Increase of pyogenic bacterial infections after relaxation of social distancing measures linked to COVID-19 pandemic.

AIM: After the relaxation of COVID-19 mitigation measures, we observed a dramatic increase in pyogenic infections. Based on this observation, we retrospectively analysed all cases of invasive bacterial infections of brain, lung and complicated ear-nose-throat (ENT) infections, in the period from 1 August to 31 March from the years 2018-2019 to 2022-2023. METHODS: The study was conducted in two Paediatric Emergency Departments, at IRCCS 'Burlo Garofolo' of Trieste and at Treviso Hospital. Electronic medical records were searched for all cases with a definitive diagnosis at discharge of mastoiditis, suppurative cervical lymphadenitis, retropharyngeal, parapharyngeal and peritonsillar abscess (ENT group), bacterial brain abscesses, epidural empyema, subdural empyema (central nervous system group), thoracic empyema and necrotising pneumonia (lung group). RESULTS: In 2022-2023, we observed an increase in infections compared to the previous years. Total number of cases were 22, 29, 8, 27 and 63 in 2018-2019, 2019-2020, 2020-2021, 2021-2022 and 2022-2023, respectively. The greater increase occurred in thoracic empyema, with a peak incidence of +120% in 2022-2023 in respect of 2021-2022. CONCLUSION: We reported an important increase in paediatric bacterial complicated infections in two North East Italian regions, possibly correlated with the relaxation of COVID-19 social distancing measures.

Pediatric schwannoma of the hypoglossal nerve: a case report and narrative literature overview.

Schwannomas are benign, slow-growing tumors originating from the Schwann cells of nerve sheaths. Extracranial schwannomas are rare, particularly in pediatric populations. Here, we report the case of a hypoglossal schwannoma in a 15-year-old male who experienced tongue paresthesia and fasciculations and difficulty swallowing two years before hospital admission. Magnetic resonance imaging showed an oval mass with sharp and regular limits of approximately 45 × 29 × 25 mm in the cranial portion of the right carotid adipose space, caudal to the right carotid and lateral foramen. The patient underwent surgery, and a histological examination confirmed a schwannoma of the hypoglossal nerve. Six months after surgery, the patient was symptom-free. The literature on schwannomas of the hypoglossal nerve is scarce, with only a few previously reported cases in the adult population. Despite their rarity, schwannomas should be considered in the differential diagnosis of masses located in the neck that present with lingual and occasionally auditory symptoms, even in pediatric patients. Surgical resection is recommended and has a low risk of long-term recurrence.

Pediatric stricturing Crohn's disease.

Crohn's disease (CD) is a chronic inflammatory disease of the digestive tract. The incidence of pediatric CD is increasing and is currently 2.5-11.4 per 100000 world-wide. Notably, approximately 25% of children with CD develop stricturing CD (SCD) that requires intervention. Symptomatic stricturing diseases refractory to pharmacological management frequently require non-pharmacological interventions. Non-pharmacological therapeutic strategies include endoscopic balloon dilatation, stricturoplasty, and surgical resection of the strictured segment. However, strictures tend to recur postoperatively regardless of treatment modality. The lifetime risk of surgery in patients with childhood SCD remains at 50%-90%. Thus, new and emerging strategies, advanced diagnostic tools, and minimally invasive approaches are under investigation to improve the outcomes and overall quality of life of pediatric patients with SCD.

Granular Cell Tumor (Abrikossoff's Tumor) of the Vulva in Childhood.

Granular cell tumors (GCTs) (Abrikossoff's tumors) are rare neoplasms derived from Schwann cells. Immunohistochemistry remains the most useful instrument for diagnosing GCTs. Complete surgical excision has been demonstrated to be curative for benign lesions. However, long-term follow-up in these patients is strongly recommended.

Management of pleural effusion and empyema in a third-level pediatric surgical center.

BACKGROUND: Pleural effusion and empyema are frequent complications of acute bacterial pneumonia in children. To date, evidence regarding the optimal treatment of this condition is limited in the literature. METHODS: Patients with pleural effusion and empyema admitted at our Department of Pediatric Surgery over the last ten years were enrolled in this retrospective study, and successively compared with the clinical charts of patients treated before the introduction of a new diagnostic and therapeutic algorithm. In particular, primary outcomes investigated between pre- and postalgorithm period were the use of diagnostic tools and antibiotics, the need for additional therapeutic approaches, complications, and the length of stay. RESULTS: After the introduction of the new algorithm there were a decrease in the use of chest radiography for re-evaluation (100% vs. 79%, P=0.003), a more focused use of computed tomography (68% vs. 15%, P=0.001), and a decrease in the use of a second computed tomography (18% vs. 3%, P=0.07); in favor of an increase in the use of the ultrasound scan (40% vs. 100%, P=0.001). There was also a shift from the use of chest tube drainage alone to the use of drainage for urokinase administration (50% vs. 92.3%, P=0.001), and a statistically significant decrease in the need for video-assisted thoracoscopic surgery (25% vs. 7.7%, P=0.001). CONCLUSIONS: The introduction of a diagnostic and therapeutic algorithm for the management of pediatric pleural effusion and empyema has notably resulted in a decrease in the utilization of radiography and computed tomography and an increase in the use of ultrasonography, reducing unnecessary radiation exposure in children and overall costs.

