Timeline of diagnosed pain causes in children with severe neurological impairment

Objective

Pain's causes in children with severe cognitive impairment may be challenging to diagnose. This study aimed to investigate if there is a relationship between pain causes and the age of children.

Methods

We conducted a multicenter retrospective study in three Italian Pediatric Units. Eligible subjects were patients from 1 to 18 years with severe neurological impairment. We collected data regarding diagnoses, pain causes and medical or surgical procedures. The timing of pain episodes was categorized into age-related periods: infants and toddlers (0-24 months), preschool children (3-5 years), schoolchildren (6-12 years), and adolescents (13-17 years).

Results

Eighty children with severe neurological impairment were enrolled. The mean age was 11 years (±5.8). Gastroenterological pain was most common in the first years of life (p = 0.004), while orthopaedic and tooth pain was the most typical in schoolchildren and adolescents (p = 0.001 and p = 0.02). Concerning surgical procedures, PEG placement and gastric fundoplication were significantly more common in the first 5 years of age (p = 0.03), and heart surgery was typical of infants (p = 0.04). Orthopaedic surgery was more commonly reported in older children and adolescents (p < 0.001).

Conclusions

Some causes of pain are more frequent in children with severe neurological impairment in defined age-related periods. Specific age-related pain frequencies may help physicians in the diagnostic approach.

Urgent Hospitalizations Related to Viral Respiratory Disease in Children during Autumn and Winter Seasons 2022/2023

AIM

The loosening of social distancing measures over the past two years has led to a resurgence of seasonal epidemics associated with respiratory viral infections in children. We aim to describe the impact of such infections through urgent hospitalizations in a pediatric emergency department.

METHODS

We performed a retrospective review of medical records of all children and adolescents with a positive nasal swab admitted at the children's hospital IRCCS Burlo Garofolo of Trieste, in Italy, from September 2021 to March 2022, and September 2022 to March 2023.

RESULTS

Respiratory Syncytial Virus and Influenza viruses accounted for up to 55% of hospitalizations for respiratory infections during the study periods. During the last season, the number of hospitalizations related to the Influenza virus was five times higher than those related to SARS-CoV-2 (25% vs. 5%). Respiratory Syncytial Virus was associated with a greater need for respiratory support, mostly HFNC (High Flow Nasal Cannula).

CONCLUSIONS

Respiratory Syncytial Virus and Influenza virus had a more significant impact on urgent hospitalizations during the past wintery seasons than SARS-CoV-2.

Active production of music as distraction for venipuncture in children and adolescents: a randomized clinical trial

More than 50% of children report considerable pain during venipuncture or intravenous cannulation. Despite the tools and techniques may be employed to reduce pain and distress in everyday clinical practice, the care offered is frequently insufficient. Music's potential effect in healthcare settings has received increasing attention. This study aimed to verify if the active production of music with a Leap Motion Controller could help decreasing pain and distress during venipuncture in children and adolescents. We conducted an open-label randomized controlled clinical trial with parallel arms. Children aged 8 to 17 were enrolled at the blood-drawing center of the Institute for Maternal and Child Health IRCCS Burlo Garofolo of Trieste, Italy. We hypothesized that in order to demonstrate an adequate improvement in the pain score in the intervention group, at least 200 children, 100 in each group, were needed, with alpha 5% and 1-beta 80%. Differences between the groups were evaluated with the nonparametric Mann-Whitney U-test. The subjects were randomly assigned either to the active production of music group or to the standard of care group. The primary outcome was the median self-reported procedural pain score between experimental and standard of care group. Secondary outcomes were: the median pain and distress scores according to parental judgment and operators' judgment between the experimental and control group. Three hundred subjects entered the study and were randomized, 150 in the active production of music group and 150 in the standard of care group. Median self-reported pain scores were 1 (0-2) in the active production of music group and 2 (1-2) in the standard of care group and this difference was statistically significant (p = 0.0016). Median procedural distress was 1 (0-3) in the active production of music group and 3 (1-6) in the standard of care group, according to parental judgment, and this difference was statistically significant (p = 0.0000016).

CONCLUSION

This research showed that the active production of music is a valuable distraction technique to decrease venipuncture related pain and distress in children and adolescents.

TRIAL REGISTRATION

The study protocol was registered with ClinicalTrial.gov (June 28[th] 2022, NCT05441241) before the start of the subjects' enrolment.

WHAT IS KNOWN

• The benefits of music on pain and anxiety are well known and have been tested during different painful procedures. • The effect of active production of music has never been tested in children during venipuncture.

WHAT IS NEW

• In our study median self-reported pain scores and median procedural distress, according to parental judgment, were lower in the active production of music group than in the standard of care group and these differences were statistically significant.

Sensor-based behavioral patterns can identify heat-sensitive lactating dairy cows

Heat stress impairs the health and performance of dairy cows, yet only a few studies have investigated the diversity of cattle behavioral responses to heat waves. This research was conducted on an Italian Holstein dairy farm equipped with precision livestock farming sensors to assess potential different behavioral patterns of the animals. Three heat waves, defined as at least five consecutive days with mean daily temperature-humidity index higher than 72, were recorded in the farm area during the summer of 2021. Individual daily milk yield data of 102 cows were used to identify "heat-sensitive" animals, meaning the cows that, under a given heat wave, experienced a milk yield drop that was not linked with other health events (e.g., mastitis). Milk yield drops were detected as perturbations of the lactation curve estimated by iteratively using Wood's equation. Individual daily minutes of lying, chewing, and activity were retrieved from ear-tag-based accelerometer sensors. Semi-parametric generalized estimating equations models were used to assess behavioral deviations of heat-sensitive cows from the herd means under heat stress conditions. Heat waves were associated with an overall increase in the herd's chewing and activity times, along with an overall decrease of lying time. Heat-sensitive cows spent approximately 15 min/days more chewing and performing activities (p < 0.05). The findings of this research suggest that the information provided by high-frequency sensor data could assist farmers in identifying cows for which personalized interventions to alleviate heat stress are needed.

Neck stiffness and bone osteolytic lesion in a 3-years old child: a case report

BACKGROUND

Neuroblastoma is the most frequent extracranial solid tumor occurring in childhood, representing approximately 28% of all cancers diagnosed in infants. Signs and symptoms of neuroblastoma vary with the site of development of the tumor and can mimic other diseases due to its extreme clinical variability. However, torticollis is not reported in the medical literature as a leading symptom of neuroblastoma.

