Increased bronchiolitis burden and severity after the pandemic: a national multicentric study

BACKGROUND

The coronavirus 2019 (COVID-19) related containment measures led to the disruption of all virus distribution. Bronchiolitis-related hospitalizations shrank during 2020-2021, rebounding to pre-pandemic numbers the following year. This study aims to describe the trend in bronchiolitis-related hospitalization this year, focusing on severity and viral epidemiology.

METHODS

We conducted a retrospective investigation collecting clinical records data from all infants hospitalized for bronchiolitis during winter (1st September-31th March) from September 2018 to March 2023 in six Italian hospitals. No trial registration was necessary according to authorization no.9/2014 of the Italian law.

RESULTS

Nine hundred fifty-three infants were hospitalized for bronchiolitis this last winter, 563 in 2021-2022, 34 in 2020-2021, 395 in 2019-2020 and 483 in 2018-2019. The mean length of stay was significantly longer this year compared to all previous years (mean 7.2 ± 6 days in 2022-2023), compared to 5.7 ± 4 in 2021-2022, 5.3 ± 4 in 2020-2021, 6.4 ± 5 in 2019-2020 and 5.5 ± 4 in 2018-2019 (p < 0.001), respectively. More patients required mechanical ventilation this winter 38 (4%), compared to 6 (1%) in 2021-2022, 0 in 2020-2021, 11 (2%) in 2019-2020 and 6 (1%) in 2018-2019 (p < 0.05), respectively. High-flow nasal cannula and non-invasive respiratory supports were statistically more common last winter (p = 0.001 or less). RSV prevalence and distribution did not differ this winter, but coinfections were more prevalent 307 (42%), 138 (31%) in 2021-2022, 1 (33%) in 2020-2021, 68 (23%) in 2019-2020, 61 (28%) in 2018-2019 (p = 0.001).

CONCLUSIONS

This study shows a growth of nearly 70% in hospitalisations for bronchiolitis, and an increase in invasive respiratory support and coinfections, suggesting a more severe disease course this winter compared to the last five years.

SARS-CoV-2-related bronchiolitis: a multicentre international study

BACKGROUND

Bronchiolitis is the main acute lower respiratory tract infection in infants. Data regarding SARS-CoV-2-related bronchiolitis are limited.

OBJECTIVE

To describe the main clinical characteristics of infants with SARS-CoV-2-related bronchiolitis in comparison with infants with bronchiolitis associated with other viruses.

SETTING, PATIENTS, INTERVENTIONS

A multicentre retrospective study was conducted in 22 paediatric emergency departments (PED) in Europe and Israel. Infants diagnosed with bronchiolitis, who had a test for SARS-CoV-2 and were kept in clinical observation in the PED or admitted to hospital from 1 May 2021 to 28 February 2022 were considered eligible for participation. Demographic and clinical data, diagnostic tests, treatments and outcomes were collected.

MAIN OUTCOME MEASURES

The main outcome was the need for respiratory support in infants testing positive for SARS-CoV-2 compared with infants testing negative.

RESULTS

2004 infants with bronchiolitis were enrolled. Of these, 95 (4.7%) tested positive for SARS-CoV-2. Median age, gender, weight, history of prematurity and presence of comorbidities did not differ between the SARS-CoV-2-positive and SARS-CoV-2-negative infants. Human metapneumovirus and respiratory syncytial virus were the viruses most frequently detected in the group of infants negative for SARS-CoV-2.Infants testing positive for SARS-CoV-2 received oxygen supplementation less frequently compared with SARS-CoV-2-negative patients, 37 (39%) vs 1076 (56.4%), p=0.001, OR 0.49 (95% CI 0.32 to 0.75). They received less ventilatory support: 12 (12.6%) high flow nasal cannulae vs 468 (24.5%), p=0.01; 1 (1.0%) continuous positive airway pressure vs 125 (6.6%), p=0.03, OR 0.48 (95% CI 0.27 to 0.85).

