April J. Kam

Active tuberculosis among adolescents in toronto, Canada: clinical features and delays in diagnosis.

There are few studies on tuberculosis (TB) in adolescents. During a 6-year period, 23 adolescents were treated for TB in our center. Most were foreign born. The average time from symptom onset to final diagnosis was 5.2 months. Multifocal and extra pulmonary disease occurred in the majority of patients. Clinicians need greater awareness of the unique features of adolescent TB.

Pediatric cellulitis: success of emergency department short-course intravenous antibiotics.

Objectives: The administration of 1 to 2 doses of intravenous (IV) antibiotics in the emergency department (ED) followed by discharge on oral antibiotics has become a treatment option for children with cellulitis, despite an absence of evidence supporting this practice. The objective of this study was to determine the failure rate of ED short-course IV antibiotic therapy (IV-short course). Methods: This retrospective study included children aged 0 to 18 years diagnosed with cellulitis in a pediatric ED during the 2005 calendar year. Treatment was categorized as (a) discharge on outpatient oral antibiotics, (b) IV-short course, or (c) admission for IV antibiotics (IV-admit). Failure was defined by a subsequent visit less than 7 days since the index visit with a change in antibiotic treatment, the administration of IV antibiotics, or hospitalization. A second data abstractor reviewed 10% of the charts to allow calculation of interobserver scores. Results: There were 321 eligible children, of whom 154 children were treated with oral antibiotics, 85 IV-short course, and 82 IV-admit. A total of 23 patients (7%) met criteria for failure. Compared with IV-admit, the odds ratio of failure among those who received IV-short course was 7.2 (95% confidence interval [CI], 1.6-33.1). Those who received IV-short course were more likely to revisit within 7 days than were children treated with oral antibiotics alone (risk ratio, 2.4; 95% CI, 1.2-4.7); however, revisits were no more frequent than among children in the IV-admit group (risk ratio, 2.8; 95% CI, 0.65-12.1). The total mean duration of hospital stay was significantly less in the IV-short course group compared with the IV-admit group (14.9 vs 118.6 hours; P < 0.001). Conclusions: Children with cellulitis frequently receive IV antibiotics. Short-course IV antibiotic therapy is associated with a high failure rate and prolonged ED stay compared with those in children treated with oral antibiotics alone. However, their clinical similarity to the IV-admit group, shorter length of hospital stay, but high failure rate mandates further evaluation before widespread adoption.

Conceptual framework for health-related quality of life assessment in acute gastroenteritis.

Background and Objectives: To date, most trials in pediatric acute gastroenteritis have evaluated short-term clinical disease activity (eg, duration of diarrhea or vomiting, level of dehydration), laboratory outcomes (eg, rotavirus, norovirus), or a composite of these outcomes. Measuring health-related quality of life may also be important in evaluating the effect of interventions for acute gastroenteritis in children. The objectives of this study were to conduct individual interviews and, when possible, focus group discussions, with parents of children with acute gastroenteritis; to determine how parent and child quality of life is negatively affected by acute gastroenteritis; and, from the perspective of parents and children, to develop a conceptual framework for quality of life instrument specific to pediatric acute gastroenteritis. Methods: We conducted interviews and focus groups with parents of children (3 months–5 years of age) given a diagnosis of gastroenteritis in a hospital emergency department. Interviews and focus groups were conducted to determine the effect of gastroenteritis on quality of life in parents and children (as perceived by the parents). Results: Interviews and focus groups involving 25 parents suggested a conceptual framework that, for children, includes 2 domains (physical and emotional function) and 14 subdomains. For parents, our framework includes 3 domains (physical, emotional, and social function) with physical function including 4 subdomains, emotional function including 7 subdomains, and social function including 2 subdomains. The framework has been used to develop a preliminary quality of life questionnaire for parents and children. Conclusions: Acute gastroenteritis has an important adverse effect on health-related quality in both children and parents involving physical symptoms and restrictions in physical function and disturbed emotional function. Upon further research on the psychometric properties of the proposed questionnaires, future trials of effectiveness should consider measuring patient important outcomes such as health-related quality of life.

Boy with 47,XXY,del(15)(q11.2q13) karyotype and Prader-Willi syndrome: a new case and review of the literature.