CASE PRESENTATION

Here we report the case of a 3 years-old girl with fever and neck stiffness. Blood tests revealed a mild anemia and a rise in inflammatory markers. CT-scan showed a solid, heterogeneous, predominantly hypodense surrenal mass with eccentric calcification and extensive inhomogeneity of the vertebral metamers. Blood tests revealed raised serum levels of Neuron-Specific Enolase. At the 24-hours urine collection urinary catecholamines were greatly increased. A course of chemotherapy for neuroblastoma was promptly started with immediate clinical improvement.

CONCLUSIONS

This case shows that the presence of torticollis could be a chief complaint of neuroblastoma. To our knowledge, neuroblastoma is not mentioned among life-threatening underlying conditions of torticollis in most recent literature reviews.

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.

Relationship between sex and clinical and imaging features of early axial spondyloarthritis: results from a 48 month follow-up (Italian arm of the SPondyloArthritis Caught Early (SPACE) study)

OBJECTIVES

To assess the association between sex and clinical and disease activity indices, and X-rays and magnetic resonance imaging (MRI) features, in early-stage axial spondyloarthritis (axSpA).

METHOD

Baseline data analysis was conducted on the Italian SPACE cohort, including patients with chronic back pain (duration ≥ 3 months and ≤ 2 years; onset < 45 years). Patients underwent MRI and X-rays of the sacroiliac joints (SIJs) to establish the diagnosis of axSpA, according to Assessment of SpondyloArthritis international Society criteria and physician's judgement. Clinical features, disease activity and functional indices, and images were collected at baseline and yearly during 48 months. Spinal and SIJ X-rays and MRI images were scored by two readers following Spondyloarthritis Research Consortium of Canada (SPARCC), modified Stoke Ankylosing Spondylitis Spinal Score, and modified New York criteria. Characteristics of axSpA patients according to sex (male/female) were compared over time using descriptive statistics.

RESULTS

Ninety-one patients had axSpA (83.5% non-radiographic; 16.5% radiographic); 47.3% were male. Males were younger, with shorter duration of axial symptoms, and more frequently had HLA-B27 positivity, radiographic sacroiliitis with a bilateral/symmetric pattern, and more signs of spondylitis. Females more frequently showed peripheral/entheseal involvement and the non-radiographic phenotype. Males showed increased pelvic/spinal radiographic progression and more often had active sacroiliitis on MRI. Although the frequency of inflammatory corner lesions did not differ between males and females, localization varied, with more cervical/thoracic MRI-spine lesions in females and more lumbar lesions in males. We observed a significant downward trend of SPARCC SIJ/spine scores in all patients, irrespective of sex. More fat lesions were observed on MRI-spine in females and on MRI-SIJ in males.

CONCLUSION

Sex was associated with distinct axSpA features: females showed low-grade radiographic sacroiliitis and spinal progression, and a higher prevalence of cervical and thoracic spine MRI signs.

Study Confirms Safety and Effectiveness of Intra-Articular Glucocorticoids for Painful Hip Dislocation in Children and Young Adults with Neurologic Impairment

BACKGROUND

Hip dislocation is a common source of pain in children with neurologic impairment. When medical interventions fail, orthopedic surgery does not guarantee a definitive result as the displacement may continue postoperatively and a second operation is often required.

METHODS

Retrospective analysis of data regarding the safety and effectiveness of an intra-articular corticosteroid injection (IACI) in 11 patients, aged 15 ± 5 years old, collected through a telephonic questionnaire administered to parents.

RESULTS

21 IACIs were performed, a mean number of 1.9 ± 1.5 times for each patient, at a mean age (of the first IACI) of 13.5 ± 5 years. According to the parents, the IACI significantly lowered the number of participants experiencing pain (82% reduction) and using analgesics (60% reduction). There was also a significant improvement in the children's hip mobility (63% reduction in patients experiencing stiffness), decubitus (90% reduction in obligated positioning), behavior (80% reduction in lamenting or crying patients), sleep quality (87.5% reduction in patients awakening every night), and caregivers' quality of life (91% reduction in worried parents). The mean reported duration of the IACIs' benefit was 5.4 ± 2.4 months (range 1-9), with a positive correlation with the number of IACIs (r = 0.48; p-value = 0.04) and a negative correlation with the age at the first injection (r = -0.71; p-value = 0.02). The only reported adverse event was mild local swelling in one child.

CONCLUSIONS

the IACI could represent a safe and effective intervention for painful hip dislocation, both before and after surgery, with a long-lasting benefit which seems to increase as multiple IACIs are performed.

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.

Transient Receptor Potential Ankyrin 1 (TRPA1) Methylation and Chronic Pain: A Systematic Review

BACKGROUND AND OBJECTIVE

Chronic pain represents a major global health issue in terms of psycho-physiological, therapeutic, and economic burden, not limited to adults but also to the pediatric age. Despite its great impact, its molecular mechanisms have still not been completely unraveled. Focusing on the impact of epigenetics in the pain complex trait, we assessed the association between chronic pain and the methylation pattern of TRPA1, a key gene related to pain sensitivity.

METHODS

We conducted a systematic review retrieving articles from three different databases. After deduplication, 431 items were subjected to manual screening, and then 61 articles were selected and screened again. Of these, only six were maintained for meta-analysis and analyzed using specific R packages.

RESULTS

Six articles were divided into two groups (group 1: comparison of mean methylation levels between healthy subjects and patients with chronic pain; group 2: correlation between mean methylation levels and pain sensation). A non-significant mean difference was obtained from the analysis of group 1 with a value of 3.97 (95% C.I. -7.79; 15.73). Analysis of group 2 showed a high level of variability between studies (correlation = 0.35, 95% C.I. -0.12; 0.82) due to their heterogeneity (I2 = 97%, p < 0.01).

CONCLUSIONS

Despite the high variability observed in the different studies analyzed, our results suggest that hypermethylation and increased pain sensitivity could be connected, possibly due to the variation of TRPA1 expression.

