Newborn screening for Duchenne muscular dystrophy: A two-year pilot study

OBJECTIVE

Duchenne muscular dystrophy (DMD) is an X-linked disorder resulting in progressive muscle weakness and atrophy, cardiomyopathy, and in late stages, cardiorespiratory impairment, and death. As treatments for DMD have expanded, a DMD newborn screening (NBS) pilot study was conducted in New York State to evaluate the feasibility and benefit of NBS for DMD and to provide an early pre-symptomatic diagnosis.

METHODS

At participating hospitals, newborns were recruited to the pilot study, and consent was obtained to screen the newborn for DMD. The first-tier screen measured creatine kinase-MM (CK-MM) in dried blood spot specimens submitted for routine NBS. Newborns with elevated CK-MM were referred for genetic counseling and genetic testing. The latter included deletion/duplication analysis and next-generation sequencing (NGS) of the DMD gene followed by NGS for a panel of neuromuscular conditions if no pathogenic variants were detected in the DMD gene.

RESULTS

In the two-year pilot study, 36,781 newborns were screened with CK-MM. Forty-two newborns (25 male and 17 female) were screen positive and referred for genetic testing. Deletions or duplications in the DMD gene were detected in four male infants consistent with DMD or Becker muscular dystrophy. One female DMD carrier was identified.

INTERPRETATION

This study demonstrated that the state NBS program infrastructure and screening technologies we used are feasible to perform NBS for DMD. With an increasing number of treatment options, the clinical utility of early identification for affected newborns and their families lends support for NBS for this severe disease.

Six Month Follow-up of Patients With Multi-System Inflammatory Syndrome in Children

BACKGROUND AND OBJECTIVES

Myocardial dysfunction and coronary abnormalities are prominent features of multisystem inflammatory syndrome in children (MIS-C). In this study we aim to evaluate the early and midterm outcomes of MIS-C.

METHODS

This is a longitudinal 6-month cohort study of all children admitted and treated for MIS-C from April 17 to June 20, 2020. Patients were followed ∼2 weeks, 8 weeks, and 6 months postadmission, with those with coronary aneurysms evaluated more frequently.

RESULTS

Acutely, 31 (62%) patients required intensive care with vasoactive support, 26 (52%) had left ventricular (LV) systolic dysfunction, 16 (32%) had LV diastolic dysfunction, 8 (16%) had coronary aneurysms (z score ≥2.5), and 4 (8%) had coronary dilation (z score <2.5). A total of 48 patients (96%) received immunomodulatory treatment. At 2 weeks, there was persistent mild LV systolic dysfunction in 1 patient, coronary aneurysms in 2, and dilated coronary artery in 1. By 8 weeks through 6 months, all patients returned to functional baseline with normal LV systolic function and resolution of coronary abnormalities. Cardiac MRI performed during recovery in select patients revealed no myocardial edema or fibrosis. Some patients demonstrated persistent diastolic dysfunction at 2 weeks (5, 11%), 8 weeks (4, 9%), and 6 months (1, 4%).

CONCLUSIONS

Children with MIS-C treated with immunomodulators have favorable early outcomes with no mortality, normalization of LV systolic function, recovery of coronary abnormalities, and no inflammation or scarring on cardiac MRI. Persistence of diastolic dysfunction is of uncertain significance and indicates need for larger studies to improve understanding of MIS-C. These findings may help guide clinical management, outpatient monitoring, and considerations for sports clearance.

Characteristics and risk factors associated with critical illness in pediatric COVID-19

BACKGROUND

While much has been reported regarding the clinical course of COVID-19 in children, little is known regarding factors associated with organ dysfunction in pediatric COVID-19. We describe critical illness in pediatric patients with active COVID-19 and identify factors associated with PICU admission and organ dysfunction. This is a retrospective chart review of 77 pediatric patients age 1 day to 21 years admitted to two New York City pediatric hospitals within the Northwell Health system between February 1 and April 24, 2020 with PCR + SARS-CoV-2. Descriptive statistics were used to describe the hospital course and laboratory results and bivariate comparisons were performed on variables to determine differences.

