Implementation and effectiveness of a delirium care protocol in Thai critically ill children.

BACKGROUND: Delirium in critically ill children can result in long-term morbidity. Our main objectives were to evaluate the effectiveness of a new protocol on the reduction, prevalence, and duration of delirium and to identify associated risk factors. METHODS: The effectiveness of the protocol was evaluated by a chart review in all critically ill children aged 1 month to 15 years during the study period. A Cornell Assessment of Pediatric Delirium score ≥9 was considered positive for delirium. Data on delirium prevalence and duration from the pre-implementation and post-implementation phases were compared. Univariate and multivariate analyses were used to identify the risk factors of delirium. RESULTS: A total of 120 children was analyzed (58 children in the pre-implementation group and 62 children in the post-implementation group). Fifty children (41.7%) screened positive for delirium. Age less than 2 years, delayed development, use of mechanical ventilation, and pediatric intensive care unit (PICU) stay >7 days were significantly associated with delirium. The proportion of children screened positive was not significantly different after the implementation (before, 39.7% vs. after, 43.5%; P=0.713). Subgroup analyses revealed a significant reduction in the duration of delirium in children with admission diagnosis of cardiovascular problems and after cardiothoracic surgery. CONCLUSIONS: The newly implemented protocol was able to reduce the duration of delirium in children with admission diagnosis of cardiovascular problems and after cardiothoracic surgery. More studies should be conducted to reduce delirium to prevent long-term morbidity after PICU discharge.

Prevalence and associating factors of long COVID in pediatric patients during the Delta and the Omicron variants.

Introduction: The number of pediatric COVID-19 infections is increasing; however, the data on long COVID conditions in children is still limited. Our study aimed to find the prevalence of long COVID in children during the Delta and Omicron waves, as well as associated factors. Methods: A single-center prospective cohort study was conducted. We included 802 RT-PCR-confirmed COVID-19 pediatric patients in the Delta and Omicron periods. Long COVID was defined as having symptoms for ≥3 months after infection. Parents and/or patients were interviewed by phone. Multivariable logistic regression was performed to find associated factors with long COVID. Results: The overall prevalence of long COVID was 30.2%. The Delta period had more prevalence than the Omicron (36.3% vs. 23.9%). Common symptoms for patients 0-3 years' old were loss of appetite, rhinorrhea, and nasal congestion. Conversely, patients 3-18 years' old had hair loss, dyspnea on exertion, rhinorrhea, and nasal congestion. However, there was no significant negative impact on daily life. Most symptoms improved after a 6-month follow-up. Factors associated with long COVID-19 conditions were infection during the Omicron period (adjusted OR: 0.54; 95% CI: 0.39-0.74, P < 0.001), fever (adjusted OR: 1.49, 95% CI: 1.01-2.20, P = 0.04) and rhinorrhea (adjusted OR: 1.47, 95% CI: 1.06-2.02, P = 0.02). Conclusion: Infection during the Omicron wave has a lower prevalence of long COVID. The prognosis is often favorable, and most symptoms gradually become less. However, pediatricians may schedule appointments to surveil long COVID in children with fever or rhinorrhea as an initial symptom.

Prevalence, risk factors, and vaccine effectiveness of COVID-19 infection in thai children, adolescents, and young adults in the omicron era.

