Virtual Schooling and Pediatric Mental Health During the COVID-19 Pandemic

Introduction: The first six months of the COVID-19 pandemic saw a nearly 50% increase in pediatric mental health emergencies. Specific factors contributing to this rise remain poorly characterized. One frequently cited contributor is pandemic-related interruptions of in-person schooling. Early studies indicate that students have experienced significantly greater psychological distress during such disruptions. We set out to investigate what correlation, if any, exists between school modality (ranging from exclusively virtual to exclusively in-person) and pediatric mental health status. Method(s): This is a retrospective, descriptive study combining patient chart review and parental telephone survey, exploring the prevalence and severity of mental illness among inpatients at a single urban, academic, midwestern tertiary care center. The study population included all patients ages 6-18 admitted to the study site during the 2015-19 and 2020- 21 school years who received Psychiatry and/or Psychology consults and/or were admitted to the inpatient psychiatry unit. Parents/guardians of participants from 2020-21 were surveyed regarding their child' educational experiences. We describe and compare participants between school years prior to and during the pandemic using descriptive demographic data and clinical data highlighting monthly admission rates and proxies for illness severity. We then assess for any correlation between these measures and recent virtual schooling. Result(s): Total mental health-related admissions rose from an average of 1070 during pre-pandemic school years to 1111 in 2020-21. Patients admitted in 2020-21 were more likely to be female, non-white, and from ZIP codes with higher median income. Primary diagnosis was more likely to be a mood or eating disorder. Patients were less likely to present primarily for suicidal ideation or self-harm. Proxies of illness severity, including utilization of PRN antipsychotics/benzodiazepines and readmission rates, rose in 2020-21. 255 of 800 (31.9%) families responded to the telephone survey. Respondents were more likely to have a child who was female and slightly younger compared to non-respondents. 98% of respondents reported some virtual schooling for their child, with 77% reporting virtual schooling for the majority of the three months prior to their child' first hospital admission. 61% indicated their child was exclusively in virtual school. No significant relationships were observed between virtual schooling and any outcome measures relating to mental health. Conclusion(s): Pediatric mental health emergencies and hospitalizations have grown and evolved since the start of the COVID-19 pandemic. This study characterizes some of the changes in patient demographics and experience with virtual schooling prior to and following the pandemic. Our results do not support any correlation between virtual schooling and mental illness requiring emergent care or hospitalization. However, this study has many significant limitations. Respondents were not representative of all admitted patients, and survey data were gathered for only one-third of families whose children were admitted at one site. Very few respondents remained in school in person throughout the pandemic, complicating efforts to make meaningful comparisons. Future work should attempt to capture a broader subject pool and obtain prospective data regarding the effects of school modality on mental health.

Evaluation of 2019-2020 pediatric ATV injuries in a children's hospital

Purpose of Study: All-terrain vehicles (ATVs) are a significant cause of morbidity and mortality in children. Annually, over 100 pediatric ATV-related fatalities and >30 000 emergency department (ED) visits occur in the US. The Consumer Product Safety Commission (CPSC) cited a significant decrease (38%) in ATV-related ED visits from 2009-2018. Our study objectives were to: evaluate changes in the number of ATV injury visits in a pre-covid vs covid time frame, provide a descriptive epidemiology of our ATV injury visits, understand the impact of median household income and population type on amount ATV injuries, and realize preventative strategies for education intervention. Methods Used: A retrospective review of children <= 16 years old (yo) presenting to our pediatric hospital ED who were coded for ATV injury during 2019-2020 was conducted. An ATV patient database was developed and managed using Excel. This study was approved by our institutional IRB. Student t test and z test for proportions were utilized for statistical comparisons. National Center for Health Statistics was used to compare county population types. Summary of Results: There were 405 pediatric ED visits for ATV injuries January 2019 - December 2020. Overall, 77% were white. Ages ranged from 1 to 16 yo with an average age 10 yo (S.D. = 3.9). In 1-4 yos, 66% were passengers, 30% drivers. After 5 yo, >50% were drivers. Most common insurances were Alabama Blue Cross (45%), Medicaid (40%). A significant increase in ATV injuries occurred between 2019 and 2020. By comparing seasons, we found increase in spring (30%), fall (72%), and winter (52%) 2020 compared to 2019. Orthopedic injuries were the most common (60%) while 12% of injuries were brain and/or spinal cord injuries. We found 40% and 60% female vs male with no significant difference in gender distribution by disposition, and no significant difference in ages for admitted vs discharged (t = 0.93, p = 0.3). The range of length of stay for the discharged was 1-9 hours (average 3.5 hours) and admitted was 0-70 days (average 5.2 days). We found a bimodal distribution among the counties. With median household income, the peaks were $30 000-39 000 with 5.7 ATV injuries per 10 000 children and $70 000-79 999 with 6.3 injuries per 10 000 children. With population types, the peaks were "large fringe metropolitan" with 9.4 injuries per 10 000 children and "noncore" with 4.2 injuries per 10 000 children. [Figure presented] Conclusion(s): Most ATV injuries occurred in whites with 62% male, 39% female. Orthopedic injuries were most common. There was a bimodal distribution of injuries among the patients' counties when evaluated by median income and population. Year 2020 had 2.2 times the rate of ED visits compared to 2019 (5.2 ATV injury visits per 1000 ED visits in 2020 and 2.4 ATV injury visit per 1000 ED visits (z = 8.1, p < 0.0001)). When comparing seasons, we found the greatest difference was fall 2020 (72% increase) vs 2019. The steady increase is the inverse of the national trend found by the CSPS. Copyright © 2023 Southern Society for Clinical Investigation.

