Clinical Application and Research Progress of Remimazolam for Pediatric Patients

Remimazolam is a novel ultrashort-acting benzodiazepine that allosterically modulates γ-aminobutyric acid type A (GABAA) receptors to exert sedative effects. Remimazolam has the properties of controllable sedation, rapid onset, and a short duration of action, along with minor depression of circulation and respiration. Remimazolam has been approved for clinical use since 2020 in Japan, and it has been applied for procedural sedation, general anesthesia induction and maintenance, and sedation in ICU patients, and has been proven to be safe and effective. Currently, no consensus has been reached on the clinical application of remimazolam in pediatric patients. This review introduces the clinical research progress and limitations of remimazolam in recent years, aiming to supply scientific guidance and a theoretical reference for the application of remimazolam in pediatric anaesthesia.

A comparative study of genotyping and antimicrobial resistance between carbapenem-resistant Klebsiella pneumoniae and Acinetobacter baumannii isolates at a tertiary pediatric hospital in China

Background

Carbapenem-resistant Klebsiella pneumoniae (CRKP) clinical isolations have rapidly increased in pediatric patients. To investigate a possible health care-associated infections of CRKP in a tertiary pediatric hospital, the circulating clones and carbapenem-resistant pattern between CRKP and carbapenem-resistant Acinetobacter baumannii (CRAB) isolates were compared to classify their epidemiological characteristics. The results will help to identify the epidemic pattern of the CRKP transmission in the hospital.

Methods

Ninety-six CRKP and forty-eight CRAB isolates were collected in Kunming Children's Hospital from 2019 through 2022. These isolates were genotyped using repetitive extragenic palindromic-PCR (REP-PCR). Carbapenemase phenotypic and genetic characterization were investigated using a disk diffusion test and singleplex PCR, respectively. In addition, these characteristics of the two pathogens were compared.

Results

The rates of CRKP and CRAB ranged from 15.8% to 37.0% at the hospital. Forty-nine and sixteen REP genotypes were identified among the 96 and 48 CRKP and CRAB isolates tested, respectively. The CRKP isolates showed more genetic diversity than the CRAB isolates. Of the 96 CRKP isolates, 69 (72%) produced Class B carbapenemases. However, all 48 CRAB isolates produced Class D carbapenemase or extended-spectrum β-lactamases (ESBL) combined with the downregulation of membrane pore proteins. Furthermore, the carbapenemase genes bla KPC, bla IMP, and bla NDM were detected in CRKP isolates. However, CRAB isolates were all positive for the bla VIM, bla OXA-23, and bla OXA-51 genes.

Conclusions

These CRKP isolates exhibited different biological and genetic characteristics with dynamic changes, suggesting widespread communities. Continuous epidemiological surveillance and multicenter research should be carried out to strengthen the prevention and control of infections.

Atypical Presentation of Periosteal Chondroma of the Talus in a 9-Year-Old Boy: A Case Report

Introduction

?Introduction: Periosteal chondromas are rare, slow-growing, benign cartilaginous tumors arising from the cortical surface of the bone, beneath the periosteal membrane. Typically affect young males, the most common site being the proximal humerus. There have been no reported cases of periosteal chondroma of the talus in the literature.

Case Report

A 9-year-old Indian boy presented with a 1.5-year history of atraumatic right ankle pain and swelling, exacerbated by walking, with limited dorsiflexion. Physical examination revealed a firm, painless swelling on the anterior ankle's talar region, accompanied by equinus deformity. Radiography displayed osseous masses on the anterior talus. Magnetic resonance imaging indicated well-defined osseous growths originating from the talus's anterior aspect, likely osteochondromas, with adjacent osseous fragments in the tibiotalar joint, suggestive of loose bodies, supporting a clinical diagnosis of synovial chondromatosis. Surgical excision revealed whitish, hard, irregular tissue, confirmed as periosteal chondroma on histopathology. After 6 months, the patient is pain-free with unrestricted movement and no clinical or radiological signs of recurrence.

Conclusion

This case report presents a unique instance of previously unreported talus periosteal chondroma, adding novelty to medical literature. It details the diagnostic challenges and its intricacies. It provides a comprehensive overview of clinical presentation, imaging and histopathological findings, differentials and provisional diagnosis, surgical approach, and post-operative outcomes. The successful surgical management, along with the specific details of the surgical procedure (anteromedial approach, excision, and curettage), adds practical insights for orthopedic surgeons and contributes to the existing knowledge on treatment strategies for talus periosteal chondroma. This report will serve as an excellent educational resource.

Arteriovenous malformation presenting as complex regional pain syndrome: illustrative case

BACKGROUND

Complex regional pain syndrome (CRPS) is typically described as a peripheral nerve disorder in which exaggerated allodynia and hyperalgesia follow a minor injury. Some researchers propose a central mechanism, although current evidence is lacking.

OBSERVATIONS

A 14-year-old female presented with classic CRPS symptoms of left upper-extremity weakness and hyperalgesia after a bout of sharp pain in her thumb while shoveling snow. A possible seizure prompted magnetic resonance imaging, revealing a right frontal Spetzler-Martin grade II arteriovenous malformation (AVM) adjacent to the primary motor cortex. Brodmann areas 1, 3a, and 3b, which are responsible for localizing and processing burning and painful sensations, were also involved. The patient underwent transarterial Onyx embolization in two sessions and microsurgical resection, after which her CRPS symptoms completely resolved.

LESSONS

To our knowledge, this is the first reported case of a cerebral AVM presenting as CRPS, which supports a central mechanism. The authors propose that rapid growth of the AVM led to a vascular steal phenomenon of surrounding parenchyma, which disrupted the patient's normal motor function and nociceptive processing. Further validation in other series is needed.

Expanded polytetrafluoroethylene conduits with curved and handsewn bileaflet designs for right ventricular outflow tract reconstruction

OBJECTIVE

This study reviewed the application of curved and bileaflet designs to pulmonary expanded polytetrafluoroethylene conduits with diameters of 10 to 16 mm and characterized this conduit on in vitro experiment, including particle image velocimetry.

METHODS

All patients who received this conduit between 2010 and 2022 were evaluated. Three 16-mm conduits were tested in a circulatory simulator at different cardiac outputs (1.5-3.6 L/minute) and bending angles (130°-150°).

RESULTS

Fifty consecutive patients were included. The median operative body weight was 8.4 kg (range, 2.6-12 kg); 10-, 12-, 14-, and 16-mm conduits were used in 1, 4, 6, and 39 patients, respectively. In 34 patients, the conduit was implanted in a heterotopic position. The overall survival rate was 89% at 8 years with 3 nonvalve-related deaths. There were 10 conduit replacements; 5 16-mm conduits (after 8 years) and 1 12-mm conduit (after 6 years) due to conduit stenosis, and the remaining 4 for reasons other than conduit failure. Freedom from conduit replacement was 89% and 82% at 5 and 8 years, respectively. Linear mixed-effects models with echocardiographic data implied that 16-mm conduits were durable with a peak velocity <3.5 m/second and without moderate/severe regurgitation until the patient's weight reached 25 kg. In experiments, peak transvalvular pressure gradients were 11.5 to 25.5 mm Hg, regurgitant fractions were 8.0% to 14.4%, and peak Reynolds shear stress in midsystolic phase was 29 to 318 Pa.

CONCLUSIONS

Our conduits with curved and bileaflet designs have acceptable clinical durability and proven hydrodynamic profiles, which eliminate valve regurgitation and serve as a reliable bridge to subsequent conduit replacement.

