The Utility of Point-of-Care Ultrasound in the Pediatric Intensive Care Unit.

Objectives: Point of care ultrasound (POCUS) in adult critical care environments has become the standard of care in many hospitals. A robust literature shows its benefits for both diagnosis and delivery of care. The utility of POCUS in the pediatric intensive care unit (PICU), however, is understudied. This study describes in a series of PICU patients the clinical indications, protocols, findings and impact of pediatric POCUS on clinical management. Design: Retrospective analysis of 200 consecutive POCUS scans performed by a PICU physician. Patients: Pediatric critical care patients who required POCUS scans over a 15-month period. Setting: The pediatric and cardiac ICUs at a tertiary pediatric care center. Interventions: Performance of a POCUS scan by a pediatric critical care attending with advanced training in ultrasonography. Measurement and Main Results: A total of 200 POCUS scans comprised of one or more protocols (lung and pleura, cardiac, abdominal, or vascular diagnostic protocols) were performed on 155 patients over a 15-month period. The protocols used for each scan reflected the clinical question to be answered. These 200 scans included 133 thoracic protocols, 110 cardiac protocols, 77 abdominal protocols, and 4 vascular protocols. In this series, 42% of scans identified pathology that required a change in therapy, 26% confirmed pathology consistent with the ongoing plans for new therapy, and 32% identified pathology that did not result in initiation of a new therapy. Conclusions: POCUS performed by a trained pediatric intensivist provided useful clinical information to guide patient management.

Ultrasound Assessment of Gastric Emptying in Premature Infants Treated With Non-Invasive Ventilatory Support.

BACKGROUND: Nasal continuous positive airway pressure (CPAP) introduces positive pressure of air into both the trachea and stomach, which may affect gastric emptying. The rate of gastric emptying can be estimated by ultrasound (US) in neonates by two validated techniques: "antral cross-sectional area" (ACSA, two-dimensional estimate of the surface area at the gastric antrum), and "spheroid gastric volume" (spheroid, three-dimensional estimate of the stomach volume). OBJECTIVE: To compare gastric emptying rates in neonates on machine-derived nasal CPAP (MD-nCPAP, Avea and RAM cannula) with those on bubble CPAP (bCPAP, Fisher Paykel and Babi.Plus nasal prongs). METHODS: Ultrasound measurements of the amount of the milk in the stomach were performed before feeding and at 1, 2, and 3 hours after the start of feeding, using both the ACSA and spheroid methods. Rates of gastric emptying were calculated during the "early" (1-2 hours) and "late" (2-3 hours) phases after feeding. RESULTS: We recruited 32 infants (25-34 weeks gestational age, full enteral tube feedings, on nasal CPAP). Seventeen infants were treated with MD-nCPAP (median birth weight 1015 g [interquartile range (IQR): 870-1300], gestational age 28 weeks [IQR: 27-29], postnatal age 20 days [IQR: 14-28]), whereas 15 infants were treated with bCPAP (median birth weight 960 g [IQR: 855-1070], gestational age 27 weeks [IQR: 26-28], postnatal age 17 days [IQR: 15-25]). Gastric emptying rates (% emptied/min) were significantly faster in the "early" compared to the "late" phase for all infants. There were no significant differences in the rates of gastric emptying (either "early" or "late") or volumes of gastric residuals between infants receiving MD-nCPAP or bCPAP, measured by either method. Although no feeding intolerance was seen in either group, the volumes of residual gastric contents measured by both methods were higher than the volumes traditionally considered abnormal when obtained by gastric tube aspiration. CONCLUSIONS: Gastric emptying is faster during the "early" compared to the "late" phase. Gastric emptying rates are not different in infants receiving MD-nCPAP versus bCPAP. The presence of large residual gastric contents in infants who are tolerating feedings challenges the value of traditional gastric aspiration for the assessment of feeding tolerance in infants.

Structured Neonatal Point-of-Care Ultrasound Training Program.

