The evaluation of the burden of multisystem inflammatory syndrome in children on health economics.

Objectives: This study aimed to evaluate the diagnostic tests and treatments applied in patients with multisystem inflammatory syndrome in children (MIS-C) and to determine the effect of the disease on health costs. Patients and methods: This retrospective cohort study included 59 MIS-C patients (40 males, 19 females; mean age: 7.7±4.2 years; range, 4 months to 16.5 years) who were admitted and treated between April 1, 2020, and November 1, 2021. Demographic and clinical features with hospital costs and length of stay were retrospectively reviewed from the medical files and computerized system of the hospital. Direct medical care costs of items were calculated with the hospital perspective using a combination of microcosting technique (resource-based accounting method) and hospital list data. Cases were classified as mild, moderate, or severe, and the patients were divided into two groups: the mild group and the moderate-severe group. Classification was determined by the vasoactive inotropic score (VIS), degree of respiratory support, and evidence of organ damage. Results: The mean age of the cases in the mild group was 6.5±3.7 years, and the mean age of the cases in the moderate-severe group was 9.2±4.3 years. Of 59 patients, 19 (32.2%) were followed up in the pediatric intensive care unit. The median duration of hospitalization in the hospital was 8 (interquartile range: 7-12) days. The total cost of the patients hospitalized with the diagnosis of MIS-C during the study period was 849,242.93$, and the mean cost per patient was 14,393.94±9,631.92$. In the distribution of the total cost of hospitalization according to expenses, the highest rate was pharmacy and blood products (51.99%) and IVIG costs (43.99%). While the mean total cost per person was 13,682.87±8,799.63$ in mild cases, it was 16,433.82±9,440.02$ in moderate-severe cases, and no statistically significant relationship was found between the two groups (p>0.05). There was no difference in the mean cost per patient between the cases with and without heart, lung, kidney, or neurologic involvement and advanced respiratory support (p>0.05). There was a strong positive correlation between the total costs and age (r=0.883, n=59, p<0.0001), with increased amount of costs with increased age. Conclusion: In the study, no statistically significant correlation was found between the total cost of per person in the mild group and the moderate-severe group (p>0.05). This finding may be due to the wide use of IVIG in MIS-C treatment, in addition to low transfer rates to pediatric intensive care units due to high-flow nasal cannula usage.

Comparative Analysis of Pediatric Brucellosis Cases With and Without Bacteremia.

Introduction: Brucellosis, which is among the endemic regions of Turkey, is a common zoonotic disease. The gold standard in diagnosing brucellosis is culture. We aimed to compare demographic characteristics, risk factors, and clinical and laboratory variables between cases with culture positivity and undetected in culture. Materials and Methods: This single-center study was conducted between January 2007 and April 2022. Clinical and laboratory data of patients with brucella growth in blood culture and patients without growth were compared. Results: A total of 150 patients were included in the study. The median age was 10 (1-18 years). Of the patients, 66 (44%) were female and 84 (56%) were male. Forty (26.7%) of the patients were bacteremic and 110 (73.3%) were nonbacteremic. In the bacteremic group, white blood cell count, platelet, and hemoglobin counts were lower, and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values were higher. In clinical evaluation, fever, hepatomegaly, splenomegaly, and abdominal pain were more common in the bacteremic group. Conclusion: The distinction between bacteremic and nonbacteremic brucellosis can be predicted using laboratory values such as white blood cells, hemoglobin counts, platelet, ALT, and AST, and clinical findings such as fever, abdominal pain, hepatomegaly, and splenomegaly.

Risk of tuberculosis in children with rheumatologic diseases treated with biological agents: A cross-sectional cohort study.

