Fatal cases in pediatric patients after post-exposure prophylaxis for rabies:A report of two cases

Rationale:Rabies is a zoonotic disease with a high mortality,primarily transmitted through the bite of infected mammals,particularly dogs and cats.Despite being a well-known disease since ancient times,it continues to cause a significant number of human deaths worldwide,with approximately 65000 fatalities reported annually.Patient concerns:We present two fatal cases of rabies in a 12-year-old immigrant boy and a 7-year-old boy.The first case was subject to a 24-hour delay in receiving appropriate medical attention and rabies preventive measures due to the lack of awareness among emergency hospital staff,leading to the administration of wound dressing only.The second case received timely rabies immunoglobulin administration;however,there was a 4-day delay in administering the fourth dose of the rabies vaccine,despite presenting evident symptoms of rabies.Diagnosis:Postmortem examination of brain samples from both patients confirmed the presence of rabies virus.Interventions:Post-exposure prophylaxis for rabies.Outcomes:Both patients were admitted to the hospital after the manifestation of rabies-related symptoms,with the 12-year-old child seeking medical care 47 days after the animal bite and the 7-year-old child seeking medical care 58 days after the exposure.Finally,the first patient died after 27 days and the second patient died after 40 days of hospitalization.Lessons:There is an urgent need for heightened awareness and education among both healthcare professionals and the public regarding the urgency of seeking immediate medical attention after potential rabies exposure.Timely recognition and initiation of post-exposure prophylaxis are pivotal in preventing the progression of the disease.Strengthening surveillance and reporting systems,coupled with continuous training for healthcare professionals,can contribute to early detection and management of rabies cases.

Comparison of Propofol and Fentanyl for Preventing Emergence Agitation Following Sevoflurane Anesthesia in Pediatric Patients: A Single-Center Study in Bangladesh

Background: Emergence agitation (EA) is a common phenomenon observed in pediatric patients following general anesthesia. This study aimed to assess the efficacy of propofol and fentanyl in preventing EA and to compare their associated complications or side effects. Methods: This prospective randomized observational comparative study was conducted at Dhaka Medical College Hospital from July 2013 to June 2014. The study aimed to evaluate the effects of propofol and fentanyl on EA in children aged 18 to 72 months undergoing circumcision, herniotomy, and polypectomy operations. Ninety children were included in the study, with 45 in each group. Patients with psychological or neurological disorders were excluded. Various parameters including age, sex, weight, American Society of Anesthesiologists (ASA) class, duration of anesthesia, Saturation of Peripheral Oxygen (SPO2), heart rate (HR), respiratory rate (RR), Pediatric Anesthesia Emergence Delirium (PAED) score, duration of post-anesthesia care unit (PACU) stay, incidence of laryngospasm, nausea, vomiting, and rescue drug requirement were compared between the two groups. Results: Age, sex, weight, ASA class, and duration of anesthesia were comparable between the two groups. Perioperative SpO2 and HR were similar in both groups. However, the PAED score was significantly higher in the fentanyl group during all follow-ups except at 30 minutes postoperatively. The mean duration of PACU stay was significantly longer in the fentanyl group. Although the incidence of laryngospasm was higher in the fentanyl group, it was not statistically significant. Conversely, nausea or vomiting was significantly higher in the fentanyl group. The requirement for rescue drugs was significantly higher in the fentanyl group compared to the propofol group. Conclusion: Both propofol and fentanyl were effective in preventing emergence agitation in pediatric patients undergoing various surgical procedures under sevoflurane anesthesia. However, propofol demonstrated a better safety profile with fewer incidences of nausea, vomiting, and rescue drug requirements compared to fentanyl.

Is it a normal phenomenon for pediatric patients to have brain leptomeningeal contrast enhancement on 3-tesla magnetic resonance imaging?

Determining whether sevoflurane sedation in children leads to“pseudo”prominent leptomeningeal contrast enhancement(pLMCE)on 3 Tesla magnetic resonance imaging will help reduce overdiagnosis by radiologists and clarify the pathophysiological changes of pLMCE.