Clinical characteristics of pediatric inpatients infected with the SARS-CoV-2 Omicron variant-a retrospective observational cohort study.

Background: The children infected with the Omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are at risk of progressing to severe disease. Clinical characteristics treatment measures and prognosis of these special age group of patients have not been completely understood which necessitate more researches. This study sought to analyze the clinical characteristics of children infected with the Omicron variant to provide evidences for the prevention, diagnosis and treatment of the Omicron variant infection in children. Methods: The subjects of this study included children hospitalized for the Omicron variant at Tianjin Binhai Hospital in November 2022. The data were collected from the electronic medical record system, and the clinical characteristics of the children were analyzed. The primary endpoints included the clinical presentation, laboratory tests, virological characteristics, treatment regimen, and clinical prognosis of the patients. Results: A total of 49 patients were enrolled, of whom 32 (65.3%) were male. The patients had a median age of 10 (interquartile range, 6-11) years, and 34.7% of the patients received 2 or more coronavirus disease 2019 (COVID-19) vaccines. The main clinical manifestations of the patients were fever (79.6%) and cough (24.5%), with a maximum temperature of 42 ℃ and a median temperature of 39 (interquartile range, 38.4-39) ℃. The proportions of neutrophils and C-reactive protein were elevated by 50.0% and 25.0%, respectively. The total percentages of white blood cells and thrombocytopenia were 12.5% and 6.3%, respectively. D-dimer was examined in 6 cases, and was elevated to 1.77 µg/mL in 1 case (16.7%), and normal in 5 cases. The liver function, kidney function, and coagulation of 9 (100%) patients were all normal. After the anti-virus, anti-inflammatory response, antipyretic, and traditional Chinese medicine treatments, all the children were cured and discharged from the hospital. There were no severe cases. Conclusions: The main manifestations of children infected with the SARS-CoV-2 Omicron variant were fever and cough. Some children had a high fever, nasal congestion, runny nose, gastrointestinal symptoms, and rash. A proportion of 12.5% of patients have a white blood cell count less than 4×109/L, and 6.3% have thrombocytopenia. The prognosis of the child was favorable after treatment with antiviral, antipyretic, and traditional Chinese medicine.

Informed consent in minor and intermediate pediatric elective surgery: results of an in-house questionnaire.

Background: The aim of this study was to evaluate the quality of our surgical informed consent and parents'/guardians' late recall of surgical procedures and risks of elective day surgery after pre-operative interview with surgeons. Methods: All parents/guardians of patients <18 years of age undergoing minor and intermediate elective procedures from January 15th to September 1st, 2022, were prospectively enrolled in the study. Before discharge, parents/guardians were asked to complete an in-house questionnaire regarding the duration of the consent procedure, duration of the interview, quality of the informative handouts, and their ability to recall the type of disease, type of surgical procedure, and surgical risks. Results: One hundred and two questionnaires were returned. In all cases, informed consent was obtained between 24 and 72 h prior to surgery. The following responses were collected: 98/102 (96%) parents/guardians reported that the duration of the consent process was adequate; 95/102 (93%) reported that the handouts were fully informative, and 7/102 (7%) reported that they were partially informative regarding explanation of the disease and surgical procedure; regarding complications, 93/102 (91%) perceived the handouts to be fully/partially informative, while 4/102 (4%) perceived the handouts to be poorly/non-informative, and 5/102 (5%) did not provide a response; 94/102 (92%) stated that they remembered the pathology, but only 87/94 (93%) recalled it correctly; 90/102 (88%) stated that they remembered the type of procedure, but only 76/90 (84%) recalled it correctly; and 53/102 (52%) stated that they remembered the surgical risks, but only 20/53 (38%) could recall more than one complication. Conclusions: Late recall of surgical complications by parents was poor despite the high perceived quality of the surgical risk handouts and medical interview. Implementation of expedient methods may improve overall comprehension and satisfaction of parents/guardians regarding the IC process. Further, more efforts should be made to develop standardized guidelines for an optimal IC process.

Robotic-assisted surgery in pediatrics: what is evidence-based?-a literature review.

