The Relationship between Depression Symptoms and Physical Activity in Children with Idiopathic Ventricular Extrasystoles.

Background and Objectives: Depression in childhood often co-occurs with anxiety disorders and a range of somatic symptoms. Recent studies have identified physical activity as a target for preventing the onset of depression. However, idiopathic ventricular extrasystoles (VEs) in children are sometimes associated with somatic symptoms and limitations in physical activity. The occurrence of arrhythmia can also be distressing for children and their parents. This study was conducted to determine the relationship between symptoms of depression, physical activity, and somatic symptoms in children with idiopathic VE. Materials and Methods: This study of children with structurally normal hearts and VE was approved by the local ethics committee (no. 2021/10-1383-859(1). The authors designed a questionnaire to assess symptoms, physical activity, and general well-being. As part of that, symptoms of depression were evaluated with a modified pediatric PHQ-9 (MP-PHQ-9) questionnaire, with scores ≤4 for no, 5-9 for mild, 10-14 for moderate, and ≥15 for severe depression. Children aged ≥12 years and parents who assessed their children's condition completed the questionnaires. All children also underwent 24-h electrocardiography and echocardiography to evaluate arrhythmia frequency and cardiac condition. Results: Questionnaires were completed by 60 children's parents and 39 children (≥12 years old). The median children's age was 13 years. Palpitations were experienced by 26 (43.3%), chest pain by 13 (21.7%), and exercise intolerance by 15 (25%) children. All patients had normal ventricular function and hemodynamically normal hearts. The median score of the MP-PHQ-9 completed by parents was 2, and by children was 4. The median VE frequency was 4.77 (0.1-32.77) % per 24 h. We found that 31 (51.7%) children engaged in extra-sports participation with a median time of 3.75 h per week. Eleven of the children were suspended from sports. There was no significant difference between VE frequency and MP-PHQ-9 scores. Higher MP-PHQ-9 scores were noted for symptomatic children who engaged in <5 h per week of physical activity. Conclusions: Higher depression scores were found for children with somatic symptoms than those without symptoms. Children who were physically active for less than 5 h per week also had higher depression risk scores than those who were more active. Our research has shown that parents underestimate the signs of depression in their children.

Ultrasonic cardiac output monitor provides effective non-invasive bedside measurements of neonatal cardiac output.

This study determined the accuracy and validity for the haemodynamic parameters of haemodynamically stable neonates after postnatal circulatory adaptation using the ultrasonic cardiac output monitor (USCOM) in comparison with echocardiography. We conducted a prospective, observational study of neonates born at 23-41 weeks of gestation. They all underwent both echocardiography and USCOM assessments for comparison purposes. The 127 neonates were examined at the median of postmenstrual age of 35 weeks and there was a very high correlation between the cardiac output measurements provided by both methods. The mean difference in cardiac output was - 12 ± 25 ml/kg/min, with percentage error of 8.3 ± 6.9%. A larger bias was observed in cases with higher left ventricular output. Bland-Altman analysis confirmed no significant bias, with acceptable limits of agreement between these two methods. There was a very good correlation between the USCOM and echocardiographic methods when we used them to measure cardiac output in neonates.

Primary child health care services in Lithuania: Does it meet the needs of the children?

BACKGROUND: Primary health care is the foundation of a health system and has a strong influence on the efficiency of the health system as a whole. For children in Europe, it is defined by three primary health care models: paediatric; mixed paediatrician and family physician; and family physician. There is much debate in Europe about which model is most appropriate for children. The Lithuanian model is mixed, although health policy is geared towards the promotion of family physicians, with a decline in the number of primary paediatricians in clinical practice. OBJECTIVES: To review the children's primary health care system in Lithuania, compare the indicators of primary care by family physicians and paediatricians in Lithuania, and identify parents' perceptions of the primary health care model for children. METHODS: A retrospective longitudinal study was performed of children's primary health care indicators for quantity and quality in 2014-2018. A representative opinion survey of 1000 adult respondents was conducted. RESULTS: A total of 3.5 million children's visits to primary care physicians (6.7 ± 3 visits for each child) were registered in Lithuania in 2018. During a recent 5-year period (2014-2018), the number of visits did not change significantly. Visits to paediatricians accounted for 41% of all children's visits to primary care physicians in 2018. Visits to Emergency Departments increased by 20%. The results of the survey showed that 72.3% of the respondents would prefer their children be treated by a primary care paediatrician. CONCLUSION: The mixed paediatrician and family physician health care model gives parents the right to choose. The results showed a decreased number of paediatricians in primary care; paediatric primary care is more frequent than family physician care; and parents tend to trust paediatricians more. The study also showed differences in the models of service used and patterns between regions in Lithuania.

