Results of neck-specific exercise for altered postural sway in individuals with chronic whiplash-associated disorders: a longitudinal case-control study.

Postural sway has not been investigated before or after a neck exercise intervention in individuals with chronic whiplash-associated disorders (WAD). The aim of the study was to investigate postural sway in individuals with chronic WAD grades 2 and 3: (a) compared with healthy matched controls at baseline; (b) after three months of neck-specific exercise and (c) to investigate the correlation between postural sway with self-reported dizziness during motion and balance problems/unsteadiness. This is a longitudinal prospective experimental case-control intervention study. Individuals with WAD (n = 30) and age- and gender-matched healthy volunteers (n = 30) participated. Postural sway was assessed using an iPhone application. Measurements were carried out at baseline, and for those with WAD a second measurement was performed at the three-month follow-up when neck-specific exercise intervention ended. The WAD group performed significantly worse than the healthy group in both pathway and ellipse area double stance eyes closed at baseline (main outcome), but not at the three-month follow-up. The WAD group significantly improved after rehabilitation in both pathway double stance eyes closed and pathway single stance eyes open. The correlation between postural sway and self-rated dizziness during motion and balance problems was low to moderate. One may conclude that postural sway was improved after a neck-specific exercise programme. The study results strengthen earlier findings that individuals with WAD have worse balance outcome when they have to rely on neck proprioception (eyes closed). The study results may be important for the development of improved rehabilitation methods for WAD.

Acute Kidney and Liver Injury Associated With Low-Dose Liraglutide in an Obese Adolescent Patient.

In 2020, the US Food and Drug Administration approved liraglutide (glucagon-like-peptide-1-receptor-agonist) as an adjunctive therapy for weight management in adolescents aged 12 to 18 years in combination with a reduced-calorie diet and increased physical activity. The 2023 American Academy of Pediatrics guidelines recommend pharmacotherapy with glucagon-like-peptide-1-receptor-agonist as a second-line therapy in obesity management. Although reports in adults have suggested a link between liraglutide and adverse effects including hepatic injury and acute kidney injury (AKI), these effects have not previously been reported among adolescents treated with liraglutide for weight loss. We present a 17-year-old male who developed AKI and evidence of hepatic injury (significant elevation of hepatic transaminases) after 3 months administration of the lowest dosage of liraglutide (0.6 mg/day) for management of class III obesity. The patient experienced significant loss of appetite, weight loss, and melancholy during the treatment period. One month after discontinuing liraglutide, his mood had improved, his liver enzymes had returned to normal, and AKI had resolved. The Adverse Drug Reaction Probability Scale suggested a high likelihood of a causative association between liraglutide and his symptoms. Our report highlights the importance of vigilance in monitoring for these potential adverse effects among adolescents treated for obesity with any dose of liraglutide.

Remote versus face-to-face fall risk assessment in home dwelling older adults: a reliability study.

BACKGROUND: Falls are a leading cause of severe injury and death in older adults. Remote screening of fall risk may prevent falls and hence, advance health and wellness of older adults. While remote health care is becoming a common practice, we question if remote evaluation of fall risk is as reliable as face-to-face (FTF). OBJECTIVE: To assess the inter-tester reliability of synchronized remote and FTF fall risk assessment. METHODS: This inter-format, inter-rater reliability study included 48 home dwelling older adults aged 65 and over. Five valid functional and balance tests were conducted: 30 Second Sit-to-Stand (STS), MiniBESTest, Timed up and go (TUG), 4-Meter Walk (4MWT), and Berg Balance Scale (BBS). Instructions were provided via videoconferencing, and two physiotherapists scored performance simultaneously, one remotely, and one in the room. Inter-rater reliability between remote and FTF scores was analyzed using intraclass correlation coefficient (ICC2,1), standard error of measurement (SEM), minimal detectable change (MDC95) and Bland and Altman analysis. RESULTS: Excellent ICCs were found for STS, MiniBESTest, TUG, and BBS (0.90-0.99), and moderate for 4MWT (0.74). SEM and MDC95 values were STS (0.37,1.03 repetitions), MiniBESTest (1.43,3.97 scores), TUG (1.22,3.37 seconds), 4MWT (0.17,0.47 m/second), and BBS (1.79,4.95 scores). The Bland and Altman analysis showed excellent agreement between remote and FTF assessments of the STS. All other tests showed low to moderate agreement. Mean difference ± SD and 95%LOA were as follows: STS (-0.11 ± 0.52), (-1.13,0.91) repetitions, MiniBESTest (0.45 ± 1.98), (-3.43,4.32) scores, TUG (-0.35 ± 1.54), (-3.37,2.67) seconds, 4MWT (-0.08 ± 0.22), (-0.35,0.51) meter/second, and BBS (0.04 ± 2.53), (-4.93,5.01) scores. CONCLUSIONS: The findings support the responsible integration of remote fall risk assessment in clinical practice, enabling large-scale screenings and referrals for early intervention to promote healthy aging and fall prevention.