Time to recovery from severe pneumonia and its predictors among pediatric patients admitted in Mizan-Tepi University Teaching Hospital,South West Ethiopia,2022

Objective:Despite trials and programs for the prevention of childhood mortality due to pneumonia,Ethiopia is among the top five countries with the highest number of deaths due to pneumonia.Although the prevalence of pneumonia has increased in the abovementioned trials,little is known about the recovery time from severe pneumonia and its predictors in the study area.Therefore,this study aimed to assess the time to recovery from severe pneumonia and its predictors among pediatric patients admitted to Mizan-Tepi University Teaching Hospital,Ethiopia,in 2022.Methods:A total of 591 children admitted for severe pneumonia were selected using simple random sampling.Data were entered into Epi-data version 4.4.2.1 and expor ted to STATA version 14 for analysis,and the assumptions of Cox propor tional hazard models and goodness of fit were assessed through Shoenfeld residual and Cox-Snell residual,respectively.Bivariate and multivariable Cox regression models were used to identify the predictors of mor tality.Results:This study revealed that 91.54%(95%confidence interval[CI]:89.00–93.53)of participants recovered with an incidence rate of 24.10(95%CI:22.15–26.21)per 100 person-day–observations.The hmedian recovery time of children was 4 days(95%CI:2–6).Children who were not exclusively breastfed(AHR=1.3;95%CI:1.03–1.66),who had a history of inability to suck/feed(AHR=0.81;95%CI:0.65–0.99)were independent predictors of the time to recovery.Conclusions:Children with severe pneumonia who had not exclusively breastfed and who had a history of inability to suck/feed were independent predictors of time to recovery.Therefore,all stakeholders and concerned health care providers should focus more on early diagnosis and management and hasten early recovery based on the identified factors.

Unilateral blurred vision in pediatric patient associated with cavum velum interpositum cyst

Dear Editor,We present for the first time,a case of a paediatric patient with symptoms of intermittent blurred vision as first symptom of a cavum of the velum interpositum(CVI).Intracranial anterior midline cysts can be found in three variants:cavum septum pellucidum,cavum vergae and cavum velum interpositum.

Patient Safety Risks and Measures for Pediatric Neurosurgery Nursing

The aim of this study was to determine the patient safety risks and measures for pediatric neurosurgery nursing.A total of 564 pediatric patients admitted to the hospital from June 2020 to June 2023 under the neurosurgery department were included in this study.We analyzed the safety incidents in pediatric neurosurgery nursing and their causes and proposed corresponding measures for pediatric neurosurgery nursing in hope to reduce the occurrence of patient safety incidents in pediatric neurosurgery nursing and establish harmonious nurse-patient relationships.

Noninvasive methods for prediction of esophageal varices in pediatric patients with portal hypertension

AIM: To evaluate clinical and laboratory parameters for prediction of bleeding from esophageal varices (EV) in children with portal hypertension. METHODS: Retrospective study of 103 children (mean age: 10.1 ± 7.7 years), 95.1% with intrahepatic portal hypertension. All patients had no history of bleeding and underwent esophagogastroduodenoscopy for EV screening. We recorded variceal size (F1, F2 and F3), red-color signs and portal gastropathy, according to the Japanese Research Society for Portal Hypertension classification. Patients were classified into two groups: with and without EV. Seven noninvasive markers were evaluated as potential predictors of EV: (1) platelet count; (2) spleen size z score, expressed as a standard deviation score relative to normal values for age; (3)platelet count to spleen size z score ratio; (4) platelets count to spleen size (cm) ratio; (5) the clinical prediction rule (CPR); (6) the aspartate aminotransferase to platelet ratio index (APRI); and (7) the risk score. RESULTS: Seventy-one children had EV on first endoscopy. On univariate analysis, spleen size, platelets, CPR, risk score, APRI, and platelet count to spleen size z score ratio showed significant associations. The best noninvasive predictors of EV were platelet count [area under the receiver operating characteristic curve (AUROC) 0.82; 95%CI: 0.73-0.91], platelet: spleen size z score (AUROC 0.78; 95%CI: 0.67-0.88), CPR (AUROC 0.77; 95%CI: 0.64-0.89), and risk score (AUROC 0.77; 95%CI: 0.66-0.88). A logistic regression model was applied with EV as the dependent variable and corrected by albumin, bilirubin and spleen size z score. Children with a CPR < 114 were 20.7-fold more likely to have EV compared to children with CPR > 114. A risk score > -1.2 increased the likelihood of EV (odds ratio 7.47; 95%CI: 2.06-26.99). CONCLUSION: Children with portal hypertension with a CPR below 114 and a risk score greater than -1.2 are more likely to have present EV. Therefore, these two tests can be helpful in selecting children for endoscopy.

