Pediatric University Hospital Research Articles

Patch test in Brazilian children with a clinical diagnosis of atopic dermatitis: a cross-sectional study using an extended patch test battery.

Atopic dermatitis (AD) is a chronic and relapsing inflammatory skin disease mainly affecting children. Similarly, Allergic contact dermatitis (ACD) is an inflammatory skin disease, but unlike AD it results from direct exposure to an external agent. Theoretically, the impaired skin barrier facilitates the penetration of potential allergens. Therefore, AD patients are at risk for an associated ACD, exacerbating their skin condition. Because eczema is similar, performing a patch test (PT) for the differential diagnosis is essential. In this cross-sectional transversal study, we performed a PT with 30 sensitizers in 26 children with AD, selected according to established criteria for suspected ACD, and treated at an AD center of a pediatric university hospital in Rio de Janeiro. Clinical presentation, patient profile, main sensitizers, and frequency of ACD caused by therapeutic skincare products were evaluated. In all, 23 (88.5%) patients reacted to at least one allergen, 21 (80.7%) had a relevant positive patch test, and 15 (57.7%) were polysensitized. The main positive sensitizers were nickel (38.5%), blue disperse (30.8%), fragrance mix (30.8%), and neomycin (23.1%). Nineteen (73%) patients reacted to substances present in therapeutic or skincare products. Our data underscore the importance of performing a PT in AD children whose eczema has atypical distribution. The expressive percentage of positive tests, especially of allergens in skincare products, indicates the constant need to review the proposed treatments. Therefore, we recommend a specific and expanded PT battery for pediatric AD patients, including a negative control, to increase sensitivity for diagnosing ACD.

Advancing pediatric head CT dose prediction: correlating patient size metrics with AP and LAT dimensions in Moroccan population

This study aims to establish comprehensive relationships between patient size, focusing on effective diameter (Deff) and water-equivalent diameter (Dw), in conjunction with anterior-posterior (AP) and lateral (LAT) dimensions. The primary goal is to refine precise patient dose estimations in pediatric head computed tomography (CT) examinations. Our examination involved a dataset of 105 pediatric head CT images sourced from a Moroccan pediatric university hospital. These images, selected from the central scanning range, underwent quantification for LAT, AP, Deff, and Dw, with measurements carried out using RadiAnt Dicom Viewer for lateral and anteroposterior dimensions. Our analytical approach encompassed modeling Deff and Dw as functions of LAT, AP, and combined AP + LAT dimensions. Additionally, Dw was modeled as a function of Deff and calculated Size Specific Dose Estimates (SSDE) based on Dw was compared to SSDE computed from one single dimension. The outcomes revealed strong correlations among Deff, Dw, and fundamental geometric dimensions (LAT, AP, and AP + LAT), as indicated by consistently high coefficients of determination (R² > 0.8). SSDE calculated from Dw shows impressive correlation with SSDE computed from a single dimension (R² > 0.9). This study offers insights into the relationships between patient size and critical dimensions, identifying high correlations that can represent a significant advancement in predicting doses for pediatric head CT examinations. This introduces the potential for streamlining the determination of head diameter and dose by relying on a single dimension, thereby enhancing the efficiency of dose predictions by facilitating the monitoring of radiation exposure of this population in clinical routine.

265 Association of premature birth with neurodevelopment delays in a cohort of Hispanic children exposed to the Neonatal Intensive Care Unit (NICU)

OBJECTIVES/GOALS: We aim to identify neurodevelopment delays among children who were born prematurely. We will also calculate the sensitivity and specificity of the assessment tools used to measure the neurodevelopmental profile in early childhood of children exposed to the Neonatal Intensive Care Unit (NICU). METHODS/STUDY POPULATION: This cross-sectional study will include 100 premature children who were born between 32 to 37 weeks of gestational age and admitted to NICU at the University Pediatric Hospital in Puerto Rico. Their neurodevelopment will be measured with the Bayley III. Statistical analysis will be performed using IBM SPSS Statistics 25.0. Descriptive statistics will be used, normality distributions among all continuous variables, frequency distribution for categorical variables and logistic regressions to test association of GA and neurodevelopment delay. We will use the raw item scores for each domain of the Bayley III assessments to measure internal consistency using Cronbach’s alpha and factor analysis. RESULTS/ANTICIPATED RESULTS: We anticipate identifying the ND among children born prematurely between 32 to 37 weeks of gestational age and who were admitted to NICU at the University Pediatric Hospital in Puerto Rico. We also expect to find if gestational age impacts adversely ND in children who were born between 32 to 37 weeks of gestation. We will be able to assess if lower gestational age will impact global ND in contrast to higher gestational age neurodevelopment delays in one specific area of development. We will also be able to assess the sensitivity and specificity of the Bayley- III. DISCUSSION/SIGNIFICANCE: Premature is a major global health problem with a 12.0% prevalence. We want to promote early identification of ND in a diverse Hispanic Puerto Rican population so we can guide public health decisions and lead research initiatives to improve outcomes in the future or facing prematurity.