OBJECTIVE: Point-of-care ultrasound (POC US) has been increasingly used by intensive care physicians. Growing use of POC US necessitates defining distinct clinical indications for its application, as well as structured POC US training programs. Homogeneous approach to POC US education combined with rigorous quality assurance should further enable POC US to become standard-of-care clinical tool. This study aimed to present the first, innovative, and structured POC US program in neonatal-perinatal medicine field. In addition, we reviewed the availability of the POC US training programs across different medical specialties. STUDY DESIGN: Available English-language publications on POC US training programs in general and neonatal-perinatal medicine were reviewed in this study. DISCUSSION: Mounting body of evidence suggests improved procedural completion rates, as well as clinical decision making with the use of POC US. However, limited research supported the existence of structured, comprehensive POC US programs. It was recognized that medical institutions need to develop syllabuses, teach, and credential increasing number of health care professionals in the use of POC US. We defined intuitive educational strategy that encompasses POC US clinical indications, educational curriculum, scanning protocols, competence evaluation, and finally credentialing process. In addition, we offered description of the imaging quality assurance, as well as POC US coding, and reimbursement. CONCLUSION: Future efforts need to be dedicated to the ongoing development of neonatal POC US as a clinical instrument. It should allow for eventual paradigm change and improved effectiveness in management of critically ill neonates.

Prophylactic inhibition of NF-κB expression in microglia leads to attenuation of hypoxic ischemic injury of the immature brain.

BACKGROUND: Periventricular leukomalacia (PVL), a devastating brain injury affecting premature infants, is the most common cause of cerebral palsy. PVL is caused by hypoxia ischemia (HI) and is characterized by white matter necrotic lesions, microglial activation, upregulation of NF-κB, and neuronal death. The microglia is the main cell involved in PVL pathogenesis. The goal of this study was to investigate the role of microglial NF-κB activity and its prophylactic inhibition in a neonate mouse model of HI. METHODS: Transgenic mice with specific knockout NF-κB in microglia and colony stimulating factor 1 receptor Cre with floxed IKKß (CSF-1R Cre + IKKßflox/wt ) were used. Postnatal day 5 (P5) mice underwent sham or bilateral temporary carotid artery ligation followed by hypoxia. After HI insult, inflammatory cytokines, volumetric MRI, histopathology, and immunohistochemistry for oligodendroglia and microglial activation markers were analyzed. Long-term neurobehavioral assessment, including grip strength, rotarod, and open field testing, was performed at P60. RESULTS: We demonstrate that selective inhibition of NF-κB in microglia decreases HI-induced brain injury by decreasing microglial activation, proinflammatory cytokines, and nitrative stress. Rescue of oligodendroglia is evidenced by immunohistochemistry, decreased ventriculomegaly on MRI, and histopathology. This selective inhibition leads to attenuation of paresis, incoordination, and improved grip strength, gait, and locomotion. CONCLUSION: We conclude that NF-κb activation in microglia plays a major role in the pathogenesis of hypoxic ischemic injury of the immature brain, and its prophylactic inhibition offers significant neuroprotection. Using a specific inhibitor of microglial NF-κB may offer a new prophylactic or therapeutic alternative in preterm infants affected by HI and possibly other neurological diseases in which microglial activation plays a role.

The superiority of point of care ultrasound in localizing central venous line tip position over time.

The primary objective was to study agreement between X-rays and point of care ultrasound (POC-US) in determining central venous line (CVL) tip position. The secondary objective was to examine malposition rates over time using POC-US. Fifty-six neonates were enrolled who had a CVL placed. Initial X-rays and POC-US were obtained. POC-US was performed daily thereafter for the total of 6 days. US video clips were acquired in four standard echocardiographic views: subcostal, four-chamber, and short- and long-axis parasternal views. Gwet's agreement coefficient (AC1) for agreement measured inter-rater reliability of X-rays and POC-US (correct position/malposition). A generalized linear mixed model for binary clustered data estimated malposition rate over time. All analyses were conducted using SAS version 9.4 and Agree Stat. The study included 108 "pairs" of X-rays and POC-US images. Agreement coefficient (AC1), with respect to correct position/malposition of CVL tip, was high AC1 = 0.872 (UVC-AC1 = 0.814, PICC-AC1 = 0.94). Among birth weight (BW) < 1000 g, 1000-1499 g, and BW > 1500 g, AC1 values were 0.922, 0.774, and 0.873, respectively. CVL tip malposition rate decreased over time.Conclusions: Agreement between POC-US and X-rays for CVL tip position was high, with the highest in BW < 1000 g. The data suggest that POC-US can be used for initial confirmation and follow up of CVL tip position. What is Known • X-ray is currently the gold standard for localizing central venous line (CVL) tip position. • Malposition of CVL tip can lead to life-threatening complications. What is New • POC-US is superior to X-ray as it can follow CVL tip position over time, detecting malpositioned lines, adjusting them in a timely manner thus preventing complications. • Standardizing CVL placement, X-ray acquisition, POC-US acquisition with four views with video clips and ultrasound operator training increases accuracy and thus agreement between X-ray and POC-US. • UVC tip is more likely to be malpositoned than PICC tip. Malposition of UVC tip using POC-US decreased over time due to shrinking of the umbilical cord in the first 48 of life.