Hepatitis A Leading to Severe Vitamin A Deficiency and Bitot's Spots in a Three-Year-Old Male Child: A Case Report

This case presentation details the clinical journey of a three-year-old male child presenting with fever, abdominal distention, and loose stools. The child's symptoms, unresponsive to initial treatment at two hospitals, led to the discovery of elevated liver enzymes and subsequent referral to a tertiary care center. Clinical examination revealed hepatomegaly, abdominal distension, and non-palpable spleen. Laboratory findings confirmed acute hepatitis, prompting further investigation into the child's dietary history and revealing a potential foodborne infection. The child was diagnosed with hepatitis-associated severe vitamin A deficiency, manifested by Bitot's spots on ophthalmic examination. Prompt initiation of antiviral therapy, nutritional supplementation, and supportive care resulted in a positive clinical response, with resolution of symptoms and normalization of liver enzymes. This case underscores the importance of recognizing nutritional deficiencies in the context of infectious diseases, emphasizing the need for a comprehensive approach to patient care. The successful management of this complex case highlights the significance of interdisciplinary collaboration in ensuring optimal outcomes in pediatric patients with overlapping infectious and nutritional etiologies.

A 4-Year-Old Boy with an Accidentally Detected Mutation in the RET Proto-Oncogene and Mutation in the Gene Encoding the Ryanodine Receptor1 (RyR1)-Case Report

Multiple endocrine neoplasia 2B (MEN2B) is a rare syndrome with prevalence estimated at approximately 0.2 per 100,000; it is caused by mutation of the RET proto-oncogene. MEN2B is characterized by early-onset medullary thyroid carcinoma (MTC), ganglioneuromatosis of the aerodigestive tract, marfanoid habitus, ophthalmologic abnormalities, and pheochromocytoma in adulthood. Mutations in the RyR1 gene manifest clinically in congenital myopathies and/or malignant hyperthermia susceptibility. We present a case of a 4-year-old boy with an accidentally detected RET and RyR1 mutations in the course of diagnostic approach of short stature and delayed motor development. Due to a poor and blurred clinical picture of MEN2B syndrome, accompanied by RyR1 mutation symptoms, the diagnostic path was extended. Our patient had no family history of MTC. In the imaging studies of the thyroid gland, no abnormalities were found, whereas the serum level of calcitonin was elevated to 34 pg/mL (N < 5.0). The patient qualified for total thyroidectomy, and the histopathological examination confirmed the diagnosis of MTC. The postoperative serum calcitonin level dropped to normal ranges. This case shows how new genetic diagnostic procedures could be crucial in accidentally diagnosing rare endocrine disease with atypical symptoms, giving an opportunity for relatively early intervention.

Foreign Body in the Nasal Cavity: A Case Report

We present a case of a pediatric patient who presented to the emergency room with acute nasal discharge, foul smell, and nasal pain. The patient's mother witnessed her inserting a foreign body into the nasal passage. After thorough examination and diagnostic imaging, a metallic necklace bead was identified as the foreign body lodged in the nasal cavity. The patient was promptly prepared for emergency operating room intervention. The metallic foreign body was successfully extracted without complications using endoscopic equipment and careful manipulation. The patient recovered well, was admitted for one day for observation and supportive care, and was discharged home in excellent condition. Follow-up in the clinic revealed a satisfied patient with no complaints, no septal perforation, and a patent airway.

Efficacy of Incisional Ropivacaine Infiltration by Presternal Multi-Orifice Catheter for Post-sternotomy Pain Relief in Pediatric Patients Undergoing Cardiac Surgery: A Prospective, Randomized, Controlled Study

OBJECTIVE

To evaluate the efficacy of incisional ropivacaine infiltration by presternal multi-orifice catheter to manage poststernotomy pain in pediatric cardiac surgery.

DESIGN

A prospective, randomized, and double-blind comparative study.

SETTING

At a single-institution tertiary referral cardiac center.

PARTICIPANTS

The study comprised 200 children undergoing cardiac surgeries through a midline sternotomy.

INTERVENTIONS

Children were allocated randomly to 1 of 3 groups. Group A (n = 65) and group B (n = 64) received 0.375% ropivacaine infusion and intermittent bolus, respectively, by presternal multi-orifice catheter, whereas Group C (n = 64) did not receive any local anesthetic (LA) drug. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl was given as rescue analgesia, respectively.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed by a Modified Objective Pain Score (MOPS) for 48 hours postextubation. Group B had significantly lower early MOPS at the first hour, but in the later period, the mean MOPS was lower in group A. The requirement of the first rescue analgesia was 3 ± 1.51, 6.1 ± 2.26, and 2.6 ± 0.87 hours for groups A (n = 60), B (n = 60), and C (n = 60), respectively. The 48-hour fentanyl consumption was significantly lower (p < 0.001) in group A (0.5 ± 0.68 µg/kg) and group B (0.7 ± 0.86 µg/kg) than the control group (3.4 ± 0.68 µg/kg). The length of intensive care unit stay was lower (p < 0.001) in groups A and B than in group C; however, the length of hospital stay was comparable (p = 0.07).

CONCLUSION

LA bolus and infusion through presternal multi-orifice catheter provided effective analgesia postoperatively. However, the bolus was more efficacious in the early phase but equivalent in later periods. Therefore, bolus and LA infusion can be used for steady poststernotomy pain relief in children undergoing cardiac surgeries.

Septic Arthritis Associated With Hip Joint Subluxation and Epiphyseal Plate Deformation as a Sequala of Sickle Cell Anemia

This case report emphasizes the critical nature of septic arthritis in pediatric patients, particularly its predilection for large joints like the hip. It underscores the importance of rapid diagnosis and early intervention to preserve joint function. The case involves a six-year-old patient with sickle cell anemia who presented with persistent hip pain and hip subluxation and underwent hip joint arthrotomy. Clinical findings revealed limited mobility, weakness, and radiographic abnormalities. Comprehensive rehabilitation resulted in significant improvements in pain, mobility, and function. The key takeaway is the pivotal role of early diagnosis and comprehensive rehabilitation in managing septic arthritis in pediatric patients, especially those with underlying conditions like sickle cell anemia.

Clinical factors associated with extended hospitalization in pediatric patients ≥3 years of age with respiratory syncytial virus or human metapneumovirus infection: A Japanese single-center, retrospective study

Respiratory syncytial virus (RSV) and human metapneumovirus (hMPV) infections are common in children worldwide. However, the clinical factors related to extended hospitalization in Japanese patients aged ≥3 years remain elusive. We aimed to elucidate the clinical risk factors contributing to hospital stays ≥7 days in patients with RSV and hMPV infections. Patients ≥3 years of age who were hospitalized due to RSV or hMPV infection between 2014 to 2020 were included. Twenty-one RSV- and 27 hMPV-infected patients were enrolled. Patients were divided into 2 groups: hospitalization for ≥ and <7 days. Univariate and multivariate analyses determined the clinical risk factors contributing to hospital stay ≥7 days. The RSV- and hMPV-infected patients had similar clinical characteristics. The clinical risk factors contributing to extended hospitalization were analyzed in the 48 infected patients of the 2 groups. The presence of prophylactic antibiotics usage, co-bacterial colonization, and underlying diseases were extracted by univariate analysis (P < .05). In multivariate analysis, underlying diseases were determined as an independent clinical risk factor (odds ratio 8.09, P = .005). Underlying diseases contributed to extended hospitalization in RSV- or hMPV-infected patients ≥3 years of age.

A scoring system categorizing risk factors to evaluate the need for ventriculoperitoneal shunt in pediatric patients after brain tumor resection

Objectives

To develop a scoring system based on independent predictors of the need for ventriculoperitoneal (VP) shunt after brain tumor resection in pediatric patients.

Methods

A total of 416 pediatric patients (≤ 14 years old) with brain tumors who underwent surgery were randomly assigned to the training (n = 333) and validation cohorts (n = 83). Based on the implementation of VP shunt, the training cohort was divided into the VP shunt group (n = 35) and the non-VP shunt group (n = 298). Univariate and multivariate logistic analyses were performed. A scoring system was developed based on clinical characteristics and operative data, and scores and corresponding risks were calculated.