Urinary tract infections in young infants with a normal urine dipstick.

AIM: To assess missed urinary tract infections (UTI) in febrile infants ≤2 months when adhering to recent guidelines suggesting not to send a urine culture with a negative dipstick. METHODS: A retrospective cohort study of 308 infants ≤2 months with a positive urine culture admitted in 2013-2023, divided into subgroups without exposure to urine dipstick results: 'urosepsis' (UTI with bacteraemia), 'UTI' (positive urine culture, elevated inflammatory markers, no other cause of fever) and 'bacteriuria' (positive urine culture, not meeting the above-mentioned criteria). After retrieving the dipstick results, the 'missed UTI' group (UTI+ negative dipstick) was described. RESULTS: A negative dipstick was found in 2/20 (10%), 32/127 (25%) and 126/161 (78%) of infants with 'urosepsis', 'UTI' and 'bacteriuria', respectively. In the 'missed UTI' group (n = 34), there were more non-Escherichia coli UTI (68% vs. 9% with positive dipstick, p < 0.001), and lower inflammatory markers (leukocytes 15.5 vs. 17.2 k/µL, p = 0.007, C-reactive protein 21 vs. 58 mg/L, p < 0.001). Three infants had high-grade vesicoureteral reflux (VUR) and renal scarring. CONCLUSIONS: There is a non-negligible rate of infants ≤2 months with UTI and without pyuria, including those with urosepsis, VUR and renal scarring. We suggest obtaining a urine culture regardless of dipstick results.

The association between forward head posture and non-specific neck pain: A cross-sectional study.

BACKGROUND: Poor posture is traditionally associated with various musculoskeletal disorders. Consequently, educators in the musculoskeletal field have been teaching postural observation as part of the physical assessment. Forward head posture (FHP) is hypothesized to be associated with neck pain; however, evidence in this topic remains inconclusive. PURPOSE: To investigate the association between FHP and neck pain intensity, disability, and cervical kinematics in individuals with neck pain compared to asymptomatic individuals. A secondary aim of this study was to explore the possible effect of a head-mounted display (HMD) used in a virtual reality (VR) assessment on FHP. METHODS: The study was conducted with 43 volunteers (20 asymptomatic individuals, 23 individuals with neck pain) aged 19 to 62. FHP was assessed by measuring craniovertebral angle on profile photographs. Secondary outcome measures included pain intensity, the neck disability index (NDI) questionnaire, and neck kinematics using specialized VR software. RESULTS: There were no significant differences between individuals with neck pain and asymptomatic individuals in FHP (craniovertebral angle = 48.24°±7.29; 48.90°±5.89, respectively, p > .05). The neck pain group demonstrated a restricted range of motion and slower neck movements (p < .05). We found no significant correlation between FHP and visual analog scale, NDI, and most neck kinematic measures. CONCLUSIONS: Our findings cannot support a clinically applicable association between FHP and neck pain. Additionally, individuals with neck pain had a lower range of motion and slower neck movements.

[13-YEAR-OLD GIRL WITH PHEOCHROMOCYTOMA PRESENTING WITH SECONDARY NOCTURNAL ENURESIS].

INTRODUCTION: Pheochromocytoma is a rare, catecholamine secreting tumor arising from chromaffin cells of the adrenal medulla and it is responsible for 0.5-2% of pediatric hypertension cases. We hereby present a case of a 13-year-old girl with obesity, excessive hypertension, prediabetes and secondary nocturnal enuresis, who was eventually diagnosed with pheochromocytoma. Most symptoms significantly improved after treating the tumor. We suggest that this diagnosis should be considered in pediatric patients presenting with similar symptoms.

Catheter-Obtained Urine Culture Contamination Among Young Infants: A Prospective Cohort Study.