It's not the shunt: an atypical cause of fever in an infant with hydrocephalus

Case Report:We present a 5-year-old male with two days of fever, cough, vomiting, and loose stools. His history is significant for premature birth (35 weeks gestational age) and shunted hydrocephalus. A ventriculoperitoneal (VP) shunt was placed 6 days prior to presentation. Parental report included episodes of post-tussive, nonbloody, non-bilious emesis, poor oral intake, tachypnea, and increased work of breathing. Physical examination demonstrated a dehydrated infant with sunken fontanelles. He had no notable rash, no lymphadenopathy, and clear conjunctiva. His VP shunt site appeared normal without swelling or erythema. Initial evaluation showed elevated inflammatory markers -ESR 51 and CRP 12.32 mg/dL. A viral respiratory PCR panel returned positive for coronavirus (not SARS-CoV-2). A head CT scan and shunt radiography series showed no abnormalities with his shunt. The following morning, Radiology reported an incidental retropharyngeal fluid collection on a re-read of the patient's initial CT scan. A neck CT was obtained and demonstrated a fluid pocket with secondary mass effect in addition to bilateral cervical lymphadenopathy. Screening blood cultures were negative. The patient remained febrile (tmax 103.6F) and developed a transaminitis (ALT 264.9, AST 654), elevated fibrinogen 476, elevated INR 1.4, and low albumin 2.1. Abdominal ultrasound showed a normal the liver and biliary tract. His transaminitis resolved without treatment. The next day, the patient developed lip erythema and conjunctival injection. An echocardiogram showed a dilated right coronary artery (z-score of 3.59) and his inflammatory markers (ESR 26, CRP 9.63) remained elevated. Treatment was initiated with IVIG and moderate-dose aspirin. The patient defervesced, and he remained afebrile for over 48 hours prior to discharge. A repeat echocardiogram 2 days later showed a slight reduction in coronary artery dilatation (z-score 3.39). Hewas discharged on lowdose aspirin, and followed up with cardiology as an outpatient. Kawasaki's Disease (KD) is most common in children from ages 1 to 4 years and is classically characterized by persistent fever with a constellation of symptoms including limbal sparing conjunctivitis, cervical lymphadenopathy, polymorphous rash, strawberry tongue, oral changes, and extremity changes. Our patient presented at a younger age with a concurrent diagnosis of coronavirus upper respiratory tract infection. His atypical hospital course and incidental finding of retropharyngeal edema and transaminitis increased the clinical suspicion for KD. His symptoms rapidly improved after administration of IVIG. Younger patients are at an increased risk for severe complications of KD including coronary aneurysm. KD has been shown in the literature to have an association with coronavirus infection as well as presentation with retropharyngeal edema. Clinicians should consider KD in their differential even if patients do not meet all criteria for diagnosis on initial presentation. Copyright © 2023 Southern Society for Clinical Investigation.

