Leng, Tomas

Objectives: Dermatological diseases constitute 4% to 12% of all emergency department (ED) visits and may contribute to high health care costs. However, little is known about pediatric visits. The aim of this study was to determine characteristics, photo app utilization, and diagnostic concordance at follow-up of pediatric visits to the ED with dermatological complaints. Methods: This was a retrospective study conducted in the ED at an academic medical center. Patients younger than or equal to 18 years of age who presented with a dermatologic concern between May 2022 and April 2023 were included. The association between clinical characteristics and the use of a photo application in the ED was evaluated using logistic regression. Results: In 380 patients who met inclusion criteria, the most common final diagnoses were rash (30%, N=115), burn (10%, N=39), and cellulitis (9%, N=35). Fourteen patients (4%) had an emergent triage category (ESI 2). Photo app was used in 38% (N=143) encounters. Factors associated with the photo app use in multivariate analysis included ESI category 2 (odds ratio [OR]: 4.08, 95% CI: 1.17-14.18, P =0.027), ESI category 3 (OR: 1.74, 95% CI: 1.07-2.82, P =0.025), and duration of illness >1 week (OR: 3.50, 95% CI: 1.54-7.96, P =0.003). The diagnosis at follow-up was identical in 68% (N=78) of cases; clarified for 22% (N=25) and altered in 11 patients (10%). Conclusions: Most pediatric visits presenting to the ED with dermatological complaints are non-urgent and ER physicians can accurately diagnose the majority of these cases. Triage category ESI 2, ESI 3, and illness duration >1 week were associated with the photo app use.

OBJECTIVES: Many PICU admissions start with presentation in the emergency department (ED). However, we do not know whether there are any ED-related factors associated with the subsequent development of pediatric delirium (PD) within 24 hours of PICU admission. DESIGN: Retrospective cohort study. SETTING: Single-center ED and PICU serving a quaternary referral center in the United States. PATIENTS: Children younger than 18 years old presenting to the ED between January 2022 and December 2023 who required direct admission to the PICU, and who had at least one positive delirium screening within 24 hours of the admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The presence of delirium in the PICU was defined as a Cornell Assessment of Pediatric Delirium (CAPD) score of 9 and higher. We identified 138 patients for the final analysis. Overall, 51 of 138 patients (37%) developed PD within 24 hours of admission. The majority of delirium cases were classified as hypoactive (53%, 27/51) and mixed (31%, 16/51) subtypes, while only 16% (8/51) were identified as hyperactive delirium. Factors associated with greater odds (95% CI) of delirium in the PICU in multivariable analysis were use of mechanical ventilation (odds ratio [OR], 3.42 [95% CI, 1.09–10.78]; p = 0.04) and intermittent urinary catheterization (OR, 3.7 [95% CI, 1.21–11.30]; p = 0.02). Initial CAPD score positively correlated with PICU length of stay (LOS; r = 0.32; p < 0.01), Pediatric Index of Mortality 3 (PIM 3) score ( r = 0.26; p < 0.01), and negatively correlated with emergency severity index (ESI) in the ED ( r = –0.35; p < 0.01). CONCLUSIONS: Mechanical ventilation and intermittent urinary catheterization in the ED are associated with greater odds of PD within 24 hours of PICU admission. CAPD at admission positively correlates with PICU LOS, PIM 3 scores, and negatively correlates with ESI in the ED.

Abstract Introduction Brain abscess is a serious condition in children, leading to rapid deterioration, and permanent neurological damage associated with significant morbidity and mortality. Current management protocols for brain abscesses focus on intravenous antibiotics and surgical excision and drainage. Case Presentation A 12-year-old adolescent male who had headache and photophobia and was diagnosed with multiple brain abscesses and was refractory to conventional medical and neurosurgical intervention. A single dose of 10 mg vancomycin was administered through endo-ventricular drain, resulting in resolution of abscesses and alleviation of symptoms. Conclusion We describe the first instance of intraventricular vancomycin use in the pediatric age group for the treatment of multiple brain abscesses. Given the variability in dosing reported in the literature, our case report warrants further studies to standardize dosage for this rare intervention.

Ebstein anomaly is a myopathy of the right ventricle characterized by failure of tricuspid valve delamination with accompanying tricuspid regurgitation. Its rarity, considerable anatomic variability, and frequent absence of symptoms can make the timing of surgery challenging. Contemporary tricuspid repair techniques can be performed with low mortality and bidirectional cavopulmonary anastomosis reduces the risk of operation when right ventricular function is poor. Here, we present a patient who presented late for surgery, failed high-risk conventional surgery and required heart transplantation.

