Mortality risk factors among critically ill children with MIS-C in PICUs: a multicenter study

BACKGROUND

This study evaluated of clinical characteristics, outcomes, and mortality risk factors of a severe multisystem inflammatory syndrome in children admitted to a the pediatric intensive care unit.

METHODS

A retrospective multicenter cohort study was conducted between March 2020 and April 2021 at 41 PICUs in Turkey. The study population comprised 322 children diagnosed with multisystem inflammatory syndrome.

RESULTS

The organ systems most commonly involved were the cardiovascular and hematological systems. Intravenous immunoglobulin was used in 294 (91.3%) patients and corticosteroids in 266 (82.6%). Seventy-five (23.3%) children received therapeutic plasma exchange treatment. Patients with a longer duration of the PICU stay had more frequent respiratory, hematological, or renal involvement, and also had higher D-dimer, CK-MB, and procalcitonin levels. A total of 16 patients died, with mortality higher in patients with renal, respiratory, or neurological involvement, with severe cardiac impairment or shock. The non-surviving group also had higher leukocyte counts, lactate and ferritin levels, and a need for mechanical ventilation.

CONCLUSIONS

In cases of MIS-C, high levels of D-dimer and CK-MB are associated with a longer duration of PICU stay. Non-survival correlates with elevated leukocyte counts and lactate and ferritin levels. We were unable to show any positive effect of therapeutic plasma exchange therapy on mortality.

IMPACT

MIS-C is a life-threatening condition. Patients need to be followed up in the intensive care unit. Early detection of factors associated with mortality can improve outcomes. Determining the factors associated with mortality and length of stay will help clinicians in patient management. High D-dimer and CK-MB levels were associated with longer PICU stay, and higher leukocyte counts, ferritin and lactate levels, and mechanical ventilation were associated with mortality in MIS-C patients. We were unable to show any positive effect of therapeutic plasma exchange therapy on mortality.

Snakebites in Pediatric Patients in Kahramanmaraş: Is Pro-brain Natriuretic Peptide a Prognostic Biomarker for Snakebites?

Background: Snake envenomations are a serious cause of mortality and morbidity in the world.

Aims: This study was conducted to investigate snake bites in pediatric patients in Kahramanmaraş and to determine whether pro-brain natriuretic peptide (proBNP) has a prognostic value in these patients.

Methods: Pediatric patients aged <18 years who presented to the pediatric emergency department with snakebites were reviewed retrospectively. The demographical, clinical, laboratory, treatments, and outcomes data were collected from their medical records. Stage 0 and 1 envenomation was considered as a non-serious complication and stage 2 and 3 envenomation was considered as a serious complication.

Results: A total of 32 pediatric patients, six females and 26 males, between 2016 and 2021, were included in the study. The mean age was 12.52±3.28 years. There were seven patients without serious complications and 25 patients with serious complications. The best cutoff point for proBNP to predict serious complications was found to be ≥272.5 ng∙L^-1 (sensitivity, 83.3%; specificity, 100%, p=0.011). We also detected complex regional pain syndrome in one of our patients.

Conclusions: In this study, proBNP was shown to be predictive of a poor outcome of snakebites. Moreover, complex regional pain syndrome, which is rarely reported in the literature, should be kept in mind during the long-term follow-up of snakebites.

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.

Influenza Virus Associated Pediatric Acute Respiratory Distress Syndrome: Clinical Characteristics and Outcomes

BACKGROUND AND OBJECTIVE

The aim of this multicenter retrospective study was to determine the clinical characteristics, treatment approaches and the course of pediatric acute respiratory distress syndrome (PARDS) which developed associated with the influenza virus in the 2019-20 season.

METHODS

Patients included 1 month to 18 years who were diagnosed with PARDS associated with the influenza virus in the 2019-20 season.

RESULTS

Sixty-seven patients were included in the study. The mean age of the patients was 64.16 ± 6.53 months, with 60% of the group <5 years. Influenza A was determined in 54 (80.5%) patients and Influenza B in 13 (19.5%). The majority of patients (73.1%) had a comorbidity. Fifty-eight (86.6%) patients were applied with invasive mechanical ventilation, Pediatric Acute Lung Injury Consensus Conference classification was mild in 5 (8.6%), moderate in 22 (37.9%) and severe in 31 (52.5%) patients. Ventilation was applied in the prone position to 40.3% of the patients, and in nonconventional modes to 24.1%. A total of 22 (33%) patients died, of which 4 had been previously healthy. Of the surviving 45 patients, 38 were discharged without support and 7 patients with a new morbidity.

CONCLUSION

Both Influenza A and Influenza B cause severe PARDS with similar characteristics and at high rates. Influenza-related PARDS cause 33% mortality and 15.5% morbidity among the study group. Healthy children, especially those aged younger than 5 years, are also at risk.

