The effect of the broad-spectrum antibiotics for prevention of postoperative intra-abdominal abscess in pediatric acute appendicitis

Background

We investigated the efficacy of broad-spectrum antibiotics for prevention of postoperative intra-abdominal abscess in pediatric acute appendicitis with our 3 risk factors:—WBC?>?16.5 (×?10³/µl), CRP?>?3.1 (mg/dl) and appendix maximum short diameter on diagnostic imaging?>?11.4 mm.

Methods

Four hundred twenty-two patients were reviewed. Patients with 0–1 risk factors were assessed as low-risk and those with 2–3 were high-risk. In the low-risk group, Group A (n?=?66) patients received broad-spectrum antibiotics and Group B patients (n?=?265) received narrow-spectrum monotherapy. In the high-risk group, Group C patients (n?=?63) received broad-spectrum antibiotics and Group D patients (n?=?28), narrow-spectrum antibiotics. The outcomes were the incidence of postoperative abscess and the total duration of intravenous (IV) antibiotics.

Results

The incidence of intra-abdominal abscess was 6.06% in Group A versus 1.89% in Group B (p?=?0.08), and 19.05% in Group C versus 3.57% in Group D (p?=?0.06). Total IV antibiotic duration (days) were 6.12?±?2.87 in Group A versus 3.83?±?0.69 in Group B (p?<?0.01), and 7.84?±?4.57 in Group C versus 4.00?±?0.82 in Group D (p?<?0.01).

Conclusion

Broad-spectrum antibiotics did not prevent postoperative intra-abdominal abscess in either low or high-risk groups.

     

Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial

Purpose

To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis.

Methods

This was a randomized controlled trial of patients aged 4–17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I—contained perforation, II—localized contamination to right gutter/pelvis, and III—diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin–clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared.

Results

Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3?±?3.6 versus 10.1?±?3.6, p?<?0.05) with higher BMI (20.9?±?5.8 versus 17.9?±?3.5, p?<?0.05). There were no differences in gender, comorbidities, or perforation grade (I—20.4% vs. 26.3%, II—36.4% vs. 34.2%, III—43.2% vs. 39.5%, all p?>?0.05). Comparing IV to oral, there was no difference in length of stay (4.4?±?1.5 versus 4.4?±?2.0 days, p?>?0.05), postoperative abscess rate (11.6% vs. 8.1%, p?>?0.05), or readmission rate (14.0% vs. 16.2%, p?>?0.05). Hospital and outpatient charges were higher in the IV group (p?<?0.0001).

Conclusion

Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.

     

Weekend vs. weekday appendectomy for complicated appendicitis,effects on outcomes and operative approach

Purpose

We hypothesized that laparoscopic (LA) or open appendectomy (OA) outcomes in complicated appendicitis are associated with weekend vs. weekday procedure date.

Methods

We queried the Kids’ Inpatient Database (1997–2012) for complicated (540.0, 540.1) appendicitis treated with LA or OA. Propensity score (PS)-matched analysis compared outcomes associated with weekend vs. weekday LA and OA.

Results

Overall, 103,501 cases of complicated appendicitis were identified. On 1:1 PS-matched analyses of complicated appendicitis, weekday OA had increased wound infection rates (odds ratio: 1.3) vs. weekend OA, p?<?0.001. Weekend OA had higher pneumonia rates (1.4) and longer length of stay, but lower home healthcare requirement following discharge vs. weekday OA, p?<?0.05. Weekend and weekday LA had no significant outcome differences.

Conclusion

On a PS-matched comparison of appendectomies performed for complicated appendicitis on weekends and weekdays, procedure day is associated with different complication rates and resource utilization for OA. For LA, no weekend effect was noted for complicated appendicitis. To ensure the optimal patient care, prospective studies should be sought to identify causes of complications dependent on the day of procedure.

     

Is contralateral inguinal exploration necessary in preterm girls undergoing inguinal hernia repair during the first months of life?

Background

To assess the need for contralateral surgical exploration in preterm girls with symptomatic unilateral inguinal hernia.

