Skin manifestations of COVID-19 in children: Part 2

The current COVID-19 pandemic is caused by the SARS-CoV-2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS-CoV-2 infection in children differ from those in adults, as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID-19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discussed one of the first and most widespread cutaneous manifestations of COVID-19, chilblain-like lesions. In this part of the review, we describe other manifestations, including erythema multiforme, urticaria and Kawasaki disease-like inflammatory multisystemic syndrome. In Part 3, we discuss the histological findings of COVID-19 manifestations, and the testing and management of infected children for both COVID-19 and any other pre-existing conditions.

Clinical and radiological outcome after anterior cruciate ligament reconstruction using the T-lock Osteotrans resorbable tendon anchor: early experience and midterm follow-up

PURPOSE

Reconstruction of the Anterior cruciate ligament (ACL) using tendon grafting is an established method for restoring knee function and stability. Multiple methods are established for graft fixation. Several involve anchoring the autograft distant to the joint with hardware that remains implanted. This study reports the first early to midterm results in patients who received ACL reconstruction (ACLR) using the T-Lock Osteotrans femoral near joint fixation method with a tibial fixation using the BioactIF Osteotrans interference screw.

METHODS

This consecutive prospective series included 20 Patients (14 Male, 6 Female) with a primary ACL rupture. All patients were treated with an ACLR using a semitendinosus autograft fixated with the T-Lock Osteotrans and were followed-up postoperatively. The following parameters were assessed: Side-to-side difference of the posterior-anterior translation measured using the KT-1000 arthrometer, Tegner activity score, Lysholm score, IKDC subjective knee evaluation form. Magnetic resonance imaging (MRI) was done to assess tunnel enlargement and integrity of the anchoring device.

RESULTS

The average follow-up duration was 2 years (range 1-4.2 years). One patient was lost to follow-up. Two Patients suffered a traumatic ACL re-rupture 2 years postoperatively and received a 2-stage revision ACLR. Difference in the posterior-anterior translation was 1.8 mm (range 0-5). The median Tegner score was 6 (range 4-10) and 9 patients (45%) returned to their preinjury level of activity. The mean IKDC subjective knee evaluation form scored 91 points (range 77-100). The mean Lysholm score was 86 points (74-96). All mentioned scores were significantly better compared to preoperative values. No relevant tunnel enlargement was seen on MRI. The anchoring device was evaluated to be intact in all patients.

CONCLUSION

ACLR with the aforementioned procedure leads to good clinical and radiological outcome.

Skin manifestations of COVID-19 in children: Part 3

The current COVID‐19 pandemic is caused by the SARS‐CoV‐2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS‐CoV‐2 infection in children differ from those in adults as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID‐19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discuss one of the first and most widespread cutaneous manifestations of COVID‐19, chilblain‐like lesions, and in Part 2 we expanded to other manifestations, including erythema multiforme, urticaria and Kawasaki disease‐like inflammatory multisystemic syndrome. In this part of the review, we discuss the histological findings of COVID‐19 manifestations, and the testing and management of infected children for both COVID‐19 and any other pre‐existing conditions.

Click here for the corresponding questions to this CME article.

Skin manifestations of COVID-19 in children: Part 1

The current COVID‐19 pandemic is caused by the SARS‐CoV‐2 coronavirus. The initial recognized symptoms were respiratory, sometimes culminating in severe respiratory distress requiring ventilation, and causing death in a percentage of those infected. As time has passed, other symptoms have been recognized. The initial reports of cutaneous manifestations were from Italian dermatologists, probably because Italy was the first European country to be heavily affected by the pandemic. The overall clinical presentation, course and outcome of SARS‐CoV‐2 infection in children differ from those in adults as do the cutaneous manifestations of childhood. In this review, we summarize the current knowledge on the cutaneous manifestations of COVID‐19 in children after thorough and critical review of articles published in the literature and from the personal experience of a large panel of paediatric dermatologists in Europe. In Part 1, we discuss one of the first and most widespread cutaneous manifestation of COVID‐19, chilblain‐like lesions. In Part 2, we review other manifestations, including erythema multiforme, urticaria and Kawasaki disease‐like inflammatory multisystemic syndrome, while in Part 3, we discuss the histological findings of COVID‐19 manifestations, and the testing and management of infected children, for both COVID‐19 and any other pre‐existing conditions.

Click here for the corresponding questions to this CME article.

