Nemours Children's Health System

Brain herniation into the dural venous sinus (BHDVS) is a rare and underrecognized imaging finding. Although often incidental, it may be associated with idiopathic intracranial hypertension (IIH), particularly in adults. Pediatric cases remain uncommon. This study presents three pediatric BHDVS cases and reviews current literature to highlight clinical relevance, imaging features, and management. Pediatric cases of BHDVS were evaluated using magnetic resonance imaging. A comprehensive literature review was conducted to summarize current knowledge on prevalence, imaging characteristics, clinical presentation, and management strategies. Case 1: A 6-year-old female with daily headaches had right occipital lobe herniation into the right transverse sinus with partial sinus filling defect, but no signs of raised intracranial pressure. Managed conservatively, follow-up imaging showed stability. Case 2: A 3-year-old male evaluated for developmental delay was incidentally found to have cerebellar herniation into the left transverse sinus. He was asymptomatic and no treatment was required. Case 3: A 3-year-old female with epilepsy had an incidental left temporal lobe herniation into the transverse sinus. The lesion was unrelated to seizures and remained stable without intervention. Very few similar cases were found in a literature review; a brief review of existing literature is presented and comparisons made between BHDVS and similar conditions. BHDVS may mimic more serious pathology. Accurate recognition of imaging, particularly in pediatric patients, is essential to prevent misdiagnosis and overtreatment. While typically managed conservatively, its association with IIH warrants further investigation. Increased awareness and continued study may refine understanding of its clinical implications.

Introduction: Increasingly children are dying in the Pediatric Intensive Care Unit (PICU) as a result of withdrawal of life sustaining technology (WOLST). High quality end of life (EOL) care after WOLST may benefit from standardization. In addition, staff may feel better equipped to care for a child after WOLST if the team participates in a deliberate multidisciplinary huddle prior to WOLST. A needs assessment on EOL practices revealed lack of clear communication and documentation on the EOL care plan as the biggest barrier to quality EOL care. In an effort to optimize EOL care for children after WOLST, we developed a clinical pathway that relies on two WOLST huddles to prepare our teams for EOL care. Methods: A multidisciplinary group from the PICU and the palliative care team met regularly to develop and review EOL interventions and outcomes. As a quality improvement project, we aimed to perform at least one multidisciplinary huddle in > 80% of deaths after WOLST in the PICU during 2024, as evidenced by documentation in the medical record, A secondary aim was to improve staff satisfaction and preparedness when caring for a child receiving WOLST. Results: Baseline data was analyzed. In 2023, there were a total of 28 deaths in the PICU; 14/28 were as a result of WOLST. Of the 14 deaths after WOLST, there was no documentation of any communication regarding the EOL care plan. Our team underwent three PDSA cycles, with interventions including dissemination and education on the WOLST huddle and clinical pathway, identifying the charge nurse to initiate a huddle, and the development of a dot phrase.. Post intervention, data was re-analyzed. In 2024 there were 21 total PICU deaths; 12/21 of those deaths were a result of WOLST. 10/12 (83%) of deaths as a result of WOLST had at least one documented WOLST huddle. After the second PDSA cycle in February 2024, 10/10 (100%) of all deaths as a result of WOLST had at least one WOLST huddle documented in EPIC. Conclusions: When a WOLST huddle was performed in our PICU, staff reported feeling more prepared, improved communication amongst the team, and improved quality of EOL care. Quantitative data from surveys of PICU staff to assess perceived effect of EOL interventions including the WOLST huddle are pending. Next steps include implementing WOLST huddles hospital wide.

On completion of the INHALE-1 randomized controlled trial (RCT), an extension phase was completed to provide longer term safety data on use of technosphere insulin (TI) in children with diabetes. In the RCT, 4- to 17-yr-olds with type 1 (98%) or type 2 (2%) diabetes treated with multiple daily injections of insulin were randomly assigned to TI or rapid-acting analog (RAA) plus continuation of long-acting basal insulin and continuous glucose monitoring (CGM). After 26 weeks, participants were provided the option to continue in an extension phase through 52 weeks in which TI was used by both treatment groups. In the TI group (N = 80), mean HbA1c was 8.1 ± 0.8% at the start of the RCT, 8.2 ± 1.2% at 26 weeks, and 8.6 ± 1.2% at 52 weeks (mean change from 26 to 52 weeks = 0.38%, 95% confidence interval [95% CI] 0.08%-0.67%, P = 0.003). In the RAA Crossover group (N = 88), mean HbA1c was 8.1 ± 1.1% at TI initiation (RCT week 26) and 8.4 ± 1.4% at 52 weeks (mean change = 0.31%, 95% CI -0.02%-0.64%, P = 0.08). There were no serious or unexpected pulmonary-related adverse events. The change in mean percent predicted forced expiratory volume in 1 s from the start of TI to 4 weeks after discontinuation was -0.5 (95% CI -1.9-0.9, P = 0.52) when combining the entire periods of TI exposure for both groups. CGM-measured time < 54 mg/dL was very low during TI use (TI group: 0.39 ± 0.61%; RAA Crossover group: 0.45 ± 0.59%). The INHALE-1 extension phase showed no safety concerns. Although HbA1c levels deteriorated slightly during the study, in view of the safety profile and increased patient satisfaction in the RCT portion of the trial, TI may be a useful treatment option for some pediatric patients with diabetes, particularly for those who choose not to or are unable to use an AID system.