Ten-year follow-up on efficacy, immunogenicity and safety of two doses of a combined measles-mumps-rubella-varicella vaccine or one dose of monovalent varicella vaccine: Results from five East European countries.

BACKGROUND: We assessed the 10-year efficacy, immunogenicity and safety of two doses of a combined measles-mumps-rubella-varicella vaccine (MMRV) or one dose of a monovalent varicella vaccine (V) in children from Czech Republic, Lithuania, Poland, Romania and Slovakia. METHODS: This was a phase IIIB follow-up of an observer-blind, randomized, controlled trial (NCT00226499). In phase A, healthy children aged 12-22 months from 10 European countries were randomized in a 3:3:1 ratio to receive two doses of MMRV (MMRV group), one dose of MMR followed by one dose of V (MMR + V group), or two doses of MMR (MMR; control group), 42 days apart. Vaccine efficacy (VE) against varicella (confirmed by viral DNA detection or epidemiological link and clinical assessment) was calculated with 95% confidence intervals using Cox proportional hazards regression model. Immunogenicity was assessed as seropositivity rates and geometric mean concentrations (GMCs). Solicited and unsolicited adverse events (AEs) and serious AEs (SAEs) were recorded. RESULTS: A total of 3705 children were vaccinated (1590, MMRV group; 1586, MMR + V group; 529, MMR group). There were 663 confirmed varicella cases (47, MMRV group; 349, MMR + V group; 267, MMR group). VE ranged between 95.4% (Lithuania) and 97.4% (Slovakia) in the MMRV group and between 59.3% (Lithuania) and 74% (Slovakia) in the MMR + V group. At year 10, seropositivity rates were 99.5%-100% in the MMRV group, 98%-100% in the MMR + V group and 50%-100% in the MMR control group, and the anti-VZV antibody GMCs were comparable between MMRV and MMR + V groups. The occurrence of solicited and unsolicited AEs was similar across groups and no SAE was considered as vaccination-related. No new safety concerns were identified. CONCLUSIONS: Our results indicated that two doses of varicella zoster virus-containing vaccine provided better protection than one dose against varicella and induced antibody responses that persisted 10 years post-vaccination.

Correlation of protection against varicella in a randomized Phase III varicella-containing vaccine efficacy trial in healthy infants.

BACKGROUND: Varicella vaccination confers high and long-lasting protection against chickenpox and induces robust immune responses, but an absolute correlate of protection (CoP) against varicella has not been established. This study models the relationship between varicella humoral response and protection against varicella. METHODS: This was a post-hoc analysis of data from a Phase IIIb, multicenter, randomized trial (NCT00226499) conducted in ten varicella-endemic European countries. Healthy children aged 12-22 months were randomized 3:3:1 to receive one dose of measles-mumps-rubella and one dose of varicella vaccine (one-dose group) or two doses of measles-mumps-rubella-varicella vaccine (two-dose group) or two doses of measles-mumps-rubella vaccine (control group) six weeks apart. The study remained observer-blind until completion, except in countries with obligatory additional immunizations. The objective was to correlate varicella-specific antibody concentrations with protection against varicella and probability of varicella breakthrough, using Cox proportional hazards and Dunning and accelerated failure time statistical models. The analysis was guided by the Prentice framework to explore a CoP against varicella. RESULTS: The trial included 5803 participants, 5289 in the efficacy (2266: one-dose group, 2279: two-dose group and 744: control group) and 5235 (2248, 2245 and 742 in the same groups) in the immunogenicity cohort. The trial ended in 2016 with a median follow-up time of 9.8 years. Six weeks after vaccination with one- or two-dose varicella-containing vaccine, more than 93.0% of vaccinees were seropositive for varicella-specific antibodies. Estimated vaccine efficacy correlated positively with antibody concentrations. The fourth Prentice CoP criterion was not met, due to predicted positive vaccine efficacy in seronegative participants. Further modelling showed decreased probability of moderate to severe varicella breakthrough with increasing varicella-specific antibody concentrations (ten-year probability <0.1 for antibody concentrations ≥2-fold above the seropositivity cut-off). CONCLUSIONS: Varicella-specific antibody concentrations are a good predictor of protection, given their inverse correlation with varicella occurrence. CLINICAL TRIAL: NCT00226499.