Results

Age < 3 (p = 0.010, odds ratio [OR] = 3.162), blood loss (BL) (p = 0.005, OR = 1.300), midline tumor location (p < 0.001, OR = 5.750), preoperative hydrocephalus (p = 0.001, OR = 7.044), and total resection (p = 0.025, OR = 0.284) were identified as independent predictors. The area under the curve (AUC) of the scoring system was higher than those of age < 3, BL, midline tumor location, preoperative hydrocephalus, and total resection (0.859 vs. 0.598, 0.717, 0.725, 0.705, and 0.555, respectively; p < 0.001). Furthermore, the scoring system showed good performance in the validation cohort (AUC = 0.971). The cutoff value for predictive scores was 5.5 points, which categorized patients into low risk (0-5 points) and high risk (6-14 points) groups.

Conclusions

Our scoring system, integrating age < 3, BL, midline tumor location, preoperative hydrocephalus, and total resection, provides a practical evaluation. Scores ranging from 6 to 14 points indicate high risk.

Survival of Hemophagocytic Syndrome Secondary to Fungal and Bacterial Infection in a Pediatric Patient with HIV: A Case Report

HIV-associated hemophagocytic lymphohistiocytosis (HLH) is mainly due to infections caused by viruses, fungi, and, to a lesser extent, bacteria, often with fatal results. Case presentation: A 15-year-old pediatric patient from another institution was admitted to our hospital with a fever of unknown origin (FUO). Clinical analysis and laboratory studies diagnosed HIV infection. The approach to an FUO in a patient with AIDS is much more complex due to the search for common etiologies and opportunistic infections. In this case, disseminated histoplasmosis, pulmonary tuberculosis, pneumocystosis, and ehrlichiosis were diagnosed, prompting an urgent and comprehensive approach to prevent mortality. Due to the multiple infections, HLH was triggered. An early intervention with trimethoprim (TMP)-sulfamethoxazole (SMX), liposomal amphotericin B, doxycycline, and quadruple antiphimic therapy to suppress infections, in conjunction with the early administration of HLH treatment, favored the survival of this patient.

Ketamine Clinical Use on the Pediatric Critically Ill Infant: A Global Bibliometric and Critical Review of Literature

The developing central nervous system is vulnerable to several stimuli, especially psychotropic drugs. Sedation procedures during the developmental period are frequent in pediatric intensive care units (PICUs), in which the use of the sedative agent is still a challenge for the PICU team. Ketamine has been indicated for sedation in critically ill children with hemodynamic and ventilatory instabilities, but the possible neurobehavioral consequences related to this use are still uncertain. Here, we performed a bibliometric analysis with conventional metrics and a critical review of clinical findings to reveal a gap in the literature that deserves further investigation. We revealed that only 56 articles corresponded to the inclusion criteria of the study. The United States of America emerges as the main country within the scope of this review. In addition, professional clinical societies play a key role in the publications of scientific clinical findings through the specialist journals, which encourages the sharing of research work. The co-occurrence of keywords evidenced that the terms "sedation", "ketamine", and "pediatric" were the most frequent. Case series and review articles were the most prevalent study design. In the critical evaluation, the scarce studies highlight the need of use and post-use monitoring, which reinforces the importance of additional robust clinical studies to characterize the possible adverse effects resulting from ketamine anesthetic protocol in critically ill children.

Small patients, big challenges: navigating pediatric drug manipulations to prevent medication errors - a comprehensive review

INTRODUCTION

Medication errors during drug manipulations in pediatric care pose significant challenges to patient safety and optimal medication management. Epidemiological studies have revealed a high prevalenceof medication errors throughout the medication process. Due to the lack of age-appropriate dosage forms, medication manipulation is common in pediatric drug administration. The consequences of these manipulations on drug efficacy and safety could be devastating, highlighting the need for evidence-based guidelines and standardized compounding practices.

AREAS COVERED

This review focuses on examining medication errors in pediatric care and delving into the manipulation of medicinal products.

EXPERT OPINION

The observed prevalence of medication errors and manipulations underscores the importance of addressing these issues to enhance patient safety and improve medication outcomes in pediatric care. Overall, the development of age-appropriate formulations and the dissemination of comprehensive clinical guidelines are essential steps toward improving medication safety and minimizing manipulations in pediatric healthcare settings.

Subglottotracheal Adenoid Cystic Carcinoma in a 16-Year-Old Female-A Case Report

Cystic adenoid carcinoma (ACC) is a rare malignant epithelial tumor arising from exocrine glands and accounts for only 1% of head and neck cancers. ACCs are common in the fifth and sixth decades of life, predominantly in women, and characterized by slow progression, local aggression, recurrence, and high metastasis. Subglottotracheal ACC is a rare tumor in the pediatric population, with only a few cases reported in the literature. We present a case of a 16-year-old female who was diagnosed with ACC in the subglottic and tracheal region. The patient presented with respiratory failure but without a history of dysphonia, dyspnea, stridor, or dysphagia. The diagnosis was confirmed by a biopsy, and subsequent imaging studies showed a large tumor involving the subglottic and tracheal region. The therapeutic management of this patient has been challenging due to the rarity of this tumor in the pediatric population and the potential long-term complications associated with tumor recurrence and psychological impact. This case highlights the diagnostic and therapeutic challenges in the management of subglottotracheal ACC in children and the importance of a multidisciplinary approach to optimize patient outcomes.

First Case of VIM-1-like-Producing Pseudomonas putida Bacteremia in an Oncohematological Pediatric Patient in Italy

Bacterial infections caused by multidrug-resistant (MDR) Gram-negatives are of great concern worldwide, as they are frequently associated with high mortality and morbidity rates. To date, two cases of VIM-2 metallo-β-lactamase (MBL)-producing Pseudomonas putida bacteremia have been ever reported in France and Spain between 2004 and 2010. Here, we present the first case of VIM-1-like-producing P. putida isolated in blood culture collected from an oncohematological pediatric patient admitted to Bambino Gesù Children's Hospital (IRCCS) in Rome, Italy.

The Ropivacaine Concentration Required for Ultrasound-Guided Rectus Sheath Block in Pediatric Patients Undergoing Single-Incision Laparoscopic Hernia Repair: A Sequential Allocation Dose-Finding Study

BACKGROUND

The local anesthetic concentration required for ultrasound-guided rectus sheath block (RSB) in children remains unknown. Knowledge of appropriate ropivacaine concentration can help clinicians reduce local anesthetic toxicity risk when performing ultrasound-guided RSB in children. This study aimed to determine the appropriate ropivacaine concentration for ultrasound-guided RSB in children undergoing laparoscopic inguinal hernia repair.

METHODS

In this single-arm prospective study with an up-down sequential allocation design of binary response variables, 18 consecutive children aged 11 months to 7 years undergoing single-incision laparoscopic percutaneous extraperitoneal closure were assessed. Orotracheal intubation was performed without intravenous anesthesia or a neuromuscular relaxant. After intubation, ultrasound-guided RSB was performed with a ropivacaine dose of 0.30 ml/kg (0.15 ml/kg per side). Dixon's up-and-down method was used to determine the concentration, starting from 0.25% in 0.05% increments. Surgery commenced ≥15 min following RSB. Body movement or a 20% increase in heart rate or systolic blood pressure within 1 min of surgery initiation determined an unsuccessful RSB. The 95% effective concentration of ropivacaine needed for successful RSB was calculated using the probit test.

RESULTS

The 95% effective concentration of ropivacaine needed for successful ultrasound-guided RSB was 0.31% (95% confidence interval, 0.25-7.29). The highest concentration of ropivacaine required for successful ultrasound-guided RSB in the group of patients in this study was 0.3%.

CONCLUSION

The 95% effective concentration of ropivacaine (0.30 ml/kg total, 0.15 ml/kg per side) for ultrasound-guided RSB was 0.31% in children undergoing single-incision laparoscopic surgery under general anesthesia.

Antibiotic prescribing practices for prophylaxis and therapy of oral/dental infections in pediatric patients - results of a cross-sectional study in Turkey

Aim

Antibiotics are often prescribed for the treatment of various infections and prophylactic purposes in dental practice. Their improper use can cause microbial resistance to antibiotics, which poses a world-wide threat. The aim of this cross-sectional study was to evaluate the knowledge and attitudes of dentists and dentistry students about antibiotic prescription practices for prophylaxis and the treatment of dental infections in pediatric patients.

