341 Alder Hey Experience of Paediatric Virtual Fracture Clinic During The COVID-19 Pandemic

Introduction The SARS-CoV2/COVID-19 pandemic represented an unprecedented emergency prompting a drive to minimise non-essential patient contact and the need for a virtual fracture clinic (VFC); an uncommon practice in paediatric units. Management of paediatric fractures requires a greater degree of vigilance to safeguard children. The current climate has created social challenges that theoretically increase the risk of harm and exploitation to children. This study investigates VFC in the management of paediatric fractures to determine the efficiency of such a process and the risk of safeguarding. Method A protocol was devised in affiliation with BSCOS for the immediate management and streamlining of paediatric fractures into VFC. We retrospectively audited 235 VFC consults over a 1-month period. Patient sex was roughly evenly distributed, and age ranged from 9 months to 16 years (mean 8.4 years). Results 42% of patients were recalled for a face-to-face (F2F) review (26% expedited), primarily for clinical assessment, plaster complaints and imaging requirements. 33% were discharged and 15% continued follow-up in VFC. All clavicle fractures were discharged. Forearm, hand, foot and elbow injuries were more likely to be discharged. Lower leg, upper arm and knee presentations more frequently required a F2F review. 2.3% of cases required safeguarding reviews. Conclusions Given the rapid transition to VFC without the use of triage we have determined a number of non-complex fractures safely managed and discharged via VFC. The low percentage of recall due to safeguarding concern highlights this may not be a barrier to the continuation of virtual care outside of the context of a pandemic.

101 Paediatric Burns and The Coronavirus Pandemic: Were Children Staying Safe in Lockdown or Did The Virus Increase Burns Admissions?

Aim We aimed to identify if there was a change in the number of paediatric burns during the coronavirus pandemic and whether there was a change in the management of said burns. Method Data on ten parameters for all burns assessed on the Burns Unit at Alder Hey Children’s Hospital from April to May of 2020 was collected and compared to the same period from 2019. Results There was a decrease in the number of patients presenting to hospital, down to 24 from 32 in 2019. Scald injuries increased to 67% compared to 44%, while all other mechanisms of injuries decreased. Fewer very small burns (<1% TBSA) presented to hospital (28%) compared to 50% the previous year. There was an overall increase in the presentation of burns greater than 1% TBSA (1-5% TBSA increased to 47% from 31%; 5-10% TBSA increased to 19% from 3%; 10-20% TBSA increased to 6% from 3%). A comparable rate of burns was managed conservatively as an outpatient (89% vs 88%), admitted for dressing changes (81% vs 78%), and managed surgically (11% vs 13%). Conclusions The coronavirus pandemic resulted in a decrease in the number of children experiencing burns, while at the same time causing an increase in the number of scald injuries. Our data showed no significant change in the management of burns indicating that regardless of the pandemic, paediatric burns were managed appropriately as per national guidelines.

Infant hydrocephalus: what valve first?

Purpose To review the use of different valve types in infants with hydrocephalus, in doing so, determining whether an optimal valve choice exists for this patient cohort. Methods We conducted (1) a literature review for all studies describing valve types used (programmable vs. non-programmable, valve size, pressure) in infants (≤ 2 years) with hydrocephalus, (2) a review of data from the pivotal BASICS trial for infant patients and (3) a separate, institutional cohort study from Alder Hey Children’s Hospital NHS Foundation Trust. The primary outcome was any revision not due to infection. Results The search identified 19 studies that were included in the review. Most did not identify a superior valve choice between programmable and non-programmable, small compared to ultra-small, and differential pressure compared to flow-regulating valves. Five studies investigated a single-valve type without a comparator group. The BASICS data identified 391 infants, with no statistically significant difference between gravitational and programmable subgroups. The institutional data from our tertiary referral centre did not reveal any significant difference in failure rate between valve subtypes. Conclusion Our review highlights the challenges of valve selection in infant hydrocephalus, reiterating that the concept of an optimal valve choice in this group remains a controversial one. While the infant-hydrocephalic population is at high risk of valve failure, heterogeneity and a lack of direct comparison between valves in the literature limit our ability to draw meaningful conclusions. Data that does exist suggests at present that there is no difference in non-infective failure rate are increasing in number, with the British valve subtypes in infant hydrocephalus, supported by both the randomised trial and institutional data in this study.

