Inter-society consensus for the use of inhaled corticosteroids in infants, children and adolescents with airway diseases

Background

In 2019, a multidisciplinary panel of experts from eight Italian scientific paediatric societies developed a consensus document for the use of inhaled corticosteroids in the management and prevention of the most common paediatric airways disorders. The aim is to provide healthcare providers with a multidisciplinary document including indications useful in the clinical practice. The consensus document was intended to be addressed to paediatricians who work in the Paediatric Divisions, the Primary Care Services and the Emergency Departments, as well as to Residents or PhD students, paediatric nurses and specialists or consultants in paediatric pulmonology, allergy, infectious diseases, and ear, nose, and throat medicine.

Methods

Clinical questions identifying Population, Intervention(s), Comparison and Outcome(s) were addressed by methodologists and a general agreement on the topics and the strength of the recommendations (according to the GRADE system) was obtained following the Delphi method. The literature selection included secondary sources such as evidence-based guidelines and systematic reviews and was integrated with primary studies subsequently published.

Results

The expert panel provided a number of recommendations on the use of inhaled corticosteroids in preschool wheezing, bronchial asthma, allergic and non-allergic rhinitis, acute and chronic rhinosinusitis, adenoid hypertrophy, laryngitis and laryngospasm.

Conclusions

We provided a multidisciplinary update on the current recommendations for the management and prevention of the most common paediatric airways disorders requiring inhaled corticosteroids, in order to share useful indications, identify gaps in knowledge and drive future research.

Impact of novel coronavirus Disease-19 (COVID-19) pandemic in Italian pediatric emergency departments: a national survey

BACKGROUND

Coronavirus Disease-19 (COVID-19) has rapidly become a pandemic emergency, distressing health systems in each affected country. Preparation strategies for managing this pandemic have been keys to face the COVID-19 surge all over the world and all levels of care.

MATERIALS AND METHODS

During the epidemic, the Italian society of pediatric emergency-urgency (SIMEUP) promoted a national survey aiming to evaluate preparedness and response of pediatric emergency departments (PED) critical in ensuring optimal management of COVID-19 cases.

RESULTS

Our results suggest that Italian PED have promptly set a proactive approach to the present emergency. 98.9% of the hospitals have defined special pathways and assistive protocols concerning the management of pediatric COVID-19 cases. The highest percentage of application of the measures for preventive and protective for COVID-19 concerned the use of personal protective equipments.

CONCLUSIONS

Results show that the following measures for pediatric patients, admitted in PED, have been promptly implemented throughout the whole country: eg. use of protective devices, pre-triage of patients accessing the hospital. Despite COVID-19 being a new threat, we have shown that by developing an easy-to-follow decision algorithm and clear plans for the interventional platform teams, we can ensure optimal health care workers and patients' safety.

SARS-COV-2 infection in children and newborns: a systematic review

A recent outbreak of a novel Coronavirus responsible for a Severe Acute Respiratory Syndrome (SARS-CoV-2) is spreading globally. The aim of this study was to systematically review main clinical characteristics and outcomes of SARS-CoV-2 infections in pediatric age. An electronic search was conducted in PubMed database. Papers published between 1 January and 1 May 2020 including children aged 0-18 years were selected. Sixty-two studies and three reviews were included, with a total sample size of 7480 children (2428/4660 males, 52.1%; weighted mean age 7.6 years). Patients showed mainly mild (608/1432, 42.5%) and moderate (567/1432, 39.6%) signs of the infection. About 2% of children were admitted to the pediatric intensive care unit. The most commonly described symptoms were fever (51.6%) and cough (47.3%). Laboratory findings were often unremarkable. Children underwent a chest CT scan in 73.9% of all cases, and 32.7% resulted normal. Overall, the estimated mortality was 0.08%. A higher proportion of newborns was severely ill (12%) and dyspnea was the most common reported sign (40%).Conclusion: SARS-CoV-2 affects children less severely than adults. Laboratory and radiology findings are mainly nonspecific. Larger epidemiological and clinical cohort studies are needed to better understand possible implications of COVID-19 infection in children.What is Known:• A novel Coronavirus has been recently identified as responsible for a new Severe Acute Respiratory Syndrome (SARS-CoV-2) spreading globally.• There is limited evidence on SARS-CoV2 infection in children.What is New:• Systematically reviewed available evidence showed that children with SARS-CoV-2 infection may have a less severe pattern of disease in comparison to adults.• Blood tests and radiology findings are mainly nonspecific in children but may help to identify those who are severely ill.

