Clinical Course, Laboratory Findings, and Prognosis of SARS-CoV-2 Infection in Infants up to 90 Days of Age: A Single-Center Experience and a Proposal for a Management Pathway

AIM

To provide a comprehensive description of the clinical features, biochemical characteristics, and outcomes of infants up to 90 days old with COVID-19. Moreover, to assess the severity of the disease and propose an effective management pathway.

METHODS

Retrospective single-center study spanning three years. Patient data includes age, sex, symptoms, comorbidities, blood and urine test results, cultures, admission, length of stay, therapies, intensive care unit admission, and mortality.

RESULTS

A total of 274 patients were enrolled in the study, comprising 55% males. Among them, 60 patients (22%) were under the age of 29 days, while 214 (78%) fell within the 29 to 90 days age range. The overall incidence of SARS-CoV-2 infections was 0.28 per 10,000 Pediatric Emergency Department admissions. Blood inflammatory markers showed no significant abnormalities, and there were no recorded instances of positive blood cultures. Less than 1% of infants showed urinary tract infections with positive urine cultures, and 1.5% of patients had a concurrent RSV infection. Hospitalization rates were 83% for neonates and 67% for infants, with a median length of stay (LOS) of 48 h for both age groups. None of the patients required admission to the Pediatric or Neonatal Intensive Care Unit, and only one required High Flow Nasal Cannula (HFNC). No secondary serious bacterial infections were observed, and all hospitalized patients were discharged without short-term sequelae. No deaths were reported.

DISCUSSION AND CONCLUSIONS

Infants with COVID-19 generally exhibit milder or asymptomatic forms of the disease, making home management a viable option in most cases. Blood tests, indicative of a mild inflammatory response, are recommended primarily for children showing symptoms of illness. Hospitalization precautions for infants without apparent illness or comorbidities are deemed unnecessary. Given the evolving nature of experiences with COVID-19 in infants, maintaining a high level of clinical suspicion remains imperative.

Peri-partum respiratory management of pregnant women with neuro-muscular disorders: a prospective observational study (IT-NEUMA-Pregn study)

BACKGROUND

Pregnant women with neuromuscular diseases (NMDs) often display respiratory muscle impairment which increases the risk for pulmonary complications (PCs). The aim of this study was to identify pregnant NMDs patients with pulmonary risk factors and to apply in these women non-invasive ventilation (NIV) combined with mechanical insufflation-exsufflation (MI-E) in the peri-partum period.

METHODS

We conducted a multicenter observational study on women with NMDs undergoing cesarean section or spontaneous labor in a network of 7 national hospitals. In these subjects we applied a protocol for screening and preventing PCs, and we evaluated PCs rate, maternal and neonatal outcome.

RESULTS

Twenty-four patients out of the 94 enrolled pregnant women were at risk for PCs and were trained or retrained to use NIV and/or MI-E before delivery. After delivery, 17 patients required NIV with or without MI-E. Despite nine out of the 24 women at pulmonary risk developed postpartum PCs, none of them needed reintubation nor tracheostomy. In addition, the average birth weight and Apgar score were normal. Only one patient without pulmonary risk factors developed postpartum PCs.

CONCLUSION

This study showed the feasibility of applying a protocol for screening and treating pregnant NMDs women with pulmonary risk. Despite a PCs rate of 37% was observed in these patients, maternal and neonatal outcome were favorable.

