Transforming Virtual Healthcare: The Potentials of ChatGPT-4omni in Telemedicine.

The introduction of OpenAI's ChatGPT-4omni (GPT-4o) represents a potential advancement in virtual healthcare and telemedicine. GPT-4o excels in processing audio, visual, and textual data in real time, offering possible enhancements in understanding natural language in both English and non-English contexts. Furthermore, the new "Temporary Chat" feature may improve privacy and data confidentiality during interactions, potentially increasing integration with healthcare systems. These innovations promise to enhance communication clarity, facilitate the integration of medical images, and increase data privacy in online consultations. This editorial explores some future implications of these advancements for telemedicine, highlighting the necessity for further research on reliability and the integration of advanced language models with human expertise.

Art or Artifact: Evaluating the Accuracy, Appeal, and Educational Value of AI-Generated Imagery in DALL·E 3 for Illustrating Congenital Heart Diseases.

Artificial Intelligence (AI), particularly AI-Generated Imagery, has the potential to impact medical and patient education. This research explores the use of AI-generated imagery, from text-to-images, in medical education, focusing on congenital heart diseases (CHD). Utilizing ChatGPT's DALL·E 3, the research aims to assess the accuracy and educational value of AI-created images for 20 common CHDs. In this study, we utilized DALL·E 3 to generate a comprehensive set of 110 images, comprising ten images depicting the normal human heart and five images for each of the 20 common CHDs. The generated images were evaluated by a diverse group of 33 healthcare professionals. This cohort included cardiology experts, pediatricians, non-pediatric faculty members, trainees (medical students, interns, pediatric residents), and pediatric nurses. Utilizing a structured framework, these professionals assessed each image for anatomical accuracy, the usefulness of in-picture text, its appeal to medical professionals, and the image's potential applicability in medical presentations. Each item was assessed on a Likert scale of three. The assessments produced a total of 3630 images' assessments. Most AI-generated cardiac images were rated poorly as follows: 80.8% of images were rated as anatomically incorrect or fabricated, 85.2% rated to have incorrect text labels, 78.1% rated as not usable for medical education. The nurses and medical interns were found to have a more positive perception about the AI-generated cardiac images compared to the faculty members, pediatricians, and cardiology experts. Complex congenital anomalies were found to be significantly more predicted to anatomical fabrication compared to simple cardiac anomalies. There were significant challenges identified in image generation. Based on our findings, we recommend a vigilant approach towards the use of AI-generated imagery in medical education at present, underscoring the imperative for thorough validation and the importance of collaboration across disciplines. While we advise against its immediate integration until further validations are conducted, the study advocates for future AI-models to be fine-tuned with accurate medical data, enhancing their reliability and educational utility.

ChatGPT-3.5 System Usability Scale early assessment among Healthcare Workers: Horizons of adoption in medical practice.

Artificial intelligence (AI) chatbots, such as ChatGPT, have widely invaded all domains of human life. They have the potential to transform healthcare future. However, their effective implementation hinges on healthcare workers' (HCWs) adoption and perceptions. This study aimed to evaluate HCWs usability of ChatGPT three months post-launch in Saudi Arabia using the System Usability Scale (SUS). A total of 194 HCWs participated in the survey. Forty-seven percent were satisfied with their usage, 57 % expressed moderate to high trust in its ability to generate medical decisions. 58 % expected ChatGPT would improve patients' outcomes, even though 84 % were optimistic of its potential to improve the future of healthcare practice. They expressed possible concerns like recommending harmful medical decisions and medicolegal implications. The overall mean SUS score was 64.52, equivalent to 50 % percentile rank, indicating high marginal acceptability of the system. The strongest positive predictors of high SUS scores were participants' belief in AI chatbot's benefits in medical research, self-rated familiarity with ChatGPT and self-rated computer skills proficiency. Participants' learnability and ease of use score correlated positively but weakly. On the other hand, medical students and interns had significantly high learnability scores compared to others, while ease of use scores correlated very strongly with participants' perception of positive impact of ChatGPT on the future of healthcare practice. Our findings highlight the HCWs' perceived marginal acceptance of ChatGPT at the current stage and their optimism of its potential in supporting them in future practice, especially in the research domain, in addition to humble ambition of its potential to improve patients' outcomes particularly in regard of medical decisions. On the other end, it underscores the need for ongoing efforts to build trust and address ethical and legal concerns of AI implications in healthcare. The study contributes to the growing body of literature on AI chatbots in healthcare, especially addressing its future improvement strategies and provides insights for policymakers and healthcare providers about the potential benefits and challenges of implementing them in their practice.