CONCLUSIONS

SARS-CoV-2 rarely causes bronchiolitis in infants. SARS-CoV-2-related bronchiolitis mostly has a mild clinical course.

Macrophage activation syndrome in a patient with systemic lupus erythematosus undergoing cyclophosphamide treatment: a case report

Macrophage activation syndrome (MAS) is a disorder related to hemophagocytic lymphohistiocytosis and is a life-threatening complication of rheumatic diseases. The diagnosis is challenging because MAS symptoms are quite similar to those of many active autoimmune diseases or severe sepsis. We describe the case of a female patient with systemic lupus erythematosus that presented with symptoms suggesting acute decompensation of autoimmune disease and sepsis. She was later diagnosed with MAS. Despite an aggressive immunosuppressive treatment, she developed a fatal outcome.

Children with mild hyponatremia at the emergency department are at higher risk of hospitalization

BACKGROUND

Mild hyponatremia is frequently encountered in the pediatric emergency department (PED). Although usually of little clinical concern, its prognostic meaning as a possible marker of more severe disease has not yet been well established.

METHODS

We retrospectively analyzed data from children and adolescents who performed a blood sample with plasmatic sodium measurement on admission to the PED of IRCCS "Burlo Garofolo" Pediatric Hospital in Trieste, Italy, in 2019. We compared the rate, length of admissions and laboratory characteristics of patients with hyponatremia to those with normal sodium.

RESULTS

Among 807 subjects, hyponatremia (sodium < 135 mEq/L) was present in 17.6%, being mild (between 130 and 134 mEq/L) in 16.5%. Hyponatremic patients were younger, more frequently males, with an infection diagnosis, mainly of the respiratory tract and viral aetiology. They presented higher C-reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR). Compared to normonatremic individuals, hyponatremic patients presented a higher risk of underlying infection (aOR 2.02; 95%CI 1.33-3.08), hospital admission (aOR 1.72; 95%CI 1.06-2.48), and a hospital stay of > 5 days (aOR 1.99; 95%CI 1.03-3.85). When considering only subjects with mild hyponatremia, we found similar results.

CONCLUSION

Hyponatremia and mild hyponatremia in the PED are associated with an increased admission rate and extended hospital stays. Mild hyponatremia should be considered a warning sign for a possibly more serious condition.

Increased use of high-flow nasal cannulas after the pandemic in bronchiolitis: a more severe disease or a changed physician's attitude?

After the SARS-CoV-2 pandemic, we noticed a marked increase in high-flow nasal cannula use for bronchiolitis. This study aims to report the percentage of children treated with high-flow nasal cannula (HFNC) in various seasons. The secondary outcomes were admissions for bronchiolitis, virological results, hospital burden, and NICU/PICU need. We conducted a retrospective study in four Italian hospitals, examining the medical records of all infants (< 12 months) hospitalized for bronchiolitis in the last four winter seasons (1 September-31 March 2018-2022). In the 2021-2022 winter season, 66% of admitted children received HFNC versus 23%, 38%, and 35% in the previous 3 years. A total of 876 patients were hospitalized in the study periods. In 2021-2022, 300 infants were hospitalized for bronchiolitis, 22 in 2020-2021, 259 in 2019-2020, and 295 in 2018-2019. The percentage of patients needing intensive care varied from 28.7% to 18%, 22%, and 15% in each of the four considered periods (p < 0.05). Seventy-seven percent of children received oxygen in the 2021-2022 winter; vs 50%, 63%, and 55% (p < 0.01) in the previous 3 years. NIV/CPAP was used in 23%, 9%, 16%, and 12%, respectively. In 2021-2020, 2% of patients were intubated; 0 in 2020-2021, 3% in 2019-2020, and 1% in 2018-2019.

CONCLUSION

This study shows a marked increase in respiratory support and intensive care admissions this last winter. While these severity indexes were all driven by medical choices, more reliable indexes such as intubation rate and length of stay did not change. Therefore, we suggest that there is a more aggressive treatment attitude rather than a more severe disease.