Effectiveness of Intranasal Analgesia in the Emergency Department

In the Emergency Department (ED), pain is one of the symptoms that are most frequently reported, making it one of the most significant issues for the emergency physician, but it is frequently under-treated. Intravenous (IV), oral (PO), and intramuscular (IM) delivery are the standard methods for administering acute pain relief. Firstly, we compared the safety and efficacy of IN analgesia to other conventional routes of analgesia to assess if IN analgesia may be an alternative for the management of acute pain in ED. Secondly, we analyzed the incidence and severity of adverse events (AEs) and rescue analgesia required. We performed a narrative review-based keywords in Pubmed/Medline, Scopus, EMBASE, the Cochrane Library, and Controlled Trials Register, finding only twenty randomized Clinical trials eligible in the timeline 1992-2022. A total of 2098 patients were analyzed and compared to intravenous analgesia, showing no statistical difference in adverse effects. In addition, intranasal analgesia also has a rapid onset and quick absorption. Fentanyl and ketamine are two intranasal drugs that appear promising and may be taken simply and safely while providing effective pain relief. Intravenous is simple to administer, non-invasive, rapid onset, and quick absorption; it might be a viable choice in a variety of situations to reduce patient suffering or delays in pain management.

Impact of COVID-19 pandemic on major depressive disorder in acute psychiatric inpatients

Introduction

The spread of the coronavirus disease 2019 (COVID-19) pandemic and the subsequent restrictions significantly affected mental health, especially major depressive disorder (MDD) whose incidence increased by 27.6% in 2020, after the COVID-19 outbreak. Few studies focused on the impact of the pandemic on the clinical characteristics of outpatients with MDD and even fewer on inpatients admitted for a major depressive episode (MDE). We aimed to compare the characteristics of MDD of two groups of patients admitted for an MDE before and after the pandemic outbreak and to investigate which variables are significantly related to post-lockdown hospitalizations.

Methods

This retrospective study included 314 patients with MDD hospitalized from January 2018 to December 2021 for an MDE (DSM-5) before (n = 154) and after (n = 160) the Italian lockdown (9th of March 2020). We compared patients' sociodemographic and clinical characteristics. The characteristics significantly different between the two groups were included in a logistic regression to identify the factors more strictly associated with post-lockdown hospitalizations.

Results

During post-lockdown hospitalization, we found a higher rate of severe MDE (33 patients, 21.4%, in the pre-lockdown and 55 patients, 34.4%, in the post), MDE with psychotic features (3 patients, 2.0%, in the pre-lockdown and 11 patients, 6.9%, in the post-lockdown), and suicidal ideation (42, 27.3%, in the pre-lockdown and 67, 41.9%, in the post-lockdown), with a lower proportion of patients followed by psychiatric services before admission (106 patients, 68.8%, in the pre-lockdown and 90 patients, 56.3%, in the post-lockdown) and a higher percentage of them in treatment with psychotherapy (18 patients, 11.7% in the pre-lockdown and 32, 20.0%, in the post-lockdown) and more frequent increase of the antidepressant dosage (16 patients, 10.4% in the pre-lockdown and 32 patients, 20.0% in the post-lockdown) and adoption of augmentation strategies (13 patients, 8.4%, in the pre-lockdown and 26 patients, 16.3%, in the post-lockdown) to treat the MDE. In the regression model, post-lockdown hospitalizations were significantly associated with suicidal ideation (OR = 1.86; p = 0.016) and psychotic features (OR = 4.41; p = 0.029) at admission, the increase in the antidepressant daily dose (OR = 2.45; p = 0.009), and the employment of an augmentation therapy (OR = 2.25; p = 0.029).

Discussion

These results showed an association between the COVID-19 pandemic and the occurrence of MDE with more severe clinical features. This might be true also for future calamities, suggesting that in these emergency contexts, patients with MDD would require more attention, resources, and intense treatments with a specific focus on suicide prevention.