Objectives: This study aimed to evaluate the risk of tuberculosis (TB) disease in children receiving biological agents for rheumatologic diseases, focusing on appropriate screening tests in a high-priority country for TB control. Patients and methods: One hundred nine children (56 females, 53 males; range, 3.4 to 16.2 years) who received any biological agent for rheumatologic diseases for more than two years between May 2012 and October 2021 were included in this retrospective study. Patients were screened for TB infection using tuberculin skin test (TST) or interferon-gamma release assay (IGRA). Following the initial evaluation, patients were clinically examined for TB every three months by a comprehensive medical history and physical examination, and every 12 months using TST or IGRA. Results: At the initiation of the biological agent, the patients' mean age was 12.4±4.5 years. The average follow-up duration was 3.6±1.3 years (range, 2.6 to 10.2 years) for patients treated with biological agents. Each patient had a documented Bacillus Calmette-Guérin vaccination. Before the initiating of therapy, TST was performed alone in 45 (41.3%) patients and in combination with IGRA in 64 (58.7%) patients. In the 64 patients who underwent both TST and IGRA, IGRA revealed nine (14.1%) positive results. Six (66.7%) of these nine patients, however, had negative baseline TST. Four (7.3%) of the 55 individuals whose initial IGRA results were negative also had positive TST results. Overall, no TB disease was observed after a follow-up period. Conclusion: This study reveals that biological agents were not associated with an increased risk of TB disease in closely monitored children. Additionally, the concomitant use of TST and IGRA for screening of TB is reasonable in patients receiving biological agents.

Readmission reasons of pediatric patients diagnosed with multisystem inflammatory syndrome after discharge.

Objectives: There is no clear information in the literature about causes of reactivation of multisystem inflammatory syndrome in children (MIS-C) or indications for readmissions for MIS-C after discharge; as a result, the conditions that may develop after infection in children with MIS-C were discussed, and the reasons for hospitalization were screened. Patients and methods: This single-center retrospective study was conducted with 95 patients (65 males, 30 females; mean age: 92.8±55.5 months; range, 5 to 17 months) between November 11, 2020, and December 30, 2021. Children who were rehospitalized in the study center after their discharge with the diagnosis of MIS-C were included in the study, and the indications for readmissions were evaluated. Results: During the study period, six (6.3%) patients (4 males, 2 females; median age: 114.5 months [interquartile range: 122 months]) had to be rehospitalized. Four of these patients had an underlying disease, while the other two were previously healthy children. Fever was the most common reason for readmissions in half of the patients, while the remaining patients were readmitted with the indications of myocarditis, pneumonia, and posttraumatic pain syndrome. Conclusion: Although no evidence for the reactivation of MIS-C was detected in patients in the literature, it should also be emphasized that close follow-up of these patients is a must, considering possible cardiac complications.

Rehospitalization indications of children hospitalized for COVID-19 infections after discharge: Should we suspect long COVID?

BACKGROUND: Complications that may develop in children after coronavirus disease 2019 (COVID-19) infections are unknown. The `Long COVID` syndrome is a new process that can also be identified in children. Therefore, in this study, the conditions that may develop in children after COVID-19 infection were discussed, and the indications for rehospitalizations were reviewed. METHODS: This retrospective cohort study was conducted in a tertiary children`s hospital in Izmir, Türkiye. All children who were rehospitalized in the study center after discharge, and the indications for readmissions were screened. RESULTS: Since the beginning of the pandemic, 777 children with COVID-19 infection were hospitalized, including 98 (12.6%) cases rehospitalized for any indication. Fifty-five (56.1%) patients were male, and 43 (43.9%) were female. The mean age of the study population was 79.3±63.5 months (1 month to 17 years). Among these 98 patients, 76 (77.6%) were rehospitalized because of the presence of their primary underlying disease, nonspecific infectious diseases unrelated to COVID-19, and the need to perform certain surgical procedures. The remaining 22 (22.4%) patients presented with symptoms such as fatigue, fever, abdominal pain, and myalgia after the COVID-19 infection. No other underlying cause was detected in approximately one-third of the patients, whose manifestations were found to be consistent with long COVID syndrome. CONCLUSIONS: The findings of acute COVID-19 infection are well characterized, but there is still limited data on its long-term outcomes. The majority of the study population that had no underlying disease were thought to have complications from the COVID-19 infection. Therefore, although the incidence rate of long COVID syndrome in childhood has not been revealed so far, it should be kept in mind among relevant differential diagnoses.

Efficacy of Teicoplanin Lock Therapy in the Treatment of Port-related Coagulase-negative Staphylococci Bacteremia in Pediatric Oncology Patients.