WHAT IS KNOWN

• COVID-19 pandemic deeply impacted bronchiolitis epidemiology, reducing hospitalizations to onetenth. In the 2021-2022 winter, bronchiolitis resurged to pre-pandemic numbers in Europe.

WHAT IS NEW

• Bronchiolitis hospitalization rose much faster in the 2021-2022 winter period, peaking at a higher level. Respiratory supports and high-flow nasal cannula increased significantly compared to the pre-pandemic era.

Effects of simultaneous exposure to stress and nicotine on nicotine-induced locomotor activation in adolescent and adult rats

Preclinical studies have shown that repeated stress experiences can result in an increase in the locomotor response to the subsequent administration of drugs of abuse, a phenomenon that has been termed behavioral cross-sensitization. Behavioral sensitization reflects neuroadaptive processes associated with drug addiction and drug-induced psychosis. Although cross-sensitization between stress- and drug-induced locomotor activity has been clearly demonstrated in adult rats, few studies have evaluated this phenomenon in adolescent rats. In the present study, we determined if the simultaneous exposure to stress and nicotine was capable of inducing behavioral sensitization to nicotine in adolescent and adult rats. To this end, adolescent (postnatal day (P) 28-37) and adult (P60-67) rats received nicotine (0.4 mg/kg, sc) or saline (0.9% NaCl, sc) and were immediately subjected to restraint stress for 2 h once a day for 7 days. The control group for stress was undisturbed following nicotine or saline injections. Three days after the last exposure to stress and nicotine, rats were challenged with a single dose of nicotine (0.4 mg/kg, sc) or saline and nicotine-induced locomotion was then recorded for 30 min. In adolescent rats, nicotine caused behavioral sensitization only in animals that were simultaneously exposed to stress, while in adult rats nicotine promoted sensitization independently of stress exposure. These findings demonstrate that adolescent rats are more vulnerable to the effects of stress on behavioral sensitization to nicotine than adult rats.

HHV-8 infection in patients with AIDS-related Kaposi's sarcoma in Brazil

The aims of the present study were to determine the prevalence of human herpesvirus type 8 (HHV-8) in HIV-positive Brazilian patients with (HIV+/KS+) and without Kaposi's sarcoma (HIV+/KS-) using PCR and immunofluorescence assays, to assess its association with KS disease, to evaluate the performance of these tests in detecting HHV-8 infection, and to investigate the association between anti-HHV-8 antibody titers, CD4 counts and staging of KS disease. Blood samples from 66 patients, 39 HIV+/KS+ and 27 HIV+/KS-, were analyzed for HHV-8 viremia in peripheral blood mononuclear cells by PCR and HHV-8 antigenemia for latent and lytic infection by immunofluorescence assay. Positive samples for latent nuclear HHV-8 antigen (LNA) antibodies were titrated out from 1/100 to (1/4)09,600 dilution. Clinical information was collected from medical records and risk behavior was assessed through an interview. HHV-8 DNA sequences were detected by PCR in 74.3% of KS+ patients and in 3.7% of KS- patients. Serological assays were similar in detecting anti-LNA antibodies and anti-lytic antigens in sera from KS+ patients (79.5%) and KS- patients (18.5%). HHV-8 was associated with KS whatever the method used, i.e., PCR (odds ratio (OR) = 7.4, 95% confidence interval (CI) = 2.16-25.61) or anti-LNA and anti-lytic antibodies (OR = 17.0, 95%CI = 4.91-59.14). Among KS+ patients, HHV-8 titration levels correlated positively with CD4 counts (rho 0.48, P = 0.02), but not with KS staging. HHV-8 is involved in the development of KS in different geographic areas worldwide, as it is in Brazil, where HHV-8 is more frequent among HIV+ patients. KS severity was associated with immunodeficiency, but no correlation was found between HHV-8 antibody titers and KS staging.