Objectives: A correct diagnosis of urinary tract infection in young infants requires an uncontaminated urine culture, commonly obtained by urethral catheterization. In the current study, we examined the rates and factors associated with contaminations of catheter-obtained urine cultures in very young infants. Methods: This prospective cohort study included 143 catheter-obtained urine cultures of infants ≤2 months of age admitted to the pediatric ward of a tertiary hospital in Israel from April 2019 to September 2020. Patient's and operator's study variables were documented at the time of catheter insertion. Positive urine cultures were reviewed by a pediatric nephrologist and a pediatric infectious disease specialist and designated as infection or contamination. The study variables were compared between those with or without contamination. Results: The contamination rate in our cohort was 29%. Females were more than twice as likely to have a contaminated urine culture (37 vs. 18%, respectively, P = 0.014). Circumcision status, official training about sterile catheterization, a sense of difficult catheterization, and the shift in which the culture was obtained did not influence the contamination rate. Conclusions: Catheter-obtained urine cultures have a high contamination rate among very young infants, especially among girls.

The prevalence and underreporting of needlestick injuries among hospital workers: a cross-sectional study.

OBJECTIVE: Needlestick and sharps injuries (NSIs) are known occupational risks among health-care workers. Reporting these injuries is important for early prevention and management of blood-borne infections. We investigated the prevalence and characteristics of NSIs and underreporting among hospital workers (HWs) from different sectors. METHODS: A single-center cross-sectional study, involving an anonymous survey delivered to 2205 HWs. The survey included demographic information about the worker and information about training, injuries and reporting. RESULTS: Of the 844 HWs respondents (40%), NSIs occurred in 443 of them (53%); the majority were from needles (68%) and at bedside (51%). Significantly higher prevalences of injuries (P < 0.001) were noted among physicians (75%) and workers in their 40s (61%) and in the emergency and surgical departments (66% and 55%, respectively). NSIs were reported among 28% of workers who did not directly use needles. Underreporting was found in 46%, with a significant decrease in the report rate as the number of injuries increased (P < 0.001). Underreporting was significantly more common (P < 0.001) among physicians (59%), especially seniors (72%), workers without training about NSIs (59%), older age groups (56% in workers above 51 years, P = 0.003) and males (54%, P = 0.01). The highest underreporting rate was in injuries occurring in the operating room and the lowest in witnessed injuries occurring while passing a needle (82% vs. 31%, P < 0.001). CONCLUSIONS: NSIs and underreporting are common among HWs from all sectors, including those who do not use needles. Improving preventive measures and reporting should be encouraged. We recommend reducing bedside procedures as possible and assigning two workers to procedures at risk for injuries, to increase the report rate.

Validity and Reliability of a Customized Smartphone Application for Postural Sway Assessment.

OBJECTIVE: The purpose of this study was to investigate the validity and reliability of a customized smartphone application (CSA) for postural sway (PS) assessment. METHODS: This validity and reliability study evaluated static balance by measuring PS in 29 healthy volunteers (15 women, 14 men, mean age 28 ± 5.11). Assessments included synchronized data collection using 3 systems: the CSA, a force plate, and the clinical modified balance error scoring system (mBESS). The experimental procedure included three 40-seconds long repetitions in 3 positions. Outcome measures included pathway and 95% ellipse area. Statistical analysis compared the developed application to both the force plate and the mBESS to test its validation and analyzed repeatability of the 3 experimental measurements. RESULTS: Good to strong correlations were found between the CSA and the force plate in double and tandem stance (pathway r = 0.81-0.91), and moderate to high reliability was found for the CSA (0.66-0.75) and for the force plate (0.69-0.77) pathway measurements. The similarity in reliability results of the 2 devices and the high correlation both support the validity of the CSA. Furthermore, a high correlation was demonstrated between the CSA and the mBESS (r = 0.80), higher than the force plate and the mBESS. CONCLUSION: The developed CSA was found valid and reliable in healthy young adults, and further research is needed to recommend it for clinical balance assessments. The CSA could therefore be considered for PS assessment in the clinical field.

Self-Kinematic Training for Flight-Associated Neck Pain: a Randomized Controlled Trial.

