Impact of COVID-19 public health restrictions on hospital admissions for young infants in Victoria, Australia.

AIM: Strict public health measures during the COVID-19 pandemic led to less support for infants and their parents. We aimed to characterise the frequency and nature of infant admissions to the Royal Children's Hospital (RCH), Melbourne in 2020, compared to the previous year. METHODS: A retrospective review of medical records identified infants ≤3 months admitted to the general medicine unit, RCH from March to September in 2019 and 2020. Diagnoses potentially related to the impact of public health measures and reduced family and community supports were identified and compared to all infant diagnoses across both years. Clinical characteristics and need for referral for additional supports or mental health services were also ascertained. RESULTS: There were fewer admissions for infants ≤3 months in 2020 (n = 411) compared to 2019 (n = 678), with a threefold increase in admissions with a primary or secondary diagnosis of feeding difficulties, growth disturbance, infant irritability or maternal mental health concerns (191/411; 46% vs. 97/678; 14%). There were more infants of first-time parents (112/191; 59% vs. 44/97; 45%) and a reduction in the number of admissions due to infection (145/411; 35%; vs. 467/678; 69%). CONCLUSION: During the COVID-19 pandemic, there was a threefold increase in admissions for infants ≤3 months due to poor growth, feeding difficulties, irritability and maternal mental health concerns in 2020 compared to 2019. These findings may inform future pandemic planning and policy development to ensure maintenance of community supports such as maternal child health nurse (MCHN) service delivery for young infants.

Nitric therapy in preterm infants: rationalised approach based on functional neonatal echocardiography.

AIM: Use of inhaled nitric oxide (iNO) in preterm infants is not supported by current evidence. In 2013, in Australia and New Zealand, 14% infants' ≤25 weeks of gestations were administered iNO. Within the cohort administered iNO, we aimed to identify subgroups where it may be more efficacious and compared characteristics before and after the set-up of the functional echocardiography (fEcho) programme. METHODS: A retrospective audit for the period 2000-2013 involving preterm infants administered iNO in the first four weeks of life was performed. Comparisons were made between the two time epochs: up to 2007 and post-2007. RESULTS: Eighty-five infants fulfilled the inclusion criteria; 62 (73%) were ≤28 weeks of gestation; 51 (60%) survived. Amongst survivors, gestation and birthweight were higher and oxygenation index (OI) was lower. Fourteen (16.5%) infants weighed small for gestation age; survival was lower in this subgroup (6/14, 43%, p = 0.0005). The fEcho programme increased prenitric assessments for a definitive diagnosis and monitoring; iNO was started earlier, at a lower OI with a trend towards reduced usage (hours). CONCLUSION: Characteristics of subgroups (within the cohort of infants ≤34 weeks of gestation) more likely to benefit from iNO therapy were identified. Use of fEcho could rationalise usage.

Palliative care in Australian medical student education.

Greater emphasis needs to be placed on medical student palliative care education within the Australian arena. The development of a comprehensive, relevant and practical educational curriculum in this area during medical school is imperative in order to adequately equip the future junior medical workforce. Further development of a national palliative care curriculum as well as research comparing various teaching methods and curricula should be the priorities in the near future.

Letter to the Editor: A comparison of post-COVID vaccine myocarditis classification using the Brighton Collaboration criteria versus (United States) Centers for Disease Control criteria: an update.

Abstract: (No abstract provided).

Long term follow up and outcomes of Covid-19 vaccine associated myocarditis in Victoria, Australia: A clinical surveillance study.