Serum Amylase Activity in Children Living with HIV-1 at the Charles de Gaulle Pediatric University Hospital in Ouagadougou

Biological monitoring is an essential part of the management of HIV infection. The aim of this study was to assess serum amylase activity during follow-up of children living with HIV-1 (CLHIV-1) at the Charles de Gaulle Pediatric University Hospital (CHUP-CDG). This was a descriptive and analytical cross-sectional study, with retrospective data collection from January 1, 2020 to December 31, 2022. Patients under 15 years of age who were being monitored for HIV-1 at CHUP-CDG and who had undergone a serum amylase assay during the study period were included. A total of 746 patients have been included, with a M/F sex ratio of 0.91 and a mean age of 8.52±4.08 years. Among CLHIV-1, 88.05% had a TCD4 lymphocyte count > 500/mm<sup>3</sup> and 60.32% an undetectable plasma viral load (PVL). The incidence of hyperamylasemia in the study population was 57.64%. Hyperamylasemia was significantly more frequent in children aged 0-2 years (<i>p<0.00001</i>), in patients with a high PVL (<i>p=0.0016</i>) and in those on the protocol combining two nucleoside reverse transcriptase inhibitors with a protease inhibitor. Several abnormalities in serum amylase activity were detected in CLHIV-1 during the course of the study. Clinical correlation and adequate follow-up of these abnormalities are essential to reduce the morbidity and mortality associated with pancreatic damage in people living with HIV.

Evaluation of coping strategies of parents of children with cystic fibrosis

ABSTRACT This cross-sectional quantitative study was conducted to evaluate the coping strategies of parents of children with cystic fibrosis. The research sample is the parents (n: 112) who presented to Thoracic Medicine Department at Hacettepe University Pediatric Hospital between 3 April 2021 - 28 May 2021 and volunteered to participate in the study. Sociodemographic Data Form and Coping Orientation to Problems Experienced Inventory (COPE Inventory) were used in the collection of data. The study examined coping strategies according to children’s characteristics such as age, sex, education, and parents’ independent variables such as employment status, income status, number of individuals and children in the family, communication with other families, social and financial support. Data were analyzed using Mann-Whitney and Kruskal-Wallis tests. Research findings show that religious coping was the most frequently preferred coping strategy, and behavioral disengagement was the least commonly used coping strategy. Emotion-Focused Coping Strategies were also commonly used. Social work interventions and strategies play an important role in helping parents to adopt positive coping strategies and improve their skills.

Unlicensed/Off-Label Drug Prescriptions at Hospital Discharge in Children: An Observational Study Using Routinely Collected Health Data.

Unlicensed and off-label (UL/OL) prescriptions have been associated with an increased risk of drug-related problems. Data of their prevalence at hospital discharge remain insufficient. We aimed to describe the prevalence of UL/OL drugs in outpatient prescriptions at discharge in children. We conducted a retrospective study using the routinely collected health data of children at discharge from 2014 to 2016. The primary reference source for determining licensed labelling was the summaries of product characteristics (SPCs) in a French industry-independent formulary named Thériaque. We described the characteristics of UL/OL prescriptions at discharge and looked for predictors of UL/OL prescriptions. We included 2536 prescriptions of 479 children. Licensed, OL, and UL prescriptions accounted for 58.6% (95% CI: 56.7-60.5), 39.2% (95% CI: 37.3-41.1), and 2.3% (95% CI: 1.7-2.9), respectively. A total of 323 (74%) children received at least one UL/OL drug. Among the licensed drugs, bronchodilators (8.8%) and analgesics (8.6%), and among the OL drugs, antibiotics (2.8%), were the most prescribed. The younger age of the children and higher number of drugs they received increased the probability of UL/OL prescriptions (unadjusted p-value of ≤0.05). The prevalence of UL/OL prescriptions is about 40% at discharge from a pediatric university hospital in France.