BACKGROUND: Flight-associated neck pain (FANP) is a serious problem in fighter pilots. Despite the high impact of FANP there is little evidence for effective management. However, self-kinematic training showed a positive effect in the general population. The purpose of this study was to investigate the effectiveness of a self-kinematic training program using virtual reality in improving neck pain in fighter pilots.METHODS: There were 45 pilots with FANP who were randomized to a control group (N 23) or a training group (N 22). Training participants were instructed to exercise using a personalized self-training program, for 20 min/wk, for 4 wk. Primary outcome measures were neck disability (NDI%) and mean velocity ( s1), and secondary were pain, health status, accuracy, and isometric strength. Assessments were conducted by a blinded assessor and intention-to-treat analysis by a blinded statistician.RESULTS: There were 40 pilots who completed the postintervention assessments, and 35 completed the 6-mo follow-up. Baseline measurements showed mild pain and disability (mean VAS 43 22.73, NDI 17.76 9.59%) and high kinematic performance. Compliance with self-training was poor. No differences were observed in self-reported measures and strength. Exercise duration was correlated with NDI% improvement.DISCUSSION: This self-kinematic training promoted kinematic performance, but was ineffective in engaging the pilots to exercise, and consequently did not improve pain and disability. Poor compliance was previously reported in self-training for FANP, suggesting further studies should prioritize supervised training. Considering the high baseline kinematic performance, kinematics does not seem to be a key factor in FANP, and future exercise research should aim for intense strengthening to increase endurance to the high Gz pilots experience.Sarig Bahat H, German D, Palomo G, Gold H, Frankel Nir Y. Self-kinematic training for flight-associated neck pain: a randomized controlled trial. Aerosp Med Hum Perform. 2020; 91(10):790797.

Predictors for Positive Response to Home Kinematic Training in Chronic Neck Pain.

OBJECTIVES: There is strong evidence for exercise therapy in neck pain, but a wide variety of protocols. Predictors for outcome are unknown and current practice is based on trial and error. The objective of this study was to identify predictors for response to home kinematic training (KT) considering improvement in both self-reported and kinematic measures. METHODS: A continuing analysis of data from the second phase of a randomized controlled trial, which included 4 weeks of KT using laser or virtual reality, with baseline, postintervention, and 3-month follow-up measures. Positive self-reported response was defined as a ≥50% pain reduction, ≥7% reduction in neck disability index (NDI), or a global perceived effect of 3 to 5 of 5. A second model defined improvement by ≥40% increase in cervical velocity. RESULTS: Data were retrieved from 79 participants with chronic neck pain who completed the postintervention evaluation and 52 who completed the 3-month follow-up. Self-reported response was 71% to 73% and kinematic response was 41% to 46%. Prediction models indicated an immediate increase in self-reported measures in men with NDI ≥ 20% slower (≤65°/s), and less accurate (≥16° error) cervical motion at baseline. In the longer term, older patients with higher NDI seemed to benefit more. In the second model, no factors significantly predicted improvement in kinematic measures at either time point. CONCLUSION: A high positive response rate to home KT was found by self-reported criteria. Males with poorer clinical and kinematic presentation at baseline, that is greater disability and slower neck motion, were more likely to respond.

Thiamine Deficiency in Adolescents with Eating Disorders: A Prospective Cohort Study.

BACKGROUND: Pediatric eating disorders (PED) patients are prone to nutritional deficiencies. Thiamine deficiency is well described in other malnutrition states but is not routinely screened for in PED. In the current study we evaluated the prevalence of thiamine deficiency among PED patients on their first admission to an outpatient day hospital for eating disorders (DH). METHODS: In this prospective cohort study, we measured whole blood thiamine pyrophosphate concentrations (TPP) in addition to a routine laboratory workup in 69 girls on their first admission to DH. Two subgroup analyses were performed: (I) Patients with a previous dietary intervention ("diet" group, n = 30) or naïve-to-treatment patients ("naïve" group, n = 39) and (II) Type of PED: Restrictive (group R, n = 44) or binge-eating/purging (group BP, n = 25). RESULTS: Thiamine deficiency was identified in four girls (6%), all in the "naïve" group. Three of them had BP, and one had R. Patients in the "diet" group had a significantly higher TPP compared to the "naïve" group (55.5 µg/L vs. 46.7 µg/L, p = 0.004). TPP levels returned to normal after two weeks of the treatment program in all deficient patients. CONCLUSION: Thiamine deficiency was uncommon among PED patients and was easily replenished. Screening for deficiency should be performed among treatment-naïve patients. Keynotes: Whole blood thiamine pyrophosphate concentrations (TPP) are seldom screened for among PED patients. In the current study, we detected thiamine deficiency in only 6% of patients on their first admission to an outpatient day hospital for eating disorders. All deficient patients did not have a recent dietary intervention. We recommend considering screening for thiamine deficiency in treatment-naïve PED patients.