Creating Accessible Infographics: Describing Scientific Data in Ways Everyone Can Understand

The COVID-19 pandemic has thrust scientific literature into the global spotlight this year, as information about the virus, how to keep safe, and how to get vaccinated has been continually updated at a rapid pace. Much of this information is being conveyed through infographics. This has resulted in an abundance of easy-to-grasp information for sighted people with no learning disabilities, but this positive impact has not been extended to people with visual or learning disabilities. In effect, these infographics often serve to further marginalize individuals with disabilities. Consistent methods for writing descriptions of images should be developed and implemented by first looking at how information moves from working memory to long-term memory, and then examining how cognitive fatigue can inhibit understanding of complex images and scientific information vital to individuals with disabilities. Considering how best to describe scientific images with concise alternative text and in plain language will have clear and immediate benefits for the health and well-being of those with print-related disabilities.

Voices from Industry Creating Accessible Infographics: Describing Scientific Data in Ways Everyone Can Understand

The COVID-19 pandemic has thrust scientific literature into the global spotlight this year, as information about the virus, how to keep safe, and how to get vaccinated has been continually updated at a rapid pace. Much of this information is being conveyed through infographics. This has resulted in an abundance of easy-to-grasp information for sighted people with no learning disabilities, but this positive impact has not been extended to people with visual or learning disabilities. In effect, these infographics often serve to further marginalize individuals with disabilities. Consistent methods for writing descriptions of images should be developed and implemented by first looking at how information moves from working memory to long-term memory, and then examining how cognitive fatigue can inhibit understanding of complex images and scientific information vital to individuals with disabilities. Considering how best to describe scientific images with concise alternative text and in plain language will have clear and immediate benefits for the health and well-being of those with print-related disabilities. © ATIA 2022.

Increased Mental Health Needs in Pediatric Admissions During COVID-19: The Epidemic Within the Pandemic

Background: Pediatric patients with increasing psychiatric needs introduce a substantial challenge for inpatient care. This study illustrates how the COVID-19 pandemic has influenced the number and acuity of psychiatry and psychology consults among pediatric inpatients at a tertiary care hospital. Methods: The study population included all pediatric patients (ages 0-25) admitted to University of Michigan's C.S. Mott Children's Hospital between March 2019 and March 2021 who received a psychology and/or psychiatry consult. Three time periods were defined: pre-pandemic, 3/1/19-3/15/20;early pandemic, 3/16/20-6/30/20;and steady-state pandemic, 7/1/20-2/28/21. The patients were described demographically and clinically. To assess differences among time periods, ANOVA testing was conducted for numeric variables and chi-square tests were used for categorical variables. The number of pediatric inpatients receiving psychiatry and/or psychology consults was reported for each month of the study period as a count and as a percent of all pediatric admissions. Psychiatric acuity was described in terms of length of stay and use of restraints and as-needed medication. Logistic regression was used to estimate the odds of requiring restraints based on time period, controlling for relevant demographic and clinical variables (age, sex, race, length of stay, and use of benzodiazepines and psychotropics). Logistic regression was also used to estimate the odds of patients requiring as-needed medications (midazolam, lorazepam, diazepam, clonazepam, alprazolam, haloperidol, chlorpromazine, quetiapine, risperidone, aripiprazole, olanzapine, and ziprasidone) based on time period, controlling for clinical and demographic variables (age, sex, race, length of stay, and restraint use). Results: Among the 1,636 patients in the study, average age was 14.0 years (IQR 8.1 to 17.2) and 57.9% were female. Overall, 68.6% were White, 13.6% were Black, and 2.4% were Asian. Among all races, 5.7% identified as Hispanic. Percent of pediatric patients receiving psychiatry and/or psychology consults was higher on average during the pandemic months (71.2% during steady-state pandemic compared to 47.9% pre-pandemic). Across all participants, 2.1% required restraints, 34.4% used psychotropics, and 42.6% used benzodiazepines. During the pandemic, admissions became proportionally more female (64.1% during steady-state pandemic vs. 55.3% pre-pandemic) and older (average age 14.8 years during steady-state pandemic vs. 13.4 years pre-pandemic). During steady-state pandemic, children admitted had 5.70 times higher odds of requiring restraints and 1.78 times higher odds of using psychotropics, compared to children admitted pre-pandemic. Length of stay decreased during the pandemic, and was associated with psychotropic use, benzodiazepine use, male sex, and younger age. Conclusion: A higher proportion of pediatric admissions during the COVID-19 pandemic required psychiatry and/or psychology consults. Additionally, these patients were of higher psychiatric acuity, based on increased use of as-needed medications and restraints. These findings highlight the dramatic changes experienced by individual patients and their healthcare teams during the pandemic.