Real-World Functioning in Psychiatric Outpatients: Predictive Factors

Introduction: Investigations on predictors of real-world functioning were mainly performed in patients with schizophrenia, while fewer studies have been conducted in other psychiatric disorders. Objective: Our objective was to identify clinical, socio-demographic, and illness-related predictors of real-world functioning during 12 months of standard treatments in outpatients with different diagnoses. Methods: Outpatients (n = 1019) with schizophrenia (SZ), major depressive disorder (MDD), bipolar disorder (BD), and borderline personality disorder (BPD) were evaluated with the following tools: SCID-5-CV and SCID-5-PD, CGI-S, SAT-P, DAI-10, and PSP. Change of PSP (ΔPSP) between baseline and 12 months was used as the dependent variable in multiple regression analysis. Results: Higher PSP score at baseline and the achievement of main milestones predicted better functioning after follow-up in all subgroups of patients, with the exception of BD. In the total sample, ΔPSP was related to age of onset, treatments, and quality of life, and inversely related to psychiatric anamnesis, antidepressants, and global symptoms. In SZ, ΔPSP was related to adherence and quality of life. In MDD, ΔPSP was related to psychotherapy and quality of life, and inversely related to antidepressants and global symptoms. In BD, ΔPSP was related to age of onset, antipsychotics, and quality of life, while it was inversely related to psychiatric anamnesis. In BPD, antipsychotics, mood stabilizers, psychotherapy, and quality of life were directly related to ΔPSP, while suicidal attempts and global symptoms had an inverse relation. Conclusions: Several socio-demographic and illness-related variables predicted improvement of real-world functioning, besides psychopathology and severity of the disease.

Impact of the first Covid-19 pandemic wave on first episode psychosis in Milan, italy

The ongoing Corona Virus Disease 2019 (COVID-19) pandemic appears to increase risk for mental illness, either directly due to inflammation caused by the virus or indirectly due to related psychosocial stress, resulting in the development of both anxious-depressive and psychotic symptoms. The purpose of the present study was to assess the frequency and characteristics of all patients with First Episodes Psychosis (FEP) without COVID-19 infection hospitalized in the first four months since lockdown in Milan. We recruited sixty-two patients hospitalized between March 8 to July 8, 2020 versus those first  hospitalized in the same period in 2019. The two subgroups were compared for sociodemographic variables and clinical characteristics of the episodes. Patients with FEP in 2020 were significantly older than patients with FEP in 2021, and presented with significantly less substances abuse. Interestingly, patients presenting with FEP in 2020 were significantly older than patients with FEP in 2019. These data are compatible with the greater vulnerability to stressful factors during the pandemic, as well as with the greater concern regarding a possible COVID-19 infection producing brain damage causing the FEP.

[Combined left atrial appendage percutaneous closure and atrial fibrillation ablation: a single center experience]

BACKGROUND

We evaluated long-term safety and efficacy of concomitant left atrial appendage (LAA) closure and atrial fibrillation (AF) ablation.

METHODS

From February 2013 to June 2017, all patients referred for AF ablation and LAA closure (group 1) were enrolled in the study and compared with a matched control group undergoing AF ablation only (group 2). Pulmonary vein isolation was achieved in all cases with radiofrequency or cryoballoon. LAA was occluded with Watchman or Amplatzer Cardiac Plug or Amulet (ACP) devices. All patients were treated with oral anticoagulation therapy for at least 3 months after the procedure ("blanking period"), and then switched to dual antiplatelet therapy with aspirin and clopidogrel for other 3 months, and then to single antiplatelet therapy with aspirin in case of LAA closure, while group 2 was treated with long-term oral anticoagulation therapy according to CHA2DS2-VASc score. Follow-up was performed with transesophageal echocardiography and clinical visit at 3, 6 and 12 months after the procedure. AF burden was evaluated by loop recorder or pacemaker interrogation in all patients.