Methods

The medical data of girls operated for inguinal hernia between 2004 and 2016 in a single pediatric surgery center were retrospectively collected. Preterm girls operated for unilateral hernia before 6 months of life were selected (55/517 cases) to assess the incidence and risk factors for contralateral metachronous inguinal hernia (CMIH).

Results

CMIH was observed in 7% of cases (4 girls with a right inguinal hernia in 3 cases) at a mean age of 4.2 years. Only one case occurred early (3 months). Birth weight and term were comparable (1674?±?620 g and 32?±?5 WA without CMIH vs. 1694?±?582 g and 33?±?3 WA with CMIH).

Conclusion

Contralateral inguinal hernia is very rare and generally occurs several years after inguinal repair surgery in preterm girls, which should encourage practitioners to follow these children throughout childhood for the subsequent development of inguinal hernia. This study did not find any arguments in favor of systematic contralateral exploration in preterm girls.

     

Age-related apparent diffusion coefficients of lumbar vertebrae in healthy children at 1.5 T

Background

Diffusion-weighted magnetic resonance imaging with apparent diffusion coefficient (ADC) calculation is important for detecting bone marrow pathologies.

Objective

To investigate age-related differences of lumbar vertebral body ADC to establish normal values for healthy children.

Materials and methods

Forty-nine healthy children without any history of oncological or hematological diseases (10.2±4.7 years, range: 0–20 years) were included in this retrospective study. All magnetic resonance imaging (MRI) examinations were performed at 1.5 T and with similar scan parameters. The diffusion-weighted sequences were performed with b values of 50, 400 and 800 s/mm². ADC values were measured by placing regions of interest at three different levels within each lumbar vertebral body (L1 to L5). ADC values were analyzed for different age groups (0–2 years, 3–6 years, 7–11 years, 12–14 years, 15–20 years), for each vertebral and intravertebral level.

Results

The mean ADC of the whole study group was 0.60±0.09?×?10^?3 mm²/s. Children between the ages of 12 and 14 years had significantly higher ADC compared to the other age groups (P≤0.0003). ADC values were significantly higher in the 1st lumbar vertebral body compared to the other levels of the lumbar spine (P<0.005) with the exception of L5, and in the upper third of the vertebral bodies compared to the middle or lower thirds (P≤0.003).

Conclusion

The age-, vertebral- and intravertebral level-dependent differences in ADC suggest a varying composition and cellularity in different age groups and in different locations.

     

Implications of non-accidental trauma on resource utilization and outcomes

Purpose

The purpose was to compare the resource utilization and outcomes between patients with suspected (SUSP) and confirmed (CONF) non-accidental trauma (NAT).

Methods

The institutional trauma registry was reviewed for patients aged 0–18 years presenting from 2007 to 2012 with a diagnosis of suspicion for NAT. Patients with suspected and confirmed NAT were compared.

Results

There were 281 patients included. CONF presented with a higher heart rate (142?±?27 vs 128?±?23 bpm, p?<?0.01), lower systolic blood pressure (100?±?18 vs 105?±?16 mm Hg, p?=?0.03), and higher Injury Severity Score (15?±?11 vs 9?±?5, p?<?0.01). SUSP received fewer consultations (1.6?±?0.7 vs 2.4?±?1.1, 95% CI ? 0.58 to ? 0.09, p?<?0.01) and had a shorter length of stay (1.6?±?1.3 vs 7.8?±?9.8 days, 95% CI ? 4.58 to ? 0.72, p?<?0.01). SUSP were more often discharged home (OR 94.22, 95% CI: 21.26–417.476, p?<?0.01). CONF had a higher mortality rate (8.2 vs 0%, p?<?0.01).

Conclusions

Patients with confirmed NAT present with more severe injuries and require more hospital resources compared to patients in whom NAT is suspected and ruled out.

     

Urinary biomarkers in pediatric appendicitis

Purpose

The diagnosis of pediatric appendicitis is still a challenge, resulting in perforation and negative appendectomies. The aim of this study was to evaluate novel biomarkers in urine and to use the most promising biomarkers in conjunction with the Pediatric Appendicitis Score (PAS), to see whether this could improve the accuracy of diagnosing appendicitis.

