Antibiotic treatment for streptococcal pharyngitis: time for a new approach?

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Bone Disorders in Pediatric Chronic Kidney Disease: A Literature Review

Intense changes in mineral and bone metabolism are frequent in chronic kidney disease (CKD) and represent an important cause of morbidity and reduced quality of life. These disorders have conventionally been defined as renal osteodystrophy and classified based on bone biopsy, but due to a lack of bone biopsy data and validated radiological methods to evaluate bone morphology in children, it has been challenging to effectively assess renal osteodystrophy in pediatric CKD; the consequence has been the suboptimal management of bone disorders in children. CKD-mineral and bone disorder (CKD-MBD) is a new expression used to describe a systemic disorder of mineral and bone metabolism as a result of CKD. CKD-MBD is a triad of biochemical imbalances in calcium, phosphate, parathyroid hormone, and vitamin D; bone deformities and soft tissue calcification. This literature review aims to explore the pathogenesis, diagnostic approach, and treatment of CKD-MBD in children and the effects of renal osteodystrophy on growing skeleton, with a specific focus on the biological basis of this peculiar condition.

Pain management in pediatric age. An update

Differently from the adult patients, in paediatric age it is more difficult to assess and treat efficaciously the pain and often this symptom is undertreated or not treated. In children, a selection of appropriate pain assessment tools should consider the age, the cognitive level, the presence of eventual disability, the type of pain and the situation in which it is occurring. Improved understanding of developmental neurobiology and paediatric analgesic drug pharmacokinetics should facilitate a better management of childhood pain. The objective of this update is to discuss the current practice and the recent advances in pediatric pain management.  Using PubMed and the Cochrane Library we conducted an extensive literature analysis on pediatric pain assessment and commonly used analgesic agents in this kind of patients. According to our results, a multimodal analgesic regimen provides a better pain control and a functional outcome in children. Cooperation and communication among the anaesthesiologist, the surgeon and the paediatrician remains essential for successful anaesthesia and pain management in childhood.

Presepsin as a diagnostic marker of sepsis in children and adolescents: a short critical update

BACKGROUND AND AIM

Sepsis is a potentially fatal condition which strikes 1.2 million children worldwide per year. New biomarkers have been proposed in the assessment of the risk of sepsis progression and in the identification of patients with the worst outcome. This review aims to assess the diagnostic value of presepsin, a promising new biomarker, in pediatric sepsis, with particular attention to its usefulness in emergency department.

METHODS

We performed a literature search of the last 10 years to find presepsin related studies and reports concerning pediatric population aged from 0 months to 18 years. We mainly focused on randomized placebo-control studies, followed by case-control studies, observational (both retrospective or prospective), and finally systematic reviews and meta-analysis. The article selection process was carried out independently by three reviewers.   Results: A total of 60 records were identified in literature, 49 were excluded according to the exclusion criteria. The highest presepsin sensitivity value was 100%, with a high cut-off (800.5 pg/mL). The highest sensitivity-specificity ratio was 94% vs 100%, with a similar considered presepsin cut-off (855 ng/L). As regards the presepsin cut-offs reported in the various studies, several authors agree on a critical threshold of about 650 ng/L to guarantee a sensitivity> 90%. The analyzed studies show a wide variability for patients' age and presepsin risk cut-offs.   Conclusions: Presepsin seems to be a new useful marker for early diagnosis of sepsis, even in a pediatric emergency setting. Being a new marker of sepsis, more studies are required to better understand its potential.

Early treatment with N-acetylcysteine reduces hepatotoxicity in acute acetaminophen poisoning

During the outbreak of COVID19 measures taken to contain the spread of the virus have influenced the mental well-being of adults and adolescents. Acetaminophen overdose is the major cause of drug intoxication among children and adolescents. We reported a case of a 15-year- old girl referred to our Emergency Department 3 hours after ingestion of 10 g of paracetamol for suicidal purposes. She promptly started the administration of intravenous N-acetylcysteine (NAC) and the patient was discharged after 5 days of hospitalization in good clinical condition and with neuropsychiatric follow-up. Our case shows that the timing of the intravenous NAC administration is considered the most important factor in the prevention of acetaminophen-induced hepatic failure, despite high serum levels after acetaminophen ingestion.

