Initiation of nutritional support before 72 hours after traumatic brain injury was associated with decreased mortality and favorable outcome in this secondary analysis. Although this provides a rationale to initiate nutritional support early after traumatic brain injury, definitive studies that control for important covariates (severity of injury, clinical site, calories delivered, parenteral/enteral routes, and other factors) are needed to provide definitive evidence on the optimization of the timing of nutritional support after severe traumatic brain injury in children.

COVID-19 has manifested with ventricular dysfunction and cardiac arrhythmias, most commonly atrial fibrillation (AFib), in adults. However, very few pediatric patients with acute COVID-19 have had cardiac involvement. AFib, an exceedingly rare arrhythmia in otherwise healthy children, has not been reported in children with COVID-19. We report a 15 year-old girl with acute COVID-19, fulminant myocarditis and AFib.

Pain is common as a presenting complaint to outpatient and emergency departments for children, yet pain management represents one of the children's largest unmet needs. A child may present with acute pain for an intermittent issue or may have acute or chronic pain in the setting of chronic illness. The mainstay of treatment for pain uses a stepwise approach for pain management, such as set up by the World Health Organization. For children with life-limiting illnesses, the Institute of Medicine guidelines recommends referral upon diagnosis for palliative care, meaning that the child receives comprehensive services that include pain control in coordination with curative therapies; yet barriers remain. From the provider perspective, pain can be better addressed through a careful assessment of one's own knowledge, skills, and attitudes. The key components of pain management in children are multimodal, regardless of the cause of the pain.

Myocarditis is an important cause of arrhythmogenic sudden cardiac arrest in the young. A strong index of suspicion is required as not only can arrhythmias be the only clinical manifestation but also because these patients can have normal cardiac biomarkers, electrocardiographic and echocardiographic findings, and inflammatory markers. Patients with ventricular arrhythmias in the setting of viral myocarditis, especially the ones in whom cardiac MRI findings normalise upon follow-up, tend to do well in the long run and an implantable cardioverter-defibrillator should be avoided in these patients; instead, a wearable defibrillator should be temporarily used as we did in this 7-year-old.

predictors of postoperative decline in EF to < 45%. Our secondary objective was to evaluate subsequent recovery. Methods: Adult patients who underwent OLT at our institution from 01/2006 to 02/2015 were included. Data was obtained from prospectively collected institutional registries. Patients with an echocardiographically documented decline in EF to <45% within 6 mo after OLT were identified. Four controls were chosen per case; matched for age, gender, transplant year and Model for End-stage Liver Disease score. Conditional multivariable logistic regression was used to determine predictors of decline in EF. Results: In a cohort of 1,234 patients, 45 patients (3.6%) had post-OLT decline in EF to < 45%. 180 matched controls were chosen. Lower EF (OR-1.11, 95% CI 1.04-1.20, P< 0.01) and diastolic dysfunction (OR-5.99, 95% CI 1.25-28.57, P= 0.02) on pre OLT echo were associated with post-OLT decline in EF. Diastolic dysfunction was found to be an independent predictor (p=0.04) in multivariable analysis. Post-OLT decline in EF was associated with a higher likelihood of 1 year mortality (OR-2.30, 95% CI 1.19-4.42, P = 0.01). Left ventricular function recovered in 21 (out of the 45) patients, after a median duration of 112 days. Patients with pre-OLT diastolic dysfunction were less likely to recover (Fischer Exact test, P= 0.05). Conclusions: Preoperative diastolic dysfunction was an independent predictor of post-OLT decline in EF and was also associated with non-recovery of left ventricular function. Patients known to have diastolic dysfunction need be followed up more closely following OLT for early detection of left ventricular failure, especially since decline in EF was associated with a higher likelihood of 1 year mortality.