Background and objectives: The study of prevalence, risk factors, and vaccine effectiveness (VE) in children, adolescents, and young adults during the Omicron era has been limited, making this the objectives of the study. Methods: A prospective, test-negative case-control study was conducted on patients aged 0-24 years old classified as patients under investigation (PUI) from January to May 2022. PUI with positive RT-PCR within 14 days were classified as cases, whilst PUI with negative RT-PCR in 14 days were controls. Univariate and multivariate analyses determined risk factors; VE was calculated using [1-adjusted odds ratio (OR)] × 100. Results: The final analyses included 3,490 patients with a PUI infection rate of 45.6%. Heterologous vaccination regimens, including inactivated vaccines, viral vectors, and mRNA were utilized during the study period. A total of 2,563 patients (73.5%) had received at least 2 vaccine doses, regardless of regimen. Male gender and household infections were independent risk factors for the development of infection, with an adjusted OR of 1.55 and 1.45, respectively. Underlying comorbidities and obesity were not significantly associated with the development of infection. Patients with underlying comorbidities were more likely to have at least moderate severity of infection with the adjusted OR of 3.07. Age older than 11 years was associated with lower infection risk and development of at least moderate infection with adjusted OR of 0.4 and 0.34, respectively. Vaccinated participants also had a lower risk of developing at least moderate infection: adjusted OR of 0.40. The adjusted VE of any vaccination regimen for infection prevention for one, two, three, or more than four doses was 21.8%, 30.6%, 53.5%, and 81.2%, respectively. The adjusted VE of any vaccination regimen for prevention of at least moderate severity of the disease for one, two, three, or more than four doses was 5.7%, 24.3% 62.9%, and 90.6%, respectively. Conclusion: Disease prevalence among PUI was substantially high during the Omicron wave. A two-dose vaccination regimen does not appear sufficient to ensure protection against infection.

Real-life effectiveness of COVID-19 vaccine during the Omicron variant-dominant pandemic: how many booster doses do we need?

The surge in coronavirus disease 2019 (COVID-19) caused by the Omicron variants of the severe acute respiratory syndrome coronavirus 2 necessitates researches to inform vaccine effectiveness (VE) and other preventive measures to halt the pandemic. A test-negative case-control study was conducted among adults (age ≥18 years) who were at-risk for COVID-19 and presented for nasopharyngeal real-time polymerase chain reaction testing during the Omicron variant-dominant period in Thailand (1 January 2022-15 June 2022). All participants were prospectively followed up for COVID-19 development for 14 days after the enrolment. Vaccine effectiveness was estimated and adjusted for characteristics associated with COVID-19. Of the 7971 included individuals, there were 3104 cases and 4867 controls. The adjusted VE among persons receiving 2-dose, 3-dose, and 4-dose vaccine regimens for preventing infection and preventing moderate-to-critical diseases were 33%, 48%, 62% and 60%, 74%, 76%, respectively. The VE were generally higher among those receiving the last dose of vaccine within 90 days compared to those receiving the last dose more than 90 days prior to the enrolment. The highest VE were observed in individuals receiving the 4-dose regimen, CoronaVac-CoronaVac-ChAdOx1 nCoV-19-BNT162b2 for both preventing infection (65%) and preventing moderate-to-critical diseases (82%). Our study demonstrated increased VE along with an increase in number of vaccine doses received. Current vaccination programmes should focus on reducing COVID-19 severity and mandate at least one booster dose. The heterologous boosters with viral vector and mRNA vaccines were highly effective and can be used in individuals who previously received the primary series of inactivated vaccine.

Incidence and associated factors of pediatric post-intensive care syndrome using the VSCAREMD model.

BACKGROUND: The VSCAREMD model is used for evaluating vaccination, sleep, and parental care burden, which includes daily activity and social interaction, rehabilitation requirements, hearing, mood, and development. It has been proposed to detect post-intensive care syndrome (PICS) in children. This study aimed to outline the incidence of PICS in children using the VSCAREMD model and to describe the associated factors. METHODS: All children ages 1 month to 15 years and admitted to the intensive care unit for at least 48 hours were evaluated using the VSCAREMD model within 1 week of intensive care discharge. Abnormal findings were assorted into four domains: physical, cognitive, mental, and social. Descriptive statistics were performed using chi-square, univariate, and multivariate analyses. RESULTS: A total of 78 of 95 children (82.1%) had at least one abnormal domain. Physical, cognitive, mental, and social morbidity were found in 64.2%, 26.3%, 13.7%, and 38.9% of the children, respectively. Prolonged intensive care unit stay greater than 7 days was associated with dysfunction in physical (adjusted odds ratio [aOR], 3.80; 95% confidence interval [CI], 1.31-11.00), cognitive (aOR, 10.11; 95% CI, 3.01-33.89), and social domains (aOR, 5.01; 95% CI, 2.01-12.73). Underlying medical conditions were associated with cognitive (aOR, 13.63; 95% CI, 2.64- 70.26) and social morbidity (aOR, 2.81; 95% CI, 1.06-7.47). CONCLUSIONS: The incidence of PICS using the VSCAREMD model was substantially high and associated with prolonged intensive care. This model could help evaluate PICS in children.