Oral ibuprofen versus oral ketorolac for children with moderate and severe acute traumatic pain: a randomized comparative study

This study is to compare ibuprofen and ketorolac for children with trauma-related acute pain. We conducted a multicentre randomized, double-blind, controlled trial in the Paediatric Emergency Department setting. We enrolled patients aged 8 to 17 who accessed the emergency department for pain related to a limb trauma that occurred in the previous 48 h. At the admission, patients were classified based on numeric rating scale-11 (NRS-11) in moderate (NRS 4-6) and severe (NRS 7-10) pain groups. Each patient was randomized to receive either ibuprofen (10 mg/kg) or ketorolac (0.5 mg/kg) and the placebo of the not given drug in a double dummies design. NRS-11 was asked every 30 min until 2 h after drug and placebo administration. The primary outcome was NRS-11 reduction at 60 min. Among 125 patients with severe pain, NRS-11 reduction after 60 min from drug administration was 2.0 (IQR 1.0-4.0) for ibuprofen and 1.0 (IQR 1.0-3.0) for ketorolac (p = 0.36). Ibuprofen was significantly better, considering secondary outcomes, at 90 min with a lower median of NRS-11 (p 0.008), more patients with NRS-11 less than 4 (p 0.01) and a reduction of pain score of more than 3 NRS-11 points (p 0.01). Among 87 patients with moderate pain, the NRS-11 reduction after 60 min from drug administration was 1.63 (± 1.8) for ibuprofen and 1.8 (± 1.6) for ketorolac, with no statistically significant difference.Conclusions: Oral ibuprofen and ketorolac are similarly effective in children and adolescents with acute traumatic musculoskeletal pain.Trial registration: ClinicalTrial.gov registration number: NCT04133623.

Suicide attempts and eating disorders in adolescents, the mental health wave of the second year of the COVID-19 pandemic: A paediatric emergency department perspective

AIM

We compared adolescents' visits to a tertiary-level paediatric emergency department (PED) in Italy during the pre-pandemic year and the first and second years of the COVID-19 pandemic, focusing on mental health presentations.

METHODS

This was a retrospective study. We collected the number of visits, the demographical features, triage codes, discharge diagnoses, and outcomes of adolescents 13-17 years old who accessed the PED from 1 March 2019 to 28 February 2022.

RESULTS

During the study period, 13,410 adolescents accessed the PED. The number of visits related to mental health problems was 304 (6.4%) in the second year of the pandemic and 306 (5.6%) in the pre-pandemic year, p = 0.07. In the same periods, females' prevalence was higher, 220 (72.4%) vs. 197 (64.4%), p = 0.03. The absolute number of subjects needing admission increased, 44 vs. 34, p = 0.21, and more urgent psychiatric consultations were needed, 161 vs. 114, p < 0.0001. The number of suicide attempts was 23 vs. 8, +188%, p = 0.01. The number of adolescents with eating disorders was 21 vs. 5, +320%, p = 0.001.

CONCLUSION

PED visits for suicide attempts and eating disorders in adolescents sharply increased in the second year of the pandemic.

SBI is uncommon in the absence of paediatricians' gut feeling and abnormal respiratory pattern

AIM

According to the Italian national statistical institute, severe bacterial infections (SBI) in Italy are responsible for 1.7% of mortality under 5 years of age and their recognition is often challenging, especially in the first stages of the disease. We tried to estimate the prevalence of SBI in our target population and to identify signs and symptoms that could guide in the initial evaluation of a child with a possible SBI.

METHODS

We designed a prospective, multicentre study and enrolled patients aged 0-14 years at the first evaluation to the emergency department with an acute illness lasting a maximum of 5 days. The presence of variables suggestive of SBI was collected for every enrolled patient. One week after the enrolment, every patient was followed up by telephone.

RESULTS

SBI is more likely to be detected with the 'gut feeling' in both univariate and multivariate models (univariate OR: 7.16, 95% CI: 4.08-12.56; multivariate OR: 5.34, 95% CI: 2.78-10.25), while abnormal breathing pattern resulted significative only in univariate model (OR 3.83, 95% CI: 1.98-7.40). Nevertheless, their associated sensitivity is low.

CONCLUSION

SBI is uncommon in the absence of paediatricians' gut feeling and abnormal respiratory pattern.

Impact of the first COVID-19 lockdown on the relationship with parents and peers in a cohort of adolescents with somatic symptom disorder

To investigate the coping strategies of a group of adolescents with somatic symptom disorder compared to non-somatic symptom disorder peers during the COVID-19 related lockdown.

This cross-sectional study is the second part of a previously published study showing an improved trend in depression and anxiety in a group of patients with somatic symptom disorder compared to non-somatic symptom disorder peers. An anonymous semi-structured survey was distributed to two groups of Italian adolescents to measure the impact of quarantine on their daily life and coping strategies.

We recruited 115 adolescents, 58 (50.4%) mean age 15.3, with a recent diagnosis of somatic symptom disorder and 57 (49.6%) mean age 15.8, control peers.

The aim of this study was to detect differences in coping strategies and relationships with parents and peers, during the lockdown period in a group of adolescents with somatic symptom disorder and low disease burden when compared with a non-somatic symptom disorder group.

The relationship with parents significantly worsened in 4 (6.9%) of adolescents with somatic symptom disorder compared to 12 (21.1%) adolescents in the non-somatic symptom disorder group (p = 0.048). The relationship with peers significantly improved in 13 (22.4%) of adolescents with symptom disorder versus 3 (5.3%) of peers of the non- somatic symptom disorder group (p = 0.013).

Adolescents with somatic symptom disorder with a low burden of physical symptoms experienced less deterioration in their relationships with parents and peers than the non-somatic symptom disorder group.

Prevalence of SARS-CoV-2 positivity in infants with bronchiolitis: a multicentre international study

BACKGROUND

Bronchiolitis is the leading acute respiratory tract infection in infants during the winter season. Since the beginning of the SARS-CoV-2 pandemic, a reduction in the number of bronchiolitis diagnoses has been registered.

OBJECTIVE

The present study aimed to describe the incidence and clinical features of bronchiolitis during the 2020-2021 winter season in a large cohort of children in Europe and Israel, and to clarify the role of SARS-CoV-2.

SETTING, PATIENTS, INTERVENTIONS

We conducted a multicentre observational cross-sectional study in 23 paediatric emergency departments in Europe and Israel. Clinical and demographic data about all the cases of infants diagnosed with bronchiolitis from 1 October 2020 to 30 April 2021 were collected. For each enrolled patient, diagnostic tests, treatments and outcomes were reported.

MAIN OUTCOME MEASURES

The main outcome was the prevalence of SARS-CoV-2-positive bronchiolitis.

