We aimed to determine paediatric hospital preparedness for a mass casualty disaster involving children in both prehospital and hospital settings. The study findings will serve to generate ...recommendations, guidelines and training objectives.
The AMAVI-PED study is a cross-sectional survey. An electronic questionnaire was sent to French physicians with key roles in specialised paediatric acute care.
In total, 81% (26 of 32) of French University Hospitals were represented in the study. A disaster plan AMAVI with a specific paediatric emphasis was established in all the paediatric centres. In case of a mass casualty event, paediatric victims would be initially admitted to the paediatric emergency department for most centres (n=21; 75%). Paediatric anaesthesiologists, paediatric surgeons and paediatric radiologists were in-house in 20 (71%), 5 (18%) and 12 (43%) centres, respectively. Twenty-three (82%) hospitals had a paediatric specialised mobile intensive care unit and seven (25%) of these could provide a prehospital emergency response. Didactic teaching and simulation exercises were implemented in 20 (71%) and 22 (79%) centres, respectively. Overall, physician participants rated the level of readiness of their hospital as 6 (IQR: 5-7) on a 10-point readiness scale.
Paediatric preparedness is very heterogeneous between the centres. Based on the study findings, we suggest that a national programme must be defined and guidelines generated.
PIK3CA-related overgrowth spectrum (PROS) includes rare genetic conditions due to gain-of-function mutations in the PIK3CA gene. There is no approved medical therapy for patients with PROS, and ...alpelisib, an approved PIK3CA inhibitor in oncology, showed promising results in preclinical models and in patients. Here, we report for the first time the outcome of two infants with PROS having life-threatening conditions treated with alpelisib (25 mg) and monitored with pharmacokinetics. Patient 1 was an 8-mo-old girl with voluminous vascular malformation. Patient 2 was a 9-mo-old boy presenting with asymmetrical body overgrowth and right hemimegalencephaly with West syndrome. After 12 mo of follow-up, alpelisib treatment was associated with improvement in signs and symptoms, morphological lesions and vascular anomalies in the two patients. No adverse events were reported during the study. In this case series, pharmacological inhibition of PIK3CA with low-dose alpelisib was feasible and associated with clinical improvements, including a smaller size of associated complex tissue malformations and good tolerability.
Despite increasing reports that Blastocystis infection is associated with digestive symptoms, its pathogenicity remains controversial. We report appendicular peritonitis in a 9-year-old girl ...returning to France from Morocco. Only Blastocystis parasites were detected in stools, appendix, peritoneal liquid, and recto-uterine pouch. Simultaneous gastroenteritis in 26 members of the child's family suggested an outbreak.
The use of isavuconazole is approved for the management of invasive aspergillosis and mucormycosis, only in adults, as no paediatric pharmacology studies have been reported to date. Very few ...paediatric cases have been published concerning the use of isavuconazole. Amphotericin B is the only antifungal agent recommended in paediatric mucormycosis, but adverse effects and especially nephrotoxicity, even with the liposomal formulation, could be problematic. In this context, the use of other antifungal molecules active on Mucorales becomes needful.
We describe a case of mucormycosis with rapid onset dissemination in a 3-year-old girl recently diagnosed with acute lymphocytic leukaemia. She was successfully treated with isavuconazole alone and then in combination with liposomal amphotericin B. Isavuconazole therapy was guided by therapeutic drug monitoring.
This case offers new perspectives on the potential use of isavuconazole in children with mucormycosis, as an alternative or adjunct to liposomal amphotericin B.
Background
In multisystem inflammatory syndrome in children (MIS-C), diagnostic delay could be associated with severity. This study aims to measure the time to diagnosis in MIS-C, assess its impact ...on the occurrence of cardiogenic shock, and specify its determinants.
Methods
A single-center prospective cohort observational study was conducted between May 2020 and July 2022 at a tertiary care hospital. Children meeting the World Health Organization MIS-C criteria were included. A long time to diagnosis was defined as six days or more. Data on time to diagnosis were collected by two independent physicians. The primary outcome was the occurrence of cardiogenic shock. Logistic regression and receiver operating characteristic curve analysis were used for outcomes, and a Cox proportional hazards model was used for determinants.