BACKGROUND: Myocarditis and myopericarditis are well described adverse events of special interest (AESI) following COVID-19 vaccinations. Although reports are reassuring regarding initial clinical outcomes, information about longer term outcomes remains limited. We aimed to further this knowledge and report outcomes to 6 months post diagnosis from a single population cohort. METHODS: Reports of myocarditis following COVID-19 vaccination were followed up by SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community), the state-wide vaccine safety service for Victoria, Australia. Confirmed myocarditis cases (Brighton Collaboration Criteria levels 1-3) were followed up via surveys at 1, 3 and 6 months post symptom onset. Responses received between 22 February 2021 and 30 September 2022 were analysed. RESULTS: 87.5 % (N = 182) of eligible participants completed at least 1 survey report. 377 reports were analysed. 76.9 % of completed reports were from male patients. The median age of patients was 21 years [IQR: 16 to 32]. 54.8 % (n = 74) of survey reports at 6 months, reported ongoing symptoms. At all follow-up time points, females were significantly more likely to have ongoing symptoms. At 6 months, 51.9 % of male respondents reported symptom resolution compared to 22.6 % of female patients (p = 0.002). Females were also more likely to continue medication and have ongoing exercise restrictions. However, males were significantly more likely to have higher initial peak troponin results and abnormal initial cardiac imaging investigations. CONCLUSIONS: There appears to be a significant proportion of patients who experience ongoing symptoms to 6 months post onset amongst patients that experience these AESI. Male patients were more likely to report earlier and more complete symptom recovery, despite significantly higher average initial peak troponin. This difference in phenotypic presentation in females compared to males warrants further investigation and there is a need for longer term follow up data.

How appropriately is blood ordered in a rural hospital?

BACKGROUND: Blood products are a limited resource particularly in a rural setting and their appropriate use is important to maintain patient safety and minimise costs. OBJECTIVE: To assess the appropriateness of transfusion practices in a rural hospital. DESIGN/DATA SOURCES: A retrospective medical record audit of packed red blood cell (PRBC) use. SETTING: A rural hospital 300 km northwest of Melbourne. PARTICIPANTS: All patients in Wimmera Base Hospital who had a PRBC crossmatch request from October 2010 to March 2011 inclusive. MAIN OUTCOME MEASURES: Proportion of appropriate transfusions and crossmatch to transfusion ratios. RESULTS: A total of 257 patients and 657 PRBC units were cross-matched during the study period. Of these patients, 28.4% had pre-procedure (elective) cross-matches. Of the elective cross-matches, 27.4% were inappropriate, compared with 16.1% of emergency cross-matches. The cross-match to transfusion ratio (C:T) was 1.59 for emergency requests and 5.96 for elective requests. The C:T ratio was high in the surgical and obstetrics and gynaecology departments. 16.3% of all transfusions were single-unit transfusions. CONCLUSIONS: Emergency requests were predominantly appropriate but a significant proportion of elective requests were inappropriate, suggesting changes in elective crossmatch request protocols, and increased education regarding ordering blood in a rural setting.

Histologically atypical case of Gaucher disease type 1.

This report presents a case of childhood Gaucher disease type 1, a rare inherited metabolic disorder. Although the clinical symptoms were classical, the histological findings in this case were atypical and initially led to diagnostic uncertainty. The pathognomonic histological finding on bone marrow is Gaucher cells, which are lipid-engorged phagocytes secondary to the accumulation of glucosylceramide. These cells typically demonstrate diffuse and avid iron staining using a Prussian blue iron stain. In this case, although the histiocytes seen on bone marrow were abnormal, the absence of iron staining on bone marrow led to a large range of other diagnoses being considered. In retrospect, this anomaly was likely in the setting of prolonged iron deficiency and anaemia as a result of the insidious nature of this presentation. The prognosis of type 1 Gaucher disease is favourable, with current treatments significantly improving duration and quality of life. We explore the utility of a collaborative multidisciplinary approach in addressing diagnostic uncertainty and the importance in making a diagnosis for Gaucher disease type 1 in order to provide appropriate and targeted treatment.

Correcting Hypernatremia in Children.