Methods

A prospective study of children with suspected appendicitis was conducted with assessment of PAS, routine blood tests, and measurements of four novel urinary biomarkers: leucine-rich α-2-glycoprotein (LRG), calprotectin, interleukin 6 (IL-6), and substance P. The biomarkers were blindly determined with commercial ELISAs. Urine creatinine was used to adjust for dehydration. The diagnosis of appendicitis was based on histopathological analysis.

Results

Forty-four children with suspected appendicitis were included, of which twenty-two (50 %) had confirmed appendicitis. LRG in urine was elevated in children with appendicitis compared to children without (p < 0.001), and was higher in children with gangrenous and perforated appendicitis compared to those with phlegmonous appendicitis (p = 0.003). No statistical significances between groups were found for calprotectin, IL-6 or substance P. LRG had a receiver operating characteristic area under the curve of 0.86 (95 % CI 0.79–0.99), and a better diagnostic performance than all routine blood tests. LRG in conjunction with PAS showed 95 % sensitivity, 90 % specificity, 91 % positive predictive value, and 95 % negative predictive value.

Conclusion

LRG, adjusted for dehydration, is a promising novel urinary biomarker for appendicitis in children. LRG in combination with PAS has a high diagnostic performance.

     

Iron Pots for the Prevention and Treatment of Anemia in Preschoolers

Objective

To assess the effect of food cooked in iron pots for the prevention and treatment of iron deficiency anemia.

Methods

In this cluster randomized clinical trial, authors evaluated preschoolers aged 4–5 y for 16 wk. Children were cluster randomized to either eating from iron pots (Group A) or aluminum pots (Group B). Primary outcome variables were change in hemoglobin concentration and anemia prevalence. Two biochemical evaluations were performed, to determine Hb concentrations, before and after intervention. This study was conducted in two public preschools, located in the municipality of Mucambo, Ceará, in the northeast of Brazil.

Results

At baseline, for group A, mean hemoglobin concentration was 12.26?±?1.02 g/dL and 12.29?±?0.95 g/dL after intervention, p?=?0.78. In group B, mean baseline hemoglobin was 12.34?±?1.04 g/dL, and 12.13?±?0.86 g/dL after intervention, p?=?0.07. All ten participants, who were anemic at baseline, were no longer anemic after intervention.

Conclusions

Using iron cooking pots in developing countries could provide an innovative strategy to prevent and treat iron deficiency anemia.

     

Non-fluoroscopic percutaneous transcatheter closure of atrial septal defects in children under transesophageal echocardiographic guidance

Background

This study sought to investigate the feasibility, safety and effectiveness of transcatheter closure of atrial septal defects (ASDs) under the guidance of transesophageal echocardiography (TEE) in children.

Methods

We reviewed the medical records of patients who underwent percutaneous ASD closure at our center from August 2016 to December 2017. For a total of 88 patients who were identified as having a single-hole defect and were undergoing percutaneous transcatheter ASD closure, a procedure completely guided by TEE was performed. There were 31 male patients and 57 female patients. The patients’ mean age was 60.09?±?36.42 months (13–182 months), and their mean body weight was 20.16?±?10.04 kg (9–77 kg). Patients were followed up by performing transthoracic echocardiography and obtaining chest X-rays and electrocardiograms.

Results

The transcatheter closure of ASDs was successful in all patients. The mean ASD size was 11.58?±?5.31 mm (3–28 mm), and the mean size of the occlusion device was 16.07?±?5.29 mm (6–36 mm). The mean procedural times were 13.33?±?2.82 minutes (6–16 minutes). The mean hospitalization costs were 27,259.66?±?2507.04 RMB (25,200.00–33,911.45 RMB). The mean postoperative hospital stay was 3.22?±?0.53 days (3–5 days). Residual shunt, occlusion device shedding or displacement, and pericardial effusion were not observed during or after the operation.

Conclusion

Percutaneous transcatheter ASD closure completely guided by TEE is a feasible, safe, non-invasive and easy procedure.