Development and validation of the predictive score for pediatric COVID-19 pneumonia: A nationwide, multicenter study.

BACKGROUND: Due to the possibility of asymptomatic pneumonia in children with COVID-19 leading to overexposure to radiation and problems in limited-resource settings, we conducted a nationwide, multi-center study to determine the risk factors of pneumonia in children with COVID-19 in order to create a pediatric pneumonia predictive score, with score validation. METHODS: This was a retrospective cohort study done by chart review of all children aged 0-15 years admitted to 13 medical centers across Thailand during the study period. Univariate and multivariate analyses as well as backward and forward stepwise logistic regression were used to generate a final prediction model of the pneumonia score. Data during the pre-Delta era was used to create a prediction model whilst data from the Delta one was used as a validation cohort. RESULTS: The score development cohort consisted of 1,076 patients in the pre-Delta era, and the validation cohort included 2,856 patients in the Delta one. Four predictors remained after backward and forward stepwise logistic regression: age < 5 years, number of comorbidities, fever, and dyspnea symptoms. The predictive ability of the novel pneumonia score was acceptable with the area under the receiver operating characteristics curve of 0.677 and a well-calibrated goodness-of-fit test (p = 0.098). The positive likelihood ratio for pneumonia was 0.544 (95% confidence interval (CI): 0.491-0.602) in the low-risk category, 1.563 (95% CI: 1.454-1.679) in the moderate, and 4.339 (95% CI: 2.527-7.449) in the high-risk. CONCLUSION: This study created an acceptable clinical prediction model which can aid clinicians in performing an appropriate triage for children with COVID-19.

Epidemiological and Clinical Characteristics of Pediatric COVID-19 in the Tertiary Care System in Thailand: Comparative Delta and pre-Delta Era.

Background: Few studies had focused on the epidemiological and clinical characteristics of pediatric COVID-19 (SARS-CoV-2) during Delta and pre-Delta eras in Asia, despite it being a pandemic. Objective: To study the epidemiological and clinical characteristics of three waves of pediatric COVID-19 infections in a tertiary-care setting in Thailand. Methods: This retrospective study reviewed all PCR-confirmed pediatric (0-18 years of age) COVID-19 infections between January 13, 2020, and October 31, 2021, in a tertiary care system in Thailand. Results: 1,019 patients, aged 0.02 - 18 years, 552 (54.2%) male, and 467 (45.8%) female, with a median age of 9.2 years, were enrolled. Asymptomatic cases accounted for 35.7%, of which 106 (18.9%) had abnormal chest X-ray findings. Most cases were classified as having mild clinical symptoms, with only 8 (0.8%) and 4 (0.4%) developing a severe and critical illness, respectively. There were no deaths. The Delta variant appeared more transmissible than previous ones, but we did not see any difference in disease severity. Upper respiratory tract symptoms were predominant, while few cases had lower respiratory tract involvement. The sensitivity and specificity of dyspnea symptoms to predict radiologically confirmed pneumonia were 14% and 95%, respectively, with a likelihood ratio of 3.37. The overall prognosis was good, with only 13 (1.3 %) needing respiratory support. All cases showed clinical improvement with a decent recovery. Conclusion: Pediatric COVID-19 during the Delta variant predominance era generally appeared more transmissible but benign. One-fifth of cases had pneumonia, but few cases needed respiratory support. Prevention remains important for disease control.

An epidemiological study of pediatric COVID-19 in the era of the variant of concern.