Results
Totally 60 children were assessed for inclusion, and 31 were finally analyzed 52% males, median age 8.8 (5.7–10.7) years. The median time to diagnosis was 5.3 (4.2–6.2) days. In univariable analysis, age above the median, time to diagnosis, high C-reactive protein, and high N-terminal pro-B-type natriuretic peptide (NT-proBNP) were associated with cardiogenic shock odds ratio (OR) 6.13 (1.02–36.9), 2.79 (1.15–6.74), 2.08 (1.05–4.12), and 1.70 (1.04–2.78), respectively. In multivariable analysis, time to diagnosis ≥ 6 days was associated with cardiogenic shock adjusted OR (aOR) 21.2 (1.98–227). Time to diagnosis ≥ 6 days had a sensitivity of 89% and a specificity of 77% in predicting cardiogenic shock; the addition of age > 8 years and NT-proBNP at diagnosis ≥ 11,254 ng/L increased the specificity to 91%. Independent determinants of short time to diagnosis were age < 8.8 years aHR 0.34 (0.13–0.88), short distance to tertiary care hospital aHR 0.27 (0.08–0.92), and the late period of the COVID-19 pandemic aHR 2.48 (1.05–5.85).
Conclusions
Time to diagnosis ≥ 6 days was independently associated with cardiogenic shock in MIS-C. Early diagnosis and treatment are crucial to avoid the use of inotropes and limit morbidity, especially in older children.
We hypothesized that antibiotic use in PICUs is based on criteria not always supported by evidence. We aimed to describe determinants of empiric antibiotic use in PICUs in eight different countries.
...Cross-sectional survey.
PICUs in Canada, the United States, France, Italy, Saudi Arabia, Japan, Thailand, and Brazil.
Pediatric intensivists.
None.
We used literature review and focus groups to develop the survey and its clinical scenarios (pneumonia, septic shock, meningitis, and intra-abdominal infections) in which cultures were unreliable due to antibiotic pretreatment. Data analyses included descriptive statistics and linear regression with bootstrapped SEs. Overall response rate was 39% (482/1,251), with individual country response rates ranging from 25% to 76%. Respondents in all countries prolonged antibiotic duration based on patient characteristics, disease severity, pathogens, and radiologic findings (from a median increase of 1.8 d 95% CI, 0.5-4.0 d to 9.5 d 95% CI, 8.5-10.5 d). Younger age, severe disease, and ventilator-associated pneumonia prolonged antibiotic treatment duration despite a lack of evidence for such practices. No variables were reported to shorten treatment duration for all countries. Importantly, more than 39% of respondents would use greater than or equal to 7 days of antibiotics for patients with a positive viral polymerase chain reaction test in all scenarios, except in France for pneumonia (29%), septic shock (13%), and meningitis (6%). The use of elevated levels of inflammatory markers to prolong antibiotic treatment duration varied among different countries.
Antibiotic-related decisions are complex and may be influenced by cultural and contextual factors. Evidence-based criteria are necessary to guide antibiotic duration and ensure the rational use of antibiotics in PICUs.
The study presents the evaluation of the reliability of the information displayed on the user interface of a homegrown electronic patient prioritization tool dedicated to pediatric emergency ...department (namely Optimum). Two ergonomists shadowed physicians and nurses throughout their shift in order to (i) identify consistencies and discrepancies between the actual step of the patients in the care process and their assigned step in Optimum and (ii) to understand the causes of the discrepancies. Even if some discrepancies are noted, results show that Optimum provides a quite good reflection of the actual position of the patients in the care process. The use of ethnographic methods allows to understand the cause of the discrepancies.
Background
Overcrowding in the emergency departments has become an increasingly significant problem. Patient triage strategies are acknowledged to help clinicians manage patient flow and reduce ...patients’ waiting time. However, electronic patient triage systems are not developed so that they comply with clinicians’ workflow.
Objective
This case study presents the development of a patient prioritization tool (PPT) and of the related patient prioritization algorithm (PPA) for a pediatric emergency department (PED), relying on a human-centered design process.
Methods
We followed a human-centered design process, wherein we (1) performed a work system analysis through observations and interviews in an academic hospital’s PED; (2) deduced design specifications; (3) designed a mock PPT and the related PPA; and (4) performed user testing to assess the intuitiveness of the icons, the effectiveness in communicating patient priority, the fit between the prioritization model implemented and the participants’ prioritization rules, and the participants’ satisfaction.