Management of congenital ichthyoses: European guidelines of care, part one

These guidelines for the management of congenital ichthyoses have been developed by a multidisciplinary group of European experts following a systematic review of the current literature, an expert conference held in Toulouse in 2016 and a consensus on the discussions. They summarize evidence and expert-based recommendations and are intended to help clinicians with the management of these rare and often complex diseases. These guidelines comprise two sections. This is part one, covering topical therapies, systemic therapies, psychosocial management, communicating the diagnosis and genetic counselling.

Management of congenital ichthyoses: European guidelines of care, part two

These guidelines for the management of congenital ichthyoses have been developed by a multidisciplinary group of European experts following a systematic review of the current literature, an expert conference held in Toulouse in 2016, and a consensus on the discussions. These guidelines summarize evidence and expert-based recommendations and intend to help clinicians with the management of these rare and often complex diseases. These guidelines comprise two sections. This is part two, covering the management of complications and the particularities of some forms of congenital ichthyosis.

[Groin pain in athletes : What does the sports physician expect from the radiologist?]

BACKGROUND

Especially in sports like professional football (soccer) making a diagnosis and generating a final prognosis concerning the time loss is demanding for the team physician and the radiologist. Therefore, the radiologist has to fulfill the requests concerning availability and quality of imaging. This is a particularly difficult task for groin pain because it can be caused by a variety of pathologies.

OBJECTIVES

In addition to the question what the sports physician expects from the radiologist, we have to look at which information the radiologist needs to answer the raised questions. Which external circumstances make a change of the normal procedures necessary when supporting athletes?

RESULTS AND DISCUSSION

Close collaboration between the radiologist and sports physician guarantees that the raised questions from the athlete and the club concerning time loss and necessary therapy can be answered. Thus, the sports physician has to give the radiologist detailed information regarding symptoms, location of the pain and other clinical findings. The radiologist has to include this information into the interpretation of the images to distinguish safely between findings caused by the actual injury and those which are pre-existing.

Experimental realization of a Rydberg optical Feshbach resonance in a quantum many-body system

Feshbach resonances are a powerful tool to tune the interaction in an ultracold atomic gas. The commonly used magnetic Feshbach resonances are specific for each species and are restricted with respect to their temporal and spatial modulation. Optical Feshbach resonances are an alternative which can overcome this limitation. Here, we show that ultra-long-range Rydberg molecules can be used to implement an optical Feshbach resonance. Tuning the on-site interaction of a degenerate Bose gas in a 3D optical lattice, we demonstrate a similar performance compared to recent realizations of optical Feshbach resonances using intercombination transitions. Our results open up a class of optical Feshbach resonances with a plenitude of available lines for many atomic species and the possibility to further increase the performance by carefully selecting the underlying Rydberg state.

[Hereditary epidermolysis bullosa in school children and adolescents. Clinical picture and interdisciplinary management]

Hereditary epidermolysis bullosa (EB) represents a clinically heterogeneous group of congenital blistering disorders requiring multiprofessional care. EB is associated with a broad spectrum of potentially severe complications often reaching their full extent during school age and adolescence. This review aims at summarizing cutaneous manifestations of EB as well as extracutaneous complications of this complex disease and their interdisciplinary management.

Drug hypersensitivity in children: report from the pediatric task force of the EAACI Drug Allergy Interest Group

When questioned, about 10% of the parents report suspected hypersensitivity to at least one drug in their children. However, only a few of these reactions can be confirmed as allergic after a diagnostic workup. There is still a lack of knowledge on drug hypersensitivity (DH) epidemiology, clinical spectrum, and appropriate diagnostic methods particularly in children. Meanwhile, the tools used for DH management in adults are applied also for children. Whereas this appears generally acceptable, some aspects of DH and management differ with age. Most reactions in children are still attributed to betalactams. Some manifestations, such as nonsteroidal anti-inflammatory drug-associated angioedema and serum sickness-like reactions, are more frequent among young patients as compared to adults. Risk factors such as viral infections are particularly frequent in children, making the diagnosis challenging. The practicability and validity of skin test and other diagnostic procedures need further assessment in children. This study presents an up-to-date review on epidemiology, clinical spectrum, diagnostic tools, and current management of DH in children. A new general algorithm for the study of these reactions in children is proposed. Data are presented focusing on reported differences between pediatric and adult patients, also identifying unmet needs to be addressed in further research.

