Simultaneous Acquired Self-limited Hemophagocytic Lymphohistiocytosis and Kikuchi Necrotizing Lymphadenitis in a 16-Year-Old Teenage Girl: A Case Report and Review of the Literature.

OBJECTIVES: The aim of this study was to increase education and awareness among pediatric practitioners of possibility of simultaneous hemophagocytic lymphohistiocytosis and Kikuchi-Fujimoto disease/Kikuchi disease occurring in the pediatric population and the diagnostic dilemma it can present. We describe a case presentation of acquired and self-limited simultaneous hemophagocytic lymphohistiocytosis and Kikuchi-Fujimoto disease in a 16-year-old in the United States who presented with fevers, night sweats, and joint pain, along with tiredness and decreased appetite along with pancytopenia and elevated lactate dehydrogenase. To the best of our knowledge, simultaneous hemophagocytic lymphohistiocytosis and Kikuchi-Fujimoto in the pediatric population has not been described in North America but remains fairly common in Asia. The literature on both diseases and their simultaneous occurrence is comprehensively reviewed. METHODS: This was a case report and review of the literature. RESULTS: The patient was diagnosed with both hemophagocytic lymphohistiocytosis and Kikuchi-Fujimoto disease based on bone marrow aspiration/biopsy and axillary node biopsy, respectively. Both illnesses resolved completely. CONCLUSIONS: Benign causes of pancytopenia and elevated lactate dehydrogenase exist, but they may not be always straightforward diagnostically. Bone marrow aspiration and lymph node biopsy may be helpful in ascertaining the diagnosis. Hemophagocytic lymphohistiocytosis and Kikuchi-Fujimoto disease may represent a continuum of illness.

Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.

BACKGROUND: The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes. OBJECTIVE: 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. PARTICIPANTS: Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006). METHODS: The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. RESULTS: The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. CONCLUSION: The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill 70% and cardiac index 3.3-6.0 L/min/m.

Bivalirudin for anticoagulation in children.

BACKGROUND: Thromboembolism in children is typically treated with unfractionated heparin (UH) or low molecular weight heparin (LMWH). Both rely on antithrombin (AT) for their action. In addition, heparin-induced thrombocytopenia (HIT) is a potentially serious complication of heparin use in children. Bivalirudin or other direct thrombin inhibitors may be a useful alternative to heparins in treating thrombosis in children. PROCEDURE: We report a retrospective review to assess the efficacy and safety of bivalirudin in pediatric patients with thrombosis. RESULTS: Sixteen children received bivalirudin for thrombosis or prevention of thrombosis at the Children's Hospital of Illinois from January 2005 to January 2007. Patients received a bolus dose of 0.25 mg/kg followed by a continuous infusion (0.16 +/- 0.07 mg kg(-1) hr(-1)) titrated to 1.5-2.5 times the baseline activated partial thromboplastin time (aPTT). Positive correlation between the bivalirudin average infusion rate and aPTT was observed in twelve patients. Ultrasonographic evidence of thrombus regression was noted at 72 hr in 10 of 10 patients. One patient experienced hematuria after catheterization of the urethra. CONCLUSION: Bivalirudin was effective and well-tolerated in these patients. Further studies should be conducted to better define safety and efficacy of bivalirudin in pediatric patients.

Pulse oximeter accuracy and precision affected by sensor location in cyanotic children.

