Suicide and Self-Harm in Adolescents During the COVID-19 Pandemic: A U.S. Virtual Pediatric Systems, LLC, Database Study of PICU Admissions, 2016-2021.

OBJECTIVES: To characterize the epidemiology of suicide and self-harm among adolescents admitted to PICUs during the first 2 years of the COVID-19 pandemic in the United States. DESIGN: Descriptive analysis of a large, multicenter, quality-controlled database (Virtual Pediatric Systems [VPS]), and of a national public health dataset (U.S. Centers for Disease Control and Prevention web-based Wide-ranging ONline Data for Epidemiology Research [CDC WONDER]). SETTING: The 69 PICUs participating in the VPS database that contributed data for the entire the study period, January 1, 2016, to December 31, 2021. PATIENTS: Adolescents older than 12 years to younger than 18 years old admitted to a participating PICU during the study period with a diagnosis involving self-harm or a suicide attempt (VPS sample), or adolescent suicide deaths over the same period (CDC WONDER sample). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 10,239 suicide deaths and 7,692 PICU admissions for self-harm, including 5,414 admissions in the pre-pandemic period (Q1-2016 to Q1-2020) and 2,278 in the pandemic period (Q2-2020 to Q4-2021). Compared with the pre-pandemic period, there was no increase in the median (interquartile range) number of suicide deaths per quarter (429 [399-453] vs. 416 [390-482]) or PICU admissions for self-harm per quarter (315 [289-353] vs. 310 [286-387]) during the pandemic period, respectively. There was an increase in the ratio of self-harm PICU admissions to all-cause PICU admissions per quarter during the pandemic (1.98 [1.43-2.12]) compared with the pre-pandemic period per quarter (1.59 [1.46-1.74]). We also observed a significant decrease in all-cause PICU admissions per quarter early in the pandemic compared with the pre-pandemic period (16,026 [13,721-16,297] vs. 19,607 [18,371-20,581]). CONCLUSIONS: The number of suicide deaths and PICU admissions per quarter for self-harm remained relatively constant during the pandemic, while the number of all-cause PICU admissions per quarter decreased compared with the pre-pandemic period. The resultant higher ratio of self-harm admissions to all-cause PICU admissions may have contributed to the perception that more adolescents required critical care for mental health-related conditions early in the pandemic.

Characteristics and Outcomes of Critically Ill Children With Multisystem Inflammatory Syndrome.

OBJECTIVES: To characterize the prevalence of pediatric critical illness from multisystem inflammatory syndrome in children (MIS-C) and to assess the influence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) strain on outcomes. DESIGN: Retrospective cohort study. SETTING: Database evaluation using the Virtual Pediatric Systems Database. PATIENTS: All children with MIS-C admitted to the PICU in 115 contributing hospitals between January 1, 2020, and June 30, 2021. MEASUREMENTS AND MAIN RESULTS: Of the 145,580 children admitted to the PICU during the study period, 1,338 children (0.9%) were admitted with MIS-C with the largest numbers of children admitted in quarter 1 (Q1) of 2021 ( n = 626). The original SARS-CoV-2 viral strain and the D614G Strain were the predominant strains through 2020, with Alpha B.1.1.7 predominating in Q1 and quarter 2 (Q2) of 2021. Overall, the median PICU length of stay (LOS) was 2.7 days (25-75% interquartile range [IQR], 1.6-4.7 d) with a median hospital LOS of 6.6 days (25-75% IQR, 4.7-9.3 d); 15.2% received mechanical ventilation with a median duration of mechanical ventilation of 3.1 days (25-75% IQR, 1.9-5.8 d), and there were 11 hospital deaths. During the study period, there was a significant decrease in the median PICU and hospital LOS and a decrease in the frequency of mechanical ventilation, with the most significant decrease occurring between quarter 3 and quarter 4 (Q4) of 2020. Children admitted to a PICU from the general care floor or from another ICU/step-down unit had longer PICU LOS than those admitted directly from an emergency department. CONCLUSIONS: Overall mortality from MIS-C was low, but the disease burden was high. There was a peak in MIS-C cases during Q1 of 2021, following a shift in viral strains in Q1 of 2021. However, an improvement in MIS-C outcomes starting in Q4 of 2020 suggests that viral strain was not the driving factor for outcomes in this population.

A Novel Maneuver to Treat Refractory Atelectasis in Mechanically Ventilated Children.