RESULTS

Overall, 42 patients were enrolled, 21 in each group. Mean age was 66.86 ± 10.35 years in group 1 vs 68.42 ± 10.61 in group 2 (p=NS); mean CHA2DS2-VASc score was 2.8 ± 1.22 in group 1 vs 2.01 ± 0.93 in group 2 (p=NS), mean HAS-BLED score was 3.2 ± 0.83 in group 1 vs 3.1 ± 0.95 in group 2 (p=NS). Persistent AF was present in 80% of patients in group 1 and in 85% in group 2. LAA closure was successful in all cases (14 Watchman, 7 ACP devices). Procedural and fluoroscopy times were shorter in group 2 (68 ± 17 vs 52 ± 15 min, p <0.05; 23 ± 5 vs 18 ± 3 min, p <0.05, respectively). No procedural complications were observed in group 2, while in group 1 one case of self-terminating pericardial effusion and one arteriovenous fistula were observed. At a mean follow-up of 14.93 ± 10.05 months, complete seal of LAA was documented in all patients, with neither dislocations nor thromboembolic events. Similarly, no long-term complications were observed in group 2. Maintenance of sinus rhythm was overlapping, with an AF relapse rate of 36% in group 1 vs 38% in group 2 (p=NS).

CONCLUSIONS

Combined LAA percutaneous closure and AF ablation appears to be feasible in high-risk patients.

Antimicrobial action of Nitens mouthwash (cetyltrimethylammonium naproxenate) on multiple isolates of pharyngeal microbes: a controlled study against chlorhexidine, benzydamine, hexetidine, amoxicillin, amoxicillin-clavulanate, clarithromycin, and cefaclor

BACKGROUND

Acute oropharyngeal and respiratory tract infections are due to a wide spectrum of microorganisms. The aim of this study was to compare and evaluate the in vitro activity of four antiseptics (cetyltrimethylammonium naproxenate, chlorhexidine, benzydamine, hexetidine) to four antibiotics (amoxicillin, amoxicillin-clavulanate, clarithromycin, cefaclor) on strains of Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pyogenes and Streptococcus pneumoniae.

METHODS

Susceptibility tests were performed on 90, aerobic and anaerobic, bacterial strains, isolated from nasopharyngeal swabs and sputum. Minimum inhibitory concentrations (by microdilution) and minimum bactericidal concentrations were determined and compared.

RESULTS

Our selected panel of bacteria was highly susceptible to the antiseptics, particularly to chlorhexidine and naproxenate, even more so than two of the most frequently used antibiotics. Data were statistically significant (p < 0.005).

CONCLUSIONS

In view of their bactericidal and anti-inflammatory properties, these antiseptics may be effective in controlling the transitory colonization of the oral cavity by microbes that cause or worsen disease in patients with mild infections.

The in vitro effects of cetyltrimethylammonium naproxenate on oral and pharyngeal microorganisms of various ecological niches

The purpose of this study was to determine the in vitro susceptibility to cetyltrimethylammonium naproxenate for various aerobic and anaerobic micro-organisms responsible for oral and pharyngeal diseases by assessing the minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) or minimum fungicidal concentrations (MFCs) and by determining kill-times. The MICs of cetyltrimethylammonium naproxenate for 46 tested strains (25 reference strains and 21 clinical isolates) ranged from 8 to 500 micrograms/ml. The MIC was found to be 31.25 micrograms/ml for 36% of the reference strains. Even lower MIC values (15.63 micrograms/ml) were observed for some anaerobic strains, for Haemophilus influenzae and for Candida tropicalis. MIC and MBC values corresponded for the majority of strains tested while the MFC for C. tropicalis and C. albicans was much higher. Only 9.5% of the clinical isolates gave a MIC value of 31.25 micrograms/ml. Enterococcus faecalis, Streptococcus pyogenes and Staphylococcus aureus showed MIC at 62.5 micrograms/ml. The MIC and MBC values among the isolates were comparable, while the MFC value for the yeasts was greater. A concentration of 125 micrograms/ml of cetyltrimethylammonium naproxenate inhibited the growth of all bacteria, except Enterobacteriaceae and Pseudomonaceae, and yeasts. Cetyltrimethylammonium naproxenate shows very rapid kill-time for S. sanguis (0"), and rapid (15") for S. pyogenes, S. dysgalactiae and S. mutans and for Moraxella catarrhalis, while a longer kill-time was necessary for the other microbes tested.

