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Movement and mobility are a significant aspect of early childhood. Assistive technology and adapted mobility can be a critical aspect of the early intervention process by promoting access to play, the environment, social opportunities, and development of visual perceptual and navigational skills. This case study describes the design, materials, and build of an inexpensive mobility device for use with a three-year-old child with LAMA2-related muscular dystrophy. This is based on an off-the-shelf toy car with independent motors which provides the child with high maneuverability in indoor environments. The adaptations made provided the child with the postural support necessary for promoting safe use of the device while increasing access to mobility, her environment, and social opportunities.

Author(s): Daniel Fredric [sup.1] , Jason H. Greenberg [sup.2] , Chirag R. Parikh [sup.3] , Prasad Devarajan [sup.4] , Hayton Chui [sup.1] , Vedran Cockovski [sup.1] , Michael Pizzi [sup.5] [...], Background Children undergoing cardiac surgery are at risk of high blood pressure (BP), a risk factor for cardiovascular and kidney disease. Twenty-four-hour ambulatory BP monitoring (ABPM) is a reference standard hypertension (HTN) test. Little data exist on ABPM abnormalities in children several years post cardiac surgery. This study aimed to (a) determine ABPM feasibility; (b) describe and compare ABPM measures and abnormalities (percent load, masked HTN [MH]; non-dipping, mean systolic/diastolic BP > 95th percentile; pre-HTN (ABPM); white-coat HTN [WCH]) to casual BP; and (c) compare BP in patients with and without acute kidney injury (AKI). Methods Prospective, follow-up pilot study of children (0-18 years) who underwent cardiac surgery from 2007 to 2009 at Montreal Children's Hospital. We recorded if participants had post-operative AKI and assessed the following outcomes at 9-year follow-up: casual BP classified by three single-visit measures (normal; elevated BP [eBP.sub.SingleVisit]; HTN.sub.SingleVisit); ABPM. Bivariable analyses were used to compare characteristics between groups. Results Twenty-three patients (median [interquartile range], 8.6 [8.0, 9.0] years post cardiac surgery) were included; 16 (70%) male. Six participants (26%) had eBP.sub.SingleVisit or higher. On ABPM, 11 (48%) had [greater than or equal to] 1 abnormality: 9 (39%) had non-dipping; 3 (13%) had pre-HTN; 3 (13%) had WCH; none had HTN or MH. There were no differences in ABPM according to AKI status. Conclusion Our pilot study determined that ABPM was feasible in children years after cardiac surgery and frequently identified ABPM abnormalities. Future research in larger populations is needed to define specific risk factors for HTN in children after cardiac surgery.

BACKGROUND: Nonconvulsive status epilepticus (NCSE) is a diagnosis that is often challenging and one that may progress to refractory NCSE. Ketamine is a noncompetitive N-methyl-d-aspartate antagonist that increasingly has been used to treat refractory status epilepticus. Current Neurocritical Care Society guidelines recommend intravenous (IV) ketamine infusion as an alternative treatment for refractory status epilepticus in adults. On the other hand, enteral ketamine use in NCSE has been reported in only 6 cases (1 adult and 5 pediatric) in the literature to date. CASE PRESENTATION: A 33-year-old woman with a history of poorly controlled epilepsy presented with generalized tonic-clonic seizures, followed by recurrent focal seizures that evolved into NCSE. This immediately recurred within 24 h of a prior episode of NCSE that was treated with IV ketamine. Considering her previous response, she was started again on an IV ketamine infusion, which successfully terminated NCSE. This time, enteral ketamine was gradually introduced while weaning off the IV formulation. Treatment with enteral ketamine was continued for 6 months and then tapered off. There was no recurrence of NCSE or seizures and no adverse events noted during the course of treatment. CONCLUSION: This case supports the use of enteral ketamine as a potential adjunct to IV ketamine in the treatment of NCSE, especially in cases without coma. Introduction of enteral ketamine may reduce seizure recurrence, duration of stay in ICU, and morbidity associated with intubation.

