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.

Publication rates of congress abstracts is associated with abstract quality: Evaluation of Turkish National Medical Education Congresses and Symposia between 2010 and 2014 using MERSQI.

There are many parameters that could be used to evaluate the quality of scientific meetings such as publication rates of meeting abstracts as full-text articles after the meeting or scoring with validated quality scales/tools that evaluate individual papers, project proposals, or submitted abstracts. This study aimed to determine the full-text publication rates for abstracts presented at Turkish National Medical Education Congresses and Symposia and to assess the quality of given abstracts. Abstracts presented at national medical education congresses and symposia between 2010 and 2014 in Türkiye were evaluated. Initially, the abstracts were evaluated if they were published as full-text articles in international and national peer-reviewed journals following the meeting. Secondly, the quality of presented abstracts was assessed with the Medical Education Research Study Quality Instrument (MERSQI) scale. Overall publication rate for the abstracts was 11.3%. The publication rate of oral and poster presentations were 26.6% and 8.1%, respectively. Oral presentations had a statistically higher publication rate than poster presentations (p = .000). The mean MERSQI score for abstracts was 7.73 ± 2.59. The oral presentations had higher MERSQI mean scores than poster presentations (8.28 ± 2.46 vs. 7.61 ± 2.6; p = .032). Similarly, published abstracts had a significantly higher score compared to unpublished abstracts (10.07 ± 2.74 vs. 7.43 ± 2.41; p = .000). Interestingly, there was no statistical difference between the mean MERSQI scores of the published oral and poster presentations (9.33 ± 2.45 vs. 10.61 ± 2.72; p = .101). This study showed that the main factor for a meeting abstract to be published as a full-text article is the scientific quality of the study. The quality of presentations at annual medical education meetings in Türkiye were low compared with international meetings which did not improve over five years. An institutional policy that would set quality standards for medical education research and increase the awareness of researchers on the topic might help improve the design, execution, and reporting of such studies in Türkiye. The MERSQI could be a valuable tool to monitor the quality of submitted abstracts and to increase the awareness of novice researchers on high quality research.

Could lactate clearance be a marker of mortality in pediatric intensive care unit?

BACKGROUND: Hyperlactatemia is a common finding in critically ill patients and has significant prognostic implications. However, a single lactate measurement has not been correlated to mortality consistently. In this study, we aimed to correlate the clinical efficacy of lactate clearance for the prediction of mortality in pediatric intensive care unit patients. METHODS: This retrospective observational study was performed in the pediatric intensive care unit in patients with lactate level >3 mmol/lt. Initial, 6th h, and 24th h lactate levels were recorded and lactate clearance was calculated using these values (lactate level at admission - level 6 h later × 100/lactate level at admission). RESULTS: A total of 172 patients were included in the study. Forty-four out of 172 patients died. Median (IQR) lactate (mmol/L) at admission was low in those who survived in comparison to nonsurvivors 4.4 (3.1) vs. 5.75 (7.7) (p = 0.002). Clearance at 6th h was significantly lower in those who died (11.7%) than those who survived (36.7) (p = 0.001). 6th h lactate clearance level <20.7% predicted mortality with a sensitivity of 63.6% and specificity of 69.5% along with a positive predictive value of 41.8 and a negative predictive value of 84.8 (p = 0.004). Both lactate levels and lactate clearance values were significantly predictive factors for mortality (p < 0.05). Only a positive moderate correlation was found between the percentage of PRISM-IV % and 6th h lactate level. DISCUSSION: The present study revealed that lactate clearance is a simple and rapid risk-stratification tool holding to be a potential biomarker of managing the treatment efficacy of children in the pediatric intensive care unit.

The First Use of Pralidoxime in a Child With Rivastigmine Poisoning.