We developed a novel airway clearance and lung recruitment maneuver for children with refractory unilateral atelectasis undergoing invasive mechanical ventilation. In this retrospective, single-center, proof of concept study, we describe the steps involved in this novel maneuver and evaluate its effectiveness in 15 patients through objective quantitation of changes in respiratory system compliance and in the degree of atelectasis assessed by a validated Modified Radiology Atelectasis Score. Compared with the premaneuver baseline, the median atelectasis score improved significantly following the maneuver (9 [7.5-10] vs. 1 [0-3.3], respectively, p < 0.01). Likewise, dynamic compliance was significantly higher following the maneuver (0.3 [0.32-0.44] vs. 0.61 [0.53-0.69] mL/kg/cm H 2 O, respectively, p < 0.01). No patients required a bronchoscopy. This simple and effective maneuver resulted in a significant improvement in the degree of atelectasis and dynamic compliance in this cohort of mechanically ventilated children with refractory unilateral atelectasis.

School Closures in the United States and Severe Respiratory Illnesses in Children: A Normalized Nationwide Sample.

OBJECTIVES: To determine the association between nationwide school closures and prevalence of common admission diagnoses in the pediatric critical care unit. DESIGN: Retrospective cohort study. SETTING: National database evaluation using the Virtual Pediatric Systems LLC database. PATIENTS: All patients admitted to the PICU in 81 contributing hospitals in the United States. MEASUREMENTS AND MAIN RESULTS: Diagnosis categories were determined for all 110,418 patients admitted during the 20-week study period in each year (2018, 2019, and 2020). Admission data were normalized relative to statewide school closure dates for each patient using geographic data. The "before school closure" epoch was defined as 8 weeks prior to school closure, and the "after school closure" epoch was defined as 12 weeks following school closure. For each diagnosis, admission ratios for each study day were calculated by dividing 2020 admissions by 2018-2019 admissions. The 10 most common diagnosis categories were examined. Significant changes in admission ratios were identified for bronchiolitis, pneumonia, and asthma. These changes occurred at 2, 8, and 35 days following school closure, respectively. PICU admissions decreased by 82% for bronchiolitis, 76% for pneumonia, and 76% for asthma. Nonrespiratory diseases such as diabetic ketoacidosis, status epilepticus, traumatic injury, and poisoning/ingestion did not show significant changes following school closure. CONCLUSIONS: School closures are associated with a dramatic reduction in the prevalence of severe respiratory disease requiring PICU admission. School closure may be an effective tool to mitigate future pandemics but should be balanced with potential academic, economic, mental health, and social consequences.

The Temporal Relationship Between Local School Closure and Increased Incidence of Pediatric Diabetic Ketoacidosis.

Importance: The incidence of pediatric diabetic ketoacidosis (DKA) increased early in the COVID-19 pandemic, but the relative contribution of behavioral changes and viral-related pathophysiology are unknown. Objective: To evaluate the relationship between school closure date and onset of increased DKA to help clarify the etiology of the increased incidence. Design: A multi-center, quality-controlled Pediatric Intensive Care Unit (PICU) database was used to identify the number of admissions to a participating PICU with DKA on each calendar day from 60 days before local school closure to 90 days after, and compared to baseline data from the same periods in 2018-2019. Interrupted time series and multiple linear regression analyses were used to identify admission rates that differed significantly between 2020 and baseline. Setting: Eighty-one PICUs in the United StatesParticipants: Children ages 29 days to 17 years admitted to a PICU with DKAExposures: Statewide school closureMain outcome/measure: Rate of admission to the PICU for DKA. Results: There were 1936 admissions for children with DKA in 2020 and 1795 admissions/year to those same PICUs in 2018-2019. Demographics and clinical outcomes did not differ before school closure, but pandemic-era patients were less often white and had longer hospital length of stay in the post-school closure period. The difference between 2020 admissions and 2018-2019 admissions was not different than zero before school closure, and significantly higher than zero after school closure, but was significantly increased in 2020 at >30 days after school closure (p = 0.039). Conclusions/Relevance: An increase in pediatric DKA admissions began one month after school closures. Given that behavioral changes started near school closure dates and viral activity peaked weeks after, this suggests that behavioral factors may not be the primary etiology and it is possible that SARS-CoV-2 infection may have direct effects on pediatric DKA.

Changes in Pediatric ICU Utilization and Clinical Trends During the Coronavirus Pandemic.

BACKGROUND: Children have been less affected by the COVID-19 pandemic, but its repercussions on pediatric illnesses may have been significant. This study examines the indirect impact of the pandemic on a population of critically ill children in the United States. RESEARCH QUESTION: Were there significantly fewer critically ill children admitted to PICUs during the second quarter of 2020, and were there significant changes in the types of diseases admitted? STUDY DESIGN AND METHODS: This retrospective observational cohort study used the Virtual Pediatric Systems database. Participants were 160,295 children admitted to the PICU at 77 sites in the United States during quarters 1 (Q1) and 2 (Q2) of 2017 to 2019 (pre-COVID-19) and 2020 (COVID-19). RESULTS: The average number of admissions was similar between pre-COVID-19 Q1 and COVID-19 Q1 but decreased by 32% from pre-COVID-19 Q2 to COVID-19 Q2 (20,157 to 13,627 admissions per quarter). The largest decreases were in respiratory conditions, including asthma (1,327 subjects in pre-COVID-19 Q2 (6.6% of patients) vs 241 subjects in COVID-19 Q2 (1.8%; P < .001) and bronchiolitis (1,299 [6.5%] vs 121 [0.9%]; P < .001). The percentage of trauma admissions increased, although the raw number of trauma admissions decreased. Admissions for diabetes mellitus and poisoning/ingestion also increased. In the multivariable model, illness severity-adjusted odds of ICU mortality for PICU patients during COVID-19 Q2 increased compared with pre-COVID-19 Q2 (OR, 1.165; 95% CI, 1.00-1.357; P = .049). INTERPRETATION: Pediatric critical illness admissions decreased substantially during the second quarter of 2020, with significant changes in the types of diseases seen in PICUs in the United States. There was an increase in mortality in children admitted to the PICU during this period.

