Creation and evaluation of a participatory child abuse and neglect workshop for medical students.

BACKGROUND: Since child abuse and neglect (CAN) is prevalent worldwide, medical students should acquire basic knowledge, skills, and confidence in identifying and addressing CAN. Although significant educational efforts have been previously described, none has focused on using participatory methods to teach medical students CAN. PURPOSE: To: 1) develop a participatory educational workshop in CAN for medical students, 2) gather, train, and establish a peer-to-peer teaching group, and 3) assess the effectiveness of the workshop in gain of knowledge and improvement of self-confidence for participants. METHODS: A two-hour workshop was created with role-playing, the use of mannikins and peer-to-peer teaching. A 15-item knowledge and a 9-item self-confidence questionnaire were used before, right after, and six months after each workshop. RESULTS: Nine workshops in two academic pediatric departments with a total attendance of 300 6th year medical students were conducted. For the 69 students who completed the questionnaires at all three times, there were statistically significant gains in knowledge right after (p < .001) and six months after (p < .0001) the workshops. Similarly, self-confidence increased right after (p < .0001) and six months after (p < .001) the workshops. Self-selection bias testing indicated that these 69 students who completed all three questionnaires were representative of those who completed the pre-testing and the testing right after. CONCLUSIONS: We successfully established a peer-to-peer teaching group to conduct nine participatory workshops that improved the participants' knowledge and self-confidence in CAN. This feasible and novel active learning approach may help address inadequacies in medical curricula.

Vulvar Ulcers in Children: Dramatic But Self-Limited.

OBJECTIVE: We aimed to describe our experience in diagnosing and managing Lipschutz ulcers in children. METHODS: This was a retrospective data review in a tertiary referral clinic for pediatric and adolescent gynecology. We identified patients referred with a vulval ulcer and recorded relating symptoms, presentation, and resolution. RESULTS: We identified 7 nonsexually active girls with vulvar ulcers presenting within the course of an upper respiratory infection, including fever and cough. Average age was 12.25 years (range, 11-14.5 years). All patients presented with at least one large painful ulcer within the inner surface of the labium minor, of up to 2 cm in diameter.Initial presentation was of a bullous lesion that was then ulcerated, covered by a black gangrenous scab. Over the course of the week, the scab fell leaving a white-based ulcer that gradually healed. All children complained of dysuria stemming from contact irritation with urine. The ulcer gradually disappeared, leaving no mark within 10 days of initial presentation.Two of 7 patients presented with 3 similar recurrences after flu-like symptoms.None of the patients qualified for diagnosis of Behcet disease. CONCLUSIONS: Lipschutz ulcers are painful genital lesions causing anxiety to the girl and her family. Pediatricians and gynecologists should be aware of the condition, diagnose it where appropriate, avoid unnecessary medication, and reassure the patient that it is self-limited.

Child Car Safety: A Parental Survey at a Tertiary Care Emergency Treatment Center in Greece.

OBJECTIVES: This study aimed to assess parental behavior in terms of child restraint systems (CRS) use under emergency conditions while driving to the hospital's outpatient settings as well as their routine child car safety (CCS) practices. METHODS: A cross-sectional survey of parents/caregivers transporting children 13 years or younger was conducted at the Emergency Treatment Center of a pediatric tertiary care center in Athens, Greece. Participants completed a questionnaire inquiring about the possession of CRS, and type and use of appropriate CRS while driving to the Emergency Treatment Center and under routine conditions. In addition, presence and type of parental education with regard to CCS and the use of seat belts among drivers were assessed. RESULTS: Of 444 participants, 51.4% children were carried restrained, although 48.6% were fastened in an improper seat for their age, in contrast with 23.7% who travel unrestrained on a daily basis. Forward-facing restraint seats were most popular, with 53.9% total use even in children younger than 2 years or older than 4 years, whereas booster seats (9.4%) and rear-facing restraint seats (18.2%) were inappropriately disfavored. Children younger than 4 years, male drivers, and drivers who had received information on CCS had higher odds of using CRS. The proportion of those had never been provided any CCS education was 38.5%. CONCLUSIONS: Child restraint systems use was inappropriately low under routine conditions and declined even further under emergency circumstances. Most children younger than 2 years and older than 4 years traveled inappropriately restrained in a forward-facing restraint seat. Parents should be more intensively educated on child car safety seat and the proper CRS use.

