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BACKGROUND: Robinsoniella peoriensis is an anaerobic gram-positive bacilli first isolated from swine manure in 2003 but has since been associated with human infections. METHODS: We describe a pediatric case of R. peoriensis infection following a below-knee amputation for a limb injury and its treatment. Methods of identifying R. peoriensis and reported in vitro antimicrobial minimum inhibitory concentrations from the literature are reviewed. RESULTS: R. peoriensis is readily identifiable via 16S rRNA gene sequencing and Matrix-Assisted Laser Desorption Ionization-Time of Flight. There is variability in the antibiotic susceptibility profiles reported in the literature, but antibiotics with low in vitro minimum inhibitor concentrations against R. peoriensis include beta-lactam/beta-lactamase inhibitors, carbapenems, vancomycin, and metronidazole. CONCLUSION: This is the first reported case of R. peoriensis infection following a traumatic injury in Canada to our knowledge and highlights the importance of recognizing this organism and other anaerobes in settings where wounds are grossly contaminated with soil.

A healthy, fully immunized 4-year-old girl was admitted to hospital after 1 week of fever and respiratory distress, when her chest radiograph showed right-sided pneumonia with large pleural effusion (Appendix 1, Figure S1, available at [www.cmaj.ca/lookup/doi/10.1503/cmaj.202468/tab-related-content

OBJECTIVES: Periorbital and orbital cellulitis are common but serious infections in children. Management of these infections varies because of an absence of clinical guidelines, but it is unclear if management within institutions has changed over time. We compared the management and outcomes of children hospitalized with periorbital and orbital cellulitis in 2 eras. METHODS: Data were extracted from records of children hospitalized at a tertiary care children’s hospital with periorbital or orbital cellulitis from 2000 to 2005 and 2012 to 2016. Patient demographics, cross-sectional imaging, antibiotic and corticosteroid use, length of stay, and surgical rates were collected. Data from the eras were compared by using descriptive statistics, t tests, Mann–Whitney U tests, Fisher’s exact tests, and χ2 tests. RESULTS: There were 318 children included, 143 from 2000 to 2005 and 175 from 2012 to 2016. Compared with the first era, in the second era there were increased rates of MRI (5% vs 11%, P = .04), although rates of computed tomography scan use remained unchanged (60% vs 65%); increased number (1 vs 3, P < .01) and spectrum of antibiotics; increased use of intranasal corticosteroids (3% vs 49%, P < .01); and subspecialty consultation (89% vs 99%, P = .01). There were no differences in length of stay, readmission, or surgical rates between eras. CONCLUSIONS: There has been considerable change in the management of hospitalized children with severe orbital infections at our institution, including the rates of MRI, number and spectrum of antibiotics used, use of adjunctive agents, and increased subspecialty involvement with no observed impact on clinical outcomes. Future research is needed to rationalize antimicrobial therapy and reduce low-value health care.

On a hospitalise une fillette de 4 ans, en bonne sante et entierement immunisee, presentant des symptomes de fievre et de detresse respiratoire perdurant depuis 1 semaine. La radiographie de son thorax montrait une pneumonie du cote droit accompagnee d’une importante effusion pleurale (

Background The overall global impact of COVID-19 in children and regional variability in pediatric outcomes are presently unknown. Methods To evaluate the magnitude of global COVID-19 death and intensive care unit (ICU) admission in children aged 0–19 years, a systematic review was conducted for articles and national reports as of December 7, 2020. This systematic review is registered with PROSPERO (registration number: CRD42020179696). Results We reviewed 16,027 articles as well as 225 national reports from 216 countries. Among the 3,788 global pediatric COVID-19 deaths, 3,394 (91.5%) deaths were reported from low- and middle-income countries (LMIC), while 83.5% of pediatric population from all included countries were from LMIC. The pediatric deaths/1,000,000 children and case fatality rate (CFR) were significantly higher in LMIC than in high-income countries (HIC) (2.77 in LMIC vs 1.32 in HIC; p < 0.001 and 0.24% in LMIC vs 0.01% in HIC; p < 0.001, respectively). The ICU admission/1,000,000 children was 18.80 and 1.48 in HIC and LMIC, respectively (p < 0.001). The highest deaths/1,000,000 children and CFR were in infants < 1 year old (10.03 and 0.58% in the world, 5.39 and 0.07% in HIC and 10.98 and 1.30% in LMIC, respectively). Conclusions The study highlights that there may be a larger impact of pediatric COVID-19 fatality in LMICs compared to HICs.

