The Fate of Mitral Valve Surgery in the Pediatric Age: A 25-Year Single-Center Experience.

Background: The aim of this study was to evaluate the natural history of patients after mitral valve intervention in the pediatric age. Methods: This is a retrospective study including all patients who underwent mitral valve surgery from 1998 to 2022. The patients' surgical reports, postoperative records, and ambulatory visits were reviewed. The endpoints of the study were survival and freedom from mitral valve reoperation. Results: Of the 70 patients included in the cohort, 61 patients (86.7%) had congenital mitral valve disease, of whom 46 patients (75.4%) had a predominantly mitral regurgitation lesion, and 15 patients (24.6%) had a predominantly mitral stenosis. In the mitral regurgitation group, all of the patients underwent valve repair with an operative mortality of one patient (2.1%), and with median follow-up of 4 years (range, 0.5-13 years), there was 4.3% mortality (n = 2) and 71.2% freedom from reoperation. In the mitral stenosis group, 11 patients underwent mitral valve repair, and 4 patients underwent valve replacement. There was an operative mortality of two patients (13.3%). With a 2-year median follow-up (range: 0.1-23 years), there were no additional mortality cases in the mitral stenosis group. All three patients who survived primary mitral valve replacement (100%) and four patients who survived a primary repair (40.0%) underwent reoperation. Conclusions: This study demonstrates encouraging outcomes for mitral valve repair. The mortality of patients with congenital mitral valve disease may also be related to a difficult postoperative course, rather than the MV lesion itself.

Safety of pediatric sedation and analgesia during burn dressing changes by pediatric residents.

BACKGROUND: Acute pain and anxiety management during pediatric burn dressing change is very challenging. There are limited data regarding feasibility and safety of sedation administration by nonanesthesiologists. We sought to describe the implementation of a sedation protocol for pediatric residents during burn dressing changes in the pediatric ward. METHODS: An analgesia and sedation protocol was designed and implemented in the pediatric wards in 2015. Retrospective data were collected on all children who were sedated by pediatric residents for burns in the pediatric wards over a 4-year period in our hospital. Demographics, burn characteristics, and data regarding adverse events were collected from patients' electronic medical records. The main outcomes were successful procedure completion and safety. RESULTS: During the study period, 1130 sedations were performed in 272 patients by pediatric residents. The median age was 2.5 years (IQR 1.3-9.1). Sixty-two percent (695/1130) of the patients were male. The majority of the burns (84%, 955/1130) were <20%, and the majority of the patients (91%, 1030/1130) had an ASA (American Society of Anesthesiologists) score of 1. The incidence rate of adverse events was 4.3% (49/1130) and 1.3% (15/1130) for serious adverse events . There were no statistically significant differences in gender, age, ASA, or burn degree between patients with or without adverse events. CONCLUSIONS: We designed and implemented an analgesia and sedation protocol for pediatric residents to be applied in patients during burn dressing change. The implemented protocol in the pediatric wards was found to be feasible and with a low incidence of adverse events.

Prevalence and clinical implication of thrombocytopenia and heparin-induced thrombocytopenia in patients who are critically ill with COVID-19.

As the COVID-19 pandemic continues to evolve, different clinical manifestations are better understood and studied. These include various haematologic disorders that have been shown to be associated with increased morbidity and mortality. We studied the prevalence of one unusual manifestation, heparin-induced thrombocytopenia (HIT) and its clinical implications in patients who are severely ill with COVID-19 in a single tertiary centre in Israel. The presence of thrombocytopenia, disseminated intravascular coagulation (DIC) and HIT, and their association with clinical course and outcomes were studied. One-hundred and seven patients with COVID-19 were included. Fifty-seven (53.2%) patients developed thrombocytopenia, which was associated with the worst outcomes (ventilation, DIC and increased mortality). Sixteen (28.0%) patients with thrombocytopenia were positive for HIT, all of which were supported by extracorporeal devices. HIT was independently associated with ventilation days, blood product transfusions, longer hospitalisation and mortality.Platelet abnormalities and HIT are common in patients who are critically ill with COVID-19 and are associated with the worst clinical outcomes. The mechanisms underlying HIT in COVID-19 are yet to be studied; HIT may contribute to the dysregulated immunologic response associated with COVID-19 critical illness and may play a significant part in the coagulopathy seen in these patients. As many patients with COVID-19 require aggressive thromboprophylaxis, further understanding of HIT and the implementation of appropriate protocols are important.