OBJECTIVE: Children's digits are often too small for proper attachment of oximeter sensors, necessitating sensor placement on the sole of the foot or palm of the hand. No study has determined what effect these sensor locations have on the accuracy and precision of this technology. The objective of this study was to assess the effect of sensor location on pulse oximeter accuracy (i.e., bias) and precision in critically ill children. DESIGN: Prospective, observational study with consecutive sampling. SETTING: Tertiary care, pediatric intensive care unit. PATIENTS: Fifty critically ill children, newborn to 2 yrs of age, with an indwelling arterial catheter. Forty-seven of 50 (94%) patients were postcardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Co-oximeter-measured arterial oxygen saturation (Sao2) was compared with simultaneously obtained pulse oximetry saturations (Spo2). A total of 98 measurements were obtained, 48 measurements in the upper extremities (finger and palm) and 50 measurements in the lower extremities (toe and sole). The median Sao2 was 92% (66% to 100%). There was a significant difference in bias (i.e., average Spo2 - Sao2) and precision (+/-1 sd) when the sole and toe were compared (sole, 2.9 +/- 3.9 vs. toe, 1.6 +/- 2.2, p = .02) but no significant difference in bias and precision between the palm and the finger (palm, 1.4 +/- 3.2 vs. finger, 1.2 +/- 2.3, p = .99). There was a significant difference in bias +/- precision when the Sao2 was <90% compared with when Sao2 was >or=90% in the sole (6.0 +/- 5.7 vs. 1.8 +/- 2.1, p = .002) and palm (4.5 +/- 4.5 vs. 0.7 +/- 2.4, p = .006) but no significant difference in the finger (1.8 +/- 3.8 vs. 1.1 +/- 1.8, p = .95) or toe (1.9 +/- 2.9 vs. 1.6 +/- 1.9, p = .65). CONCLUSIONS: The Philips M1020A pulse oximeter and Nellcor MAX-N sensors were less accurate and precise when used on the sole of the foot or palm of the hand of a child with an Sao2 <90%.

The Impact of Automated Electronic Surveillance of Electronic Medical Records on Pediatric Inpatient Care.

Purpose To assess the impact of the automated surveillance of the electronic medical record process on clinical interventions among hospitalized children at a tertiary care pediatric center. Methods A retrospective chart review of the alerts triggered for central line-associated blood stream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), neonatal sepsis, or clinical deterioration through elevated pediatric early warning scores (PEWS) by automated electronic surveillance of the hospital electronic medical record (EMR) over a five-month period among hospitalized children. Interventions instituted in response to the alerts were reviewed from the hospital EMR. Fisher's exact test was performed to detect any significant difference in the proportion of interventions performed for alerts triggered between groups. Results A total of 244 alerts were collected (27 CAUTI, 55 CLABSI, 10 neonatal sepsis, and 152 PEWS alerts). A significant difference in the proportion of interventions instituted after neonatal sepsis and PEWS alerts (9/162, 5.6%) as compared to CLABSI and CAUTI alerts (20/82, 24.4%) was observed (p<0.001; Odds ratio (95% CI): 0.182 (0.079-0.422)). Neonatal sepsis triggered the least number of alerts (10/244, 4.1%) and proportionately fewer interventions than the other clinical alerts. Conclusions Alerts for potential device-associated infections resulted in more clinical intervention than less-specific alerts. Neonatal sepsis alerts resulted in minimal interventions undertaken in response to the alert. Identifying and focusing on alerts benefitting the patient can serve as a better allocation of time and resources. Future studies should explore which newer alerts and their accompanying interventions improve patient outcomes.

Biliary dyskinesia: the most common indication for cholecystectomy in children.

BACKGROUND: The purpose of this study is to examine the current indications for cholecystectomy in children and to evaluate the results after such surgery. METHODS: Retrospective analysis of 107 consecutive cholecystectomies performed in children at the Children's Hospital of Illinois between October 1998 and September 2003. Hospital medical charts and outpatient clinic charts were reviewed. Patients' families were contacted by telephone to obtain longer-term follow-up. Results were analyzed with SPSS 12.0 for Windows (SPSS Inc, Chicago, Ill). RESULTS: Biliary dyskinesia (BD) was the indication for surgery for 62 (58%) of the 107 children who underwent cholecystectomy during the study period. Gallbladder calculus (GC) disease was the next most common indication with 29 (27%) children. The duration of symptoms was longer for BD. The most common presenting symptom in both groups was abdominal pain. Food intolerance was reported by 45% of patients with BD, significantly higher than patients with GC. Mean length of stay after cholecystectomy was 17 hours and 45 hours for BD and GC, respectively. Short-term follow-up showed relief or improvement of symptoms in 85% of children with BD and in 97% with GC. There were no deaths. Two (1.9%) children of the total of 107 developed complications; both had intra-abdominal abscesses. Most patients had complete or considerable long-term improvement in symptoms. CONCLUSIONS: Biliary dyskinesia was the most common indication for cholecystectomy in children in our study. More than half of the surgeries were performed on an outpatient basis. Morbidity was minimal and mortality was zero. We had satisfactory short- and long-term symptom resolution with long-term patient satisfaction reaching 95%.