A national educational campaign to raise awareness of child physical abuse among health care professionals.

Education is necessary to improve child physical abuse detection and management. A few studies have described national child abuse training programs, but none has measured changes in knowledge among participants. A collaboration of child abuse experts from the USA, an academic pediatric department, and a non-governmental organization in child protection aimed at (a) training hospital physicians in a train-the-trainer course for the detection and management of child physical abuse and (b) conducting workshops and measuring attendance and gain of knowledge of participants. A train-the-trainer and a national curriculum were created. A 78-item and a 20-item knowledge questionnaire were used pre and post the train-the-trainer course and all workshops, respectively. Nineteen physicians from all pediatric departments of the seven medical schools in Greece attended the course. Eight workshops in seven cities took place with a total attendance of 1220 health care professionals. Gain of knowledge was demonstrated for participants in the train-the-trainer course (p = 0.0015) and local workshops (p < 0.001).Conclusion: We successfully engaged physicians from all medical schools in Greece and conducted a train-the-trainer module and eight workshops in major cities that improved the participants' knowledge in child physical abuse. This approach may help address physician deficiencies in emerging areas of child abuse clinical practice. What is Known: • Education is necessary to improve child physical abuse detection and management. • Although national training programs have been described, none has measured participants' changes in knowledge. What is New: • A collaboration of child abuse experts, all medical schools in Greece, and a non-governmental organization resulted in a national educational campaign in child physical abuse and gains in knowledge for participants. • This approach may help address deficiencies in emerging areas of clinical practice.

Adolescents and young women with functional hypothalamic amenorrhoea: is it time to move beyond the hormonal profile?

PURPOSE: To ascertain the role of deranged eating behaviours (DEBs) in the development of functional hypothalamic amenorrhoea (FHA) and the reciprocal role of psychopathological traits on both disorders. METHODS: A prospective case-control study was conducted spanning the period January 2016 to April 2018. Forty-one consecutive FHA females and 86 healthy controls were recruited. We assessed the DEBs and other FHA predisposing factors via self-reported questionnaires. Possible correlations amongst the variables were examined using the Spearman's correlation coefficient (rho), whilst multivariate logistic regression was carried out to identify independent predictors of DEBs. RESULTS: Mean scores on Eating Attitudes Test-26 (EAT-26) were significantly higher in females with FHA (p < 0.0001). Women with FHA were characterised by significantly higher scores at the sub-scale items of dieting (p = 0.03) and bulimia and food preoccupation (p < 0.001) compared to healthy controls. Significant difference was also observed between the mean scores of the two groups in all other questionnaires: State-Trait-Anxiety-Inventory (STAI) (p < 0.0001), Multidimensional Body-Self-Relations Questionnaire (MBSRQ) (p < 0.0001) and International Physical Activity Questionnaire (IPAQ) (p = 0.004). EAT-26 scores were positively correlated with scores on STAI (ρ = 0.26, p = 0.04), MBSRQ (ρ = 0.79, p < 0.0001) and IPAQ (ρ = 0.35, p = 0.03). High scores on IPAQ and STAI were correlated with a 12.2-fold (p = 0.008) and 4.3-fold (p = 0.04) increased risk for high scores on EAT-26 respectively. CONCLUSIONS: DEBs may occur in FHA populations at a higher frequency compared to the general population. Anxiety and overweight preoccupation may underlie and independently contribute to development and maintenance of both DEBs and FHA. This evidence may have future implications for both screening and interventions that target DEBs and other psychological factors.

Diabetic neuropathy in children and adolescents with type 1 diabetes mellitus: Diagnosis, pathogenesis, and associated genetic markers.

Diabetic neuropathy (DN) is a common long-term complication of type 1 (T1D) and type 2 (T2D) diabetes mellitus, with significant morbidity and mortality. DN is defined as impaired function of the autonomic and/or peripheral nervous system, often subclinical, particularly in children and adolescents with T1D. Nerve conduction studies (NCS) and skin biopsies are considered gold-standard methods in the assessment of DN. Multiple environmental and genetic factors are involved in the pathogenesis of DN. Specifically, the role of metabolic control and glycemic variability is of paramount importance. A number of recently identified genes, including the AKR1B1, VEGF, MTHFR, APOE, and ACE genes, contribute significantly in the pathogenesis of DN. These genes may serve as biomarkers to predict future DN development or treatment response. In addition, they may serve as the basis for the development of new medications or gene therapy. In this review, the diagnostic evaluation, pathogenesis, and associated genetic markers of DN in children and adolescents with T1D are presented and discussed.