Point-of-Care Ultrasound Use in Neonatal Peripheral Intravenous Extravasation Injuries: A Case Series.

PURPOSE: The primary aim of this study was to examine and describe peripheral intravenous extravasation (PIVE) injuries using point-of-care ultrasound (POC-US). A secondary aim was to define skin tissue changes before and after hyaluronidase application using POC-US. DESIGN: Case series design. SUBJECTS AND SETTING: We report on 10 neonates with stage 3 or 4 PIVE who were studied clinically and with POC-US. All infants were studied during the December 2015 to September 2016 period in a large academic neonatal intensive care unit. METHODS: Initially, neonates with PIVE were staged using 3 criteria: physical findings, nature of the infusate, and the size of the injury. Next, we described different ultrasound appearances of the tissue injury in PIVE based on the type of the infusate (clear fluid, blood, or both). We then located the largest PIVE pocket and measured the skin elevation over it. Skin elevation ratio was measured at 3 time points: before hyaluronidase injection followed by 3 to 6 hours and 24 hours after hyaluronidase therapy. Each ultrasound examination of the skin injury was staged (severe, moderate, mild, or minimal) based on the skin elevation ratio obtained. In addition, we described changes in the skin using ultrasound before and after hyaluronidase treatment. RESULTS: Three types of ultrasound images based on the type of the extravasated fluid were described in detail. Based on the initial ultrasound measurements of the skin elevation ratio, 6 infants were staged with severe PIVE and 4 were staged as moderate PIVE. Finally, POC-US was used to describe the tissue changes before and after hyaluronidase injection. CONCLUSIONS: Point-of-care ultrasound may offer more structured and objective staging of PIVE injuries due to direct visualization of the skin tissue. This method needs to be further studied and introduced as a practical tool to complement physical examination of PIVE injuries.

Galantamine ameliorates hyperoxia-induced brain injury in neonatal mice.

Introduction: Prolonged oxygen therapy in preterm infants often leads to cognitive impairment. Hyperoxia leads to excess free radical production with subsequent neuroinflammation, astrogliosis, microgliosis and apoptosis. We hypothesized that Galantamine, an acetyl choline esterase inhibitor and an FDA approved treatment of Alzheimer's disease, will reduce hyperoxic brain injury in neonatal mice and will improve learning and memory. Methods: Mouse pups at postnatal day 1 (P1) were placed in a hyperoxia chamber (FiO2 95%) for 7 days. Pups were injected IP daily with Galantamine (5 mg/kg/dose) or saline for 7 days. Results: Hyperoxia caused significant neurodegeneration in cholinergic nuclei of the basal forebrain cholinergic system (BFCS), laterodorsal tegmental (LDT) nucleus and nucleus ambiguus (NA). Galantamine ameliorated this neuronal loss. Treated hyperoxic group showed a significant increase of choline acetyl transferase (ChAT) expression and a decrease of acetyl choline esterase activity, thus increasing acetyl choline levels in hyperoxia environment. Hyperoxia increased pro-inflammatory cytokines namely IL -1ß, IL-6 and TNF α, HMGB1, NF-κB activation. Galantamine showed its potent anti- inflammatory effect, by blunting cytokines surges among treated group. Treatment with Galantamine increased myelination while reducing apoptosis, microgliosis, astrogliosis and ROS production. Long term neurobehavioral outcomes at P60 showed improved locomotor activity, coordination, learning and memory, along with increased hippocampal volumes on MRI with Galantamine treated versus non treated hyperoxia group. Conclusion: Together our findings suggest a potential therapeutic role for Galantamine in attenuating hyperoxia-induced brain injury.

Video laryngoscopy-assisted less-invasive surfactant administration quality improvement initiative.