The aim of this report is to describe the successful use of pralidoxime in a pediatric patient who accidentally ingested 12 mg of rivastigmine and presented to the emergency department with weakness, drowsiness, hyporeactivity to environmental stimuli, and full cholinergic syndrome. CASE: The patient presented to the emergency department 2 hours after a suspected ingestion of rivastigmine. He was sleepy but oriented and cooperative, hypotonic, and hyporeflexic and has a Glasgow Coma Scale score of 13 (E3M6V4). Laboratory tests showed a low plasma cholinesterase levels of 2141 U/L (reference range, 5300-12 900 U/L), hyperglycemia (251 mg/dL), and leukocytosis with neutrophilia (21 900/mL, 75.2% neutrophils). CONCLUSIONS: Only 2 pediatric cases of rivastigmine poisoning have been reported in the literature, and there are no previous reports of using pralidoxime in the management of this poisoning. In the present case, intravenous pralidoxime (30 mg/kg) was administered twice at the fifth and sixth hours of ingestion for nicotinic and central effects. There is reasonable theoretical science to suggest pralidoxime in case of acetylcholinesterase inhibitor toxicity. We conclude that observed clinical improvement in weakness temporally associated with pralidoxime administration. Increased plasma cholinesterase activity after pralidoxime administration also makes it useful in this type of poisoning.

Severe hepatic sinusoidal obstruction syndrome in a patient with Wilms tumor and hereditary spherocytosis.

A 7-year-old girl with a history of splenectomy for hereditary spherocytosis (HS) was diagnosed with renal hematoma after a blunt abdominal trauma while receiving aspirin. Multiple erythrocyte transfusions and transarterial embolization were performed without success. Eventual nephrectomy revealed severely necrotic and perforated Stage III Wilms tumor (WT). Radiochemotherapy was administered, but by the eighth week, she developed severe hepatic sinusoidal obstruction syndrome (HSOS). Her ferritin level at the time was 3406 ng/ml. Defibrotide and aggressive supportive measures provided full recovery. The patient was given deferasirox for iron chelation therapy and finished her treatment without incident. To our knowledge, just one patient with HS and WT has been described in the literature. The role of iron excess in HSOS pathogenesis in non-transplant patients has not been addressed before either. Transfusional hyperferritinemia, in addition to chemotherapeutics and radiation, may have contributed to the development of severe HSOS in our patient.

A Comparative Analysis of Pediatric Emergency Department Admissions Before and During the COVID-19 Pandemic.

Objectives This study aims to evaluate the outbreak's impact on emergency services, with findings obtained from patients who applied to our pediatric emergency service before and during the pandemic period. Methods In this study, the Pediatric Emergency Polyclinic of Hatay Mustafa Kemal University (MKU) Department of Pediatrics was evaluated during the COVID-19 pre-pandemic period and the COVID-19 pandemic period. Demographic features, complaints, discharge situations, diagnostic groups, and diagnoses of 16,730 non-traumatic patients one month to 18 years old were compared retrospectively. Results Comparing the pre-pandemic period and the pandemic period, it was determined that there was a statistically significant difference in the average age of patients, age groups, admission hours, triage classification, complaints, and diagnoses seen. Conclusion According to the findings obtained in the study, pediatric emergency department admissions decreased significantly during the pandemic period. As a result of the pandemic measures taken, the incidence of diseases caused by infectious agents, such as respiratory tract infections, decreased. The change in pediatric emergency service habits with the pandemic highlights the importance of conducting more comprehensive epidemiological studies in terms of more efficient and effective use of pediatric emergency health services in Turkey.

Evaluation of renal near-infrared spectroscopy for predicting extubation outcomes in the pediatric intensive care setting.

