Risk Factors for Urinary Tract Infections in Children with Hematuria in the Emergency Department.

INTRODUCTION: Hematuria is a worrisome symptom in children and is sometimes associated with urinary tract infections (UTIs). This study aimed to identify useful clinical factors that can predict UTIs in hematuria patients without pyuria in the pediatric emergency department (ED). METHODS: We retrospectively recruited patients with hematuria from the pediatric ED. Clinical symptoms, urine biochemistry and microscopic examination results, and blood laboratory tests were analyzed to identify the predictors of UTIs. Patients were divided into the verbal group (age ≥ 2 years) and non-verbal group (age < 2 years) for identifying predictors of UTIs. Causes of hematuria were also investigated. RESULTS: A total of 161 patients with hematuria without pyuria were evaluated. Among symptoms, dysuria was significantly correlated with UTIs. Regarding urine biochemistry data, urine esterase and urine protein > 30 mg/dl were found to be significant parameters for predicting UTIs, while urine esterase and urine nitrite showed significant differences in children with age < 2 years. In the urine microscopic examinations, urine red blood cells (RBC) > 373/µL in children aged ≥ 2 years and urine RBC > 8/µL in children aged < 2 years were associated with UTIs. In addition, UTIs and urinary tract stones were found to be the top two causes of hematuria. CONCLUSIONS: Dysuria, urine esterase, urine nitrite, and urine protein may be useful parameters for predicting UTIs in pediatric patients with hematuria but no pyuria in the ED. In addition, a UTI was the most commonly identified etiology of hematuria without pyuria, followed by urinary tract stones.

Psychological disorders and suicide attempts in youths during the pre-COVID and post-COVID era in a Taiwan pediatric emergency department.

Background: The COVID-19 pandemic has had a significant impact on pediatric patients, increasing their vulnerability to psychological fragility. The aim of this study was to investigate the epidemiology and clinical spectrum of pediatric psychological fragility and suicide attempts in the emergency department (ED) before and after the onset of the COVID-19 outbreak. Methods: A total of 340 pediatric patients admitted to the ED for psychological fragility between 2019 and 2022 were retrospectively collated and categorized according to three periods: pre pandemic, pandemic, and post pandemic. Epidemiological and clinical information were analyzed and compared among the three groups. Moreover, patients with suicidal ideation or suicidal attempts and types of substance use disorders in children with suicidal attempts sent to the ED were analyzed. Results: The proportion of psychological fragility increased during the pandemic period (0.4%) and the post-pandemic period (0.8%) compared to that in the pre-pandemic period (0.28%). Suicide ideation was the highest before the pandemic period (0.04%), while suicidal attempts were the highest in the post pandemic period (0.42%). Significantly elevated trends in suicide attempts involving overdose and injury were observed among the three groups (p < 0.05). Intensive care unit (ICU) admission rates increased significantly after the COVID-19 outbreak (p < 0.05), and major depressive disorder was the most common psychological fragility in the ED in all three groups. Conclusion: An increase in the proportion of pediatric psychological fragility in the ED was noted in the post pandemic period than before or during the pandemic. With higher rates of ICU admissions and an increase in suicide attempts among children and adolescents during the pandemic compared to before or after the pandemic, it is of utmost importance to provide mental health support to this vulnerable population in order to prevent suicide attempts in the event of a new global outbreak of infectious diseases.

Influence of the domestic COVID-19 pandemic on the pediatric emergency department.

Objectives: After the coronavirus disease 2019 (COVID-19) pandemic emerged, there has been a substantial decline in emergency department (ED) visits. However, the impact of the pandemic on pediatric ED (PED) visits has not been well discussed. This study aimed to compare the epidemiology and clinical characteristics of PED visits before and after the time of the COVID-19 outbreak. Methods: Data of pediatric patients admitted to the PED between February 2019 and January 2021 were retrospectively collected. All patients were divided into two groups: 1 year before the COVID-19 pandemic (group 1) and 1 year after the COVID-19 outbreak (group 2). Basic demographics, clinical characteristics, triage levels, categories of diagnosis at PED, disposition, and hospitalization rates (wards and intensive care units) were further analyzed and compared between the two groups. Results: During the study period, 48,146 pediatric patients were enrolled (30,823 in group 1, and 17,323 in group 2). PED visits represented a 43.8% annual decline. The most common diseases in the PED in group 1 were infectious diseases, whereas digestive system diseases were the most common diseases in group 2 (both P < 0.001). In group 2, shorter PED observational time, longer hospital stay, and higher admission rates were noted compared to those in group 1 (all P < 0.001). Conclusion: During the COVID-19 pandemic, the proportion of respiratory system diseases and infectious diseases sharply decreased in the PED, whereas the proportion of digestive system diseases relatively increased. The COVID-19 pandemic has impacted the nature of PED visits and we should pay more attention on digestive system diseases and the rates of out-of-hospital cardiac arrest and overall mortality.

Serum Soluble CD40 Ligand in Predicting Simple Appendicitis and Complicated Appendicitis at Different Time Points in Children.