Phakic posterior chamber intraocular lens for unilateral high myopic amblyopia in Chinese pediatric patients

AIM： To assess the outcomes of posterior chamber implantable collamer lens （ICL） implantation in Chinese pediatric patients with unilateral high myopic amblyopia.METHODS： Eleven eyes of 11 amblyopic patients aged 11.02±3.34y underwent ICL （model V4, Staar Surgical Inc.） implantation to treat unilateral anisometropia were studied. Visual acuity, cycloplegic refraction, contrast sensitivity, stereopsis, intraocular pressure （IOP）, vaulting, corneal endothelial cell count and complications were evaluated. Patients completed follow-up at 3d, 1, 3mo and the last follow-up time （mean 8.18±2.82mo） after surgery.RESULTS： The mean myopic anisometropia was -13.70±3.25 D preoperatively and ＋0.69±2.63 D at 8mo postoperatively. The logMAR corrected distance visual acuity （CDVA） of the amblyopic eye was 1.51±0.72 preoperatively and 0.75±0.40 at 8mo postoperatively. The logMAR CDVA at 3d, 1, 3 and 8mo postoperatively improved by a mean of 0.64, 1.55, 1.82 and 2.64 lines and gained more than 2 lines accounted for 18%, 45%, 45%, 64%, respectively. The contrast sensitivity of 0.5, 1 and 2 cpd in amblyopic eyes was significantly increased after surgery. No patient had near stereopsis recovery. The vaulting at 3 and 8mo was significantly lower than that at 1mo postoperatively. No other intraoperative or postoperative complications were observed, except an acute pupillary block glaucoma happened in a patient at two weeks postoperatively.CONCLUSION： This short-term results indicate that ICL implantation can be a promising alternative therapy for high myopic anisometropic amblyopia in pediatric patients who have failed with conventional treatments and not suitable to corneal refraction surgery.

Clinical Characteristics, Imaging Findings and Surgical Outcomes of Chiari Malformation Type I in Pediatric and Adult Patients

A growing number of children and adolescents are being diagnosed as Chiari malformation type I （CM- I ） for behavioral disorders, developmental delay, seizures, or abnormal orpharyngeal function. The aim of this study was to compare the clinical characteristics, imaging findings and surgical outcomes of CM- I in pediatric and adult patients. Between January 2014 and June 2017, 84 patients with CM- I underwent surgical treatment in our department. We divided the patients into two groups： pediatric group （n=l 1, age 〈18 years） and adult group （n=73, age 〉18 years）. Data on clinical characteristics, imaging findings, surgical outcomes, and prognosis were retrospectively reviewed and compared between these two groups. For clinical presentation, scoliosis （36.4%） and developmental delay （36.4%） were more common in pediatric patients, whereas, sensory disturbance （58.9%） and motor weakness （41. 1%） were more common in adult patients. Imaging findings showed that the incidence of hydrocephalus and craniovertebral junctional abnormalities was significantly higher in pediatric group than in adult group （P〈0.05）. Compared to adult group, pediatric group showed a better improvement or resolution of syrinx and tonsillar herniation after surgical treatments （P〈0.05）. The total Chicago Chiari Outcome Scale （CCOS） score in pediatric patients at the last follow- up was significantly higher than that in adult patients （P=0.002）. In conclusion, the clinical characteristics and imaging findings appeared to be different in pediatric and adult patients with CM- I. The surgical outcomes of pediatric patients were shown to be significantly better than those of adult patients.