We report on a 10‐year‐old boy with a 47,XXY,del(15)(q11.2q13) karyotype and a Prader–Willi syndrome phenotype. His medical history and physical examination conformed to all of the major clinical criteria for Prader–Willi syndrome, but his height was taller than expected based on his hand and foot sizes. The deleted chromosome 15 was paternal in origin and molecular analysis showed maternal origin for the additional X chromosome. These findings suggest that the presence of these two disorders was coincidental in our patient. This supports the findings in the two other 47,XXY and Prader–Willi cases for which parent of origin studies have been published. Given the information from the literature and presented herein, we suggest that genetic counseling for cases of PWS and 47,XXY should address these two conditions separately.

Process Mapping in a Pediatric Emergency Department to Minimize Missed Urinary Tract Infections

Urinary tract infections (UTIs) are common in young children and are seen in emergency departments (EDs) frequently. Left untreated, UTIs can lead to more severe conditions. Our goal was to undertake a quality improvement (QI) initiative to help minimize the number of children with missed UTIs in a newly established tertiary care pediatric emergency department (PED). A retrospective chart review was undertaken to identify missed UTIs in children < 3 years old who presented to a childrens hospitals ED with positive urine cultures. It was found that there was no treatment or follow-up in 12% of positive urine cultures, indicating a missed or possible missed UTI in a significant number of children. Key stakeholders were then gathered and process mapping (PM) was completed, where gaps and barriers were identified and interventions were subsequently implemented. A follow-up chart review was completed to assess the impact of PM in reducing the number of missed UTIs. Following PM and its implementation within the ED, there was no treatment or follow-up in only 1% of cases. Based on our results, the number of potentially missed UTIs in the ED decreased dramatically, indicating that PM can be a successful QI tool in an acute care pediatric setting.

A 10-Year Review of Necrotizing Fasciitis in the Pediatric Population: Delays to Diagnosis and Management.

Objective. To assess the promptness and appropriateness of management in pediatric cases of necrotizing fasciitis (NF). Methods. A retrospective chart review examined cases of pediatric NF treated at a pediatric tertiary care center over a 10-year period. Results. Twelve patients were identified over the 10-year period. The median (25th to 75th centile) times to appropriate antibiotic administration, infectious disease consults, surgical consults and debridement surgeries were 2.6 (2.1-3.2), 7.7 (3.4-24.4), 4.6 (1.7-21.0), and 22.1 (10.3-28.4) hours following assessment at triage. The initial antibiotic(s) administered covered the causative organism in 9 of 12 cases. The median (25th to 75th centile) length of hospital stay was 21 (14.0-35.5) days. Conclusions. The large variability in the care of these patients speaks to the range of their presenting symptomatology. The lack of a standardized approach to the pediatric patient with suspected NF results in delays in management and suboptimal antibiotic choice.

Short-course antimicrobial therapy for paediatric respiratory infections (SAFER): study protocol for a randomized controlled trial

BackgroundCommunity-acquired pneumonia (CAP) is commonly diagnosed in children. The Infectious Disease Society of America guidelines recommend 10 days of high-dose amoxicillin for the treatment of non-severe CAP but 5-day “short course” therapy may be just as effective. Randomized trials in adults have already demonstrated non-inferiority of 5-day short-course treatment for adults hospitalized with severe CAP and for adults with mild CAP treated as outpatients. Minimizing exposure to antimicrobials is desirable to avoid harms including diarrhoea, rashes, severe allergic reactions, increased circulating antimicrobial resistance, and microbiome disruption.MethodsThe objective of this multicentre, randomized, non-inferiority, controlled trial is to investigate whether 5 days of high-dose amoxicillin is associated with lower rates of clinical cure 14–21 days later as compared to 10 days of high-dose amoxicillin, the reference standard. Recruitment and enrolment will occur in the emergency departments of McMaster Children’s Hospital and the Children’s Hospital of Eastern Ontario. All children in the study will receive 5 days of amoxicillin after which point they will receive either 5 days of a different formulation of amoxicillin or a placebo. Assuming a clinical failure rate of 5% in the reference arm, a non-inferiority margin of 7.5%, one-sided alpha set at 0.025 and power of 0.80, 270 participants will be required. Participants from a previous feasibility study (n = 60) will be rolled over into the current study. We will be performing multiplex respiratory virus molecular testing, quantification of nasopharyngeal pneumococcal genomic loads, salivary inflammatory marker testing, and faecal microbiome profiling on participants.DiscussionThis is a pragmatic study seeking to provide high-quality evidence for front-line physicians evaluating children presenting with mild CAP in North American emergency departments in the post-13-valent pneumococcal, conjugate vaccine era. High-quality evidence supporting the non-inferiority of short-course therapy for non-severe paediatric CAP should be generated prior to making changes to established guidelines. Trial registrationClinicalTrials.gov, NCT02380352. Registered on 2 March 2015.

