Pediatric admissions to emergency departments of North-Western Italy during COVID-19 pandemic: A retrospective observational study

Background

COVID-19 pandemic caused huge decrease of pediatric admissions to Emergency Department (ED), arising concerns about possible delays in diagnosis and treatment of severe disorders.

Methods

Impact of COVID-19 on Pediatric Emergency Room (ICOPER) was a retrospective multicentre observational study including 23 Italian EDs.

All the children <18 years admitted, between March 9th and May 3rd 2020 stratified by age, priority code, cause of admission and outcome have been included and compared to those admitted in the same period of 2019.

Our objectives were to assess the characteristics of pediatric admissions to EDs since COVID-19 outbreak until the end of lockdown, and to describe the features of critical children.

Findings

16,426 children were admitted in 2020, compared to 55,643 in 2019 (-70·48%). Higher reduction was reported in hospitals without Pediatric Intensive Care Unit (PICU) (-73·38%) than in those with PICU (-64·08%) (P<0·0001). Admissions with low priority decreased more than critical ones (-82·77% vs. 44·17% respectively; P<0·0001). Reduction of discharged patients was observed both in hospitals with (-66·50%) and without PICU (-74·65%) (P<0·0001). No difference in the duration of symptoms before admission was reported between 2019 and 2020, with the majority of children accessing within 24 h (55·08% vs. 57·28% respectively; P = 0·2344).

Interpretation

Admissions with low priority decreased significantly more than those with high priority; we suppose that the fear of being infected in hospital maybe overcame the concerns of caregivers. Compared to 2019, no significant referral delay by caregivers was reported. Our data suggest the need of adaptation of EDs and primary care services to different needs of children during COVID-9 pandemic.

Sleep-related risk and worrying behaviours: a retrospective review of a tertiary centre's experience

This retrospective study aims at helping physicians select babies considered at risk for fatal events during sleep. It does so by describing the clinical features and outcome of worrying infants' behaviour during sleep, with the activation of an emergency medical service and/or emergency department, subsequently referred to the Centre for Paediatric Sleep Medicine and sudden infant death syndrome, Regina Margherita Children's Hospital, Turin, Italy. We analysed the medical records of infants < 12 months whose parents reported they had worrying behaviour during sleep in the period 1 January 2009- 31 December 2015. Regional guidelines suggest performing anamnesis and capillary blood gas analysis in case of apparent life-threatening events. There were 33 males, average age 55 ± 54.37 days. On arrival at the emergency medical service/emergency department 97 % infants were asymptomatic; 61 % patients had a capillary blood gas analysis as suggested by the regional guidelines. A clear acid-base disorder was observed in two infants, asymptomatic at medical evaluation, that had assumed an unsafe sleeping position. Two patients presented recurrence of the episode at 3 months.Conclusions: Most worrying infant behaviour during sleep can be related to paraphysiological phenomena; capillary blood gas analysis and anamnesis are pivotal to identify the cases at risk of fatal events.What is Known:• Events that happen during sleep often frighten the parents of newborns. This fear may be induced by the fact that Sudden Infant Death Syndrome typically occurs during sleep.• This tragic event is unpredictable by any clinical features or findings in instrumental examinations and cannot be prevented with an early resuscitation.What is New:• In our retrospective study, most worrying infant behaviour during sleep can be related to paraphysiological phenomena.• Capillary blood gas analysis and anamnesis collection were crucial to identify the only two life-threatening events.

Skin-to-skin contact and delivery room practices: a longitudinal survey conducted in Piedmont and the Aosta Valley

Background

Sudden unexpected postnatal collapse of presumably healthy neonates during early skin-to-skin contact is a rare, yet recognized occurrence, associated with a high risk of mortality and morbidity. A survey was conducted in 2012 in 30 delivery wards throughout Piedmont and the Aosta Valley to evaluate the environmental and logistical aspects that could be linked to SUPC. The survey was again conducted in 2016 in 28 delivery wards in Piedmont and the Aosta Valley in order to evaluate organizational improvements introduced after ministerial indications and recommendations by the Italian Society of Neonatology were published in 2014, in light of new findings regarding the phenomenon.