BACKGROUND: In children with hypernatremia, current clinical guidelines recommend a reduction in serum sodium of 0.5 mmol/L per hour or less to avoid complications of cerebral edema. However, no large-scale studies have been conducted in the pediatric setting to inform this recommendation. Therefore, this study aimed to report the association between the rate of correction of hypernatremia, neurological outcomes, and all-cause mortality in children. METHODS: A retrospective cohort study was conducted from 2016 to 2019 at a quaternary pediatric center in Melbourne, Victoria, Australia. All children with at least one serum sodium level ≥150 mmol/L were identified through interrogation of the hospital's electronic medical record. Medical notes, neuroimaging reports, and electroencephalogram results were reviewed for evidence of seizures and/or cerebral edema. The peak serum sodium level was identified and correction rates over the first 24 hours and overall were calculated. Unadjusted and multivariable analyses were used to examine the association between the rate of sodium correction and neurological complications, the requirement for neurological investigation, and death. RESULTS: There were 402 episodes of hypernatremia among 358 children over the 3-year study period. Of these, 179 were community-acquired and 223 developed during admission. A total of 28 patients (7%) died during admission. Mortality was higher in children with hospital-acquired hypernatremia, as was the frequency of intensive care unit admission and hospital length of stay. Rapid correction (>0.5 mmol/L per hour) occurred in 200 children and was not associated with greater neurological investigation or mortality. Length of stay was longer in children who received slow correction (<0.5 mmol/L per hour). CONCLUSIONS: Our study did not find any evidence that rapid sodium correction was associated with greater neurological investigation, cerebral edema, seizures, or mortality; however, slow correction was associated with a longer hospital length of stay.

Analyzing an immunization resource website: User browsing trends.

PURPOSE: Access to internet-based resources may help to improve population health awareness and literacy surrounding immunization related topics. The primary aim of this study was to evaluate and analyze trends for a single immunization resource website, the Melbourne Vaccine Education Centre (MVEC). PRINCIPAL RESULTS: Over a four-year period from 2019 to 2022, the website had over 2 million visitors from 236 countries. Users were predominantly female, in the 25 to 44 year age bracket and accessed resources using a mobile device. There was significant interest in specific vaccine related topics, particularly during the COVID-19 pandemic, that corresponded with key vaccine related recommendations and updates from a national level. Usage patterns saw spikes in interest around topics including COVID-19 vaccine administration techniques and adverse events following immunization. MAJOR CONCLUSIONS: Use of online platforms including websites such as MVEC may reflect trends and behaviors towards immunization related information. Analysis of usage patterns have provided user insights into key domains of interest including areas such as vaccine administration, policies and programs, vaccine safety and barriers to vaccine uptake.

Clinical and Health System Impact of Biofire Filmarray Meningitis/Encephalitis Routine Testing of CSF in a Pediatric Hospital: An Observational Study.

BACKGROUND: Rapid cartridge-based molecular test panels targeting multiple pathogens are increasingly available, improve pathogen detection and reduce turn-around-time but are more expensive than standard testing. Confirmation that these test panels contribute to improved patient or health service outcomes is required. METHODS: In March 2021, our pediatric hospital laboratory implemented the BioFire Filmarray™ meningitis/encephalitis (M/E) panel as an additional routine test for all cerebrospinal fluid (CSF) samples collected from infants <90 days or from any patient in the emergency department. A retrospective chart review was done to ascertain changes in clinical outcomes, antimicrobial prescribing practices, and hospital length of stay, comparing two discrete 6-month periods: preimplementation (March-August 2019) and postimplementation (March-August 2021). RESULTS: Both pre- and postimplementation groups were similar at baseline, except the preimplementation group had a higher proportion of infants with enterovirus and parechovirus meningitis. There was no significant difference between the groups in terms of median length of stay (2.94 vs 3.47 days, p = 0.41), duration of antibiotic treatment (2.0 vs 2.3 days, p = 0.25), need for central venous access (12.9% vs 17%, p = 0.38) or hospital-in-the-home admission (9.4% vs 9%, p = 0.92). A similar proportion of infants received aciclovir (33% vs 31%), however, a reduction in duration was observed (1.36 vs 0.90 days, p = 0.03) in the postimplementation period. CONCLUSIONS: Introduction of the Biofire Filmarray™ M/E panel for routine testing of CSF samples reduced the duration of antiviral prescribing but had only a minor impact on antibiotic prescribing practices or health service outcomes in our pediatric hospital. The introduction of new laboratory testing needs to be supported by a comprehensive stewardship program to see optimal outcomes from new testing platforms.