Retrospective review of dog bites in pediatric patients

Purpose of Study Dog bites have historically been a common cause of pediatric emergency department (ED) visits. In June 2020 in the Journal of Pediatrics, 'Dog Bites in Children Surge during Coronavirus Disease-2019: A Case for Enhanced Protection' discussed an almost three-fold increase in dog bites treated in the ED since the beginning of the COVID-19 pandemic at an urban Children's Hospital in the Midwest. This study aimed to describe the epidemiology of dog bite ED visits and to evaluate changes in dog bite visits over 2019 (pre-COVID) and 2020 (during COVID). This study addressed two objectives: 1) To describe the epidemiology of dog bite related ED visits and admissions;2) To evaluate changes in the rate of dog bite ED visits during pre- Covid and during Covid. Methods Used This study reviewed 2 years (2019 and 2020) of dog bite visit data from the 'Children's Injury Database' (CID), our injury surveillance system of ED attended injuries. Descriptive statistical and epidemiologic analyses were conducted using Epi Info 7 (CDC). Statistical comparisons and analyses of continuous and categorical data were performed. Differences in proportions and T Test of means were reported with corresponding 95% Confidence Intervals (CI's). Summary of Results During the 2 year period, 522 dog bite cases were treated representing 1.7% of all injury visits. Gender analyses indicated a higher proportion of males vs females (53.6% vs 46.4%), respectively, overlap of exact CI's of proportions were observed. A higher proportion of white patients vs nonwhites among dog bite cases was observed (62.8% vs 37.2%), respectively, (no overlap of exact confidence intervals of proportions). This difference was also significant when comparing race proportions of dog bite visits to all other injury visits (62.8% vs 48.7%), respectively, difference of 14.1%, 95% CI (9.8, 18.2). Mean patient age was 6.1 yrs. Outcome metrics included patient disposition (3 categories): Admitted 57 (10.9%), Discharged 458 (87.7%), Other 7 (1.4%). Admitted patients were younger (statistically) 4.9 yrs vs 6.3 yrs, age difference -1.4 yrs 95% CI diff (-0.3, -2.5). Total length of stay for Admitted = 117 days (mean 2.1 days) and for Discharged mean hrs in the ED 3.7 (s.d. 8.7). Total charges were $2.6 million (mean = $4902, median $2043). The leading anatomic sites injured were head, face, and neck, all ages, (61.1%), but accounted for 79.8% for ages under 6 yrs. An increase in the rate of dog bite visits was detected during 2020 vs 2019, (20.4 per 1,000 injury visits vs 14.6 per 1,000 visits, rate difference = 5.8, 95% CI (3.4, 9.6). Conclusions The pandemic of COVID-19 with a national shel- #538 Figure 1 Overall CMV testing among failed hearing ter in place order was associated with more dog bite visits in the ED. 2020 had 20% fewer total injury visits than 2019, yet 10.5% higher number of dog bite visits. Dog bites are a significant cause of injury in children and result in costly visits seen in the ED. These data will support parental education on preventing dog bite injuries in children.

Trends in Pediatric Emergency Department Acuity and Trauma During the COVID-19 Pandemic