BACKGROUND: There were limited epidemiological data of pediatric COVID-19 in Asia outside China, especially during the era of the variants of concern such as the Delta and Alpha variants. The objective was to describe the clinical epidemiology of pediatric COVID-19 in a tertiary care center in Thailand from April to August 2021. The identification of risk factors for the development of pneumonia in these children was also performed. METHODS: This retrospective cohort study was conducted by retrospective chart review of all children aged 0-15 years admitted to Thammasat University Hospital care system during the study period. The risk factors for the development of pneumonia were analyzed using logistic regression. RESULTS: A total of 698 children were included for analysis, of which 52% were male. The mean age of the cohort was 7.2 + 4.5 years old. Radiographic pneumonia was identified in 100 children (14.3%) and a total of 16 children (2.3%) were diagnosed with severe and critical diseases. The mortality rate was 0.1%. Children younger than 1 year and children with comorbidity were at higher risk of developing pneumonia (Adjusted odds ratios 2.99 (95% confidence interval (CI): 1.56-5.74) and 2.32 (95% CI: 1.15-4.67), respectively). CONCLUSION: In the era of the variants of concern, the proportion of children with severe and critical diseases remained low. However, prudence must be taken in caring for younger children and children with comorbidity.

Hearing screening outcomes in pediatric critical care survivors: a 1-year report.

BACKGROUND: Hearing loss is a potentially serious complication that can occur after surviving a critical illness. Study on screening for hearing problems in pediatric critical care survivors beyond the neonatal period is lacking. This study aimed to identify the prevalence of abnormal hearing screening outcomes using transitory evoked otoacoustic emission (TEOAE) screening in children who survived critical illness and to find possible associating factors for abnormal hearing screening results. METHODS: This study was a single-center, prospective, observational study. All children underwent otoscopy to exclude external and middle ear abnormalities before undergoing TEOAE screening. The screening was conducted before hospital discharge. Descriptive statistics, chi-square, and logistic regression tests were used for data analysis. RESULTS: A total of 92 children were enrolled. Abnormal TEOAE responses were identified in 26 participants (28.3%). Children with abnormal responses were significantly younger than those with normal responses with a median age of 10.0 months and 43.5 months, respectively (P<0.001). Positive association with abnormal responses was found in children younger than 12 months of age (adjusted odds ratio [OR], 3.07; 95% confidence interval [CI], 1.06-8.90) and children with underlying genetic conditions (adjusted OR, 6.95; 95% CI, 1.49-32.54). CONCLUSIONS: Our study demonstrates a high prevalence of abnormal TEOAE screening responses in children surviving critical illness, especially in patients younger than 12 months of age. More extensive studies should be performed to identify the prevalence and associated risk factors of hearing problems in critically ill children.

Comparing real-life effectiveness of various COVID-19 vaccine regimens during the delta variant-dominant pandemic: a test-negative case-control study.

Data on real-life vaccine effectiveness (VE), against the delta variant (B.1.617.2) of the severe acute respiratory syndrome coronavirus 2 among various coronavirus disease 2019 (COVID-19) vaccine regimens are urgently needed to impede the COVID-19 pandemic. We conducted a test-negative case-control study to assess the VE of various vaccine regimens for preventing COVID-19 during the period when the delta variant was the dominant causative virus (≥ 95%) in Thailand (25 July 2021-23 Oct 2021). All individuals (age ≥18 years) at-risk for COVID-19, presented for nasopharyngeal real-time polymerase chain reaction (RT-PCR) testing, were prospectively enrolled and followed up for disease development. Vaccine effectiveness was estimated with adjustment for individual demographic and clinical characteristics. Of 3353 included individuals, there were 1118 cases and 2235 controls. The adjusted VE among persons receiving two-dose CoronaVac plus one BNT162b2 booster was highest (98%; 95% confidence interval [CI] 87-100), followed by those receiving two-dose CoronaVac plus one ChAdOx1 nCoV-19 booster (86%; 95% CI 74-93), two-dose ChAdOx1 nCoV-19 (83%; 95% CI 70-90), one CoronaVac dose and one ChAdOx1 nCoV-19 dose (74%; 95% CI 43-88) and two-dose CoronaVac (60%; 95% CI 49-69). One dose of CoronaVac or ChAdOx1 nCoV-19 had a VE of less than 50%. Our study demonstrated the incremental VE with the increase in the number of vaccine doses received. The two-dose CoronaVac plus one BNT162b2 or ChAdOx1 nCoV-19 booster regimens was highly effective in preventing COVID-19 during the rise of delta variant.