Catheter-directed thrombolysis for in situ pulmonary artery thrombosis in children.

In situ pulmonary artery thrombosis (ISPAT) is a unique form of pulmonary embolism characterized by local formation of thrombus in the pulmonary arteries. We present here a baby with hypoplastic left heart syndrome who developed ISPAT after Glenn surgery. The patient underwent catheter-directed thrombolysis, followed by systemic anticoagulation with excellent results.

Interleukin-8 Predicts Fatigue at 12 Months Post-Injury in Children with Traumatic Brain Injury.

Despite many children experiencing fatigue after childhood brain injury, little is known about the predictors of this complaint. To date, traditional indices of traumatic brain injury (TBI) severity have not predicted reliably persisting fatigue (up to three years post-injury). This study aimed to establish whether persisting fatigue is predicted by serum biomarker concentrations in child TBI. We examined whether acute serum biomarker expression would improve prediction models of 12-month fatigue based on injury severity. Blood samples were collected from 87 children (1-17 years at injury) sustaining mild to severe TBI (Glasgow Coma Scale [GCS] range 3-15; mean 12.43; classified as mild TBI [n = 50, 57%] vs. moderate/severe TBI [n = 37, 43%]), and presenting to the emergency departments (ED) and pediatric intensive care units (PICU) at one of three tertiary pediatric hospitals (Royal Children's Hospital (RCH); Hospital for Sick Children (HSC), Toronto; St Justine Children's Hospital (SJH), Montreal). Six serum biomarker concentrations were measured within 24 h of injury (interleukin-6, interleukin-8 [IL-8], soluble vascular cell adhesion molecule [SVCAM], S100 calcium binding protein B [S100B], neuron specific enolase [NSE], and soluble neural cell adhesion molecule [sNCAM]). Fatigue at 12 months post-injury was measured using the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (parent report), classified as present/absent using previously derived cut-points. At 12 months post-injury, 22% of participants experienced fatigue. A model including IL-8 was the best serum biomarker for estimating the probability of children experiencing fatigue at 12 months post-injury. The IL-8 also significantly improved predictive models of fatigue based on severity.

Methylene Blue Administration for Distributive Shock States in Critically Ill Children.

BACKGROUND: Methylene blue (MB), an inhibitor of nitric oxide synthesis and its effects is a potentially effective treatment against distributive shock states such as septic shock and vasoplegic syndrome. MB has been shown to alleviate vasoplegia and promote an increase in blood pressure. It may reduce mortality. However, in the pediatric population, there are few case reports and only one controlled study on administration of MB use for vasoplegia, sepsis, or shock in general. OBJECTIVES: To summarize the experience of administering MB for vasoplegic shock in a tertiary care pediatric intensive care unit. METHODS: A retrospective chart review of seven pediatric cases treated with MB for vasoplegic shock was conducted. MB was administered as a bolus followed by continuous infusion. The authors measured blood pressure, vasopressor, and inotropic support. Patient outcome was monitored. RESULTS: The authors observed a favorable hemodynamic response with an increase in blood pressure and a reduction in vasopressor and inotropic support needed following MB administration in six patients. No side effects were observed. Three patients eventually died one to two days later, secondary to their underlying disease. CONCLUSIONS: This case series adds to the small body of evidence in the pediatric population supporting the use of MB for distributive shock states and emphasizes the need for larger, randomized trials evaluating its role in vasoplegic shock treatment.

Characterisation of serum total tau following paediatric traumatic brain injury: a case-control study.