Clinical evaluation and treatment outcomes of caustic ingestion injuries in Syrian pediatric patients: A retrospective study: Short title: High-dose steroids for pediatric caustic ingestions in Syria.

Accidental ingestion of caustic agents poses a significant concern in pediatric emergency departments globally. It is a growing public health concern in low-to-middle income countries, which often lack comprehensive data reporting. This study examines high doses of corticosteroid treatment outcomes of caustic ingestion injuries in Syrian pediatric patients, addressing clinical features, and associated variables. A retrospective observational study was conducted at University Pediatric Hospital from January 2016 to January 2019. Medical records were reviewed for patients aged <10 years with esophagoscopy-confirmed grade IIa, IIb, or III burns. Data collected included sociodemographics, esophagoscopy results, treatment details, and outcomes. Among 114 pediatric patients, 76 (67%) were males and 38 (33%) were females. Age groups included <1 year (11%), 1-3 years (39%), 3-5 years (29%), 5-7 years (11%), and >7 years (11%). Alkaline burns accounted for 54% of injuries, acidic for 32%, and other substances for 13%. Complications included bleeding (19%) and psychomotor disability (7%). The most common burn site was the entire esophagus (62%), with 81% having grade II burns. Healing was achieved in 71% of patients with high doses of corticosteroids treatment, and 29% required dilation, with final 92% healing rate. The use of corticosteroids for esophageal strictures remains inconclusive, demanding further robust research with larger sample sizes and control groups. While our study revealed that high doses of corticosteroids treatment followed by esophageal dilation had a 92% success rate. However, our study demonstrates promising results, methodological limitations and absence of a control group underscore the need for more definitive evidence. Both alkali and acidic ingestion contribute to stricture development.

Dengue Fever Seroprevalence among Children Aged 0-5 Years at Paediatric University Hospital, Ouagadougou

Dengue Fever Seroprevalence among Children Aged 0-5 Years at Paediatric University Hospital, Ouagadougou

Prevalence of Dyslipidemia among Patients Received at the Biochemistry Unit of the Charles de Gaulle Pediatric University Hospital in Ouagadougou

Prevalence of Dyslipidemia among Patients Received at the Biochemistry Unit of the Charles de Gaulle Pediatric University Hospital in Ouagadougou

Immunovirological Profile of HIV1 Infection in Children and Adolescents Followed at the Bangui Pediatric University Hospital

Immunovirological Profile of HIV1 Infection in Children and Adolescents Followed at the Bangui Pediatric University Hospital

Intrainstitutional Changes of the Treatment of Supracondylar Humerus Fracture in Children over a Period of 9 Years.

To assess changes in treatment modalities for supracondylar humerus fractures (SCHFs) at a large pediatric university hospital, we analyzed patient data from 2014 to 2022. A total of 233 SCHFs treated surgically at our hospital were included. To evaluate postoperative outcome and quality of life, DASH and EuroQol-5D-Y questionnaires were sent to patients. In addition to a significant fluctuation in fracture severity, we found an increase in training interventions (more surgeries were performed by trainees) and a significant decrease in surgery times after 2016. From 2020, there was a significant shift in the type of surgical method away from closed reduction with elastic stable intramedullary nailing (ESIN) and towards closed reduction and crossed K-wire osteosynthesis (CRK). Surgeries performed in the morning and evening hours increased, while those performed in the afternoon and after midnight decreased. After a mean follow-up of 4 years, there was no difference in elbow function between ESIN and open reduction and K-wires (ORK). Treatment with ESIN was equivalent to ORK in terms of function, at least in the medium-term follow-up. In summary, the combination of shifting treatment from SCHF to daytime hours, increasing trainee participation and using cross K-wire fixation instead of ESIN had no negative impact on surgery times. In our setting, these measures have reduced resource utilization and increased efficiency without compromising patient care.