Aortitis in a child with Abiotrophia defectiva endocarditis.

Abiotrophia defectiva, one of several nutritionally variant Streptococcus species, is an uncommon but important cause of endocarditis in children. We describe an unusual case complicated by extensive aortitis with pits in the ascending aorta and the proximal aortic arch.

Computerized pharmaceutical algorithm reduces medication administration errors during simulated resuscitations.

OBJECTIVE: Medication errors involving intravenous medications continue to be a significant problem, particularly in the pediatric population due to the high rate of point-of-care and weight-adjusted dosing. The pharmaceutical algorithm computerized calculator (pac2) assists in converting physician medication orders to correct volumes and rates of administration for intravenous medications. This study was designed to assess the efficacy of the pac2 in simulated clinical scenarios of point-of-care dosing. METHODS: The study design was a within-subject controlled study in which 33 nurses from pediatrics, pediatric critical care, or critical care (mean nursing experience of 10.9 years) carried out various point-of-care medication-dosing scenarios with and without the aid of the pac2. RESULTS: Use of the pac2 resulted in a significantly higher percentage (mean [95% CI]) of medication volumes calculated and drawn accurately (91% [87-95%] versus 61% [52-70%], p<0.0001), a higher percentage of correct recall of essential medication information (97% [95-99%] versus 45% [36-53%], p<0.0001), and better recognition of unsafe doses (93% [87-99%] versus 19% [12-27%], p<0.0001) as compared to usual practice. The pac2 also significantly reduced average medication calculation times (1.5 minutes [1.3-1.7 minutes] versus 1.9 minutes [1.6-2.2 minutes], p=0.0028) as compared to usual practice. CONCLUSIONS: The pac2 significantly improved the performance of drug calculations by pediatric and critical care nurses during simulated clinical scenarios designed to mimic point-of-care dosing. These results suggest that the pac2 addresses an area of safety vulnerability for point-of-care dosing practices and could be a useful addition to a hospital's overall program to minimize medication errors.

Development of a pediatric age- and disease-specific severity measure.

OBJECTIVES: To adapt the adult Comprehensive Severity Index (CSI) for hospitalized pediatric patients and evaluate the ability of the CSI to predict common outcomes. STUDY DESIGN: Adult CSI was modified by a panel of pediatric subspecialists from 10 children's hospitals. Predictive power was evaluated by using retrospective data collected from 16,495 randomly selected children admitted to these hospitals from April 1995 through September 1996. Outcomes were mortality, length of stay (LOS), and cost. RESULTS: Admission CSI score predicted mortality well (Hosmer-Lemeshow tests: P =.41-.98) and discriminated well (area under receiver operating characteristic [ROC] curve range = 0.80-0.99) within 9 case-mix groups with > or =10 deaths (P <.0001). Maximum CSI score explained the variation in LOS (r2 = 0.13-0.67) and cost (r2 = 0.08-0.73) within 32 case-mix groups (P <.005). Significant differences existed in admission and maximum average CSI scores across sites in 26 and 29 of 32 case-mix groups, respectively (P <.05). CSI had better predictability than Pediatric Risk of Mortality. CONCLUSIONS: The age- and disease-specific pediatric CSI score correlates highly with LOS, cost, and mortality in hospitalized children and can help determine the best clinical practices for specific diseases and adjust for differences in severity of illness across providers.

Pulse oximetry in children with congenital heart disease: effects of cardiopulmonary bypass and cyanosis.

