Efficacy, Safety, and Complications of Pigtail Thoracostomy for the Treatment of Pediatric Pleuropneumonia.

OBJECTIVE: Pigtail thoracostomy (PT) has become the mainstay technique for the drainage of pediatric pleuropneumonic effusions (PLPe). However, its efficacy and complication profile has been questioned when compared with video-assisted thoracoscopic surgery and larger bore traditional tube thoracostomy. The aim of this study was to assess the efficacy, safety, and complications associated with PT. METHODS: A cross-sectional study at a freestanding tertiary children's hospital. We extracted the medical records of all children aged younger than 18 years treated with PT for PLPe from June 2016 to June 2020. The primary efficacy outcome was treatment failure defined as the need for a repeat drainage procedure, thoracostomy, or video-assisted thoracoscopic surgery. Secondary efficacy outcomes were length of hospital stay (LOS) and duration of in situ PT. The primary safety outcomes were adverse events during or after insertion. We also recorded any associated complications. RESULTS: During the study period, 55 children required PT. The median age was 25 months (interquartile range, 14-52) and 58.2% were boys. Eight (14.4%) were bacteremic or in septic shock. There were no adverse events related to insertion. Forty-two (76.3%) children were treated with fibrinolysis. There were 2 (3.6%) treatment failures. The median LOS and PT durations were 13 and 4 days (interquartile ranges, 10-14.8, 3-6.7), respectively. Eight (14.4%) children experienced complications that were nonoperatively managed. CONCLUSIONS: Our findings suggest that PT drainage offers a safe and highly effective option for managing PLPe and carries a very low failure rate.

Outcomes of Infants Who Are Febrile Aged 29-90 Days Discharged from the Emergency Department.

OBJECTIVE: To evaluate the characteristics and outcomes of infants aged 29-90 days who are febrile discharged from the pediatric emergency department (ED). STUDY DESIGN: This was a multicenter, retrospective cohort study of infants aged 29-90 days who visited any of the 7 Clalit Health Services pediatric EDs in Israel between January 1, 2019, and March 31, 2022. Infants who were febrile discharged from the ED after having blood and urine cultures taken were included. The primary outcome measure was the incidence of return visit (RV) to an ED. Secondary outcome measures were the incidence of invasive bacterial infection, urinary tract infection, pediatric intensive care unit admissions, and deaths. We assessed variables associated with the primary outcomes. RESULTS: A total of 1647 infants were included. Their median (IQR) age at ED visit was 58.5 (47.7, 72.7) days, 53.1% were male. A total of 329 patients (20%) returned to the ED within 120 hours. Overall, 7.8% of discharged infants had a positive urine culture, 4 (0.2%) had a positive blood culture, and none had meningitis. One patient was admitted to the pediatric intensive care unit, and there was no death. Abnormal C-reactive protein was associated with RV among 61- to 90-day-old infants. CONCLUSIONS: Infants aged 29-90 days who were febrile and discharged following a protocol-driven pathway from the pediatric ED had a relatively high RV rate. However, the rate of urinary tract infection was relatively low, and rate of invasive bacterial infection was extremely low. There were no deaths or serious sequelae.

Early unplanned return visits to pediatric emergency departments in Israel during the SARS-CoV-2 pandemic.

INTRODUCTION: During the SARS-CoV-2 pandemic there was a considerable drop in the number of visits to Pediatric Emergency Departments (PED). Unplanned return visits (URV) might represent inadequate emergency care. We assessed the impact of the pandemic on early URV to PEDs in Israel. METHODS: This multicenter cross-sectional study analyzed the 72-h URV to PEDs among patients under the age of 18 years during a one-year pandemic period (March 1st, 2020, to February 28th, 2021), and compared them with the 72-h URV of the corresponding pre-pandemic period (March 1st, 2019, to February 28th, 2020). Data was extracted from Clalit Health Services (CHS), the largest public health care organization in Israel. RESULTS: The pandemic and pre-pandemic early URV rates were 5465 (5.1%) and 8775 (5.6%), respectively (OR = 0.90, 95% CI 0.92-0.99). The rate of return-visit admissions to hospital wards during these periods were 29.5% and 32.1%, respectively (OR = 0.83, 95% CI 0.86-0.98). The rate of return-visit admissions to ICUs during these periods were 0.64% and 0.52%, respectively (OR = 1.11, 95% CI 0.67-1.62). On return-visit, 3 (0.055%) and 5 (0.057%) URV patients were declared dead on arrival during the pandemic and pre-pandemic periods, respectively (OR = 0.96, 95% CI 0.23-4.03). The distributions of the time interval from index visit to return visit remained consistent between the periods. DISCUSSION: In our study, early URV to PED's were only mildly influenced by the SARS-CoV-2 pandemic.