Background and Objective: The use of robotic-assisted surgery (RAS) has increased more slowly in pediatrics than in the adult population. Despite the many advantages of robotic instruments, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) still presents some limitations for use in pediatric surgery. This study aims to examine evidence-based indications for RAS in the different fields of pediatric surgery according to the published literature. Methods: A database search (MEDLINE, Scopus, Web of Science) was performed to identify articles covering any aspect of RAS in the pediatric population. Using Boolean operators AND/OR, all possible combinations of the following search terms were used: robotic surgery, pediatrics, neonatal surgery, thoracic surgery, abdominal surgery, urologic surgery, hepatobiliary surgery, and surgical oncology. The selection criteria were limited to the English language, pediatric patients (under 18 years of age), and articles published after 2010. Key Content and Findings: A total of 239 abstracts were reviewed. Of these, 10 published articles met the purposes of our study with the highest level of evidence and therefore were analyzed. Notably, most of the articles included in this review reported evidence-based indications in urological surgery. Conclusions: According to this study, the exclusive indications for RAS in the pediatric population are pyeloplasty for ureteropelvic junction obstruction in older children and ureteral reimplantation according to the Lich-Gregoire technique in selected cases for the need to access the pelvis with a narrow anatomical and working space. All other indications for RAS in pediatric surgery are still under discussion to date, and cannot be supported by papers with a high level of evidence. However, RAS is certainly a promising technology. Further evidence is strongly encouraged in the future.

Oxygen-enriched oleic matrix (NovoX) for wound healing in pediatric patients undergoing open surgical treatment for pilonidal disease: Preliminary experience.

Introduction: Pilonidal disease (PD) is a common infectious and inflammatory condition affecting the gluteal cleft and sacrococcygeal region. The optimal treatment for PD remains controversial. While the open technique reduces the number of relapses compared to minimally invasive approaches, it is associated with a longer healing time. Reactive oxygen species are a key part of the normal wound-healing process. Herein, we reported our preliminary experience using a new oxygen-enriched oil-based product called NovoX for wound healing after open surgery for PD. Materials and methods: We used a new oxygen-enriched product for wound healing in three pediatric patients undergoing open surgical repair for PD between December 2021 and April 2022. During postoperative follow-up, healing time and the aesthetic result were evaluated. Results: Our preliminary study included three patients with chronic PD. The average follow-up time was 5 weeks, corresponding to the end of the healing process and the resumption of normal daily activities. Only one mild complication occurred during the study period. No short-term side effects were reported. The cosmetic result was reported as satisfactory. Conclusion: NovoX is easy to apply, safe, and effective for treating pediatric patients undergoing open surgical treatment for PD, leading to slightly faster wound healing with good aesthetic outcomes.

Management of Primary Spontaneous Pneumothorax in a Third-Level Pediatric Surgical Center: A Retrospective Study.

Introduction: The management of primary spontaneous pneumothorax (PSP) in pediatrics remains controversial. The aim of this study was to investigate the risk of recurrence after non-surgical treatment vs. surgery, the difference in the length of stay (LOS) between various treatment options, and the role of computed tomography (CT) in the management of PSP. Materials and Methods: We retrospectively reviewed patients admitted to our Pediatric Surgery Unit for an episode of PSP between June 2009 and July 2020. Medical records including clinical presentation at admission, diagnostics, treatments, complications, and LOS were collected. Results: Twenty-three patients (22 males and 1 female) were included in this study. Median age was 15.65 (range 9-18). Chest X-rays were performed in all patients and showed 5 small (22%) and 18 large (78%) PSP. Chest drain was used for large PSP (≥2 cm) if the patient was clinically unstable. Eleven patients (48%) were managed non-operatively with observation alone and a recurrence rate of 18%, chest drain was used in 11 patients with a recurrence rate of 36%, and surgery was deemed necessary as a first treatment choice in one case. Six patients (27%) had an episode of relapse after non-operative management or chest drain placement. Following surgery, a relapse occurred in 2 of the 6 patients. Chest drain insertion was associated with a longer LOS than observation alone (6.36 vs. 2.4 days), and surgery resulted in a longer LOS than other types of treatment (P = 0.001). Conclusion: According to our experience, small PSP or clinically stable larger PSP can be treated conservatively with observation alone. Operative management should be taken into consideration in children with large symptomatic PSP, persistent air leak, and/or relapse after chest drain insertion.

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.

Pyogenic granuloma arising within capillary malformations in children: A case report and literature review.

Pyogenic granuloma (PG) is an acquired benign vascular hyperplasia. Even though PG is not so rare, its etiology is still unclear. Assuredly, an association between vascular anomalies and PG is an extremely rare finding, and a proper management of these cases is not well standardized to date. Herein, we report our experience with a giant PG arising spontaneously within a port-wine stain of the thorax. Previous cases reported in the pediatric literature and strategies of treatment are also discussed.