The objective of this prospective, observational study with consecutive sampling was to assess the reliability, bias, and precision of Nellcor N-395 (N) and Masimo SET Radical (M) pulse oximeters in children with cyanotic congenital heart disease and children with congenital heart disease recovering from cardiopulmonary bypass-assisted surgery admitted to a cardiovascular operating suite and pediatric intensive care unit at a tertiary care community hospital. Forty-six children with congenital heart disease were studied in 1 of 2 groups: (1) those recovering from cardiopulmonary bypass with a serum lactic acid > 2 mmol/L, and (2) those with co-oximetry measured saturations (SaO(2)) < 90% and no evidence of shock. Measurements of SaO(2) of whole blood were compared to simultaneous pulse oximetry saturations (SpO(2)). Data were analyzed to detect significant differences in SpO(2) readout failures between oximeters and average SpO(2) - SaO(2) +/- 1 SD for each oximeter. A total of 122 SaO(2) measurements were recorded; the median SaO(2) was 83% (57 - 100%). SpO(2) failures after cardiopulmonary bypass were 41% (25/61) for N versus 10% (6/61) for M (P < .001). There was a significant difference in bias (ie, average SpO(2) - SaO(2)) and precision (+/- 1 SD) between oximeters (N, 1.1 +/- 3.3 vs M, -0.2 +/- 4.1; P < .001) in the postcardiopulmonary bypass group but no significant difference in bias and precision between oximeters in the cyanotic congenital heart disease group (N, 2.9 +/- 4.6 vs M, 2.8 +/- 6.2; P = .848). The Nellcor N-395 pulse oximeter failed more often immediately after cardiopulmonary bypass than did the Masimo SET Radical pulse oximeter. SpO2 measured with both oximeters overestimated SaO2 in the presence of persistent hypoxemia.

Noncardiac surgery in children with hypoplastic left heart syndrome.

BACKGROUND/PURPOSE: Hospital mortality rate among children with hypoplastic left heart syndrome (HLHS) after cardiac repair is well documented, but comparable data after noncardiac, surgical procedures are unknown. The authors hypothesized an increasing number of noncardiac procedures were being performed on children with HLHS, less than 2 years of age, from 1988 to 1997, and that these procedures were associated with a substantial mortality rate. METHODS: A retrospective review of hospital discharge data for 2,457 children less than 2 years of age with HLHS for 1988 through 1997 was performed. The authors examined the outcomes of HLHS children undergoing only noncardiac surgical procedures during their hospital stay. Differences in hospital mortality rates between 1988 through 1992 versus 1993 through 1997 were assessed using the Chi2 square statistic. RESULTS: Nineteen percent of the 147 children with HLHS undergoing noncardiac, surgical procedures died (95% CI, 13% to 25%). Comparing the 2 study periods, there was no significant change in outcome among HLHS children undergoing noncardiac, surgical procedures (78% v. 83%; P >.1). There was no significant difference in the percentage of hospital discharges with noncardiac, surgical procedures performed per year. CONCLUSIONS: Although children with HLHS were not undergoing an increase in the number of noncardiac surgical procedures performed annually, even minor surgical procedures were associated with considerable mortality. Outcomes after noncardiac surgery in high-risk children with congenital heart disease warrant further investigation.

Evaluación 3 años después de realizados 61 tratamientos pulporradiculares / An evaluation 3 years after performing 61 pulporadicular treatments

Se realizan radiografías periapicales por el método de bisección a 47 pacientes que presentaban un total de 61 dientes con tratamientos pulporradiculares realizados con 3 o más años de antelación, con el fin de conocer la efectividad de los mismos y las principales causas que pudieran incidir en los tratamientos fracasados. Se detectaron 13 tratamientos fracasados, lo que representa el 21,3 por ciento de la muestra; además, el 42,6 por ciento de los conductos se encontraban instrumentados parcialmente; esto constituyó la principal causa de fracasos. En sentido general, no se encontraron diferencias apreciables en cuanto a las principales causas expresadas por otros autores