Workflow Improvement of Electronic Health Record Usage in a Tertiary Pediatric Burns Clinic.

BACKGROUND: As a high patient-throughput clinic, the Royal Children's Hospital's multidisciplinary burns clinic's efficiency of clinic workflow and streamlined patient assessment is crucial. The clinic has been using a customized "burns assessment tool" (BAT) as part of its integrated electronic health record (EHR) since 2016. OBJECTIVES: The aim was to assess the usage patterns of the BAT at baseline, followed by re-evaluation following interventions to improve efficiency and utilization of the BAT. METHODS: This study was a prospective observational time-motion quality improvement study. Observations of 19 clinicians in the pediatric burns clinic by five trained observers using a validated time-motion capture tool (TimeCaT 3.9) to map clinician workflow, with specific reference to time spent on a list of predetermined tasks, were conducted. Baseline data were collected for 7 weeks followed by three cycles of interventions and observations over 5 months. RESULTS: At baseline, the median time for a patient visit was 24.56 minutes (range: 2.78-73.72 minutes, interquartile range: 14.17-27 minutes), with most of the time spent on documentation (34.6%) and patient contact tasks (26.0%). In each of the study cycles, the median time spent on documentation within the EHR was significantly reduced compared with baseline (cycle 1 29.8%, p = 0.08; cycle 2 20.4%, p ≤ 0.01; cycle 3 27.32%, p = 0.04). The time spent on patient contact increased when comparing baseline to data of cycles 1, 2, and 3 (25.96 vs. 33.27% of visit, p = 0.04). There was no significant change in absolute time spent on the BAT during the study. CONCLUSION: The study findings of clear, significant, and sustained improvement in documentation efficiency and the corresponding increase in patient contact time after interventions were introduced reinforce the importance of integration of an EHR with clinical workflow.

Paediatric admissions with SARS-CoV-2 during the Delta and Omicron waves: an Australian single-centre retrospective study.

BACKGROUND: The clinical course of Australian children admitted to hospital with COVID-19 infection is not well understood, particularly over the Omicron period. METHODS: This study describes paediatric admissions to a single tertiary paediatric institution through the Delta and Omicron variant waves. All children admitted from 1 June 2021 to 30 September 2022 with a diagnosis of COVID-19 infection were included for analysis. RESULTS: 117 patients were admitted during the Delta wave compared with 737 during the Omicron wave. The median length of stay was 3.3 days (IQR 1.7-6.75.1) during Delta, compared with 2.1 days (IQR 1.1-4.53.4) during Omicron (p<0.01). 83 patients (9.7%) required intensive care unit (ICU) admission, a greater proportion during Delta (20, 17.1%) than Omicron (63, 8.6%, p<0.01). Patients admitted to the ICU were less likely to have received a dose of COVID-19 vaccination prior to admission than patients admitted to the ward (8, 24.2% vs 154, 45.8%, p=0.028). CONCLUSION: The Omicron wave resulted in an absolute increase in the number of children compared with Delta, but cases had lower severity, demonstrated by shorter length of stay and a smaller proportion of patients requiring intensive care. This is consistent with US and UK data describing a similar pattern.

Shoulder injury following COVID-19 vaccine administration: a case series and proposed diagnostic algorithm.