Drug hypersensitivity in children: report from the pediatric task force of the EAACI Drug Allergy Interest Group

When questioned, about 10% of the parents report suspected hypersensitivity to at least one drug in their children. However, only a few of these reactions can be confirmed as allergic after a diagnostic workup. There is still a lack of knowledge on drug hypersensitivity (DH) epidemiology, clinical spectrum, and appropriate diagnostic methods particularly in children. Meanwhile, the tools used for DH management in adults are applied also for children. Whereas this appears generally acceptable, some aspects of DH and management differ with age. Most reactions in children are still attributed to betalactams. Some manifestations, such as nonsteroidal anti-inflammatory drug-associated angioedema and serum sickness-like reactions, are more frequent among young patients as compared to adults. Risk factors such as viral infections are particularly frequent in children, making the diagnosis challenging. The practicability and validity of skin test and other diagnostic procedures need further assessment in children. This study presents an up-to-date review on epidemiology, clinical spectrum, diagnostic tools, and current management of DH in children. A new general algorithm for the study of these reactions in children is proposed. Data are presented focusing on reported differences between pediatric and adult patients, also identifying unmet needs to be addressed in further research.

Capillary saturation and desaturation

Capillary desaturation experiments produce disconnected (trapped) ganglia of mesoscopic sizes intermediate between pore size and system size. Experimental evidence for interactions between these mesoscale clusters during desaturation is analyzed and discussed within the established microscopic and macroscopic laws of Newton, Young-Laplace, and Darcy. A theoretical expression for capillary number correlations is introduced that seems to have remained unnoticed. It expresses capillary desaturation curves in terms of stationary capillary pressures and relative permeabilities. The theoretical expression shows that the plateau saturation in capillary desaturation curves may in general differ from the residual nonwetting saturation defined through the saturation limit of the main hysteresis loop. Hysteresis effects as well as the difference between wetting and nonwetting fluids are introduced into the analysis of capillary desaturation experiments. The article examines experiments with different desaturation protocols and discusses the existence of a mesoscopic length scale intermediate between pore scale and sample scale. The theoretical expression is derived entirely within the existing traditional theory of two-phase flow in porous media and compared to a recent experiment.

Predictive values of component-specific IgE for the outcome of peanut and hazelnut food challenges in children

BACKGROUND

Oral challenges are the gold standard in food allergy diagnostic, but time-consuming. Aim of the study was to investigate the role of peanut- and hazelnut-component-specific IgE in the diagnostics of peanut and hazelnut allergy and to identify cutoff levels to make some challenges superfluous.

METHODS

In a prospective and multicenter study, children with suspected peanut or hazelnut allergy underwent oral challenges. Specific IgE to peanut, hazelnut, and their components (Ara h 1, Ara h 2, Ara h 3, and Ara h 8, Cor a 1, Cor a 8, Cor a 9, and Cor a 14) were determined by ImmunoCAP-FEIA.

RESULTS

A total of 210 children were challenged orally with peanut and 143 with hazelnut. 43% of the patients had a positive peanut and 31% a positive hazelnut challenge. With an area under the curve of 0.92 and 0.89, respectively, Ara h 2 and Cor a 14-specific IgE discriminated between allergic and tolerant children better than peanut- or hazelnut-specific IgE. For the first time, probability curves for peanut and hazelnut components have been calculated. A 90% probability for a positive peanut or hazelnut challenge was estimated for Ara h 2-specific IgE at 14.4 kU/l and for Cor a 14-specific IgE at 47.8 kU/l. A 95% probability could only be estimated for Ara h 2 at 42.2 kU/l.

CONCLUSIONS

Ara h 2- and Cor a 14-specific IgE are useful to estimate the probability for a positive challenge outcome in the diagnostic work-up of peanut or hazelnut allergy making some food challenges superfluous.

Austausch von 32P zwischen markierten und unmarkierten Serumlipoproteiden in vitro

Werden Serumlipoproteide, die biologisch mit 32P markiert wurden, elektrophoretisch getrennt und mit unmarkierten, gleichfalls elektrophoretisch getrennten, Serumlipoproteid-Fraktionen inkubiert, dann kommt in vitro eine Übertragung des Markierungsisotops zwischen signiertem α1-Lipoproteid und unsigniertem β-Lipoproteid und umgekehrt zustande. Die viel zu kurzen Halbwertszeiten für 32P-markierte Serumphosphatide gegenüber 131J-markierten sind durch Phosphorübertragungen erklärbar.

Phenotypic spectrum of epidermolysis bullosa associated with α6β4 integrin mutations

BACKGROUND

Integrin α6β4 is a transmembrane receptor and a key component of the hemidesmosome anchoring complex. It is involved in cell-matrix adhesion and signalling in various tissues. Mutations in the ITGA6 and ITGB4 genes coding for α6β4 integrin compromise dermal-epidermal adhesion and are associated with skin blistering and pyloric atresia (PA), a disorder known as epidermolysis bullosa with PA (EB-PA).