Home Blood Pressure Monitoring in Children and Adolescents: Systematic Review of Evidence on Clinical Utility.

PURPOSE OF REVIEW: For the accurate diagnosis and management of hypertension, out-of-office blood pressure evaluation using ambulatory (ABPM) or home monitoring (HBPM) is currently recommended. In children, there is considerable evidence on the clinical utility of ABPM, whereas the evidence on HBPM is limited. This systematic review presents (i) the benefits of HBPM in children; (ii) the evidence on normal range, diagnostic accuracy, and relationship with preclinical organ damage; and (iii) guidance for devices, monitoring schedule, and interpretation. RECENT FINDINGS: HBPM is a useful adjunct to the conventional office measurements for the evaluation of children with suspected or treated hypertension. HBPM is feasible in children and has good reproducibility, diagnostic accuracy and acceptability by users, and relatively low cost. Thus, it has greater potential for widespread and long-term use than ABPM, which is more expensive and often not available or not tolerated. Automated monitors that have been clinically validated specifically in children should be used with appropriate cuff size. HBPM for 7 days (minimum 3) with duplicate morning and evening measurements (minimum 12 readings) should be performed in children with suspected or treated hypertension before each office visit. Until more data become available, in case of diagnostic disagreement between office blood pressure and HBPM, treatment decisions should be based on ABPM. HBPM is clinically useful in children with hypertension. More research is needed on its clinical application, and more automated devices need to be clinically validated in this population.

Quantiferon-Cytomegalovirus assay: A potentially useful tool in the evaluation of CMV-specific CD8+ T-cell reconstitution in pediatric hematopoietic stem cell transplant patients.

Pediatric HSCT recipients are at high risk for CMV reactivation due to their immature immune system and therapy following transplantation. Reconstitution of CMV-specific T-cell immunity is associated with control and protection against CMV. The clinical utility of monitoring CMV-specific CMI to predict CMV viremia in pediatric HSCT patients using the Quantiferon-CMV (QIAGEN® ) test was investigated prospectively. Thirty-seven pediatric allogeneic HSCT recipients were enrolled from 3/2010-6/2012. CMV viremia was detected via weekly real-time PCR. The Quantiferon-CMV test was conducted pretransplant, early after transplantation, 30, 90, 180, 270, and 360 days post-transplantation. The incidence of CMV viremia was 51% (19/37) with half of the episodes within ≤30 days post-transplant. Fifteen patients showed CMV-specific immunity (average of 82 days). The cumulative incidence of CMV reactivation in patients who developed CMV-specific immunity was lower than those who did not (15% vs 53%; P = .023). The ROC statistical analysis showed that the AUC was 0.725 in predicting viremia, for Quantiferon-CMV test. In this cohort, the Quantiferon-CMV assay was a valuable method for identifying pediatric HSCT patients at high risk for CMV viremia, suggesting potential clinical utility to individualize patient's management post-transplant.

A cohort of children with type 1 diabetes in Greece: predictors of direct costs of care.

AIM: To examine the predictors of direct costs of pediatric type 1 diabetes (T1D) in a hospital-based outpatient clinic in Greece. METHODS: The outpatient records of 89 children and adolescents (mean age: 12.05 ± 5.15 y) with T1D followed in the Second Department of Pediatrics, University of Athens Medical School, were analyzed. RESULTS: The mean ± SD diabetes duration was 4.9 ± 3.88 y (range: 0.25-17) and glycated hemoglobin (HbA1c) was 8.2 ± 1.09% (66 ± 11.9 mmol/mol). A total of 80% of patients were on multiple daily injections regimen, 10% on pump therapy, and 10% on conventional regimen. Total direct costs per patient-year (ppy) were estimated at €2.712 [95% confidence interval (CI): 2.468-2.956]. Supply costs accounted for 73.7% of total costs and were the highest for pump therapy (P < .001). Multivariate linear regression analysis showed that costs were significantly higher for children (1) on multiple daily injections or pump therapy (r = 0.364, P < .001), (2) of older age (r = 0.25, P < .001) and (3) higher daily insulin dose (r = 0.46, P < .001). Patients on pump therapy had significantly higher costs €5.538 (95%CI 4480-6597) compared with patients on multiple daily injections €2.447 (95% CI 2320-2574) and conventional regimen €1.978.5 (95%CI 1682-2275) (P = .0001). Patients on pump therapy had better glycemic control compared with all other patients [HbA1c (mean ± SD): 7.2% ± 1.0 vs 8.3% ±1.5, P = .039]. CONCLUSION: The total T1D cost in this cohort of Greek children was €2712 ppy. The main factor that predicted direct cost was the use of pump. However, pump therapy was associated with better glycaemic control, which may decrease the risk of total long-term diabetes care cost.