Study Objective: SARS-CoV-2 was declared a pandemic March 11, 2020 by the WHO. Adult health care systems faced tremendous challenges in volume and acuity;however, morbidity and mortality among children is low and pediatric emergency departments (EDs) have been spared the same challenges. Treatment of SARS-CoV-2 patients and efforts to curb disease transmission affected health care delivery in the United States causing negative effects on the delivery of routine primary care, the closures of schools, the implementation of shelter-in-place orders, and the cancellation of typical activities for children. The impact of these factors and the COVID-19 epidemic on pediatric EDs has yet to be fully understood. Our study contributes by demonstrating the COVID-19 epidemic’s impact on our tertiary care pediatric ED and level 1 trauma center. Methods: This retrospective time series study was conducted in a southern state with data coming from three sources: 1. State Office of EMS 2. ED visits and admissions 3. Hospital trauma database. The hospital is a free-standing children’s hospital with an annual ED census around 75,000 prior to 2020. The hospital is the only state certified pediatric level I trauma center. Strict criteria exist for triggering trauma team activation. Four years of data were analyzed for number of patients seen, number and percent of patients admitted to a critical care unit, number and percent patients who met trauma activation criteria, and number of EMS transfers. This study was deemed exempt by the institutional review board since data were de-identified and aggregate. Data were managed using Excel™. Results: Overall volume decreased 34% from 74,513 (2019) to 48,924 (2020) in contrast to trends of volume from 2017 through 2019, which had shown a steady increase by an additional 1,100 patients per year. Annual admission rate rose from 13.4-13.9% in 2017-2019 to 18.6% in 2020. The institution saw a linear increase in combined admission rates to the intensive care and intermediate care units from a high of 23.7% (2019) to 25.4% (2020) with a corresponding decrease in admission rates to acute care floors. Rate of admission to inpatient psychiatry unit increased from an average yearly rate of 7.2-7.7% in 2017-2019 to 9.3% in 2020. The number of patients transferred via EMS to our institution from outside facilities increased 8.8% from 1,868 in 2019 to 2,034 in 2020. Trauma alert activations increased from 0.65% of total patient volume in 2019 to 1.2% in 2020 with a noticeable increase in firearm related injuries from 44 in 2019 to 66 in 2020. Conclusion: While total volumes of patients seen in our tertiary pediatric ED showed a significant decrease during the COVID-19 pandemic there were significant increases in acuity as evidenced by admission rate, admission location, and number of interfacility transfers to our pediatric emergency department. There were also significant increases in psychiatric admissions and trauma alerts.

Micro Optical Coherence Tomography Demonstrates Ciliated Cell Dysfunction in COVID-19 Patients

RATIONALE: Micro optical coherence tomography (μOCT) is a minimally invasive intranasal imaging technique that can determine cellular and functional dynamics of respiratory epithelia at 1-μm resolution, enabling real time visualization and quantification of ciliary motion, inflammation, and mucus transport. Multiple abnormalities including reduced mucociliary transport were reported in patients with cystic fibrosis (Leung et al., Sci Trans Med 2019). Severe acute respiratory syndrome coronavirus (SARS-CoV-2), causative agent of COVID- 19, binds via ACE2 receptors, highly expressed in the ciliated and secretory cells of the nasal epithelium. We hypothesized that respiratory epithelial cell dysfunction in COVID-19 will manifest as abnormal mucociliary transport due to reduced ciliated cell function, features readily visualized by μOCT. METHODS: Symptomatic outpatients aged ≥ 18 years were recruited within 7 days of symptom onset and known SARS-CoV-2 RT-PCR positivity. Detailed clinical history and nasal swab for PCR quantification of viral RNA were obtained. Subjects were imaged inside a custom designed negative pressure isolation booth to minimize risk of virus transmission. Following inspection with a rhinoscope, the μOCT probe was maneuvered into the inferior meatus while acquiring data from approximately five discrete sites at both turbinate and floor of each nare. Long-term follow up, including clinical outcomes at 21 days were collected. Data was interpreted in comparison to previously imaged healthy controls. RESULTS: Eight subjects underwent imaging without complications, and additional enrollment is in progress. Mean age was 29.4 years (SD 8.2), and average duration of illness from symptom onset to imaging was 8.8 days (SD 4.3). Most common symptoms reported were fatigue (75%), headache, anosmia, fever, and sore throat (50% each). Viral load (mean log10) at time of imaging was 4.3 copies per mL. Imaging abnormalities identified to date (N=5) included denuded epithelium, presence of excessive mucus (Figure.1,B), and increased inflammatory cell counts (Figure.1,C) compared to healthy control (Figure.1,A). Reduced mucociliary transport (2.7 ± 0.3 mm/min COVID-19 vs 11.2 ± 0.8 mm/min healthy controls, P= 0.0016) and diminished periciliary liquid depth (4.3± 0.8 μm COVID-19 vs 6.8 ± 0.3 μm healthy controls, P= 0.028) were evident. CONCLUSION: Subjects with mild but symptomatic COVID-19 exhibit functional abnormalities of the respiratory mucosa, including delayed mucociliary transport. Mucociliary dysfunction in COVID-19, as also seen in Syrian hamsters (See Li Q et al., ATS 2021 Abstract), may increase risk for descending infection and disease progression. μOCT imaging may be a useful tool to evaluate prognosis, disease progression, and monitor emerging therapy.