Results
The workflow analysis identified that the PPT interface should meet the needs of physicians and nurses, represent the stages of patient care, and contain patient information such as waiting time, test status (eg, prescribed, in progress), age, and a suggestion for prioritization. The mock-up developed gives the status of patients progressing through the PED; a strip represents the patient and the patient’s characteristics, including a delay indicator that compares the patient’s waiting time to the average waiting time of patients with a comparable reason for emergency. User tests revealed issues with icon intuitiveness, information gaps, and possible refinements in the prioritization algorithm.
Conclusions
The results of the user tests have led to modifications to improve the usability and usefulness of the PPT and its PPA. We discuss the value of integrating human factors into the design process for a PPT for PED. The PPT/PPA has been developed and installed in Lille University Hospital's PED. Studies are carried out to evaluate the use and impact of this tool on clinicians’ situation awareness and prioritization-related cognitive load, prioritization of patients, waiting time, and patients’ experience.
The procalcitonin (PCT) assay is an accurate screening test for identifying invasive bacterial infection (IBI); however, data on the PCT assay in very young infants are insufficient.
To assess the ...diagnostic characteristics of the PCT assay for detecting serious bacterial infection (SBI) and IBI in febrile infants aged 7 to 91 days.
A prospective cohort study that included infants aged 7 to 91 days admitted for fever to 15 French pediatric emergency departments was conducted for a period of 30 months (October 1, 2008, through March 31, 2011). The data management and analysis were performed from October 1, 2011, through October 31, 2014.
The diagnostic characteristics of the PCT assay, C-reactive protein (CRP) concentration, white blood cell (WBC) count, and absolute neutrophil cell (ANC) count for detecting SBI and IBI were described and compared for the overall population and subgroups of infants according to the age and the duration of fever. Laboratory test cutoff values were calculated based on receiver operating characteristic (ROC) curve analysis. The SBIs were defined as a pathogenic bacteria in positive culture of blood, cerebrospinal fluid, urine, or stool samples, including bacteremia and bacterial meningitis classified as IBIs.
Among the 2047 infants included, 139 (6.8%) were diagnosed as having an SBI and 21 (1.0%) as having an IBI (11.0% and 1.7% of those with blood culture (n = 1258), respectively). The PCT assay offered an area under the curve (AUC) of ROC curve similar to that for CRP concentration for the detection of SBI (AUC, 0.81; 95% CI, 0.75-0.86; vs AUC, 0.80; 95% CI, 0.75-0.85; P = .70). The AUC ROC curve for the detection of IBI for the PCT assay was significantly higher than that for the CRP concentration (AUC, 0.91; 95% CI, 0.83-0.99; vs AUC, 0.77; 95% CI, 0.65-0.89; P = .002). Using a cutoff value of 0.3 ng/mL for PCT and 20 mg/L for CRP, negative likelihood ratios were 0.3 (95% CI, 0.2-0.5) for identifying SBI and 0.1 (95% CI, 0.03-0.4) and 0.3 (95% CI, 0.2-0.7) for identifying IBI, respectively. Similar results were obtained for the subgroup of infants younger than 1 month and for those with fever lasting less than 6 hours.
The PCT assay has better diagnostic accuracy than CRP measurement for detecting IBI; the 2 tests perform similarly for identifying SBI in febrile infants aged 7 to 91 days.
Aim
Our objectives were to measure the vaccine coverage rates for children with chronic diseases as well as the prevalence of potentially harmful delays for generally recommended vaccines. We also ...identified the factors influencing non‐adherence to vaccines specifically recommended for chronic conditions.
Methods
Three non‐interventional point‐prevalence surveys were performed in 2014 in all paediatric units at Lille University Hospital among children aged 2 months‐18 years with chronic diseases and vaccination data. Vaccine coverage and delays for generally recommended vaccines were studied. The children who were up‐to‐date and those under‐vaccinated for specifically indicated vaccines were compared and the factors potentially associated with under‐vaccination were studied with multivariable analysis.
Results
We screened 682 patients: of 207 with chronic diseases, mainly neurological, muscular and respiratory disorders, 146 had vaccination data. Only 47% (95% confidence interval 39‐55) were up‐to‐date for all generally recommended vaccinations; potentially harmful vaccination delays were high (26%‐75%). Only 11% of the 81% of patients for whom some vaccines were specifically recommended were up‐to‐date. Low maternal education level was significantly associated with under‐vaccination (adjusted odds ratio 10.5, 95% confidence interval 1.3‐86.9, P = .03).
Conclusion
This study showed inadequate vaccine coverage rates and significant delays among children with chronic diseases.
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