Improving cardiovascular magnetic resonance access in low- and middle-income countries for cardiomyopathy assessment: rapid cardiovascular magnetic resonance.

AIMS: To evaluate the impact of a simplified, rapid cardiovascular magnetic resonance (CMR) protocol embedded in care and supported by a partner education programme on the management of cardiomyopathy (CMP) in low- and middle-income countries (LMICs). METHODS AND RESULTS: Rapid CMR focused particularly on CMP was implemented in 11 centres, 7 cities, 5 countries, and 3 continents linked to training courses for local professionals. Patients were followed up for 24 months to assess impact. The rate of subsequent adoption was tracked. Five CMR conferences were delivered (920 attendees-potential referrers, radiographers, reporting cardiologists, or radiologists) and five new centres starting CMR. Six hundred and one patients were scanned. Cardiovascular magnetic resonance indications were 24% non-contrast T2* scans [myocardial iron overload (MIO)] and 72% suspected/known cardiomyopathies (including ischaemic and viability). Ninety-eighty per cent of studies were of diagnostic quality. The average scan time was 22 ± 6 min (contrast) and 12 ± 4 min (non-contrast), a potential cost/throughput reduction of between 30 and 60%. Cardiovascular magnetic resonance findings impacted management in 62%, including a new diagnosis in 22% and MIO detected in 30% of non-contrast scans. Nine centres continued using rapid CMR 2 years later (typically 1-2 days per week, 30 min slots). CONCLUSIONS: Rapid CMR of diagnostic quality can be delivered using available technology in LMICs. When embedded in care and a training programme, costs are lower, care is improved, and services can be sustained over time.

Sedation for Forearm Fracture Reduction in the Pediatric Emergency Department: Impact on Hospitalization and Length of Stay.

BACKGROUND: Children with forearm fractures who present to the emergency department (ED) often need a closed reduction. In our institution, until 2017, pediatric trauma patients presented to the general trauma ED (GTED) where no sedation services for pediatric patients were available. From 2017, patients presented to the pediatric emergency department (PED) where closed reductions were performed under sedation when appropriate. OBJECTIVES: To compare GTED and PED with regard to length of stay (LOS) and hospitalization rates of pediatric patients with forearm fractures who needed a closed reduction. METHODS: Our retrospective observational study was conducted at a regional hospital. The study population consisted of all patients younger than 18 years of age who presented to the ED with a forearm fracture that needed a closed reduction. The primary outcome measure was the hospitalization rate. The secondary outcome measure was LOS in the ED. RESULTS: The study comprised 165 patients with forearm fractures who needed a closed reduction; 79 presented to the GTED, and 96 presented to the PED. Hospitalization rates were lower for patients undergoing closed reduction under sedation in the PED compared to the GTED (6.3% and 21.5%, respectively; P = 0.003). Median ED LOS was longer among patients undergoing sedation in the PED compared to the GTED (237 vs. 168 minutes respectively, P < 0.0001). CONCLUSIONS: Sedation for forearm fracture reduction in a hospital's PED was associated with a decrease of more than three times in hospitalization rate. Despite the need for more resources, PED LOS was only mildly increased.

Pediatric Hospitalizations After School Reopening During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Alpha (B.1.1.7) Variant Spread: A Multicenter Cross-sectional Study in Israel.

This multicenter, cross-sectional study provides evidence on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated emergency department visits and hospitalizations in pediatric wards and intensive care units after school reopening during the SARS-CoV-2 Alpha (B.1.1.7) variant spread in Israel. Study findings suggest that school reopening was not followed by an increase in SARS-CoV-2-related pediatric morbidity.