Background: In pediatric intensive care units, extubation failure following invasive mechanical ventilation poses significant health risks. Determining readiness for extubation in children can minimize associated morbidity and mortality. This study investigates the potential role of renal near-infrared spectroscopy (RrSO2) in predicting extubation failure in pediatric patients. Methods: A total of 84 patients aged between 1 month and 18 years, mechanically ventilated for at least 24 h, were included in this prospective study. RrSO2 levels were measured using near-infrared spectroscopy before and during an extubation readiness test (ERT). The primary outcome measure was extubation failure, defined as a need for reintubation within 48 h. Results: Of the 84 patients, 71 (84.6%) were successfully extubated, while 13 (15.4%) failed extubation. RrSO2 was found to be lower in the failed extubation group, also decrease in RrSO2 values during ERT was significantly greater in patients with extubation failure. ROC analysis indicated a decrease in ΔRrSO2 of more than 6.15% from baseline as a significant predictor of extubation failure, with a sensitivity of 0.984 and a specificity of 0.889. Conclusion: Monitoring changes in RrSO2 values may serve as a helpful tool to predict extubation failure in pediatric patients. Further multi-center research is warranted to improve the generalizability and reliability of these findings.

Spectrofluorimetric determination of aliskiren in tablets and spiked human plasma through derivatization with dansyl chloride.

A simple and sensitive method has been developed and validated for the determination of aliskiren (ALS) in its dosage forms and spiked plasma. The method was based on the reaction of the drug with dansyl chloride in the presence of bicarbonate solution of pH 10.5 to give a highly fluorescent derivative which was measured at 501 nm with excitition at 378 nm in dichloromethane. Different experimental parameters affecting the development of the method and stability were carefully studied and optimized. The calibration curves were linear over the concentration ranges of 100-700 and 50-150 ng/mL for standard solution and plasma, respectively. The limits of detection were 27.52 ng/mL in standard solution, 4.91 ng/mL in plasma. The developed method was successfully applied to the analysis the drug in the commercial tablets and spiked plasma samples. The mean recovery of ALS from tablets and plasma was 100.10 and 97.81%, respectively. A proposal of the reaction pathway was presented.

Automated closed-loop FiO2 titration increases the percentage of time spent in optimal zones of oxygen saturation in pediatric patients-A randomized crossover clinical trial.

Introduction: We aimed to compare automated ventilation with closed-loop control of the fraction of inspired oxygen (FiO2) to automated ventilation with manual titrations of the FiO2 with respect to time spent in predefined pulse oximetry (SpO2) zones in pediatric critically ill patients. Methods: This was a randomized crossover clinical trial comparing Adaptive Support Ventilation (ASV) 1.1 with use of a closed-loop FiO2 system vs. ASV 1.1 with manual FiO2 titrations. The primary endpoint was the percentage of time spent in optimal SpO2 zones. Secondary endpoints included the percentage of time spent in acceptable, suboptimal and unacceptable SpO2 zones, and the total number of FiO2 changes per patient. Results: We included 30 children with a median age of 21 (11-48) months; 12 (40%) children had pediatric ARDS. The percentage of time spent in optimal SpO2 zones increased with use of the closed-loop FiO2 controller vs. manual oxygen control [96.1 (93.7-98.6) vs. 78.4 (51.3-94.8); P < 0.001]. The percentage of time spent in acceptable, suboptimal and unacceptable zones decreased. Findings were similar with the use of closed-loop FiO2 controller compared to manual titration in patients with ARDS [95.9 (81.6-98.8) vs. 78 (49.5-94.8) %; P = 0.027]. The total number of closed-loop FiO2 changes per patient was 52 (11.8-67), vs. the number of manual changes 1 (0-2), (P < 0.001). Conclusion: In this randomized crossover trial in pediatric critically ill patients under invasive ventilation with ASV, use of a closed-loop control of FiO2 titration increased the percentage of time spent within in optimal SpO2 zones, and increased the total number of FiO2 changes per patient. Clinical trial registration: ClinicalTrials.gov, identifier: NCT04568642.

Randomized crossover trial to compare driving pressures in a closed-loop and a conventional mechanical ventilation mode in pediatric patients.