The Role of ProBNP on Prognosis in Scorpion Stings

INTRODUCTION

Scorpion stings are a major health problem with potentially fatal consequences. Children under the age of 10 y especially face a great risk. Predicting the prognosis is important in reducing mortality and morbidity because it enables the use of early treatment options. In this study, we examine the relationship between proBNP and prognosis in scorpion stings.

METHODS

This is a retrospective analysis of patients aged ≤18 y who were admitted to the child emergency service with a scorpion sting. We examined the demographical data, clinical findings, laboratory records, treatments, and results of the patients. We classified stage 1 and stage 2 scorpion envenomation as group 1 (mild-moderate) and stage 3 and 4 as group 2 (severe). A t test was used for normally distributed data, and the Mann-Whitney U test was used for nonnormally distributed data. The correlation analysis was done using the Spearman test.

RESULTS

There were 32 (74%) patients in the mild-moderate group and 11 (26%) in the severe group. ProBNP 1 was significantly higher in the severe group at admission (P=0.016). There was no difference between the troponin I values (P=0.051). ProBNP 2 (12th hour) and proBNP 3 (24th hour) were higher in the severe group (P=0.001 and P=0.032, respectively). There was a negative correlation between proBNP and echocardiographic findings involving ejection fraction and shortening fraction (r=-0.703, P=0.002).

CONCLUSIONS

In our study, the first proBNP values were significantly higher in the severe group. This suggests that proBNP may be beneficial in predicting prognosis.

The Role of Natural Antioxidants Against Reactive Oxygen Species Produced by Cadmium Toxicity: A Review

Cadmium (Cd) is a significant ecotoxic heavy metal that adversely affects all biological processes of humans, animals and plants. Exposure to acute and chronic Cd damages many organs in humans and animals (e.g. lung, liver, brain, kidney, and testes). In humans, the Cd concentration at birth is zero, but because the biological half-life is long (about 30 years in humans), the concentration increases with age. The industrial developments of the last century have significantly increased the use of this metal. Especially in developing countries, this consumption is higher. Oxidative stress is the imbalance between antioxidants and oxidants. Cd increases reactive oxygen species (ROS) production and causes oxidative stress. Excess cellular levels of ROS cause damage to proteins, nucleic acids, lipids, membranes and organelles. This damage has been associated with various diseases. These include cancer, hypertension, ischemia/perfusion, cardiovascular diseases, chronic obstructive pulmonary disease, diabetes, insulin resistance, acute respiratory distress syndrome, idiopathic pulmonary fibrosis, asthma, skin diseases, chronic kidney disease, eye diseases, neurodegenerative diseases (amyotrophic lateral sclerosis, Parkinson's disease, Alzheimer's disease, and Huntington disease). Natural antioxidants are popular drugs that are used by the majority of people and have few side effects. Natural antioxidants play an important role in reducing free radicals caused by Cd toxicity. Our goal in this review is to establish the relationship between Cd and oxidative stress and to discuss the role of natural antioxidants in reducing Cd toxicity.

Ultrasound Elastography in Pediatric Congenital Hypothyroid Patients

OBJECTIVES

Congenital hypothyroidism (CH) is most frequently encountered in newborns as an endocrine disorder characterized by thyroid hormone deficiency, and is one of the most common reasons for preventable mental retardation. This prospective study was designed to detect the pediatric occurrences of CH followed as euthyroid, with no anomalies detected via US on the gray scale, in comparison with a pediatric group with normal levels.

METHODS

A total of 42 apparently healthy children with no thyroid disorder (Group 1) and 54 euthyroid CH (Group 2) using thyroid hormone were included in this study. Both B-mode gray scale ultrasound (US) and elastography examinations were made using Toshiba Aplio 400 device (Toshiba Medical Systems Corporation, Otawara, Japan), with a 12 MHz linear probe. All the radiological examinations were made by a single radiologic physician with at least 5 years of experience in elastography.

RESULTS

In total, 96 occurrences in the right and left lobes of 192 thyroid gland measurements were included in the research. There were 20 males and 22 females in the healthy group (n=42), and 28 males and 26 females in the CH group (n=54). Although, there were no significant differences in the average age or gender (p=0.563), there were significant differences in the strain index (SI) values in the CH group.The receiver operating characteristics (ROC) curve was done to calculate the cut-off value for diagnosing CH with strain index ratio (SIR); the value of the cut-off was 0.695, with 63.1% sensitivity and 50.9% specificity.

CONCLUSIONS

This was the first study about CH in children. Our study found the SIR of CH to be higher than the normal thyroid parenchyma. It showed that in parenchymal related CH, SE should be used. This study should be a guide for new studies that should be done about the different etiological factors of CH.