RESULTS

Three hundred and fourteen infants received a diagnosis of bronchiolitis during the study period. Among 535 infants who tested positive for SARS-CoV-2, 16 (3%) had bronchiolitis. Median age, male sex predominance, weight, history of prematurity and presence of comorbidities did not differ between the SARS-CoV-2-positive and SARS-CoV-2-negative groups. Rhinovirus was the most common involved pathogen, while respiratory syncytial virus (RSV) was detected in one case. SARS-CoV-2 bronchiolitis had a mild clinical course, with one patient receiving oxygen supplementation and none requiring paediatric or neonatal intensive care unit admission.

CONCLUSIONS

During the SARS-CoV-2 pandemic, a marked decrease in the number of bronchiolitis diagnoses and the disappearance of the RSV winter epidemic were observed. SARS-CoV-2-related bronchiolitis was rare and mostly displayed a mild clinical course.

AB0806 Gender and Imaging Progression in early Axial Spondyloarthritis: Results from a 48-month follow-up (Italian arm of SPACE study)

Background

Gender differences in disease presentation and imaging features of early axial-spondyloarthritis (axSpA) have not been thoroughly investigated.

Objectives

To assess the influence of gender on spinal/pelvic radiographic progression and magnetic-resonance-imaging (MRI) features in early-stage axSpA.

Methods

Baseline data from the Italian arm of SPondyloArthritis-Caught-Early-cohort, including patients with chronic-back-pain (CBP;duration≥3 months and ≤2 years;onset<45 years) were analyzed.Patients underwent a diagnostic work-up, including MRI and X-rays of the sacroiliac joints (SIJ), to establish a diagnosis of axSpA (according ASAS criteria). Clinical features, disease-activity and functional indices, imaging were collected at baseline (T0) and yearly during 48-months.Spinal and SIJ X-rays and MRIs were performed every 2-years and scored independently by 2 readers following Stoke Ankylosing Spondylitis Spinal Score System modified by Creemers (mSASSS) (score 0-72),modified New York criteria grading system (mNY-criteria) (score 0-4 per each joint) and Spondyloarthritis Research Consortium of Canada (SPARCC) (score of 0–40 for SIJ and of 0-92 for the spine). Characteristics of axSpA patients according the gender (male/female) were compared over-time with descriptive-statistics; multivariate-logistic-regression model was constructed to assess predictors of spinal and SIJ radiographic progression at 48-months.

Results

Out of 98 CBP patients, 91 had axSpA (83.5% non-radiographic;16.5% radiographic);47.3% were male. At T0 males were younger with less axial symptoms duration (p=0.04);had more frequently human-leukocyte-antigen (HLA)-B27+ (p=0.02),radiographic sacroiliitis with bilateral/symmetric pattern (p<0.02) and more signs of spondylitis (p=0.03).Females presented more frequently an associated peripheral/entheseal involvement (p=0.04) and a non-radiographic form (p=0.03). Functional and disease-activity indices decreased with slightly higher Maastricht Ankylosing Spondylitis Enthesitis Score (MASES),Visual Analogue Scale of pain (VAS),Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI) values in females (p<0.04). Males showed a slight increased for both pelvic and spinal radiographic progression than females (Figure 1 A-E).At T0, 62 (68.1%) axSpA patients presented inflammatory lesions on MRI-SIJ, with more signs of active sacroiliitis in males (83.7% vs. 54.2%;p<0.05).Fifty-seven (62.6%) patients showed inflammatory-corner-lesions on MRI-spine: the frequency of these lesions no differed between males and females, while the localization varied:prevalently cervical/thoracic lesions were observed in females, instead lumbar lesions in males (p<0.05).We also found a higher prevalence of signs of active anterior spondylitis without active sacroiliitis on MRI in females (29.2% vs. 14.0%;p=0.03).Signs of enthesitis were found in 68.1% patients, with slightly higher prevalence of these lesions in thoracic area in females (p=0.04).Significant downtrend of SPARCC SIJ/spine scores was found, regardless the gender.More fat lesions were observed on MRI-spine in females, while more fat lesions were observed on MRI-SIJ in males (Figure 1F-G).Skin psoriasis was a predictor of spinal progression in all patients (OR=0.18; 95%CI:0.04-0.78).

Conclusion

The gender was associated with distinct axSpA features.Males had an increased pelvic and spinal radiographic progression and more frequently active sacroiliitis on MRI.Female axSpA showed a higher prevalence of cervical and thoracic spine-MRI signs (inflammatory-corner-lesions and fat lesions).

Disclosure of Interests

Mariagrazia Lorenzin: None declared, Augusta Ortolan: None declared, Stefania Vio: None declared, Giacomo Cozzi: None declared, Vanna Scapin: None declared, Giorgio De Conti: None declared, Andrea Doria Grant/research support from: AD has received honoraria and speaker fees from Novartis, Abbvie, Pfizer, MSD, Janssen., Roberta Ramonda Grant/research support from: RR has received honoraria and speaker fees from Novartis, Abbvie, Pfizer, MSD, Janssen.

POS0297 EFFECTIVENESS AND SAFETY OF SECUKINUMAB IN AXIAL SPONDYLOARTHRITIS: A 24-MONTH PROSPECTIVE, MULTICENTER REAL-LIFE STUDY

Background

Axial Spondyloarthritis (axSpA) can be distinguished in radiographic axSpA (r-axSpA) and non-radiographic (nr-axSpA). Secukinumab (SEC) is a novel treatment for axSpA, but data from real-life are still missing.

Objectives

To evaluate, in a multicentric-Italian-cohort of axSpA patients on SEC followed for 24-months: a)the long-term effectiveness and safety of SEC; b)the drug-retention-rate and low-disease-activity (LDA) measured as BASDAI<4/ASDAS<2.1 and very-low-disease-activity (VLDA) measured as BASDAI<2/ASDAS<1.3; c)any differences in outcomes according to: line of biological treatment (naïve/non-naïve), gender (male/female), subtype of axSpA (r-axSpA/nr-axSpA).

Methods

Consecutive patients with active axSpA (diagnosis according Assessment of SpondyloArthritis International Society ASAS criteria), who started SEC treatment, were evaluated prospectively. Data on disease characteristics, previous/ongoing treatments and imaging were collected. Disease-activity/functional/clinical scores and biochemical values were recorded at baseline (T0), at 6 (T6), 12 (T12), and 24 (T24) months. Effectiveness was evaluated over-time with descriptive statistics; multivariate Cox and logistic regression models were used to evaluate predictors of drug-discontinuation and LDA at T6. Infections, adverse events were recorded.