Delayed treatment of the first febrile urinary tract infection in early childhood increased the risk of renal scarring.

AIM: This study evaluated the controversial relationship between the duration of fever before treatment initiation (FBT) for a febrile urinary tract infection (UTI), with renal scarring based on dimercaptosuccinic acid scintigraphy (DMSA) findings. METHODS: The inpatient records of 148 children under two years of age with a first episode of febrile UTI were analysed. Acute and repeat DMSA findings, and clinical and laboratory parameters were evaluated. RESULTS: Acute DMSA showed that 76 of the 148 children with a febrile UTI had renal lesions: 20 were mild, and 56 were moderate or severe. Repeat DMSA showed renal scarring in 34 patients. The only factors associated with the development of renal scars in the repeat DMSA were FBT of more than 72 hours, the presence and severity of vesicoureteral reflux and increased procalcitonin levels and absolute neutrophil counts. Multiple regression analysis showed that an FBT above 72 hours was the only significant factor that predicted renal scars. CONCLUSION: Delay in treatment initiation of 72 hours or more was a risk factor for permanent renal scars after the first episode of febrile UTI. Other associated factors were increased procalcitonin and absolute neutrophil count on admission and the presence and severity of vesicouretal reflux.

Postinfectious Rhabdomyolysis in a 5-Year-Old Boy: When to Look a Little Deeper.

UNLABELLED: We report on a 5-year-old boy with recurrent severe postinfectious rhabdomyolysis who, after systematic stepwise evaluation, was found to have the adult form of carnitine palmityl transferase II (CPT II) deficiency directly by blood mutation analysis. Timely diagnosis of CPT II deficiency in this case prevented further potentially devastating episodes of rhabdomyolysis by avoiding triggering factors. CONCLUSION: Although most cases of rhabdomyolysis are nonrecurrent and benign, a metabolic myopathy, such as CPT II deficiency, should be suspected in children with episodic muscle necrosis and paroxysmal myoglobinuria.

The Mediating Role of Anxiety in the Relationship between Job Satisfaction and Psychosocial Functions of Nurses and Pediatricians in PICUs.

Background: Job satisfaction refers to an individual's overall attitude towards their job. It is influenced by various factors such as work environment, job role, work-life balance, compensation, anxiety, opportunities for growth and development. However, low levels of job satisfaction can have a significant impact on an individual's mental health and overall well-being. Objective: We contacted this study in order to assess the effect of PICU nurses' and pediatricians' job satisfaction on their psychosocial functioning and to examine the role of anxiety as a mediating factor in this relationship. Methods: A sample of 155 nurses and pediatricians at 7 University Hospitals in Greece has consented to participate in the study. Socio-demographic data, Hamilton Rating Scale for Anxiety, Minnesota Satisfaction Questionnaire -short form and a Brief Inventory of Psychosocial Functioning were used to evaluate anxiety, job satisfaction and psychosocial functions. Results: According to our results, participants with moderate or severe levels of anxiety showed moderate or low job satisfaction, while moderate or severe anxiety was also associated with low levels of participants' psychosocial functioning. Job satisfaction is a dynamic situation that is affected by the levels of anxiety of each worker in PICU. Conclusion: The presence of anxiety may be related to comorbid mental health disorders since it affects the psychosocial functions of the worker. We propose a longer rest period, a change of department in case an employee wishes it or shows symptoms of increased stress or another mental health disorder, regular assessments by mental health experts for all PICU's staff and support after a diagnosis of a mental health problem.