Outcomes of Cardiopulmonary Resuscitation in the Pediatric Intensive Care of a Tertiary Center.

Understanding the factors affecting survival and modifying the preventable factors may improve patient outcomes following cardiopulmonary resuscitation (CPR). The aim of this study was to assess the prevalence and outcomes of cardiac arrest and CPR events in a tertiary pediatric intensive care unit (PICU). Outcomes of interest were the return of spontaneous circulation (ROSC) lasting more than 20 minutes, survival for 24 hours post-CPR, and survival to hospital discharge. We analyzed data from the PICU CPR registry from January 1, 2011 to January 1, 2018. All patients who underwent at least 2 minutes of CPR in the PICU were included. CPR was administered in 65 PICU instances, with a prevalence of 1.85%. The mean patient age was 32.7 months. ROSC occurred in 38 (58.5%) patients, 30 (46.2%) achieved 24-hour survival, and 21 (32.3%) survived to hospital discharge. Younger age ( p < 0.018), respiratory cause ( p < 0.001), bradycardia ( p < 0.018), and short duration of CPR ( p < 0.001) were associated with better outcomes, while sodium bicarbonate, norepinephrine, and vasopressin were associated with worse outcome ( p < 0.009). The off-hour CPR had no impact on the outcome. The patients' cumulative predicted survival declined by an average of 8.7% for an additional 1 minute duration of CPR ( p = 0.001). The study concludes that the duration of CPR, therefore, remains one of the crucial factors determining CPR outcomes and needs to be considered in parallel with the guideline emphasis on CPR quality. The lower survival rate post-ROSC needs careful consideration during parental counseling. Better anticipation and prevention of CPR remain ongoing challenges.

ChatGPT Surpasses 1000 Publications on PubMed: Envisioning the Road Ahead.

The exponential growth of ChatGPT in medical literature, amassing over 1000 PubMed citations by August 2023, underscores a pivotal juncture in the convergence of artificial intelligence (AI) and healthcare. This remarkable rise not only showcases its potential to revolutionize medical academia but also indicates its impending influence on patient care and healthcare systems. Notwithstanding this enthusiasm, one-third of these citations are editorials or commentaries, stressing a gap in empirical research. Alongside its potential, there are concerns about ChatGPT becoming a "Weapon of Mass Deception" and the need for rigorous evaluations to counter inaccuracies. The World Association of Medical Editors has released guidelines emphasizing that AI tools should not be manuscript co-authors and advocates for clear disclosures in AI-assisted academic works. Interestingly, ChatGPT achieved its citation milestone within nine months, compared to Google's 14 years. As Large Language Models (LLMs), like ChatGPT, become more integral in healthcare, issues surrounding data protection, patient privacy, and ethical implications gain prominence. As the future of LLM research unfolds, key areas of interest include its efficacy in clinical settings, its role in telemedicine, and its potential in medical education. The journey ahead necessitates a harmonious partnership between the medical community and AI developers, emphasizing both technological advancements and ethical considerations.

ChatGPT and the Future of Digital Health: A Study on Healthcare Workers' Perceptions and Expectations.

This study aimed to assess the knowledge, attitudes, and intended practices of healthcare workers (HCWs) in Saudi Arabia towards ChatGPT, an artificial intelligence (AI) Chatbot, within the first three months after its launch. We also aimed to identify potential barriers to AI Chatbot adoption among healthcare professionals. A cross-sectional survey was conducted among 1057 HCWs in Saudi Arabia, distributed electronically via social media channels from 21 February to 6 March 2023. The survey evaluated HCWs' familiarity with ChatGPT-3.5, their satisfaction, intended future use, and perceived usefulness in healthcare practice. Of the respondents, 18.4% had used ChatGPT for healthcare purposes, while 84.1% of non-users expressed interest in utilizing AI Chatbots in the future. Most participants (75.1%) were comfortable with incorporating ChatGPT into their healthcare practice. HCWs perceived the Chatbot to be useful in various aspects of healthcare, such as medical decision-making (39.5%), patient and family support (44.7%), medical literature appraisal (48.5%), and medical research assistance (65.9%). A majority (76.7%) believed ChatGPT could positively impact the future of healthcare systems. Nevertheless, concerns about credibility and the source of information provided by AI Chatbots (46.9%) were identified as the main barriers. Although HCWs recognize ChatGPT as a valuable addition to digital health in the early stages of adoption, addressing concerns regarding accuracy, reliability, and medicolegal implications is crucial. Therefore, due to their unreliability, the current forms of ChatGPT and other Chatbots should not be used for diagnostic or treatment purposes without human expert oversight. Ensuring the trustworthiness and dependability of AI Chatbots is essential for successful implementation in healthcare settings. Future research should focus on evaluating the clinical outcomes of ChatGPT and benchmarking its performance against other AI Chatbots.

