Serious mental illness and in-hospital mortality among hospitalized patients with acute COVID-19: A large-database analysis in Japan.

OBJECTIVE: The association of serious mental illness (affective or non-affective psychotic disorders) with higher mortality in patients infected with acute coronavirus disease 2019 (COVID-19) has been suggested. Although this association remains significant after adjusting for medical comorbidities in previous studies, admission clinical status and treatment modalities should be considered as important confounding factors. METHODS: We aimed to assess whether serious mental illness is associated with in-hospital mortality, in patients with COVID-19 by adjusting for comorbidities, admission clinical status, and treatment modalities. Our nationwide cohort in Japan included consecutive patients admitted to 438 acute care hospitals for laboratory-confirmed acute COVID-19 from January 1, 2020 to November 30, 2021. RESULTS: Of 67,348 hospitalized patients (mean [standard deviation] age, 54 [18.6] years; 3891 [53.0%] female), 2524 patients (3.75%) had serious mental illness. In-hospital mortality was 282/2524 (11.17%) among patients with serious mental illness, while it was 2118/64,824 (3.27%) in other patients. In the fully adjusted model, serious mental illness was significantly associated with in-hospital mortality (odds ratio, 1.49; 95% CI, 1.27-1.72). E-value analysis confirmed the robustness of the results. CONCLUSION: Serious mental illness remains a risk for mortality in acute COVID-19 after adjusting for comorbidities, admission clinical status, and treatment modalities. Vaccination, diagnosis, early assessment and treatment should be prioritized for this vulnerable group.

Improving subacute management of post concussion symptoms: a pilot study of the Melbourne Paediatric Concussion Scale parent report.

Aim: To pilot a modification of the Post Concussion Symptom Inventory, the Melbourne Paediatric Concussion Scale (MPCS) and examine its clinical utility. Materials & methods: A total of 40 families of concussed children, aged 8-18 years, were recruited from the emergency department. Parent responses to the MPCS in the emergency department and 2-weeks post injury determined child symptomatic status. Association between MPCS symptom endorsement and symptomatic group status was examined. Results: All additional MPCS items were endorsed by at least 25% of the parents of symptomatic children at 2 weeks. MPCS items were classified into nine symptom domains, with most falling in mood, neurological, autonomic and vestibular domains. Conclusion: The additional items and domain classifications in the MPCS have the potential to improve subacute diagnostic precision, monitoring of clinical recovery and identification of appropriate interventions post pediatric concussion.

Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children.

OBJECTIVE: Children frequently present with head injuries to acute care settings. Although international paediatric clinical practice guidelines for head injuries exist, they do not address all considerations related to triage, imaging, observation versus admission, transfer, discharge and follow-up of mild to moderate head injuries relevant to the Australian and New Zealand context. The Paediatric Research in Emergency Departments International Collaborative (PREDICT) set out to develop an evidence-based, locally applicable, practical clinical guideline for the care of children with mild to moderate head injuries presenting to acute care settings. METHODS: A multidisciplinary Guideline Working Group (GWG) developed 33 questions in three key areas - triage, imaging and discharge of children with mild to moderate head injuries presenting to acute care settings. We identified existing high-quality guidelines and from these guidelines recommendations were mapped to clinical questions. Updated literature searches were undertaken, and key new evidence identified. Recommendations were created through either adoption, adaptation or development of de novo recommendations. The guideline was revised after a period of public consultation. RESULTS: The GWG developed 71 recommendations (evidence-informed = 35, consensus-based = 17, practice points = 19), relevant to the Australian and New Zealand setting. The guideline is presented as three documents: (i) a detailed Full Guideline summarising the evidence underlying each recommendation; (ii) a Guideline Summary; and (iii) a clinical Algorithm: Imaging and Observation Decision-making for Children with Head Injuries. CONCLUSIONS: The PREDICT Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children provides high-level evidence and practical guidance for front line clinicians.

Protocol for a randomised clinical trial of multimodal postconcussion symptom treatment and recovery: the Concussion Essentials study.