The acute bronchiolitis rebound in children after COVID-19 restrictions: a retrospective, observational analysis

BACKGROUND AND AIM

Bronchiolitis represents the main cause of illness and hospitalization in infants and young children. The aim of this study was to compare the Pediatric Emergency Department (PED) admissions for bronchiolitis during the post-COVID (Coronavirus disease) period to those of previous seasons and to analyze their etiology during COVID and post-COVID period.

METHODS

We compared demographics, clinical and microbiological data of children admitted to PED with bronchiolitis between September 2021 and March 2022 (post-COVID period) to the previous seasons (COVID and pre-COVID period).

RESULTS

During the post-COVID period the bronchiolitis season started earlier than usual, with a peak reached in November 2021; a gradual reduction was subsequently observed between December 2021 and January 2022. Our data showed a prevalence of High Priority code in children admitted to the PED with bronchiolitis during the post-COVID period (61.4%) compared the pre-COVID period (34.8%) (p=0.00). Also regarding the hospitalization of these patients, we found a major rate of hospitalization during this epidemic season (p=0.035). In addition, only 4 (1.5%) of the tested children resulted positive for SARS-CoV-2 and all of them were admitted to PED during the post-COVID period. The search for the other respiratory viruses showed during the current season a prevalence of respiratory syncytial virus (RSV) (60.2%), followed by Human Rhinovirus (30.1%).

CONCLUSIONS

The post-COVID period was characterized by an early and short-term peak in acute bronchiolitis, with an increased rate of hospitalization. In addition, SARS-CoV-2 infection was rarely cause of bronchiolitis in children under 2 years old.

A scoping review of the management of acute mastoiditis in children: What is the best approach?

BACKGROUND

Acute mastoiditis (AM) is a severe infection of the mastoid air cells that occurs in cases of acute, sub-acute, or chronic middle ear infections. No definitive consensus regarding the management of AM has been identified. The current guidelines include a conservative approach (parenteral antibiotics alone, antibiotics plus minor surgical procedures such as myringotomy with a ventilation tube inserted or drainage of the subperiosteal abscess through retro-auricolar incision or needle aspiration) or surgical treatment (mastoidectomy). The main aim of this review was to evaluate and summarize the current knowledge about the management of pediatric AM by analyzing the current evidence in the literature.

METHODS

We examined the following bibliographic electronic databases: Pubmed and the Cochrane Library, from the inception date until February 2023. The search was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISM). The key words used for the search across electronic databases were: `mastoiditis` and `management`; `mastoiditis` and `surgery`; `mastoiditis` and `conservative`; `mastoiditis` and `antibiotics`; `mastoiditis` and `myringotomy`; `mastoiditis` and `grommet`; `mastoiditis` and `drainage`; and `mastoiditis` and `mastoidectomy`.

RESULTS

We selected 12 articles involving 1124 episodes of mastoiditis. Some of these studies considered medical therapy alone as a valid first step, whereas others considered a minor surgical intervention as an initial approach along with antibiotic therapy. Considering the studies that evaluated medical therapy as the initial sole treatment option, the success rate of antibiotics alone was 24.6%. Overall, the success rate of minor surgical procedures, excluding mastoidectomy, was 87.7%, whereas the mastoidectomy success rate was 97%.

CONCLUSIONS

Overall, there is no shared consensus on the diagnostic or therapeutic approach to mastoiditis. Conservative therapy has gained considerable ground in recent times, quite limiting the predominant role of mastoidectomy. Further studies will be necessary to definitely develop standardized protocols shared in the scientific community.

Foreign Body Ingestion in Children: Epidemiological, Clinical Features and Outcome in a Third Level Emergency Department

Ingestion of foreign bodies is a frequent pediatric cause of access to the Emergency Department (ED). The aim of this study was to determine the epidemiological and clinical features of pediatric patients with a diagnosis of foreign body ingestion and to identify the factors associated with an urgent invasive procedure or hospitalization. This is a retrospective study conducted on a population of 286 pediatric patients (0-17 years) evaluated for foreign body ingestion at the Pediatric ED of "Fondazione Policlinico Universitario A. Gemelli, IRCSS" between October 2014 and June 2019. Data concerning age and gender, underlying diseases, type of foreign body, symptoms and signs, instrumental tests, specialist visits, treatment and outcome were analyzed. The majority of foreign bodies were coins (23%). Symptoms recurred in 50% of the foreign bodies with esophageal localization and between the 92 (32%) patients with symptoms the most common was vomiting (7%). X-rays was performed in 61% of patients. Among all patients, 253 patients (88.8%) had been discharged, 21 (7%) had been hospitalized, and four (1.4%) were sent to an outpatient facility. Besides, 17 (5.9%) patients had been transferred to the Observation Unit. Of the hospitalized patients (21 (7.3%)), clinical observation was performed for 57% and endoscopic procedure for 45%. Our data confirm that the ESPGHAN-ESGE guidelines application prevents interventions that are not necessary, avoiding diagnostic and therapeutic delays.