Results

249 patients (47.8% male; median age 51 years) were enrolled; 40.9% had HLA-B27; 53.8% had r-axSpA and 46.2% nr-axSpA. SEC was prescribed in 28.9% naïve and in 71.1% non-naïve patients. SEC effectiveness was shown as an improvement in several outcomes, such as ASDAS [T0=3.5(2.9-4.4) vs. T24=1.9(1.2-2.4);p=0.02] and BASDAI [T0=6.5(5.0-7.5) vs. T24=2.8(1.8-4.0);p=0.03]. After 24-months of treatment, 90.7% of naïve and 75.3% of non-naïve patients achieved LDA (BASDAI<4). At T24 naïve-patients showed better physical-functioning and lower disease-activity than non-naïve (Table 1). Similarly, at T24 we observed better physical functioning and lower inflammatory activity in males vs. females and in nr-axSpA vs. r-axSpA subjects. Retention-rate at T24 was 75% in the whole population, with some difference depending on gender (log-rank 9.319; p=0.002) (Figure 1). Treatment was discontinued in 61 patients (24.5%), mainly due to primary/secondary loss of effectiveness events (20 and 24 subjects, respectively), and only 17 patients (6.8%) due to adverse events (7 for reactions at the injection site or skin manifestations, 1 for gastro-intestinal complications, 1 for relapsing uveitis, 1 for hypertransaminasemia, 4 for severe recurrent infections, 3 due to the onset of new cancer).

Table 1.

Clinical, functional, disease activity and serological parameters of naïve (n=72) and non-naïve (n=177) axSpA patients during the 24-month follow-up

T0T6T12T24BASMI [0-10], median (IQR)naïve2.0 (1.0-4.0)2.0 (0.0-3.3)1.0 (0.0-2.8)1.0 (0.0-2.0)non-naïve4.0 (1.0-7.0)4.0 (1.0-7.0)2.0 (1.0-4.0)2.0 (1.0-3.0)pp=0.03p=0.04nsnsHAQ-S [0-8], median (IQR)naïve0.8 (0.5-1.3)0.5 (0.0-1.0)0.3 (0.0-1.0)0.1 (0.0-0.5)non-naïve1.1 (0.8-1.5)1.0 (0.4-1.3)0.6 (0.4-0.9)0.7 (0.1-0.9)pp=0.04p=0.04p=0.04p=0.04ASDAS [0-6], median (IQR)naïve3.3 (2.7-3.9)2.1 (1.6-2.7)2.0 (1.2-2.8)1.3 (1.0-2.2)non-naïve3.7 (2.9-4.7)2.9 (2.0-3.7)2.1 (1.9-3.1)2.3 (1.6-2.3)pnsnsnsp=0.04ESR [0-25](mm/h), median (IQR)naïve14.0 (6.0-27.0)10.0 (4.0-19.5)8.0 (3.1-12.8)5.0 (2.0-15.0)non-naïve18.5 (10.0-31.3)15.0 (8.0-25.0)12.0 (6.0-20.0)12.0 (6.0-19.0)pp=0.04p=0.04p=0.04p=0.04

Legend: BASMI: Bath Ankylosing Spondylitis Metrology Index; HAQ: Health Assessment Questionnaire modified for spondyloarthritis; ASDAS: Ankylosing Spondylitis Disease Activity Score; ESR: erythrocyte sedimentation rate

Conclusion

In a real-life clinical-setting, SEC proved to be safe and effective in axSpA, mainly in naïve-patients, with a notable drug-retention-rate. No differences were observed between r-axSpA and nr-axSpA.

Acknowledgements

Contributing authors of the Spondyloartritis and Psoriatic Arthritis SIR Study Group “Antonio Spadaro”: Alberto Cauli, MD, PhD, Rheumatology Unit, Department of Medical Sciences, AOU and University of Cagliari, Cagliari, Sardegna, Italy; Angelo Semeraro, MD, Rheumatology Unit, Martina Franca-ASL Taranto, Puglia, Italy; Leonardo Santo, MD, Rheumatology Unit, ASL BT Andria – DSS4 Barletta, Italy, Barletta-Andria-Trani, Puglia, Italy; Emanuela Praino, MD, Rheumatology Unit, ASL BT Andria – DSS4 Barletta, Italy, Barletta-Andria-Trani, Puglia, Italy; Giorgio Amato, MD, Rheumatology Unit, A.O.U. Policlinico S. Marco, Catania, Sicilia, Italy; Nicolò Girolimetto, MD, Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Emilia Romagna, Italy.

Disclosure of Interests

Giacomo Cozzi: None declared, Mariagrazia Lorenzin: None declared, Maria Sole Chimenti: None declared, Salvatore D’Angelo: None declared, Antonio Marchesoni: None declared, Carlo Salvarani: None declared, Ennio Lubrano: None declared, Luisa Costa: None declared, Ylenia Dal Bosco: None declared, Elena Fracassi: None declared, Augusta Ortolan: None declared, Mario Ferraioli: None declared, Antonio Carriero: None declared, elisa visalli: None declared, RICCARDO BIXIO: None declared, Francesca Desiati: None declared, ALBERTO BERGAMINI: None declared, elisa pedrollo: None declared, Andrea Doria Grant/research support from: Novartis, Abbvie, Pfizer, MSD, Janssen, Rosario Foti: None declared, Antonio Carletto: None declared, Roberta Ramonda Grant/research support from: Novartis, Abbvie, Pfizer, MSD, Janssen

POS0952 THE IMPACT OF DIET ON DISEASE ACTIVITY IN SPONDYLOARTHRITIS: A SYSTEMATIC LITERATURE REVIEW

Background

Diet is thought to have a role in inflammatory diseases development and course. However, at present, no recommendations can be given to spondyloarthritis (SpA) patients regarding a specific type of diet/dietary supplement, as evidence on the topic is sparse.

Objectives

To review the evidence about the effect of diet/dietary supplements on SpA disease activity

Methods

A systematic literature review (SLR) was conducted in MEDLINE and SCOPUS according to the “PEO” format (Population: SpA, axial or peripheral, including Psoriatic Arthritis-PsA; Exposure: any kind of diet/dietary supplement; Outcome: any available disease activity measurement). Inclusion criteria were: adult patients, Randomized Controlled Trials (RCTs) and longitudinal studies (so that a pre-and post-intervention assessment were available), papers in English. Risk of bias (RoB) was independently judged by 2 authors (AO, MF) and conducted with different tools according to the study design: Newcastle Ottawa Scale (NOS) for observational studies, the ROBINS-1 tool for non-randomized studies, and the Cochrane risk of Bias tool 2.0 for RCTs.