Methods

A questionnaire was e-mailed to 2,100 dentists and 300 senior dentistry students. The questionnaire was filled out by the participants within a 2-month period (May-June 2020). A 30-point scoring system was developed to assess the knowledge levels of the dentists according to the guidelines. Descriptive statistical analyses were performed. One-way ANOVA test and the Chi-Squared test were used to compare qualitative variables.

Results

The response rate was found to be 24.2% for dentists and 49% for senior dentistry students. 19.4% of the participants were found to be moderately knowledgeable and 80.6% of them were highly knowledgeable. Students' knowledge scores were found to be higher than the general dentists and other specialists (p<0.05). There was no significant difference between students and pedodontists.

Conclusion

Dentists were found to have sufficient knowledge about the usage of antibiotics in children, but there is still a lack of information about circumstances under which antibiotics should not be prescribed. Dentists and dentistry students should attend continuing education programs to keep their information up-to-date and should also prescribe antibiotics in adherence with the current guidelines to prevent antibiotic resistance.

Acute Upper Respiratory Infection in a Pediatric Patient During the COVID-19 Pandemic: A Case Report

Upper respiratory infections (URIs) are a frequent presentation of the COVID-19 pandemic, which has had a major detrimental impact on the pediatric population. In this case report, we detail the pandemic-related treatment of a five-year-old patient who had an acute upper respiratory illness. The case report begins with an overview of the COVID-19 pandemic, then discusses the difficulties in identifying and treating pediatric patients with respiratory illnesses in the current setting. In this report, we describe the case of a five-year-old child who originally displayed signs and symptoms of a viral URI that, with further investigation, proved unrelated to COVID-19. Treatment for the patient included symptom control, monitoring, and ultimately recovery. This study stresses the necessity for adequate diagnostic testing, individualized treatment plans, and ongoing surveillance for respiratory infections in pediatric patients during the COVID-19 pandemic.

Views on Short Stature of Female Versus Male Endocrine Pediatric Patients Undergoing Provocative Growth Hormone Testing and Their Parents

OBJECTIVE

Boys outnumber girls in short stature evaluations and growth hormone treatment despite absence of gender differences in short stature prevalence. Family views on short stature influence medical management, but gender-based analysis of these views is lacking. This study explored endocrine patients' and their parents' perceptions of short stature and its impact on quality of life by patient gender.

METHODS

Patients aged 8-14 years undergoing provocative growth hormone testing and one parent each completed semi-structured interviews. Clinical data were extracted by chart review.

RESULTS

24 patient-parent dyads (6 female patients, 22 mothers; predominantly non-Hispanic White) participated. Six major themes emerged: 1) patients' perceptions of their short stature were similar by gender, 2) physical experiences of short stature were similar by gender, 3) social experiences of short stature were both similar and different by gender, 4) parental perceptions of short stature as a factor limiting their child's functionality were similar by gender, 5) concern about societal stigma related to short stature arose for both genders, and 6) patients' perceptions of parental messaging about the import of their short stature were similar by gender.

CONCLUSION

Our data reveal more similarities than differences between genders in patient perceptions and patient and parent-reported experiences of short stature. Worry about stature-related stigma was noted for patients of both genders. Parental messaging about short stature emerged as an important area to explore further by patient gender. Our findings suggest that clinicians should be wary of making gender or stigma-based assumptions when evaluating children with short stature.

Clinical and Cytokine Profile of Children With COVID-19: A Report From Turkey

Background

We aimed to analyze the expression of infection-related biomarkers and inflammatory cytokines in laboratory-confirmed cases and compare the differences between clinically severe and non-severe ones.

Method

We randomly selected 35 patients who were hospitalized with the diagnosis of coronavirus disease 2019 (COVID-19). Blood serum was obtained at the time of admission to the hospital, on the third to the fifth day, and at the time of discharge.

Result

The median age of our patients was 56.5±69.7 months (range: 1-205 months). The mean pro-B-type natriuretic peptide (pro-BNP) was significantly higher at the time of admission than on the third to the fifth day of illness. The mean pro-B-type natriuretic peptide levels at three time points were significantly higher in patients with severe cases than in mild-moderate cases. However, there was no significant difference between the clinical severity with regard to the cytokine levels at disease onset and recovery.

Conclusion

In the study, it was shown that cytokines play an important role in the pathogenesis of COVID-19. Therefore, it may be beneficial to use agents such as tocilizumab in the treatment.

A Parotid Gland Mammary Analogue Secretory Carcinoma in a 4-Year-Old Boy: Case Report and Literature Review

Background: Mammary analogue secretory carcinoma (MASC) is characterized by similar histologic, immunohistochemical, and molecular features with breast secretory carcinoma. MASC usually occurs in adults. Case report: A 4-year-old boy presented with a right infra-auricular mass. Features of the tumor include solid, tubular, and papillary growth patterns, with homogenous eosinophilic secretions inside microcystic structures. Immunohistochemical stains showed strong, diffuse staining for CK7, S100, pan-TRK protein. P63 was positive in a peripheral pattern. Fluorescence in situ hybridization (FISH) analysis showed the characteristic ETV6-NTRK3 gene fusion. Conclusion: Typical histological, immunohistochemical, and molecular features are present in MASC occurring early in childhood.

Classification of Bone Bruises in Pediatric Patients With Anterior Cruciate Ligament Injuries

Background

Bone bruises are frequently found on magnetic resonance imaging (MRI) after an anterior cruciate ligament (ACL) tear in pediatric patients.

Purpose

To establish a classification system for different bone bruise patterns to estimate the severity of a knee injury in pediatric patients with ACL tears.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A medical database was retrospectively reviewed to identify all cases of primary ACL tears in patients who were aged ≤17 years at the time of the injury and underwent MRI at our institution within 4 weeks of the injury between January 2011 and December 2020. A total of 188 patients were identified (67 male, 121 female; mean age, 15.1 ± 1.4 years). Bone bruises were classified according to their depth and location on MRI in the sagittal and coronal planes.

Results

The new classification system identified 3 grades of depth: grade I, the bone bruise was located within the epiphysis but did not reach the epiphyseal plate (n = 54 [35.3%]); grade II, the bone bruise was within the epiphysis that reached the epiphyseal plate (n = 55 [35.9%]); and grade III, the bone bruise was in both the epiphysis and metaphysis (n = 44 [28.8%]). The bone bruise location was classified into 4 types: type a, the deepest bone bruise area was in the lateral tibial plateau (n = 66 [43.1%]); type b, the deepest bone bruise area was in the lateral femoral condyle, commonly occurring in the lateral one-third to two-thirds of the lateral femoral condyle (n = 22 [14.4%]); type c, the bone bruise area had a similar depth in both the lateral femoral condyle and lateral tibial plateau (n = 54 [35.3%]); and type d, the bone bruise area was in the lateral tibial plateau and lateral femoral condyle and extended to the fibular head (n = 11 [7.2%]). The prevalence of collateral ligament injuries increased from grade I to III. All patients with grade III type c bone bruises had meniscal lesions.

Conclusion

This new classification system provides a basis for estimating associated lesions of the knee before surgery.

Systematic review and metanalysis

Background

Osteocalcin plays a role in glucose metabolism in mice, but its relevance in human energetic metabolism is controversial. Its relationship with markers of energetic metabolism in the pediatric population has not been systematically addressed in infants and adolescents.

Objective

This study aims to assess the mean differences between tOC, ucOC, and cOC among healthy children and children with type 1 or type 2 diabetes (T1D or T2D) and the correlation of these bone molecules with metabolic markers.

Methods

A systematic review and metanalysis were performed following PRISMA criteria to identify relevant observational studies published in English and Spanish using PubMed, Scopus, EBSCO, and Web of Science databases. The risk of bias was assessed using New Castle-Ottawa scale. Effect size measures comprised standardized mean difference (SMD) and Pearson correlations. Heterogeneity and meta-regressions were performed.