Ethics consultation in paediatric and adult emergency departments: an assessment of clinical, ethical, learning and resource needs

Objective We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments (EDs) in order to build ethics capacity and provide a foundation for the development of an ethics education programme. Methods This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity. Results Of the 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress (16%), conflict management with patients or families (16%) and resource issues (15%). Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams (42%) was the most desired method. Conclusions Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists.

An Interesting Case of Viral Pericarditis.

Abstract A previously healthy 14-year-old girl presented to the emergency department with a 3-day history of upper respiratory symptoms and 2 syncopal episodes. She was initially febrile, tachycardic, and tachypneic; the initial electrocardiogram showed diffuse T-wave inversions and right atrial enlargement. There was no pericardial effusion on bedside and formal echocardiography; the latter, however, revealed a hyperechogenic pericardium. A viral swab was positive for influenza B. Treatment with intravenous rehydration and ibuprofen was started with good response. The patient went home 24 hours later with the diagnosis of mild pericarditis and syncope likely secondary to dehydration impaired diastolic filling. The incidence of acute pericarditis in previously healthy children is unknown. There are no known case reports of influenza B–associated pericarditis in the pediatric population. There is little high quality evidence to guide the diagnosis and management of pericarditis in children. However, limited data suggest that the typically described presentation of chest pain, pericardial rub, pericardial effusion, and electrocardiogram changes occurs in children. The pediatric population seems to respond well to nonsteroidal anti-inflammatory drugs.

An Infant With Persistent Failure to Thrive

A female infant presented with failure to thrive (FTT) starting at 6 months of age, falling from the 90th percentile for weight at 4 months, to 25th percentile at 6 months, and subsequently to below the 5th percentile at 8 months. She was otherwise healthy and developmentally normal, with a happy personality. History revealed that she had suboptimal volumes and symptoms of feeding aversion related to introduction of solid foods at 5 months. Parents had been counseled to wait until 6 months of age to introduce solids; thus, they gradually cut down solids and increased formula. Unfortunately, at this time the patient started refusing the bottle and then gradually solids as well. She was followed as an outpatient by a pediatrician, and then at 8 months, she was admitted to hospital for a month to evaluate her FTT. Investigations included the following: normal complete blood count, electrolytes, renal and liver function, stool studies, urine studies, thyroid, and negative celiac and cystic fibrosis testing. A significant feeding aversion was noted with some vomiting; thus, a nasogastric tube was inserted and she was started on ranitidine. During the hospitalization she gained an average of 40 grams per day. She showed adequate weight gain and the nasogastric tube was later converted to a gastrostomy tube (G-tube). Over the next few months she was followed closely as an outpatient, and despite adequate G-tube feeds with maximally optimized calories she showed variable weight gain with no catch-up growth. She continued to maintain growth in head circumference (75th percentile) and length, achieving greater than 95th percentile for length. She also attained developmental milestones appropriately. As her weight still persisted below the 5th percentile (Figure 1), she was electively readmitted to hospital at 18 months for reevaluation. Further workup, including expanded metabolic workup, was negative and the diagnosis of feeding aversion was confirmed. Then, at 20 months she presented to hospital with a 2-week history of intermittent nystagmus and 3 days of early morning vomiting, which was different from her previous pattern of vomiting. Full neurological examination was otherwise unremarkable. A brain magnetic resonance imaging (MRI) revealed the underlying diagnosis. Hospital Course and Diagnosis