Acute myocardial infarction in progressively elderly patients. A comparative analysis of immediate results in patients who underwent primary percutaneous coronary intervention

OBJECTIVE

Analysis of the in-hospital results, in progressively elderly patients who undergo primary percutaneous coronary intervention (PCI) in the first 24 hours of AMI.

METHODS

The patients were divided into three different age groups (60/69, 70/79, and > or =80 years) and were treated from 7/95 until 12/99. The primary success rate and the occurrence of major clinical events were analyzed at the end of the in-hospital phase. Coronary stent implantation and abciximab use were employed at the interventionist discretion.

RESULTS

We analyzed 201 patients with age ranging from 60 to 93 years, who underwent primary PCI. Patients with ages above 70 were more often female (p=.015). Those with ages above 80 were treated later with PCI (p=.054), and all of them presented with total occlusion of the infarct-related artery. Coronary stents were implanted in 30% of the patients. Procedural success was lower in > or =80 year old patients (p=.022), and the death rate was higher in > or =70 years olds (p=.019). Reinfarction and coronary bypass surgery were uncommon events. A trend occurred toward a higher combined incidence of major in-hospital events according to increased age (p=.064).

CONCLUSION

Elderly patients (> or =70 years) presented with adverse clinical and angiographic profiles and patients > or =80 years of age obtained reduced TIMI 3 flow success rates after primary PTCA, and those > or =70 years had a higher death rate.

Seroprevalence of human herpesvirus 8 and its association with Kaposi sarcoma in Brazil

BACKGROUND

Epidemiologic studies have indicated that human herpesvirus 8 is implicated in the development of Kaposi sarcoma in different geographic areas worldwide.

GOAL

To provide information on the prevalence of human herpesvirus 8 in Brazil and its association with Kaposi sarcoma.

STUDY DESIGN

An immunofluorescence assay was performed to test 1,044 serum samples from 747 blood donors, 73 patients presenting to casualty departments, and 224 patients attending sexually transmitted disease/AIDS clinics. The sexually transmitted disease group was composed of 88 patients with HIV (40 Kaposi sarcoma positive, 48 Kaposi sarcoma negative) and 136 patients without HIV.

RESULTS

Antibodies to human herpesvirus 8-latent nuclear antigens were found in 34 blood donors (4.6%), and in seven casualty patients (9.6%). The highest frequency of human herpesvirus 8 antibodies was found in the sexually transmitted disease group: 32 HIV-positive patients with Kaposi sarcoma (80%) and seven patients without Kaposi sarcoma (14.6%).

CONCLUSION

The presence of human herpesvirus 8 in patients with HIV was strongly associated with Kaposi sarcoma (odds ratio, 23.4; 95% CI, 7.7-71.4), male gender, homosexual or bisexual orientation, and hepatitis B virus infection, but not with the other sexually transmitted diseases that were investigated.

Cloning and characterization of polyphosphate kinase and exopolyphosphatase genes from Pseudomonas aeruginosa 8830

Pseudomonas aeruginosa accumulates polyphosphates in response to nutrient limitations. To elucidate the function of polyphosphate in this microorganism, we have investigated polyphosphate metabolism by isolating from P. aeruginosa 8830 the genes encoding polyphosphate kinase (PPK) and exopolyphosphatase (PPX), which are involved in polyphosphate synthesis and degradation, respectively. The 690- and 506-amino-acid polypeptides encoded by the two genes have been expressed in Escherichia coli and purified, and their activities have been tested in vitro. Gene replacement was used to construct a PPK-negative strain of P. aeruginosa 8830. Low residual PPK activity in the ppk mutant suggests a possible alternative pathway of polyphosphate synthesis in this microorganism. Primer extension analysis indicated that ppk is transcribed from a sigmaE-dependent promoter, which could be responsive to environmental stresses. However, no coregulation between ppk and ppx promoters has been demonstrated in response to osmotic shock or oxidative stress.