Stronger and durable SARS-CoV-2 immune response to mRNA vaccines in 5–11 years old children with prior COVID-19

Background and objectivesmRNA vaccines elicit a durable humoral response to SARS-CoV-2 in adults, whereas evidence in children is scarce. This study aimed to assess the early and long-term immune response to the mRNA vaccine in children with or without previous SARS-CoV-2 infection. MethodsIn a multicentre prospective observational study, we profiled the immune response to the Pfizer BioNTech (BNT162b2) vaccine in 5–11-year-old children attending the University Pediatric Hospital of Padua and Bambino-Gesù Hospital in Rome (Italy) from December-2021 to February-2023. Blood samples were collected pre-, 1-, and 6-months after vaccination. Neutralizing antibodies (NAbs) and anti-spike-receptor-binding-domain (anti-S-RBD) IgG titers were analyzed through Plaque Reduction Neutralization Test (PRNT) and chemiluminescent immune-enzymatic assay (CLIA), respectively. Immune cell phenotypes were analyzed by flow cytometry. ResultsSixty children (26 [43 %] female, median age = 8 years [IQR = 7–10.7]) were enrolled in the study, including 46 children with a laboratory-confirmed previous COVID-19 (SARS-CoV-2-recovered) and 14 SARS-CoV-2-naïve participants defined as the absence of antigen-specific antibodies before vaccination. SARS-CoV-2-recovered participants recorded higher anti-S-RBD IgG and Wild-type and Omicron BA.2 NAbs titers than SARS-CoV-2-naïve participants at both 1- and 6-months after vaccination. Antibody titers correlated with T (Tregs) and B (Bregs) regulatory cell frequencies in SARS-CoV-2-recovered children. Both SARS-CoV-2-recovered and SARS-CoV-2-naïve participants decreased antibody titers by approximately 100 to 250 % from 1 to 6 months. While children with immunocompromising underlying conditions developed immune responses comparable to those of healthy children, solid organ transplant recipients exhibited lower levels of NAbs and anti-S-RBD IgG titers, as well as reduced frequencies of Tregs and Bregs. ConclusionsmRNA vaccination triggered a higher production of specific anti-SARS-CoV-2 antibodies along with increased levels of regulatory cells in children with previous SARS-CoV-2 infection up to the following 6 months. These findings provide insights into boosting pre-existing immunity.

Retrospective and Observational Study on CAR-T 19 Bridge Therapies in Pediatric, Adolescents and Young Adults &amp;lt;24 Years with B-Cell Precursor Acute Lymphoblastic Leukemia (BCP-ALL): Experience of the Spanish Hematopoietic Stem Cell Trasplantation and Cellular Therapy Group (GETH-TC)