1. Carsten Krueger, MD*,† 2. Ruth McWhannell, MD*,† 3. Andreas Schulze, MD, PhD, FRCPC*,†,‡ 1. *Department of Paediatrics, §Department of Biochemistry, University of Toronto, Toronto, Ontario, Canada 2. †Division of General Paediatrics, 3. ‡Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, Ontario Canada A 40-day-old girl of Ghanaian descent presents to a general hospital with a 1 day history of nonbloody, nonbilious emesis. She was born to consanguineous parents who are first cousins. Her health has been good since her birth at term apart from a brief course of phototherapy for breastfeeding jaundice. Given her history of vomiting, she underwent an ultrasound evaluation to exclude pyloric stenosis at the general hospital. This revealed irregular gall bladder thickening, but, more impressively, a lobulated soft tissue mass at the pancreatic head that was 2 cm in diameter and surrounded by a moderate volume of complex ascites (Fig 1). Given her unusual presentation and imaging findings suggesting pancreatitis, she is transferred to a pediatric center for further diagnostic clarification and management. Figure 1. Abdominal ultrasound of the patient reveals a lobulated mass of the pancreatic head that is roughly 2 × 2 cm in diameter. Initial laboratory investigations are remarkable for an elevated lipase of >1,200 U/L (reference range, 4 to 39), a C-reactive protein of 91 mg/L (reference range, 0.1 to 1), triglycerides of 276 mmol/L (reference range

BACKGROUND: Pediatric orbital cellulitis is a common but serious infection that, if untreated, can result in severe complications such as meningitis, sinus venous thrombosis, and blindness. Clinically, orbital cellulitis can be difficult to differentiate from periorbital cellulitis, and often requires orbital imaging. The most common causal infectious agents have changed over time largely due to the development of vaccines (e.g. H. influenzae serotype b and heptavalent pneumococcal conjugate vaccines), and with them, empiric antibiotic recommendations. OBJECTIVES: To compare the management and outcomes of children hospitalized with periorbital or orbital cellulitis from two eras. DESIGN/METHODS: Data were extracted from the health records of children less than 18 years hospitalized at a tertiary care pediatric hospital with a diagnosis of periorbital or orbital cellulitis from 2000–2005 and 2012–2016. Patient demographics, use of diagnostic imaging (CT and/or MRI), number and type of intravenous antibiotics, use of intranasal steroids, length of stay, and rates of surgery were collected using a standardized data collection form. Data from the two eras were compared using t-tests and Mann–Whitney U tests (for continuous data) and chi-square tests (for proportions). RESULTS: Overall, 362 children were included, 161 from 2000–2005, and 201 from 2012–2016. There were no significant differences in mean age (75 months) or sex distribution (67% male) between the two eras. There was no significant difference in rates of CT scan (56% vs 59%), but there was a significant increase in rates of MRI (5% vs 12%, p=0.03). There was an increase in the mean number of intravenous antibiotics used (1.7 vs 2.4, p

OBJECTIVESThis prospective study tested whether transmitral flow patterns add incremental value to peak oxygen consumption (V̇;-4uo2) in determining the prognosis of patients with chronic congestive heart failure (CHF) and systolic dysfunction.BACKGROUNDPeak V̇;-4uo2is an objective marker of functional capacity and is routinely used as a criterion to identify heart transplant candidates. Diastolic dysfunction limits functional capacity, but its prognostic importance relative to that of peak V̇;-4uo2is unknown.METHODSPeak V̇;-4uo2and mitral inflow velocities were prospectively measured in 311 consecutive patients (mean age 54 years, 84% male) with impaired left ventricular function (ejection fraction 14 ml/min per kg, the outcome was less favorable in the presence of restrictive filling patterns (two-year survival rate 80% vs. 94%). A risk-stratification model based on the identified independent noninvasive predictors separated groups into those with high (93%), intermediate (65%) and low (39%) two-year survival rates.CONCLUSIONSTransmitral flow patterns add incremental value to peak V̇;-4uo2in determining the prognosis of patients with CHF and impaired systolic function.