Italian guidelines on the assessment and management of pediatric head injury in the emergency department

OBJECTIVE

We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury.

METHODS

These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text.

CONCLUSIONS

Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.

Traumatic diaphragmatic rupture in pediatric age: review of the literature

PURPOSE

Traumatic diaphragm rupture (TDR) is a rare complication of trauma in pediatric age and may be easily missed by the severity of associated injuries so that delayed emergent presentation can occur with increased rate of morbidity and mortality. No review has been available to guide clinicians through the pitfalls and the initial diagnostic approach to pediatric TDR.

METHODS

A Medline thorough search on TDR was conducted using different queries. English language citations were identified during the period of January 2000 through December 2014 limiting the search to pediatric age (0-18 years). Abstracts were reviewed to determine eligibility and texts were obtained for further review. Differences were resolved by consensus and only reliable data were included.

RESULTS

Most frequently reported presenting symptoms of TDR are respiratory and abdominal. While respiratory symptoms are among the most frequently described at the onset in pediatric and adult series, abdominal symptoms result to be more frequent in adult than pediatric patients. Chest X-ray (CXR) is the first-line imaging exam which is reported to show pathognomonic or suspect findings in 85 %. CT was the second main radiological technique used, in particular to confirm the suspicion of TDR.

CONCLUSIONS

A high clinical index of suspicion is needed to diagnose and effectively manage diaphragmatic rupture. TDR should be kept in mind while dealing with patients assessed for abdominal or respiratory symptoms whenever there is history of trauma or blunt injury especially in children as the increasing of non-operative management of blunt abdominal trauma could result in missing important injuries as TDR.

Buried in the Middle but Guilty: Intronic Mutations in the TCIRG1 Gene Cause Human Autosomal Recessive Osteopetrosis

Autosomal recessive osteopetrosis (ARO) is a rare genetic bone disease with genotypic and phenotypic heterogeneity, sometimes translating into delayed diagnosis and treatment. In particular, cases of intermediate severity often constitute a diagnostic challenge and represent good candidates for exome sequencing. Here, we describe the tortuous path to identification of the molecular defect in two siblings, in which osteopetrosis diagnosed in early childhood followed a milder course, allowing them to reach the adult age in relatively good conditions with no specific therapy. No clearly pathogenic mutation was identified either with standard amplification and resequencing protocols or with exome sequencing analysis. While evaluating the possible impact of a 3'UTR variant on the TCIRG1 expression, we found a novel single nucleotide change buried in the middle of intron 15 of the TCIRG1 gene, about 150 nucleotides away from the closest canonical splice site. By sequencing a number of independent cDNA clones covering exons 14 to 17, we demonstrated that this mutation reduced splicing efficiency but did not completely abrogate the production of the normal transcript. Prompted by this finding, we sequenced the same genomic region in 33 patients from our unresolved ARO cohort and found three additional novel single nucleotide changes in a similar location and with a predicted disruptive effect on splicing, further confirmed in one of them at the transcript level. Overall, we identified an intronic region in TCIRG1 that seems to be particularly prone to splicing mutations, allowing the production of a small amount of protein sufficient to reduce the severity of the phenotype usually associated with TCIRG1 defects. On this basis, we would recommend including TCIRG1 not only in the molecular work-up of severe infantile osteopetrosis but also in intermediate cases and carefully evaluating the possible effects of intronic changes.

Dapsone treatment in a girl with severe chronic thrombocytopenic purpura. Does it work? Do not touch it!

Dapsone has been shown to be effective in treating immune thrombocytopenic purpura (ITP) in adults. In children the experience is limited. We describe our experience using dapsone in a female with refractory, symptomatic ITP who suffered intracranic haemorrhage and massive gastric bleeding. After treatment platelet counts was more than 100 x 103/μL, and reached 1000x103/μL. Discontinuation resulted in a rapid decrease in platelet counts, with severe intracranial haemorrhage (ICH). The recovery of dapsone led the platelets count to lower values. We suggest that treatment should not be discontinued in responders, at least in children with symptomatic ITP. Additional studies of dapsone in children are warranted.

Perineal ultrasound evaluation of urethral mobility after the TVT-O procedure

AIMS

The aim of study was to assess, by means of perineal ultrasound (US), women treated with the trans-obturator suburethral sling procedure for urinary stress incontinence (USI).