BACKGROUND: Traumatic brain injury (TBI) is a major health problem in children. Blood-based biomarkers interpreted by use of normative values might improve the accuracy of diagnosis. Ultrasensitive assays can quantify serum concentrations of the neuronal microtubule-associated protein tau, which is increased in adult brains following TBI. We aimed to determine if serum total tau correlates with TBI diagnosis, severity, and radiological findings on CT scans in children younger than 18 years. METHODS: In this case-control study, we included venous blood samples from healthy control children in the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER) biobank. For TBI cases, we recruited children (aged 0-17 years) who presented to the emergency department within 24 h of a TBI in three tertiary-care paediatric hospitals (Toronto, Vancouver, and Melbourne). Children were eligible if they required hospital observation for a minimum of 4 h or admission to the intensive care unit, and were excluded if they had had hospital treatment for a previous TBI, had birth trauma, or their parents could not speak English or French and therefore could not readily give consent. All available control samples were used and a case-control match was therefore not done. Venous and arterial blood samples were collected from patients with TBI within 28 h of injury (day 1). We used an ultrasensitive single-molecule immunoassay to measure serum total tau in blood samples. We first generated reference intervals of serum total tau from the control group, and used these normative data to interpret injury-associated changes in serum total tau in children with TBI. Concentrations of serum tau were measured in all CALIPER participants and patients with TBI, and no participants were excluded before analysis. FINDINGS: We included samples from 416 control participants from the CALIPER cohort. Median total tau concentrations did not differ between sexes (p=0·12), but three significant reference intervals based on age groups were identified (1-3 years [0·88-19·2 pg/mL], 4-15 years [0·93-5·31 pg/mL], and 16-19 years [0·79-4·20 pg/mL]). Blood samples were obtained from 158 patients with TBI recruited between April 30, 2011, and June 28, 2013. Serum total tau on day 1 of TBI was negatively associated with Glasgow Coma Scale (GCS) score (rs=-0·42, 95% CI -0·55 to -0·28, p<0·0001). Median total tau was 2·86 pg/mL (IQR 1·52-4·83) in patients with GCS score 13-15 points (n=114), 7·08 pg/mL (3·75-41·1) in those with GCS score 9-12 points (n=13), and 8·48 pg/mL (2·53-70·6) in those with GCS score 3-8 points (n=31). Notably, participants who had GCS scores of 15 points had median total tau concentrations (2·57 pg/mL [1·50-4·61]) indistinguishable from those of control participants (2·46 pg/mL [1·77-3·42]), whereas those with GCS score 13-14 points had elevated total tau (6·41 pg/mL [2·97-42·5]). Serum total tau was not strongly associated with CT findings in patients with mild TBI. INTERPRETATION: Serum total tau might help to differentiate between patients with mild TBI (GCS 13-14 vs GCS 15), but larger studies are needed to validate these results before this biomarker can be used for diagnosis and prognosis. FUNDING: Canadian Institutes of Health Research, Ontario Neurotrauma Foundation, and Victoria Neurotrauma Foundation.

Management of Ingested Hijab-Pin.

BACKGROUND AND STUDY AIMS: Accidental swallowing of hijab (or turban) pin was reported mainly among adolescent girls. Current guidelines indicate emergent intervention endoscopy in case a long sharp object is found in the gastrointestinal tract. The aims of the current study are to present the results of an observational approach and to assess the need for intervention. PATIENTS AND METHODS: A retrospective cohort study was conducted including all 5-18-year-old patients who presented with hijab-pin ingestion between 2003 and 2014. The need for intervention was assessed using both univariable and multivariable statistical analyses. RESULTS: Two hundred three cases of hijab-pin ingestion were documented. In the majority of cases, the pin was observed in the stomach (137/203, 67.4%) upon arrival. Most pins that were located at the upper gastrointestinal tract (proximal to the ligament of Treitz) ejected spontaneously (120/169, 71%, Pv = 0.005). The absence of pin progression in an X-ray performed 12 h following presentation was significantly more frequent in the intervention group (46/51, 90%, Pv = 0.001). CONCLUSIONS: In most cases, the outcome is spontaneous ejection from the digestive tract. However, if needle location remains unchanged on two consecutive X-rays, an endoscopic intervention is recommended.