Methods

A questionnaire specifically asking about the organization of delivery wards, and surveillance or supervision during early skin-to-skin contact, was sent to all of the hospitals taking part in the survey in both 2012 and 2016. The collected data were elaborated anonymously and the statistical analysis was performed by using the two by two table.

Results

In 2012, 28 out of 30 delivery wards in Piedmont and Aosta, with a total of 31,074 newborns out of 35,435, were evaluated in all of the environmental and logistical aspects that might be cause for SUPC to occur. An identical survey was taken again in 2016; 26 out of 28 wards participated with a total of 27,484 newborns out of 30,339. In 2012, early skin-to-skin contact took place immediately in all the delivery rooms in 27 wards, and soon after in the post-partum room in one; in 11 out of 28 wards there was early skin-to-skin contact in the operating theater itself, following caesarean sections (11/26 in 2016). Routine newborn care was given after 3 h in 8 delivery wards (7/26 in 2016); after 2 h in 12 (7/26 in 2016); after 1 h in 2 (4/26 in 2016); after 30 min in 3 (2/26 in 2016); after 10 min in 1 (0/26 in 2016); after 1 or 2 min in 1 (0/26 in 2016) and at any time in one ward (6/26 in 2016).

Conclusion

Periodic surveys of delivery wards are useful for the assessment of all the aspects and risk factors that need to be changed in order to implement safe early skin-to-skin contact.

Electronic supplementary material

The online version of this article (10.1186/s13052-019-0688-9) contains supplementary material, which is available to authorized users.

Early Effect of Implant-Supported Rehabilitation and Nocturnal Bruxism on Maximum Occlusal Force: A Cross-Sectional Study

This clinical study evaluated the early effect of oral rehabilitation with dental implants and nocturnal bruxism on maximum occlusal force (MOF), before sensorimotor adaptation. A consecutive sample consisted of 127 patients divided into three groups according to their dental state: G1- implant-supported fixed complete denture (IFCD) opposing to a small fixed prosthesis or natural dentition; G2- IFCD opposing to a complete denture; and G3- small fixed prosthesis or natural dentition in both arches. Clinical data were collected after prosthesis installation: systemic and oral health conditions, MOF, self-reported bruxism, and bruxism severity (low, moderate, severe). Data were analysed by ANOVA and Tukey-Krammer tests. Dental state and the interaction sex-bruxism had significant effect on MOF. G1 had higher MOF than G3, but G2 was not significantly different from G1 and G3. Men with bruxism had the highest MOF. The levels of bruxism severity did not have a significant effect on MOF. The results suggest that MOF varies as a function of dental state and the interaction sex-bruxism. However, presence and severity of bruxism alone does not affect MOF.

GAGs-Potentiated Inhibition of Thrombin, Factor Xa and Plasmin in Plasma and in a Purified System Containing Antithrombin III – Correlation with Total Charge Density

The ability of heparin and related glycosaminoglycans (GAGs) to accelerate the inhibition of thrombin, factor Xa and plasmin in plasma and in a purified system containing antithrombin III (At III) was studied using chromogenic peptide substrate assays

There was a good correlation between the charge density of the mucopolysaccharides and the activities investigated. While the difference between potentiation of the antithrombin activity by GAGs in plasma and in the purified system was slight, the inhibition of factor Xa in plasma was more pronounced than in the presence of purified At III, indicating the mechanisms for GAGs-potentiated inhibition of thrombin and factor Xa are not identical.

For the antiplasmin activity, there was a good correlation between the chemical structure and biological activity only in the pure system, confirming that the antithrombin-GAG complex plays a very limited role in the inactivation of plasmin in plasma.