Results

The 20 studies included were of high quality and comprised 3,000 pediatric patients who underwent tOC, cOC, or ucOC measurements. Among healthy subjects, there was a positive correlation of ucOC with WC and weight, a positive correlation of tOC with FPG, HDL-c, WC, height, and weight, and a negative correlation between tOC and HbA1c. Among diabetic subjects, a negative correlation of ucOC with HbA1c and glycemia in both T1D and T2D was found and a negative correlation between tOC and HbA1c in T1D but not in T2D. The ucOC concentrations were lower in T2D, T1D, and patients with abnormal glucose status than among controls. The serum concentrations of tOC concentrations were lower among T1D than in controls. The patient's age, altitude, and HbA1c influenced the levels of serum tOC.

Conclusion

Osteocalcin is involved in energy metabolism in pediatric subjects because it is consistently related to metabolic and anthropometric parameters.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42019138283.

A cross-sectional study evaluating health-related quality of life of Chinese pediatric patients with hematological malignancies using EQ-5D-Y

Background

The study aimed to assess health-related quality of life (HRQoL) and to estimate the health utility of pediatric patients with hematological malignancies (HMs) in China.

Method

A cross-sectional study recruited a series of pediatric inpatients diagnosed with HM from November 2018 to May 2019 in the Shanghai Children's Medical Center. Subjects were interviewed to collect sociodemographic information about themselves and their guardians. The EQ-5D-Y was completed by each patient to rate their own HRQoL, which later derived the health utility. The health status was also assessed by clinicians following the Eastern Cooperative Oncology Group (ECOG) system. Upon the descriptive analysis and univariate analysis, multivariate generalized linear models were built to explore the associations of risk factors with HRQoL measures of utility, Visual Analog Scale (VAS) score, and the five EQ-5D-Y domains.

Results

The 96 subjects had a mean age of 10.5 years and included 62 (64.4%) boys. There were 46 (47.9%) and 25 (26.0%) children diagnosed with acute lymphoblastic leukemia and non-Hodgkin's lymphoma, respectively. The means (SD) of utility and EQ-VAS scores were 0.88 (0.10) and 85.8 (15.1), respectively. Twenty-six (27.1%) patients were graded poor health by the ECOG standard (score 2/3). Both univariate and multivariate analyses found strong correlations between ECOG and HRQoL. After adjusting for covariates, poor ECOG score was significantly associated with an impaired utility and VAS of -0.103 and -8.65, respectively. With regard to individual HRQoL domains, worse ECOG was more likely to report health problems with an increased risk of 2.94 to 12.50; residence, income, guardians' education, and disease duration were also found to be significantly related to either the utility or certain health domains.

Conclusion

The HRQoL of Chinese pediatric patients with HM is considered relatively poor and of great concern to healthcare. With the strong correlations between EQ-5D-Y-related HRQoL measures and the traditional clinical index ECOG, the EQ-5D-Y is able to provide valuable evidence for clinical decision-making at the individual level. At the same time, its health utility can inform resource allocation at a macro level.

The Importance of Immunological Disorders in the Pathogenesis of Lichen Sclerosus in Pediatric Patients: A Systematic Review

Lichen sclerosus (LS) is defined as a chronic mucocutaneous inflammatory disease with a localization predominantly to the anus and genitals (vulvar sclerosus (VLS)). Pediatric lichen sclerosus (LS) is a chronic inflammatory skin condition with predilection for the anogenital area that if untreated can lead to scarring. Vulvar LS is characterized by two peaks in incidence: it occurs in prepubertal girls and in postmenopausal women. To date, several mechanisms and risk factors have been proposed in the pathogenesis of pediatric vulvar LS; however, the etiology of this condition is still not fully understood and constitutes a challenge for scientists and clinicians. The presented research aimed to systematically review the existing literature on the pathogenesis of pediatric LS and to identify possible underlying autoimmune mechanisms and molecular networks. The clinical presentation of pediatric lichen sclerosus and available treatment modalities are also presented to acquaint a broader audience with this underdiagnosed and undertreated condition. As a result of our review, we discuss several potential mechanisms, molecules, and pathways that have been recognized in this disease. The purpose of our review was also to summarize what we can induce in further studies, which will ultimately help to identify the mechanism responsible for the disease and aid in the development of new, more effective treatment strategies for diagnosis and treatment by clinicians and researchers.

Effect of comprehensive nursing intervention in children with respiratory failure

OBJECTIVE

To investigate the effect of comprehensive nursing intervention in the management of pediatric patients with respiratory failure.

METHODS

A total of 60 pediatric patients were selected as research subjects, and the clinical data were collected and retrospectively investigated. The patients were divided either into a control group (n=30) or an observation group (n=30) according to the nursing care methods. Pediatric patients from the observation group underwent comprehensive nursing intervention, while those in the control group received conventional nursing care intervention. The clinical effects, negative emotions, SF-36 scores, hospital stays, clinical symptom indicators, blood gas indices, lung function indicators and the nursing satisfaction rates were compared between the two groups.

RESULTS

The clinical effect in the observation group was significantly better than that in the control group. Compared with those in the control group, significantly lower scores of the Self-Rating Anxiety Scale and the Self-Rating Depression Scale were observed in the observation group. The indicators associated with blood gas and lung function in the observation group were significantly improved in contrast to those in the control group. Moreover, the disappearance time of pulmonary rales, disappearance time of cyanochroia, alleviation time of dyspnea and hospital stays in the observation group were significantly shorter than those in the control group, while the SF-36 scores and the nursing satisfaction rate in the observation group were significantly higher than those in the control group (all P<0.05).

CONCLUSION

Comprehensive nursing intervention significantly improved clinical treatment effects and patient satisfaction, alleviated the clinical symptoms, increased life quality and shortened hospital stay. So, it is worth being promoted in clinical practice.

Ultrasound-guided totally implantable venous access ports placement via right brachiocephalic vein in pediatric population: A clinical debut

BACKGROUND AND OBJECTIVES

To investigate the feasibility and safety of ultrasound-guided totally implantable venous access ports (TIVAPs) via the right brachiocephalic vein (BCV) in pediatric patients.

METHODS

A single-institute retrospective review was performed on 35 pediatric patients with predominantly hematological malignancies (88.6%) who underwent TIVAP implantation via ultrasound-guided right BCV approach from July 2018 to June 2021. The catheter tip was adjusted to be positioned at the cavoatrial junction under pulsed fluoroscopic guidance. Technical success rate, procedural information, and TIVAP-related complications were evaluated.

RESULTS

All the pediatric TIVAP devices were successfully implanted via right BCV access. Venous access was successful by first attempt in 32 children (91%), two cases (5.7%) required a second attempt, and one patient (2.9%) required a third attempt. The mean procedural time was 44.6 ± 6.4 minutes (range: 34-62 minutes). No intraoperative complications occurred. The average TIVAP indwelling time was 564 ± 208 days (range: 193-1014 days), with a cumulative 19,723 catheter-days. Overall, three patients (8.6%) experienced four postoperative complications (two cases of local hematoma and two catheter dysfunctions) at a rate of 0.2 per 1000 catheter-days. No other complications such as wound dehiscence, delayed incision healing, catheter-related thrombosis (CRT), catheter malposition/fracture, surgical site infection, catheter-related bloodstream infection (CRBSI), pinch-off syndrome, and drug extravasation were observed during follow-up.

CONCLUSIONS

Ultrasound-guided right BCV access for TIVAP placement in pediatric patients appears to be technically feasible, safe, and effective. Further large-sample, prospective studies are warranted.