BACKGROUND: Shoulder Injury Related to Vaccine Administration (SIRVA) is a preventable adverse event following incorrect vaccine administration, which can result in significant long-term morbidity. There has been a notable surge in reported cases of SIRVA as a rapid national population-based COVID-19 immunization program has been rolled out across Australia. METHODS: Surveillance of Adverse Events Following Vaccination in the Community (SAEFVIC) in Victoria identified 221 suspected cases of SIRVA following the commencement of the COVID-19 vaccination program, reported between February 2021 and February 2022. This review describes the clinical features and outcomes of SIRVA in this population. Additionally, a suggested diagnostic algorithm is proposed, in order to facilitate early recognition and management of SIRVA. RESULTS: 151 cases were confirmed as SIRVA, with 49.0% having received vaccines at state vaccination centers. 75.5% were suspected incorrect administration site, with most patients experiencing shoulder pain and restricted movement within 24 hours of vaccination, lasting on average 3 months. CONCLUSION: Improved awareness and education regarding SIRVA is imperative in a pandemic vaccine roll-out. The development of a structured framework for evaluating and managing suspected SIRVA will aid in timely diagnosis and treatment, essential to mitigate potential long-term complications.

Recurrent 6th nerve palsy in a child following different live attenuated vaccines: case report.

BACKGROUND: Recurrent benign 6th nerve palsy in the paediatric age group is uncommon, but has been described following viral and bacterial infections. It has also been temporally associated with immunization, but has not been previously described following two different live attenuated vaccines. CASE PRESENTATION: A case is presented of a 12 month old Caucasian boy with recurrent benign 6th nerve palsy following measles-mumps-rubella and varicella vaccines, given on separate occasions with complete recovery following each episode. No alternate underlying etiology was identified despite extensive investigations and review. CONCLUSIONS: The majority of benign 6th nerve palsies do not have a sinister cause and have an excellent prognosis, with recovery expected in most cases. The exact pathophysiology is unknown, although hypotheses including autoimmune mechanisms and direct viral invasion could explain the pathophysiology behind immunization related nerve palsies. It is important to rule out other aetiologies with thorough history, physical examination and investigations. There is limited information in the literature regarding the safety of a repeat dose of a live vaccine in this setting. Future immunizations should be considered on a case-by-case basis.

Improving Asthma Care Documentation with a Digital Tool-Experience in a Pediatric Institution.

BACKGROUND: Asthma affects approximately 10% of Australian children. Electronic medical record (EMR) systems and clinical decision support initiatives have been shown to improve the delivery of asthma care. Our institution implemented an EMR-based asthma "hub," which collates asthma-related information to a central location within a patient's record, provides a template to collect relevant clinical information, allows clinicians to evaluate a patient's history and presentation in a systematic manner and prompts relevant actions. OBJECTIVE: The aim of the study is to measure year-on-year improvement in asthma-related documentation and provide a key gold-standard aspects of asthma management after the introduction of an EMR asthma "hub" tool in the outpatient setting. METHODS: The asthma "hub" was introduced in November 2020. A chart review was conducted of all patients who attended the Complex Asthma Clinic between January-April 2020 and January-April 2021. The provision and presence of documentation of core aspects of asthma care were described in percentages and comparisons of pre- and post-introduction of the asthma "hub" were assessed. RESULTS: There was a significant increase in the documentation of asthma triggers, including smoking/smoker exposure, (47.5-92.6%, p <0.001), current asthma action plans (70.4-86.3%, p = 0.02), and severity scores (46.3-81%, p <0.001) post the introduction of the asthma "hub." There was no significant difference in documentation of reliever (as required) or regular preventer medications. CONCLUSION: An evidence-based EMR intervention improved the documentation and provision of aspects of asthma care in an outpatient clinic setting at a tertiary pediatric hospital, suggesting replication in the inpatient and emergency settings would be worthwhile. Further research is required to understand the tool's impact on clinical outcomes and on clinical efficiency and workflow.

Aiming too high: Shoulder injury related to vaccine administration (SIRVA): A case series.