High-vs. low-tech cervical movement sense measurement in individuals with neck pain.

OBJECTIVES: To compare diagnostic ability of the clinical cervical movement sense (CCMS) test to the neck virtual reality (VR) system accuracy module. BACKGROUND: Altered cervical proprioception is common in patients with persistent neck pain (NP). Recently a simple CCMS has been found to be feasible and reliable. However, it is not known how this compares to a valid method. METHODS: Twenty participants with persistent NP and 20 healthy controls were videoed while performing the CCMS using a laser pointer and traced a zigzag pattern and then assessed using the VR accuracy module which consisted of following 8 segments in four directions. Diagnostic ability using a model from potential variables from the video analysis of number of errors and task performance time was compared to a model provided from VR data. RESULTS: Subjects with NP had significantly greater horizontal errors in the CCMS and VR accuracy. Both CCMS and VR measurement models utilising measurements of horizontal movement error demonstrated good diagnostic ability (AUC = 0.88, 0.91 respectively) and there was no statistical difference between the models' AUC (p = 0.7). CONCLUSION: The simple clinical testing tool appears to provide a measure of cervical movement sense, similar to the established Neck VR accuracy measure. Both tools differentiated individuals with NP from controls with similar sensitivity and specificity, with some advantage to the VR. The rotational motion measures seem most suitable in the assessment of motion accuracy. CCMS has potential to be used as a simple clinical measure and warrants further research.

The Role of an Interventional Program for Improving Pharmacovigilance at a Pediatric Facility.

Background: The reporting rate of adverse drug reactions (ADRs) by healthcare professionals is low. ADR interventional programs may improve the reporting rate by the medical team. Our literature search revealed that only a few interventional studies among the pediatric population have been published. Objective: We aimed to create an interventional program in order to improve the reporting rate of ADRs during the interventional period compared to the control period, detect which drugs frequently lead to ADRs and determine the most serious ADRs. Design: A 3-month prospective intervention study compared with one year prior to the intervention (control period). ADR data was also collected for the year following the study period. Healthcare professionals were encouraged to report ADRs and an ADR reporting system was created for them. Setting: Pediatric Division at Shamir Medical Center (Assaf Harofeh), a tertiary care medical center. Results: The study population included 3,753 admitted patients with 1,323 prescriptions during the study period. During the period before the intervention was started, the ADR reporting rate was null. During the study period, 46 reports were collected: 46% from the general pediatric department, 26% from the pediatric neurology department, and 22% and 6% from the pediatric and neonatal intensive care units, respectively. Antiepileptic medications, IVIG, steroids and antibiotics were frequently reported to induce ADRs. Serious ADRs were also reported in 5 cases. One year of follow up after the intervention revealed a significant decline in the reporting rate. Conclusion: It is important to periodically encourage healthcare professionals to report any ADRs in order to increase knowledge about medication safety and prevent fatal harm.

Robot-assisted Laparoscopic Pyeloplasty for "Huge" Hydronephrosis Causing Vena Cava Thrombus.

OBJECTIVE: To present a rare case of "huge" hydronephrosis causing distortion of large vessels and formation of a thrombus in the inferior vena cava. Multidisciplinary treatment was applied with particular focus on pyeloplasty utilizing a robot-assisted laparoscopic approach. METHODS: A 20-month-old male presented to the emergency room severely ill with abdominal pain, nausea, vomiting, and fever and was subsequently transferred to the intensive care unit, in septic shock. An abdominal ultrasound revealed a large multilobular cystic structure in the right hemiabdomen, which was initially interpreted as an infected mesenteric cyst. CT scan revealed a huge hydronephrotic kidney crossing the midline, causing a mass effect that compressed and distorted the vena cava laterally, in addition to a thrombus between the hepatic vein and right renal vein. Intravenous Ceftriaxone and Amikacin, as well as anticoagulation therapy with low molecular weight heparin (Enoxaparin) were initiated. A nephrostomy tube was inserted that drained 900 mL of purulent urine. A full hematology investigation including protein C, S, and antithrombin III was carried out, excluding factor V Leiden and prothrombin mutation. All values were in the normal range. Dimercaptosuccinic Acid (DMSA) scan showed 30% function on the affected kidney and Voiding Cystourethrogram (VCUG) excluded any bladder pathology or reflux. Subcutaneous Enoxaparin was continued for 3 months, maintaining antifactor Xa in the therapeutic range (0.7-1 IU/mL). Ultrasound Doppler of the vena cava showed full resolution of the thrombus. Robot-assisted laparoscopic pyeloplasty was performed and significant reduction of the renal pelvis was carried out, taking care to preserve the calyces. Postoperative ultrasound 4 months after surgery showed a complete resolution of the hydronephrosis. CONCLUSION: Giant hydronephrosis is a rare finding. Distortion of adjacent veins and formation of thrombosis should be kept in mind, as they are life threatening. A multidisciplinary collaboration is mandatory to ensure optimal treatment.