INTRODUCTION CAR-T therapy has revolutionized the treatment of B-ALL. The development of CAR-T therapy is a long and delicate process where once apheresis is done, a bridge period that least until CAR-T cells are infused starts. Meanwhile, the objective will be to maintain disease control, decrease tumor burden (TB) and prevent disease progression with no severe comorbidities by the administration of a bridge chemotherapy. That will decrease the risk of severe (grade 3-4 ASTCT) Cytokine Release Syndrome (CRS) and Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) with an improvement of event free survival. Nevertheless, there is no consensus nor standard guidelines about bridge chemotherapy type, especially in pediatric patients. In this way, the main objective of this study is to identify CAR-T outcomes in pediatric, adolescents and young adults (AYA) diagnosed of BCP-ALL based on bridge chemotherapy. MATHERIAL AND METHODS An observational, retrospective and non-interventional study of Spanish pediatric and AYA under 24 years old diagnosed with BCP-ALL treated with tisagenlecleucel that have been registered by the Spanish Hematopoietic Stem Cell Transplantation and Cellular Therapy (GETH-TC) CAR-T clinical database from years 2017 to 2022. Data have been collected from nine centers members of GETH-TC CAR-T workgroup: La Paz University Hospital, Sant Joan de Déu University Hospital, Virgen del Rocío University Hospital, Niño Jesús Pediatric University Hospital, Gregorio Marañón General University Hospital, Vall d'Hebron University Hospital, Salamanca Clinic University Hospital, Germans Trials i Pujol University Hospital and Valencia Clinic Hospital. General, pre-CAR-T, CAR-T-related and post-CAR-T variables have been analysed from GET-TC CAR-T database, highlighting those related to bridge therapy and related outcomes. Bridging chemotherapy was analyzed considering whether the patients had received high (myelosuppression ≥7 days) or low (myelosuppression ≤7 days) intensity schemes, or in contrast, immunotherapy. Fisher's Exact Test for count data and Log Rank test for Overall Survival (OS), Relapse Free Survival (RFS) and Duration of Response (DOR). Variables with p&amp;lt;0.05 value have been considered of statistical significance. RESULTS Baseline characteristics of the 103 patients are summarized in Table 1. CRS after infusion was presented in 86 (83.5%) patients. Grade 3-4 was developed in 4/29 (13.8%) with low pre infusion TB in contrast to 18/55 (32.7%) with high TB (p=0.001). Complete remission (CR) was achieved 87 (85.3%) patients. All patients (100%) with a low TB were in CR VS 78.2% in the high TB arm (p=0.015). Otherwise, 91.9% of those patients that received low intensity bridge chemotherapy or immunotherapy were in CR VS 71% of those where high intensity bridge was administered (p=0.027). With a median of 23.75 months, OS at 12 months was 62.23% (CI95% 51.71-74.89). No statistical significance was found between bridge chemotherapy groups, although it was higher in low intensity and immunotherapy group (68.33% CI95% 55.41-84.27) VS (57.89% CI95% 40.43-82.89) (p=0.11). With a median of 9.26 months, RFS at 12 months was 41.7% (CI95% 31.71-54.85). No statistical significance was found between bridge chemotherapy groups, but was higher in low intensity group and immunotherapy (51.8% CI95% 39.45-68.01) VS (34.69% CI95% 18.59-64.74) (p=0.089). With a median of 8.28 months, DOR at 12 months was 41.7% (CI95% 31.71-54.85). No statistical significance was found between bridge chemotherapy groups, with an increasing tendency in low intensity group and immunotherapy (51.8% CI95% 39.45-68.01) VS (34.69% CI95% 18.59-64.74) (p=0.089). In the multivariate analysis, grade 3-4 CRS HR 8.7 (CI95% 0.82-92) (p = 0.072) and high TB HR 4.7 (CI95% 1.1-20) (p = 0.038) were related with a decreased OS. CONCLUSIONS Receiving low intensity bridge or immunotherapy is related with high rates of CR. In the same way, in this group of patients there is tendency to achieve higher OS, RFS and DOR. This is the reason because its use should be prioritized avoiding those of high intensity bridge chemotherapy. High TB is an important risk factor related with a poor response and high grade CRS development, so it is essential to reduce TB previous CAR-T infusion in order to improve outcomes and reduce toxicities.

Oral health-related quality of life, impaired physical health and orofacial pain in children and adolescents with juvenile idiopathic arthritis – a prospective multicenter cohort study

BackgroundKnowledge on oral health-related quality of life (OHRQoL) in children and adolescents with juvenile idiopathic arthritis (JIA) is limited, and longitudinal studies are lacking. We aimed to describe OHRQoL in children and adolescents with JIA compared to controls, and to explore the validity and internal consistency of the Early Childhood Oral Health Impact Scale (ECOHIS) and the Child Oral Impact on Daily Performance (Child-OIDP). Furthermore, we wanted to investigate associations between OHRQoL and orofacial pain, physical health, disease activity, and temporomandibular joint (TMJ) involvement in JIA.MethodsThe Norwegian prospective, multicenter cohort study recruited participants with JIA between 4 and 16 years of age and corresponding controls from three pediatric university hospital departments and public dental health services. In the present study, we analyzed OHRQoL in all children < 12 years with the ECOHIS and adolescents ≥ 12 years with the Child-OIDP at the first visit and the two-year follow-up. Associations between OHRQoL and JIA characteristics, collected in clinical exam and questionnaires, were analyzed in logistic regressions.ResultsThe same OHRQoL questionnaire was completed both at first visit and two-year follow-up in 101 children < 12 years (47 JIA, 54 controls) and 213 adolescents ≥ 12 years (111 JIA, 102 controls). The frequency of OHRQoL impacts in children was similar at the first visit and the two-year follow-up (ECOHIS > 0: JIA group 81% and 85%, p = 0.791; control group 65% and 69%, p = 0.815), while adolescents with JIA reported fewer impacts at the two-year follow-up (Child OIDP > 0: JIA group 27% and 15%, p = 0.004; control group 21% and 14%, p = 0.230). The internal consistency of the OHRQoL instruments was overall acceptable and the criterion validity indicated that the instruments were valid at both visits. Orofacial pain was more frequent in children and adolescents with JIA than in controls. We found associations between OHRQoL impacts and orofacial pain, impaired physical health, disease activity, and TMJ involvement.ConclusionsChildren and adolescents with orofacial pain or impaired physical health were more likely to report impacts on daily life activities than those without. Pediatric rheumatologists and dentists should be aware of impaired OHRQoL in individuals with JIA with active disease or temporomandibular joint involvement.Trial registrationRegistered on clinicaltrials.gov (NCT03904459, 05/04/2019).