The number of studies evaluating teicoplanin lock therapy in coagulase-negative staphylococcus-associated catheter infection in pediatric malignancies is limited. The aim of this study was to evaluate the efficacy of teicoplanin lock therapy in pediatric cancer cases. Twenty-two patients with coagulase-negative staphylococcus-associated totally implantable venous access device infection, who had undergone teicoplanin closure treatment, were included in the study. Demographic data, number of lock treatment days, and treatment success data were obtained from the medical files of the patients. Fourteen of the patients (63.6%) had acute lymphocytic leukemia, 3 (13.6%) had acute myelocytic leukemia, and 5 (22.7%) had solid cancer. The median neutrophil count was 240×10 3 /µL (interquartile range: 0 to 1195×10 3 /µL). Between patients with and without catheter removal, no statistically significant difference was found in terms of baseline C-reactive protein, absolute neutrophil count, and the day of starting systemic teicoplanin treatment ( P >0.05). The overall port survival rate of teicoplanin lock therapy was 72.7%. Within an average of 4 days, negative cultures of 16 (72.7%) patients whose catheters had not been removed were obtained. In conclusion, we suggest that teicoplanin lock therapy is an effective and safe treatment for catheter-related infections, caused by methicillin-resistant coagulase-negative staphylococcus.

Follow-Up of Cases with the Telemedicine Method During the COVID-19 Pandemic: An Alternative Strategy for Reduction of Hospital Workload and Hospital-Related Transmissions.

Background: This study evaluated the effect of telemedicine use in children with COVID-19 to reduce the workload of health care facilities. Methods: This study was conducted at Dr. Behçet Uz Children's Hospital between October and December 2020. The complaints of the children who were called because of positivity for severe acute respiratory syndrome-CoV-2-PCR were questioned and also the duration of talk was recorded. Children were classified according to their symptoms. Cases with severe symptoms were invited to the hospital and were hospitalized according to their clinical findings. Results: The median age of 506 patients reached was 10.8 ± 5.5. Phone calls lasted <3 min in 498 (98.6%) cases. Only 33 (6.5%) patients with severe symptoms were invited to the hospital, and 6 (18.2%) of these cases were hospitalized. Conclusion: During the pandemic, interviews with patients through telephone may help to reduce the patient burden and to prevent the contact of healthy individuals.

Which Findings Make multisystem Inflammatory Syndrome in Children Different from the Pre-Pandemic Kawasaki Disease?

Multisystem Inflammatory Syndrome in Children associated with COVID-19 infection attracted attention because some features overlapped with Kawasaki disease. And due to these overlapping features with Kawasaki disease, it has become difficult to diagnose both disorders. Therefore, this study focused on the differences between the patients diagnosed with MIS-C after COVID-19 and Kawasaki patients analyzed, particularly during the pre-pandemic period. In this way, it is aimed to reduce the dilemmas experienced in Diagnosis. In this descriptive study, 98 patients diagnosed with MIS-C throughout the pandemic were compared to 37 patients diagnosed with Kawasaki Disease during the pre-pandemic period.The patients in the MIS-C group were older children and clinically suffered from more headaches, vomiting, diarrhea, abdominal pain, and chest pain than Kawasaki patients. Signs of shock such as hypotension and tachycardia were more remarkable. Also, myocarditis and mitral regurgitation were detected at a higher rate in the MIS-C group. Besides, in the laboratory, lymphopenia, hypoalbuminemia, and creatinine elevation were more apparent.In conclusion, our present study findings support that although the MIS-C and Kawasaki share common features, they present with different clinical and laboratory features. And these differences are thought to be supportive in treatment and patient management.

The Evaluation of Troponin I Levels and Myocarditis in Children with COVID-19: A Pediatric Single-Center Experience.