INTRODUCTION: While most children recover from a concussion shortly after injury, approximately 30% experience persistent postconcussive symptoms (pPCS) beyond 1-month postinjury. Existing research into the treatment of pPCS have evaluated unimodal approaches, despite evidence suggesting that pPCS likely represent an interaction across various symptom clusters. The primary aim of this study is to evaluate the effectiveness of a multimodal, symptom-tailored intervention to accelerate symptom recovery and increase the proportion of children with resolved symptoms at 3 months postconcussion. METHODS AND ANALYSIS: In this open-label, assessor-blinded, randomised clinical trial, children with concussion aged 8-18 years will be recruited from The Royal Children's Hospital (The RCH) emergency department, or referred by a clinician, within 17 days of initial injury. Based on parent ratings of their child's PCS at ~10 days postinjury, symptomatic children (≥2 symptoms at least 1-point above those endorsed preinjury) will undergo a baseline assessment at 3 weeks postinjury and randomised into either Concussion Essentials (CE, n=108), a multimodal, interdisciplinary delivered, symptom-tailored treatment involving physiotherapy, psychology and education, or usual care (UC, n=108) study arms. CE participants will receive 1 hour of intervention each week, for up to 8 weeks or until pPCS resolve. A postprogramme assessment will be conducted at 3 months postinjury for all participants. Effectiveness of the CE intervention will be determined by the proportion of participants for whom pPCS have resolved at the postprogramme assessment (primary outcome) relative to the UC group. Secondary outcome analyses will examine whether children receiving CE are more likely to demonstrate resolution of pPCS, earlier return to normal activity, higher quality of life and a lower rate of utilisation of health services, compared with the UC group. ETHICS AND DISSEMINATION: Ethics were approved by The RCH Human Research Ethics Committee (HREC: 37100). Parent, and for mature minors, participant consent, will be obtained prior to commencement of the trial. Study results will be disseminated at international conferences and international peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12617000418370; pre-results.

Child concussion recognition and recovery: a community delivered, evidenced-based solution.

Pediatric concussion is a growing health concern. Concussion is generally poorly understood within the community. Many parents are unaware of the signs and varying symptoms of concussion. Despite the existence of concussion management and return to play guidelines, few parents are aware of how to manage their child's recovery and return to activities. Digital health technology can improve the way this information is communicated to the community. A multidisciplinary team of pediatric concussion researchers and clinicians translated evidence-based, gold-standard guidelines and tools into a smartphone application with recognition and recovery components. HeadCheck is a community facing digital health application developed in Australia (not associated with HeadCheck Health) for management of concussion in children aged 5-18 years. The application consists of (I) a sideline concussion check and (II) symptom monitoring and symptom-targeted psychoeducation to assist the parent manage their child's safe return to school, exercise and sport. The application was tested with target end users as part of the development process. HeadCheck provides an accessible platform for disseminating best practice evidence. It provides feedback to help recognize a concussion and symptoms of more serious injuries and assists parents guide their child's recovery.

Post-traumatic stress symptoms and cognition in children exposed to motor vehicle accident trauma.

Research investigating the cognition of children exposed to non-familial trauma is scarce and the effects of post-traumatic stress symptoms in this population remain unclear. Thus, this research aimed to investigate the cognition of children exposed to motor vehicle accidents given the high incidence of this trauma globally. It was hypothesized that children with post-traumatic stress symptoms (PTSS; i.e., children with subthreshold or a full diagnosis of PTSD; n = 6) would perform significantly worse on cognitive measures compared to children exposed to trauma only (TO; i.e., children with very minimal or no PTSS; n = 10) and a healthy control group (n = 19). Analyses showed children with PTSS demonstrated significantly poorer perceptual reasoning F(2,32) = 7.21, p = .01, partial η2 = .31; verbal learning F(2,32) = 3.87, p = .05, partial η2 = .20; and delayed verbal memory F(2,32) = 4.40, p = .05, partial η2 = .22, compared to HCs. The magnitude of the differences between the groups was large. Differences in immediate verbal recall, executive functioning, and verbal intellectual abilities were moderate to large in magnitude, with the PTSS group performing worse than both groups, but these findings did not reach significance. Overall findings from this study provide further support for the notion that children exposed to non-familial trauma with significant PTSS display cognitive difficulties compared to healthy children.

Feasibility and acceptance of oral human papillomavirus detection in the dental office: Results from The National Dental Practice-Based Research Network.