Precision medicine provides individualized treatment of diseases through leveraging patient-to-patient variation. Aneurysmal subarachnoid hemorrhage carries tremendous morbidity and mortality with cerebral vasospasm and delayed cerebral ischemia proving devastating and unpredictable. Lack of treatment measures for these conditions could be improved through precision medicine. Areas covered: Discussed are the pathophysiology of CV and DCI, treatment guidelines, and evidence for precision medicine used for prediction and prevention of poor outcomes following aSAH. A PubMed search was performed using keywords cerebral vasospasm or delayed cerebral ischemia and either biomarkers, precision medicine, metabolomics, proteomics, or genomics. Over 200 peer-reviewed articles were evaluated. The studies presented cover biomarkers identified as predictive markers or therapeutic targets following aSAH. Expert commentary: The biomarkers reviewed here correlate with CV, DCI, and neurologic outcomes after aSAH. Though practical use in clinical management of aSAH is not well established, using these biomarkers as predictive tools or therapeutic targets demonstrates the potential of precision medicine.

The objective of this study is to determine the inter-rater reliability of the Pizzi Health and Wellness Assessment (PHWA) by comparing the consistency in scores between clients and their caregivers in the following areas of participation: social, physical, family, occupational, mental/emotional, and spiritual. A retrospective inter-rater correlational design was used to analyze the agreement of scores from a convenience sample consisting of two groups: clients with disabilities (n = 19) and their healthy caregivers (n = 19). Inter-rater reliability was calculated using correlations for the PHWA as a whole, and for the current level of participation and wishing to improve participation subsections. Inter-rater reliability as calculated by an Intraclass Correlation Coefficient, and either the Pearson or Spearman rho correlation and found to be reliable between clients and caregivers (rICC =.636, p <.001; rho =.642, p <.001). More specifically, current level of participation demonstrated acceptable reliability (rICC =.513, p <.001; r =.521, p <.001) as did wishing to improve participation (rICC =.689, p <.001; r =.725, p <.001). This supports the PHWA as a clinically relevant health and wellness occupational therapy assessment. [ABSTRACT FROM AUTHOR]

Author(s): Erin Hessey [sup.1] , Rami Ali [sup.2] [sup.3] , Marc Dorais [sup.4] , Geneviève Morissette [sup.5] , Michael Pizzi [sup.1] , Nikki Rink [sup.7] , Philippe Jouvet [sup.6] , [...], Background Baseline serum creatinine (bSCr) is required for diagnosing acute kidney injury (AKI). In children, bSCr is commonly defined as the lowest measurement within 3 months of admission. Measured values are often missing and estimating bSCr using height-based glomerular filtration rate (GFR) equations is problematic when height is unavailable. Methods This is a retrospective cohort study including 538 children admitted to the intensive care unit (ICU) between 2003 and 2005 at two centers in Canada, with measured bSCr, height, and ICU-SCr values. We evaluated the bias, accuracy, and precision of back-calculating bSCr from height-dependent and height-independent GFR equations. Agreement of AKI defined using measured and estimated bSCr was calculated. Multivariate analyses were performed to assess the impact of bSCr estimation methods on the association between AKI and ICU mortality, length of stay, and duration of mechanical ventilation. Results Both methods underestimated bSCr by 1-3%, showed good accuracy (~30% of patients with estimated bSCr within 10% of measured bSCr), but poor precision (wide 95% limits of agreement). The agreement between AKI defined by estimated versus measured bSCr was >80% ([kappa] >0.5). The height-independent method performed best in children >13 years old; however, overall, both methods performed similarly across age subgroups. AKI was associated with longer stay, prolonged mechanical ventilation, and ICU mortality using measured and estimated bSCr. Conclusions Height-dependent and height-independent bSCr estimation methods were comparable. This may have significant implications for performing pediatric AKI research using large databases, and in clinical care to define AKI when height is unknown.