OBJECTIVE: To describe the use of quality improvement methodology in transitioning from delivery of surfactant by INSURE (INtubation-SURfactant administration-Extubation) to video laryngoscope-assisted LISA (less-invasive surfactant administration) for infants with respiratory distress syndrome (RDS) receiving non-invasive ventilatory support. SETTING: Two large neonatal intensive care units (NICUs) at Northwell Health (New Hyde Park, New York, USA). STUDY POPULATION: Infants with RDS receiving continuous positive airway pressure in the NICU and eligible for surfactant administration. RESULTS: LISA was initiated in our NICUs in January 2021, after extensive guideline development, education programmes, hands-on training and provider credentialing. Our Specific, Measurable, Achievable, Relevant and Timely aim was to deliver surfactant by LISA for 65% of total doses by 31 December 2021. This goal was achieved within 1 month of go-live. In total, 115 infants received at least one dose of surfactant during the year. Of those, 79 (69%) received it via LISA and 36 (31%) via INSURE. Two Plan-Do-Study-Act cycles contributed to improved adherence to guidelines on timely surfactant administration and both written and video documentation. CONCLUSIONS: Safe and effective introduction of LISA with the use of video laryngoscopy is achievable with careful planning, clear clinical guidelines, adequate hands-on training and comprehensive safety and quality control.

Correlation between visual inspection/physical exam and point-of-care ultrasound exam in the evaluation of neonatal peripheral intravenous catheter site.

BACKGROUND: A peripheral intravenous catheter (PIVC) is used to administer IV fluids and medications. The most common PIVC complication is peripheral intravenous extravasation and infiltration (PIVE/I). Early visual inspection and physical exam (VI/PE) of the insertion site performed by a registered nurse (RN) are essential to prevent or limit tissue damage caused by displaced PIV catheters. Skin ultrasound (US) of the PIVC site provides rapid, real-time, high-resolution images of the anatomic structures at the point of care (POC). OBJECTIVES: To correlate the standard practice of clinical assessment (VI/PE) with POC-US exam to determine the location and function of PIVC suspicious for malfunctioning. DESIGN/METHODS: PIVC sites suspicious of malfunctioning were assessed by RN and findings were recorded in the electronic medical record. POC-US exam of the PIVC site was performed immediately after VI/PE. Sonographic exam included B-mode assessment of the PIVC site subcutaneous tissue characteristics and PIVC location as assessed by the Doppler flow tracing during RN's normal saline flush. RN's decision to continue or discontinue the PIVC was based solely on her/his VI/PE. RESULTS: Forty-four infants were studied. We found sufficient disagreement between the two methodologies (p = .0074), with discordance noted in 15 (34.1%) cases. In 29 (65.9%) cases there was concordance between VI/PE and POC-US, 18 to remove and 11 not to remove PIVC (Gwet AC1 correlation coefficient = 0.34). There was no significant correlation between VI/PE finding of tissue edema, the most common initial clinical evaluation sign, and POC-US finding of tissue edema or fluid pockets (p = .67, p = .21 respectively). RN's findings during the PIVC flush with normal saline (NS) were in perfect agreement with the findings of the Doppler signal on POC-US (Gwet's AC1 = 0.82) as well as with the final US-based decision to remove PIVC (p < .0001). CONCLUSION: We found only a fair correlation between RN's VI/PE of the suspicious PIVC site and the POC-US exam of the same site. However, our data suggest that in the evaluation of questionable PIVC, POC-US could be used in conjunction with VI/PE. This combination may improve the accuracy of decisions to remove or maintain PIVCs, which will result in a decreased number of PIVC placement attempts and complications.

Lung ultrasound assessment of pulmonary edema in neonates with chronic lung disease before and after diuretic therapy.

INTRODUCTION: Bronchopulmonary dysplasia (BPD) is characterized by lung injury with varying degrees of disrupted alveolarization, vascular remodeling, inflammatory cell proliferation, and pulmonary edema. Diuretics are often used to ameliorate the symptoms or progression of BPD. Our primary objective was to use lung ultrasound (LUS) to determine if diuretics decrease pulmonary edema in infants with BPD. The secondary objective was to assess changes in respiratory support during the first week after initiation of diuretics. METHODS: Premature infants requiring noninvasive respiratory support and starting diuretic therapy for evolving BPD were compared with a similar group of infants not receiving diuretics (control). For the diuretic group, LUS exams were performed before and on Days 1, 3, and 6 after initiation of treatment. For the control group, LUS was performed at equivalent time points. A composite pulmonary edema severity (PES) score of 0-5 was calculated based on the total number of B-lines in six scanned areas. Respiratory support parameters (FiO2 , nasal cannula flow, or CPAP) were also recorded. RESULTS: Infants in the diuretic (n = 28) and control (n = 23) groups were recruited at median corrected gestational ages of 34.2 (33.3-35.9) and 34.0 (33.4-36.3) weeks, respectively (p = 0.82). PES scores, FiO2 , and respiratory flow support decreased significantly from Days 0 to 6 (p < 0.0001, p = 0.001, and p = 0.01, respectively) in the diuretic group, but not in the control group. CONCLUSION: Diuretic use is associated with decreased pulmonary edema and improved oxygenation in infants with BPD during the first week of treatment.