A questionnaire-based study to assess knowledge and attitudes to meningococcal disease and prevention among parents of children up to two years in Lithuania.

OBJECTIVES: In July 2018, vaccine against meningococcal B infection in Lithuania was added to the national vaccination calendar. However, vaccination rates were low. The aim of the study was to identify parents' attitudes towards meningococcal disease and vaccination. METHODS: In the period from February to March 2019, a questionnaire survey was conducted; 483 parents of children aged up to 2 years participated. In the validated questionnaire respondents provided data on their gender, education, age and answered questions that helped to estimate knowledge and attitudes towards meningococcal disease and vaccination. RESULTS: Parents with higher education are more likely to believe that meningococcal infection can be prevented; 316 (65.4%) parents are concerned that their child is at high risk of infection and evaluated the level of anxiety M = 7.39, SD = 2.29 out of 10 points; 309 (64.0%) believe that the vaccine is effective (M = 8.41; SD = 1.15 out of 10 points). One third of parents will not vaccinate their children because they believe that the MenB vaccine is not safe (71.2%); 370 (76.6%) have heard negative information about this vaccine, the majority (83.2%) from the Internet. The negative information received is positively correlated with the belief that the vaccine is not effective (r = 0.18, p = 0.031) and not safe (r = 0.35, p < 0.001); 49.3% of parents report side effects after vaccination; 326 (67.5%) parents believe that they need more evidence-based information on MenB vaccination and 90.8% would like to get it from a healthcare professional. CONCLUSIONS: Due to high level of mistrust of vaccines and the lack of evidence-based information, parents decide not to vaccinate their children against meningococcal B infection. There is a great need for parents' education and the dissemination of evidence-based information among them.

A Randomized Phase 4 Study of Immunogenicity and Safety After Monovalent Oral Type 2 Sabin Poliovirus Vaccine Challenge in Children Vaccinated with Inactivated Poliovirus Vaccine in Lithuania.

BACKGROUND: Understanding immunogenicity and safety of monovalent type 2 oral poliovirus vaccine (mOPV2) in inactivated poliovirus vaccine (IPV)-immunized children is of major importance in informing global policy to control circulating vaccine-derived poliovirus outbreaks. METHODS: In this open-label, phase 4 study (NCT02582255) in 100 IPV-vaccinated Lithuanian 1-5-year-olds, we measured humoral and intestinal type 2 polio neutralizing antibodies before and 28 days after 1 or 2 mOPV2 doses given 28 days apart and measured stool viral shedding after each dose. Parents recorded solicited adverse events (AEs) for 7 days after each dose and unsolicited AEs for 6 weeks after vaccination. RESULTS: After 1 mOPV2 challenge, the type 2 seroprotection rate increased from 98% to 100%. Approximately 28 days after mOPV2 challenge 34 of 68 children (50%; 95% confidence interval, 38%-62%) were shedding virus; 9 of 37 (24%; 12%-41%) were shedding 28 days after a second challenge. Before challenge, type 2 intestinal immunity was undetectable in IPV-primed children, but 28 of 87 (32%) had intestinal neutralizing titers ≥32 after 1 mOPV2 dose. No vaccine-related serious or severe AEs were reported. CONCLUSIONS: High viral excretion after mOPV2 among exclusively IPV-vaccinated children was substantially lower after a subsequent dose, indicating induction of intestinal immunity against type 2 poliovirus.

The Effect of Prolonged Freezing and Holder Pasteurization on the Macronutrient and Bioactive Protein Compositions of Human Milk.

