Hashimoto thyroiditis.

Few data on the clinical course after levothyroxine (L-T4) discontinuation in pediatric patients with Hashimoto thyroiditis (HT) are available. We investigated outcomes and predictors for successful withdrawal from L-T4 among children with HT. Among 168 patients diagnosed with HT between January 2000 and March 2021 at Seoul National University Children's Hospital and in whom L-T4 therapy was initiated during childhood, we attempted to discontinue this therapy in 47, 3 boys and 44 girls. L-T4 was restarted when patients developed overt or subclinical hypothyroidism (thyroid-stimulating hormone [TSH] levels≥10 mIU/L) after L-T4 discontinuation. Median age at discontinuation was 15.4 years (12.7-18.4 years) with a median duration of L-T4 therapy of 47 months (20.3-80.3 months). During the median 30 months of follow-up (10.6-61.0 months) after L-T4 discontinuation, 33 (70.2%) developed thyroid dysfunction. Among these patients, 17 were eventually restarted on L-T4. TSH levels over 50 mIU/L at L-T4 initiation (hazard ratio, HR 3.5, P=0.002), age under 12 years at L-T4 discontinuation (HR 11.1, P=0.0001), and TSH levels higher than the upper 50% of normal (above 2.25 mIU/L in the present study) at L-T4 discontinuation (HR 2.7, P=0.014) were significantly predictive for overt hypothyroidism or subclinical hypothyroidism after L-T4 discontinuation. In addition, age under 12 years at L-T4 discontinuation was only predictive factor for restarting L-T4 medication (HR 4.3, P=0.012). L-T4 discontinuation in pediatric patients with HT resulted in thyroid dysfunction in 70.2% of cases; 36.2% of patients who attempted discontinuation required resumption of L-T4. Older age and lower TSH levels at L-T4 discontinuation were advantageous for successful withdrawal.

Cortical Alterations Associated with Executive Function Deficits in Youth with a Congenital Heart Defect

Abstract Adolescents and young adults born with a complex congenital heart defect (CHD) are at risk for executive function (ExF) impairments, which contribute to the psychological and everyday burden of CHD. Cortical dysmaturation has been well described in fetuses and neonates with CHD and early evidence suggests that cortical alterations in thickness, surface area, and gyrification index are non-transient and can be observed in adolescents with CHD. However, cortical alterations have yet to be correlated with ExF deficits in youth with CHD. This study aims to use a data-driven approach to identify the most important cortical features associated with ExF deficits in adolescents and young adults with CHD. To do so, we combined two comparable datasets acquired at the Research Institute of the McGill University Health Centre and the University Children’s Hospital Zurich each including both youth with CHD and healthy controls. For each participant, a high-resolution T1-weighted magnetic resonance image, a self-reported ExF assessment (the Behaviour Rating Inventory of Executive Function— Adult Scale), and their clinical and demographic characteristics were available. Corticometric Iterative Vertex-Based Estimation of Thickness (CIVET) was used to extract cortical thickness, cortical surface area, and local gyrification index measures. Using orthogonal projective non-negative matrix factorization (OPNMF), we identified non-overlapping spatial components that integrate cortical thickness, cortical surface area, and local gyrification index and capture structural covariance across these features. Behavioural partial least squares correlation (bPLS) analysis was then used to compute correlations between the individual variability in the OPNMF covariance patterns and ExF outcomes for each subject. A total of 56 youth with CHD who underwent cardiopulmonary bypass surgery before three years of age and 56 age- and sex-matched healthy controls were included in our analyses. Cortical grey matter volume, cortical thickness, and cortical surface area were found to be significantly reduced in CHD patients compared to controls. OPNMF identified 12 stable cortex-wide components summarizing the inter-subject variability in cortical thickness, cortical surface area, and local gyrification index. bPLS revealed two significant latent variables (LV) accounting for a total of 82.8% of the variance in the sample, each describing distinct patterns between the brain and cognitive data. LV1 summarized a pattern of belonging to the CHD group, worse scores on most BRIEF-A scales, younger age at MRI, and female sex. This pattern was associated with increased cortical thickness, local gyrification index, and decreased cortical surface area in several OPNMF components. Finally, we identified a positive relationship between the LV1 brain-behaviour pattern and total aortic cross-clamp time in the CHD group, indicating that longer aortic cross-clamp time was associated with worse neurodevelopmental outcomes. In this study, we uncover novel multivariate relationships between ExF and alterations in cortical thickness, surface area, and local gyrification index in adolescents and young adults with CHD using a data-driven approach. Although our findings highlight the important role played by the cortex in higher order cognitive processes, future studies are needed to elucidate the individual contribution of individual and clinical attributes into the deficits observed in this population.