Pathophysiology behind prolonged whiplash associated disorders: study protocol for an experimental study.

BACKGROUND: There is insufficient knowledge of pathophysiological parameters to understand the mechanism behind prolonged whiplash associated disorders (WAD), and it is not known whether or not changes can be restored by rehabilitation. The aims of the projects are to investigate imaging and molecular biomarkers, cervical kinaesthesia, postural sway and the association with pain, disability and other outcomes in individuals with longstanding WAD, before and after a neck-specific exercise intervention. Another aim is to compare individuals with WAD with healthy controls. METHODS: Participants are a sub-group (n = 30) of individuals recruited from an ongoing randomized controlled study (RCT). Measurements in this experimental prospective study will be carried out at baseline (before intervention) and at a three month follow-up (end of physiotherapy intervention), and will include muscle structure and inflammation using magnetic resonance imaging (MRI), brain structure and function related to pain using functional MRI (fMRI), muscle function using ultrasonography, biomarkers using samples of blood and saliva, cervical kinaesthesia using the "butterfly test" and static balance test using an iPhone app. Association with other measures (self-reported and clinical measures) obtained in the RCT (e.g. background data, pain, disability, satisfaction with care, work ability, quality of life) may be investigated. Healthy volunteers matched for age and gender will be recruited as controls (n = 30). DISCUSSION: The study results may contribute to the development of improved diagnostics and improved rehabilitation methods for WAD. TRIAL REGISTRATION: Clinicaltrial.gov Protocol ID: NCT03664934, initial release 09/11/2018.

Phospholipase C-Gamma 2 Activity in Familial Steroid-Sensitive Nephrotic Syndrome.

BACKGROUND: Familial Steroid-sensitive Nephrotic Syndrome (SSNS) is rare, complicating the identification of candidate genes. A recent population-based approach study of SSNS identified HLA-DQA1 and Phospholipase C-Gamma 2 (PLCG2) missense coding variants as candidate loci. PLCG2 is a signaling molecule regulated by phosphorylation and is critical for Ca2+ flux in cells of the immune system. METHODS: In order to detect a candidate gene for familial SSNS, we conducted an whole-exome sequencing in a pedigree consisting of two healthy parents, two non-identical twin brothers with SSNS, and a healthy young sibling. Flow cytometric assays were conducted to investigate the effects of the identified PLCG2 rare variants on B cell receptor-mediated PLCG2 tyrosine 759 phosphorylation, as well as on Ca2+ flux. RESULTS: Two missense rare variants in the PLCG2 gene were detected in the affected twins. An increase in tyrosine phosphorylation of PLCG2 as well as more rapid Ca2+ flux were noted in response to stimulation in the affected twins compared to their parents. CONCLUSIONS: Rare variants in PLCG2 segregated with disease in familial SSNS. Functional studies suggest the combined rare variants result in a gain of function in PLCG2 activity. Taken together, these results support PLCG2 as a possible candidate locus for familial SSNS.

Predictors of grade 3-5 vesicoureteral reflux in infants ≤ 2 months of age with pyelonephritis.