RESULTS

Forty-seven patients (61%) were admitted to the general pediatric floor and thirty (39%) to the PICU. The majority (97%, n = 75) survived to discharge, 1.3% (n = 1) remain admitted, and 1.3% (n = 1) died. Common indications for PICU admission included hypoxia (50%), hemodynamic instability (20%), diabetic ketoacidosis (6.7%), mediastinal mass (6.7%), apnea (6.7%), acute chest syndrome in sickle cell disease (6.7%), and cardiac dysfunction (6.7%). Of PICU patients, 46.7% experienced any significant organ dysfunction (pSOFA >  = 2) during admission. Patients aged 12 years or greater were more likely to be admitted to a PICU compared to younger patients (p = 0.015). Presence of an underlying comorbidity was not associated with need for PICU admission (p = 0.227) or organ dysfunction (p = 0.87). Initial white blood cell count (WBC), platelet count, and ferritin were not associated with need for PICU admission. Initial C-reactive protein was associated with both need for PICU admission (p = 0.005) and presence of organ dysfunction (p = 0.001). Initial WBC and presenting thrombocytopenia were associated with organ dysfunction (p = 0.034 and p = 0.003, respectively).

CONCLUSIONS

Age over 12 years and initial CRP were associated with need for PICU admission in COVID-19. Organ dysfunction was associated with elevated admission CRP, elevated WBC, and thrombocytopenia. These factors may be useful in determining risk for critical illness and organ dysfunction in pediatric COVID-19.

Early Experience of COVID-19 in a US Children's Hospital

OBJECTIVES

We aim to describe the demographics, clinical presentation, hospital course, and severity of pediatric inpatients with coronavirus disease 2019 (COVID-19), with an emphasis on healthy, immunocompromised, and chronically ill children.

METHODS

We conducted a single-center retrospective cohort study of hospitalized children aged younger than 22 years with COVID-19 infection at Steven and Alexandra Cohen Children's Medical Center at Northwell Health. Cases were identified from patients with fever and/or respiratory symptoms who underwent a nucleic acid amplification-based test for severe acute respiratory syndrome coronavirus 2.

RESULTS

Sixty-five patients were identified. The median age was 10.3 years (interquartile range, 1.4 months to 16.3 years), with 48% of patients older than 12 years and 29% of patients younger than 60 days of age. Fever was present in 86% of patients, lower respiratory symptoms or signs in 60%, and gastrointestinal symptoms in 62%. Thirty-five percent of patients required ICU care. The white blood cell count was elevated in severe disease (P = .0027), as was the C-reactive protein level (P = .0192), compared with mild and moderate disease. Respiratory support was required in 34% of patients. Severity was lowest in infants younger than 60 days of age and highest in chronically ill children; 79% of immunocompromised children had mild disease. One death was reported.

CONCLUSIONS

Among children who are hospitalized for COVID-19, most are younger than 60 days or older than 12 years of age. Children may have severe infection requiring intensive care support. The clinical course of immunocompromised patients was not more severe than that of other children. Elevated white blood cell count and C-reactive protein level are associated with greater illness severity.

Characteristics, Cardiac Involvement, and Outcomes of Multisystem Inflammatory Syndrome of Childhood Associated with severe acute respiratory syndrome coronavirus 2 Infection

We report on the presentation and course of 33 children with multisystem inflammatory syndrome in children and confirmed severe acute respiratory syndrome coronavirus 2 infection. Hemodynamic instability and cardiac dysfunction were prominent findings, with most patients exhibiting rapid resolution following anti-inflammatory therapy.

Incidence of arrhythmias and electrocardiographic abnormalities in symptomatic pediatric patients with PCR-positive SARS-CoV-2 infection, including drug-induced changes in the corrected QT interval

Background

There is limited data regarding the electrophysiological abnormalities and arrhythmias in children with COVID-19, including those associated with treatment using potentially proarrhythmic hydroxychloroquine (HCQ) and azithromycin (AZN).