Results

Literature search yielded 286 publications. After exclusion of 59 duplicates, 171 titles/abstract, and 44 full-texts, we included 8 interventional and 3 observational studies (Table 1). Among the former, 2 RCTs, one at unclear and one at low RoB, failed to show benefit of probiotics in SpA. One RCT at unclear RoB showed that weight loss, but not hypocaloric diet, was associated to MDA achievement in PsA. The other RCT, as well as the 4 quasi-interventional studies, were at high/serious RoB respectively. Among the observational studies, one study on Mediterranean diet demonstrated an association of diet adherence and a>=20% decrease of ASDAS in axSpA. Two other studies were judged of poor quality.

Table 1.

Characteristics of the included studies

Author yearPopula- tionInterven tionStudy designRando-mizedControlledSample sizeFollow-up (weeks)Primary outcomeMale Sex (%)Mean Age (years)Concomitant medications besides symptomaticsExperimental designLassus 1990PsAPU ethyl ester lipids supplementationQuasi-expNoNo808NR5049stable csDMARDsAppelboom 1994ASMilk product deprivationQuasi-expNoYes (AS vs RA)25/106NRNRNR28% on stable csDMARDsSundström 2006ASOmega 3 fatty acidsRCTYesYes (high vs low dose)2421NR61NRNo csDMARDsDi Minno 2014Obese/ overweight PsAHypocaloric dietRCTYesYes (hypocaloric vs free diet)13824MDA (+)3645All patients started anti-TNF; concomitant MTX in 29%Klinberg 2019Obese PsAHypocaloric dietQuasi-expNoNo4612-16MDA (+)3656100% on stable cs/bDMARDsKlinberg 2020Obese PsAHypocaloric dietQuasi-expNoYes (PsA vs controls)7420NR3656100% on stable cs/bDMARDsBrophy 2008SpAProbioticsInternet- based RCTYesYes (probiotics vs placebo)14712Satisfaction of CONSORT statement (+)644410% on stable b/csDMARDsJenks K 2010SpAProbioticsRCTYesYes (probiotics vs placebo)6312BASFI (-)634328.5% on csDMARDsObservational DesignAdawi 2018PsAIntermittent fastingcohort-No374NR3743100% on stable cs/bDMARDsBen Nessib 2020SpAFasting-refeedingcohort-No1228NR454740% on stable cs/ bDMARDsOmetto 2021axSpAMediterra-nean dietcohort-Yes (Mediterra-nean vs free diet)16124NR6551100% on stable cs/bDMARDs

PsA: Psoriatic arthritis, AS ankylosing spondylitis, SpA spondyloarthritis, ax: axial; RA Rheumatoid Arthritis, PU polyunsaturated; RCT Randomized Controlled Trial; exp=experimemntal; MDA Minimal Disease Activity; CONSORT CONsolidated Standards of Reporting Trials; BASFI Bath Ankylosing Spondylitis Functional Index; (+) or (-) indicate whether the primary outcome of the study was met or not

Conclusion

weight loss seems to be able to impact disease activity in SpA, while probiotics were not effective in the available RCTs so far. Adherence to Mediterranean diet might play a role in reducing disease activity. Evidence for effectiveness of dietary behaviors in SpA is quite heterogeneous and high quality studies are warranted to better understand the role of diet in SpA.

Disclosure of Interests

Augusta Ortolan: None declared, Mara Felicetti: None declared, Mariagrazia Lorenzin: None declared, Giacomo Cozzi: None declared, Giovanni Striani: None declared, Andrea Doria Speakers bureau: Novartis, AbbVie, Pfizer, MSD, Janssen, GSK, Consultant of: Novartis, AbbVie, Pfizer, MSD, Janssen, GSK, Roberta Ramonda Speakers bureau: honoraria and speaker fees from Novartis, AbbVie, Pfizer, MSD, Janssen, Consultant of: Novartis, AbbVie, Pfizer, MSD, Janssen

The first winter of social distancing improved most of the health indexes in a paediatric emergency department

Aim

We compared visits to a tertiary level paediatric emergency department (PED) in Italy, during winter 2020–2021, when COVID‐19 social distancing measures were in place, with winter 2019–2020.

Methods

This was a retrospective analysis of an electronic database. We obtained the number of visits and the ages, main complaints, triage codes, discharge diagnoses and outcomes of patients who accessed the PED from the 1 October 2020 to 28 February 2021. These were compared to the same period in 2019–2021.

Results

Visits fell by 52%, from 10982 in 2019–2020 to 5317 in 2020–2021 (p < 0.0001). The reductions were 52% in neonates, 58% in infants, 53% in toddlers, 61% in preschool children, 48% in school children and 46% in adolescents. Non‐urgent and urgent triage codes declined. Respiratory and gastrointestinal infections fell by 72% and 71% respectively. Injuries declined by 42%, mainly among adolescents. Accidental intoxication, psychiatric symptoms and substance or alcohol abuse declined by 24%, 33% and 64%. Hospital admissions reduced by 8% and admissions to intensive care fell by 29%.

Conclusion

During the first winter of pandemic social distancing visits to an Italian PED fell by 52%, with higher reductions in younger children and infants, and hospital admissions fell by 8%.

Spread of Respiratory Pathogens During the COVID-19 Pandemic Among Children in the Northeast of Italy

The social distancing measures adopted during the coronavirus disease 2019 (COVID-19) pandemic led to a profound change in the behavioral habits of the population. This study analyzes the impact of restriction measures on the shaping of the epidemiology of common winter respiratory pathogens in the pediatric population of northeast of Italy. From August 2020 to March 2021, a total of 1,227 nasopharyngeal swabs from symptomatic pediatric patients were tested for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), influenza A and B, adenovirus, other coronaviruses, parainfluenza virus 1–4, enterovirus, bocavirus, metapneumovirus, respiratory syncytial virus, rhinovirus, Bordetella pertussis, Bordetella parapertussis, and Mycoplasma pneumoniae. To relate virus positivity with the clinic characteristics of the subjects enrolled, multinomial logistic models were estimated. SARS-CoV-2 was detected in 5.2% of the children; fever resulted as risk factor for infection [relative risk ratio (RRR) = 2.88, p = 0.034]. Rhinovirus was detected in the 40.7% of the subjects, with cough and rhinitis as risk factors (respectively, RRR = 1.79, p = 0.001 and RRR = 1.53, p = 0.018). Other coronaviruses were found in 10.8% of children and were associated to pharyngodynia (RRR = 4.94, p < 0.001). Adenovirus, observed in 11.6% of subjects, showed to have fever as risk factor (RRR = 6.44, p < 0.001). Bocavirus was detected in 3.2% of children. In conclusion, our results showed that social isolation measures had an impact on the circulation of RSV and influenza, although children under the age of 2 were most affected by the other respiratory infections. Therefore, this study highlights the need for continuing surveillance for a delayed spread of RSV and other respiratory pathogens.