Prevalence of antimicrobial resistance in eighty clinical isolates of Helicobacter pylori

We studied the in vitro susceptibility of 80 Helicobacter pylori clinical isolates to several antimicrobials commonly used to treat the infection, using the Epsilometer test (E-test). We also compared E-test and disk diffusion test in determining H. pylori susceptibility to the same antibiotics. We found a high prevalence of H. pylori strains resistant to metronidazole (23.7%), whereas the prevalence of H. pylori strains resistant to clarithromycin was 10%. Also, a significant correlation was found between MICs obtained with the disk diffusion test and E-test for metronidazole and clarithromycin. In conclusion, our study confirms a high prevalence of metronidazole- or clarithromycin-resistant H. pylori strains. Also, our data suggest that the E-test is a single, reliable, and cost-effective method to assess in vitro susceptibility of H. pylori to antimicrobial agents commonly used to eradicate the infection.

Reduced left ventricular mechanical efficiency in elderly patients with coronary artery disease

We evaluated left ventricular (LV) mechanical efficiency in 23 elderly patients (mean age 67 +/- 2) with coronary artery disease (CAD) and in 22 patients younger than 65 years (mean age 49 +/- 8) with similar severity of CAD (2.4 +/- 0.8 and 2.2 +/- 0.8 vessels per patient, respectively) and history of myocardial infarction (34% and 41%, respectively). LV mechanical efficiency was calculated as the ratio of LV work per minute and myocardial O2 consumption. LV stroke volume was calculated from left ventriculography. Coronary blood flow was measured by thermodilution. Older patients had lower values of LV stroke volume (49 +/- 16 vs 73 +/- 16 mL, p < 0.005), ejection fraction (41 +/- 17 vs 58 +/- 17%, p < 0.05), LV stroke work (93 +/- 26 vs 131 +/- 41 g.m., p < 0.02) and LV work per minute (6.7 +/- 2.6 vs 9.3 +/- 2.7 kg.m./min, p < 0.05). Since myocardial O2 consumption was similar in the two groups, LV mechanical efficiency was lower in older CAD patients (16.2 +/- 15 vs 23.8 +/- 12%, p < 0.05). Thus, elderly patients with CAD show a reduced LV mechanical pump performance and efficiency, compared with younger patients with similar disease severity and history of myocardial infarction. These observations may contribute to understanding the higher frequency of congestive heart failure in elderly patients with CAD.

[Reduced endothelium-dependent peripheral vasodilation in the aged]

Endothelial dysfunction may be present years before the clinical manifestations of atherosclerosis, which is particularly frequent in the late decades of life. Therefore, we have evaluated the presence of endothelial dysfunction in the elderly by measuring, by echo-Doppler technique, the vasodilatation of brachial artery in response to the hyperemia following forearm occlusion and decompression, a response that is dependent on endothelial function. We studied 10 subjects > 65 years (mean 72 +/- 8) and 10 subjects < 65 years (mean 40 +/- 6) all without clinical signs and without risk factors for atherosclerosis. The increase in brachial arterial flow during reactive hyperemia was similar in the young and elderly subjects (152 +/- 74% vs 129 +/- 63%, NS). While in the young at peak hyperemia we found a significant increase in brachial artery diameter from 3.4 +/- 0.9 to 4.1 +/- 1.0 mm (p < 0.005), there was no significant change in the elderly (from 3.0 +/- 0.7 to 3.1 +/- 0.7 mm, NS). In both groups sublingual glyceryl trinitrate produced a significant increase in brachial artery diameter (from 3.0 +/- 0.7 to 3.5 +/- 0.8 mm in the elderly, p < 0.01, and from 3.4 +/- 0.9 to 3.9 +/- 0.9 mm in the young subjects, p < 0.01, NS among groups), showing the absence in the elderly of structural vascular changes potentially responsible for absence of dilatation. In conclusion, elderly subjects without clinical signs or risk factors for atherosclerosis have a vascular endothelial dysfunction that may play an important role in pathologic processes of the cardiovascular system in the late decades of life.

