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Introduction Generalized tetanus from Clostridium tetani infections is rare in the United States due to widespread use of tetanus toxoid-containing vaccines, and management of these critically ill patients can be challenging. We report a case of generalized tetanus in a pediatric patient treated with multiple sedatives and paralytics whose stabilization was associated with initiation of intrathecal baclofen.Case A 16-year-old unvaccinated male suffered a puncture wound to his left heel and presented with trismus, difficulty swallowing, diaphoresis, hypertension at 153/86 mmHg, and tachycardia at 120 bpm one week after sustaining the injury. The patient was intubated, received wound debridement, antibiotics, tetanus immune globulin, and a Tdap (tetanus, diphtheria, acellular, pertussis) vaccine. His tetany and autonomic stability worsened. He received norepinephrine, esmolol, midazolam, magnesium, morphine, propofol, vecuronium, dexmedetomidine, dantrolene, and oral baclofen without improvement. Intrathecal baclofen was started on hospital day 18, and within a day vecuronium was discontinued, and multiple sedatives were titrated down. He received intrathecal baclofen until hospital day 35 and was discharged on hospital day 40.Discussion Intrathecal baclofen is a potential treatment for generalized tetanus which may allow for reduction in paralytic and sedative use, and possibly shorter duration of mechanical ventilation and inpatient time.

Purpose: To develop and validate machine learning models for predicting the length of stay (LOS) in the Pediatric Intensive Care Unit (PICU) using data from the Virtual Pediatric Systems (VPS) database. Methods: A retrospective study was conducted utilizing machine learning (ML) algorithms to analyze and predict PICU LOS based on historical patient data from the VPS database. The study included data from over 100 North American PICUs spanning the years 2015–2020. After excluding entries with missing variables and those indicating recovery from cardiac surgery, the dataset comprised 123,354 patient encounters. Various ML models, including Support Vector Machine, Stochastic Gradient Descent Classifier, K-Nearest Neighbors, Decision Tree, Gradient Boosting, CatBoost, and Recurrent Neural Networks (RNNs), were evaluated for their accuracy in predicting PICU LOS at thresholds of 24 h, 36 h, 48 h, 72 h, 5 days, and 7 days. Results: Gradient Boosting, CatBoost, and RNN models demonstrated the highest accuracy, particularly at the 36 h and 48 h thresholds, with accuracy rates between 70 and 73%. These results far outperform traditional statistical and existing prediction methods that report accuracy of only around 50%, which is effectively unusable in the practical setting. These models also exhibited balanced performance between sensitivity (up to 74%) and specificity (up to 82%) at these thresholds. Conclusions: ML models, particularly Gradient Boosting, CatBoost, and RNNs, show moderate effectiveness in predicting PICU LOS with accuracy slightly over 70%, outperforming previously reported human predictions. This suggests potential utility in enhancing resource and staffing management in PICUs. However, further improvements through training on specialized databases can potentially achieve better accuracy and clinical applicability.

Mechanical ventilation is a common procedure performed in pediatric intensive care units, with over 20% of patients requiring invasive ventilator support. The most common indication for endotracheal intubation and ventilation in the pediatric population is respiratory failure either due to respiratory embarrassment or neurologic pathology. Despite the use of ventilation modes that are lung protective in the pediatric population, complications of mechanical ventilation occur frequently. These include atelectasis, post-extubation stridor, perioral tissue damage, ventilator associated pneumonia, mucus plugging, pneumothorax, pneumomediastinum, and ICU neuromyopathy. The purpose of this review is to discuss the risk factors, presentation and management of complications associated with mechanical ventilation in the pediatric population.

Unilateral lung diseases such as unilateral pneumonia, trauma or pulmonary hemorrhage can cause profound hypoxemic respiratory failure necessitating mechanical ventilation. These disorders are characterized by marked asymmetry in lung mechanics, with the affected lung having a lower compliance compared to the healthier lung, and management involves complex strategies such as simultaneous independent lung ventilation. However, such strategies can be challenging in pediatric populations due to technical limitations, and also lead to ventilator induced lung injury. We report two unique cases that support the use of venovenous extracorporeal membrane oxygenation as an alternative strategy for management of unilateral lung disease in children. Keywords: Unilateral lung disease, Pediatric, ECMO, Extracorporeal membrane oxygenation, Ventilator induced lung injury, Lung protection

Severe pediatric ARDS remains a significant challenge for clinicians, and management strategies are essentially limited to lung protective ventilation strategies, and adjunct approaches such as prone positioning, steroids, surfactant, and inhaled nitric oxide in unique situations. Inhaled nitric oxide produces pulmonary vasodilation in ventilated regions of the lung, shunting blood away from poorly ventilated areas and thus optimizing the ventilation perfusion ratio. A subset of patients with ARDS are known to be non-responders to nitric oxide, and selective pulmonary vasodilators such as Epoprostenol can be useful as rescue therapy in such cases. We describe a case of severe pediatric ARDS in the setting of pre-existing pulmonary hypertension and Trisomy 21, whose clinical course improved remarkably once inhaled Epoprostenol was initiated.

INTRODUCTION: Studies have shown a high prevalence of psychiatric illnesses among patients in primary health care settings. Family physicians have a fundamental role in managing psychiatric illness with psychopharmacological medications. Providing information about the disease, its management and the potential adverse effects of the medications is an important part of the management of mental illnesses. Our objective was to determine if patients who were prescribed psychopharmacological drugs by family physicians at a community health center in Karachi, Pakistan were provided adequate education about their disease and its management. METHODS: A cross-sectional study was conducted at the Community Health Centre (CHC), Aga Khan University Hospital Karachi, Pakistan. Details about the prescriptions and patient education were acquired from the patients after their consultations. RESULTS: A total of 354 adult patients were interviewed during 3 days. Among them, 73 (20.6%) were prescribed psychopharmacological medications. Among patients receiving psychopharmacological medicines, 37 (50.7%) did not know their diagnosis; 50 (68.5%) were unaware of the disease process; 52 (71.2%) were unaware of alternative treatments; 63 (86.3%) were not cautioned about the potential adverse effects of the drugs; 24 (32.9%) were unaware of the duration of treatment and in 60 (82.2%) of the participants an appropriate referral had not been discussed. For all aspects of education, patients prescribed psychopharmacological medications knew less as compared to those patients that were prescribed other medications. DISCUSSION: The practice of imparting information to patients who receive psychopharmacological medications seems to be inadequate in Pakistan. We have hypothesized about the possible reasons for our findings, and identified a need for further research to determine the cause for such findings and to address them accordingly. At the same time there is a need to educate family physicians in Pakistan about the special importance of providing adequate information to such patients.

Presentation, management, and outcomes of COVID-19 infections among younger patients is an area of medicine with deficits in research, likely due to the lower incidence of severe COVID-19 disease among the younger population. Management can be challenging, and clinicians often guide their decision-making based on the ever-changing protocols that are tailored mostly to the elderly population. Even more underrepresented in COVID-19 research are patients with chromosomal abnormalities and trisomy syndromes, as they appear less frequently, but have risk of increased morbidity and mortality due to underlying medical conditions. We describe a case of severe COVID-19 infection in a young patient with mosaic trisomy 13 and pre-existing polycystic kidney disease, who developed severe acute hypoxic respiratory failure and acute chronic kidney injury. The patient was provided maximal pharmacological support and her clinical course helps to shape the understanding of COVID-19 infections in the setting of chromosomal abnormalities and complex medical history.