Comparison of Clinical Characteristics and Outcomes of Pediatric and Adult Patients with Coronavirus Disease 2019 in Shenzhen,China

Objective Here we aimed to investigate the difference in clinical characteristics and outcomes between pediatric and adult patients with COVID-19.Methods A total of 333 consecutive patients with laboratory-confirmed SARS-CoV-2 infection treated in the departments of Internal medicine of Shenzhen Third People’s Hospital from January 11 th to February 10 th,2020 were included.The data were obtained from electronic medical records.The epidemiological data,clinical characteristics,length of hospital stays,and outcomes of pediatric and adult patients were compared.Results Compared with adult patients,pediatric patients had a shorter time of symptom onset to hospitalization than adults[median time,1(IQR,1.0-1.0)d vs.3(IQR,2.0-6.0)d,P<0.001],milder or fewer symptoms,less severe chest CT findings.The clinical severity classification of children was less severe than adults.Up to 15 th March,the end of the follow-up,33(100%)children and 292(97.3%)adult patients had been discharged from hospital.Only 2(0.7%)adult patients died,with an overall case mortality of 0.6%.The median length of hospital stay of pediatric patients was shorter than that of adult patients[19(95%CI:16.6-21.4)d vs.21(95%CI:19.9-22.1)d,P=0.024].Conclusion Pediatric patients with COVID-19 had milder or less clinical symptoms,less evident pulmonary imaging changes,better prognosis,and shorter length of hospital stay.

Comment on review article:Chronic hepatitis C virus infection cascade of care in pediatric patients

An enhanced cascade of care should include a younger population,helping to achieve the goal of the World Health Organization with a focus on elimination in the pediatric population.Furthermore,enhanced screening and awareness efforts and continued education of health care providers will improve the outcomes of chronic hepatitis C virus(HCV)infection in the pediatric population.The present work discusses and comments on the topic"cascade of care in HCV chronic pediatric patients".

Jaundice in pediatric visceral leishmaniasis (kala-azar) patients

Objective:Visceral leishmaniasis(Kala-azar) is endemic in many countries including Bangladesh.Clinical presentation of visceral leishmaniasis in children and adult may vary and at time may simulate many tropical and hepatobiliary diseases.Jaundice and ascites are not common in kala-azar patients.Methods:During the period of January 2005 to December 2006,all the records of the confirmed kala-azar patients presented with jaundice were included in this study.Kala-azar was confirmed by serology test ICT(Immuno Chromatography) and Bone Marrow study.Results:Total 12 kala-azar patients were encountered during this period.Among these twelve cases,presenting features were jaundice(7),splenomegaly(12),hepatomegaly(11) and ascites (4).Initial clinical diagnosis of chronic liver disease(CLD) was made in(5),Congenital hemolytic anaemia in(1) and kala-azar in rest of the patients(6 ).Common leucopenia and relative lymphocytosis was not observed in any patients.Conclusion:Kala-azar may present with various clinical manifestation in children and adult.Jaundice can be considered to be a common manifestation particularly in pediatric kala-azar patients.Otherwise,it may mislead to another diagnosis if it is taken as a rare feature in kala-azar.

Microsatellite instability and expression of DNA mismatch repair genes in malignant astrocytic tumors from adult and pediatric patients

Microsatellite instability (MSI) is used as a molecular marker for defective DNA mismatch repair (MMR) genes.We report here alterations of MSI in 15 malignant astrocytomas (WHO grade Ⅲ) and glioblastomas (GBM; WHO grade Ⅳ) of pediatric patients (2-21 years) and 12 GBM from adults (44-68 years) by comparative analysis of BAT25/BAT26 loci and 10 other microsatellite markers. High-level microsatellite instability (MSI-H) occurred in 4 of the 15 pediatric cases (26.7%) and in 1 of the 12 adult GBM cases (8.3%). Low-level mi-

Early vasopressin initiation for pediatric patients with vasodilatory shock after cardiac surgery

Objective Vasopressin has showed a beneficial use in pediatric patients with vasodilatory shock after cardiac surgery. However, the optimal timing of vasopressin initiation has not been investigated.Our aim was to evaluate the effect of early vasopressin initiation for these patients.