METHODS

Twelve women with USI and urethral hypermobility were enrolled. Static and dynamic perineal US of urethral mobility was performed before and after tension-free vaginal tape opturator (TVT-O) procedure: US parameters evaluated were pubis-urethra distance and inclination angle of the urethral axis.

RESULTS

The Valsalva stress US evaluation showed a return to normal range of the pubic urethral distance in all cases (p = 0.0001); also a correction of the angle of inclination of the urethral axis occurred in all patients (p < 0.0001).

CONCLUSIONS

Our results propose the use of perineal US for patients with USI as an additional diagnostic tool and a means for postsurgical follow-up.

Non-anaplastic pleomorphic xanthoastrocytoma with neuroradiological evidences of leptomeningeal dissemination

CASE REPORT

A case of a non-anaplastic pleomorphic xanthoastrocytoma (PXA) presenting with leptomeningeal dissemination (LMD) affecting a 9-year-old girl is presented.

DISCUSSION

The neoplasia in this young girl had the otherwise classical clinical features of PXA: the relatively advanced paediatric age of the patient, the seizures as presenting sign; the primary site in the temporal lobe; and the MRI findings of the partially solid and cystic superficial lesion. Only the tumour involvement of the chiasma and the infundibulus was a relatively unusual finding. In a 5-year period, the tumour underwent malignant transformation, bringing the child to death because of the primary tumour progression. However, the leptomeningeal deposits remained unchanged throughout the clinical course.

CONCLUSION

To our knowledge, this is the first case of a non-anaplastic PXA presenting with disseminated disease. Thus, it was thought important to describe this case in order to add further information regarding the spectrum of the presenting clinical features of this rare neoplasm and the phenomenon of LMD of non-malignant glioma.

Embryonal tumor with abundant neuropil and true rosettes. A new entity or only variations of a parent neoplasms (PNETs)? This is the dilemma

A rare embryonal brain tumor has been diagnosed in a 4-year-old boy. The mass, located at the pons and mesencephalon, has been histologically classified as an embryonal tumor containing abundant neuropil and true rosettes. After surgical complete removal of the neoplasia, the child received intensive combined chemotherapy and radiotherapy. He is alive and free of disease at 34 months from surgery. Difficulties in histological definition, possible suggestions for treatment proposals are discussed.

Successful treatment with the monoclonal antibody rituximab in two children with refractory autoimmune thrombocytopenia

Rituximab is a chimeric monoclonal antibody directed against normal and malignant mature B-lymphocytes and results in prolonged and severe B-cell depletion. Recently, rituximab has been successfully used in adult and paediatric disorders of B-lymphocytes such as autoimmune haemolytic anaemia and Werlhof disease. We report on two children with chronic immune thrombocytopenic purpura (ITP) refractory to steroids and immunoglobulins who achieved complete normalisation of their platelet counts after treatment with rituximab, 375 mg/m2 given weekly in four doses. In both cases the B-lymphocyte count dropped to zero after the second dose of rituximab and an unsupported platelet count > 100 x 10(9)/l was achieved during treatment. Six and 12 months after treatment, both patients remain well with normal platelet counts.

CONCLUSION

This report supports the concept that rituximab may also be a valuable therapeutic option in children with chronic immune thrombocytopenic purpura refractory to standard treatment. Controlled clinical trials are needed to evaluate the efficacy and long-term side-effects of rituximab in this group of patients.

Hansenula anomala killer toxin induces secretion and severe acute injury in the rat intestine

BACKGROUND & AIMS

The yeast Hansenula anomala has been associated with gastrointestinal symptomatology and damage to the intestinal wall in humans. In vitro and in vivo, H. anomala secretes a toxin, killer toxin, which is lethal to other microorganisms. In view of the very high rate of killer phenotype expression recorded for H. anomala strains in nature, this study aimed to investigate the hypothesis that H. anomala killer toxin plays a role in the pathogenesis of H. anomala-induced enteritis.

METHODS

Effects of active and heat-inactivated H. anomala killer toxin on intestinal fluid homeostasis and electrolyte balance were investigated in rat small intestine using a standard intestinal perfusion technique. Sections of the perfused jejunum tracts were examined histologically.

RESULTS

H. anomala killer toxin induced a significant secretion of water and electrolytes. No significant change was observed when either heat-inactivated H. anomala killer toxin or control growth medium were tested. Histological analysis showed ischemic degeneration of villi and sloughing of surface epithelium in 50% of active H. anomala killer toxin-perfused jejuna.