Specification and guideline for technical aspects and scanning parameter settings of neonatal lung ultrasound examination.

Lung ultrasound (LUS) is now widely used in the diagnosis and monitor of neonatal lung diseases. Nevertheless, in the published literatures, the LUS images may display a significant variation in technical execution, while scanning parameters may influence diagnostic accuracy. The inter- and intra-observer reliabilities of ultrasound exam have been extensively studied in general and in LUS. As expected, the reliability declines in the hands of novices when they perform the point-of-care ultrasound (POC US). Consequently, having appropriate guidelines regarding to technical aspects of neonatal LUS exam is very important especially because diagnosis is mainly based on interpretation of artifacts produced by the pleural line and the lungs. The present work aimed to create an instrument operation specification and parameter setting guidelines for neonatal LUS. Technical aspects and scanning parameter settings that allow for standardization in obtaining LUS images include (1) select a high-end equipment with high-frequency linear array transducer (12-14 MHz). (2) Choose preset suitable for lung examination or small organs. (3) Keep the probe perpendicular to the ribs or parallel to the intercostal space. (4) Set the scanning depth at 4-5 cm. (5) Set 1-2 focal zones and adjust them close to the pleural line. (6) Use fundamental frequency with speckle reduction 2-3 or similar techniques. (7) Turn off spatial compounding imaging. (8) Adjust the time-gain compensation to get uniform image from the near-to far-field.

Neonatal lung diseases: lung ultrasound or chest x-ray.

Chest X-ray (CXR) examination is a well-recognized imaging modality in the diagnosis of neonatal lung diseases. On the other hand, lung ultrasound (LUS) has been an emerging and increasingly studied modality. However, the role of LUS as well as its potential to replace CXRs in the detection of neonatal lung diseases has been debated. We combine the present research progress and our own clinical experience to elaborate on various aspects of the potential routine use of lung ultrasound in neonatal intensive care units. We conclude that both LUS and CXR have a number of advantages and disadvantages. They should serve as complementary diagnostic methods in providing accurate, timely, and reliable information.

Determination of optimal endotracheal tube tip depth from the gum in neonates by X-ray and ultrasound.

Background/objective: Proper placement of endotracheal tube (ETT) in the midtrachea is essential. Initial depth of placement of oral ETT from the lips is commonly estimated based on weight ("7-8-9 rule"), gestational age, or nasal-tragus distance. However, these measurements can be altered by superficial factors and the mobility of the lips relative to the airway, so the upper alveolar ridge (gum) may provide a superior landmark. Also, confirmation of ETT tip position by point of care ultrasound (POC-US) is noninvasive and may enable localization of the ETT tip in real time. The objective of this study is to define optimal initial ETT depth from the gum in infants relative to weight, and to compare the efficacy of POC-US with standard chest X-ray (CXR) for confirming ETT tip position.Methods: Neonates requiring oral intubation were enrolled. At the time of CXR that were obtained for clinical indications, the position of the ETT at both the lip and gum were recorded. "Optimal" ETT placement in midtrachea (from lip and gum) was calculated based on the observed measurements and the distance of the ETT tip from the carina on CXR. Linear regression was used to model ideal placement of ETT, as a function of weight. POC-US was performed using a 10 MHz cardiac probe and high parasternal view. Distance from the ETT bevel to the superior aspect of the right pulmonary artery, which is at the level of carina, was measured using electronic calipers.Results: Infants were recruited at a median age of 3 days (n = 75), weight 1300 g, and corrected gestational age 31.6 ± 5.8 weeks. The regression equation for optimal placement from the gum (in cm) was 5.21 + 1.03 × weight (kg). Using estimates of 5 or 5.5 cm + weight (kg) to the gum yielded accuracy similar or superior to the 7-8-9 rule to the lip. Most of the variability in ideal placement of ETT tip from the gum was determined by weight (R2 = 0.83). The difference between optimal placement using lip and gum was 0.51 ± 0.24 cm. ETT location by POC-US (n = 40) was in substantial agreement with CXR (intraclass correlation coefficient 0.95, 95% CI: 0.92, 0.98).Conclusions: Marking oral ETT placement to the gum is feasible, with optimal depth of about 5.2 cm + weight (kg), across all weight categories. POC-US can be used for rapid confirmation of continued ideal ETT tip location, with accuracy similar to CXR. Further studies will be needed to determine whether marking ETT depth to the gum or using POC-US achieves the goal of decreased complications of ETT misplacement or displacement.