BACKGROUND: Oral human papillomavirus (HPV) infection is the principal underlying cause of a dramatic increase in oropharyngeal cancer. Dentistry can play an important role in developing clinical algorithms for secondary prevention. METHODS: The authors conducted this cross-sectional pilot study with practices of The National Dental Practice-Based Research Network. The authors evaluated the feasibility and acceptability of screening and testing procedures as judged by practitioners and patients. The authors used tablet devices for patient screening, obtaining consent, and administering a confidential oral HPV risk factor survey. RESULTS: Most patients (85%) were comfortable being asked about their cigarette use and their sexual behavior (69%) and were interested in participating again (79%). More than 90% of practitioners were comfortable with study procedures except the extra time required for patient participation (75% comfortable). There were no problems with oral rinse collection as reported by patients or practitioners. CONCLUSIONS: It is feasible in community dental offices to collect oral rinses for HPV detection and to ask patients explicit questions about sexual history when using a tablet device for confidentiality. PRACTICAL IMPLICATIONS: Discussing high-risk types of HPV and appropriately assessing that risk are a challenge for oral health care professionals. These results are positive from a research perspective but do not address the advisability of routine HPV screening in dentistry.

Common sports-related musculoskeletal injuries presenting to the emergency department.

Young athletes are specialising in sports at a younger age, placing the developing musculoskeletal system under considerable stress. Overuse injuries such as apophysitis are chronic in nature and account for a large proportion of musculoskeletal injuries suffered by young athletes; however, with an increased emphasis on success in sport, tendinopathy and fatigue fractures are now being reported with increasing frequency, in the adolescent population. Correct diagnosis and early protection, rest, ice, compression and elevation therapy is critical, along with supervised rehabilitation an expert in paediatric and adolescent sports medicine. Acute traumatic knee injury and ankle sprain account for most acute injuries. Although most are soft tissue in nature, radiography may be useful in specific situations before early initiation of protection, rest, ice, compression and elevation therapy. These injuries will also require follow-up by an expert in paediatric and adolescent sports medicine to confirm the diagnosis and instigate ongoing rehabilitation and/or orthopaedic referral. Many of these injuries are preventable and due consideration should be given to simple prevention strategies.

Complex Regional Pain Type 1.

Complex regional pain syndrome is increasingly recognized in the pediatric population. Owing to the nature of presentation with pain, many of these children present to the emergency setting at different stages of the syndrome with or without numerous prior interactions with health professionals. Complex regional pain syndrome type 1 (CRPS1) is a clinical syndrome characterized by amplified musculoskeletal limb pain that is out of proportion to the history and physical findings, or pain due to non-noxious stimuli (allodynia/hyperalgesia), and accompanied by one or more signs of autonomic dysfunction. Differential diagnosis may include significant trauma (eg, fractures), inflammatory conditions, malignancies, and systemic illness. The diagnosis is clinical. The treatment goals for CRPS1 are restoration of function and relief of pain. Education, physical, and occupational therapy with psychotherapy and defined goals of achievement with reward are the mainstay of treatment for this population. Most children with CRPS1 will have a favorable outcome.

Challenging cases of professionalism in Japan: improvement in understanding of professional behaviors among Japanese residents between 2005 and 2013.

BACKGROUND: Professionalism is deemed as the basis of physicians' contract with society in Japan. Our study in 2005, using a questionnaire with scenarios to professionalism, suggested that many physicians at various levels of training in Japan encounter challenges when responding to these common scenarios related to professionalism. It is unclear how medical professionalism has changed among Japanese residents in over time. METHODS: We conducted a follow-up survey about challenges to professionalism for Japanese residents using the same Barry Questionnaire after a seven-year interval from the prior survey. The survey uses six clinical scenarios with multiple choice responses. The six cases include the following challenges: acceptance of gifts; conflict of interest; confidentiality; physician impairment; sexual harassment; and honesty in documentation. Each scenario is followed by 4 or 5 possible responses, including the "best" and the "second best" responses. The survey was conducted as a part of nationwide general medicine in-training examination. RESULTS: We collected data from 1,049 participants (290 women, 28%; 431 PGY-1 and 618 PGY-2 residents). Overall, the current residents performed better than their colleagues in the earlier survey for five scenarios (gifts, conflict of interest, confidentiality, impairment, and honesty) but not for the harassment scenario. PGY-2 residents were more likely to select either the best or 2nd best choices to gifts (p = 0.002) and harassment (p = 0.031) scenarios than PGY-1 residents. Residents in the current study chose either the best or 2nd best choices to the gifts (p < 0.001) and honesty (p < 0.001) scenarios than those of the previous study conducted seven years ago, but not for the harassment scenario (p = 0.004). CONCLUSIONS: Our study suggests that there is improvement of medical professionalism with respect to some ethical challenges among the Japanese residents in the current study compared to those in our previous study.