Introduction: Human donor milk is widely used to feed premature and sick newborns when the milk of their own mothers is insufficient. All treatment processes involving human milk affect its composition. The aim of this study was to assess changes in the macronutrients and bioactive protein (lactoferrin and lysozyme) content in human milk caused by freezing and Holder pasteurization. Materials and Methods: Milk samples were collected from 42 mothers 14-16 days after delivery. Each sample was divided into two parts and tested twice for macronutrient content, once upon being freshly collected and again after freezing at -40°C, thawing and Holder pasteurization. The lysozyme and lactoferrin concentrations were first determined in the unpasteurized thawed human milk after it was stored frozen at -80°C for up to 10 months and again after Holder pasteurization. The macronutrient concentrations were determined by midinfrared spectrophotometry, and enzyme-linked immunosorbent assay was used to measure the lysozyme and lactoferrin concentrations. Results: Freezing and Holder pasteurization had no significant effects on the macronutrient concentrations. The mean lactoferrin content before and after pasteurization was 2.5 ± 1.07 and 0.03 ± 0.03 mg/mL, respectively (p < 0.001), and the lysozyme content was 19.57 ± 20.11 and 12.62 ± 14.14 µg/mL, respectively (p = 0.007). Conclusions: Freezing and Holder pasteurization did not decrease the nutritional value of human milk but caused considerable loss of lactoferrin and lysozyme. New methods for treating human milk are needed that ensure the destruction of pathogenic microorganisms while retaining the biological and nutritional value of the milk. The Clinical Trial Registration number: NCT04382989.

Circadian changes in the composition of human milk macronutrients depending on pregnancy duration: a cross-sectional study.

BACKGROUND: The purpose of this study was to evaluate the circadian variation of human milk macronutrients and energy content depending upon pregnancy duration. METHODS: One hundred eighty fresh human milk samples from 45 mothers (27 of preterm and 18 of full-term newborns) were collected on a single day chosen between the 14th to 16th day after delivery. The samples were taken four times per day at 12 PM, 6 PM, 12 AM and 6 AM. Only lactating women, who could not breastfeed their hospitalized newborns and expressed milk by breast pump, were enrolled in the study. Human milk macronutrient composition and energy count were evaluated by mid-infrared spectrophotometry. RESULTS: Significant differences in macronutrient content were observed between 6 AM and 12 PM for mean protein content (t = - 4.62, df = 44, p < 0.001), for mean fat content (t = - 2.10, df = 44, p = 0.04) and for mean energy content (t = - 2.24, df = 44, p = 0.03); between 6 AM and 6 PM for mean protein content (t = - 2.41, df = 43, p = 0.02), for mean fat content (t = - 3.76, df = 43, p = 0.001) and for mean energy content (t = - 3.85, df = 43, p < 0.001); between 12 PM and 12 AM for mean protein content (Wilcoxon test V = 75.5, p = 0.001), for mean fat content (t = 2.50, df = 44, p = 0.02) and for mean energy content (t = 2.74, df = 44, p = 0.01); between 6 PM and 12 AM for mean protein content (V = 229, p = 0.02), for mean fat content (t = 4.39, df = 43, p < 0.001) and for mean energy content (t = - 4.57, df = 43, p < 0.001). The average content of carbohydrates did not change significantly during the 24 h. The samples of preterm newborns' mothers had more apparent diurnal fluctuations in macronutrient content. CONCLUSIONS: Our study revealed significant diurnal variations in protein and fat in human milk, and these circadian fluctuations were more apparent in the milk of mothers of preterm infants.

Meropenem vs standard of care for treatment of neonatal late onset sepsis (NeoMero1): A randomised controlled trial.