Post-Traumatic Stress Disorder Symptoms among Pediatric Healthcare Workers.

Post-traumatic stress disorder symptoms related to work in pediatric departments aremajor public health problems, as they directly affect health organizations, healthcare workers, and, due to the poor quality of care, the patients as well. The post-traumatic symptoms that a healthcare worker may experience are related to intrusion, avoidance, negative changes in cognition and mood, and changes in arousal and reactivity. The aim of the present investigation was to identify risk factors that contribute to the development of PTSD in pediatric healthcare workers, in order to implement necessary workplace measures. A sample of four hundred and forty-five pediatric workers at seven Greek public hospitals consented to participate in the survey. Socio-demographic data and a post-traumatic checklist (5th edition) were used to diagnose post-traumatic stress disorder. According to the results, risk factors for the development of post-traumatic symptoms include medical or nursing errors, threats to a child's life, and incidents of workplace bullying. More specifically, 25.2% of the participants had a provisional PTSD diagnosis, 72.8%of the sample experienced an incident involving a medical or nursing error in their workplace related to the treatment or care of a child, 56% experienced an incident involving a child's death or a threat to a child's life due to a serious illness or injury, and 55.5% experienced an incident of workplace bullying. In addition, it was found that having a university-level education, master's, or PhD, working in a circular shift, being assigned to a department by management rather than the worker, and dissatisfaction with salary were associated with post-traumatic stress disorder. The high rates of PTSD symptoms among participants highlight the need for prevention and management measures to protect and support the mental health of workers in pediatric departments. We propose frequent evaluations of the mental health of employees, more time for rest, incentives for professional development, utilization of their specializations and specialties, support from mental health specialists when symptoms are diagnosed, and the option for employees to change departments if they wish or if they show symptoms of mental trauma.

A toddler with severe vitamin D-dependent rickets type 1 A (VDDR1A), hungry bone syndrome, and severe RSV infection: presentation and therapeutic challenges.

BACKGROUND: Vitamin D-dependent rickets type 1 A (VDDR1A) is an autosomal recessive disorder due to mutations in the CYP27B1 gene which result in inability to generate 1,25(OH)2D. CASE PRESENTATION: An 18-month-old boy with VDDR1A presented with hypotonia and respiratory distress. He had been diagnosed 2 months earlier, having been evaluated for stunted growth, hypotonia, and delayed developmental milestones. He was stabilized with oxygen and bronchodilators for his bronchiolitis and high doses of alfacalcidol, calcium, and phosphate supplements for his hungry bone syndrome. Of note, the patient sustained upper limb fractures after a fall from his bed during admission. Overall, he had a protracted disease course; however, his bone profile gradually improved and he steadily recovered. CONCLUSION: VDDR1A causes failure to thrive, hypotonia, and increased fracture risk and may complicate the clinical course of lower respiratory tract infections. Furthermore, management of hungry bone syndrome requires supraphysiologic doses of vitamin D metabolites and calcium.

Transient effect of anti-CD20 therapy in a child with 22q11.2 deletion syndrome and severe steroid refractory cytopenias: a case report.

We report on the development of steroid-refractory recurrent cytopenias in a child with 22q11.2 deletion syndrome. His first hematological complication was autoimmune hemolytic anemia at 3 months of age. Thereafter, he developed severe autoimmune cytopenias of all 3 hematological lineages with poor response to steroids and intravenous immunoglobulin. At the age of 2½ years, a course of anti-CD20 therapy (Rituximab) was given with transient hematological recovery. Because of persistent symptoms, bone marrow transplantation from a matched unrelated donor was performed. Although the data in the use of anti-CD20 therapy in children with 22q11.2 deletion syndrome and autoimmune cytopenias are limited, our experience suggests its potential benefit.

SARS-CoV-2 vaccination in children and adolescents with and without type 1 diabetes mellitus.