Visual-motor involvement in autism spectrum disorder: could the stereopsis deficit affect motor coordination?

PurposeGiven the known difficulty in sensory processing and in motor skills in patients with Autism Spectrum Disorder (ASD), and since visual impairment could interfere with children’s behaviour, early detection and management of visual-motor difficulties are crucial. This exploratory study aims to evaluate the visual-motor status in a cohort of children affected by ASD.MethodsThe records of patients affected by ASD and admitted between 2018 and 2022 to the Pediatric University Hospital of Verona were reviewed. Best Corrected Visual Acuity, cycloplegic refraction, stereopsis, convergence, complete ocular motility, strabismus examination, slit-lamp anterior segment examination and fundus ophthalmoscopy were collected and reviewed.ResultsA total of 253 patients (203 ASD and 50 healthy controls) were included in the study. A higher number of total orthoptic defects were detected in the ASD group, in comparison with the control group. Specifically, a higher percentage of stereopsis deficit and convergence insufficiency was observed.ConclusionIn our cohort of children with ASD stereopsis deficit, convergence insufficiency and refractive errors are the most observed ocular conditions. These findings are consistent with the known alterations of motor skills and sensory processing in ASD. Moreover, our study supports the hypothesis that visual acuity is not compromised in children with ASD. As a result, a complete ophthalmic evaluation is highly recommended in children with ASD, to guarantee early detection and treatment of possible visual-motor defects.

Medication errors related to high-alert medications in a paediatric university hospital – a cross-sectional study analysing error reporting system data

BackgroundPaediatric patients are prone to medication errors, and only a few studies have explored errors in high-alert medications in children. The present study aimed to investigate the prevalence and nature of medication errors involving high-alert medications and whether high-alert medications are more likely associated with severe patient harm and higher error risk classification compared to other drugs.MethodsThis study was a cross-sectional report of self-reported medication errors in a paediatric university hospital in 2018–2020. Medication error reports involving high-alert medications were investigated by descriptive quantitative analysis to identify the prevalence of different drugs, Anatomical Therapeutic Chemical groups, administration routes, and the most severe medication errors. Crosstabulation and Pearson Chi-Square (χ2) tests were used to compare the likelihood of more severe consequences to the patient and higher error risk classification between medication errors involving high-alert medications and other drugs.ResultsAmong the reported errors (n = 2,132), approximately one-third (34.8%, n = 743) involved high-alert medications (n = 872). The most common Anatomical Therapeutic Chemical subgroups were blood substitutes and perfusion solutions (B05; n = 345/872, 40%), antineoplastic agents (L01; n = 139/872, 16%), and analgesics (N02; n = 98/872, 11%). The majority of high-alert medications were administered intravenously (n = 636/872, 73%). Moreover, IV preparations were administered via off-label routes (n = 52/872, 6%), such as oral, inhalation and intranasal routes. Any degree of harm (minor, moderate or severe) to the patient and the highest risk classifications (IV-V) were more likely to be associated with medication errors involving high-alert medications (n = 743) when compared to reports involving other drugs (n = 1,389).ConclusionsPreventive risk management should be targeted on high-alert medications in paediatric hospital settings. In these actions, the use of intravenous drugs, such as parenteral nutrition, concentrated electrolytes, analgesics and antineoplastic agents, and off-label use of medications should be prioritised. Further research on the root causes of medication errors involving high-alert medications and the effectiveness of safeguards is warranted.

Health Care Professionals' Experiences and Views of eHealth in Pediatric Care: Qualitative Interview Study Applying a Theoretical Framework for Implementation.