International Expert Consensus and Recommendations for Neonatal Pneumothorax Ultrasound Diagnosis and Ultrasound-guided Thoracentesis Procedure.

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic compromise, a life-threatening disorder. Traditionally, neonatal pneumothorax diagnosis has been based on clinical images, auscultation, transillumination, and chest X-ray findings. This approach may potentially lead to a delay in both diagnosis and treatment. The use of lung US in diagnosis of PTX together with US-guided thoracentesis results in earlier and more precise management. The recommendations presented in this publication are aimed at improving the application of lung US in guiding neonatal PTX diagnosis and management.

The use of less invasive surfactant administration (LISA) in the United States with review of the literature.

BACKGROUND: The majority of extremely low gestational age neonates undergo intubation for surfactant therapy. Less invasive surfactant administration (LISA) uses a thin catheter inserted into the trachea to deliver the surfactant. During the procedure, the infant is breathing spontaneously while supported with continuous positive airway pressure. Although LISA is widely adapted in Europe and Australia, the rate of LISA use in the United States is unknown. STUDY DESIGN: The aim of this study is to evaluate the use of LISA in the US. A web-based survey was distributed via SurveyMonkey to 2550 neonatologists from AAP's SoNPM mailing list. RESULTS: Of the 472 neonatologists who answered the survey, 15% used LISA either as a part of routine care (8%) or as part of research (7%). CONCLUSION: Unlike several regions of Europe, LISA is not widely used in the US. Future studies should address ambiguities regarding infant selection, procedure training and "roadblocks" to its broader application.

Protocol and Guidelines for Point-of-Care Lung Ultrasound in Diagnosing Neonatal Pulmonary Diseases Based on International Expert Consensus.

Ultrasound is a safe bedside imaging tool that obviates the use of ionizing radiation diagnostic procedures. Due to its convenience, the lung ultrasound has received increasing attention from neonatal physicians. Nevertheless, clear reference standards and guideline limits are needed for accurate application of this diagnostic modality. This document aims to summarize expert opinions and to provide precise guidance to help facilitate the use of the lung ultrasound in the diagnosis of neonatal lung diseases.

Point-Of-Care Ultrasound as an Adjunct in the Diagnosis of Neonatal and Pediatric Superficial Soft Tissue Infection: A Report of Two Cases.

Considerable technological advances, good safety profile, and ease of use have converged to support the use of ultrasound (US) as an important adjunct in the evaluation of superficial soft tissue infections (SSTI) in general and the differential diagnosis of cellulitis and abscess in particular. However, its use in neonatal populations has not been described. Pediatric studies report clinical examination is not always a reliable method of distinguishing cellulitis from abscess. Two (2) case reports are presented to supplement the growing body of published data that describe US imaging of SSTIs. In both cases, the US exam included the affected area as well as contralateral or adjacent normal skin for comparison. Case 1 describes a preterm infant boy who required placement of a peripheral intravenous (PIV) line and subsequently developed warm, painful, erythematous, and indurated skin in the area of the insertion. Point-of-care US (POC-US) was used to diagnose cellulitis, which initiated treatment with intravenous antibiotics. Case 2 involves a 7-year-old boy with multiple comorbidities who developed a PIV extravasation-related injury that subsequently progressed to cellulitis, likely secondary to wound infection with methicillin-resistant Staphylococcus aureus. Both patients healed completely and without any complications. Because treatment of cellulitis is different from that of abscess, it is important to obtain real-time data supportive of an accurate diagnosis. In these cases, POC-US confirmed the clinical diagnosis of cellulitis and ruled out the presence of an abscess.

Otopalatodigital syndrome type 2 in a male infant: A case report with a novel sequence variation.

We report a male infant with typical clinical, pathological and radiological features of otopalatodigital syndrome type 2 (OPD 2) with a novel sequence variation in the FLNA gene. His clinical manifestations include typical craniofacial features, cleft palate, hearing impairment, omphalocele, bowing of the long bones, absent fibulae and digital abnormalities consistent with OPD 2. Two hemizygous sequence variations in the FLNA gene were identified. The variation c.5290G>A/p.Ala1764Thr has been previously reported in a patient with periventricular nodular heterotopia, but subsequently it has been reported as a polymorphism. The other variation c.613T>C/p.Cys205Arg detected in the proband has not been previously reported and our analysis indicates that this is a novel disease-causing mutation for OPD2.