Novel pathway for conversion of chlorohydroxyquinol to maleylacetate in Burkholderia cepacia AC1100

Burkholderia cepacia AC1100 metabolizes 2,4,5-trichlorophenoxyacetic acid (2,4,5-T) via formation of 5-chlorohydroxyquinol (5-CHQ), hydroxyquinol (HQ), maleylacetate, and beta-oxoadipate. The step(s) leading to the dechlorination of 5-CHQ to HQ has remained unidentified. We demonstrate that a dechlorinating enzyme, TftG, catalyzes the conversion of 5-CHQ to hydroxybenzoquinone, which is then reduced to HQ by a hydroxybenzoquinone reductase (HBQ reductase). HQ is subsequently converted to maleylacetate by hydroxyquinol 1,2-dioxygenase (HQDO). All three enzymes were purified. We demonstrate specific product formation by colorimetric assay and mass spectrometry when 5-CHQ is treated successively with the three enzymes: TftG, TftG plus HBQ reductase, and TftG plus HBQ reductase plus HQDO. This study delineates the complete enzymatic pathway for the degradation of 5-CHQ to maleylacetate.

[Gastric neoplasia in pregnancy: report of a case]

CASE REPORT

Gastric cancer in a 29 years old pregnant woman. A total of 109 cases were collected in the whole from 1916 to 1988; to these, we add one new case of a 29 years old pregnant woman observed in 1993 in Verona University Surgical Sciences Department.

DISCUSSION

Cancer of the digestive tract during pregnancy is really rare and has poor prognosis. The diagnosis during pregnancy is difficult because the symptoms are frequently masked by factors related to the normal first trimester in pregnancy. X-ray are often restricted. Gastroendoscopy is applied to pregnant women only when evident symptoms are present such as: severe anemia, jaundice and weight loss. The incidence of inoperable cases is elevated such as the mortality in the operated cases. The whole survival rate after three years is 21%.

CONCLUSION

Gastric cancer in pregnancy has a poor prognosis. The possible reasons are: delayed detection, low differentiation degree, restricted therapeutic approach because of pregnancy, personal factors as the patients' desire for a child, religious, ethical considerations.

[Splenic epidermoid cyst. Clinical case and review of the literature]

The occasional discovery of an epidermoid cyst of the spleen, rare kind of lesion, in a 25 years old man who underwent a US for urethral colic, permit to the authors a review of the literature. Treatment is individualized in a partial or total splenectomy.

[Perforated diverticulum of the cecum: a difficult preoperative diagnosis]

A patient was admitted for a suspected appendicitis; occasionally, a roentgenogram of abdomen, an echography and a tomography: confirmed the suspect. At laparotomy a perforated diverticulum of cecum is suddenly reported: a segmentary resection of ascending colon is performed. Authors remark, according to literature, that preoperative diagnosis of perforated cecal diverticulum is difficult even today, in spite of diagnostic procedures.

[Cystic lymphangioma of the transverse mesocolon simulating neoplasm of the pancreatic tail]

Mesenteric cysts are uncommon lesions interesting surgeons above all for frequently difficulties in the preoperatory diagnosis. The role of radiology is to demonstrate the nature of these abdominal masses, but only with surgery we can establish a definitive histologic diagnosis. The authors report a case of a lynphangioma of the transverso mesocolon, miming a pancreatic neoplasm.

Cloning, sequencing, and expression in Escherichia coli of the Bacillus pumilus gene for ferulic acid decarboxylase

The Bacillus pumilus gene encoding a ferulic acid decarboxylase (fdc) was identified and isolated by its ability to promote ferulic acid decarboxylation in Escherichia coli DH5 alpha. The DNA sequence of the fdc gene was determined, and the recombinant enzyme produced in E. coli was purified and characterized.