Performance and satisfaction during the E-learning transition in the COVID-19 pandemic among psychiatry course medical students.

Background: In the field of medical education, students faced significant challenges during the COVID-19 pandemic. Abrupt alterations were made in the form of preventative precautions. Virtual classes replaced onsite classes, clinical placements were canceled, and social distance interventions prevented face-to-face practical sessions. The present study aimed to assess students' performance and satisfaction before and after the transition of a psychiatry course from onsite to entirely online during the COVID-19 pandemic. Methods: A retrospective, non-clinical, and non-interventional comparative educational research study included all students registered in the psychiatric course for the academic year 2020 (pre-pandemic/onsite) and 2021 (during the pandemic/online).To assess students' satisfaction, we utilized the National Commission for Academic Accreditation and Assessment (NCAAA) students' satisfaction survey used by the academic quality unit at KSU, College of Medicine.Satisfaction was assessed in six domains: course organization, learning resources, faculty experiences, clinical teaching, practical sessions, and overall satisfaction. The reliability of the questionnaire was measured using Cronbach's alpha test.To assess their performance, students' grades from both periods were obtained from the exam center. Results: A total of 193 medical students enrolled in the study; 80 received onsite learning and assessment, while another 113 received full online learning and assessment. The students' mean indicators of course satisfaction for the online courses exceeded their corresponding indicators significantly compared to the onsite courses. These indicators included students' satisfaction in terms of course organization, p < 0.001; medical learning resources, p < 0.050; faculty experience, p < 0.050; and overall course, p < 0.050. There were no significant differences regarding satisfaction in both practical sessions, p > 0.050, and clinical teaching, p > 0.050. The students' performance mean was significantly higher in the online (M = 91.76) compared to the onsite courses (M = 88.58) (p < 0.001), and the Cohen's D statistic showed there was a medium level of enhancement in students' overall grades (Cohen's d = 0.41). Conclusion: Students perceived the switch to online delivery methods very favorably. Students' satisfaction significantly improved regarding the themes of course organization, faculty experience, learning resources, and overall course satisfaction, while a similar level of adequate student satisfaction was maintained in terms of clinical teaching and practical sessions during the transition of the course to e-learning. In addition, the online course was associated with a trend toward higher students' grades. However, the assessment of the achievement of course learning outcomes and the maintenance of this positive impact warrants further investigation.

Enhancing Expert Panel Discussions in Pediatric Palliative Care: Innovative Scenario Development and Summarization With ChatGPT-4.

This study presents a novel approach to enhance expert panel discussions in a medical conference through the use of ChatGPT-4 (Generative Pre-trained Transformer version 4), a recently launched powerful artificial intelligence (AI) language model. We report on ChatGPT-4's ability to optimize and summarize the medical conference panel recommendations of the first Pan-Arab Pediatric Palliative Critical Care Hybrid Conference, held in Riyadh, Saudi Arabia. ChatGPT-4 was incorporated into the discussions in two sequential phases: first, scenarios were optimized by the AI model to stimulate in-depth conversations; second, the model identified, summarized, and contrasted key themes from the panel and audience discussions. The results suggest that ChatGPT-4 effectively facilitated complex do-not-resuscitate (DNR) conflict resolution by summarizing key themes such as effective communication, collaboration, patient and family-centered care, trust, and ethical considerations. The inclusion of ChatGPT-4 in pediatric palliative care panel discussions demonstrated potential benefits for enhancing critical thinking among medical professionals. Further research is warranted to validate and broaden these insights across various settings and cultures.

ChatGPT-4 and the Global Burden of Disease Study: Advancing Personalized Healthcare Through Artificial Intelligence in Clinical and Translational Medicine.