BACKGROUND: The early use of broad-spectrum antibiotics remains the cornerstone for the treatment of neonatal late onset sepsis (LOS). However, which antibiotics should be used is still debatable, as relevant studies were conducted more than 20 years ago, recruited in single centres or countries, evaluated antibiotics not in clinical use anymore and had variable inclusion/exclusion criteria and outcome measures. Moreover, antibiotic-resistant bacteria have become a major problem in many countries worldwide. We hypothesized that efficacy of meropenem as a broad-spectrum antibiotic is superior to standard of care regimens (SOC) in empiric treatment of LOS and aimed to compare meropenem to SOC in infants aged <90 days with LOS. METHODS AND FINDINGS: NeoMero-1 was a randomized, open-label, phase III superiority trial conducted in 18 neonatal units in 6 countries. Infants with post-menstrual age (PMA) of ≤44 weeks with positive blood culture and one, or those with negative culture and at least with two predefined clinical and laboratory signs suggestive of LOS, or those with PMA >44 weeks meeting the Goldstein criteria of sepsis, were randomized in a 1:1 ratio to receive meropenem or one of the two SOC regimens (ampicillin+gentamicin or cefotaxime+gentamicin) chosen by each site prior to the start of the study for 8-14 days. The primary outcome was treatment success (survival, no modification of allocated therapy, resolution/improvement of clinical and laboratory markers, no need of additional antibiotics and presumed/confirmed eradication of pathogens) at test-of-cure visit (TOC) in full analysis set. Stool samples were tested at baseline and Day 28 for meropenem-resistant Gram-negative organisms (CRGNO). The primary analysis was performed in all randomised patients and in patients with culture confirmed LOS. Proportions of participants with successful outcome were compared by using a logistic regression model adjusted for the stratification factors. From September 3, 2012 to November 30th 2014, total of 136 patients (instead of planned 275) in each arm were randomized; 140 (52%) were culture positive. Successful outcome at TOC was achieved in 44/136 (32%) in the meropenem arm vs. 31/135 (23%) in the SOC arm (p = 0.087). The respective numbers in patients with positive cultures were 17/63 (27%) vs. 10/77 (13%) (p = 0.022). The main reason of failure was modification of allocated therapy. Treatment emergent adverse events occurred in 72% and serious adverse events in 17% of patients, the Day 28 mortality was 6%. Cumulative acquisition of CRGNO by Day 28 occurred in 4% of patients in the meropenem and 12% in the SOC arm (p = 0.052). CONCLUSIONS: Within this study population, we found no evidence that meropenem was superior to SOC in terms of success at TOC, short term hearing disturbances, safety or mortality were similar in both treatment arms but the study was underpowered to detect the planned effect. Meropenem treatment did not select for colonization with CRGNOs. We suggest that meropenem as broad-spectrum antibiotic should be reserved for neonates who are more likely to have Gram-negative LOS, especially in NICUs where microorganisms producing extended spectrum- and AmpC type beta-lactamases are circulating.

Expert panel diagnosis demonstrated high reproducibility as reference standard in infectious diseases.

OBJECTIVE: If a gold standard is lacking in a diagnostic test accuracy study, expert diagnosis is frequently used as reference standard. However, interobserver and intraobserver agreements are imperfect. The aim of this study was to quantify the reproducibility of a panel diagnosis for pediatric infectious diseases. STUDY DESIGN AND SETTING: Pediatricians from six countries adjudicated a diagnosis (i.e., bacterial infection, viral infection, or indeterminate) for febrile children. Diagnosis was reached when the majority of panel members came to the same diagnosis, leaving others inconclusive. We evaluated intraobserver and intrapanel agreement with 6 weeks and 3 years' time intervals. We calculated the proportion of inconclusive diagnosis for a three-, five-, and seven-expert panel. RESULTS: For both time intervals (i.e., 6 weeks and 3 years), intrapanel agreement was higher (kappa 0.88, 95%CI: 0.81-0.94 and 0.80, 95%CI: NA) compared to intraobserver agreement (kappa 0.77, 95%CI: 0.71-0.83 and 0.65, 95%CI: 0.52-0.78). After expanding the three-expert panel to five or seven experts, the proportion of inconclusive diagnoses (11%) remained the same. CONCLUSION: A panel consisting of three experts provides more reproducible diagnoses than an individual expert in children with lower respiratory tract infection or fever without source. Increasing the size of a panel beyond three experts has no major advantage for diagnosis reproducibility.

Protection against varicella with two doses of combined measles-mumps-rubella-varicella vaccine or one dose of monovalent varicella vaccine: 10-year follow-up of a phase 3 multicentre, observer-blind, randomised, controlled trial.