Adjuvant lidocaine to a propofol-ketamine-based sedation regimen for bone marrow aspirates and biopsy in the pediatric population.

Pediatric patients with hematological malignancies repeatedly undergo painful bone marrow aspirates and biopsies (BMABs) in routine care. No standard sedation regimen has been established. This study evaluated the addition of injected local lidocaine to a propofol-ketamine sedation for BMAB and its effects on propofol dosing, safety, and efficacy. A retrospective analysis of children undergoing BMAB with propofol-ketamine with (PK+L) and without (PK-only) the injection of local lidocaine. Patients were matched through propensity probability scores. To measure efficacy, dosing, procedure length, and recovery time were evaluated. To assess safety, adverse and serious events were recorded. As an indirect measurement of analgesia, changes in heart rate and blood pressure were analyzed. Of the 420 encounters included, 188 matched pairs (376 patients) were analyzed. Patient demographics were comparable. The median dose of propofol was not significantly different between both groups. The incidence of adverse events was similar. There were no significant differences in the changes in heart rate and blood pressure with sedation between groups.Conclusion: This study suggests that the addition of local lidocaine injection to a propofol-ketamine sedation for BMAB pediatric patients does not affect the propofol dose, safety, or efficacy properties of the regimen. What is Known: •Although propofol is commonly used, there is no standard sedation regimen for pediatric patients undergoing bone marrow aspiration and biopsy. •Local lidocaine is used in analgesia in the adults undergoing the same procedure. What is New: •Local lidocaine adjuvant to propofol-ketamine sedation does not affect propofol dosing, the safety of efficacy properties of the regimen in the pediatric population.

Successful Use of Tissue Plasminogen Activator in an Adolescent Male with Pyogenic Liver Abscess.

Large pyogenic liver abscess is a rare and difficult to treat entity in pediatric patients. Percutaneous drainage rather than open surgical drainage has become more common in recent years, even for large abscesses. Percutaneous drainage can be complicated by catheter obstruction. We present the case of a 16-year-old male presenting with abdominal pain, fever, and chills. He was diagnosed with a 9-centimeter liver abscess. A CT-guided percutaneous drainage was placed. The catheter initially drained well, but then became occluded. Tissue plasminogen activator was instilled into the catheter every 6 hours for a total of five doses, resulting in increased drainage and improved clinical state of the patient. To our knowledge, this is the first reported use of tissue plasminogen activator in pyogenic liver abscess in the pediatric population.

Adherence to pediatric diabetic ketoacidosis guidelines by community emergency departments' providers.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common presentation of type I diabetes mellitus to the emergency departments. Most children with DKA are initially managed in community emergency departments where providers may not have easy access to educational resources or pediatric-specific guidelines and protocols that are readily available at pediatric academic medical centers. The aim of this study is to evaluate adherence of community emergency departments in the state of Indiana to the pediatric DKA guidelines. METHODS: We performed a retrospective chart review of patients, age 18 years of age or under, admitted to the pediatric intensive care unit with a diagnosis of DKA. RESULTS: A total of 100 patients were included in the analysis. Thirty-seven percent of patients with DKA were managed according to all six guideline parameters. Only 39% of patients received the recommended hourly blood glucose checks. Thirty percent of patients received intravenous insulin bolus, which is not recommended. CONCLUSIONS: Non-adherence to pediatric DKA guidelines still exists in the state of Indiana. Further, larger studies are needed to reveal the etiology of non-adherence to pediatric DKA guidelines and strategies to improve that adherence.

Live tweeting in medicine: 'Tweeting the meeting'.

Medical conferences create an opportunity for lifelong learning for healthcare practitioners. The use of Twitter at such conferences continues to expand. This article focuses on how Twitter can be used by physicians and other healthcare providers at regional, national and international conferences, and also at local conferences, such as grand rounds. It also addresses the potential utility of Twitter chats and journal clubs in the promotion of lifelong learning. The impact of Twitter use in healthcare in general, and specifically at conferences, and how it can be measured, is discussed.