Cardiovascular magnetic resonance characterization of rheumatic mitral stenosis: findings from three worldwide endemic zones.

BACKGROUND: Cardiac remodeling in rheumatic mitral stenosis (MS) is complex and incompletely understood. The objective of this study was to evaluate cardiac structural and functional changes in a cohort of patients with rheumatic MS using cardiovascular magnetic resonance (CMR). METHODS: This retrospective study included 40 patients with rheumatic MS, consisting of 19 patients from India, 15 patients from China, and 6 patients from Mexico (median (interquartile range (IQR)) age: 45 years (34-55); 75% women). Twenty patients were included in the control group. CMR variables pertaining to morphology and function were collected. Late gadolinium enhancement (LGE) sequences were acquired for tissue characterization. Statistical analyses were performed using the Kruskal-Wallis test and the chi-square test. RESULTS: Compared to the control group, patients with MS had lower left ventricular (LV) ejection fraction (51% (42%-55%) vs 60% (57%-65%), p < 0.001), lower right ventricular (RV) ejection fraction (44% (40%-52%) vs 64% (59%-67%), p < 0.001), higher RV end-diastolic volume (72 (58-87) mL/m2 vs 59 (49-69) mL/m2, p = 0.003), larger left atrial volume (87 (67-108) mL/m2 vs 29 (22-34) mL/m2, p < 0.001), and right atrial areas (20 (16-23) cm2 vs 13 (12-16) cm2, p < 0.001). LGE was prevalent in patients with rheumatic MS (82%), and was commonly located at the RV insertion sites. Furthermore, the patient cohorts from India, China, and Mexico were heterogeneous in terms of baseline characteristics and cardiac remodeling. CONCLUSION: Our findings demonstrated that biventricular dysfunction, right and left atrial remodeling, and LGE at the RV insertion sites are underappreciated in contemporary rheumatic MS. Further studies are needed to elucidate the prognostic implications of these findings.

The role of fundoscopy in pediatric seizures.

Fundoscopy can guide clinicians in the decision to perform neuroimaging. Our aim was to evaluate the rate of abnormal neuroimaging following fundoscopy in children presenting with seizures to the pediatric emergency department (PED). This was a retrospective single-center study. Patients with a discharge diagnosis of seizures were evaluated. Outcome measures were the rate of abnormal brain imaging following a finding of papilledema, and the rate of repeat fundoscopies due to an inconclusive initial examination. A total of 646 patients with seizures underwent fundoscopy. Out of 3 patients who were diagnosed initially with papilledema, only one patient had an abnormal brain CT. He was diagnosed with papilledema previously, and neuroimaging was previously recommended. A total of 7.6% (49/646) of patients underwent a second fundoscopic evaluation. In view of the limited yield and accuracy of fundoscopy in the PED, its role in the clinical decision making in children with seizures is questionable. What is Known: • Seizures are not described as an isolated presenting symptom of increased ICP. • Fundoscopy in children requires skill, time, cooperation. What is New: • Papilledema was found in only one patient who presented with seizures. • Fundoscopy in the PED has limited yield and accuracy in children with seizures.

Latency of Symptom Progression in Mild Daboia palaestinae Envenomation.

INTRODUCTION: Daboia palestinae is the most common venomous snake in Israel. In most cases, snakebite does not develop into a systemic disease. Since the introduction of specific antivenom therapy, the mortality rate has declined sharply. Nevertheless, there is still no uniform therapeutic protocol in Israel for patients who have been envenomated, and there is no current data regarding latency of symptom development. We aimed to evaluate the latency of symptom development after D palaestinae snakebite in patients presenting to the emergency department (ED) with local reaction. METHODS: This was a retrospective single-center study of all patients who presented following a snakebite from 2015 to 2020. Patients with confirmed or suspected D palaestinae bite were included. Demographical and clinical data were extracted from each electronical medical record and subjected to descriptive and comparative analysis. RESULTS: Sixty-two patients met the inclusion criteria. Their median (IQR) age was 30 (17-48) y, and 75% were male. Forty-one percent presented with local reactions to the snakebite, 29% presented with advanced local reaction, and 29% presented with systemic symptoms. Antivenom was given to 22% of patients with advanced local reaction and 89% of patients with systemic reaction. The median (IQR) time from bite to antivenom and from ED arrival to antivenom were 2 (1.5-2.5) h and 1 (0.75-1.5) h, respectively. Antivenom was administered at the latest 3.5 h after presentation to the ED for progression of local symptoms. CONCLUSIONS: Our study may support a 4- to 6-h observation period in the ED for patients with mild clinical presentation after D palaestinae bite. Further larger prospective studies are needed.