Use of an endolaparoscopic probe in conservative management of Fallopian pregnancy

The incidence of extrauterine pregnancy has shown an increasing trend, exceeding one out of every 100 term pregnancies. This has resulted in the development of more and more conservative surgical treatments in order to retain the fertility of women. The use of operative laparoscopy has led to progress being made in this direction, due to reduced tissue trauma and a reduction in the number of peritoneal adhesions. Tubal isthmic pregnancies tend to cause an irregular increase in the size of the whole tube, which causes problems for pinpointing the exact site of the ectopic implantation. It is often necessary to make a longitudinal incision in the tubal wall to identify the chorionic tissue and remove it completely. In an attempt to avoid this unnecessarily extensive surgery, we used an echographic sector probe under laparoscopic control to locate the exact area of the ectopic implantation. We found it was possible to remove the villous tissue through a very short and precise cut in the tubal wall which facilitated the drainage of the lumen and reduced the bleeding normally associated with more extensive tubal surgery. Hysterosalpingographic follow-up studies after 2 months showed good tubal recanalization.

Preclinical comparative evaluation of aminoglycosides

Five aminoglycoside antibiotics including gentamicin, sisomicin, tobramycin, amikacin and netilmicin were comparatively tested in vitro against 283 clinical isolates of Pseudomonas, Enterobacteriaceae and Gram-positive cocci, using the agar dilution technique according to I.C.S. recommendations. In respect to potency by weight, netilmicin proved the most active aminoglycoside against E. coli, K. pneumoniae, Enterobacter, Serratia spp. and Staphylococcus aureus, followed by sisomicin or tobramycin in relation to various bacterial species. Against Pseudomonas aeruginosa, sisomicin and tobramycin had the lowest MICs (minimum inhibitory concentrations). Amikacin had overall less activity but the widest spectrum. Rate of killing curves showed few differences among the aminoglycosides tested. Against gentamicin-resistant strains (MIC greater than or equal to 16 micrograms/ml) the activity of netilmicin was comparable to or higher than that of amikacin, except for P. aeruginosa, P. cepacia and indole-positive Proteus, which were inhibited by amikacin only. Netilmicin also showed the highest "therapeutical index" calculated as the ratio between MIC and blood levels for each aminoglycoside against each most important bacterial specie.

Regional services for children and youth with diabetes

A regional diabetes program for children and youth comprising outreach clinics, frequent routine and emergency telephone contact, and a camping program was developed within the State Children's Medical Services (Crippled Children's) Program. The pediatric nurse specialist in diabetes served as the pivotal professional in the education and supervision of patients. Cost benefit was calculated from estimated hospital days prevented based on average length of admissions at diagnosis (14 days) and hospital days in the year prior to referral of those with established diabetes. During the first year 369 hospital days were prevented, for an estimated savings of $65,000; the second year 547 hospital days were avoided, a value of $96,000. Total annual program costs to the state and private patients (including camp fees) were $36,000. Although hospital costs are an apparent and useful reference to justify funding, the main value of the program must be in the prevention of secondary physical and emotional disability. This requires continuous commitment and availability of persons who know the patient and family, who can interpret information related to metabolic control of diabetes, and who are able to influence the family and community to respond appropriately to the youngster's needs.

Joint contracture--common manifestation of childhood diabetes mellitus

Sixty-five of 229 seven to eighteen-year-old campers with diabetes were found to have contractures of finger joints; in two thirds of affected children only the fifth finger was involved. Stiff resistance to passive finger manipulation and thickened adherent skin over the dorsa of the hands were additional features. Short stature was associated with involvement of more than one finger; the shortest youngsters also had contractures of large joints. Joint changes were independent of age, sex, age of onset of diabetes, and control of diabetes, but correlated with duration of the diabetes.