Nurse-driven early rehabilitation protocol for critically ill children.

BACKGROUND: Physical impairment is a major morbidity in children surviving intensive care. The main objective of this study was to evaluate the effectiveness of a nurse-driven protocol in the early mobilization of critically ill children in terms of reduction of motor dysfunction, pediatric intensive care unit stays, and ventilator days. The secondary objective was to evaluate safety, in terms of injury, dislodgement of medical devices, and cardiorespiratory instability attributable to the intervention. METHODS: The early rehabilitation intervention was initiated in July 2020. This retrospective interrupted time-series study was divided into the pre-implementation phase (January-June 2020) and the post-implementation phase (July-December 2020). The motor function domain of the Functional Status Scale was used to define the motor dysfunction after pediatric intensive care unit discharge. RESULTS: Twenty-five children were allocated in each group. The median age of the whole cohort was 11.5 months and approximately 58% of the population was male. The baseline characteristics of both groups were not statistically significant. There was a statistically significant reduction in motor dysfunction after protocol implementation (64.0% vs 36.0%; P = 0.044) with an absolute risk reduction of 28%. The number needed to treat was 3.6 children. There were no statistically significant differences in the median ventilator days, length of stay in the intensive care unit, and hospital length of stay. No complications were found. CONCLUSIONS: A nurse-driven protocol for the early mobilization of critically ill children was feasible and could be effective in reducing post-intensive care motor dysfunction.

Management of Pediatric Septic Shock and Acute Respiratory Distress Syndrome in Thailand: A Survey of Pediatricians.

Introduction: Pediatric septic shock and acute respiratory distress syndrome (pARDS) are major causes of morbidity and mortality in pediatric intensive care units (PICUs). While standardized guidelines for sepsis and pARDS are published regularly, their implementation and adherence to guidelines are different in resource-rich and resource-limited countries. The purpose of this study was to conduct a survey to ascertain variation in current clinician-reported practice in pediatric septic shock and acute respiratory distress syndrome, and the clinician skills in a variety of hospital settings throughout Thailand. Methods: We conducted an electronic survey in pediatricians throughout the country between August 2020 and February 2021 using multiple choice questions and clinical case scenarios based on the 2017 American College of Critical Care Medicine's Consensus guideline for pediatric and neonatal septic shock and the 2015 Pediatric Acute Lung Injury Consensus Conference. Results: The survey elicited responses from 255 pediatricians (125 general pediatricians, 38 pulmonologists, 27 cardiologists, 32 intensivists, and 33 other subspecialists), with 54.5% of the respondents having <5 years of PICU experience. Among the six sepsis scenarios, 72.5 and 78.4% of the respondents had good adherence to the guidelines for managing fluid refractory shock and sedation for intubation, respectively. The ICU physicians reported greater adherence during more complex shock. In ARDS scenarios, 80.8% of the respondents reported having difficulty diagnosing ARDS mimic conditions and used lesser PEEP than the recommendation. Acceptance of permissive hypercapnia and mild hypoxemia was accepted by 62.4 and 49.4% of respondents, respectively. The ICU physicians preferred decremental PEEP titration, whereas general pediatricians preferred incremental PEEP titration. Conclusion: This survey variation could be the result of resource constraints, knowledge gaps, or ambiguous guidelines. Understanding the perspective and rationale for variation in pediatricians' practices is critical for successful guideline implementation.

Can central venous access device care bundles and regular feedback reduce central line-associated complications in pediatric patients?