Objectives: Appendicitis is a common abdominal emergency in children. It is difficult for clinicians to distinguish between simple appendicitis (SA), gangrenous appendicitis (GA), and ruptured appendicitis (RA) in children based on physical and current laboratory tests. Abdominal computed tomography with the disadvantage of excess radiation exposure is usually used in the emergency room for appendicitis surveys. Serum soluble CD40 ligand (sCD40L) is an inflammatory biomarker. This study aimed to use sCD40L to distinguish SA, GA, and RA. Methods: All patients aged <18 years old with suspected appendicitis were tested once for serum sCD40L within 72 h of appendicitis symptoms. We compared sCD40L levels of SA, GA, and RA individually on days 1, 2, and 3 in patients with normal appendix (NA), a total of nine subgroups. Thereafter, the diagnostic performance of sCD40L in predicting appendicitis and the receiver operating characteristic curves were carried out. Results: Of 116 patients, 42 patients had SA, 20 GA, 44 RA, and 10 NA. We found six subgroups with significant p-values of sCD40L predicting appendicitis as follows: SA on day 2, GA on days 2 and 3, and RA on days 1-3. The sensitivity and specificity of sCD40L at the best cutoff point with 178 pg/mL in these six subgroups range from 0.75 to 1.00 and 0.90, respectively. Conclusions: SCD40L is a good predictor of pediatric appendicitis. Clinicians can use sCD40L to distinguish from SA, GA, and RA in children with suspected appendicitis.

A Case Report of a 3-Year-Old Child With Anaphylactic Shock After a Diclofenac Suppository Confirmed by Serial Tryptase and a Basophil Activation Test.

Diclofenac is one of the most commonly used non-steroidal anti-inflammatory drug (NSAID) agents for fever management by general practitioners. Anaphylaxis due to suppository of diclofenac sodium (Voltaren) is extremely rare in children. We report the case of a 3-year-old girl with anaphylactic shock after a diclofenac suppository with confirmation by serial tryptase and a basophil activation test.

Factors Associated With In-hospital Mortality of Children With Acute Fulminant Myocarditis on Extracorporeal Membrane Oxygenation.

Aim: To analyze the factors associated with in-hospital mortality of children with acute fulminant myocarditis on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Methods: This was a retrospective cohort study using chart reviews of patients diagnosed with acute fulminant myocarditis at the pediatric intensive care unit of two tertiary medical centers between January 1, 2005 and December 31, 2017. The inclusion criteria for this study were: (1) age from 1 month to 18 years; (2) diagnosed with acute myocarditis; (3) cardiogenic shock and need vasoactive-inotropic score ≥20 within 48 h after the use of vasoactive-inotropic agents; and (4) the need for ECMO placement. Results: Thirty-three children with acute fulminant myocarditis who needed ECMO were included. Clinical parameters were retrospectively reviewed. The overall survival rate was 69.6%. Higher levels of pre-ECMO troponin-I and pre-ECMO lactate, and lower post-ECMO left ventricular ejection fraction (LVEF) were significantly associated with in-hospital mortality in univariate analysis. Only higher pre-ECMO lactate and lower post-ECMO LVEF remained as predictors for in-hospital mortality in multivariate analysis. The areas under the curve of pre-ECMO lactate and post-ECMO LVEF in predicting survival were 0.848 (95% CI, 0.697-0.999, p = 0.002) and 0.824 (95% CI, 0.704-0.996, p = 0.01), respectively. A pre-ECMO lactate level of 79.8 mg/dL and post-ECMO LVEF of 39% were appropriate cutoff points to predict mortality. Conclusion: Pre-ECMO lactate level was associated with mortality in children with acute fulminant myocarditis, with an optimal cutoff value of 79.8 mg/dL. After VA-ECMO implantation, post-ECMO LVEF was associated with mortality, with an optimal cutoff value of 39%. The use of LVADs or urgent heart transplantation should be considered if the post-ECMO LVEF does not improve.

Diagnostic performance of the Sputum Gram Stain in predicting sputum culture results for critically ill pediatric patients with pneumonia.

BACKGROUND: The sputum Gram stain is an inexpensive, rapid, and convenient laboratory method that predicts the bacterial pathogens in patients with pneumonia. This study aimed to evaluate the diagnostic performance of this method in predicting sputum culture results for critically ill pediatric patients. METHODS: From June 2008 to June 2018, patients with pneumonia with an endotracheal or a tracheostomy tube in place in the Pediatric Intensive Care Unit at Changhua Christian Hospital were enrolled retrospectively. Sputum was collected from each patient via the artificial airway for Gram stain and culture evaluations of bacterial pathogens. Mixed culture results were excluded. A successful prediction was defined as a match of the sputum Gram stain and culture results. RESULTS: A total of 622 records were reviewed, of which 542 were analyzed. Haemophilus influenzae, Pseudomonas aeruginosa, and Streptococcus pneumoniae were the three most common pathogens found. The overall prediction success rate of the sputum Gram stain was 59.23%. The sensitivity of the method in predicting gram-negative bacilli (GNB), gram-negative cocci (GNC), and gram-positive cocci (GPC) was 0.45, 0.67, and 0.61, respectively. Its specificity in predicting GNB, GNC, and GPC was 0.87, 0.98, and 0.87, respectively. Its positive likelihood ratio in predicting GNB, GNC, and GPC was 3.46, 33.50, and 4.69, respectively. The highest prediction success rate among all pathogens was for GNC. CONCLUSION: The sputum Gram stain had high specificity and relatively low sensitivity in predicting the bacterial pathogens in critically ill pediatric patients. Its high specificity in predicting sputum culture results means that clinicians can confidently use sputum Gram stain results to guide their antibiotic choice for treatment.