[When to combine internal sphincterotomy with hemorrhoidectomy]

396 patients, treated with hemorrhoidectomy (278 Parks, 118 Milligan-Morgan) were submitted to preoperative manometry, which, in 158 patients (39.9%), revealed high anal resting pressure (TBS), with or without an associated anal fissure; this group was submitted to a regulated lateral sphincterotomy (SILR) in association with the haemorroidectomy. The manometric follow-up, two mounts after the operations showed similar TBS values in both groups of patients. The authors conclude that normal values of TBS after Hemorroidectomy can be reached only by associating sphincterotomy in manometrically selected cases.

[Anorectal manometry in hemorrhoidal disease]

Manometry is an important approach to anorectal function. In the haemorrhoids the evaluation of the anal resting tone, of the squeeze and of the sphincterial length is very useful to realize the best surgical treatment. Anorectal manometry is neither invasive nor expensive; it can be ready repeated and the results are reproducible. This examination must be considerated as essential part of the diagnostic routine of the anorectal diseases.

[Submucosal reconstructive hemorrhoidectomy (A.G. Parks operation)]

Indications and procedure of submucosal reconstructive hemorrhoidectomy (A.G. Parks hemorrhoidectomy) are described and discussed. This procedure is more difficult and time consuming than other techniques, but results are better in high degree hemorrhoids. Authors consider complications and sequelae on 278 patients operated in their Department.

[Cervical-mediastinal emphysema of abdominal origin]

Cervical mediastinic emphysema usually does not demand emergency procedures: nevertheless its ethiology must be promptly assessed though his achievement may prove less than easy owing the vague clinical presentation and to the limits imposed by regional topography. Among the possible etiologic factors one should take into account the rare abdominal source too. Indeed the cervical region is connected to the retroperitoneal space through a virtual "visceral space" via the thoracic cavity and some diaphragmatic break-throughs variable in size. The communication allows, in some pathologic conditions, the unopposed circulation of air and fluids. Our interest in the topic is due to the occurrence of a cervical mediastinic emphysema in a patient suffering from a colonic perforation.

[Appendicular mucocele. A report of a case diagnosed preoperatively]

Mucocele of the appendix is an unusual clinical entity. Despite a recognized constellation of findings, the diagnosis is not usually made prior to surgical exploration. A 35 year old man is reported in whom clinical evaluation, including US and CT scans, resulted in the correct preoperative diagnosis confirmed at surgery and leading to appropriate operative decisions.

[Evaluation of the tolerance of a lipid emulsion administrated during total parenteral nutrition in surgical patients]

Tolerance's evaluation of a lipid emulsion given in course of parenteral total nutrition in surgical patient's. The first fat emulsions for intravenous application were thrown on the market in the 1920's years. Authors make a study on a limited sample of surgical patients about type and incidence of both immediate and late adverse reactions versus intravenous administration of Lipofundin S. They also suggest, on the same time, a protocol for the survey of these reactions. The results suggest a good tolerance to Lipofundin S intravenous administration and no influence on haematic biochemical parameters.

[Rare colonic occlusions: volvulus of the splenic flexure]

Authors report a case of perforated splenic flexure volvulus, treated with resection, end colostomy and closure of the distal stump. From the revision of literature it comes out the case reported is the 30th recorded till now, the 6th with ischemic complications, and the only one with perforation. Actual pathogenetic trends and various therapeutic options are reported.

[Laparoscopic cholecystectomy: considerations on the technique]

The Authors analyze the single steps of laparoscopic cholecystectomy and describe the technique usually preferred. On the basis of the experience acquired, advantages and disadvantages of each manoeuver and instrument available are pointed out.

[Biliary pathology in chronic pancreatitis]

The authors expose in a very accurate discussion the biliary pathology during chronic pancreatitis. They divide the biliary lesions into associated with pancreatitis and secondary to chronic pancreatitis. They emphasize the necessity to practise a detailed study of the biliary tract in all patients affected by chronic pancreatitis and the good results showed by a very simple surgical act.