Children with COVID-19 usually show milder symptoms than adults; however, a minority of them may have cardiac involvement. We aimed to identify the role of troponin I levels that may predict early cardiac involvement in children with COVID-19. A single-center retrospective study was conducted to evaluate hospitalized children diagnosed with COVID-19 between March 11, 2020, and December 31, 2021. Patients with available troponin I levels and with no known cardiac disease were included. During the study period, 412 children with COVID-19 who had troponin I levels on admission were identified. Troponin levels were elevated in 7 (1.7%) patients and were normal in 395 (98.3%) patients. The median age of patients with elevated troponin levels was 4 (min. 2-max. 144) months, which was statistically lower than the age of patients with normal troponin levels (P = 0.035). All the patients with elevated troponin levels had tachycardia. Out of 7 patients with high troponin levels, 3 (42.9%) of them were admitted to the pediatric intensive care unit (PICU), 2 (28.6%) required oxygen support, and 1 (14.3%) required a mechanical ventilator. Patients with elevated troponin levels had a statistically longer hospital stay (P < 0.001). Neutropenia, tachycardia, PICU admission, oxygen support, and mechanical ventilation were statistically more common in patients with elevated troponin levels (P values were 0.033, 0.020, < 0.001, 0.050, and < 0.001, respectively). Electrocardiography (ECG) and echocardiography (ECHO) were performed on all patients with elevated troponin levels, and 6 (85.8%) patients were diagnosed with myocarditis. The ECG and ECHO have been performed in 58 (14.3%) out of 405 patients with normal troponin levels. Two (3.5%) patients had negative T waves on ECG, and all ECHOs were normal. Our results suggest that elevated troponin I levels in children with COVID-19 can be used to evaluate cardiac involvement and decide the need for further pediatric cardiologist evaluation.

Multiple thrombi in a child diagnosed with coronavirus disease 2019 treated with cardiac surgery.

Coronavirus disease 2019 (COVID-19) is characterized predominantly by respiratory symptoms but may affect all systems, and it has been associated with thrombosis in adults. Case series investigating the COVID-19-associated multisystem inflammatory syndrome in children have reported high fibrinogen and D-dimer levels; however, it is not known whether this causes thrombophilia. Herein, we report a previously healthy 13-year-old male patient who had multiple thromboses associated with COVID-19, which occurred during long-term follow-up and was successfully treated with cardiac surgery. We want to emphasize that the long-term effects of COVID-19 are not yet known and that the follow-up of these cases should be continued.

A retrospective comparative analysis of factors affecting the decision and outcome of initial intravenous immunoglobulin alone or intravenous immunoglobulin plus methylprednisolone use in children with the multisystem inflammatory syndrome.

BACKGROUND: For children with the multisystem inflammatory syndrome(MIS-C), intravenous immunoglobulins (IVIG) with or without methylprednisolone are the most effective treatment. In this study, IVIG combined with methylprednisolone was compared to IVIG used alone in children with MIS-C. METHODS: This retrospective cohort study was carried out between April 1, 2020, and November 1, 2021. This study covered all children with MIS-C. According to whether they received IVIG alone or IVIG with methylprednisolone as an initial treatment for MIS-C, the patients were split into two groups. The IVIG dosage for the patients in group I was 2 gr/kg, whereas the IVIG dosage for the patients in group II was 2 gr/kg + 2 mg/kg/day of methylprednisolone. These two groups were contrasted in terms of the frequency of fever, length of hospital stay, and admission to the pediatric intensive care unit. RESULTS: The study comprised 91 patients who were diagnosed with MIS-C and were under the age of 18. 42 (46.2%) of these patients were in the IVIG alone group (group I), and 49 (53.8%) were in the IVIG + methylprednisolone group (group II). Patients in group II had a severe MIS-C ratio of 36.7%, which was substantially greater than the rate of severe MIS-C patients in group I (9.5%) (p 0.01). When compared to group I (9.5%), the rate of hypotension was considerably higher in group II (30.6%) (p = 0.014). Additionally, patients in group II had considerably higher mean serum levels of C-reactive protein. The incidence of fever recurrence was 26.5% in group II and 33.3% in group I, however the difference was not statistically significant (p > 0.05). CONCLUSIONS: The choice of treatment for patients with MIS-C should be based on an individual evaluation. In MIS-C children with hypotension and/or with an indication for a pediatric intensive care unit, a combination of IVIG and methylprednisolone may be administered. For the treatment modalities of children with MIS-C, however, randomized double-blind studies are necessary.

Evaluation of children diagnosed with a lower respiratory tract infection due to Human metapneumovirus.