Outpatient versus inpatient IV antibiotic management for pediatric oncology patients with low risk febrile neutropenia: a randomised trial.

BACKGROUND: Febrile neutropenia (FN) is a frequent, serious complication of intensive pediatric chemotherapy regimens. The aim of this trial was to compare quality of life (QOL) between inpatient and outpatient intravenous antibiotic management of children and adolescents with low risk febrile neutropenia (LRFN). PROCEDURE: In this randomised non-blinded trial, patients between 1 and 21 years old, receiving low/moderate intensity chemotherapy were pre-consented and, on presentation to emergency (ED) with FN satisfying low risk criteria, randomised to either outpatient or inpatient care with intravenous cefepime 50 mg/kg (12 hourly). All patients continued antibiotics for at least 48 hours, until afebrile for 24 hours and demonstrating a rising absolute neutrophil count ≥200/mm(3). Several domains of QOL were examined by daily questionnaire. RESULTS: Eighty-one patients presented to ED with 159 episodes of fever. Thirty-seven FN presentations involving 27 patients were randomised to inpatient (18) and outpatient (19) management. Combined QOL mean scores for parents were higher for the outpatient group and scores for three specific parent variables (keeping up with household tasks/time spent with partner/time spent with other children) were higher among outpatients. There was no difference in parent confidence/satisfaction in care between groups. Patients scored better in the outpatient group overall and for sleep and appetite. The mean length of fever was equivalent between groups and there were no serious adverse events attributable to cefepime or outpatient care. CONCLUSION: Outpatient cefepime management of LRFN provided significant benefit to parents and patients across several QOL domains and appeared both feasible and safe.

Functional outcome after air-stirrup ankle brace or fiberglass backslab for pediatric low-risk ankle fractures: a randomized observer-blinded controlled trial.

OBJECTIVES: Pediatric ankle fractures are usually treated by immobilization with either a posterior splint, cast, or ankle brace. We set out to determine if the below-knee fiberglass posterior splint was as effective as the Air-Stirrup ankle brace in returning children with a low risk ankle fracture to their normal level of activity. METHODS: This was a randomized, single-blinded, noninferiority, controlled trial at the Royal Children's Hospital, Melbourne. Children aged 5 to 15 years presenting acutely with a low-risk ankle fracture were randomized to the Air-Stirrup ankle brace or fiberglass posterior splint. A validated self-reported outcome tool, the Activities Scale for Kids performance (ASKp), was used to measure physical functioning over the 4 week period. Main outcome was ASKp scores at 2 and 4 weeks with secondary outcomes including pain, weight-bearing ability, and acceptability of device. RESULTS: Forty-five patients were randomized: 23 in the posterior splint group and 22 in the Air-Stirrup ankle brace. Study groups were similar in terms of age, fracture type, and baseline pain. More of the posterior splint group were non-weight bearing "at enrollment" (96%) compared with the ankle brace group (77%). The median ASKp score at 4 weeks was 91.9 in the brace group and 84.2 in the posterior splint group. Scores on the ASKp as well as ASKp differences were favorable toward the brace in the 11- to 15-year age group at 2 weeks (69.6 vs 55.6) and 4 weeks (97.5 vs 90.2) but trended toward the posterior splint in the 5- to 10-year age group (47.5 vs 56). CONCLUSIONS: There was no difference between the Air-Stirrup ankle brace and the fiberglass posterior splint in returning children to their normal levels of activity.

Petechiae/purpura in well-appearing infants.