The fusion of insights from the comprehensive global burden of disease (GBD) study and the advanced artificial intelligence of open artificial intelligence (AI) chat generative pre-trained transformer version 4 (ChatGPT-4) brings the potential to transform personalized healthcare planning. By integrating the data-driven findings of the GBD study with the powerful conversational capabilities of ChatGPT-4, healthcare professionals can devise customized healthcare plans that are adapted to patients' lifestyles and preferences. We propose that this innovative partnership can lead to the creation of a novel AI-assisted personalized disease burden (AI-PDB) assessment and planning tool. For the successful implementation of this unconventional technology, it is crucial to ensure continuous and accurate updates, expert supervision, and address potential biases and limitations. Healthcare professionals and stakeholders should have a balanced and dynamic approach, emphasizing interdisciplinary collaborations, data accuracy, transparency, ethical compliance, and ongoing training. By investing in the unique strengths of both ChatGPT-4, especially its newly introduced features such as live internet browsing or plugins, and the GBD study, we may enhance personalized healthcare planning. This innovative approach has the potential to improve patient outcomes and optimize resource utilization, as well as pave the way for the worldwide implementation of precision medicine, thereby revolutionizing the existing healthcare landscape. However, to fully harness these benefits at both the global and individual levels, further research and development are warranted. This will ensure that we effectively tap into the potential of this synergy, bringing societies closer to a future where personalized healthcare is the norm rather than the exception.

Presentations and outcomes of familial hemophagocytic lymphohistiocytosis in the pediatric intensive care units (PICUs).

Objectives: We aimed to describe Familial Hemophagocytic Lymphohistiocytosis (F-HLH) patients' clinical features, intensive care courses, and outcomes. Methods: Multi-center retrospective cohort study of pediatric patients diagnosed with F-HLH from 2015 to 2020 in five tertiary centers in Saudi Arabia. Patients were classified as F-HLH based on their genetic confirmation of known mutation or on their clinical criteria, which include a constellation of abnormalities, early disease onset, recurrent HLH in the absence of other causes, or a family history of HLH. Results: Fifty-eight patients (28 male, 30 female), with a mean age of 21.0 ± 33.9 months, were included. The most common principal diagnosis was hematological or immune dysfunction (39.7%), followed by cardiovascular dysfunction in 13 (22.4%) patients. Fever was the most common clinical presentation in 27.6%, followed by convulsions (13.8%) and bleeding (13.8%). There were 20 patients (34.5%) who had splenomegaly, and more than 70% of patients had hyperferritinemia >500 mg/dl, hypertriglyceridemia >150 mg/dl and hemophagocytosis in bone marrow biopsy. Compared to deceased patients 18 (31%), survivors had significantly lower PT (p = 041), bilirubin level of <34.2 mmol/L (p = 0.042), higher serum triglyceride level (p = 0.036), and lesser bleeding within the initial 6 h of admission (p = 0.004). Risk factors for mortality included requirements of higher levels of hemodynamic (61.1% vs. 17.5%, p = 0.001) and respiratory (88.9% vs. 37.5%, p < 0.001) support, and positive fungal cultures (p = 0.046). Conclusions: Familial HLH still represents a challenge in the pediatric critical care setting. Earlier diagnosis and prompt initiation of appropriate treatment could improve F-HLH survival.

Exploring Determinants of COVID-19 Vaccine Acceptance, Uptake, and Hesitancy in the Pediatric Population: A Study of Parents and Caregivers in Saudi Arabia during the Initial Vaccination Phase.

OBJECTIVES: This study aims to assess COVID-19 vaccine acceptance, uptake, and hesitancy among parents and caregivers of children in Saudi Arabia during the initial rollout of pediatric COVID-19 vaccination. METHODS: An electronic survey was used to collect data from participants who visited a COVID-19 vaccine center. The survey included demographic data, COVID-19 vaccine status among participants and their children, and reasons for vaccine acceptance or rejection. The Vaccine Hesitancy Scale (VHS) tool was also employed to assess vaccine hesitancy and attitudes toward the COVID-19 vaccine and routine childhood vaccination. Multivariate binary regression analysis was used to identify predictors of actual COVID-19 vaccine uptake among children. RESULTS: Of the 873 respondents included in the analysis, 61.5% were parents and 38.5% were other caregivers. Of the participants, 96.9% had received the COVID-19 vaccine. Six hundred and ninety-four participants accepted the vaccine for their children, with the main reasons being an endorsement by the Saudi Ministry of Health (60%) and the importance of going back to school (55%). One hundred and seventy-nine participants would not vaccinate their children, with the most common reasons being fear of adverse effects (49%) and inadequate data about vaccine safety (48%). Factors such as age, COVID-19 vaccination status, self-rated family commitment level, attitudes toward routine children's vaccines, and participants' generalized anxiety disorder (GAD7) score did not significantly correlate with children's COVID-19 vaccination status. Parents were less likely to vaccinate their children compared to other caregivers, and participants with a higher socioeconomic status were more likely to vaccinate their children. CONCLUSION: Vaccine acceptance and uptake were high during the initial pediatric COVID-19 vaccination rollout in Saudi Arabia. Still, the ongoing endorsement of the Ministry of Health and healthcare authorities should continue to advocate for better vaccine uptake in children.