Hypotonic-hyporesponsive episodes after administration of hexavalent DTP-based combination vaccine: A description of 12 cases

Hypotonic-hyporesponsive (HHE) episodes are known and recognized phenomena, which typically occur within 48 hours of immunisation..Our aim is to describe 12 cases of HHE brought to the Center of Pediatric Sleep Medicine, with attention to the clinical features of the episode and their follow-up. Medical charts of infants visited between 2005-2015 were reviewed. Twelve infants showed a HHE using HHE using Brighton Collaboration Criteria. All infants received a Hexavalent diphtheria -tetanus -pertussis acellular component -hepatitis B-,inactivated poliovirus- Haemophilus influenzae type-b conjugate vaccine. Five out of 12 were brought to Emergency Department, where 2 were symptomatic (one was hyporeactive, the other had fever). No infant died during the episode, or the follow-up, nor developed neurological disease after subsequent vaccinations. HHE are confirmed as benign events, even after administration of hexavalent vaccination, devoid of negative neuropsychomotor outcome.

Apparent life-threatening events could be a wake-up call for sleep disordered breathing

INTRODUCTION

Polysomnographic recordings of children with an apparent life-threatening event (ALTE) have often displayed signs of partial or complete obstruction during sleep. Various studies have focused on facial dysmorphia in infants with ALTE and tried to establish a correlation between ALTE and obstructive sleep apnoea. Our study evaluates the phenotypic characteristics and the presence of sleep disorders in pre-school children who had at least one ALTE in the first year of life.

MATERIALS AND METHODS

We analyzed a group of pre-school children (mean age 5.21 ± 0.90 years) who were referred for an ALTE between 2008 and 2010. Children with no history of ALTEs were recruited as a control group. A detailed personal and family history was obtained for all the participants. Moreover, all the children underwent a general clinical examination and an ear, nose, and throat and orthodontic assessment. A clinical score was calculated according to the previously validated Sleep Clinical Record (SCR).

RESULTS

In the ALTE group (n = 107), snoring (25.2% vs. 6.1%), apnoeas (19.6% vs. 4.3%), restless sleep (31.7% vs. 6.1%), and habitual mouth breathing (35.5% vs. 12.2%, P < 0.05) were significantly more common (P < 0.05) than in the control group (n = 115). The ALTE group also displayed a higher frequency of Angle class II (27.1% vs. 15.7%, P < 0.05), narrow palate (72.9% vs. 51.3%, P < 0.05), and Friedman palate position (grades III-IV) (31.7% vs. 16.6%, P < 0.05) than the control group. Moreover, 38/107 (35.5%) children in the ALTE group had a positive SCR score compared with 14/115 controls (12.2%) (P < 0.05).

CONCLUSIONS

Pre-school age children with previous ALTE had a higher frequency of sleep disordered breathing and malocclusion phenotypes. The occurrence of ALTEs may be predictive of the development of sleep disordered breathing and highlight the importance of a long-term follow-up. Pediatr Pulmonol. 2016;51:1403-1408. © 2016 Wiley Periodicals, Inc.

Variability in baseline laboratory measurements of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

Multi-center epidemiological studies must ascertain that their measurements are accurate and reliable. For laboratory measurements, reliability can be assessed through investigation of reproducibility of measurements in the same individual. In this paper, we present results from the quality control analysis of the baseline laboratory measurements from the ELSA-Brasil study. The study enrolled 15,105 civil servants at 6 research centers in 3 regions of Brazil between 2008-2010, with multiple biochemical analytes being measured at a central laboratory. Quality control was ascertained through standard laboratory evaluation of intra- and inter-assay variability and test-retest analysis in a subset of randomly chosen participants. An additional sample of urine or blood was collected from these participants, and these samples were handled in the same manner as the original ones, locally and at the central laboratory. Reliability was assessed with the intraclass correlation coefficient (ICC), estimated through a random effects model. Coefficients of variation (CV) and Bland-Altman plots were additionally used to assess measurement variability. Laboratory intra and inter-assay CVs varied from 0.86% to 7.77%. From test-retest analyses, the ICCs were high for the majority of the analytes. Notably lower ICCs were observed for serum sodium (ICC=0.50; 95%CI=0.31-0.65) and serum potassium (ICC=0.73; 95%CI=0.60-0.83), due to the small biological range of these analytes. The CVs ranged from 1 to 14%. The Bland-Altman plots confirmed these results. The quality control analyses showed that the collection, processing and measurement protocols utilized in the ELSA-Brasil produced reliable biochemical measurements.