BACKGROUND: Human metapneumovirus (hMPV) is one of the leading causes of acute respiratory infections and bronchiolitis in infants. A history of prematurity and chronic diseases such as congenital heart disease or asthma/reactive airway disease (RAD) increases the risk of severe lower respiratory tract infection (LRTI) due to hMPV. In this cross-sectional study, we aimed to analyze the clinical outcome and risk factors for severe disease in children with LRTI due to hMPV. METHODS: The current cross-sectional study included children between 28 days and 18 years of age with the diagnosis of hMPV-associated LRTI hospitalizations, over two years from January 2016 to September 2018 in Health Science University Dr. Behçet Uz Child Disease and Pediatric Surgery Training and Research Hospital. hMPV virus was detected by the multiplex polymerase chain test (PCR) (Commercial Multiplex Real-Time PCR: FTD Respiratory 21 plus, Fast Track Diagnostics, Luxembourg) from a nasopharyngeal swab. Patients who had positive results in multiplex PCR tests with other viral agents simultaneously were not included in the study. Data were retrospectively collected from the computerized hospital system. RESULTS: In this cross-sectional study, 62 patients who were hospitalized with the diagnosis of LRTI due to hMPV infection were included. Thirty-five (55.7%) of the patients were male. The median age was one year (2 months-15 years). Fifty-one (82.2%) patients were younger than two years. The median hospital length of stay was found to be 10 days (2-33 days) in patients with an underlying disease and 7,5 days (ranging from 2 to 20 days) in the patients without an underlying disease, this difference was significant (p=0.031). CONCLUSIONS: Clinicians should consider hMPV as an important pathogen of LRTI even in healthy children, although we expect a poor course of disease in children with an underlying disease.

A rare complication of pulmonary tuberculosis in childhood: Rasmussen`s aneurysm in a 9-year-old child with Down syndrome.

BACKGROUND: As an extremely rare entity reported in children, Rasmussen`s aneurysm is an inflammatory pseudo-aneurysmal dilatation of a branch of the pulmonary artery adjacent to or within a tuberculous cavity. CASE: Here, we reported a 9-year-old child with Down syndrome who presented with massive hemoptysis. Endovascular coil embolization was performed for Rasmussen`s aneurysm. During the 2-year follow-up period, she had no further episodes of bleeding. CONCLUSIONS: In case of the development of massive hemoptysis in the follow-up of a patient with pulmonary tuberculosis and Down syndrome, this lethal complication should be considered.

Evaluation of proximal tubule functions in children with COVID-19: a prospective analytical study.

BACKGROUND: There are limited numbers of studies focusing on renal effects of coronavirus disease 2019 (COVID-19) infection and proximal tubular dysfunction in children with COVID-19 infections. The purpose of this study was to evaluate the functions of the proximal tubule in hospitalized children with confirmed acute COVID-19. METHODS: The children who were hospitalized for confirmed COVID-19 were included in this prospective descriptive analysis. The presence of at least two of the following four abnormalities was used to diagnose proximal tubule injury: abnormal tubular reabsorption of phosphate, normoglycemic glycosuria, hyperuricosuria, and proteinuria. RESULTS: A total of 115 patients were included in the study. About a third of the individuals had elevated blood creatinine levels or proteinuria. In addition, abnormal renal tubular phosphate loss measured by renal tubular phosphate loss was found in 10 (8.7%) patients, as was hyperuricosuria in 28.6%. As a result, total proximal tubular dysfunction was found in 24 (20.9%) patients. CONCLUSIONS: One in every five children with acute COVID-19 infections had proximal tubular dysfunction, according to our data. Although, the rate of proximal tubular dysfunction was lower than in adults, it should be noted. The recovery of proximal tubular function in children with COVID-19 should be followed.

Comparison of the pediatric hospitalizations due to COVID-19 and H1N1pdm09 virus infections during the pandemic period.