BACKGROUND: The use of indwelling central venous access devices (CVADs) in children can result in complications such as infection, occlusion, and dislodgement. PURPOSE: To evaluate whether reinforcing CVAD care bundles by using a regular direct feedback system could reduce such complications in children. METHODS: The intervention in this retrospective interrupted time-series study was initiated in January 2019. The study was divided into the preintervention (October-December 2018), 3-month postintervention (January-March 2019), and 6-month postintervention (April-June 2019) phases. Risk difference and Poisson regression analyses were used to illustrate the effectiveness of the intervention. RESULTS: The hospital-wide central line-related bloodstream infection rate decreased from 10.0/1,000 catheter-days to 4.5/1,000 catheter-days at 3-month postintervention (P=0.39) and to 1.4/1,000 catheter-days at 6-month postintervention (P=0.047). The central line occlusion rate significantly decreased from 30% to 12.8% (P=0.04) and 8.3% (P=0.002) at 3 and 6 months, respectively. Approximately 7% of CVADs became dislodged during the preintervention phase versus 8.5% (P=0.364) and 3.3% (P=0.378) at 3 and 6 months, respectively. CONCLUSION: Reinforcing CVAD care bundles with direct feedback could significantly decrease CVAD-associated complications in terms of infection at 6-month postintervention, and occlusion at 3- and 6-month postintervention. Thus, reinforcement and regular direct feedback might improve care quality in children with CVADs.

Pediatric postintensive care syndrome: high burden and a gap in evaluation tools for limited-resource settings.

This article aimed to summarize the impact and burden of pediatric postintensive care syndrome (PICS-p) in the physical, mental, cognitive, and social health domains after a review of the current pediatric literature in MEDLINE and PubMed. We also aimed to elucidate the limitations of the current evaluation tools used in limited-resource settings. PICS-p can impact a child's life for decades. Most validated tools are time-consuming, require qualifications, and expertise, are often limited to older children, and can evaluate only one domain. A novel, simple, and comprehensive surveillance tool can aid healthcare providers in the early detection and intervention of PICS-p. Further studies should validate and refine the parameters that will enhance the outcomes of pediatric intensive care unit survivors.

Connecting two worlds: positive correlation between physicochemical approach with blood gases and pH in pediatric ICU setting.

OBJECTIVE: Physicochemical approach such as strong ion difference provides a novel concept in understanding and managing acid-base disturbance in patients. However, its application in pediatrics is limited. This study aimed to evaluate a correlation between the physicochemical approach and blood gas pH for acid-base determination in critically ill pediatric patients. RESULTS: A total of 130 pediatric patients were included, corresponding to 1338 paired measures for analyses. Of these, the metabolic subgroup (743 paired measures) was defined. Among physicochemical parameters, the effective strong ion difference showed the best correlation with the blood gas pH in the whole cohort (R = 0.398; p < 0.001) and the metabolic subgroup (R = 0.685; p < 0.001). Other physicochemical parameters (i.e., the simplified and the apparent strong ion difference, the strong ion gap, and the sodium chloride gap) and the traditional measures (standard base excess, lactate, chloride and bicarbonate) also showed varying degrees of correlation. This study revealed the positive correlation between physicochemical parameters and the blood gas pH, serving as a connecting dot for further investigations using physicochemical approach to evaluate acid-base disturbance in pediatric population.

Comparison of three non-invasive hemodynamic monitoring methods in critically ill children.

INTRODUCTION: Hemodynamic parameters measurements were widely conducted using pulmonary artery catheter (PAC) with thermodilution as a reference standard. Due to its technical difficulties in children, transthoracic echocardiography (TTE) has been widely employed instead. Nonetheless, TTE requires expertise and is time-consuming. Noninvasive cardiac output monitoring such as ultrasonic cardiac output monitor (USCOM) and electrical velocimetry (EV) can be performed rapidly with less expertise requirement. Presently, there are inconsistent evidences, variable precision, and reproducibility of EV, USCOM and TTE measurements. Our objective was to compare USCOM, EV and TTE in hemodynamic measurements in critically ill children. MATERIALS AND METHODS: This was a single center, prospective observational study in critically ill children. Children with congenital heart diseases and unstable hemodynamics were excluded. Simultaneous measurements of hemodynamic parameters were conducted using USCOM, EV, and TTE. Inter-rater reliability was determined. Bland-Altman plots were used to analyse agreement of assessed parameters. RESULTS: Analysis was performed in 121 patients with mean age of 4.9 years old and 56.2% of male population. Interrater reliability showed acceptable agreement in all measured parameters (stroke volume (SV), cardiac output (CO), velocity time integral (VTI), inotropy (INO), flow time corrected (FTC), aortic valve diameter (AV), systemic vascular resistance (SVR), and stroke volume variation (SVV); (Cronbach's alpha 0.76-0.98). Percentages of error in all parameters were acceptable by Bland-Altman analysis (9.2-28.8%) except SVR (30.8%) and SVV (257.1%). CONCLUSION: Three noninvasive methods might be used interchangeably in pediatric critical care settings with stable hemodynamics. Interpretation of SVV and SVR measurements must be done with prudence.

