Paediatric hypertension for the primary care provider: What you need to know.

The prevalence of hypertension has increased in the paediatric and adolescent populations, and is estimated between 1% and 2% in Canada. Paediatric and adolescent hypertension differs from adult hypertension in many ways, and primary care providers may not be up to date with current guidelines and recommendations. Recently, the American Academy of Pediatrics updated and published guidelines on the diagnosis, evaluation, and management of hypertension in children and adolescents. This paper summarizes these new guidelines in addition to the existing Canadian guidelines in a simple four-step approach, catered to a primary care setting, detailing the diagnosis, evaluation, workup, and management of hypertension in children and adolescents.

A novel computational method for assigning weights of importance to symptoms of COVID-19 patients.

BACKGROUND AND OBJECTIVE: The novel coronavirus disease 2019 (COVID-19) is considered a pandemic by the World Health Organization (WHO). As of April 3, 2020, there were 1,009,625 reported confirmed cases, and 51,737 reported deaths. Doctors have been faced with a myriad of patients who present with many different symptoms. This raises two important questions. What are the common symptoms, and what are their relative importance? METHODS: A non-structured and incomplete COVID-19 dataset of 14,251 confirmed cases was preprocessed. This produced a complete and organized COVID-19 dataset of 738 confirmed cases. Six different feature selection algorithms were then applied to this new dataset. Five of these algorithms have been proposed earlier in the literature. The sixth is a novel algorithm being proposed by the authors, called Variance Based Feature Weighting (VBFW), which not only ranks the symptoms (based on their importance) but also assigns a quantitative importance measure to each symptom. RESULTS: For our COVID-19 dataset, the five different feature selection algorithms provided different rankings for the most important top-five symptoms. They even selected different symptoms for inclusion within the top five. This is because each of the five algorithms ranks the symptoms based on different data characteristics. Each of these algorithms has advantages and disadvantages. However, when all these five rankings were aggregated (using two different aggregating methods) they produced two identical rankings of the five most important COVID-19 symptoms. Starting from the most important to least important, they were: Fever/Cough, Fatigue, Sore Throat, and Shortness of Breath. (Fever and cough were ranked equally in both aggregations.) Meanwhile, the sixth novel Variance Based Feature Weighting algorithm, chose the same top five symptoms, but ranked fever much higher than cough, based on its quantitative importance measures for each of those symptoms (Fever - 75 %, Cough - 39.8 %, Fatigue - 16.5 %, Sore Throat - 10.8 %, and Shortness of Breath - 6.6 %). Moreover, the proposed VBFW method achieved an accuracy of 92.1 % when used to build a one-class SVM model, and an NDCG@5 of 100 %. CONCLUSIONS: Based on the dataset, and the feature selection algorithms employed here, symptoms of Fever, Cough, Fatigue, Sore Throat and Shortness of Breath are important symptoms of COVID-19. The VBFW algorithm also indicates that Fever and Cough symptoms were especially indicative of COVID-19, for the confirmed cases that are documented in our database.

Coarctation of the Aorta in Adolescence: Significance of Detailed Cardiac Examination in Pediatric Hypertension.

ABSTRACT: Although coarctation of the aorta (CoAo) is a congenital anomaly, it can pose a diagnostic challenge in those presenting beyond neonatal period, as some patients can remain asymptomatic until complications of hypertension develop later in life. Careful physical examination can play an important role in timely diagnosis and prevention of complications.We present 2 cases of adolescents with undiagnosed CoAo who both presented with nonspecific headaches and hypertension. Both were initially misdiagnosed as essential hypertension until careful detailed physical examination later detected weak/absent femoral pulses and discrepancy in upper and lower limb blood pressures. These findings raised the clinical suspicion of CoAo, which was confirmed on further investigations.Our cases highlight the importance of considering CoAo in the differential diagnosis of hypertension in adolescents. These cases also stress the significance of detailed cardiac examination including 4-limb blood pressure and femoral pulses in a patient presenting to the emergency department with high blood pressure irrespective of the primary complaint.

An IoT-based framework for early identification and monitoring of COVID-19 cases.

The world has been facing the challenge of COVID-19 since the end of 2019. It is expected that the world will need to battle the COVID-19 pandemic with precautious measures, until an effective vaccine is developed. This paper proposes a real-time COVID-19 detection and monitoring system. The proposed system would employ an Internet of Things (IoTs) framework to collect real-time symptom data from users to early identify suspected coronaviruses cases, to monitor the treatment response of those who have already recovered from the virus, and to understand the nature of the virus by collecting and analyzing relevant data. The framework consists of five main components: Symptom Data Collection and Uploading (using wearable sensors), Quarantine/Isolation Center, Data Analysis Center (that uses machine learning algorithms), Health Physicians, and Cloud Infrastructure. To quickly identify potential coronaviruses cases from this real-time symptom data, this work proposes eight machine learning algorithms, namely Support Vector Machine (SVM), Neural Network, Naïve Bayes, K-Nearest Neighbor (K-NN), Decision Table, Decision Stump, OneR, and ZeroR. An experiment was conducted to test these eight algorithms on a real COVID-19 symptom dataset, after selecting the relevant symptoms. The results show that five of these eight algorithms achieved an accuracy of more than 90 %. Based on these results we believe that real-time symptom data would allow these five algorithms to provide effective and accurate identification of potential cases of COVID-19, and the framework would then document the treatment response for each patient who has contracted the virus.

Point-of-Care Ultrasound in Pediatric Diagnostic Dilemmas: Two Atypical Presentations of Intussusception.