The development and evaluation of eHealth interventions in clinical care should be accompanied by a thorough assessment of their implementation. The NASSS (Non-adoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies) framework was designed to facilitate the implementation and scale-up of health technology programs, providing an option for analyzing the progression of these initiatives as they are implemented in real-time. Considering health care provider perspectives within the framework for implementation offers valuable insights into the early identification of barriers and facilitators in the implementation of potentially effective eHealth innovations. Nevertheless, there is a dearth of studies on eHealth interventions that encompass longer time frames and delve into the complexities of scaling up and sustaining such interventions within real-world health care environments. This study aims to investigate the perspectives and insights of health care professionals (HCPs) regarding the implementation of an eHealth intervention in pediatric health care while applying the NASSS framework to theorize and evaluate the conditions influencing the implementation of eHealth solutions. Semistructured interviews were performed with health care providers, including both staff and management personnel, within a university pediatric hospital (N=10). The data collection process occurred concurrently with a clinical trial focused on developing and assessing an eHealth app for self-management in pediatric care following hospital discharge. Using an abductive approach, the interviews were initially analyzed qualitatively and subsequently mapped onto the 7 domains of the NASSS framework to identify factors influencing implementation, encompassing facilitators, barriers, and varying levels of complexity. In the realm of pediatric care, the family was identified as the primary unit of care, and patient heterogeneity was a prominent feature. The implementation of eHealth tools, while deemed usable and flexible, was also seen as a delicate balance between safety and adaptability, highlighting challenges related to health care integration. Child participation and secrecy, especially for adolescents, contributed to the complexity of using eHealth. HCPs had high eHealth literacy, and thus challenges concerning adoption were related to work adaptations and the risk of "app overload." The readiness for implementation was experienced as induced through the research study and the pandemic situation. However, to move from research to implementation in clinical practice, organizational challenges identified a need to update the concept of care and ensure activity measurements. In a wider context, HCPs raised concerns related to regulatory requirements for documentation, public procurement, and data safety. Implementation became more complex due to a lack of overview in a large organization. Important perspectives for implementation were considerations of regulatory requirements, as well as the need for a shared vision of eHealth and the establishment of eHealth-related work as part of regular health care. Key contextual factors that support reach and impact are communication channels between different levels at the hospital and a need for paths and procedures compatible with legal, technological, and security concerns. Further research should focus on how eHealth interventions are perceived by children, adolescents, their parents, and other stakeholders. ClinicalTrials.gov NCT04150120; https://clinicaltrials.gov/ct2/show/NCT04150120.

Teamwork and mental workload in postsurgical pediatric patient handovers: Prospective effect evaluation of an improvement intervention for OR-PICU patient transitions

Postsurgical handover of pediatric patients from operating rooms (OR) to pediatric intensive care units (PICU) is a critical step. This transition is susceptible to errors and inefficiencies particularly if poor multidisciplinary teamwork occurs. Despite wide adoption of standardized handover interventions, comprehensive investigations into joint effects for patient care and provider outcomes are scarce. We aimed to improve OR-PICU handovers quality and sought to evaluate the intervention with particular attention to patient care effects and provider outcomes. A prospective, before-after-study design with an interrupted-series and a multi-source, mixed-methods evaluation approach was established. Drawing upon a participative plan-do-study-act approach, a standardized, checklist-based handover process was designed and implemented. For effect assessments, we observed OR-PICU handovers on site (pre implementation: n = 31, post: n = 30), respectively, with standardized expert observation and provider self-report tools (n = 111, n = 110). Setting was a tertiary Pediatric University Hospital. Supplementary qualitative, semi-structured interviews were conducted, and a general inductive content analysis approach was used to identify key facilitators and barriers on implementation. Improvement efforts focused on stepwise implementation of (1) standardized handover process and (2) a checklist for multi-professional OR-PICU handover communication. We observed significant increases in team and patient setup (pre: 79.3%, post: 98.6%, p < .01), enhanced team engagement (pre: 50%, post: 81.7%, p < .01), and comprehensive information transfer by the anesthesia sub-team (pre: 78.6%, post: 87.3%, p < .01). Expert-rated teamwork outcomes were consistently higher, yet self-reported teamwork did not change over time. Provider perceived stress and disruptions did not change, mental workload tended to decrease over time (pre: M = 3.2, post: 2.9, p = .08). Comprehensiveness of post-operative patient information reported by PICU physician increased significantly: pre: 65.9%, post: 76.2%, p < .05. After implementation, providers acknowledged the importance of standardized handover practices and associated benefits for facilitation of information transfer and comprehensiveness. Among reported barriers were obstacles during implementation as well as insufficient consideration of professionals’ individual workflow after surgery.Conclusion: A multidisciplinary intervention for postsurgical pediatric patient handovers was associated with improved expert-rated teamwork and fewer omissions of key patient information over time. Inconsistent results were obtained for provider-rated mental workload and teamwork outcomes. The findings contribute to a better understanding concerning the interplay of teamwork and provider cognitions in the course of establishing safe patient transitions in pediatric care.What is Known:• Transfer of critically ill children conveys significant challenges for interprofessional communication and teamwork. Prospective research into interventions for safe and efficient handover practices of OR PICU patient transitions is necessary.• Checklists are assumed to facilitate cognitive load among providers in acute clinical environments.What is New:• A standardized, checklist-based handover intervention was associated with improvements in team set-up and information transfer. Provider outcomes such as mental workload and stress did not change over time.• The combination of teamwork and provider assessments allows a more nuanced understanding of implementation barriers and sustainable effects in course of OR-PICU handover interventions.