Background: Visual evaluation of wall motion is subjective and may be difficult in patients with impaired left ventricular function. Current algorithms used to analyze wall motion usually neglect motion asynchrony that may be profoundly altered in coronary artery disease. This study was to investigate whether the extent of left ventricular asynergy can be used to quantify the severity of regional myocardial dysfunction by the use of Fourier phase imaging. Methods: Echocardiographic cine loops of 21 patients with ischemic cardiomyopathy (EF ≤ 40%) were mathematically transformed using a first-harmonic Fourier algorithm displaying the sequence of wall motion as phase angles in parametric images and regional phase histograms. Segmental fractional area shortening (FAC) and qualitative assessment of regional wall motion based on visual inspection served as reference method. Results: There was an inverse linear relationship between FAC and phase angles (r = −0.75, p < 0.01). Normal endocardial motion yielded low phase angles (mean 16 ± 15° SD). With an increase in wall motion abnormalities, phase angles were progressively delayed by 56 ± 38° in hypokinetic, by 88 ± 38° in akinetic, and by 143 ± 33° (p < 0.001) in dyskinetic segments. Conclusions: These results demonstrate that left ventricular asynchrony is an indicator of regional myocardial dysfunction in coronary artery disease. Echocardiographic Fourier phase imaging can be used to quantify wall motion displaying contraction sequence in a simple and objective format.

Background: The prognostic role of asymptomatic nonsustained ventricular tachycardia (NSVT) and programmed ventricular stimulation (PVS) in patients with idiopathic dilated cardiomyopathy (IDC) remains controversial. Methods: The prognostic significance of ventricular arrhythmias, ejection fraction, NYHA class, atrial fibrillation and age for overall and sudden death mortality was prospectively studied in 157 patients with IDC (group 1) free of documented sustained ventricular arrhythmia and syncope. In 99 patients with asymptomatic NSVT (group 2), PVS with 2 – 3 extrastimuli was performed. Non-inducible patients were discharged without specific antiarrhythmic therapy, whereas those with inducible monomorphic ventricular tachycardia were implanted with an ICD. Results: In group 1, 48% of patients had NSVT. Overall and sudden death mortality were significantly higher in patients with NSVT (34.2 vs. 9.8%, p = 0.0001 and 15.8 vs. 3.7%, p = 0.0037; follow-up 22 ± 14 months). Multivariate analysis revealed that NSVT independently predicts both overall and sudden death mortality (p = 0.0021 and .0221, respectively; adjusted for EF, NYHA class and age). In group 2, inducibility of sustained ventricular tachyarrhythmia was 7%, but sustained monomorphic VT occurred in 3% only. Two of 7 inducible patients experienced arrhythmic events during a follow-up of 25 ± 21 months (positive predictive value 29%). Overall and sudden death mortality were 29% and 0% in the inducible group vs. 17 and 4% in the non-inducible group. Both overall and sudden death mortality were signi.cantly lower in non-inducible patients from group 2 as compared to patients from group 1 with NSVT (p = 0.0043 and 0.0048), most likely due to a more common use of betablockers and a higher EF in the former group (p < 0.001, respectively). Conclusions: In patients with IDC, NSVT independently predicts both overall and sudden death mortality. Due to a low inducibility rate and a poor positive predictive value, PVS seems inappropriate for further arrhythmia risk assessment. However, in spite of documented NSVT, the incidence of SCD in patients on optimized medical treatment including betablockers seems to be very low, questioning the need for specific arrhythmia risk stratification.

However, in the Mbulu area, a rural and very remote region between Lake Eyasi and Lake Manyara in Northern Tanzania, three tribes of non-Bantu origin live among Bantu tribes 3-5 . The Southern Cushitic Iraqw (approximately 500 000 people), are subsistence farmers who probably migrated from Ethiopia several centuries ago 2,3 . The Southern Nilotic Datoga (100 000–200 000people) are nomadic pastoralists, probably of past centuries’ Sudanese origin 2,4 . Although there has been inter-marriage between these two tribes, until recently they have rarely inter-married with Bantu tribes, thus they comprise a largely genetically homogenous group. Of the smallest group, the Khoisan Hadzabe (1000–1500 people) who are believed to be the original hunter-gatherers, virtually nothing is known of their health status 5 .