Overview of Early ChatGPT's Presence in Medical Literature: Insights From a Hybrid Literature Review by ChatGPT and Human Experts.

ChatGPT, an artificial intelligence chatbot, has rapidly gained prominence in various domains, including medical education and healthcare literature. This hybrid narrative review, conducted collaboratively by human authors and ChatGPT, aims to summarize and synthesize the current knowledge of ChatGPT in the indexed medical literature during its initial four months. A search strategy was employed in PubMed and EuropePMC databases, yielding 65 and 110 papers, respectively. These papers focused on ChatGPT's impact on medical education, scientific research, medical writing, ethical considerations, diagnostic decision-making, automation potential, and criticisms. The findings indicate a growing body of literature on ChatGPT's applications and implications in healthcare, highlighting the need for further research to assess its effectiveness and ethical concerns.

Mitigating the Burden of Severe Pediatric Respiratory Viruses in the Post-COVID-19 Era: ChatGPT Insights and Recommendations.

In the current post-pandemic era, the rapid spread of respiratory viruses among children and infants resulted in hospitals and pediatric intensive care units (PICUs) becoming overwhelmed. Healthcare providers around the world faced a significant challenge from the outbreak of respiratory viruses like respiratory syncytial virus (RSV), metapneumovirus, and influenza viruses. The chatbot generative pre-trained transformer, ChatGPT, which was launched by OpenAI in November 2022, had both positive and negative aspects in medical writing. Still, it has the potential to generate mitigation suggestions that could be rapidly implemented. We describe the generated suggestion from ChatGPT on 27 Feb 2023 in response to the question "What's your advice for the pediatric intensivists?" We as human authors and healthcare providers, do agree with and supplement with references these suggestions of ChatGPT. We also advocate that artificial intelligence (AI)-enabled chatbots could be utilized in seeking a vigilant and robust healthcare system to rapidly adapt to changing respiratory viruses circulating around the seasons, but AI-generated suggestions need experts to validate them, and further research is warranted.

Risk factors, outcomes, and predictors of resolution of acute kidney injury in children with diabetic ketoacidosis.

BACKGROUND: Acute kidney injury (AKI) is a common complication in patients with diabetic ketoacidosis (DKA) (incidence 35-77%). AKI evolution during DKA treatment/recovery is poorly understood. Our aim was to assess children with DKA for prevalence, short-term kidney outcomes, severity, and predictors of AKI development and resolution. METHODS: This retrospective cohort study included children aged 2-14 years admitted with DKA between January 2016 and May 2020 in a Saudi tertiary care hospital. We defined AKI as an increase in serum creatinine of > 1.5 times baseline or > 3 mg/dL (26 mmol/L) within 48 h. RESULTS: Of 213 patients admitted with DKA, 172 (80.75%) developed AKI: stage 1 in 83 (38.96%), stage 2 in 86 (40.37%), and stage 3 in 3 (1.4%). No patient required dialysis. Multivariate analysis showed an increased risk of developing AKI with male gender (OR = 2.85) and lower serum bicarbonate (OR = 0.83) when adjusted for initial heart rate, hematocrit, new onset diabetes, and recurrent AKI. The mean time to AKI resolution was 13.21 ± 6.78 h. Factors leading to prolonged recovery from AKI in linear regression analysis were older age (B coefficient = 0.44, p = 0.01), recurrent DKA episodes (B coefficient = 3.70, p value 0.003), increased acidosis severity (B coefficient = - 0.44, p = 0.04), increased time to anion gap normalization (B coefficient = 0.44, p = 0.019), and increased initial glucose (B coefficient = 0.01, p = 0.011). CONCLUSION: In our cohort, AKI is a common, but mostly transient complication in children presenting with DKA, and its severity is associated with longer intensive care stays and time for acidosis resolution. AKI was associated with male gender, and lower serum bicarbonate. Proper consideration of such risk factors is needed for AKI assessment and management in future DKA clinical practice guidelines. A higher resolution version of the Graphical abstract is available as Supplementary information.