A Novel Framework for Phenotyping Children With Suspected or Confirmed Infection for Future Biomarker Studies

Background: The limited diagnostic accuracy of biomarkers in children at risk of a serious bacterial infection (SBI) might be due to the imperfect reference standard of SBI. We aimed to evaluate the diagnostic performance of a new classification algorithm for biomarker discovery in children at risk of SBI.Methods: We used data from five previously published, prospective observational biomarker discovery studies, which included patients aged 0– <16 years: the Alder Hey emergency department (n = 1,120), Alder Hey pediatric intensive care unit (n = 355), Erasmus emergency department (n = 1,993), Maasstad emergency department (n = 714) and St. Mary's hospital (n = 200) cohorts. Biomarkers including procalcitonin (PCT) (4 cohorts), neutrophil gelatinase-associated lipocalin-2 (NGAL) (3 cohorts) and resistin (2 cohorts) were compared for their ability to classify patients according to current standards (dichotomous classification of SBI vs. non-SBI), vs. a proposed PERFORM classification algorithm that assign patients to one of eleven categories. These categories were based on clinical phenotype, test outcomes and C-reactive protein level and accounted for the uncertainty of final diagnosis in many febrile children. The success of the biomarkers was measured by the Area under the receiver operating Curves (AUCs) when they were used individually or in combination.Results: Using the new PERFORM classification system, patients with clinically confident bacterial diagnosis (“definite bacterial” category) had significantly higher levels of PCT, NGAL and resistin compared with those with a clinically confident viral diagnosis (“definite viral” category). Patients with diagnostic uncertainty had biomarker concentrations that varied across the spectrum. AUCs were higher for classification of “definite bacterial” vs. “definite viral” following the PERFORM algorithm than using the “SBI” vs. “non-SBI” classification; summary AUC for PCT was 0.77 (95% CI 0.72–0.82) vs. 0.70 (95% CI 0.65–0.75); for NGAL this was 0.80 (95% CI 0.69–0.91) vs. 0.70 (95% CI 0.58–0.81); for resistin this was 0.68 (95% CI 0.61–0.75) vs. 0.64 (0.58–0.69) The three biomarkers combined had summary AUC of 0.83 (0.77–0.89) for “definite bacterial” vs. “definite viral” infections and 0.71 (0.67–0.74) for “SBI” vs. “non-SBI.”Conclusion: Biomarkers of bacterial infection were strongly associated with the diagnostic categories using the PERFORM classification system in five independent cohorts. Our proposed algorithm provides a novel framework for phenotyping children with suspected or confirmed infection for future biomarker studies.

Skin biopsy in Paediatric Rheumatology: 10 years review of practice.

BACKGROUNDSkin biopsy has limited but sometimes distinctly useful place in diagnosis of childhood rheumatologic disorders. For example, skin biopsy is of little value in differentiating lupus from dermatomyositis. The purpose of skin biopsy is to support diagnosis, disease monitoring (e.g.scleroderma) or treatment (e.g., skin cancer). OBJECTIVETo evaluate skin biopsy practices in a tertiary paediatric rheumatology unit in order to determine the usefulness. METHODA retrospective review of medical records of paediatric rheumatology patients who have had skin biopsy over a 10-year period between 2008 and 2018 at Alder Hey Children Hospital.RESULTS & DISCUSSIONA total of 49 skin biopsies with an average of 5 per year was performed. Patients age range from 0.75 -18 years with mean of 10 years. Sites of biopsy and main diagnoses are as shown in figure 1 & 2. Fifty nine percent had excision biopsy while 41% had punch biopsy. Majority of skin biopsies (94%) were performed to aid diagnosis. Severe HSP was the most common indi?cation for skin biopsies requested by rheumatologist. A high proportion of the biopsies (84%) were helpful in the patient care; 55% confirmed clinical suspicions, 25% excluded. CONCLUSION & PERSPECTIVESRheumatologist are selective in the use of skin biopsy for diagnosis. When indicated, skin biopsy is often helpful in the diagnosis and monitoring of rheumatologic disorders. It must be ensured that sufficient information with clear clinico-pathologic question is provided when requesting skin biopsy to enhance positive result.

How Does Hypodontia Compare in Nonsyndromic Pierre Robin Sequence Versus Isolated Cleft Palate and Isolated Cleft Lip?

Objective: To assess the prevalence and patterns of hypodontia in nonsyndromic Pierre Robin sequence (PRS) and compare it with hypodontia in nonsyndromic isolated cleft palates and isolated cleft lips. Design: Retrospective cohort study. Setting: Alder Hey Children’s Hospital, United Kingdom. Patients: Patients with nonsyndromic PRS (group 1), isolated cleft palate (group 2), and isolated cleft lip (group 3). Main Outcome Measures: Hypodontia in the permanent dentition assessed from orthopantomographs. Results: A total of 154 patients were included. Group 1 had the highest incidence of hypodontia with 47% having at least one tooth congenitally absent. Groups 2 and 3 had reduced rates of hypodontia with 27% and 19% of the groups missing teeth, respectively; 93% of cases of hypodontia in group 1 involved the absence of at least one second premolar. Of these patients, there was found to be bilateral agenesis of second premolars in 50% of cases. Conclusions: Patients with PRS and cleft palates are more likely to have hypodontia than those with isolated cleft palates or unilateral cleft lips. Patients with PRS have more severe hypodontia than those with isolated cleft palates or unilateral cleft lips. Bilateral agenesis of lower second premolars is a commonly seen pattern among patients with PRS. In this large UK study, a similar prevalence and pattern of hypodontia to other nonsyndromic PRS populations worldwide has been demonstrated.