AbstractBackgroundRoutine defibrillation threshold testing (DFT) of transvenous implantable defibrillators (ICDs) has largely been in decline. In patients with non‐transvenous ICDs that utilize subcutaneous and pleural ICD leads, serial DFT testing can detect a significant number of failures. Data about the utility of follow‐up defibrillation safety margin testing (DSM) testing in pediatric patients and young adults with an epicardial ICD are lacking.MethodsPatients aged < 25 years old who underwent epicardial ICD placement at Mayo Clinic from 2014 to 2023 with at least one follow‐up DSM test were included. The patients were divided into a “routine” (R) and “clinically indicated” (CI) group based on the index of clinical concern. Inadequate DSM was defined as unsuccessful defibrillation at an output of less than 10 J below the maximum output of the device. The purpose of this study was to assess the utility of follow‐up DSM testing.ResultsAn epicardial ICD system was placed in 122 patients. A total of 26 patients met inclusion criteria and underwent a total of 47 DSM follow up tests. Inadequate DSM occurred in 1/33 (3%) in the R group and 2/14 (14%) DSM tests in the CI group. The median follow‐up period was 54 and 36 months for the R and CI group, respectively.ConclusionsOur data suggest that epicardial ICDs are reliable and routine follow‐up DSM testing may not be necessary for all patients. DSM testing should be performed in individuals with epicardial ICD systems when there is clinical concern about lead or coil performance.

AbstractMetabolic pathways are known to generate byproducts—some of which have no clear metabolic function and some of which are toxic. Nicotinamide adenine dinucleotide phosphate hydrate (NAD(P)HX) is a toxic metabolite that is produced by stressors such as a fever, infection, or physical stress. Nicotinamide adenine dinucleotide phosphate hydrate dehydratase (NAXD) and nicotinamide adenine dinucleotide phosphate hydrate epimerase (NAXE) are part of the nicotinamide repair system that function to break down this toxic metabolite. Deficiency of NAXD and NAXE interrupts the critical intracellular repair of NAD(P)HX and allows for its accumulation. Clinically, deficiency of NAXE manifests as progressive, early onset encephalopathy with brain edema and/or leukoencephalopathy (PEBEL) 1, while deficiency of NAXD manifests as PEBEL2. In this report, we describe a case of probable PEBEL2 in a patient with a variant of unknown significance (c.362C>T, p.121L) in the NAXD gene who presented after routine immunizations with significant skin findings and in the absence of fevers.

Abstract Background Pulmonary embolism (PE) in the pediatric population is uncommon, and due to a silent presentation often unrecognized entity that remains one of the most challenging medical conditions in the emergency department (ED). Risk factors for PE in children include nephrotic syndrome, immobility, obesity, congenital heart disease, and malignancy. In patients with PE, thromboembolism has been reported to occur at unusual venous sites including the veins within the central nervous system and abdomen. Although penile pain is a rare presenting symptom in the ED, in patients with hypercoagulability, it can herald a life threating event such as PE prompting further evaluation. Case presentation A 15-year-old male with a history of B-cell acute lymphoblastic leukemia who presented to the ED with an 18-hour history of penile pain. In the ED, the patient was in acute distress and rated his pain as 9/10. Initial vital signs were within normal limits, except mild tachypnea. On physical examination, his penile shaft was erythematous, indurated, and tender to palpation. He received fentanyl and morphine for pain. A complete blood cell count revealed pancytopenia with a platelet count of 73 x 109/L (139–320 x 109/L). A work-up for sexually transmitted diseases, urolithiasis, urinary tract infection, deep venous thrombosis (DVT), and priapism was negative. Approximately two hours after morphine administration, his saturations started dropping to mid-70’s. A computed tomography pulmonary angiogram (CTPA) revealed bilateral segmental acute pulmonary embolism involving multiple segmental right and left lower lobe pulmonary arteries. Penile pain and hypoxia have resolved with heparin. Conclusions PE is easily missed diagnosis among children who present to the ED and can be potentially fatal. A high index of suspicion is required in asymptomatic and oligo-symptomatic children with prothrombotic risk factors who develop thromboembolism-related symptoms at unusual sites as well as hypoxia in the ED setting.