OBJECTIVES

To elucidate the molecular pathology of skin fragility in eight cases, disclose the underlying ITGA6 and ITGB4 mutations and study genotype-phenotype correlations.

METHODS

DNA was isolated from ethylenediaminetetraacetic acid-blood samples, and the coding exons and exon-intron boundaries of ITGA6 and ITGB4 were amplified by polymerase chain reaction (PCR), and directly sequenced. Skin samples were submitted to immunofluorescence mapping with antibodies to adhesion proteins of the dermal-epidermal junction. Primary keratinocytes were isolated, and used for RNA and protein extraction, reverse transcription PCR and immunoblotting. Ultrastructural analysis of the skin was performed in one patient.

RESULTS

We disclose 10 novel mutations, one in ITGA6 and nine in ITGB4. Skin cleavage was either intraepidermal or junctional. Lethal outcome and PA correlated with loss-of-function mutations in two cases. Solely mild skin involvement was associated with deletion of the C-terminus of β4 integrin. Combinations of missense, nonsense or frameshift mutations caused severe urinary tract involvement in addition to skin fragility in five cases.

CONCLUSIONS

The present study reveals novel ITGA6 and ITGB4 gene mutations and supports previous reports showing that the phenotype may lack PA and be limited to skin and nail involvement. In four out of six cases of EB-PA, life expectancy was not impaired. A high frequency of urinary tract involvement was found in this study, and represented the main cause of morbidity. Low levels of β4 integrin expression were compatible with hemidesmosomal integrity and a mild skin phenotype.

Pore-scale micro-computed-tomography imaging: nonwetting-phase cluster-size distribution during drainage and imbibition

We investigated the cluster-size distribution of the residual nonwetting phase in a sintered glass-bead porous medium at two-phase flow conditions, by means of micro-computed-tomography (μCT) imaging with pore-scale resolution. Cluster-size distribution functions and cluster volumes were obtained by image analysis for a range of injected pore volumes under both imbibition and drainage conditions; the field of view was larger than the porosity-based representative elementary volume (REV). We did not attempt to make a definition for a two-phase REV but used the nonwetting-phase cluster-size distribution as an indicator. Most of the nonwetting-phase total volume was found to be contained in clusters that were one to two orders of magnitude larger than the porosity-based REV. The largest observed clusters in fact ranged in volume from 65% to 99% of the entire nonwetting phase in the field of view. As a consequence, the largest clusters observed were statistically not represented and were found to be smaller than the estimated maximum cluster length. The results indicate that the two-phase REV is larger than the field of view attainable by μCT scanning, at a resolution which allows for the accurate determination of cluster connectivity.

Groin pain in athletes

Groin pain in athletes is one of the most difficult to treat clinical entities in sports medicine. The reasons are the amount of differential diagnoses, complexity of pathophysiologic causes and the long time of limited participation in sport. In order to maximize efficient treatment, thorough diagnostics and a clear therapeutic regimen are crucial. To succeed with this issue, a close cooperation between physicians and radiologists is mandatory. MRI is gold standard in the diagnostic work-up of the principal differential diagnoses, such as muscle tears, avulsion injuries, stress fractures, tears of acetabular labrum, and osteitis pubis. The article gives a comprehensive overview of the special anatomy and biomechanics of the pubic region and of typical MRI findings in athletes with groin pain. The use of dedicated imaging protocols is also discussed.

Controlling the dynamics of an open many-body quantum system with localized dissipation

We experimentally investigate the action of a localized dissipative potential on a macroscopic matter wave, which we implement by shining an electron beam on an atomic Bose-Einstein condensate (BEC). We measure the losses induced by the dissipative potential as a function of the dissipation strength observing a paradoxical behavior when the strength of the dissipation exceeds a critical limit: for an increase of the dissipation rate the number of atoms lost from the BEC becomes lower. We repeat the experiment for different parameters of the electron beam and we compare our results with a simple theoretical model, finding excellent agreement. By monitoring the dynamics induced by the dissipative defect we identify the mechanisms which are responsible for the observed paradoxical behavior. We finally demonstrate the link between our dissipative dynamics and the measurement of the density distribution of the BEC allowing for a generalized definition of the Zeno effect. Because of the high degree of control on every parameter, our system is a promising candidate for the engineering of fully governable open quantum systems.