Author(s): Jeremy Andrew Saban[sup.1] , Michael Pizzi[sup.1] , Jillian Caldwell[sup.1] , Ana Palijan[sup.1] , Michael Zappitelli[sup.1] Author Affiliations: (1) Division of Nephrology, Department of Pediatrics, Montreal Children's Hospital, McGill University [...], Objectives Aminoglycosides (AG) are a group of bactericidal antibiotics with nephrotoxic effects that are commonly used in the treatment of hospitialized children. We have examined previous AG treatment as a risk factor for acute kidney injury (AKI) during current AG treatment. Study design We performed a retrospective cohort study of children ranging in age from 1 month to 18 years who were treated with AG between October 2008 and April 2012 at Montreal&apos;s Children&apos;s Hospital. Children for whom no serum creatinine data (SCr) were available and those with baseline renal disease were excluded from the analysis. Main exposures were prior AG use (number and hours of prior treatments) and time since last AG treatment. The main outcome was AKI, defined on the basis of the Kidney Disease: Improving Global Outcomes guidelines. Logistic regression was used to examine exposure-outcome associations. Results AG treatments episodes with Stage 1, 2, and 3 AKI, respectively, were associated with a median of 98 [interquartile range (IQR) 339], 231 (IQR 688), and 111 (IQR 505) h of prior AG treatment, respectively, versus non-AKI (median 0, IQR 54 h) (p < 0.0001). AKI episodes were associated with a mean (± standard deviation) of 1.5 ± 1.8 AG treatments in the previous 6 months, versus 0.9 ± 1.6 AG treatments for non-AKI. The number of AG-treatment days during the preceding 6 months [adjusted odds ratio (adjOR) 1.04, 95 % confidence interval (CI) 1.03-1.06; p < 0.001], younger age (adjOR 0.96, 95 % CI 0.93-0.99; p = 0.009), admission to hematology-oncology department (adjOR 3.88, 95 % CI 2.17-6.96; p < 0.001), and tobramycin use (adjOR 1.77, 95 % CI 1.04-3.02; p = 0.04) were independently associated with AKI. Episodes with Stage 1 and 2 AKI were associated with fewer days since last treatment compared to non-AKI treatment (p < 0.02 and p < 0.005, respectively; Mann-Whitney test). Conclusions Based on these results, prior AG treatment is a risk factor for AKI and should be considered when dosing and monitoring hospitalized children being treated with AG.

Author(s): Lorraine Lau[sup.1] , Zubaida Al-Ismaili[sup.1] , Maya Harel-Sterling[sup.1] , Michael Pizzi[sup.1] , Jillian S. Caldwell[sup.1] , Melissa Piccioni[sup.1] , Larry C. Lands[sup.1] , Theresa Mottes[sup.2] , Prasad Devarajan[sup.2] , [...], Background Serum cystatin C (CysC) is a more accurate glomerular filtration rate marker than serum creatinine (SCr) and may rise more quickly with acute kidney injury (AKI). Methods We performed a prospective cohort study of 81 non-critically ill children during 110 aminoglycoside (AG) treatments. We calculated area under the curve (AUC) for CysC to diagnose SCr-defined AKI and predict persistent AKI. SCr-AKI definition was based on the Kidney Disease: Improving Global Outcomes ([greater than or equal to]stage 1: [greater than or equal to]50 % or 26.5 [mu]mol/l SCr rise from baseline; stage 2: SCr doubling); CysC-AKI was based on a modified version using CysC rise. Results SCr-AKI and CysC-AKI developed in 45 and 48 % treatments, respectively. CysC rise predicted stage 1 (AUC = 0.75, 95 % CI 0.60-0.90) and 2 (AUC = 0.85, 95 % CI 0.75-0.95) SCr-AKI 2 days before SCr-AKI attainment. The best combined sensitivity/specificity for percent CysC rise to predict stage 1 SCr-AKI was with a 44 % CysC rise (sensitivity = 65 %, specificity = 83 %). CysC rise on day of SCr-AKI development was associated with SCr-AKI [greater than or equal to]48 h (AUC = 0.73, 95 % CI 0.56-0.90) and [greater than or equal to]50 % persistent SCr rise at treatment end (AUC = 0.76, 95 % CI 0.61-0.90). Conclusions CysC is as an early AKI biomarker and predictive of persistent AKI on aminoglycoside treatment.