Society for Cardiovascular Magnetic Resonance (SCMR) guidance for re-activation of cardiovascular magnetic resonance practice after peak phase of the COVID-19 pandemic.

During the peak phase of the COVID-19 pandemic, alterations of standard operating procedures were necessary for health systems to protect patients and healthcare workers and ensure access to vital hospital resources. As the peak phase passes, re-activation plans are required to safely manage increasing clinical volumes. In the context of cardiovascular magnetic resonance (CMR), re-activation objectives include continued performance of urgent CMR studies and resumption of CMR in patients with semi-urgent and elective indications in an environment that is safe for both patients and health care workers.

Educational intervention does not reduce non-invasive urine contamination rates in children presenting to the emergency department.

AIM: Urinary tract infection is common in children with high contamination rates with non-invasive urine sampling (NIU). Our aims were to evaluate an educational tool for decreasing contamination rates and find factors associated with contamination. METHODS: This was a prospective cohort interventional study with a review of microbiology data and medical records of all NIU specimens collected at a large tertiary children's emergency department (ED) over a 1-year period. The intervention was the provision of a urine collection kit and educational pamphlet and education of staff. NIU contamination was calculated for 6 months pre-intervention and 6 months post-intervention. The association of factors with NIU contamination was evaluated for all cohorts (age, gender, presence of diarrhoea, season, time of day, time to incubation and activity of the ED). RESULTS: A total of 2104 NIU samples were included (median age 3 years, 52% females). There was no difference between periods in contamination rates (29.2% and 31.2%, respectively, P = 0.322). Collectively, high monthly activity of the department, age and female gender were associated with contamination. The highest contamination rates were among children aged 0-3 months and 12 years and older (38.1 and 48.9%, respectively). CONCLUSIONS: The urine collection kit and educational tool did not decrease NIU contamination rates in our ED. Contamination rates were correlated with the monthly activity of our department and female gender and were noticeably high among infants and adolescents. Given the high prevalence of urinary tract infection among these age groups, measures should be taken to reassess indications and methods for urine collection.

Reduced SERCA activity underlies dysregulation of Ca2+ homeostasis under atmospheric O2 levels.

Unregulated increases in cellular Ca2+ homeostasis are a hallmark of pathophysiological conditions and a key trigger of cell death. Endothelial cells cultured under physiologic O2 conditions (5% O2) exhibit a reduced cytosolic Ca2+ response to stimulation. The mechanism for reduced plateau [Ca2+]i upon stimulation was due to increased sarco/endoplasmic reticulum Ca2+ ATPase (SERCA)-mediated reuptake rather than changes in Ca2+ influx capacity. Agonist-stimulated phosphorylation of the SERCA regulatory protein phospholamban was increased in cells cultured under 5% O2. Elevation of cytosolic and mitochondrial [Ca2+] and cell death after prolonged ionomycin treatment, as a model of Ca2+ overload, were lower when cells were cultured long-term under 5% compared with 18% O2. This protection was abolished by cotreatment with the SERCA inhibitor cyclopiazonic acid. Taken together, these results demonstrate that culturing cells under hyperoxic conditions reduces their ability to efficiently regulate [Ca2+]i, resulting in greater sensitivity to cytotoxic stimuli.-Keeley, T. P., Siow, R. C. M., Jacob, R., Mann, G. E. Reduced SERCA activity underlies dysregulation of Ca2+ homeostasis under atmospheric O2 levels.

A PP2A-mediated feedback mechanism controls Ca2+-dependent NO synthesis under physiological oxygen.