Diagnostic dilemmas are ubiquitous in pediatric emergency medicine because of the varied and often insidious presentations of many pediatric conditions. Point-of-care ultrasound (POCUS) in emergency departments is being used for some of these diagnostic challenges and can often provide rapid and valuable information to supplement a physician's clinical assessment. Intussusception is a pediatric condition that may be challenging to recognize because of its subtle and varied presenting symptoms. An unrecognized or delayed diagnosis of intussusception can be catastrophic, with complications including bowel obstruction, bowel perforation, and death. Here we present two challenging cases of intussusception, one due to its atypical age of presentation and the other due to its unique symptoms. These cases demonstrate the benefits of point-of-care ultrasound for diagnostically challenging cases in the emergency department.

Emergency Point-of-Care Ultrasound Detection of Cancer in the Pediatric Emergency Department.

The use of point-of-care ultrasound in the pediatric emergency department is evolving beyond conventional applications as users become more expert with the technology. In this case series, we describe the potential utility of recognizing abnormal anatomy to impact care in the context of possible cancer in pediatric patients. We describe 4 patients with Langerhans histiocytosis, neuroblastoma, Wilms tumor, and rhabdomyosarcoma, in which point-of-care ultrasound was used to facilitate the diagnoses.

Importance of CMR within the Task Force Criteria for the diagnosis of ARVC in children and adolescents.

BACKGROUND: Cardiac magnetic resonance (CMR) is a component of the revised Task Force Criteria (rTFC) for the diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC). However, its diagnostic value in a pediatric population is unknown. OBJECTIVES: This study examined the contribution of CMR to diagnosing ARVC using the rTFC in a pediatric population. METHODS: Clinical CMR studies of 142 pediatric patients evaluated for ARVC between 2005 and 2009 were reviewed. Patients were categorized into "definitive," "borderline," "possible," or "no" ARVC diagnostic groups based on the rTFC. The extent to which each element of the rTFC contributed to diagnosing ARVC was determined using a c-statistics model. RESULTS: A total of 23 (16%), 32 (23%), 37 (26%), and 50 (35%) patients had definite, borderline, possible, and no ARVC, respectively, applying the rTFC. The prevalence of regional wall motion abnormalities in these groups was 83%, 53%, 22%, and 16%, respectively (p < 0.001). By CMR, right ventricular end-diastolic volumes were 118 ± 31 cc/m², 108 ± 22 cc/m², 94 ± 14 cc/m², and 92 ± 18 cc/m², respectively (p < 0.001). Right ventricular fatty infiltration and fibrosis were detected in only 1 and 3 patients, respectively, all of whom had definitive ARVC. Of all rTFC major criteria, CMR had the largest c-statistic decline (c = -0.163). Eleven of the 23 patients (48%) with definite ARVC would not have been in this group if CMR had not been performed. CONCLUSIONS: CMR parameters are important contributors to a diagnosis of ARVC in children, using the rTFC. Fatty infiltration and myocardial fibrosis provide limited value in children and adolescents.

Evaluation of children with heart murmurs.

Cardiac murmurs can be a source of anxiety for both physicians and parents until serious cardiac disorders are excluded. The innocent cardiac murmur is still the most common finding in healthy children and can usually be diagnosed through obtaining a complete history and performing a complete physical examination. However, a cardiac murmur may be the first sign of a structural cardiac disease and should not be ignored. Referral to a pediatric cardiologist for further evaluation is required when murmur assessment is not clear and diagnostic uncertainty is present. Educating and reassuring parents remains an important aspect of this evaluation. This article discusses features of innocent and pathological murmurs and provides an approach to cardiac murmurs in children.

Foetal echocardiographic assessment of borderline small left ventricles can predict the need for postnatal intervention.

BACKGROUND: We sought to prospectively determine foetal echocardiographic factors associated with neonatal interventions in borderline hypoplastic left ventricles. METHODS: Foetuses were included who had a left ventricle that was 2-4 standard deviations below normal for length or diameter and had forward flow across the mitral and aortic valves. Factors associated with an intervention in the first month of life or no need for intervention were sought using univariate and multivariate logistic regression models. RESULTS: From 2005 to 2008, 47 foetuses meeting the criteria had an additional diagnosis (+foetal coarctation/+transverse arch hypoplasia): atrioventricular septal defect 7 (+2/+0), double outlet right ventricle 2 (+0/+0), Shone's complex 19 (+9/+4), and ventricular disproportion 19 (+13/+11; 4 both). There were seven pregnancies terminated, three foetal demises, and five had compassionate care. There were 32 livebirths that either had a biventricular repair (n = 20, n = 2 dead), univentricular palliation (n = 2, both alive), or no intervention (n = 9). Overall survival of livebirths to 6 months of age was 79%. Factors associated with early intervention on first foetal echocardiogram were: obstructed or retrograde arch flow (p = 0.08, odds ratio 3.3), coarctation (p = 0.05, odds ratio 11.4), and left ventricle outflow obstruction (p = 0.05, odds ratio 12.5). Neonatal factors included: Shone's diagnosis (p = 0.02, odds ratio 4.9), bicuspid aortic valve (p = 0.005, odds ratio 11.7), and larger tricuspid valve z-score (p = 0.05, odds ratio 3.6). A neonatal factor associated with no intervention was a larger mitral valve z-score (mean 23.8 versus 24.2 intervention group, p = 0.04, odds ratio 2.8). DISCUSSION: The need for early intervention in foetuses with borderline hypoplastic left ventricle can be predicted by foetal echocardiography.