Core-flood experiment for transport of reactive fluids in rocks

Investigation of the transport of reactive fluids in porous rocks is an intriguing but challenging task and relevant in several areas of science and engineering such as geology, hydrogeology, and petroleum engineering. We designed and constructed an experimental setup to investigate physical and chemical processes caused by the flow of reactive and volatile fluids such as supercritical CO(2) and/or H(2)S in geological formations. Potential applications are geological sequestration of CO(2) in the frame of carbon capture and storage and acid-gas injection for sulfur disposal and/or enhanced oil recovery. The present paper outlines the design criteria and the realization of reactive transport experiments on the laboratory scale. We focus on the spatial and time evolution of rock and fluid composition as a result of chemical rock fluid interaction and the coupling of chemistry and fluid flow in porous rocks.

Macroscopic Zeno effect and stationary flows in nonlinear waveguides with localized dissipation

We theoretically demonstrate the possibility of observing the macroscopic Zeno effect for nonlinear waveguides with localized dissipation. We show the existence of stable stationary flows, which are balanced by losses in the dissipative domain. The macroscopic Zeno effect manifests itself in the nonmonotonic dependence of the stationary flow on the strength of the dissipation. In particular, we highlight the importance of the dissipation parameters in observing the phenomenon. Our results are applicable to a large variety of systems, including the condensates of atoms or quasiparticles and optical waveguides.

Symmetry of orbital order in Fe3O4 studied by Fe L(2,3) resonant x-ray diffraction

We studied the symmetry of the Fe 3d wave function in magnetite below the Verwey temperature T(V) with resonant soft-x-ray diffraction. Although the lattice structure of the low-temperature phase of Fe(3)O(4) is well described by the pseudo-orthorhombic Pmca with a slight monoclinic P2/c distortion, we find that the 3d wave function does not reflect the Pmca symmetry, and its distortion toward monoclinic symmetry is by far larger than that of the lattice. The result supports a scenario in which the Verwey transition involves the ordering of t(2g) orbitals with complex-number coefficients.

[Indications and evidence base for specific immunotherapy in childhood]

Allergic rhinitis (AR) is a common disease affecting 7-17% of children and adolescents who may suffer from a significantly impaired quality of life. For 100 years subcutaneous immunotherapy (SCIT) has been used to treat AR. If patients are chosen carefully, a clinically relevant reduction of seasonal symptoms and medication use can be achieved by SCIT. Serious adverse events are rarely encountered during adequately performed and monitored SCIT. Sublingual immunotherapy (SLIT) may be used as a less painful therapeutic alternative in children if the administration of SCIT is impossible. Recent controlled trials have shown that SLIT performed over one pollen season also ameliorates seasonal symptoms and reduces the need for concomitant medication. Local reactions are frequently encountered during SLIT whereas systemic and life-threatening adverse events under correctly performed SLIT have not been reported so far.

[Cutaneous adverse drug reactions in childhood and adolescence]

Adverse drug reactions (ADR) occur in nearly 10% of hospitalized children and in about 1.5% of ambulatory pediatric patients. The skin is the most frequently affected target organ in drug hypersensitivity (DH) reactions, which account for 20% of all ADR. Due to its pathophysiological heterogeneity and the ensuing morphological diversity, DH often represents a clinical and therapeutic challenge. Urticarial and maculopapular eruptions are usually restricted to the skin and rarely require systemic treatment or hospital admission once the culprit drug has been withdrawn. However, extracutaneous affections should be ruled out promptly in individuals with polymorphous rashes accompanied by fever and lymphadenopathy as well as in patients with bullous skin lesions. Children affected by severe drug reactions usually require in-hospital surveillance and interdisciplinary supportive therapy.

Resonant soft x-ray scattering from stepped surfaces of SrTiO3

We studied the resonant diffraction signal from stepped surfaces of SrTiO(3) at the Ti 2p → 3d (L(2,3)) resonance in comparison with x-ray absorption (XAS) and specular reflectivity data. The steps on the surface form an artificial superstructure suitable as a model system for resonant soft x-ray diffraction. A small step density on the surface is sufficient to produce a well defined diffraction peak. We determined the optical parameters of the sample across the resonance and found that the differences between the energy dependence of the x-ray absorption signal, the specular reflectivity and the step-related peak reflect the different quantities probed in these signals. When recorded at low incidence or detection angles, XAS and specular reflectivity spectra are strongly distorted by the changes of the angle of total reflection with energy. The resonant diffraction spectrum is less affected and can be used as a spectroscopic probe even in less favorable geometries.