BACKGROUND: Well infants with petechiae and/or purpura can present to emergency departments, and their management can be difficult. Many will have extensive investigations and treatment that may not be necessary. METHODS: This was a retrospective and descriptive audit investigating well infants (<8 months of age) presenting with petechiae or purpura in the absence of fever to a pediatric emergency department over a 9½-year period. All presenting problems of petechiae or purpura were reviewed. Patients were excluded if they appeared unwell, were febrile or have a history of fever, or had eccyhmoses on presentation. RESULTS: Thirty-six babies were identified. The average age was 3.8 months (range, 1-7 months). The majority of the infants had localized purpura/petechiae to the lower limbs (92%) with two thirds of these patients having bilateral signs. None had generalized signs. Most infants had a full blood count (94%), coagulation profile (59%) and C-reactive protein (59%), and blood cultures (59%), with all being normal (except for mild elevation in platelets). Nine patients were admitted for observation, with only 1 patient having progression of signs. This patient had a diagnosis of acute hemorrhagic edema of infancy. The rest of the patients were thought to have either a mechanical reason for their petechiae/purpura (tourniquet phenomena) or a formal diagnosis was not specified. CONCLUSIONS: Well infants with localized purpura and/or petechiae with an absence of fever are more likely to have a benign etiology. Further study is required to determine if a full blood count and coagulation profile is necessary, or a period of observation (4 hours) is all that is required. If there is no progression of signs, it is likely that they can be safely discharged. The likely cause may be due to a tourniquet phenomenon (eg, diaper).

Prospective audit of patients with haemophilia: bleeding episodes and management.

BACKGROUND: Haemophilia is a congenital bleeding disorder that requires replacement of factor VIII (haemophilia A) or factor IX (haemophilia B) via intravenous infusions. Children can either be treated with prophylactic treatment to prevent bleeding or be managed with on-demand therapy and treat specific bleeding episodes. AIMS: The aim of this paper was to prospectively follow a cohort of haemophilia patients to determine the incidence of bleeding, re-bleeding, re-treatment and adjunct management over a period of 5 months. METHODS: Sixty-six boys with haemophilia were followed. Age range was 10 months to 19 years; 70% of patients had severe haemophilia and 38 (58%) of all patients were on prophylaxis. RESULTS: Twenty-nine patients experienced at least one episode of bleeding during study period which included 70 home bleeding episodes and 20 emergency department (ED) presentations. Secondary treatments occurred in 38% of all bleeding episodes. The incidence of re-bleeds occurring within 3 weeks of the initial bleeding episode was 11%. CONCLUSIONS: Further study focusing on optimising treatment regimes for patients with haemophilia presenting with bleeding episodes is necessary.

The role of imaging studies for evaluation of stroke in children.

Stroke is a major cause of morbidity and mortality in children and long-term neurological deficits. Although cerebrovascular disorders occur less often in children than in adults, recognition of stroke in children has probably increased because of the widespread application of noninvasive diagnostic studies such as magnetic resonance imaging and computed tomography.Computed tomography (CT) should be the first imaging choice in the emergency setting when stroke is suspected. It will show the presence of hemorrhage (eg, bleeding from arteriovenous malformation). It is often normal within the first hours in arterial ischemic stroke. As in adults, magnetic resonance imaging is the neuroimaging modality to confirm the clinical diagnosis of ischemic stroke. In children, however, magnetic resonance imaging requires sedation and may not be as readily available as CT. Perfusion imaging demonstrates flow within the brain and can detect areas that are at risk of ischemia; however, further studies in the pediatric population need to be validated for this technique in children. Angiography detects arterial disease (eg, aneurysm); however, its use has been largely superseded by better magnetic resonance angiography, which is sensitive enough to visualize lesions in the proximal anterior cerebral artery, middle cerebral artery, and distal internal carotid artery (ICA). Magnetic resonance imaging using diffusion- weighted imaging is the most versatile and sensitive imaging technique for identifying ischemic lesions. In the future, we need to identify the pediatric patient presenting to the emergency department with an acute stroke and develop a pathway for the use of particular imaging techniques (eg, CT vs magnetic resonance imaging).

Parental disciplinary practices following acquired brain injury in children.