Pediatric acetaminophen intoxication in Korea: characteristics and prognosis

Purpose: Acetaminophen overdose accounts for the largest proportion of pediatric poisoning reported in South Korea. We investigated the characteristics and prognosis of pediatric acetaminophen overdose.Methods: We retrospectively reviewed medical records of patients younger than 19 years with acetaminophen overdose who visited the emergency department (ED) of Pusan National University Children’s Hospital from January 2009 through December 2022. We investigated age, sex, dose, clinical findings, and treatment, and compared the differences in the variables according to the intentionality of ingestion and the presence of hepatotoxicity.Results: Among the 132,691 pediatric patients who visited the ED during the period, 555 did for drug intoxication, of whom 51 with acetaminophen overdose were included in this study. The overdose was intentional in 43 patients (the intentional group; median age, 15.4 years [interquartile range, 13.9-16.8]) and accidental in 8 patients (the accidental group; 7.7 years [2.3-15.4]). The mean ingested dose was higher in the intentional group than in the accidental group (170.3 ± 129.0 vs. 105.3 ± 37.5 mg/kg; P = 0.016). Hospitalization tended to be implemented more frequently in the intentional group (53.5% vs. 12.5%; P = 0.081). All patients with hepatotoxicity (n = 10) belonged to the same group, and showed a higher or longer median age (15.9 [14.6-17.1] vs. 13.8 years [13.7-16.4]; P = 0.030), mean ingested dose (13,230.0 ± 10,544.8 vs. 7,654.0 ± 6,752.3 mg; P = 0.043), mean time from ingestion to arrival at the ED (22.6 ± 23.4 vs. 5.5 ± 6.4 hours; P = 0.048), and frequency of hospitalization (80.0% vs. 39.0%; P = 0.048).Conclusion: It is necessary to track the occurrence of hepatotoxicity in patients who intentionally ingest acetaminophen.

Changes in Pediatric End-of-Life Process After the Enforcement of the Act on Life-Sustaining Treatment Decisions-The Experience of a Single Children's Hospital.

Background: The Act on Life-Sustaining Treatment (LST) for patients at the end of life (the Korean LST Decision Act), implemented in the Republic of Korea in February 2018, has led to changes in the end-of-life decision-making (EOLDM) process in children. This study aimed to investigate changes in pediatric EOLDM process and LST practices since the Korean LST Decision Act. Methods: This retrospective cohort study included 107 patients who died at Kyungpook National University Children's Hospital from January 2015 to December 2020. Patients were divided into two groups: pre-law (January 2015-January 2018, n = 55) and post-law (February 2018-December 2020, n = 52). We analyzed medical records for EOLDM process, patient characteristics, intensive care unit (ICU) admission, documentation types, and LST withholding or withdrawal decisions. Results: After the Korean LST Decision Act, the median total hospitalization duration decreased significantly (14 days [IQR, 3-80] vs. 6 days [IQR, 2-18], p = 0.020), as did the median ICU length of stay (3 days [IQR 1-33] vs. 2.5 days [IQR 1-10.3], p = 0.002). The time from admission to end-of-life decision documentation was significantly shorter in group 2 (6 days [IQR 1-31] vs. 4 days [IQR 1-9], p = 0.027). The use of physician orders for life-sustaining treatment (POLST) documents increased (0% to 33.3%), while do-not-resuscitate (DNR) orders decreased (85.3% to 16.7%). Notably, LST withdrawal decisions increased from 0% to 27.8% (p = 0.001) in the post-legislation period. Conclusions: The Korean LST Decisions Act has led to significant changes in the EOLDM process for terminally ill children, including earlier decision-making, increased use of POLST documents, more frequent LST withdrawal decisions, and shorter hospital and ICU stays. These findings suggest a shift towards more structured and timely end-of-life care discussions in pediatric settings.