     

Development of a Prognostic Prediction Model to Determine Severe Dengue in Children

Objective

To develop a prognostic prediction model using the seven warning signs highlighted by WHO revised Dengue fever classification 2009 to determine severe dengue in children.

Methods

In this prospective analytical study conducted in a tertiary care centre, consecutive sampling of all children aged 1mo to 12y admitted with serologically confirmed Dengue was done from May 2015 through August 2016. After excluding 27 patients with co-infections and co-morbidities, 359 patients were followed up daily to assess clinical and laboratory progression till discharge/ death. Independent predictors were abdominal pain or tenderness, persistent vomiting, lethargy, mucosal bleed, clinical fluid accumulation, hepatomegaly >2 cm and rising hematocrit concurrent with platelet count <100?×?10⁹/L. Outcome measure was severe dengue defined as per WHO guidelines 2009.

Results

Among 359 children, 93 progressed to severe dengue. In univariate analysis, significant predictors were clinical fluid accumulation (OR 4.773, p?=?0.000, 95%CI 2.511–9.075), persistent vomiting (OR 1.944, p?=?0.010, 95%CI 1.170–3.225), mucosal bleed (OR 2.045, p?=?0.019, 95%CI 1.127–3.711) and hematocrit ≥0.40 concurrent with platelet count <100?×?10⁹/L (OR 2.985, p?=?0.000, 95%CI 1.783–4.997). The final multivariable model included clinical fluid accumulation (aOR 3.717, p?=?0.000, 95%CI 1.901–7.269), hematocrit ≥0.40 concurrent with platelet count <100?×?10⁹/L (aOR 2.252, p?=?0.004, 95%CI 1.302–3.894) and persistent vomiting (p?=?0.056) as predictors of severe dengue.

Conclusions

Among seven WHO warning signs, predictors of severe dengue as suggested by the present multivariable prediction model include clinical fluid accumulation, persistent vomiting and hematocrit ≥0.40 concurrent with platelet count <100?×?10⁹/L.

     

Body composition and phase angle as an indicator of nutritional status in children with juvenile idiopathic arthritis

Background

Juvenile idiopathic arthritis (JIA) is the most common chronic, systemic autoimmune connective tissue disease diagnosed in children and adolescents. An important aspect of monitoring of children with JIA is a precise assessment of the nutritional status to identify children and adolescents at risk of malnutrition. The aim of the study was to assess the body composition and phase angle in children diagnosed with JIA in comparison to age and sex matched healthy children since there are scarce reports in paediatric patients.

Methods

A total of 46 children and adolescents aged 4–18?years, with JIA were included in the cross-sectional study. Controls were selected from the group of healthy children and adolescents. Children with diagnosed JIA and healthy children were strictly matched for age and gender. In both groups BIA with phase angle calculation was performed.

Results

Phase angle score was significantly lower in the study group compared to control group (5.45?±?0.64 vs. 5.85?±?0.80, p?=?0.010). Also lower percentage of body cell mass (50.63?±?3.46 vs. 52.70?±?4.06, p?=?0.010) and muscle mass (46.02?±?6.32 vs. 49.53?±?6.67, p?=?0.005) were revealed. In the analysis of subtypes of JIA we found significant differences between children and adolescents with polyarthritis compared to control group, while no significant differences were found between patients with oligoarthritis and control group.

Conclusions

The obtained results indicate a higher risk of malnutrition in children and adolescents with JIA compared to healthy peers, predominantly in patients with polyarthritis.

     

Anterior Fontanelle Size in Healthy Indian Late Preterm and Full Term Newborns

Objective

To measure the size of the anterior fontanelle (AF) in healthy late-preterm and term newborns and correlate it with birth weight, gestational age, gender, occipito-frontal circumference, small for gestational age status and birth weight z-score.

Methods

This was an observational study carried out from October 2013 through April 2015 at a tertiary care hospital. Newborns?≥?34 wk gestation were enrolled. Fontanelle edge was palpated with index finger and size calculated by adding anterior-posterior and transverse diameters and dividing by two.