Successful laparoscopy-assisted en bloc resection of bulky omental malignant lymphoma involving the ascending colon and multiple lymph node metastases: Report of a technically demanding case in a pediatric patient

We herein report a 13-year-old boy with a chief complaint of abdominal pain and a palpable mass. Contrast-enhanced computed tomography (CT) scan showed an abdominal bulky tumor involving the ascending colon causing severe stenosis, with multiple abdominal lymph node metastases detected by positron emission tomography (PET)-CT. Laparoscopic radical resection with right hemicolectomy and lymph node dissection was planned. The bulky tumor was dissected from the retroperitoneum and resected en bloc with the right-side colon and omentum. The preoperatively detected metastatic lymph nodes were resected along with the tumor. A 6-cm longitudinal umbilical incision was made, and the huge tumor was removed, with functional end-to-end anastomosis performed for intestinal reconstruction. The pathological diagnosis was Burkitt-like lymphoma with 11q aberration. The postoperative course was uneventful. Laparoscopy-assisted extirpation is feasible for pediatric solid tumors involving other organs, but indications and procedures should be carefully determined based on preoperative imaging, intraoperative findings and surgeon's skills.

Airway Management in Pediatric Patients: Cuff-Solved Problem?

Traditionally, uncuffed tubes were used in pediatric patients under 8 years in pursuit of reducing the risk of postextubation stridor. Although computed tomography and magnetic resonance imaging studies confirmed that the subglottic area remains the narrowest part of pediatric airway, the use of uncuffed tubes failed to reduce the risk of subglottic swelling. Properly used cuffed tubes (correct size and correct cuff management) are currently recommended as the first option in emergency, anesthesiology and intensive care in all pediatric patients. Clinical practice particularly in the intensive care area remains variable. This review aims to analyze the current recommendation for airway management in children in emergency, anesthesiology and intensive care settings.

Continuous Peripheral Block as a Pain Treatment for Redressment and Physical Therapy in a 7-Year-Old Child - A Case Report

Continuous peripheral nerve block, also known as "local anesthetic perineural infusion," refers to percutaneous placement of a catheter near a peripheral nerve or plexus followed by administration of a local anesthetic through a catheter to provide anesthesia, or analgesia for several days, in some cases even for a month. This report describes the case of a 7 year old boy with left elbow contracture with limited flexion and extension who was admitted to the Clinic of Pediatric Surgery for redressment of the elbow and physical therapy. An ultrasound-guided axillary brachial plexus block was performed, with placement of a non-tunneled perineural catheter. Redressment of the left elbow was performed twice and before each redressment boluses of local anesthetic were applied through the perineural catheter. Physical therapy was performed painlessly with continuous perineural infusion. On the 5th day of catheter placement, the perineural catheter was removed without any prior complications such as hematoma, infection, catheter dislocation or leakage of local anesthetic. Our goal is to minimize the psychological and physical trauma to the patient, no matter how immature the patient is. Continuous regional anesthesia in children is a safe technique in postoperative pain management that facilitates early mobilization due to its sufficient analgesia and better comfort. It can provide in-home treatment, with adequate education for patients and parents, and improve rehabilitation in children.

Radiologic placement of Hickman catheters using intravenous sedation in pediatric patients under 20 kg

Surgeons generally perform Hickman catheter insertion in children under general anesthesia. At times, it is difficult to perform procedures with an anesthesiologist for an interventional radiologist. Several diagnostic and therapeutic procedures are efficiently and safely conducted using intravenous (IV) sedation in children with a pediatrician. This study aims to evaluate the efficacy and safety of radiologically placed Hickman catheters using IV sedation in children under 20 kg.Fifty-nine catheters were inserted in 45 children under IV sedation. With continuous monitoring of vital signs, IV midazolam and ketamine were slowly infused by a pediatrician. Mean age and body weights were 3.2 years and 15.2 kg, respectively. Acute leukemia was the most common disease for the procedure (72.9%). The location of the catheter tip was evaluated by measuring the height of the thoracic vertebra.Technical success rate was 100%, and IV sedation-related complications did not occur. The right internal jugular vein was accessed for 51 catheters (86.4%), and the mean procedure time was 21.5 minutes. The 2 vertebral body units below the carina were the cavoatrial junction on a fluoroscopy image. Mean catheter life was 285 days, and catheters were removed post-treatment (35.6%). During follow-up, complications occurred in 29 cases (1.72 per 1000 catheter-days). Catheter-related infections were suspected in 4 patients (6.8%), with 1 positive result.Radiological Hickman catheter placement in children under 20 kg using IV sedation by pediatricians is effective and safe, with minimal complications. The carina is a landmark to estimate the cavoatrial junction in pediatric patients.

A rare occurrence of nonsyndromic focal microdontia of primary teeth with hypodontia of permanent teeth in a pediatric patient

Dental anomalies in human dentition consist of a considerable variation in size, number, position, shape and structure of the tooth. Microdontia is defined as a condition in which teeth are abnormally smaller in size. Hypodontia is defined as developmental absence of 1–5 teeth excluding third molars. Simultaneous occurrence of multiple dental anomalies is most commonly seen in patients with some abnormality or syndrome; it can also occur in nonsyndromic patients. This case report describes about an unusual simultaneous occurrence of dental anomalies such as localized microdontia of primary teeth and hypodontia in a nonsyndromic 10-year-old male patient. Simultaneous occurrence of multiple dental anomalies in a nonsyndromic patient is rare. As the treatment of such cases involves multiple phases, identification and proper timely management is important to help the patient lead a better quality life.

A Diagnostic Algorithm to Guide Operative Intervention of Zone 5 Flexor Injuries

Background: Given the importance of the neurovascular structures in the volar forearm, accurate diagnosis of zone 5 flexor injuries is critical. Purpose: We sought to test the hypothesis that tendinous injury would be more likely in the distal 50% of the forearm and muscle belly injury would be more likely in the proximal 50% of the forearm. Methods: From December 2015 to December 2016, we conducted a prospective clinical study of patients 18 years and older with zone 5 flexor lacerations. We excluded those with concomitant ipsilateral injuries in flexor zones 1 to 4, multiple lacerations in flexor zone 5, prior neurovascular injuries, crush injuries, patients who underwent operative exploration prior to transfer to our facility, and patients who were unable or unwilling to provide consent. Neurovascular and musculotendinous injuries on physical examination were recorded. All patients underwent operative exploration. Physical examination accuracy and the incidence of musculotendinous and neurovascular injury in the distal 50% of the forearm were compared with the proximal 50% of the forearm. Results: The distal 50% of the forearm (group 1, n = 14) had higher probability of tendon injury (64%), whereas lacerations of the proximal 50% of the forearm (group 2, n = 5) did not result in any tendinous injuries. Rather, all patients in group 2 had muscle belly injuries. There was no difference in the rate of neurovascular injury between groups. Physical examination alone was highly accurate in diagnosing nerve injuries (93%-100%) but less accurate in diagnosing arterial injuries (79%-80%) regardless of the location of injury. Conclusions: Due to the lack of tendinous injuries in proximal zone 5 lacerations, along with the accuracy of physical examination in determining the presence of neurovascular injuries, patients with lacerations in the proximal half of the forearm, without evidence of nerve or arterial injury, can likely be observed in lieu of immediate operative exploration.

Steroid-resistant peripheral neuropathy in a child: a rare finding in immunoglobulin a vasculitis

BACKGROUND

Immunoglobulin A vasculitis (IgAV; Henoch-Schönlein purpura) is the most common vasculitis of childhood, affecting the small vessels with systemic involvement, especially the skin, joints, gastrointestinal system and kidneys. Peripheral neuropathy is very rare. Herein, we present a patient who was diagnosed as IgAV and developed refractory peripheral neuropathy in the course of disease.