The burden of viral infections in pediatric intensive care unit between endemic and pandemic coronavirus infections: A tertiary care center experience.

OBJECTIVES: To measure the prevalence of viral infections, length of stay (LOS), and outcome in children admitted to the pediatric intensive care unit (PICU) during the period preceding the COVID-19 pandemic in a MERS-CoV endemic country. METHODS: A retrospective chart review of children 0-14 years old admitted to PICU with a viral infection. RESULTS: Of 1736 patients, 164 patients (9.45%) had a positive viral infection. The annual prevalence trended downward over a three-year period, from 11.7% to 7.3%. The median PICU LOS was 11.6 days. Viral infections were responsible for 1904.4 (21.94%) PICU patient-days. Mechanical ventilation was used in 91.5% of patients, including noninvasive and invasive modes. Comorbidities were significantly associated with intubation (P-value = 0.025). Patients infected with multiple viruses had median pediatric index of mortality 2 (PIM 2) scores of 4, as compared to 1 for patients with single virus infections (p < 0.001), and a median PICU LOS of 12 days, compared to 4 in the single-virus group (p < 0.001). Overall, mortality associated with viral infections in PICU was 7 (4.3%). Patients with viral infections having multiple organ failure were significantly more likely to die in the PICU (p = 0.001). CONCLUSION: Viral infections are responsible for one-fifth of PICU patient-days, with a high demand for mechanical ventilation. Patients with multiple viral infections had longer LOS, and higher PIM 2 scores. The downward trend in the yearly rate of PICU admissions for viral infections between the end of the MERS-CoV outbreak and the start of the COVID-19 pandemic may suggest viral interference that warrants further investigations.

Parental perceptions and the 5C psychological antecedents of COVID-19 vaccination during the first month of omicron variant surge: A large-scale cross-sectional survey in Saudi Arabia.

Background: With the rapid surge of SARS-CoV-2 Omicron variant, we aimed to assess parents' perceptions of the COVID-19 vaccines and the psychological antecedents of vaccinations during the first month of the Omicron spread. Methods: A cross-sectional online survey in Saudi Arabia was conducted (December 20, 2021-January 7, 2022). Convenience sampling was used to invite participants through several social media platforms, including WhatsApp, Twitter, and email lists. We utilized the validated 5C Scale, which evaluates five psychological factors influencing vaccination intention and behavior: confidence, complacency, constraints, calculation, and collective responsibility. Results: Of the 1,340 respondents, 61.3% received two doses of the COVID-19 vaccine, while 35% received an additional booster dose. Fify four percentage were unwilling to vaccinate their children aged 5-11, and 57.2% were unwilling to give the additional booster vaccine to children aged 12-18. Respondents had higher scores on the construct of collective responsibility, followed by calculation, confidence, complacency, and finally constraints. Confidence in vaccines was associated with willingness to vaccinate children and positively correlated with collective responsibility (p < 0.010). Complacency about COVID-19 was associated with unwillingness to vaccinate older children (12-18 years) and with increased constraints and calculation scores (p < 0.010). While increasing constraints scores did not correlate with decreased willingness to vaccinate children (p = 0.140), they did correlate negatively with confidence and collective responsibility (p < 0.010). Conclusions: The findings demonstrate the relationship between the five antecedents of vaccination, the importance of confidence in vaccines, and a sense of collective responsibility in parents' intention to vaccinate their children. Campaigns addressing constraints and collective responsibility could help influence the public's vaccination behavior.

Impact of an electronic alert system for pediatric sepsis screening a tertiary hospital experience.