BACKGROUND: This study aimed to assess predictors for grade 3-5 vesicoureteral reflux (VUR) in infants ≤ 2 months of age admitted for first urinary tract infection (UTI). METHODS: Retrospective cohort study of 195 infants ≤ 2 months admitted to a pediatric ward for first UTI between 2006 and 2017. Clinical, laboratory, and imaging data were collected from electronic medical charts. We examined associations between grade 3-5 VUR and different patient characteristics. RESULTS: Twenty infants (10%) were diagnosed with grade 3-5 VUR; all had fever. Infants with grade 3-5 VUR had higher blood neutrophil percentage (BNP) (65% vs. 46%, P < 0.001), higher neutrophil-to-lymphocyte ratio (NLR) (2.6 vs. 1.3, P < 0.001), more renal ultrasound abnormalities (prenatal 26% vs. 5%, P = 0.007; postnatal 84% vs. 55%, P = 0.015), and Pseudomonas UTI (15% vs. 1%, respectively, P < 0.001). NLR > 1.65 showed sensitivity 100% and specificity 61% for detecting grade 3-5 VUR. BNP > 53% showed sensitivity 100% and specificity 60% for detecting grade 3-5 VUR. BNP was the best single marker for grade 3-5 VUR with area under the curve (AUC) of 0.82 (95% CI 0.75-0.89). In a multivariate model, AUC for combination of BNP and hydronephrosis was 0.86 (95% CI 0.79-0.93, P = 0.007). CONCLUSIONS: Infants ≤ 2 months of age admitted for a first UTI are at risk for grade 3-5 VUR and thus should undergo a voiding cystourethrography (VCUG) if their renal ultrasound is abnormal or if they have Pseudomonas UTI. Avoiding VCUG can be considered in afebrile infants and in infants with BNP < 53% or NLR < 1.65.

Japanese scoring systems to predict resistance to intravenous immunoglobulin in Kawasaki disease were unreliable for Caucasian Israeli children.

AIM: This study assessed the validity of using established Japanese risk scoring methods to predict intravenous immunoglobulin (IVIG) resistance to Kawasaki disease in Israeli children. METHODS: We reviewed the medical records of 282 patients (70% male) with Kawasaki disease from six Israeli medical centres between 2004 and 2013. Their mean age was 2.5 years. The risk scores were calculated using the Kobayashi, Sano and Egami scoring methods and analysed to determine whether a higher risk score predicted IVIG resistance in this population. Factors that predicted a lack of response to the initial IVIG dose were identified. RESULTS: We found that 18% did not respond to the first IVIG dose. The three scoring methods were unable to reliably predict IVIG resistance, with sensitivities of 23%-32% and specificities of 67%-87%. Calculating a predictive score that was specific for this population was also unsuccessful. The factors that predicted a lacked of response to the first IVIG dose included low albumin, elevated total bilirubin and ethnicity. CONCLUSION: The established risk scoring methods created for Japanese populations with Kawasaki disease were not suitable for predicting IVIG resistance in Caucasian Israeli children, and we were unable to create a specific scoring method that was able to do this.

Diagnostic markers of acute infections in infants aged 1 week to 3 months: a retrospective cohort study.

OBJECTIVE: History and physical examination do not reliably exclude serious bacterial infections (SBIs) in infants. We examined potential markers of SBI in young febrile infants. DESIGN: We reviewed white cell count (WBC), absolute neutrophil count (ANC), neutrophil to lymphocyte count ratio (NLR) and C reactive protein (CRP) in infants aged 1 week to 90 days, admitted for fever to one medical centre during 2012-2014. RESULTS: SBI was detected in 111 (10.6%) of 1039 infants. Median values of all investigated diagnostic markers were significantly higher in infants with than without SBI: WBC (14.4 vs 11.4 K/µL, P<0.001), ANC (5.8 vs 3.7 K/µL, P<0.001), CRP (19 vs 5 mg/L, P <0.001) and NLR (1.2 vs 0.7, P<0.001). Areas under the receiver operating characteristic curve (AUC) for discriminating SBI were: 0.65 (95% CI 0.59 to 0.71), 0.69 (95% CI 0.63 to 0.74), 0.71 (95% CI 0.65 to 0.76) and 0.66 (95% CI 0.60 to 0.71) for WBC, ANC, CRP and NLR, respectively. Logistic regression showed the best discriminative ability for the combination of CRP and ANC, with AUC: 0.73 (95% CI 0.67 to 0.78). For invasive bacterial infection, AUCs were 0.70 (95% CI 0.56 to 0.85), 0.80 (95% CI 0.67 to 0.92), 0.78 (95% CI 0.68 to 0.89) and 0.78 (95% CI 0.66 to 0.90), respectively. CRP combined with NLR or ANC were the best discriminators of infection, AUCs: 0.82 (95% CI 0.70 to 0.95) and 0.82 (95% CI 0.68 to 0.95), respectively. CONCLUSIONS: Among young febrile infants, CRP was the best single discriminatory marker of SBI, and ANC was the best for invasive bacterial infection. ANC and NLR can contribute to evaluating this population.