There are two major pandemics in the new millennium, including the pandemic of swine influenza and the COVID-19 pandemic. These two pandemics affected children as well as the adult population. In this case-control study, we compared children with COVID-19 infection and those with H1N1pdm09 virus infection. We also compared the demographic factors, underlying disease, and the requirement for intensive care admission between the hospitalized children with COVID-19 infection and children with H1N1pdm09 virus infection who were hospitalized during the 2009 H1N1 pandemic. In this study, we evaluated 103 patients with H1N1pdm09 virus infection and 392 patients with COVID-19 infection. The age was significantly higher in the COVID-19 patients' group compared to the pandemic influenza group (p < 0.001). The ratio of the children ≥12 years was 10.7% (n = 11) in the H1N1pdm09 virus infection and 36.2% (n = 142) in the COVID-19 group. The rate of underlying disease was significantly higher in the patients with H1N1pdm09 virus infections (p = 0.02). The prevalence of underlying disease in patients requiring PICU hospitalization was 69.2% (n = 9/13) compared to 25.7% (n = 124/482) in patients who did not require PICU hospitalization. The rate of underlying disease was significantly higher in the PICU group regardless of COVID-19 or H1N1pdm09 virus (p = 0.002). Our results suggest that older children were more hospitalized for COVID-19 infections compared to pandemic influenza. In addition, regardless of the type of pandemic infection, the underlying disease is an important factor for pediatric intensive care unit admission. This finding is important for developing strategies for the protection of children with the underlying disease in the upcoming pandemics.

Evaluation of childhood hospitalization rates and degree of severity of SARS-CoV-2 variants, including B.1.1.7 (Alpha), B.1.315/P.1 (Beta/Gamma), and B.1.617.2 (Delta).

Severe acute respiratory syndrome coronavirus 2 is reappearing with an increasing number of variants every day; this study aimed to determine the effect of B.1.1.7 (Alpha), B.1.351 (Beta), P.1 (Gamma), and B.1.617.2 (Delta) variants on hospitalization rates. This single-center study was conducted at the University of Health Sciences Dr. Behçet Uz Children's Hospital from March 11 to August 27, 2021. Variant analyses of symptomatic patients admitted to the hospital who were found to be positive for COVID 19 PCR was performed. Out of 680 cases, 329 (48.4%) were B.1.1.7 variant, 17 (2.5%) were B.1.351/P.1 variant, and 165 (24.2%) were B.1.617.2 variant. One hundred and sixty-nine (24.9%) case variant analysis results were negative. The hospitalization rate of patients with the B.1.617.2 variant was 19.4%, the B.1.351/P.1 variant was 18%, the B.1.1.7 variant was 9.4%, and the negative variant was 10.1%. The B.1.617.2 (Delta) variant, which has become widespread all over the world recently, increases the rate of hospitalization in children.

Is respiratory syncytial virus infection more dangerous than COVID 19 in the neonatal period?

OBJECTIVE: We aimed to compare the clinical features, laboratory findings and primary outcomes of the neonates with RSV and neonates with SARS-CoV-2 infections. MATERIALS AND METHODS: This nested case-control study included the neonates who were administered in the neonatal intensive care unit (NICU) of the University of Health Sciences, Dr Behçet Uz Children's Hospital during the period of 01 March-30 April 2020. Respiratory PCR samples and COVID-19 samples were taken simultaneously. Only RSV positive and COVID-19 positive infants were compared. Demographic, epidemiological and clinical data were obtained from hospital electronic information system medical records. The chest radiographs at the admission were evaluated by using standard definitions for normal chest X-ray, atelectasis, bronchopenumonia, peribronchial thickening and hyperinflation in various lung volumes. RESULTS: A total of 30 infants were enrolled in the study and RSV was identified in 20/30 infants (66%). No significant differences were observed between the two groups in terms of general characteristics. Comparing to the infants with Covid-19 infections, infants with RSV infections had significantly higher rates of having oxygen support (p = .03). Total NICU duration time was 6.7 ± 1.6 days in COVID positive group and 11.1 ± 5.1 days in the RSV group (p = .01). Infants with COVID-19 had more normal chest X-rays. Infants with RSV-positive had a significantly higher proportion of atelectasis than those with COVID-19 infants (p = .04). DISCUSSION: This is the first study that compares RSV infection and COVID-19 infection. RSV infection can be more serious in the neonatal period. In cases with suspected COVID-19 infection, it should be kept in mind if atelectasis is seen on chest radiography. Respiratory failure may be more serious in RSV positive infants and RSV infection may be more dangerous for the neonatal period.