Adolescents' Utilization of a Tertiary-Level Pediatric Emergency Department in Italy

Aim

Describe the use of the emergency department of a tertiary-level children's hospital in Italy by adolescents.

Methods

This retrospective study was based on the medical records of patients aged 13 to 17 years, who accessed the emergency department of the Institute for Maternal and Child Health of Trieste, from 1 January to 31 December 2018. The primary outcome was to describe the leading causes of access, diagnoses, rate of hospitalization, and ward of destination among adolescent patients.

Results

During the study period, 24,599 patients accessed the department. Among them, 3,062 were adolescents, for a total of 3,895 unscheduled visits. The principal causes of access were trauma (45.3%) and organic diseases (38.8%). Two hundred and forty nine adolescents (6.4%) had mental health problems. One hundred and forty two adolescents (3.6%) Were Admitted to the Hospital, 54 of Whom (38%) to the Neuropsychiatric Ward, for Mental Health Problems.

Conclusions

Among adolescents seen in this Italian tertiary-level children's hospital, mental health problems represented a small proportion of emergency department visits but were the leading cause of urgent hospitalization.

[Mental health and pandemic in children and adolescents: what is likely to label as "long-covid".]

Long-covid is a typical condition of adults with a history of probable or confirmed SARS-CoV-2 infection in the previous 3 months and with symptoms lasting over 2 months not explained by an alternative diagnosis. In pediatric age the lack of significative differences comparing the reported symptoms between seropositive and seronegative suggests that long-covid might be less common than previously thought, emphasizing the impact of pandemic-associated symptoms regarding the well-being and mental health of young adolescents. Many children-adolescents, who have had SARS-CoV-2 infection or not, have a health request to which we must respond with a professional approach aimed at a complex functional rehabilitation. The risk is that the "long-covid" becomes a "long-inattention" on relevant mental health problems.

Recovery characteristics and parental satisfaction in pediatric procedural sedation

BACKGROUND

Despite being a standard of care for children undergoing stressful procedures, little data exist on parental perception of pediatric sedation.

AIMS

This study aimed to investigate recovery characteristics and parental satisfaction for pediatric sedations performed with four widely used sedative regimens.

METHODS

A prospective observational study was conducted at the Institute for Maternal and Child Health of Trieste, Italy, enrolling children undergoing procedural sedation with one of the following pharmacological regimens: propofol, propofol + midazolam, ketamine + propofol, and dexmedetomidine + midazolam. A questionnaire was used to assess the occurrence of symptoms upon recovery from sedation and the following day, and the caregivers' satisfaction for both the recovery pattern and the overall sedation experience, according to a numerical rating scale (0-10). Answers were collected through a telephone survey. The primary outcome was the difference in the quality of the recovery as perceived by caregivers; the secondary and tertiary outcomes were the perceived quality of the overall sedation experience and the frequency of sedation-related adverse events, respectively.

RESULTS

Data from 655 patients, 149 receiving propofol, 245 propofol + midazolam, 134 ketamine + propofol, and 127 dexmedetomidine + midazolam, were analyzed. The level of parents' satisfaction for both the recovery and the sedation experience was overall high and increased with the patients' age in all the pharmacological groups (Spearman's rank correlation, ρ .083, p = .033, and ρ .087, p = .026, respectively), with no statistically significant differences between groups when adjusting for age. The occurrence of irritability, prolonged sleepiness, hyperactivity, unsteadiness, hallucinations, emesis, and respiratory distress at any moment negatively affected parental satisfaction.

CONCLUSIONS

In this study, caregivers' satisfaction with pediatric sedation was high, regardless of the regimen used. Lower parental satisfaction was associated with younger age, irritability after sedation, prolonged sleepiness, hyperactivity, unsteadiness, hallucinations, emesis, and respiratory distress.

Magnetic resonance imaging accuracy before surgery in children with retropharyngeal abscesses

AIMS

Retropharyngeal abscess (RPA) is a deep neck infection occurring in childhood. The gold standard technique for diagnosis is computerised tomography (CT) with a contrast medium. The aim of this study is to answer the question of whether magnetic resonance imaging (MRI) can be an alternative in diagnosing RPA and predicting pus drainage at surgery.

METHODS

This is a retrospective study conducted at the paediatric emergency department of a tertiary level children hospital. The medical records of 31 children admitted to the Otorhinolaryngology and Paediatric ward, with a suspected diagnosis of RPA, were reviewed. The primary study outcome was the diagnostic accuracy of CT and MRI in predicting the amount of pus during surgery.

RESULTS

Twenty-two patients (71%) underwent surgery. Among them, 18 had imaging before surgery. Eleven patients evaluated with CT scan underwent surgery: four had non-significant purulent drainage, three of them were reported to have a significant fluid collection (negative predictive value 66% and positive predictive value of 55%). Nine patients evaluated with MRI underwent surgery: four cases had non-significant purulent drainage, three of them showed a significant fluid collection at MRI (negative predictive value of 60%; positive predictive value of 56%).

CONCLUSION

MRI and CT scans showed similar accuracy in predicting successful pus drainage during surgery; therefore, it could be a valid alternative in the diagnosis of RPA in children.

Does a standard triage tool adequately detect the needs of children and adolescents admitted for mental health problem?

BACKGROUND

the visits to the paediatric emergency department for mental problems are increasing exponentially, but the emergency department team in not ready enough to manage them, due to the lack of adequate training. This study aimed to evaluate how the Italian Society of Paediatric Emergency Medicine and Urgency triage system was able to estimate urgency in patients accessing the paediatric emergency department for a mental health problem.