PURPOSE: This study describes the disciplinary practices of parents following acquired brain injury (ABI) of their child and examines the relationship between disciplinary use, family-parental adversities and children's behavioural sequelae. METHOD: Participants were 48 parent respondents of children between 3-12 years with mild, moderate and severe ABI. Parents provided demographic information and completed questionnaires investigating disciplinary strategy use, parental-family functioning and child behaviour. RESULTS: Over-reactive and lax disciplinary strategies were endorsed most by parents. Dysfunctional levels of disciplinary use were associated with children who displayed more behaviour problems, parents with elevated distress and families experiencing more dysfunction and social adversity. CONCLUSION: Dysfunctional parenting practices, if not ameliorated, could exacerbate problematic child behaviour following ABI, as well as parent and family difficulties. Parental assessment may be useful as a method of screening for parental factors that put children at risk for ongoing behaviour problems and families for ongoing stress.

Clinical and microbiologic features associated with novel swine-origin influenza A pandemic 2009 (H1N1) virus in children: a prospective cohort study.

BACKGROUND: Novel swine-origin influenza A pandemic 2009 (H1N1) virus (S-OIV) infection in the context of other respiratory viruses circulating in winter has not been studied. METHODS: Clinical and microbiologic data were collected prospectively from 444 consecutive patients presenting with an influenza-like illness (ILI) to a large pediatric hospital at the beginning of the S-OIV outbreak in Australia. RESULTS: Of 444 patients, 119 had polymerase chain reaction-confirmed S-OIV. Influenza A virus was detected by direct immunofluorescence in only 69 of these. Overall, inadequate respiratory samples were more common with rayon than flocked swabs (P = 0.01). The mean age of patients with S-OIV was higher than those with another cause of an ILI (10.2 vs. 6.4 years; P < 0.0001). The commonest symptoms in S-OIV were fever (93%) and cough (92%), followed by coryza (78%), sore throat (72%), headache (59%), myalgia (49%), vomiting (23%), and diarrhea (16%). Clinical features did not discriminate between patients with S-OIV and those with another ILI, except headache and myalgia, which were more common in children younger than 5 years who had S-OIV than those who did not (headache: P < 0.0001; myalgia: P = 0.0004). More patients with S-OIV had contact with a confirmed case but contact history had insufficient positive predictive value (44%) and negative predictive value (78%) for identifying S-OIV. Only 2% of the patients had a history of travel, and only 1 of these had S-OIV. CONCLUSIONS: A clinical case definition is unlikely to be useful for discriminating patients with S-OIV from those with another cause of an ILI during winter. Direct immunofluorescence for influenza A cannot be used alone to reliably detect S-OIV.

Mathematical modeling of triamcinolone acetonide drug release from the I-vation intravitreal implant (a controlled release platform).

In-vitro drug release of triamcinolone acetonide from the I-vation implant can be controlled and tuned by varying its formulation ingredients. These release characteristics can be modeled using a parabolic partial differential equation to describe one dimensional Fickian drug diffusion in a durable polymer matrix.

Questionnaire survey for challenging cases of medical professionalism in Japan.

BACKGROUND: Little information is available on evaluation of medical professionalism among Japanese physicians and on its education in Japanese medical schools. AIMS: To assess professionalism and its education in Japan. METHOD: We analysed the responses to challenges to professionalism for Japanese residents and physicians, using the Barry Questionnaire, and to survey the extent of education related to professionalism during medical school curricula. The survey was conducted at 14 teaching hospitals in Kyushu and Okinawa, using existing hospital conferences. RESULTS: We collected data from 175 participants (60 residents and 115 faculty physicians). The most challenging was the sexual harassment scenario, in which 51.4% provided the best or 2nd best answers, followed by the honesty scenario with 69.7% and the confidentiality scenario with 76.0%. Participants were more likely to provide the best or 2nd best responses to the scenarios involving physician impairment (87.4%), conflict of interest (81.1%), and acceptance of gifts (78.3%). Five (3%) participants reported learning experiences about professionalism during the curricula and the median hours for its course work were two hours. Only one resident reported that she was satisfied with these educational sessions. CONCLUSIONS: Many Japanese physicians were unable to provide an acceptable response to challenges to professionalism in several issues and few had received education in professionalism during school curricula. Greater teaching of professionalism is needed in medical education in Japan.