Results

A total of 1010 neonates were enrolled. The mean AF size was 2.23?±?0.52 cm (mean?±?SD). There was a significant decrease in the size of the AF with advancing gestational maturity on one-way ANOVA (F?=?31.30) (P?<?0.001) and also by increasing birth weight (F?=?20.34) (P?<?0.001). There was no significant difference in the mean AF size between males; 2.21?±?0.54 cm and females; 2.25?±?0.55 cm (mean?±?SD) (P?=?0.575). There was a strong correlation between AF size with increasing birth weight; correlation (r)?=?0.985. In small for gestational age neonates the AF was larger, 2.27?±?0.55 (mean?±?SD) and a strong correlation between birth weight z-score and AF size was noted (r?=?1.012).

Conclusions

The mean AF size in late-preterm and term Indian newborns in a mixed community hospital was 2.23?±?0.52. A strong correlation was found between AF size with increasing birth weight and with birth weight z-score in small for gestational age babies.

     

Erosive Potential of Sugar Free and Sugar Containing Pediatric Medicines Given Regularly and Long Term to Children

Objective

To assess the erosive potential of 94 pediatric medicines of various therapeutic groups in vitro.

Methods

In vitro measurement of endogenous pH and titratable acidity (mmol) of 94 formulations was done. Endogenous pH was measured using a pH meter, followed by titration with 0.1-M NaOH using phenolphthalein as indicator.

Results

Overall, 55 (59%) formulations had an endogenous pH of <5.5. The mean (±SD) endogenous pH and titratable acidity for 45 SC formulations were 5.52?±?1.18 and 0.165?±?0.131 mmol, respectively; for 49 sugars-free (SF) formulations, these figures were 5.81?±?1.43 and 0.393?±?1.225 mmol (P?>?0.05).Compared with their SC bioequivalents, eight SF medicines showed no significant differences for pH or titratable acidity, while 10 higher-strength medicines showed lower pH (P 0.035) and greater titratable acidity (P 0.026) than their lower-strength equivalents. Chewable and dispersible tablets, gastrointestinal medicines and antibiotics were significant predictors of higher pH. In contrast, effervescent tablets, and nutrition and blood preparations were significant predictors of higher titratable acidity.

Conclusions

Pediatric SF medicines were not more erosive than SC medicines in vitro; a more significant predictor of their erosive potential was dose form. Higher the dose form more was the erosive potential of the medicine.

     

Assessment of Fruit and Vegetable Intake Behavior Among Adolescents in Hangzhou,China

Objective

To evaluate the fruit and vegetable (FV) intake of adolescents, assess factors influencing intake and discuss health education strategies related to this behavior.

Methods

In Hangzhou, China, 861 students aged 13.68?±?1.03 years were randomly recruited to carry out a cross-sectional, school-based survey. The design of the survey questionnaire was based on the Transtheoretical Model (TTM) of Behavior Change. Results of the survey rated FV consumption and children’s readiness to assume healthier dietary choices. The study design incorporated the four core constructs of TTM: stages of change, processes of change, decisional balance and self-efficacy. Results were assessed by chi-square tests, analysis of variance, Tukey’s post-hoc tests and logistic regression analysis.

Results

Majority of the participants were in the TTM contemplation stage of change. The average number of FV servings among participants was 3.12?±?1.41 per day. The specific process of change, number of decisional balance pros (as opposed to cons), and self-efficacy ratings were positively correlated with stage of change transition (Spearman r?>?0, P?>?0, P?<?0.05).

Conclusions

The use of TTM may be a powerful personalized means of decreasing poor dietary behaviors and promoting healthy behaviors, compared to traditional methods of behavioral change.

     

Computed tomography localization of the appendix in the pediatric population relative to the lumbar spine

Background

Computed tomography (CT) is commonly used to evaluate suspected acute appendicitis. Although very effective, CT uses ionizing radiation, exposing patients to an increased risk of cancer.

Objective

This study assessed the potential for decreasing the field of view of the CT (and therefore the dose to the patient) in the evaluation of suspected acute appendicitis in children.

Materials and methods

This study was a retrospective review of prospectively collected data from 212 consecutive patients who underwent CT for suspected acute appendicitis. The most superior aspect of the appendix with respect to vertebral bodies was recorded. Age, gender and diagnosis (negative, acute appendicitis or alternative diagnosis) were noted.