METHODS

We conducted a retrospective study at the emergency department of the Institute for Maternal and Child Health, IRCCS Burlo garofolo of Trieste (Italy), from December 2015 to April 2017. During the study period, we identified all the patients undergoing an urgent psychiatric consultation. We collected demographic variables, triage code, diagnosis, and outcomes of each patient. Subsequently, we have assigned a degree of psychiatric urgency, based on Gail and Rosenn's classificationwhich is a specific tool to evaluate psychiatric urgency. The primary study outcome was the comparison between the degree of urgency assigned using the triage system and the Gail and Rosenn's classification.

RESULTS

In this series, 567 patients underwent an urgent psychiatric consultation, and 280 of them received a diagnosis of a mental health problem. The degree of urgency assigned at the triage was: emergency for 5 cases (2%), urgency for 96 (34%) and non-urgency for 179 (64%). Instead, the degree assigned with GRC was: emergency for 95 cases (34%), urgency for 112 (42%) and non-urgency for 73 (26%). The number of patients, detected as emergency and urgency by the two tools, was significantly different (p = 0.0001).

CONCLUSIONS

In this study, we demonstrated that the Italian Society of Paediatric Emergency Medicine and Urgency triage system underestimated the urgency of patients with mental health problems compared to a specific tool to assess the degree of psychiatric urgency.

Intranasal dexmedetomidine and intranasal ketamine association allows shorter induction time for pediatric sedation compared to intranasal dexmedetomidine and oral midazolam

BACKGROUND

Non-painful diagnostic procedures require an inactive state for a prolonged time, so that sedation is often needed in younger children to perform the procedures. Our standard of care in this setting consists of the association between oral midazolam (0.5 mg/kg) and intranasal dexmedetomidine (4 mcg/kg). One of the limits of this approach is that the onset of action is quite delayed (up to 55 min) and poorly predictable. We chose to compare this association with intranasal-ketamine and intranasal-dexmedetomidine.

METHODS

This is a "pre-post" study. The study population included the first forty children receiving sedation with the "new" combination intranasal ketamine (3 mg/kg) and intranasal dexmedetomidine (4 mcg/kg) compared to a historical cohort including the last forty children receiving sedation with our standard of care combination of intranasal dexmedetomidine (4mcg/kg) and oral midazolam (0,5 mg/kg).

RESULTS

The association intranasal dexmedetomidine and intranasal ketamine allowed for a significantly shorter sedation induction time than the combination intranasal dexmedetomidine and oral midazolam (13,5 min versus 35 min). Both group's cumulative data showed a correlation between age and sedation effectiveness, with younger children presenting a higher success rate and shorter induction time (p 0,001).

CONCLUSIONS

This study suggests that the ketamine and dexmedetomidine intranasal association may have a shorter onset of action when compared to intranasal dexmedetomidine and oral midazolam.

Case Report: Simil-Appendicitis Presentation May Precede Cardiac Involvement in MIS-C Patient

INTRODUCTION

Multisystem inflammatory syndrome in children (MIS-C) is a new clinical entity characterized by a systemic hyperinflammation triggered by SARS-CoV-2 infection in children and adolescents. This condition could potentially involve all organs with main complications concerning cardiovascular system. Despite up to 90% of patients complain gastrointestinal symptoms (nausea, vomit, and diarrhea), a presentation mimicking acute appendicitis has rarely been reported, and can be the presenting feature of the disease, potentially leading to misdiagnosis and delayed treatment.

CASE DESCRIPTION

A 15-year-old boy presented to the Emergency Department for a 2-day history of fever, vomiting, and mild abdominal pain. One month before, the patient complained ageusia and anosmia while his mother tested positive for Sars-CoV2 nasopharyngeal swab. At admission, laboratory tests showed leukocytosis with lymphopenia and elevation of inflammatory markers, while cardiac enzymes, electrocardiogram and echocardiography were unremarkable. An abdominal ultrasound displayed a thickening of terminal ileus and cecum with ascites. Because of the worsening abdominal pain and a physical examination suggestive of acute appendicitis, a laparoscopy was performed but no surgical condition was found. After surgery, fever and generalized malaise persisted, so a cardiac evaluation was repeated, showing a relevant increase in inflammatory markers and cardiac enzymes. Electrocardiogram demonstrated a QTc prolongation with mild decrease in left ventricular ejection fraction at echocardiogram. A MIS-C was diagnosed and intravenous immunoglobulin along with a steroid treatment started. After 36 h, the patient presented a complete clinical recovery with fever cessation. Cardiac anomalies normalized in 3 weeks.

CONCLUSION

MIS-C has been defined as a systemic inflammation, involving at least two organs, after a previous SARS-CoV2 infection in children and adolescents. Physicians should be aware that while gastrointestinal manifestations are common, a pseudo appendicitis presentation may also occur, leading to misdiagnosis and delayed treatment. This report suggests that in patients with symptoms suggestive of an acute appendicitis, the presence of lymphopenia, hypoalbuminemia and ultrasound images of terminal ileus inflammation, should raise the suspect for MIS-C even without initial overt signs of cardiac involvement.

Pediatric Emergency Cases in the First Year of the COVID-19 Pandemic in a Tertiary-Level Emergency Setting

AIM

Emergency cases are uncommon events in the pediatric emergency setting. This study aimed to evaluate the effect of the Coronavirus disease 2019 (COVID-19) pandemic by describing the number and type of pediatric emergency cases that arrived at the pediatric emergency department (PED) of a tertiary-level children's hospital in Italy.

METHODS

We performed a retrospective study, collecting the main features of pediatric emergency patients who arrived during the first year of the COVID-19 pandemic (March 2020-February 2021) compared to the pre-pandemic period (March 2016-February 2020).

RESULTS

During the study period, 112,168 patients were visited at the PED, and 237 (0.21%) were emergency cases, median age of 4 years (IQR: 1-12). In the first year of the pandemic, 42 children were coded as emergency cases compared to 195 (49/year) during the pre-pandemic period. The proportion of emergency cases was stable (0.27% during the COVID-19 period versus 0.20% during the pre-COVID-19 period, p = 0.19). No differences were found regarding the age, gender, hour of arrival, and outcome of patients. We found a significant decrease in the proportion of emergency cases related to respiratory diseases (9/42, 21.4% during the COVID-19 period versus 83/195 during the pre-COVID-19 period (42.6%), p = 0.01).

CONCLUSION

In conclusion, our data suggest that the pandemic had a more significant impact on respiratory emergency cases than on pediatric emergencies in general.

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.