CASE

An 11-year-old boy was admitted to our clinic with pain and swelling in both ankles and symmetric palpable purpura extending from the knees to the dorsum of his feet. IgAV diagnosis was established and outpatient follow-up was started. On the 18th day of follow-up, he was admitted with widespread palpable purpura, myalgia and edema in the lower extremity, abdominal pain and left scrotal swelling. Intravenous prednisolone 2 mg/kg/day was started, all his symptoms improved and edema was resolved, but on the third day of the prednisolone therapy, the patient suffered from numbness in the left foot. Electromyoneurography showed moderate to severe axonal degeneration of the left tibial nerve. The symptoms of patient didn`t improve with bolus methylprednisolone and intravenous immunoglobulin therapy. All of the patient`s neurological complaints and signs regressed significantly within one week after bolus cyclophosphamide therapy. His oral prednisolone was gradually tapered and stopped at the end of the third month. After a follow-up period of six months, the patient had no complaints.

CONCLUSION

Peripheral neuropathy is a rare complication of IgAV and occasionally it could be severe. Cyclophosphamide therapy should be kept in mind in patients with refractory neuropathy due to IgAV.

Clinical Profile and Risk Factors for Cardiac Death in Pediatric Patients With Primary Dilated Cardiomyopathy at a Tertiary Medical Center in China

AIM

We sought to identify the clinical characteristics and risk factors for cardiac mortality in pediatric patients with primary dilated cardiomyopathy (DCM) in China.

METHODS

A total of 138 pediatric patients who were consecutively diagnosed with primary DCM from January 2011 to December 2020 were included. We assessed patients' clinical symptoms and performed laboratory examinations, electrocardiography, and echocardiography.

RESULTS

Of these patients, 79 (57%) had severe systolic dysfunction (left ventricular ejection fraction of < 30%), 79 (57.2%) developed DCM before 12 months of age, 62 (45%) were male, 121 (87.7%) presented with advanced heart failure (cardiac functional class III/IV), and 54 (39.1%) presented with arrhythmia. At a median follow-up of 12 months, the overall cardiac mortality rate was 33%, and 40 of 46 deaths occurred within 6 months following DCM diagnosis. A multivariate Cox regression analysis identified several independent cardiac death predictors, including an age of 12 months to 5 years [hazard ratio (HR) 2.799; 95% confidence interval (CI) 1.160-6.758; P = 0.022] or 10-15 years (HR 3.617; 95% CI 1.336-9.788; P = 0.011) at diagnosis, an elevated serum alanine aminotransferase (ALT) concentration (≥ 51.5 U/L) (HR 2.219; 95% CI 1.06-4.574; P = 0.031), and use of mechanical ventilation (HR 4.223; 95% CI 1.763-10.114; P = 0.001).

CONCLUSION

The mortality rate of primary DCM without transplantation is high. Age, an elevated serum ALT concentration, and the need for mechanical ventilation predict mortality in patients with primary DCM, providing new insights into DCM risk stratification.

Evaluation of thymic dimensions in patients with multisystem inflammatory syndrome

BACKGROUND

Multisystem inflammatory syndrome (MIS-C) is the most important complication of COVID-19 in the pediatric population. Unfortunately, this problem is an unpredictable situation in patients with COVID-19. We aimed to evaluate the effects of MIS-C on thymus dimensions in pediatric patients.

METHODS

We retrospectively analyzed the files of 368 pediatric patients aged 2-18 years, who were diagnosed with COVID-19. Computer Tomography (CT) images of 22 patients diagnosed with COVID-19 and 10 patients diagnosed with MIS-C were evaluated in detail by two board-certified radiologists. Eighteen age and sexmatched patients who applied to the emergency department of our hospital for any reason and had a CT scan for any reason were selected as the control group. The data of both groups were statistically compared.

RESULTS

Considering the differences between the groups in terms of laboratory data, monocytes, hemoglobin, and platelet were significantly lower in the MIS-C group than the other groups. Procalcitonin, C- reactive protein, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and proBNP levels were statistically significantly higher in the MIS-C group compared to the other groups Regarding the differences in thymus dimensions, thymus AP diameter, transverse diameter, length, thickness, and volume were significantly higher in the MIS-C group than in the other groups There was a significant positive correlation between the transverse diameter of the thymus and CRP, procalcitonin, pro-brain natriuretic peptide (proBNP), and NLR levels.

CONCLUSIONS

Our study shows that thymus dimensions and acute phase reactants are higher in pediatric patients in the MIS-C group. Also, thymus transverse diameter, thymus thickness, and PLR values pose a risk for the development of MIS-C. More research is needed on the role of the thymus gland in the pathogenesis and diagnosis of MIS-C.

A study of referral pattern to pediatric ophthalmology department in a tertiary eye-care center of South-India

Purpose:

The study was aimed at finding out the present pattern of referrals to the Pediatric Ophthalmology outpatient department (OPD) in a tertiary eye care hospital and thus identify the discrepancy of referral, if any, which would help to modify and enhance the practice guidelines.

Methods:

The study was conducted by retrospectively collecting data from all referral letters that were already uploaded in the Electronic Medical Report (EMR) against all patients from June 2019 to December 2019. All pediatric patients in the age group of 0–16 years were included in the study. The practicing field of referring clinicians was noted along with the maximum information that could be collected from the referral letter and were thus assessed for the quality, accuracy, and timely referral.

Results:

Out of 77 referrals received in the study period, six referral letters neither had any mention of the designation of the referring clinician nor any specific diagnosis or details. Thus, only 71 patients were included for further study. The referring clinicians were mainly ophthalmologists, pediatricians, general practitioners (GPs), and others (cardiologists, neurologists). Maximum patients were referred by ophthalmologists (76%) but visual acuity was noted only for 30% of these patients. Almost half of the referral diagnosis was accurate. Pediatrician referrals were found to be more detailed and précised.

Conclusion:

There is a need for a standardized hospital-specific format of referrals and basic training to primary care providers on some simple tests (Lights reflex tests) for identifying the “red flags” in pediatric eye examination and thus enhancing the quality and timely referral perse.

Thrombotic Microangiopathy in a Severe Pediatric Case of COVID-19

In this case report, we report a pediatric patient with COVID-19 and atypical hemolytic uremic syndrome (aHUS). A 3-year-old girl with fever and respiratory distress was admitted to the hospital. The patient tested positive for COVID-19 by a PCR test. As her respiratory distress increased and blood gas indicated deep respiratory acidosis on the third day of the pediatric intensive care unit follow-up, the patient was intubated and ventilated. Thorax computerized tomography (CT) showed bilateral effusion and atelectasis. During her follow-up, the pleural effusion resolved but there were marked consolidation areas and ground glass opacities compatible with COVID-19 on the follow-up CT. On the 10th day, she became anuric and developed progressive thrombocytopenia and persistent microangiopathic hemolytic anemia, which were suggestive of HUS given a high creatinine level (1.9 mg/dl), an undetectable haptoglobin level, reticulocytosis (8%), and an LDH level of 2540 U/l. Direct Coombs test returned negative. Examination of a peripheral blood smear revealed schistocytes. Disseminated intravascular coagulation was ruled out by normal INR and PTT. In the light of the available findings, we considered the patient to have thrombotic microangiopathy (TMA) triggered by COVID-19. It was not a TTP-form of TMA but rather an aHUS type, based on an ADAMTS13 activity level >5%. Hence, plasmapheresis was performed with fresh frozen plasma (FFP). After 4 weeks, she became completely asymptomatic, and her hemodynamic parameters normalized. COVID-19 induced uncontrolled complement activation leading to the development of aHUS. Early diagnosis and treatment may reduce morbidity and mortality since its treatment options.

Endobronchial Malignant Peripheral Nerve Sheath Tumor in a Pediatric Patient

A 13-year-old girl presented to the emergency department with exertional dyspnea. She had no notable medical history. A chest radiograph revealed left pulmonary atelectasis. Bronchoscopy showed an endobronchial tumor obstructing the left main bronchus, protruding into the trachea. Endobronchial polypectomy was performed under general anesthesia. The specimen was found to be a malignant peripheral nerve sheath tumor. The tumor had a local recurrence. However, it probably went into spontaneous regression. She is alive 25 years after the initial surgery. This is the first reported case of an endobronchial malignant peripheral nerve sheath tumor in a pediatric patient.