Objectives

To describe the electrophysiologic findings and arrhythmias associated with pediatric COVID-19 and its treatment.

Methods

A single-center retrospective chart review was undertaken and included all patients with (1) symptoms of COVID-19 and (2) PCR-positive nasopharyngeal swabs for SARS-CoV-2 who were placed on continuous telemetry for the duration of their hospitalization during March through May, 2020.

Results

Thirty-six patients were included in the study. Significant arrhythmias were found in 6 (nonsustained ventricular tachycardia in 5 and sustained atrial tachycardia in 1). All were self-resolving and half prompted prophylactic antiarrhythmic therapy. Patients with significant arrhythmias were likely to have noncardiac comorbidities (4/6), but these were not more common than in patients without arrhythmias (20/30, P = 1). The use of HCQ was associated with statistically significant QTc prolongation (413 ± 19 ms vs 425 ± 16 ms, P =.005). QTc was not statistically different in patients with and without arrhythmias (425 ± 15 ms vs 425 ± 15 ms, P = 1).

Conclusions

In pediatric patients with PCR-positive active COVID-19 infection, significant arrhythmias are infrequent, but are more common than expected in a general pediatric population. Comorbidities are not more common in patients with arrhythmias than in patients without arrhythmias. COVID-19 treatment using HCQ is associated with QTc prolongation but was not associated with arrhythmias in pediatric patients.

Novel Approach to Emergency Departments' Pediatric Readiness Across a Health System

STUDY OBJECTIVE

A gap analysis of emergency departments' (EDs') pediatric readiness across a health system was performed after the appointment of a service line health system pediatric emergency medicine (PEM) quality director.

METHODS

A 55-question survey was completed by each eligible ED to generate a weighted pediatric readiness score (WPRS). The survey included questions regarding volume, ED configuration, presence of a pediatric emergency care coordinator (PECC), quality initiatives, policies and procedures, and equipment. Surveys were completed from June 1 to November 12, 2016.Analysis of variance was used to compare the 4 groups of EDs based upon their annual pediatric volume as a continuous measure (low, <1800 visits; medium, 1800-4999 visits; medium-high, 5000-9999 visits; high, >10,000 visits). The Fisher exact test was used to compare the 4 groups for the remaining categorical variables represented as frequencies and percentages. A result was considered statistically significant at the P < 0.05 level of significance.

RESULTS

There were a total of 16 hospitals (after the exclusion of the children's hospital, the hub for pediatric care in the health system, and 1 adult-only hospital) with the following pediatric capability: 7 basic (no inpatient pediatrics), 7 general (inpatient pediatrics, with/without a neonatal intensive care unit), and 2 comprehensive (inpatient pediatrics, pediatric intensive care unit, and a neonatal intensive care unit). In 12 EDs, adults and children are treated in the same space. These EDs see a total of 800,000 annual visits including 120,000 pediatric visits. Two low pediatric volume EDs had a median WPRS of 69, range of 62 to 76 (national median, 61.4); 6 medium pediatric volume EDs had a median WPRS of 51, range of 42 to 81 (national median, 69.3); 4 medium-high pediatric volume EDs had a median WPRS of 69.3, range of 45 to 98 (national medium, 74.8); 4 high pediatric volume EDs had a WPRS score of 84.5, range of 58 to 100 (national medium, 89.8). There were 4 sites with PECCs: 1 medium-high volume and 3 high volume, with a median WPRS of 98.5, range of 81 to 100 (national medium, 89.8). Two low-volume EDs have Neonatal Resuscitation Program training for nurses (P < 0.0083). One medium-high volume ED requires specific pediatric competency evaluations for advanced level practitioners staffing the ED. Pediatric-specific quality programs are present in the 2 low volume EDs, 3 of the 6 EDs in the medium group, 3 of 4 EDs in the medium-high group, and all 4 high volume hospitals. After the implementation of the health system PEM quality director, all EDs have a doctor and nurse PECC with a median WPRS of 81. In additiona, a committee was formed with the following key stakeholders: PECCs, pediatric nursing educators, pediatric quality, pharmacy, obstetrics, behavioral health, and neonatology. The committee is part of the health system quality program within both pediatrics and emergency medicine and is spearheading the standardization of code carts and medications, dissemination of pediatric clinical guidelines, and the development of a pediatric quality program across the health system.