CONCLUSIONS

This paper presents original observations compatible with the hypothesis that H. anomala killer toxin plays a role in the pathogenesis of H. anomala-induced enteritis.

Cholera toxin-induced small intestinal secretion has a secretory effect on the colon of the rat

BACKGROUND/AIMS

Little information is available on the role of colon during small intestinal secretion. The aim of this study was to examine the effects of secretory changes in the small intestine on the colonic transport of electrolytes and water in vivo.

METHODS

The jejunum and colon of the rat were perfused in vivo simultaneously but separately, and jejunal secretion was induced by exposing the jejunum to cholera toxin, 8-bromo-cyclic guanosine monophosphate, or hyperosmolarity.

RESULTS

Jejunal perfusion with a hyperosmolar mannitol solution (600 mOsm/L) or with 8-bromo-cyclic guanosine monophosphate (0.5 mmol/L) resulted in net secretion of water in the jejunum but did not affect the baseline rate of water transport in the colon. On the contrary, addition of cholera toxin (1 microgram/loop) to the jejunal segment not only induced a significant local secretory change but also resulted in a similar change in the colon, which was not exposed to cholera toxin. The intestine was transected immediately below the jejunum, thus interrupting the anatomical continuity of the enteric nervous system. This procedure eliminated the distant secretory effect of cholera toxin, thus allowing the conclusion that the enteric nervous system is involved in the distant propagation of the local secretion induced by cholera toxin.

CONCLUSIONS

Cholera toxin, but not other secretagogues, triggers a secretory response that is not only local but also extends to distal segments via the enteric nervous system.

Comparative effects of atrial natriuretic peptide and E. coli heat-stable toxin on rat intestinal transport

Conflicting data have been published in favor of or against a secretory effect of atrial natriuretic peptide (ANP) in the intestine. The reported effects resemble that of Escherichia coli heat-stable enterotoxin (ST). In this work the effects of ANP were studied in well established experimental systems and compared with that of ST. Both peptides induced a prompt secretion of water, Na, and Cl with no effects on K net transport in the in vivo rat perfused jejunum. The addition of ST, but not of ANP, evoked an increase of short circuit current in rat intestinal mucosa mounted in Ussing chambers. ST induced a significant increase in guanylate cyclase activity in intestinal homogenates, whereas ANP showed no effect. No binding sites for ANP were detected in basolateral or brush border membranes, nor in isolated enterocytes by a suction filtration technique. In conclusion, ANP acts as a short-lived intestinal secretagogue in the rat. Its mechanism of action is different from that of E. coli ST and appears to be indirect, since is not mediated by specific intestinal receptors and is not evident in vitro.

[Visceral leishmaniasis complicated by herpes zoster. An unusual case in the pediatric age]

The Authors describe a case report of a girl of 7 years affected by visceral leishmaniasis (VL) complicated by herpes zoster (Hz). Hz infection is unusual in paediatric age, but it may complicate immunodeficiency states. VL causes, as well known, T cell immunity depression: Hz infection could be facilitated by this situation.

Transient gluten hypersensitivity

We report a case of transient gluten hypersensitivity, demonstrated by jejunal histology at diagnosis, normalization after gluten-free diet, and acute clinical and histological relapse after a challenge with gluten powder at the age of 1 year, resembling that observed in cow's milk protein intolerance. Subsequent provocation tests did not show any alteration. Cases of supposed transient gluten hypersensitivity are rarely reported; our patient is characterized by the acute reaction to gluten challenge associated with a damaged histological picture and depressed levels of complement.

Unconjugated bilirubin and the bile from light exposed Gunn rats inhibit intestinal water and electrolyte absorption

Jaundiced babies undergoing phototherapy often develop diarrhoea. The cause of it is still uncertain. Increasing evidence supports a role of a secretory mechanism for the diarrhoea. We therefore studied the effects of bile from congenitally jaundiced rats undergoing phototherapy and of unconjugated bilirubin on rat small intestine in vivo and in vitro. Results suggest that: (1) the bile from homozygous Gunn rats under phototherapy has an anti-absorptive effect when tested in the perfused jejunum of normal Wistar rats; (2) unconjugated bilirubin has a dose dependent secretory effect on the intestinal transport of water and electrolytes, when tested in the same system. Alteration of cyclic AMP or cyclic GMP, known intracellular mediators of secretion, was not observed. We conclude that free bilirubin is an intestinal secretagogue acting by an as yet unknown mechanism, that may mediate the secretory type of diarrhoea in jaundiced neonates undergoing phototherapy.