Millions of children worldwide are experiencing prolonged symptoms after SARS-CoV-2 infection, yet social risk factors for developing long COVID are largely unknown. As child health is influenced by the environment in which they live and interact, adverse social determinants of health (SDOH) may contribute to the development of pediatric long COVID. To identify whether adverse SDOH are associated with increased odds of long COVID in school-aged children and adolescents in the US. This cross-sectional analysis of a multicenter, longitudinal, meta-cohort study encompassed 52 sites (health care and community settings) across the US. School-aged children (6-11 years; n = 903) and adolescents (12-17 years; n = 3681) with SARS-CoV-2 infection history were included. Those with an unknown date of first infection, history of multisystem inflammatory syndrome in children, or symptom surveys with less than 50% of questions completed were excluded. Participants were recruited via health care systems, long COVID clinics, fliers, websites, social media campaigns, radio, health fairs, community-based organizations, community health workers, and existing research cohorts from March 2022 to August 2024, and surveys were completed by caregivers between March 2022 and August 2024. Twenty-four individual social determinant of health factors were grouped into 5 Healthy People 2030 domains: economic stability, social and community context, caregiver education access and quality, neighborhood and built environment, and health care access and quality. Latent classes were created within each domain and used in regression models. Presence of long COVID using caregiver-reported, symptom-based, age-specific research indices. The mean (SD) age among 4584 individuals included in this study was 14 (3) years, and 2330 (51%) of participants were male. The number of latent classes varied by domain; the reference group was the class with the least adversity. In unadjusted analyses, most classes in each domain were associated with higher odds of long COVID. After adjusting for many factors, including age group, sex, timing of infection, referral source, and other social determinant of health domains, economic instability characterized by difficulty covering expenses, poverty, receipt of government assistance, and food insecurity were associated with an increased risk of having long COVID (class 2 adjusted odds ratio [aOR], 1.57; 95% CI, 1.18-2.09; class 4 aOR, 2.39; 95% CI, 1.73-3.30); economic instability without food insecurity (class 3) was not (aOR, 0.93; 95% CI, 0.70-1.23). Poorer social and community context (eg, high levels of discrimination and low social support) was also associated with long COVID (aOR, 2.17; 95% CI, 1.77-2.66). Sensitivity analyses stratified by age group and adjusted for race and ethnicity did not alter or attenuate these results. In this study, economic instability that included food insecurity and poor social and community context were associated with greater odds of pediatric long COVID. Those with food security, despite experiencing other economic challenges, did not have greater odds of long COVID. Further study is needed to determine if addressing SDOH factors can decrease the rate of pediatric long COVID.

Song V lateral humeral condyle fractures represent a displaced and rotated fragment, historically treated with open reduction and percutaneous pinning (ORPP) or screw fixation (ORSF). We aim to describe outcomes of Song V fractures and analyze the effect of fixation and reduction type on outcomes. This retrospective review assessed data from 6 level 1 trauma centers from 2005 to 2019. Inclusion criteria were children aged 1 to 12 with a Song V fracture. Patient clinic and surgical notes until 1 year after the primary intervention were reviewed. Radiographic healing data were collected. Complication metrics included nonunion, delayed union, elbow stiffness, and superficial or deep infection. A total of 281 Song V lateral humeral condyle fractures were analyzed from the 6 centers. The mean age was 8.8 years, and 65.1% were male. K-wires were used in 223 patients (79%) and screws in 58 patients (21%). In all, 6 patients (2.1%) experienced a superficial infection, and 6 patients (2.1%) experienced a deep infection. Five patients experienced nonunion (1.8%). For patients undergoing an ORSF, 78% were radiographically healed at 3 months compared to 81% of patients undergoing an ORPP. No statistically significant differences between ORSF and ORPP were observed for outcome measures such as nonunion, stiffness, and infection, but notably, all 12 infections occurred in the K-wire group. Open reduction was utilized in 268 (95.4%) patients, compared with closed reduction in 13 (4.6%) patients. No significant relationships were seen between reduction type and complications, although results suggested increased rates of infection and elbow stiffness for those with open reduction. The current study is the largest analysis of Song V fractures. We found nonunion and deep infection to occur in roughly 2% of patients. Outcomes were comparable between ORSF and ORPP, with similar rates of radiographic healing, nonunion, and stiffness, while increased infection rates were seen for ORPP. Our findings also suggest closed reduction may be noninferior to open reduction, although further research with a larger sample size is necessary. Level III.

Hip joint morphology varies by sex and age. Computed tomography (CT) provides excellent evaluation of acetabular morphology; however, a description of the normal range of CT measurements in healthy children is lacking. This study aimed to describe the acetabular morphology on CT in healthy children by sex and at specific ages. Children who underwent pelvic CT from February 2016 to 2022 were retrospectively studied. The anterior pelvic plane was the basis for measuring lateral center-edge angle (LCEA), acetabular angle, anterior center-edge angle (ACEA), acetabular version (AcetV), anterior acetabular sector angle (AASA), and posterior acetabular sector angle (PASA). This study included 55 females and 55 males. The mean age was 12.5 years (range: 1-18 years). Patients were grouped by age: 2-7 years ( n = 50 hips), 8-11 years ( n = 50 hips), and 12-18 years ( n = 120 hips). Mean AcetV was 16.5° (range: 5.8-29.5°), mean AASA was 58.38° (range: 40.0-69.4°), mean PASA was 90.6° (range: 68.8-111.00°), mean LCEA was 27.9° (range: 19.0-40.4°), mean acetabular angle was 45.1° (range: 33.6-55.9°), and mean ACEA was 47.6° (range: 23.0-64.4°). The AcetV, AASA, PASA, LCEA, and ACEA increased with age, while the acetabular angle decreased ( P < 0.001). AcetV and PASA were highest in females ( P < 0.001). Hip joint development varies by sex across specific ages. The measurements reported provide descriptive reference data that may be used as an assessment tool for early identification of pediatric hip deformities and aid surgical planning.