INTRODUCTION: In mechanically ventilated patients, driving pressure (ΔP) represents the dynamic stress applied to the respiratory system and is related to ICU mortality. An evolution of the Adaptive Support Ventilation algorithm (ASV® 1.1) minimizes inspiratory pressure in addition to minimizing the work of breathing. We hypothesized that ASV 1.1 would result in lower ΔP than the ΔP measured in APV-CMV (controlled mandatory ventilation with adaptive pressure ventilation) mode with physician-tailored settings. The aim of this randomized crossover trial was therefore to compare ΔP in ASV 1.1 with ΔP in physician-tailored APV-CMV mode. METHODS: Pediatric patients admitted to the PICU with heterogeneous-lung disease were enrolled if they were ventilated invasively with no detectable respiratory effort, hemodynamic instability, or significant airway leak around the endotracheal tube. We compared two 60-min periods of ventilation in APV-CMV and ASV 1.1, which were determined by randomization and separated by 30-min washout periods. Settings were adjusted to reach the same minute ventilation in both modes. ΔP was calculated as the difference between plateau pressure and total PEEP measured using end-inspiratory and end-expiratory occlusions, respectively. RESULTS: There were 26 patients enrolled with a median age of 16 (9-25 [IQR]) months. The median ΔP for these patients was 10.4 (8.5-12.1 [IQR]) and 12.4 (10.5-15.3 [IQR]) cmH2O in the ASV 1.1 and APV-CMV periods, respectively (p < .001). The median tidal volume (VT) selected by the ASV 1.1 algorithm was 6.4 (5.1-7.3 [IQR]) ml/kg and RR was 41 (33 50 [IQR]) b/min, whereas the median of the same values for the APV-CMV period was 7.9 (6.8-8.3 [IQR]) ml/kg and 31 (26-41[IQR]) b/min, respectively. In both ASV 1.1 and APV-CMV modes, the highest ΔP was used to ventilate those patients with restrictive lung conditions at baseline. CONCLUSION: In this randomized crossover trial, ΔP in ASV 1.1 was lower compared to ΔP in physician-tailored APV-CMV mode in pediatric patients with different lung conditions. The use of ASV 1.1 may therefore result in continued, safe ventilation in a heterogeneous pediatric patient group.

A neglected cause of recurrent rhabdomyolysis, LPIN1 gene defect: a rare case from Turkey.

BACKGROUND: Rhabdomyolysis; can occur due to toxic, infectious, metabolic, and genetic causes. Severe rhabdomyolysis may progress to several clinical manifestations such as cardiac arrest and may pose a risk of mortality if it is not treated timely. CASE: In this article, we presented a 26-month-old patient who was admitted with an acute rhabdomyolysis attack and a venovenous hemodiafiltration (CVVHDF) was initiated on the 5th hour of hospitalization. Creatine kinase (CK) levels of the patient continued to increase (max: 943 452 IU/L) until the 5th day of treatment and hereafter began to decrease. As the common causes of rhabdomyolysis were excluded and the CK levels were the highest values reported in the literature, although, LPIN1 deficiency was the most suspected diagnosis, to facilitate the diagnostic procedures a whole-exome sequencing was performed. A homozygous [c.1696G > C p. (Asp566His)] mutation was detected on LPIN1 gene. This variant has not been described previously, however, when examined with programs such as SIFT and Mutation taster, it has been considered as pathogenic. CONCLUSION: In the pediatric age group, especially in infants presenting with severe rhabdomyolysis, LPIN1 deficiency should also be considered; as early diagnosis and appropriate treatment may reduce mortality.

The colonization rate of needleless connector and the impact of disinfection for 15 s on colonization: A prospective pre- and post-intervention study.