Transient cortical blindness secondary to hepatic encephalopathy in a pediatric patient: A case report and literature review

Cortical blindness, also known as cerebral visual impairment, may occur in pediatric patients. Hepatic encephalopathy is a rare cause of cortical blindness in children. This report describes a girl with underlying type 1 autoimmune hepatitis, who complained of sudden-onset, painless visual loss in both eyes, which was associated with generalized headache and altered mental status. She was treated with intravenous antibiotics and syrup lactulose. The patient regained full visual recovery after 1 week. Prompt diagnosis and treatment are mandatory in such uncommon instances.

A rare case of type II negative pressure pulmonary edema following extraction of inhaled peanuts in a 21-month-old boy

To date, only one case of pediatric type II negative pressure pulmonary edema (NPPE) caused by removal of an endobronchial foreign body has been documented. We report another case of type II NPPE that developed after extraction of inhaled peanuts. A 21-month-old boy who presented with wheezing and intermittent cough for 1 month after eating peanuts was admitted to our department. A chest computed tomographic scan showed foreign bodies lodged in the right main bronchus. Fiberoptic bronchoscopy was performed, and three pieces of peanuts were removed. Fifteen minutes after this procedure, the child grew restless and started coughing with frothy pink sputum. Tachypnea and rales were observed. A chest radiograph showed patchy opacification in both lungs, especially in the right lower zone, leading to the diagnosis of type II NPPE. Intravenous furosemide and dexamethasone were immediately administered, followed by non-invasive continuous positive airway pressure ventilation. Twelve hours later, the patient recovered uneventfully and was discharged home the following day. In conclusion, pediatric type II NPPE rapidly occurs following the relief of upper airway obstruction. Clinicians need to be aware of the acuteness and manifestations of type II NPPE to make an early diagnosis and initiate prompt treatment.

Analysis of the Therapeutic Effects of Staged Posterior-Anterior Combined Surgery for Cervicothoracic Segmental Tuberculosis with Kyphosis in Pediatric Patients

Objective

The present study aimed to investigate the surgical efficacy of staged posterior–anterior combined surgery for the treatment of cervicothoracic segmental tuberculosis (TB) with kyphosis in pediatric patients.

Methods

The clinical data of 15 pediatric patients admitted to our hospital from January 2010 to December 2017 who underwent staged posterior–anterior combined surgery for cervicothoracic segmental TB with kyphosis were collected. A posterior median incision was made for patients after general anesthesia. Autologous bone particles or allogeneic bone particles were taken, trimmed, and placed in the articular eminence of the diseased vertebral body. Fifteen pediatric patients underwent second-stage lesion removal using the anterior approach. The left sternocleidomastoid muscle was selected as the medial oblique incision approach. The abscess and caseous necrotic material were removed and sent for pathological examination. The sagittal and coronal parameters (including the local Cobb angle, the sagittal vertical axis [SVA], and the coronal balance distance [CBD]) were measured at three time points: preoperatively, postoperatively, and at the final follow-up. The American Spinal Injury Association’s spinal-cord injury classification, the Japanese Orthopaedic Association’s (JOA) cervical spine function score, the neck disability index (NDI), and the visual analogue score (VAS) for cervicothoracic segment pain were adopted for the assessment of functional improvement and quality of life.

Results

All 15 pediatric patients completed the surgery successfully, with an operation duration of 3.56 ± 0.68 h, an intraoperative hemorrhage of 289.7 ± 84.3 mL, an average fixation of 7.3 ± 1.8 segments, and a follow-up duration of 28.1 ± 9.7 months. The preoperative and postoperative sagittal local Cobb angle was 67.06 ± 17.54° vs 19.48 ± 2.32° (P < 0.01), the SVA was 35.19 ± 10.69 mm vs 7.67 ± 1.40 mm (P < 0.01), and CBD was 22.58 ± 7.59 mm vs 8.99 ± 1.25 mm (P < 0.01). The levels of the postoperative erythrocyte sedimentation rate and C-reactive protein were significantly lower in all patients. The preoperative and postoperative JOA scores were 8.93 ± 3.51 and 14.67 ± 1.34, respectively, the preoperative and postoperative VAS was 7.40 ± 1.35 and 2.67 ± 0.62, respectively, and the preoperative and postoperative NDI was 32.67 ± 4.83 and 13.73 ± 2.08, respectively. There were statistically significant differences in the above indicators before and after surgery (P < 0.05).

Conclusion

In the surgical treatment of cervicothoracic TB with kyphosis in pediatric patients, staged posterior–anterior combined surgery significantly corrects deformity, achieves the safe and effective neurological decompression of the spinal cord, and obtains good neurological recovery and bone-graft fusion according to the extent of the involved segments of kyphosis, the characteristics of the lesion, and the degree of neurospinal injury.

The Effect of Intraoperative Body Temperature on Postoperative Nausea and Vomiting in Pediatric Patients

PURPOSE

Pediatric patients are at greater risk for both perioperative hypothermia and postoperative nausea and vomiting (PONV). The primary aim of this study was to investigate whether there is a relationship between intraoperative body temperature and PONV in children undergoing anesthesia. The secondary aim was to investigate the relationship between PONV and intraoperative fentanyl use, age and duration of operation.

DESIGN

A prospective cohort study METHODS: The study included 80 children who were undergoing lower abdominal surgery. Body temperature was monitored after routine preoperative preparation and standard induction. Analgesic and antiemetic requirements and the presence of nausea and vomiting were assessed postoperatively on the 30th minute and the 6th, 12th and 24th hour.

FINDINGS

The children with or without PONV were compared. At the postoperative 6th hour, the incidence of nausea was statistically significant in the children with a mean body temperature below 36°C (P = 0.044; P < 0.05). The mean duration of the surgery was statistically significant longer in the children with PONV (P = 0.001; P = 0.004; P <0.05). Mean body temperature was not statistically significant when comparing children with and without vomiting(P > 0.05).

CONCLUSION

While a body temperature below 36°C increases the incidence of postoperative nausea, it does not cause an increase in the incidence of vomiting. A long operation time in pediatric patients causes an increase in the incidence of PONV. Although not statistically significant, PONV is encountered more than twice as much in patients receiving intraoperative fentanyl administration.

Quiet Diffusion-weighted MR Imaging of the Brain for Pediatric Patients with Moyamoya Disease

PURPOSE

Diffusion-weighted MRI (DWI) is an essential sequence for evaluating pediatric patients with moyamoya disease (MMD); however, acoustic noise associated with DWI may lead to motion artifact. Compared with conventional DWI (cDWI), quiet DWI (qDWI) is considered less noisy and able to keep children more relaxed and stable. This study aimed to evaluate the suitability of qDWI compared with cDWI for pediatric patients with MMD.

METHODS

In this observational study, MR examinations of the brain were performed either with or without sedation in pediatric patients with MMD between September 2017 and August 2018. Three neuroradiologists independently evaluated the images for artifacts and restricted diffusion in the brain. The differences between qDWI and cDWI were compared statistically using a chi-square test.

RESULTS

One-hundred and six MR scans of 56 patients with MMD (38 scans of 15 sedated patients: 6 boys and 9 girls; mean age, 5.2 years; range, 1-9 years; and 68 scans of 42 unsedated patients: 19 boys and 23 girls; mean age, 10.7 years; range, 7-16 years) were evaluated. MR examinations were performed either with or without sedation (except in one patient). In sedated patients, no artifact other than susceptibility was observed on qDWI, whereas four artifacts were observed on cDWI (P = .04). One patient awoke from sedation during cDWI scanning, while no patient awoke from sedation during qDWI acquisition. For unsedated patients, three scans showed artifacts on qDWI, whereas two scans showed artifacts on cDWI (P = .65). Regarding restricted diffusion, qDWI revealed three cases, while two cases were found on cDWI (P = .66).

CONCLUSION

qDWI induced fewer artifacts compared with cDWI in sedated patients, and similar frequencies of artifacts were induced by qDWI and by cDWI in unsedated patients. qDWI showed restricted diffusion comparable to cDWI.