Intracellular O2 is a key regulator of NO signaling, yet most in vitro studies are conducted in atmospheric O2 levels, hyperoxic with respect to the physiologic milieu. We investigated NO signaling in endothelial cells cultured in physiologic (5%) O2 and stimulated with histamine or shear stress. Culture of cells in 5% O2 (>5 d) decreased histamine- but not shear stress-stimulated endothelial (e)NOS activity. Unlike cells adapted to a hypoxic environment (1% O2), those cultured in 5% O2 still mobilized sufficient Ca2+ to activate AMPK. Enhanced expression and membrane targeting of PP2A-C was observed in 5% O2, resulting in greater interaction with eNOS in response to histamine. Moreover, increased dephosphorylation of eNOS in 5% O2 was Ca2+-sensitive and reversed by okadaic acid or PP2A-C siRNA. The present findings establish that Ca2+ mobilization stimulates both NO synthesis and PP2A-mediated eNOS dephosphorylation, thus constituting a novel negative feedback mechanism regulating eNOS activity not present in response to shear stress. This, coupled with enhanced NO bioavailability, underpins differences in NO signaling induced by inflammatory and physiologic stimuli that are apparent only in physiologic O2 levels. Furthermore, an explicit delineation between physiologic normoxia and genuine hypoxia is defined here, with implications for our understanding of pathophysiological hypoxia.-Keeley, T. P., Siow, R. C. M., Jacob, R., Mann, G. E. A PP2A-mediated feedback mechanism controls Ca2+-dependent NO synthesis under physiological oxygen.

Falls in young children with minor head injury: A prospective analysis of injury mechanisms.

BACKGROUND: Fall is a common mechanism of injury (MOI) in young children and an important risk factor for traumatic brain injury (TBI). Most children who fall have a minor head injury (MHI), defined as a blunt head trauma that occurred in a patient who is conscious and responsive. OBJECTIVE: To seek a possible association between MOI and injury severity. METHODS: A single centre cohort study was conducted. Data were collected on patients aged 0-2 years with MHI. Clinically-significant TBI (csTBI), defined as head injury resulting in death, intubation or neurosurgery, was the primary outcome measure. Traumatic finding on CT scan (TFCT) was the secondary outcome measure. RESULTS: Five hundred and ninety-five patients were analysed. Eight types of falls were identified: from ground-level, down stairs, from a bed, from a changing table, from furniture, from adult-hold, from a playground-device and from a stroller/baby-carriage. One patient (0.16%) had csTBI. Thirty-one (5.2%) underwent CT scans, TFCT was diagnosed in 17 (2.8%) patients; 10 (1.7%) linear skull-fractures, two (0.3%) depressed skull-fractures and five (0.8%) intracranial haemorrhages. Regression analysis did not reveal a statistically significant association between any of the MOI and the presence of TFCT. CONCLUSIONS: The risk for csTBI was low and no association was found between MOI and injury severity.

[Pediatric anesthesia emergence delirium after elective ambulatory surgery: etiology, risk factors and prevalence].

INTRODUCTION: Emergence delirium (ED) is a common problem among children and adults recovering from general anesthesia after surgery. Its symptoms include psychomotor agitation, hallucinations, and aggressive behavior. The phenomenon, which is most probably an adverse effect of general anesthesia agents, harms the recovery process and endangers the physical safety of patients and their health. Ranging between 10% and 80%, the exact prevalence of ED is unknown, and the risk factors of the phenomenon are unclear. GOALS: The aim of the current retrospective study was to determine the prevalence rate of ED in 3947 children recovering from general anesthesia after short elective ambulatory surgery, and to map the influence of various risk factors on this phenomenon. METHOD: Data were collected using electronic medical records. ED severity was assessed using the Pediatric Anesthesia Emergence Delirium Scale. RESULTS AND DISCUSSION: Results showed the prevalence of ED among children. ED was significantly correlated with patients' age, type of surgery and premedication. ED was not correlated with severity of pain, type of anesthesia or with patients' sex.

Multimodal Imaging Findings Associated With Cardiac Oxalosis Cardiomyopathy.

We report the case of a 50-year-old woman with secondary oxalosis following bowel resection resulting in restrictive cardiomyopathy and a diagnosis of cardiac amyloidosis based on the initial workup. The case documented findings by cardiac magnetic resonance imaging and technetium Tc 99m-labeled pyrophosphate scan in patients with cardiac oxalosis, which can mimic findings in cardiac amyloidosis, expanding the differential diagnosis.