Staphylococcus Aureus Panton-Valentine Leukocidin causing hip osteomyelitis, thrombophlebitis and necrotizing pneumonia in an immuocompetent child.

Panton-Valentine leukocidin (PVL) represents an important virulence factor for many strains of Staphylococcus aureus. PVL is an esotoxin causing leucocyte destruction and tissue necrosis. We report on a case of osteomyelitis involving the hip joint with thromblophlebitis complicated by necrotizing pneumonia and life-threatening septic shock. The child required advance respiratory support for 14 days with circulatory support for 7 days in ICU (intensive care unit), surgical draninage via arthrotomy of hip joint and second-line antibiotic treatment for 1 month. Among a wide literature, in Europe over half of Panton-Valentine St. Aureus (PVL-SA) is MSSA. Investigations for PVL are not always available determining an under-recognition of the episodes. Data on prevalence of PVL-SA in Italy are scarce. With this clinical report, we emphasize the recognition of clinical features that must lead to suspect PVL-SA osteomyelitis in children, providing their adequate management.

Survey on Energy Drinks consumption and related lifestyle among students of two Italian high schools.

BACKGROUND: The European Food Safety Authority (EFSA) has identified some risk factors for the occurrence of side effects linked to energy drinks (EDs) consumption by young people. EDs consumption has been evaluated in a sample of students in Italy together with some aspects of their lifestyle. METHODS: The survey was performed in two high schools from September 2016 to June 2017. 583 students between 14 to 18 years were recruited and a standard questionnaire (EFSA checklist) was used to collect information on responders characteristics, beverages consumption, EDs with alcohol, and EDs and sports. RESULTS: Despite 350 out of 583 responders (60%) consumed EDs, only 146 out of 583 (25%) were EDs-alcohol consumers. Moreover, 208 out of 379 (55%) of all physically active adolescents reported frequent EDs consumption before sport trainings. CONCLUSIONS: Study results highlight the need for primary prevention measures in communication campaigns and training delivered by school to limit potential health threats related to excess of EDs consumption.

Efficacy of high-dose methylprednisolone pulses in a child with noninfectious persistent pleuropericarditis revealing systemic juvenile idiopathic arthritis.

Not available.

Colonization by Legionella spp. of water networks in residential buildings of the Province of Pisa, Italy.

BACKGROUND: Despite the increase of community acquired cases of legionellosis in Italy over the last years, the Italian guidelines do not give indications for prevention and control of Legionella in the hot water networks (or centralized conditioning systems) of residential buildings. We performed a survey on eight medium sized apartment buildings in the Pisa district to assess the prevalence of Legionella spp. in the water network and the respondance to drinking water requisites at the point of use, according to the Italian norms. METHODS: For each building two hot water and three cold water samples (located at water entrance from the aqueduct network into the building pipework, at the exit from pressure autoclave, and at a remote tap) were collected. RESULTS: Legionella was detected in 20% of residential buildings, mostly in those with a central hot water production system. CONCLUSIONS: The study highlights a condition of potential risk for susceptible population subgroups and supports the need for measures of risk assessment and control.

Current practice and recent advances in pediatric pain management.

BACKGROUND: Differently from the adult patients, in pediatric age it is more difficult to assess and treat efficaciously the pain and often this symptom is undertreated or not treated. In children, selection of appropriate pain assessment tools should consider age, cognitive level and the presence of eventual disability, type of pain and the situation in which it is occurring. Improved understanding of developmental neurobiology and paediatric analgesic drugs pharmacokinetics should facilitate a better management of childhood pain. AIM: The objective of this review is to discuss current practice and recent advances in pediatric pain management. METHODS: Using PubMed we conducted an extensive literature review on pediatric pain assessment and commonly used analgesic agents from January 2000 to January 2012. CONCLUSIONS: A multimodal analgesic regimen provides better pain control and functional outcome in children. Cooperation and communication between the anaesthesiologist, surgeon, and paediatrician are essential for successful anaesthesia and pain management.

Ductopenia and fetal liver-like architecture as unique and evocative sign of Turner syndrome.