Machine Learning Approach to Injury Monitoring in Children and Adolescents

Abstract Pediatric injuries are common and associated with individual suffering and costs for the healthcare systems and society. The incidence of injuries among children in Switzerland has so far been insufficiently monitored. Emergency department patient records can be a valuable database to assess medically relevant injuries and gain information for monitoring and evidence-based prevention. The talk will outline our stepwise development of a machine-learning program for a pediatric injury monitoring system and lessons learnt. In this feasibility study we draw on electronic case histories of children treated for injuries between 2018 and 2022 at the University Children’s Hospital Zürich emergency department (N= to 30’884). The ML- approach follows different steps: step 1. utility evaluation of electronic pediatric patient records regarding ML and injury monitoring and prevention requirements in a test-sample of 100 electronic pediatric case histories; step 2. choice/adaptation of coding tree; step 3. coder training and inter-coder reliability testing; step 4. manual annotation of a sub-sample (n 1000) of the electronic pediatric patient records, step 5. design and testing of the ML program in an iterative process, and step 6. performance testing in a random sample of pediatric patient records. First lessons learnt indicate that electronic case history data contain relevant data and fulfill requirements for monitoring and prevention purposes. The IDB coding system proved too complex and detailed for the pediatric data base, providing too few examples for the ML-learning process, and needed to be adapted. Initial data analyses indicate the majority of cases are classified as less severe (73%) and only few (&amp;lt;1%) as very severe but the later provide the most detailed data. ML is a promising approach and makes use of hospital data for a national monitoring of pediatric injuries in Switzerland.

Machine Learning powered Patient Records Analysis for Injury Monitoring in Children and Adolescents

Abstract Background Injuries to children and adolescents are common and are associated with individual suffering and costs. Switzerland lacks data of injuries in children and adolescents. This study investigates the feasibility of utilizing machine learning (ML) methodology to automatically extract relevant data from electronic pediatric patient records needed for monitoring and prevention purposes. Methods The feasibility study follows three steps. 1. Utility evaluation of text data from electronic pediatric patient records regarding ML, injury monitoring and prevention requirements in a test-sample. 2. The development of an ML-based approach to extract relevant information based on electronic pediatric patient records (N = 30’884) of children treated for injuries at the University Children’s Hospital Zurich emergency department between 2018-2022. 3. The performance of the ML methodology is evaluated. Results Qualitative and ML expert assessment of the sample showed that the desired data on injuries is contained in the test-sample and necessary requirements are met. Data records differ in detail with severe injuries providing especially rich information records. The international IDB code-tree was proved to be too elaborate and adult-orientated and was adapted. Preliminary data analyses indicate that the number of accidents is highest in the age group from 0 to 4 years (36%). More male (58%) children were treated. Majority of accidents were classified as less severe (73%), few (&amp;lt;1%) as very severe. Further lessons learned, along with more detailed prevalence data on injuries in children and adolescents, will be available by August 2024. Conclusions Extraction of injury information from electronic patient record by means of ML may provide valuable information for injury monitoring and prevention, so far missing in Switzerland. Prerequisites for the successful application of ML are digital record access, usable coding-tree, and detailed text input by the emergency departments. Key messages • An ML-based approach has the potential to improve the data basis by extracting valuable accidents information from existing texts of patient records. • To successfully apply this method, digital record access and detailed text data are needed.

Validation of Fat Mass Metrics in Pediatric Obesity

Introduction: Hudda-Index is a prediction model for fat mass (FM) based on simple anthropometric measures. FM is a crucial factor in the development of comorbidities, i.e., type 2 diabetes. Hence, Hudda-Index is a promising tool to facilitate the identification of children at risk for metabolic comorbidities. It has been validated against deuterium dilution assessments; however, independent validation against the gold standard for body composition analysis, magnetic resonance imaging (MRI), is lacking. The aim of this study was to validate FM calculated by Hudda-Index against FM measured by MRI. The secondary aim was to compare Hudda-Index to other anthropometric measures including body mass index (BMI), BMI-standard deviation score (BMI-SDS), waist/hip-ratio, waist circumference (WC), and skinfold thickness. Methods: The study cohort consists of 115 individuals between the age of 9 and 15 years, recruited at Paracelsus Medical University Hospital in Salzburg (Austria) and Uppsala University Children’s Hospital (Sweden). Anthropometry, blood samples, and oral glucose tolerance tests followed standard procedures. MRI examinations were performed to determine visceral adipose tissue (VAT) and subcutaneous adipose tissue. Results: BMI and WC showed slightly stronger associations with the reference standard VAT (r = 0.72 and 0.70, p < 0.01, respectively) than Hudda-Index (r = 0.67, p < 0.01). There is an almost perfect linear association between BMI and Hudda-Index. Accordingly, BMI and Hudda-Index both showed an acceptable association with cardiometabolic parameters. VAT was strongly associated with markers of liver status (LFF r = 0.59, p < 0.01) and insulin resistance (HOMA-IR r = 0.71, p < 0.01) and predicted metabolic dysfunction-associated steatotic liver disease. Conclusion: BMI, although an imperfect measure, remains the most reliable tool and estimates cardiometabolic risk more reliably than other anthropometry-based measures.