Adults with Diabetes Mellitus (DM) have increased risk of severe clinical presentation during COVID-19 infection, while children and adolescents with type 1 diabetes (T1D) have the same mild clinical course as their healthy peers, especially those with optimal glycemic control. The present review focuses on the necessity of COVID-19 vaccination among children and adolescents with T1D, and also in their non-diabetic peers. The efficacy and safety of COVID-19 vaccines are also discussed, as well as their various side-effects, ranging from common mild to very rare and serious ones. Furthermore, the results of COVID-19 vaccination of adolescents with and without T1D are reported, as well as the efficacy and concerns about childhood vaccination. It is concluded that patients with DM of all age groups should maintain optimal diabetic control in order to avoid glycemic deterioration during COVID-19 infection. Furthermore, despite the very rare and serious complications of COVID-19 vaccines, vaccination against COVID-19 is recommended for children and adolescents with T1D to prevent glycemic deterioration and rare but serious complications of COVID-19 infection.

Lifestyle and Pharmacological Interventions and Treatment Indications for the Management of Obesity in Children and Adolescents.

Obesity is a multifactorial chronic impairment that further decreases quality of life and life expectancy. Worldwide, childhood obesity has become a pandemic health issue causing several comorbidities that frequently present already in childhood, including cardiovascular (hypertension, dyslipidemia), metabolic (Type 2 diabetes mellitus, fatty liver disease, metabolic syndrome), respiratory, gastrointestinal and musculoskeletal disorders. In addition, obese children frequently experience stress and psychosocial symptoms, including mood disorders, anxiety, prejudice and low self-esteem. Given that cardiovascular risk factors and pediatric obesity have the tendency to pertain into adulthood, obesity management, including weight control and physical activity, should start before the late teens and certainly before the first signs of atherosclerosis can be detected. This review aims to concisely present options for childhood obesity management, including lifestyle modification strategies and pharmacological treatment, as well as the respective treatment indications for the general practitioner.

Covid-19 infection in children and adolescents and its association with type 1 diabetes mellitus (T1d) presentation and management.

Children seem to be affected by the new SARS-CoV-2 virus less severely than adults, with better prognosis and low mortality. Serious complications of COVID-19 infection in children include multisystem inflammatory response syndrome in COVID-19 infection (MIS-C), myo-or pericarditis and, less frequently, long COVID syndrome. On the other hand, adults with type 1 (T1D) or type 2 diabetes (T2D) are among the most vulnerable groups affected by COVID-19, with increased morbidity and mortality. Moreover, an association of SARS-CoV-2 with diabetes has been observed, possibly affecting the frequency and severity of the first clinical presentation of T1D or T2D, as well as the development of acute diabetes after COVID-19 infection. The present review summarizes the current data on the incidence of T1D among children and adolescents during the COVID-19 pandemic, as well as its severity. Moreover, it reports on the types of newly diagnosed diabetes after COVID infection and the possible pathogenetic mechanisms. Additionally, this study presents current data on the effect of SARS-CoV-2 on diabetes control in patients with known T1D and on the severity of clinical presentation of COVID infection in these patients. Finally, this review discusses the necessity of immunization against COVID 19 in children and adolescents with T1D.

The role of various influence sources on sexual behavior in adolescents with type 1 diabetes in comparison to healthy peers: a cross-sectional study from Greece.

PURPOSE: Patients with type 1 diabetes mellitus (T1D) are at increased risk of sexually risky behaviors, such as unintended pregnancies. Adolescents with T1D use different sources of information on sexual education such as parents, friends, teachers, and the media. The study aim was to investigate the effect of different sources of information in development of sexual risk behaviors in T1D adolescents in comparison to healthy peers. METHODS: The study included 174 adolescents (58 adolescents with T1D and 116 healthy controls). Anonymous questionnaires were used to evaluate sexually risky behaviors. RESULTS: T1D adolescents were more frequently asking advice from friends on sexual matters concerning the opposite sex (p = 0.026) and from school teachers (p = 0.059) when compared to controls. The proportion of sexually active T1D adolescents who had ever consumed alcohol before any sexual intercourse was higher when informed by friends of the opposite sex (p = 0.039) and not informed by a physician (p = 0.025) and lower when informed by parents (p = 0.015). When comparing among sexually active adolescents those who felt that they were adequately informed to those not well informed, no significant difference in high risk behaviors was found. CONCLUSIONS: The majority of T1D adolescents felt that they were adequately informed on sexual matters compared to healthy peers. They mostly used friends of the opposite sex and teachers as information sources. Nevertheless, T1D adolescents were more likely to adopt a risky sexual behavior if they were not informed by their parents and medical professionals, or preferred friends of the opposite sex.