Atypical Reye syndrome: three cases of a problem that pediatricians should consider and remember

INTRODUCTION

Reye syndrome is a rare acquired metabolic disorder appearing almost always during childhood. Its aetiopathogenesis, although controversial, is partially understood. The classical disease is typically anticipated by a viral infection with 3-5 days of well-being before the onset of symptoms, while the biochemical explanation of the clinical picture is a mitochondrial metabolism disorder, which leads to a metabolic failure of different tissues, especially the liver. Hypothetically, an atypical response to the preceding viral infection may cause the syndrome and host genetic factors and different exogenous agents, such as toxic substances and drugs, may play a critical role in this process. Reye syndrome occurs with vomiting, liver dysfunction and acute encephalopathy, characterized by lack of inflammatory signs, but associated with increase of intracranial pressure and brain swelling. Moreover, renal and cardiac dysfunction can occur. Metabolic acidosis is always  detected, but diagnostic criteria are not specific. Therapeutic strategies are predominantly symptomatic, in order to manage the clinical and metabolic dysfunctions.

CASE REPORTS

We describe three cases of children affected by Reye syndrome with some atypical features, characterized by no intake of potentially trigger substances, transient hematological changes and dissociation between hepatic metabolic impairment, severe electroencephalographic slowdown and slightly altered neurological examination.

CONCLUSIONS

The syndrome prognosis is related to the stage of the syndrome and the rapidity and the adequateness of intensive care treatments. The analysis of the patients leads to a greater awareness of the difficult diagnosis of this not well completely known syndrome.

Intranasal drugs for analgesia and sedation in children admitted to pediatric emergency department: a narrative review

Acute pain is one of the most common symptoms in children admitted to the Pediatric Emergency Department (PED) and its management represents a real clinical challenge for pediatricians. Different painful procedures can be very stressful for young children and their perception of pain can be enhanced by emotional factors, such as anxiety, distress, or anger. Adequate procedural sedation reduces anxiety and emotional trauma for the patient, but it reduces also stress for operators and the time for procedures. We have reviewed the literature on this topic and the drugs covered in these papers were: midazolam, fentanyl, ketamine, and dexmedetomidine. There are several routes of administering for these drugs to provide analgesia and anxiolysis to children: oral, parenteral, or intranasal (IN). Intravenous (IV) sedation, since it involves the use of needles, can be stressful; instead, IN route is a non-invasive procedure and generally well tolerated by children and it has become increasingly widespread. Some medications can be administered by a mucosal atomizer device (MAD) or by drops. The benefits of the atomized release include less drug loss in the oropharynx, higher cerebrospinal fluid levels, better patient acceptability, and better sedative effects. IN midazolam has a sedative, anxiolytic and amnesic effect, but without analgesic properties. Fentanyl and ketamine are mainly used for pain control. Dexmedetomidine has anxiolytic and analgesic properties. In conclusion, IN analgo-sedation is a simple, rapid and painless option to treat pain and anxiety in the PED requiring brief training on the administration process and experience in sedation.

Telephone consultation during Coronavirus outbreak in a Pediatric Emergency Department: methodological approach of a tertiary care center in a COVID-19 hospital setting

OBJECTIVE

A computerized system of telephone consultation has been experimented at the Pediatric Emergency Department (ED) of Policlinico Gemelli Hospital in Rome during the outbreak of Coronavirus Disease 2019 (COVID-19).

MATERIALS AND METHODS

Twenty monothematic items with a series of questions to evaluate child's clinical conditions have been set up in order to evaluate the different situations according to their severity. All items were highlighted according to conventional scores corresponding to the different answers (yes/no) given by the child's parents. This system has been implemented with large diffusion of computer programs and applications by the availability of a computer station in every ED room.

RESULTS

The system allows healthcare workers to establish the medical check-up urgency which may be immediate, within the next 24 hours or scheduled in the pediatric ward. Therefore, it has been implemented a telephone triage consultation with a standardized method.