Clinical Management and Therapy of Precocious Puberty in the Sapienza University Pediatrics Hospital of Rome, Italy.

Puberty identifies the transition from childhood to adulthood. Precocious puberty is the onset of signs of pubertal development before age eight in girls and before age nine in boys, it has an incidence of 1/5000-1/10,000 with an F:M ratio ranging from 3:1 to 20:1. Precocious puberty can be divided into central, also known as gonadotropin-dependent precocious puberty or true precocious puberty, and peripheral, also recognized as gonadotropin-independent precocious puberty or precocious pseudopuberty. Thus, the main aim of this narrative report is to describe the standard clinical management and therapy of precocious puberty according to the experience and expertise of pediatricians and pediatric endocrinologists at Policlinico Umberto I, Sapienza University of Rome, Italy. In the suspicion of early sexual maturation, it is important to collect information regarding the age of onset, the speed of maturation of secondary sexual features, exposure to exogenous sex steroids and the presence of neurological symptoms. The objective examination, in addition to the evaluation of secondary sexual characteristics, must also include the evaluation of auxological parameters. Initial laboratory investigations should include serum gonadotropin levels (LH and FSH) and serum levels of the sex steroids. Brain MRI should be performed as indicated by the 2009 Consensus Statement in all boys regardless of chronological age and in all girls with onset of pubertal signs before 6 years of age. The gold standard in the treatment of central precocious puberty is represented by GnRH analogs, whereas, as far as peripheral forms are concerned, the triggering cause must be identified and treated. At the moment there are no reliable data establishing the criteria for discontinuation of GnRH analog therapy. However, numerous pieces of evidence suggest that the therapy should be suspended at the physiological age at which puberty occurs.

'Working outside the box'-an interview study regarding manipulation of medicines with registered nurses and pharmacists at a Swedish paediatric hospital.

Studies on frequencies of manipulated medicines in paediatric care are common, but there is little knowledge of experiences of pharmacists and registered nurses in this area. The aim of this study was to explore registered nurses' and pharmacists' reasoning in the manipulation of medicines to paediatric inpatients. Semistructured interviews with twelve registered nurses and seven pharmacists were performed at a Swedish paediatric university hospital. The interviews were transcribed verbatim and analysed using content analysis. Four major categories emerged from the analysis of the interviews: medicines management, knowledge, consulting others and organisation. Medicines management involved the process of drug handling, which is prescribing, reconstitution or manipulation and administration. Knowledge concerned both the knowledge base and how healthcare personnel seek information. Consulting others involved colleagues, registered nurses and pharmacists, between registered nurses, pharmacists and physicians and between registered nurses, pharmacists and caregivers. Organisation covered documentation, time and working environment. Both pharmacists and registered nurses stated that manipulation of medicines to paediatric patients was often necessary but felt unsafe due to lack of supporting guidelines. Pharmacists were natural members of the ward team, contributing with specific knowledge about medicines and formulations.