BACKGROUND: The duration of protection provided by varicella vaccines is unclear. We assessed the 10-year vaccine efficacy of two doses of a combined measles-mumps-rubella-varicella vaccine (MMRV), one live attenuated varicella vaccine (V) dose given after one measles-mumps-rubella vaccine (MMR) dose (MMR + V), versus two MMR doses (control vaccine) for the prevention of confirmed varicella. METHODS: This was a phase 3b follow-up of an observer-blinded, randomised, controlled trial. In phase a, children aged 12-22 months (at first vaccination) from Czech Republic (Czechia), Greece, Italy, Lithuania, Norway, Poland, Romania, Russia, Slovakia, and Sweden were randomly assigned by computer-generated randomisation list (3:3:1) to receive two doses of MMRV, one dose of MMR and one dose of varicella vaccine, or two doses of MMR, 42 days apart. Varicella cases were confirmed by detection of viral DNA, or epidemiological link and clinical assessment, by an independent data monitoring committee; disease severity was based on a modified Vázquez scale. Hazard ratios for MMRV and MMR + V versus MMR estimated in the per-protocol cohort using a Cox proportional hazards regression model were used to calculate vaccine efficacy and 95% CI. Serious adverse events were recorded throughout the study in all vaccinated children. Study objectives were secondary and descriptive. The trial is registered at ClinicalTrials.gov, number NCT00226499. FINDINGS: Between Sept 1, 2005, and May 10, 2006, 5803 children (mean age 14·2 months, SD 2·5) were vaccinated. The per-protocol cohort included 2279 children from the MMRV group, 2266 from the MMR + V group, and 744 from the MMR group. From baseline to a median follow-up of 9·8 years, 76 (3%) children in the MMRV group, 469 (21%) in the MMR + V group, and 352 (47%) in the MMR group had varicella. Vaccine efficacy against all varicella was 95·4% (95% CI 94·0-96·4) for MMRV and 67·2% (62·3-71·5) for MMR + V; vaccine efficacy against moderate or severe varicella was 99·1% (97·9-99·6) for MMRV and 89·5% (86·1-92·1) for MMR + V. During phase b, serious adverse events were reported by 290 (15%) of 1961 children in the MMRV group, 317 (16%) of 1978 in the MMR + V group, and 93 (15%) of 641 in the MMR group. There were no treatment-related deaths. INTERPRETATION: The 10-years vaccine efficacy observed, suggests that a two-dose schedule of varicella vaccine provided optimum long-term protection for the prevention of varicella by offering individual protection against all severities of disease and leading to a potential reduction in transmission, as observed in the US experience with universal mass vaccination. FUNDING: GlaxoSmithKline Biologicals.

Burden of varicella in Central and Eastern Europe: findings from a systematic literature review.

INTRODUCTION: Vaccination against varicella rapidly reduces disease incidence, resulting in reductions in both individual burden and societal costs. Despite these benefits, there is no standardization of varicella immunization policies in Europe, including countries in Central and Eastern Europe (CEE). AREAS COVERED: This systematic literature review identified publications on the epidemiology of varicella, its associated health and economic burden, and vaccination strategies within the CEE region, defined as Albania, Bosnia-Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Serbia, Slovakia, and Slovenia. Twenty-six studies were identified from a search of PubMed, Embase®, and MEDLINE® biomedical literature databases, supplemented by gray literature and country-specific/global websites. EXPERT COMMENTARY: Limited information exists in published studies on the burden of varicella in CEE. The wide variability in incidence rates between countries is likely explained by a lack of consistency in reporting systems. Funded universal varicella vaccination (UVV) in CEE is currently available only in Latvia as a one-dose schedule, but Hungary together with Latvia are introducing a two-dose strategy in 2019. For countries that do not provide UVV, introduction of vaccination is predicted to provide substantial reductions in cases and rates of associated complications, with important economic benefits.

Clinical and laboratory features of children with community-acquired pneumonia are associated with distinct radiographic presentations.

Chest radiographs from children with community-acquired pneumonia (CAP) were categorized into three distinct presentations and each presentation was correlated to clinical and laboratory findings. Children < 59 months with CAP presenting to pediatric emergency rooms during two years were enrolled prospectively in eight centers across Europe. Clinical and laboratory data were documented and radiographs obtained from patients. Of the 1107 enrolled patients, radiographs were characterized as 74.9% alveolar CAP, 8.9% non-alveolar CAP, and 16.3% clinical CAP. Alveolar CAP patients had significantly higher rates of fever (90.7%), vomiting (27.6%), and abdominal pain (18.6%), while non-alveolar CAP patients presented more with cough (96.9%). A model using independent parameters that characterize alveolar, non-alveolar, and clinical CAP demonstrated that alveolar CAP patients were significantly older (OR = 1.02) and had significantly lower oxygen saturation than non-alveolar CAP patients (OR = 0.54). Alveolar CAP patients had significantly higher mean WBC (17,760 ± 8539.68 cells/mm3) and ANC (11.5 ± 7.5 cells/mm3) than patients categorized as non-alveolar CAP (WBC 15,160 ± 5996 cells/mm3, ANC 9.2 ± 5.1 cells/mm3) and clinical CAP (WBC 13,180 ± 5892, ANC 7.3 ± 4.7). CONCLUSION: Alveolar CAP, non-alveolar CAP, and clinical CAP are distinct entities differing not only by chest radiographic appearance but also in clinical and laboratory characteristics. Alveolar CAP has unique characteristics, which suggest association with bacterial etiology. TRIAL REGISTRATION: Trial number 3075 (Soroka Hospital, Israel) What is Known: • Community-acquired pneumonia in children is diagnosed based on clinical and radiological definitions. • Radiological criteria were standardized by WHO-SICR and have been utilized in vaccine studies. What is New: • Correlation between the WHO-SICR radiological definitions and clinical and laboratory parameters has not been studied. • Using the WHO-SICR radiological definitions for alveolar community-acquired pneumonia (CAP) and non-alveolar CAP and the study definition for clinical CAP, it was found that the groups are distinct, differing clinically and in laboratory parameters.