CONCLUSIONS

Telephone consultation during outbreaks, considering the risks of contagion, allows healthcare workers to decrease the concern of families and to reduce indiscriminate access to ED. The remote approach will not solve logistic and setting problems related to COVID-19 outbreak17, but it would be a valid tool to improve medical evaluation without deep change in infrastructure and clinical organization.

Pisotriquetral joint disorders: an under-recognized cause of ulnar side wrist pain

Pisotriquetral joint disorders are often under-recognized in routine clinical practice. They nevertheless represent a significant cause of ulnar side wrist pain. The aim of this article is to present the main disorders of this joint and discuss the different imaging modalities that can be useful for its assessment.

Incidence of bacteremias and invasive mycoses in children with acute non-lymphoblastic leukemia: results from a multi-center Italian study

BACKGROUND

Data on the epidemiology of bacteremias and invasive fungal diseases (IFD) in children with acute myeloid leukemia (AML) are scarce.

DESIGN AND METHODS

In a multi-center, retrospective study, we analyzed proportion, rate per 1,000 person-days at risk, and cumulative risk of bacteremias and IFD in children with AML.

RESULTS

Between January 1998 and December 2005, 240 children were treated for AML at 8 Italian Centers, for a total of 521 treatment courses and 63,232 person-days at risk. Bacteremia was observed in 32% of treatment courses and IFD was seen in 10% (P < 0.0001), with rates of 2.62 and 0.84, respectively (P < 0.001). There was a significantly higher frequency of IFD during relapse treatment: proportion 15% versus 9% (P = 0.05), rate 2.10 versus 0.64 (P = 0.008) and cumulative risk 32% versus 12% (P = 0.007), while there were no differences in the proportion, rate and cumulative risk of bacteremia during front-line or relapse treatment. The epidemiology of bacteremias and IFD was different during front-line therapy for M3 as compared to other types of AML, but the differences were not statistically significant.

CONCLUSIONS

Severe infectious complications are frequent during the treatment of pediatric AML, especially during relapse treatment, and bacteremias are more frequent than IFD.

Idiopathic thrombocytopenic purpura (ITP) in children

Idiopathic thrombocytopenic purpura in children remits spontaneously in the majority of cases but most children require treatment. Between 1995 and 2005, 265 children (0-15 years old) have been consecutively observed and treated: 28 children with high doses of methylprednisolone (HDMP) (15 mg/kgx4 days), 63 with HDMP (7.5 mg/kgx4 days), 37 with HD dexamethasone (DXM) pulses, 29 with low doses of MP, and 51 with different doses of intravenous immunoglobulins (IVIG) (0.4 or 0.8 g/kg). Fifty-seven children have not been treated because of a platelet count>or=10x10(9)/L and no significant bleeding. Two hundred forty-four (92.1%) children reached a persistent CR, 237 (89.4%) after a first-line treatment or the wait and see strategy. No statistically significant differences in CR related to different treatments have been observed. IVIG and HDMP (7.5 mg/kg for 4 days) are the best treatments to reach quickly safe platelet levels>or=30x10(9)/L (3-6 days) and CR (7-11 days). Among non-responding (NR) patients, seven have been splenectomized and three reached stable CR. These results emphasize differences with adult ITP.

Operative office hysteroscopy without anesthesia: analysis of 4863 cases performed with mechanical instruments

STUDY OBJECTIVE

To evaluate the efficacy of, and patients' satisfaction with, office hysteroscopic treatment of benign intrauterine pathologies using 5F hysteroscopic instruments.

DESIGN

Observational clinical study (Canadian Task Force classification II).

SETTING

University center.

PATIENTS

Four thousand eight hundred sixty-three (4863) women.

INTERVENTION

Office hysteroscopy without analgesia or anesthesia.

MEASUREMENTS AND MAIN RESULTS

We used 5F mechanical instruments (scissors, grasping forceps) to treat cervical and endometrial polyps ranging between 0.2 and 3.7 cm, as well as intrauterine adhesions and anatomic impediments. From 71.9% to 93.5% of women underwent the procedure without discomfort for all pathologies treated except endometrial polyps larger than the internal cervical os, for which 63.6% experienced low or moderate pain. At 3-month follow-up, pathology persisted in 364 patients (5.6%).

CONCLUSION

Simple instruments enable us to perform many operative procedures in an office setting with excellent patient satisfaction, provided that the indications are correct.

Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification

BACKGROUND

Deeply infiltrating endometriosis (DIE) is recognized as a specific entity responsible for pain. The distribution of locations and their contribution to surgical management has not been previously studied.

METHODS

Medical, operative and pathological reports of 241 consecutive patients with histologically proven DIE were analysed. DIE lesions were classified as: (i). bladder, defined as infiltration of the muscularis propria; (ii). uterosacral ligaments (USL), as DIE of the USL alone; (iii). vagina, as DIE of the anterior rectovaginal pouch, the posterior vaginal fornix and the retroperitoneal area in between, and (iv). intestine, as DIE of the muscularis propria.

RESULTS

A total of 241 patients presented 344 DIE lesions: USL (69.2%; 238); vaginal (14.5%; 50); bladder (6.4%; 22); intestinal (9.9%; 34). The proportion of isolated lesions differed significantly according to the DIE location: 83.2% (198) for USL DIE; 56.0% (28) for vaginal DIE; 59.0% (13) for bladder DIE; 29.4% (10) for intestinal DIE (P < 0.0001). The total number of DIE lesions varied significantly according to the location (P < 0.0001). In 39.1% of cases (9/23) intestinal lesions were multifocal. Only 20.6% (seven cases) of intestinal DIE were isolated and unifocal.

CONCLUSIONS

Multifocality must be considered during the pre-operative work-up and surgical treatment of DIE. We propose a surgical classification based on the locations of DIE. Operative laparoscopy is efficient for bladder, USL and vaginal DIE. However, indications for laparotomy still exist, notably for bowel lesions.

Indications and outcome for intensive care unit admission during puerperium

BACKGROUND

A significant decrease of maternal mortality related to improvement in diagnosis and prevention of disorders in pregnancy has been observed without a similar reduction of puerperal morbidity. Objective of this study was to identify risk factors and outcome of patients, which required intensive care during puerperium.

METHODS

During the period 1987-1998 all pregnant patients, which were transferred from Department of Obstetrics and Gynecology to Intensive Care Unit (ICU) of University of Bari, were retrospectively included into the study. Several risk factors (age, preexisting diseases, gestational age, medical complication of pregnancy, mode of delivery, surgical additional procedure, fetal outcome, intrapartum transfusions, and puerperal complications) and the indications for transfer were evaluated.

RESULTS

The overall incidence of admission into Intensive Care Unit was 0.17% (41/23.694) of deliveries. Indications for admission into ICU were worsening of preeclampsia in 75.6% of cases, severe bleeding in 14.7% of cases, maternal cardiac disease stage III AHA in 4.9% of cases, pulmonary embolism and acute pulmonary oedema respectively in 2.4% of cases.

CONCLUSIONS

Transfer of patients to ICU due to hypovolemic postraumatic shock seems progressively declining thanks to modern criteria of obstetric management; on the contrary we assist to a prevalence of serious intrinsic maternal diseases often preexisting pregnancy or late consequence of preeclampsia, pulmonary embolism and sequelae of abnormal insertion of placenta.

Maternal complications after caesarean section in HIV infected women

OBJECTIVE

To assess the intervention related risk in HIV-infected women, undergoing caesarean section (CS).

SETTING

Tertiary care center for high risk obstetrics and infectious diseases in pregnancy.

PATIENTS AND METHODS

Thirty-three HIV-positive women and one hundred and sixty-eight controls, cross matched for age, weight, parity, obstetrical characteristics at delivery and indication for CS, were prospectively recruited for the study. Infection related characteristics, as mode of acquisition, drug abuse, immune status and stage of disease were also recorded. Complications of the intervention were evaluated according to infectious status and risk factors.

RESULTS

Post-operative complications were significantly more frequent among HIV-infected mothers. More advanced disease and maternal age were the risk factors statistically related to complications.

DISCUSSION

According to our data, CS carries a higher chance of post-operative complications in HIV-infected women, these complications being also related with the severity of infection (stage and duration of the disease). Given the characteristics of the population in the study (mode of acquisition, prevalence of early stage of the disease), the rate of complication is still relatively low compared to non-western, malnourished, drug-abusers groups.

[Ehlers-Danlos syndrome and pregnancy. Report of a case with favourable outcome]

Ehlers-Danlos syndrome is a heterogeneous group of diseases, where connective tissue laxity is the main feature. Several pregnancy and delivery complications, mainly related to vascular and uterine rupture or to soft tissue tears, are described. A case of a full term pregnancy is reported and the clinical value of obstetrical management is discussed.