Seizure as First Manifestation of Hemolytic Uremic Syndrome with Bacteremia due to Shiga Toxin-Producing Escherichia coli.

Hemolytic uremic syndrome (HUS) often causes neurologic symptoms, but they typically occur as a later symptom of the syndrome. In addition, the Shiga toxin- producing E. coli (STEC) which causes HUS rarely causes bacteremia. We present the case of a 10-year-old male with Smith-Magenis syndrome who was admitted to the hospital due to STEC gastroenteritis, who was initially improving with supportive care, and then subsequently developed fever and had multiple seizures which were different from his typical seizure semiology. Over the subsequent 48 hours he gradually developed microangiopathic hemolytic anemia consistent with HUS. His course was further complicated by E. coli bacteremia and oliguric renal failure requiring renal replacement therapy, depressed mental status, and difficult-to-control hypertension. This case demonstrates the importance of neurologic manifestations as a harbinger of developing HUS.

Torticollis and Fever in a Young Boy: A Unique Presentation of Cat-Scratch Disease With Vertebral Osteomyelitis and Epidural Phlegmon.

Cat-scratch disease-associated vertebral osteomyelitis and epidural involvement are rare and may manifest with nonspecific chronic symptoms in children, such as fever or torticollis. We present only the fourth case in the literature describing epidural involvement in an immunocompetent boy presenting with fever, torticollis, and indiscriminate left upper back tenderness. Bartonella henselae serologies are important to consider because such atypical complications often are responsive to conservative management with antibiotics.

Clinical Outcomes of Bronchiolitis After Implementation of a General Ward High Flow Nasal Cannula Guideline.

OBJECTIVE: The goal of this study was to assess the association of the introduction of a ward's high-flow nasal cannula (HFNC) guideline with clinical outcomes of infants with bronchiolitis. METHODS: We conducted a retrospective, pre-post intervention study with an interrupted time series analysis of infants admitted with bronchiolitis between 2010 and 2014 at an urban, tertiary care children's hospital. Patients admitted in the 24 months before and after initiation of a guideline for HFNC use on the general wards were compared. The primary outcome was length of hospital stay. Secondary outcomes were PICU transfer rate and length of stay, intubation rate, and 30-day readmission, adjusted for season. RESULTS: A total of 1937 patients met inclusion criteria; 936 were admitted before and 1001 admitted after the introduction of HFNC use on the general wards. Comparing the 2 groups, the hospital-wide rate of HFNC use in bronchiolitis treatment increased after HFNC became available on the wards (23.9% vs 35.2%; P < .001). The ward's HFNC guideline was not associated with a change in preintervention trajectory of total hospital length of stay (P = .48), PICU length of stay (P = .06), or rate of PICU transfer (P = .97). There was also no difference in intubation rate or 30-day readmission between the 2 groups. CONCLUSIONS: Initiating a guideline for HFNC use on the general pediatric wards was associated with an increase in the use of the intervention with no significant change in total hospital length of stay, PICU length of stay and transfer rate, intubation rate, or 30-day readmission for patients with bronchiolitis.

Effect of a Hospital-wide High-Flow Nasal Cannula Protocol on Clinical Outcomes and Resource Utilization of Bronchiolitis Patients Admitted to the PICU.

OBJECTIVE: To assess the association of the introduction of a high-flow nasal cannula (HFNC) protocol with clinical outcomes and hospital charges of infants with bronchiolitis initially admitted to the PICU. METHODS: We conducted a retrospective, nonrandomized, preintervention-postintervention study of infants with bronchiolitis initially admitted to the PICU for HFNC. We compared patients admitted in the 24 months before and after protocol initiation for HFNC use on the general wards. The primary outcome assessed was length of hospital stay (LOS), and the secondary outcomes included total hospital charges, intubation, and 30-day readmission. We conducted bivariate analysis using χ² test for categorical variables and Student's t test or Wilcoxon rank sum test for continuous variables. RESULTS: Two hundred and ninety patients were admitted to the PICU on HFNC; 120 patients were admitted before and 170 admitted after the introduction of HFNC use on the general wards. Comparing the 2 groups, the median LOS was significantly reduced (4 days vs 3 days; P < .001), as was the median total hospital charges ($12 257 vs $9337; P < .001). After starting HFNC use on the wards, 30% of patients initially admitted to the PICU were ultimately transferred to the wards while still on HFNC. There was no difference in intubation rate or 30-day readmission between the 2 groups. CONCLUSIONS: For bronchiolitis patients initially admitted to the PICU, initiating a guideline for HFNC use on the general pediatric wards is associated with reduced total hospital LOS and total hospital charges, with no difference in intubation rates or 30-day readmission.

Demographic factors associated with bronchiolitis readmission.

OBJECTIVES: The goal of this study was to evaluate patient characteristics and medical management and their association with readmission in children with bronchiolitis. METHODS: This retrospective chart review included children admitted with bronchiolitis to 2 children's hospitals. Reviewers selected charts based on International Classification of Diseases, Ninth Revision, diagnosis and collected information on demographic characteristics, treatment, diagnostic testing, length of stay, and adverse outcomes. Univariate analyses were used to identify risk factors associated with any-cause readmission in 4 weeks. RESULTS: A total of 1229 patients met inclusion criteria. Younger children were more likely to be readmitted within 4 weeks of discharge compared with older children (mean age: 4.5 vs 5.7 months; P = .005). Readmissions did not differ based on length of stay, and no medical intervention was associated with risk for readmission. Of patients readmitted from the large service area hospital, 57% lived ≤20 miles away, compared with 26.9% of those who were not readmitted (P = .03). Patients from the lowest income zip codes within the catchment area of the small service area hospital were more likely to be readmitted compared with patients from the highest income zip codes (7.8% vs 0%; P = .025). CONCLUSIONS: Overall, 6.4% of hospitalized patients with bronchiolitis were readmitted. Our data did not identify any inpatient medical management or modifiable risk factor associated with readmission.

Is dexamethasone an effective alternative to oral prednisone in the treatment of pediatric asthma exacerbations?

BACKGROUND: A short course of systemic corticosteroids is an important therapy in the treatment of pediatric asthma exacerbations. Although a 5-day course of oral prednisone or prednisolone has become the most commonly used regimen, dexamethasone has also been used for a shorter duration (1-2 days) with potential for improvement in compliance and palatability. We reviewed the literature to determine if there is sufficient evidence that dexamethasone can be used as an effective alternative in the treatment of pediatric asthma exacerbations in the inpatient setting. METHODS: A Medline search was conducted on the use of dexamethasone in the treatment of asthma exacerbations in children. The studies selected were clinical trials comparing the efficacy of dexamethasone with prednisone. Meta-analysis was performed examining physician revisitation rates and symptomatic return to baseline. RESULTS: Six completed pediatric clinical trials met the inclusion criteria. All of the pediatric trials found that prednisone is not superior to dexamethasone in treating mild to moderate asthma exacerbations. Meta-analysis demonstrated homogeneity between the dexamethasone and prednisone groups when examining symptomatic return to baseline and unplanned physician revisits after the initial emergency department encounter. Some studies found potential additional benefits of dexamethasone, including improved compliance and less vomiting. CONCLUSIONS: The current literature suggests that dexamethasone can be used as an effective alternative to prednisone in the treatment of mild to moderate acute asthma exacerbations in children, with the added benefits of improved compliance, palatability, and cost. However, more research is needed to examine the role of dexamethasone in hospitalized children.