Results

The appendix was visualized in 190 of 212 subjects (89.6%). Overall, all visualized appendixes were located at or below the level of L1. Sixty-three of the subjects (29.7%) were diagnosed with acute appendicitis via CT imaging. All appendixes in patients with acute appendicitis were located at or below the level of the L3 vertebral body, predominating at the level of L5. Six subjects (3.1%) received alternative diagnoses, including pneumonia, pyelonephritis, small bowel obstruction and infected urachal cyst. There were no differences in appendix location with regard to diagnosis, gender, or age (P=0.664, 0.748 and 0.705, respectively).

Conclusion

CT field of view may be decreased to the level of L1 or L3 superiorly, decreasing radiation dose without affecting the rate of appendix visualization.

     

Fn14 hepatic progenitor cells are associated with liver fibrosis in biliary atresia

Purpose

The liver in biliary atresia (BA) is characterized by progressing fibrosis which is promoted by unclear reasons. We aimed to understand the factors influencing liver fibrosis. This study hypothesized that HPCs (hepatic progenitor cells) are activated and associated with liver fibrosis in biliary atresia.

Methods

Liver samples from biliary atresia patients are as BA group, and the normal liver derived from hepatoblastoma infants during operation are control group. The extent of fibrosis in liver samples was blindly evaluated by two experienced pathologists depending on Ishak system. The BA liver samples were divided into mild liver fibrosis group (grade I–IV, BA_a) and severe liver fibrosis group (grade V–VI, BA_b) to detect Fn14 protein expression.

Results

In mRNA level, Fn14 expression was 21.23?±?8.3 vs. 1.00?±?0.17, p?=?0.023?<?0.05 and CD133 expression was 6.02?±?2.16 vs. 1.14?±?0.75, p?=?0.008?<?0.01 between BA group and control group. Fn14 cells co-expressed the progenitor marker CD133 in liver, and activated in BA. Fn14 andα-SMA were co-location in fibrous area in liver. Compared to the control group, Fn14, CD133, and α-SMA protein expression were 2.10?±?0.53 vs. 0.97?±?0.2, p?=?0.001, 2.23?±?0.57 vs. 1.00?±?0.03, p?=?0.000, 4.96?±?2.4 vs. 1.00?±?0.22, p?=?0.001. The Fn14 protein expression was 2.60?±?0.35 vs. 1.86?±?0.42, p?=?0.012, between BA_b and BA_a group.

Conclusion

Fn14 cells, which co-express the progenitor marker CD133 in liver, are HPCs and activated in BA. Fn14?+?HPCs are associated with liver fibrosis in BA.

     

Can common serum biomarkers predict complicated appendicitis in children?

Purpose

As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis.

Methods

Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal–Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)].

Results

Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5–12, 38% 13–17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5–12- (p < 0.0001) and 13–17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 10⁹/L in 58% CA and 43% SA (p < 0.0001).

Conclusions

Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

     

Myocardial stress perfusion magnetic resonance: initial experience in a pediatric and young adult population using regadenoson

Background

Dipyridamole and adenosine are traditional pharmacological stressors for myocardial perfusion. Regadenoson, a selective adenosine A2A agonist, has a lower side effect profile with lower incidence of bronchospasm and bradycardia. There is a growing need for myocardial perfusion assessment within pediatrics. There is no report on the utility of regadenoson as a stress agent in children.

Objective

To observe the safety and feasibility of regadenoson as a pharmacologic stressor for perfusion cardiac MR in a pilot cohort of pediatric patients weighing more than 40 kg who have congenital heart disease and pediatric acquired heart disease.

Materials and methods

We reviewed our initial experience with regadenoson stress cardiac MR in 31 pediatric patients 15.8?±?1.7 years (range 12–22 years) with congenital heart disease and acquired heart disease. Mean patient weight was 60?±?15 kg (range of 40–93 kg). All patients underwent cardiac MR because of concern for ischemia. The cohort included a heterogeneous group of patients at a pediatric institution with potential risk for ischemia. Subjects’ heart rate and blood pressure were monitored and pharmacologic stress was induced by injection of 400 mcg of regadenoson. We evaluated their hemodynamic response and adverse effects using changes in vital signs and onset of symptoms. A pediatric cardiologist and radiologist qualitatively assessed myocardial perfusion and viability images.