Fasting plasma glucose to avoid a full OGTT in the diagnosis of gestational diabetes

AIMS

To evaluate the performance of fasting plasma glucose (FPG) in determining the need for a full oral glucose tolerance test (OGTT) to diagnose gestational diabetes (GDM) by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria.

METHODS

A multicenter cohort study of 4926 pregnant women 20 years or older consecutively enrolled in prenatal care clinics of the Brazilian National Health Service from 1991 to 1995. All women underwent a single 2 h 75 g OGTT by weeks 24-28 of pregnancy and were followed to detect adverse pregnancy outcomes.

RESULTS

A FPG cut-off value of 80 mg/dl indicated that only 38.7% of all women needed to undergo a complete OGTT, while detecting 96.9% of all GDM cases. When the 85 mg/dl cut-off was used, the corresponding percentages were 18.7% and 92.5%, respectively. The fraction of women labeled with GDM who had adverse pregnancy outcomes was nearly identical when using FPG strategies and universal full testing.

CONCLUSIONS

Using a FPG cut-off to diagnose GDM and to determine the need for post-load OGTT measurements is a valid strategy to diagnose GDM by IADPSG criteria. This approach may improve feasibility of applying IADPSG diagnostic criteria by reducing costs and increasing convenience.

Glutamic acid decarboxylase antibodies are indicators of the course, but not of the onset, of diabetes in middle-aged adults: the Atherosclerosis Risk in Communities Study

To efficiently examine the association of glutamic acid decarboxylase antibody (GADA) positivity with the onset and progression of diabetes in middle-aged adults, we performed a case-cohort study representing the ~9-year experience of 10,275 Atherosclerosis Risk in Communities Study participants, initially aged 45-64 years. Antibodies to glutamic acid decarboxylase (GAD65) were measured by radioimmunoassay in 580 incident diabetes cases and 544 non-cases. The overall weighted prevalence of GADA positivity (>or=1 U/mL) was 7.3%. Baseline risk factors, with the exception of smoking and interleukin-6 (P <or= 0.02), were generally similar between GADA-positive and -negative individuals. GADA positivity did not predict incident diabetes in multiply adjusted (HR = 1.04; 95%CI = 0.55, 1.96) proportional hazard analyses. However, a small non-significant adjusted risk (HR = 1.29; 95%CI = 0.58, 2.88) was seen for those in the highest tertile (>or=2.38 U/mL) of positivity. GADA-positive and GADA-negative non-diabetic individuals had similar risk profiles for diabetes, with central obesity and elevated inflammation markers, aside from glucose, being the main predictors. Among diabetes cases at study's end, progression to insulin treatment increased monotonically as a function of baseline GADA level. Overall, being GADA positive increased risk of progression to insulin use almost 10 times (HR = 9.9; 95%CI = 3.4, 28.5). In conclusion, in initially non-diabetic middle-aged adults, GADA positivity did not increase diabetes risk, and the overall baseline profile of risk factors was similar for positive and negative individuals. Among middle-aged adults, with the possible exception of those with the highest GADA levels, autoimmune pathophysiology reflected by GADA may become clinically relevant only after diabetes onset.

Leptin and incident type 2 diabetes: risk or protection?

AIMS/HYPOTHESIS

The aim of this study was to investigate the association of leptin levels with incident diabetes in middle-aged adults, taking into account factors purportedly related to leptin resistance.

SUBJECTS AND METHODS

We conducted a case-cohort study (570 incident diabetes cases and 530 non-cases) representing the 9-year experience of 10,275 participants of the Atherosclerosis Risk in Communities Study. Plasma leptin was measured by direct sandwich ELISA.