This study aimed to assess the potential impact of implementing an electronic alert system (EAS) for systemic inflammatory syndrome (SIRS) and sepsis in pediatric patients mortality. This retrospective study had a pre and post design. We enrolled patients aged ≤ 14 years who were diagnosed with sepsis/severe sepsis upon admission to the pediatric intensive care unit (PICU) of our tertiary hospital from January 2014 to December 2018. We implemented an EAS for the patients with SIRS/sepsis. The patients who met the inclusion criteria pre-EAS implementation comprised the control group, and the group post-EAS implementation was the experimental group. Mortality was the primary outcome, while length of stay (LOS) and mechanical ventilation in the first hour were the secondary outcomes. Of the 308 enrolled patients, 147 were in the pre-EAS group and 161 in the post-EAS group. In terms of mortality, 44 patients in the pre-EAS group and 28 in the post-EAS group died (p 0.011). The average LOS in the PICU was 7.9 days for the pre-EAS group and 6.8 days for the post-EAS group (p 0.442). Considering the EAS initiation time as the "zero time", early recognition of SIRS and sepsis via the EAS led to faster treatment interventions in post-EAS group, which included fluid boluses with median (25th, 75th percentile) time of 107 (37, 218) min vs. 30 (11,112) min, p < 0.001) and time to initiate antimicrobial therapy median (25th, 75th percentile) of 170.5 (66,320) min vs. 131 (53,279) min, p 0.042). The difference in mechanical ventilation in the first hour of admission was not significant between the groups (25.17% vs. 24.22%, p 0.895). The implementation of the EAS resulted in a statistically significant reduction in the mortality rate among the patients admitted to the PICU in our study. An EAS can play an important role in saving lives and subsequent reduction in healthcare costs. Further enhancement of systematic screening is therefore highly recommended to improve the prognosis of pediatric SIRS and sepsis. The implementation of the EAS, warrants further validation in multicenter or national studies.

The outcome of rituximab in treating steroid dependent nephrotic syndrome.: Histopathology and immunosuppressive drugs as predicting factors.

OBJECTIVES: To present our experience of treating steroid-dependent nephrotic syndrome (SDNS) in children with repeated doses of rituximab (RTX) with a relatively long follow-up, and to discuss the role of the histopathology type and previous immune-suppressor (IS) drugs on the outcome of these patients. METHODS: The patients included in this prospective study were children with SDNS who were in remission on a high-dose steroid or with additional IS drugs. All patients underwent renal biopsy before RTX treatment. Intravenous RTX was administered monthly at 375 mg/m2 for 4 doses. Response to treatment was defined as maintaining remission with no steroid-sparing agents or prednisone for one year. RESULTS: Seventeen (14 males) patients were enrolled. Approximately 76% had minimal change disease (MCD) and 3 (18%) patients had immunoglobulin M (IgM) nephropathy. Approximately 85% of MCD and 33% of IgM nephropathy showed complete response to RTX. CONCLUSION: Compared to other IS used to treat SDNS, RTX showed a significant decrease in relapse rate with fewer side effects. The dose and interval should be modified according to the patient's characteristics, such as medical history, pathology type, and previous IS agents.

Suboptimal vancomycin levels in critically ill children with sickle cell disease and acute chest syndrome.

OBJECTIVES: This is a pilot retrospective study to assess the effect of glomerular hyper-filtration (GHF) related to sickle cell disease (SCD) on vancomycin clearance and ultimately on therapeutic drug levels in children admitted to the pediatric intensive care unit (PICU) with acute chest syndrome (ACS). METHOD: The patients' steady-state vancomycin trough levels (VTL) and the area under the curve (AUC) were compared with those of age- and gender-matched control group; matching was made at a 1:3 ratio. RESULTS: Twelve SCD patients with ACS and treated with vancomycin were compared with 36 non-SCD patients (control group). Compared with the control patients, the ACS patients had significantly lower initial serum VTL (median = 6.00 mcg/mL vs. 9.75 mcg/mL) (p = 0.007), and their average VTL were still lower (median = 6.65 mcg/mL vs. 10.00 mcg/mL) post vancomycin dose adjustment (p = 0.039). The time to achieve the therapeutic vancomycin level was significantly longer for the ACS patients (median = 4.75 days) than for the control group (median = 1 day) (p = 0.009). The AUC was also significantly lower in the ACS patients (median = 293 mg*h/L) than in the control group (median = 405.5 mg*h/L) (p = 0.007). The AUC was negatively associated with creatinine clearance (Beta Coefficient = -0.366, p-value=<0.001) even when adjusted for receiving loading dose, standard dose per weight, and severity of critical illness. CONCLUSION: These findings support the attributed role of the GHF associated with SCD leading to lower vancomycin level in ACS cases. Therefore, the standard dosing approach for vancomycin in ACS patients may be ineffective. We thus advocate for individualized dosing with careful monitoring of drug levels to account for GHF.