Evaluation of Predictors of Suicidal Re-Attempt in Pediatric Patients in the Emergency Department

Background: Suicidal attempt in children is a serious public health problem. A proper identification of features of suicide-related behavior may help physicians to develop an accurate approach. The aim of this study was to clarify the characteristics of children with poisoning due to suicidal attempt and to determine the risk factors of suicidal re-attempt in the Emergency Department (ED) via a simple questionnaire. Methods: We collected medical data of patients under 18 years who were admitted to our ED with intoxication due to suicidal attempt, retrospectively. General characteristics of patients were evaluated. Patients were divided into 2 groups as 1) High risk: patients with repetitive suicide attempt;2) Low risk: patients with first time suicidal attempt. Results: A total of 57 patients were included in this study. The mean age was 15.91 ± 0.97. Majority of the patients were female (73.7%). Analgesics were the most frequent abused drugs with a ratio of 51.1%. It is determined that the most important variables affecting the risk of suicidal re-attempt are “idea about the suicide” and “purpose”. It was determined that patients with an idea of repetitive suicide (I will try again) and whose purpose was to die (I wish I have died) were in the most risky group with a history of previous suicidal attempt. Conclusion: This study suggests that answers of the pediatric patients to some question have a potential to predict the high risk patients. The risk of suicidal re-attempt may be predicted by the answers given to these questions: 1) What is your idea about suicide? 2) What was your purpose?

Theatment strategies for pediatric patients with primary cardiac tumors

Objective To analyze the experience of treatment strategies for pediatric patients with primary cardiac tumors. Methods The clinical data of 27 patients with primary cardiac tumors which detected by echocardiography from May 1999 to May 2009 was analyzed retrospectively. There were 20 male and 7 female patients,aged from 24 d to 12. 6 years. There were 59. 2% less than 1 year old at the time of diagnosis. A single tumor were present in 22 cases and multiple in 5 cases. Surgery was performed on 22 patients due to the varied

Long-term outcomes of pediatric liver transplantation in acute liver failure vs end-stage chronic liver disease:A retrospective observational study

BACKGROUND Children with acute liver failure(ALF)who meet the criteria are eligible for super-urgent transplantation,whereas children with end-stage chronic liver disease(ESCLD)are usually transplanted electively.Pediatric liver transplantation(PLT)in ALF and ESCLD settings has been well described in the literature,but there are no studies comparing the outcomes in these two groups.AIM To determine if there is a difference in post-operative complications and survival outcomes between ALF and ESCLD in PLT.METHODS This was a retrospective observational study of all primary PLTs performed at a single center between 2000 and 2019.ALF and ESCLD groups were compared for pretransplant recipient,donor and operative parameters,and post-operative outcomes including graft and patient survival.RESULTS Over a 20-year study period,232 primary PLTs were performed at our center;195 were transplanted for ESCLD and 37 were transplanted for ALF.The ALF recipients were significantly older(median 8 years vs 5.4 years;P=0.031)and heavier(31 kg vs 21 kg;P=0.011).Living donor grafts were used more in the ESCLD group(34 vs 0;P=0.006).There was no difference between the two groups concerning vascular complications and rejection,but there were more bile leaks in the ESCLD group.Post-transplant patient survival was significantly higher in the ESCLD group:1-,5-,and 10-year survival rates were 97.9%,93.9%,and 89.4%,respectively,compared to 78.3%,78.3%,and 78.3%in the ALF group(P=0.007).However,there was no difference in 1-,5-,and 10-year graft survival between the ESCLD and ALF groups(90.7%,82.9%,77.3%vs 75.6%,72.4%,and 66.9%;P=0.119).CONCLUSION Patient survival is inferior in ALF compared to ESCLD recipients;the main reason is death in the 1st year post-PLT in ALF group.Once the ALF children overcome the 1st year after transplant,their survival stabilizes,and they have good long-term outcomes.