PURPOSE: The optimal scrubbing time for the disinfection of the surface of needleless connectors has not been determined. The evidence for successful needleless connector decontamination with 70% isopropyl alcohol ranges from 5 to 60 s. The aim of this prospective study was to identify colonization on the external surface of needleless connectors on central venous catheters and measure the efficiency of 15 s of scrubbing with 70% alcohol. METHOD: A total of 31 patients were included. Samples were collected adhering to aseptic no-touch technique policies. Two samples were collected from the injectable surface of the needleless connector with sterile sodium chloride 0.9% moistened and a dry swab from the same site. Then the surface was scrubbed with alcohol 70% for 15 s for disinfection and second couples of samples for the cultures were taken after disinfection. FINDINGS: A total of 420 swabs were obtained. The number of colonization (equal or higher than 15 CFU/plate) was present on 21 of the needleless connectors (20.0%). Coagulase-negative staphylococci was responsible for all the colonization. After disinfection for 15 s, no isolation exceeding 1 CFU/plate was present. CONCLUSION: Scrubbing for 15 s with 70% alcohol was found to be successful at elimination of colonization of the surface of needleless connector even in high microorganism counts.

Assesment of perinatal mortality in two different periods: results of a single center.

AIM: This study aimed to investigate the perinatal mortality rate with 37 864 deliveries which occured in two different periods in a single center, to compare the components of perinatal mortality and affecting factors with the results of the study related with perinatal mortality which we conducted in 1999 and to emphasize the precautions directed to reduce mortality rates. MATERIAL AND METHODS: All live births and stillbirths which occurred in Bakirköy Obstetrics and Pediatrics Training and Research Hospital between January 2007 and December 2007 were evaluated. The results were compared with the results of the study conducted in 1999. Newborns with a weight above five hundred grams and a gestational age above 22 weeks were enrolled in the study. The stillbirth rate, early neonatal mortality rate, late neonatal mortality rate, perinatal mortality rate and corrected perinatal mortality rate were calculated. Modified Wigglesworth Classification was used for evaluating the perinatal mortality and the subjects were examined in 7 groups. The characteristics belonging to the years of 2007 and 1999 were examined, the differences were recorded and the results were discussed. When the two periods were compared, it was observed that the perinatal mortality rate increased from 23.5‰ to 26‰. RESULT: When the causes were investigated, it was observed that the stillbirth rate was increased in 2007 (84%) and especially congenital anomalies had an important role in this increment. The early neonatal mortality rate declined from 0.8% in 1999 to 0.4% in 2007. It was found that especially the premature mortality rate (Group 3) and the mortality rate related with perinatal asphyxia (Group 4) were significantly decreased. CONCLUSION: The decrease in early neonatal mortality rate could be best explained by productive operation of the new neonatal intensive care unit which had been established after 2002.

Outcome of Candida Parapsilosis Complex Infections Treated with Caspofungin in Children.

BACKGROUND: We aimed to evaluate the correlation of caspofungin E-tests with the prognosis and response to caspofungin therapy of Candida parapsilosis complex bloodstream infections in children hospitalized in a pediatric intensive care unit. METHODS: All children who had C. parapsilosis complex bloodstream infections and who were treated with caspofungin were included in this retrospective study. For each patient, the following parameters, including all consecutive blood and central venous catheter (CVC) cultures, the duration between diagnosis and CVC removal, mortality rate, relapses of the C. parapsilosis complex infections as well as the demographic features, were recorded. RESULTS: The central venous catheter survival rate was 33.3% under caspofungin treatment. In 92.4 % of the patients, the negative culture was achieved within a median duration of 12.5 days. The rate of relapses was 18.9%. The overall mortality rate was 37.7% (20 of 53 patients), and the 30-days mortality rate was 7.5% (4 of 53 patients). There was no statistically significant difference between the groups with MIC<2 mg/l and MIC =2 mg/l using CVC survival rate; rate and duration of achieving negative blood culture for C. parapsilosis complex; duration of hospital stay; rate and duration of relapses; overall mortality and 30-days mortality. CONCLUSIONS: The beneficial effects of Caspofungin on biofilms has been shown in vivo, while its impact in children for maintenance of CVC was limited in our study but should not be underestimated in children who strongly need the presence of CVCs. The clinicians should weigh their priority for their patients and choose the optimal antifungal therapy for C. parapsilosis complex infections in children.