RESULTS

In proportional hazards models adjusting for age, study centre, ethnicity and sex, high leptin levels (defined by sex-specific cut-off points) predicted an increased risk of diabetes, with a hazard ratio (HR) comparing the upper with the lower quartile of 3.9 (95% CI 2.6-5.6). However, after further adjusting additionally for obesity indices, fasting insulin, inflammation score, hypertension, triglycerides and adiponectin, high leptin predicted a lower diabetes risk (HR=0.40, 95% CI 0.23-0.67). Additional inclusion of fasting glucose attenuated this protective association (HR=0.59, 95% CI 0.32-1.08, p<0.03 for linear trend across quartiles). In similar models, protective associations were generally seen across subgroups of sex, race, nutritional status and smoking, though not among those with lower inflammation scores or impaired fasting glucose (interaction p=0.03 for both).

CONCLUSIONS/INTERPRETATION

High leptin levels, probably reflecting leptin resistance, predict an increased risk of diabetes. Adjusting for factors purportedly related to leptin resistance unveils a protective association, independent of adiponectin and consistent with some of leptin's described protective effects against diabetes.

Evaluation of left ventricular diastolic function in insulin dependent diabetic children by M-mode and Doppler echocardiography

To evaluate the presence of diabetic cardiomyopathy, we measured various parameters of left ventricular systolic and diastolic function by means of M-mode and Doppler echocardiography in 50 IDDM children (mean age 13 +/- 3 years; mean IDDM duration 5.9 +/- 4.1 years) free of cardiovascular symptoms. As compared to age-matched healthy control subjects, diabetic children evidenced a significant increase in mean values of pressure half time (PHT), an index of the early diastolic phase (53.7 +/- 10.2 msec vs 44.5 +/- 9, p < 0.002). When the patients were subdivided on the basis of IDDM duration, metabolic control and the presence of retinal microangiopathic abnormalities, those with longer IDDM duration and poor glycemic balance had higher PHT values. These data indicate that an early diastolic dysfunction, expressed by reduced left ventricular compliance, can be found in children with Type 1 diabetes mellitus of relatively short duration. Doppler echocardiography is a reliable non-invasive means to assess early impairment of cardiac function in IDDM patients.

Course of retinopathy in children and adolescents with insulin-dependent diabetes mellitus: a ten-year study

The prevalence and development of retinal changes were longitudinally documented from 1978 to 1987 in 112 insulin-dependent diabetic children by means of fluorescein angiography and fundus photography. At the end of the study period, 43 patients (38.4%) developed retinal changes, most of which were classified as minimal. Age, diabetes duration, puberty and long-term metabolic control were found to be independent factors affecting the development of retinopathy.

Low-dose heparin in thoracic surgery: effect on blood coagulation and fibrinolysis system

Plasma kallikrein, antithrombin III and antiplasmin were determined with chromogenic methods in 29 patients pre-, per- and post-operatively in a controlled, randomized study. 16 patients received calcium heparin, 5000 IU s. c. every 8 hr for 7 days, the first administration given 2 hr before surgical procedure. 13 control patients received saline. A significant reduction of kallikrein and antiplasmin in per- and post-operative periods was observed in the control patients compared with the heparin-treated patients, while there was a significant reduction of anti-thrombin III in the control patients compared with the treated patients only in the per-operative period. The results obtained suggest that activation of the coagulation and fibrinolysis system occurs in patients undergoing thoracic surgery, and that it is inhibited significantly by calcium heparin prophylaxis.

GAGs-potentiated inhibition of thrombin, factor Xa and plasmin in plasma and in a purified system containing antithrombin III - correlation with total charge density

The ability of heparin and related glycosaminoglycans (GAGs) to accelerate the inhibition of thrombin, factor Xa and plasmin in plasma and in a purified system containing antithrombin III (At III) was studied using chromogenic peptide substrate assays. There was good correlation between the charge density of the mucopolysaccharides and the activities investigated. While the difference between potentiation of the antithrombin activity by GAGs in plasma and in the purified system was slight, the inhibition of factor Xa in plasma was more pronounced than in the presence of purified At III, indicating the mechanisms for GAGs-potentiated inhibition of thrombin and factor Xa are not identical. For the antiplasmin activity, there was a good correlation between the chemical structure and biological activity only in the pure system, confirming that the antithrombin-GAG complex plays a very limited role in the inactivation of plasmin in plasma.