Results

One child was unable to complete the stress perfusion portion of the examination, but did complete the remaining portion of the CMR. Resting heart rate was 72?±?14 beats per minute (bpm) and rose to peak of 124?±?17 bpm (95?±?50% increase, P?<?0.005) with regadenoson. Image quality was considered good or diagnostic in all cases. Three patients had irreversible perfusion defects. Four patients had reversible perfusion defects. Nine of the patients underwent cardiac catheterization with angiography and the findings showed excellent agreement.

Conclusion

Regadenoson might be a safe and feasible pharmacologic stress agent for use in cardiac MR in older pediatric patients with congenital heart disease and acquired heart disease. The ease of use as a bolus and the advantage of a prolonged hyperemia make its use appealing in pediatrics. In a limited number of cases, regadenoson stress perfusion showed excellent agreement with cardiac catheterization. Regadenoson might be a viable pharmacologic stress agent in this population.

     

Pediatric non-diabetic ketoacidosis: a case-series report

Background

This study is to explore the clinical characteristics, laboratory diagnosis, and treatment outcomes in pediatric patients with non-diabetic ketoacidosis.

Methods

Retrospective patient chart review was performed between March 2009 to March 2015. Cases were included if they met the selection criteria for non-diabetic ketoacidosis, which were: 1) Age?≤?18 years; 2) urine ketone positive ++ or >8.0 mmol/L; 3) blood ketone >3.1 mmol/L; 4) acidosis (pH?<?7.3) and/or HCO₃?<?15 mmol/L; 5) random blood glucose level?<?11.1 mmol/L. Patients who met the criteria 1, 4, 5, plus either 2 or 3, were defined as non-diabetic ketoacidosis and were included in the report.

Results

Five patients with 7 episodes of non-diabetic ketoacidosis were identified. They all presented with dehydration, poor appetite, and Kussmaul breathing. Patients treated with insulin plus glucose supplementation had a quicker recovery from acidosis, in comparison to those treated with bicarbonate infusion and continuous renal replacement therapy. Two patients treated with bicarbonate infusion developed transient coma and seizures during the treatment.

Conclusion

Despite normal or low blood glucose levels, patients with non-diabetic ketoacidosis should receive insulin administration with glucose supplementation to correct ketoacidosis.

     

Application of a score system to evaluate the risk of malnutrition in a multiple hospital setting

Background

An increased but unpredictable risk of malnutrition is associated with hospitalization, especially in children with chronic diseases. We investigated the applicability of Screening Tool for Risk of Impaired Nutritional Status and Growth (STRONGkids), an instrument proposed to estimate the risk of malnutrition in hospitalized children. We also evaluated the role of age and co-morbidities as risk for malnutrition.

Methods

The STRONGkids consists of 4 items providing a score that classifies a patient in low, moderate, high risk for malnutrition. A prospective observational multi-centre study was performed in 12 Italian hospitals. Children 1–18 years consecutively admitted and otherwise unselected were enrolled. Their STRONGkids score was obtained and compared with the actual nutritional status expressed as BMI and Height for Age SD-score.

Results

Of 144 children (75 males, mean age 6.5?±?4.5 years), 52 (36%) had an underlying chronic disease. According to STRONGkids, 46 (32%) children were at low risk, 76 (53%) at moderate risk and 22 (15%) at high risk for malnutrition. The latter had significantly lower Height for Age values (mean SD value -1.07?±?2.08; p?=?0.008) and BMI values (mean SD-values -0.79?±?2.09; p?=?0.0021) in comparison to other groups. However, only 29 children were actually malnourished.

Conclusions

The STRONGkids is easy to administer. It is highly sensitive but not specific. It may be used as a very preliminary screening tool to be integrated with other clinical data in order to reliably predict the risk of malnutrition.