Encephalitis with convulsive status in an immunocompetent pediatric patient caused by Bartonella henselae

Cat scratch's disease caused by Bartonella henselae, is known to be a self-limited benign process in immunocompetent children. The association with neurologic manifestations is very uncommon especially in patient with no immunologic defects and in cases without specific treatment. A 7 years old male patient, without any immunocromised defect, presented an atypic presentation of the cat scratch disease. The patient came to the hospital in two opportunities in a status epilepticus, in both cases the diagnosis was encephalitis by Bartonella henselae and the evolution with treatment was monitored with PCR(polymerase chain reaction) in cerebrospinal fluid and blood, as well as IFI(IgM, IgG) serology(indirect immunofluorescence). The patient had a favorable clinical and laboratory evolution for 6 months showing no recurrence of the disease.

Anesthesia management in a pediatric patient with Becker muscular dystrophy undergoing laparoscopic surgery:A case report

BACKGROUND Patients with Becker muscular dystrophy(BMD)have a high risk of developing hyperkalemia,rhabdomyolysis,and malignant hyperthermia when exposed to volatile anesthetics and depolarizing muscle relaxants.Patients with BMD are also prone to respiratory depression after general anesthesia.Thus,it is extremely challenging for anesthesiologists to manage anesthesia in BMD patients,particularly in pediatric BMD patients.Here,we present successful anesthesia management using transversus abdominis plane block(TAPB)combined with total intravenous anesthesia(TIVA)in a pediatric BMD patient undergoing laparoscopic inguinal hernia repair.CASE SUMMARY A 2-year-old boy,weighing 15 kg,with BMD,was scheduled for laparoscopic inguinal hernia repair.TIVA was used for induction,and continuous infusions of short-acting intravenous anesthetics combined with TAPB were performed for anesthesia maintenance.Moreover,TAPB provided good postoperative analgesia.The patient underwent uneventful surgery and anesthesia,and over the 17 mo follow-up period showed no anesthesia-induced complications.CONCLUSION TAPB combined with TIVA,using short-acting intravenous anesthetic agents,can provide safe and effective anesthesia management in pediatric BMD patients undergoing short-term abdominal surgery.

More common RNAemia in the early stage of severe SARS-CoV-2 BF.7.14 infections in pediatric patients

The risk factors of severe infections in children during the severe acute respiratory syndrome coronavirus 2(SARS‐CoV‐2)outbreak in Beijing remain elusive.SARS‐CoV‐2‐positive children admitted to the intensive care unit(ICU)with collected plasma specimens were enrolled and screened for common pathogens using capillary electrophoresis‐based multiplex PCR from December 12,2022,to January 24,2023.The SARS‐CoV‐2 subvariants were identified using next‐generation sequencing.Plasma was positive for two(positive;P),one(suspicious;S),or no(negative;N)SARS‐CoV‐2 genes were classified as plasmatic RNA‐positive(RNAemia;P+S)or without RNAemia(N).Clinical and laboratory data of the enrolled cases were then collected and analyzed.The 34 enrolled children included 26 males and 24 younger than three years.All were negative for other respiratory pathogens.BF.7.14(18/29)was the predominant subvariant.Viral loads in respiratory specimens,hours from symptom onset to the first respiratory specimen collection(time‐variable),with comorbidities and BF.7.14 and BA.5.2 distributions were significantly different in P vs.N and RNAemia vs.without RNAemia group.Among most cases,the T lymphocyte ratios decreased,while the cytokine level and the B lymphocyte ratio increased.The time variables were 2.22±2.05 and 4.00±2.49 days in BF.7.14 and BA.5.2 infections,respectively.In conclusion,SARS‐CoV‐2 was more likely to cause severe infections among males aged≤3 years old with comorbidities during the SARS‐CoV‐2 outbreak in Beijing,while RNAemia is more common in children at the early stage of severe BF.7.14 infections,and most had high cytokine levels and B‐cell activation.