PURPOSE: Shoulder injury directly related to vaccination (SIRVA) occurs when a vaccine is administered too high in the shoulder. The primary aim of this study was to accurately detail the occurrence, symptoms, diagnosis, management and long-term outcomes of SIRVA cases in Victoria, Australia. PRINCIPAL RESULTS: The study identified 102 SIRVA cases from 2007 to 2020 from the Surveillance of Adverse Events Following Vaccination in the Community (SAEFVIC) database. The majority [73/85; (86 %)] of cases resolved completely with a median time to resolution of 8 weeks and no statistically significant difference in recovery by immunisation provider type or baseline imaging. MAJOR CONCLUSIONS: This large case series includes long-term clinical progress in SIRVA, allowing accurate evaluation and analysis. Further evaluation is required to establish if other risk factors contribute to SIRVA, which may help with targeted, tailored education for providers on correct vaccine administration technique, including in large and rapid vaccine rollouts.

Myocarditis and myopericarditis cases following COVID-19 mRNA vaccines administered to 12-17-year olds in Victoria, Australia.

IMPORTANCE: COVID-19 mRNA vaccine-associated myocarditis has previously been described; however specific features in the adolescent population are currently not well understood. OBJECTIVE: To describe myocarditis adverse events following immunisation reported following any COVID-19 mRNA vaccines in the adolescent population in Victoria, Australia. DESIGN: Statewide, population-based study. SETTING: Surveillance of Adverse Events Following Vaccination in the Community (SAEFVIC) is the vaccine-safety service for Victoria, Australia. PARTICIPANTS: All SAEFVIC reports of myocarditis and myopericarditis in 12-17-year-old COVID-19 mRNA vaccinees submitted between 22 February 2021 and 22 February 2022, as well as accompanying diagnostic investigation results where available, were assessed using Brighton Collaboration criteria for diagnostic certainty. EXPOSURES: Any mRNA COVID-19 vaccine. MAIN OUTCOMES/MMEASURE: Confirmed myocarditis as per Brighton Collaboration criteria (levels 1-3). RESULTS: Clinical review demonstrated definitive (Brighton level 1) or probable (level 2) diagnoses in 75 cases. Confirmed myocarditis reporting rates were 8.3 per 100 000 doses in this age group. Cases were predominantly male (n=62, 82.7%) and post dose 2 (n=61, 81.3%). Rates peaked in the 16-17-year-old age group and were higher in males than females (17.7 vs 3.9 per 100 000, p=<0.001).The most common presenting symptoms were chest pain, dyspnoea and palpitations. A large majority of cases who had a cardiac MRI had abnormalities (n=33, 91.7%). Females were more likely to have ongoing clinical symptoms at 1-month follow-up (p=0.02). CONCLUSION: Accurate evaluation and confirmation of episodes of COVID-19 mRNA vaccine-associated myocarditis enabled understanding of clinical phenotypes in the adolescent age group. Any potential vaccination and safety surveillance policies needs to consider age and gender differences.

A digital approach in the rapid response to COVID-19 - Experience of a paediatric institution.

INTRODUCTION: COVID-19 has radically changed the delivery of healthcare in Australia. Central to a tertiary paediatric institution's (The Royal Children's Hospital Melbourne (RCH) response was a digital health approach comprising a broad suite of informatics and technology solutions including optimising a fully integrated electronic medical record (EMR). METHODS: This comprehensive approach spanned all patient care areas and encompassed a broad range of hospital operations. They included patient triage, registration, COVID-19 screening clinic operations, electronic ordering, prescribing and documentation, telehealth, reporting and analytics and research. DISCUSSION: This paper outlines key aspects of our COVID-19 digital health strategy, highlighting the rapid transition to telehealth and the development of a remote "virtual telehealth" strategy for clinicians which proved popular and allowed true "working from home". CONCLUSION: COVID-19 has inadvertently focussed the spotlight on the utility of digital health for clinical care. The speed and uptake of digital health within this pandemic has been remarkable and unprecedented in both an Australian and global setting. Whilst many of these changes have been beneficial, some may have been rushed or forced with minimal consideration of ongoing governance. Key stakeholders and enablers should be identified for post-pandemic consideration in future digital health implementation and adoption strategies.