Prescription of antibiotics in Riga and Vilnius tertiary children's hospitals.

OBJECTIVES: The aim of this study was to compare the use of antibiotics among hospitalised children in Riga (Latvia) and in Vilnius (Lithuania) at two tertiary paediatric centres. METHODS: A point prevalence survey (PPS) was conducted using validated and standardised Antibiotic Resistance and Prescribing in European Children (ARPEC) project methodology during November 2012. All inpatients less than 18 years old were included in the study. All data were recorded for patients with active antimicrobial prescriptions at 8 am on the day of the survey. Data were entered into the ARPEC-webPPS programme and were validated online for accuracy. RESULTS: The proportion of patients receiving antimicrobial therapy was statistically different: 128 (37.0%) patients in Riga and 83 (26.3%) in Vilnius. The most common age group in Riga and Vilnius was 1-5 years. The most commonly used antibiotic classes for the treatment and prophylaxis of infection were third-generation cephalosporins (38; 25.5% prescriptions) in Riga and second-generation cephalosporins (16; 19.8%) in Vilnius. Parenteral use of antimicrobials was higher in Riga than in Vilnius: 111 (74.5%) prescriptions to paediatric patients in Riga and 45 (55.6%) prescriptions in Vilnius. CONCLUSIONS: The PPS identified differences in antibiotic use in both hospitals and problem areas for improvement: high use of third-generation cephalosporins for paediatric patients (in Riga) and predominant use of parenteral antibiotics. Further collaboration between both centres is needed because sharing audit data and antimicrobial stewardship initiatives may encourage further changes in practice at both institutions.

Factors Determining Parents' Decisions to Bring Their Children to the Pediatric Emergency Department for a Minor Illness.

BACKGROUND The number of children visiting Emergency Departments (EDs) is increasing in Lithuania; therefore, the aim of this study was to determine the factors influencing the parental decision to bring their child to the ED for a minor illness that could be managed in a primary healthcare setting, and to compare parents' and medical professionals' attitudes toward a child's health status and need for urgent care. MATERIAL AND METHODS A prospective observational study was performed at the tertiary-level teaching Children's Hospital in Vilnius. A total of 381 patients' parents were interviewed using an original questionnaire based on Andersen's behavioral model of healthcare utilization; in addition, the medical records of patients were reviewed to identify factors that might have an impact on parental decisions to bring their child to the ED for a minor health problem. The study participants were enrolled from October 1, 2013 to August 31, 2014. The urgency of medical care needed to be provided to the patients was evaluated by a tertiary-level triage system. RESULTS Based on the assessment of the triage nurses, the need for emergency care to patients was distributed as follows: 298 patients (78.2%) needed non-urgent care and 83 patients (21.8%) needed urgent care. More than one-third (38.8%) of the parents reported that they came to the ED due to their child's urgent care need and worsened child's health; however, the opinion of ED professionals indicated only a fifth of patients required urgent care. Parents who brought their children to the ED without physician referral were five times more likely to visit the ED during evening hours and on weekends (OR=5.416; 95% CI, 3.259-8.99; p<0.001). The decision to come to the ED without visiting a primary care physician was made more often by parents with a higher income (OR=2.153; 95% CI, 1.167-3.97) and those who came due to children having rash (OR=4.303; 95% CI, 1.089-16.995) or fever (OR=3.463; 95% CI, 1.01-11.876). Older parents were 2.07 (95% CI, 1.1224-3.506) times more likely to evaluate their child's health unfavorably than younger parents. CONCLUSIONS We identified predisposing, enabling, and need factors that influenced the parents' decision to bring their child to the ED for minor health problems that could be managed by a primary care physician. Parents assessed their child's condition more critically and thought that their child required urgent medical aid more frequently than healthcare professionals.