Validation of pediatric early warning score in pediatric emergency department.

BACKGROUND: One of the most important functions of the emergency department (ED) is to assess patient status. Only one, the pediatric early warning score (PEWS), has been designed for ED with acceptable validity, but it has never been validated in Thailand. The objective of this study was to validate PEWS in predicting hospitalization in children visiting the ED. METHODS: During the initial phase, two triage nurses performed blind scoring (in order to determine inter-rater reliability using kappa statistics) for the first 30 patients who presented to the ED at Ramathibodi Hospital between March and May 2014 and who were aged < 15 years. The second phase then consisted of validation and involved 1136 patients. Patients who presented with trauma, psychiatric, dental and surgical concerns were excluded. Validity of the scoring system in predicting admission was assessed using area under the receiver operating characteristics (ROC) curve (AUC), sensitivity, and specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: Phase I demonstrated good inter-rater reliability (kappa = 0.75). In phase II, of the total group of 1136 patients, 168 patients (14.8%) were admitted: 162 to the general ward and six to the intensive care unit (ICU) during the study period. AUC for predicting overall, ICU, and general ward admission were 0.73 (95%CI: 0.68-0.77), 0.98 (95%CI: 0.96-1) and 0.71 (95%CI: 0.66-0.75), respectively. The sensitivity and specificity in predicting overall admission with a cut-off of PEWS ≥ 1 was 78% and 60%, respectively (PPV, 28%; NPV, 95%). Sensitivity and specificity in predicting ICU admission with the cut-off PEWS ≥ 3 was 100% and 91%, respectively (PPV, 5%; NPV, 100%). Using the cut-off PEWS ≥ 1, sensitivity and specificity in predicting ward admission were 77% and 59%, respectively (PPV, 24%; NPV, 94%). CONCLUSION: PEWS can be helpful in assessing patient status in pediatric ED with acceptable validity and can serve as a potentially excellent screening tool for prediction of ICU admission.

Acne-like presentation of recurrent varicella infection in a child with nephrotic syndrome.

Primary infection with varicella zoster virus was assumed to confer lifelong immunity. Nevertheless, cases of varicella reinfection had been reported regardless of immune status. Here the authors described a case of 11-year old girl with nephrotic syndrome, currently on 80 milligrams of prednisolone for one month. She presented with one day of fever, diarrhea and acne-like rash at her forehead, nose and few on the neck. She had a past history of chickenpox. Her vesicles were examined by pediatric dermatologist and Tzanck smear was performed. Multinucleated giant cells were detected and diagnosis of varicella was made. This report infers that positive varicella history alone might not be sufficient to confer immunity, especially in immunocompromised host. Atypical presentation of recurrent varicella in immunocompromised host can be presented.

Successful medical treatment in a child with E. coli ESBL meningitis with acute communicating hydrocephalus and ventricular empyema: a case report.

Extended-spectrum beta-lactamase (ESBL) producing organisms cause wide spectrum of diseases including urinary tract infection, cholangitis, intra-abdominal abscess or pneumonia but rarely meningitis. The present report a successful nonsurgical, medical treatment in a child with Escherichia coli ESBL meningitis with acute symptomatic communicating hydrocephalus and ventricular empyema. Incidence of infections from ESBL producing organisms are increasingly emerging and causing wide spectrum of illnesses which prompts for both aggressive medical and surgical intervention to prevent morbidity and mortality. Antimicrobial agents must be vigilantly utilized to prevent possible development of new highly-resistant organisms.