CONCLUSIONS

Pediatric emergency care coordinators play an important role in ED readiness to care for pediatric patients. In a large health system, a service line PEM quality director with the support of emergency medicine and pediatrics, a committee with solid frontline ED base, and a diverse array of stakeholders can foster the engagement of all EDs and improve compliance with published guidelines.

Characterization of the Development of Acute-on-Chronic Exertional Compartment Syndrome A Case Report of Symmetric Compartment Syndromes and Review of the Literature

Acute-on-chronic exertional compartment syndrome is a rare and severe progression of the likely common and more benign chronic exertional compartment syndrome. This is a report of one 17-year-old male on a pediatric inpatient service with bilateral anterior leg pain of unknown origin. Because of the nonspecific nature of pain, a high level of suspicion is required for timely diagnosis to avoid compartment ischemia and irreversible soft tissue and nerve damage. While high-energy orthopaedic trauma, orthopaedic surgery, or closed reduction and casting are common preceding events for compartment syndrome, this patient presented with acute-on-chronic exertional compartment syndrome. A dearth of literature of this condition hampered its morbiditysparing diagnosis. While there is a spectrum of clinical findings for the acute decompensation of chronic exertional compartment syndrome, like any compartment syndrome, pain disproportionate to physical exam is the most sensitive sign. Understanding the exertional compartment syndrome spectrum is tantamount to avoid the devastating complications of a missed diagnosis of acute compartment syndrome.

International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines

The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) formulated new evidenced-based recommendations for neonatal resuscitation. These guidelines comprehensively update the last recommendations, published in 1992 after the Fifth National Conference on CPR and ECC. As a result of the evidence evaluation process, significant changes occurred in the recommended management routines for: * Meconium-stained amniotic fluid: If the newly born infant has absent or depressed respirations, heart rate <100 beats per minute (bpm), or poor muscle tone, direct tracheal suctioning should be performed to remove meconium from the airway. * Preventing heat loss: Hyperthermia should be avoided. * Oxygenation and ventilation: 100% oxygen is recommended for assisted ventilation; however, if supplemental oxygen is unavailable, positive-pressure ventilation should be initiated with room air. The laryngeal mask airway may serve as an effective alternative for establishing an airway if bag-mask ventilation is ineffective or attempts at intubation have failed. Exhaled CO(2) detection can be useful in the secondary confirmation of endotracheal intubation. * Chest compressions: Compressions should be administered if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. The 2-thumb, encircling-hands method of chest compression is preferred, with a depth of compression one third the anterior-posterior diameter of the chest and sufficient to generate a palpable pulse. * Medications, volume expansion, and vascular access: Epinephrine in a dose of 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) should be administered if the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions. Emergency volume expansion may be accomplished with an isotonic crystalloid solution or O-negative red blood cells; albumin-containing solutions are no longer the fluid of choice for initial volume expansion. Intraosseous access can serve as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available. * Noninitiation and discontinuation of resuscitation: There are circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate.

Granulocyte transfusions--a review for the intensive care physician

In order to achieve the maximum therapeutic benefit in the treatment of malignancies, doses of chemotherapeutic agents are pushed to the point of severe marrow toxicity. This aggressive therapy can lead to iatrogenic complications including haemorrhage and sepsis due to the depletion of platelets and granulocytes. Prior to the advent of platelet transfusions, haemorrhage was the leading cause of death in these patients. Advances in blood banking and the availability of platelet transfusions have markedly decreased the incidence of fatal haemorrhage. As a result, infection has become the leading cause of death in patients with marrow failure. Although the risk of infection in patients with neutropenia has been well documented, the role of granulocyte transfusions in the treatment and prevention of these infections remains controversial. This paper will attempt to review the currently available literature regarding granulocyte procurement techniques and the efficacy of granulocyte transfusions.