Unscheduled return visits to a pediatric emergency department.

BACKGROUND AND OBJECTIVE: Return visits (RVs) to a pediatric emergency department (ED) within a short period after discharge have an influence on overcrowding of the ED and reveal some weaknesses of the health care system. The aim of this study was to determine the rate of RVs and factors related to RVs to the pediatric ED in Lithuania. MATERIALS AND METHODS: A retrospective study in an urban, tertiary-level teaching hospital was carried out. Electronic medical records of all patients (n=44097) visiting the ED of this hospital between 1 January and 31 December 2013 were analyzed. Demographic and clinical characteristics of patients who return to the ED within 72h and those who had not visited the ED were compared. Factors associated with RVs were determined by multivariable logistic regression. RESULTS: Of the overall ED population, 33889 patients were discharged home after the initial assessment. A total of 1015 patients returned to the ED within 72h, giving a RV rate of 3.0%. Being a 0-7-year old, visiting the ED during weekdays, having a GP referral, receiving of laboratory tests and ultrasound on the initial visit were associated with greater likelihoods of returning to the ED. Patients who arrived to the ED from 8:01a.m. to 4:00p.m. and underwent radiological test were less likely to return to the ED within 72h. Diseases such as gastrointestinal disorders or respiratory tract/earth-nose-throat (ENT) diseases and symptoms such as fever or pain were significantly associated with returning to the ED. The initial diagnosis corresponded to the diagnosis made on the second visit for only 44.1% of the patients, and the highest rate of the congruity in diagnosis was for injuries/poisoning, surgical pathologies (77.2%) and respiratory tract diseases (76.9%). CONCLUSIONS: RVs accounted for only a small proportion of visits to the ED. RVs were more prevalent among younger patients and patients with a GP referral as well as performed more often after discharging from the ED in the evening and at night.

Respiratory syncytial virus infection in a selected sample of infants hospitalized for lower respiratory tract infection in Lithuania and Estonia.

BACKGROUND: The study presents data on a sample of children under one year of age hospitalized with lower respiratory tract infections (LRTIs) in Lithuania and Estonia. SUBJECTS AND METHODS: This large, retrospective, cross-sectional, observational epidemiologic survey was conducted in 12 countries in Central and Eastern Europe. Eligible subjects were under one year of age, hospitalized for LRTIs, for whom RDT (Rapid Diagnostic Test) was performed. Physicians completed questionnaires at discharge or on the first check-up visit after hospitalization. To test for RSV, the immunochromatographic method was used in Lithuania, and immunofluorescense or the PCR methods were applied in Estonia. RESULTS: In two countries, 482 patients fulfilling the definition of a LRTI case (i.e., children below one year of age hospitalized with a diagnosis of bronchiolitis and/or pneumonia) were enrolled during two consecutive RSV seasons. Bronchiolitis was the most common diagnosis (84%). In Lithuania and Estonia, 36.6% and 83.3% of cases were conscious at admission. RSV was confirmed in 87.3% and 54.2% of tested LRTI cases in Estonia and Lithuania, respectively. Intensive care unit hospitalization was required for 9.1% of LRTI cases in Lithuania and for 3.1% of cases in Estonia. Supplemental oxygen was required for 23.2% and 31.6% in cases in Lithuania and Estonia, respectively. In Lithuania, complete recovery at discharge was assessed for 35.8% of LRTI cases and improvement in 62.2% of cases. In Estonia, all LRTI cases were improved at discharge and there were no complete recoveries. CONCLUSION: RSV was prevalent among children hospitalized for LRTI in Lithuania and Estonia; bronchiolitis was the most common diagnosis in hospitalized patients.

Sternal Osteomyelitis after Bacillus Calmette-Guérin Vaccination.

Presented here is the case of a nine-month-old boy with the osteomyelitis of the upper area sternum caused by bacillus Calmette-Guerin (BCG), the Danish 1331 strain vaccine against tuberculosis. Upon examination, a swelling of approximately 2×3 cm diameter was observed in the upper sternal area. The mass was hard, fixed and sensitive to palpation with no local skin hyperaemia. Chest X-rays revealed a round mass anterior to the sternum, suggesting a diagnosis of osteomyelitis. A consequent sternal biopsy was performed and Mycobacterium bovis BCG was identified by a positive growth culture.