BACKGROUND: Turner syndrome is the most common genetic disorder in females. In most subjects, with a normal physical appearance at birth, the diagnosis is suspected long after birth because of short stature, delayed puberty, primary or secondary amenorrhea or infertility. Abnormalities of liver function tests are reported in literature, with a prevalence ranging from 20% to 80%. In most subjects liver diseases are self-limiting, associated with obesity, hormonal therapy and autoimmune diseases. An association between Turner syndrome and cryptogenic liver disease has been reported. Abnormalities of liver function tests could be the unique sign of Turner syndrome in subjects with normal phenotypes. The histological picture of "fetal liver-like architecture" and "ductopenia" is of fundamental importance for the diagnosis of chromosomopathy. AIM: Review the causes of hypertransaminasemia by focusing on more rare as metabolic and genetic diseases. MATERIALS AND METHODS: We evaluated a 10 year old girl with a normal phenotype affected by chronic hypertransaminasemia and cholestasis, in whom a needle liver biopsy was performed after the most common causes of hypertransaminasemia were excluded. RESULTS: Liver histological evaluation revealed a smoldering colangiopathy with mild ductopenia and a fetal liver-like architecture. Turner syndrome, suspected on the basis of this histological picture, was confirmed by a pelvic ultrasound and a chromosome analysis. CONCLUSIONS: The histological features of "fetal liver-like architecture" and "ductopenia" represent an evocative sign that could indicate the diagnostic suspicion of Turner syndrome in a subject lacking in signs or symptoms of this disease. It is important to perform a pelvic ultrasound and an endocrinological evaluation in all females with chronic asymptomatic hypertransaminasemia even though they have normal phenotypes.

A longitudinal follow-up study of saffron supplementation in early age-related macular degeneration: sustained benefits to central retinal function.

Objectives. In a previous randomized clinical trial (Falsini et al. (2010)), it was shown that short-term Saffron supplementation improves retinal flicker sensitivity in early age-related macular degeneration (AMD). The aim of this study was to evaluate whether the observed functional benefits from Saffron supplementation may extend over a longer follow-up duration. Design. Longitudinal, interventional open-label study. Setting. Outpatient ophthalmology setting. Participants. Twenty-nine early AMD patients (age range: 55-85 years) with a baseline visual acuity >0.3. Intervention. Saffron oral supplementation (20 mg/day) over an average period of treatment of 14 (±2) months. Measurements. Clinical examination and focal-electroretinogram-(fERG-) derived macular (18°) flicker sensitivity estimate (Falsini et al. (2010)) every three months over a followup of 14 (±2) months. Retinal sensitivity, the reciprocal value of the estimated fERG amplitude threshold, was the main outcome measure. Results. After three months of supplementation, mean fERG sensitivity improved by 0.3 log units compared to baseline values (P < 0.01), and mean visual acuity improved by two Snellen lines compared to baseline values (0.75 to 0.9, P < 0.01). These changes remained stable over the follow-up period. Conclusion. These results indicate that in early AMD Saffron supplementation induces macular function improvements from baseline that are extended over a long-term followup.

Congenital cytomegalovirus infection: current strategies and future perspectives.

INTRODUCTION: Cytomegalovirus is the most common cause of congenital infections in humans and it produces considerable morbidity in newborns. AIMS: The present study reviews current concepts on epidemiology, clinical manifestations, diagnosis, treatment, future strategies and prognosis of children with congenital cytomegalovirus infection. RESULTS: Congenital cytomegalovirus infection can be symptomatic or not at birth, but about 10-20% of them all will exhibit neurological damage when followed up. Sensorineural hearing loss is the most frequent long-term consequence and is not manifest invariably at birth or in the neonatal period but in many cases becomes clinically apparent in later childhood. There are growing evidences that newborns with symptomatic congenital cytomegalovirus infection would benefit from treatment with either ganciclovir or valganciclovir, the most widely studied drugs in this setting. It is not yet clear if children with asymptomatic or pauci-symptomatic infection at birth would benefit from treatment. DISCUSSION: Studies evaluating treatment and long-term follow-up of infants with both symptomatic and asymptomatic infection are necessary, in order to definitely evaluate the short and long-term effectiveness and safety of both ganciclovir and valganciclovir and to identify risk factors associated to the development of long-term sequelae. In this way it will be possible to select those children that might benefit for treatment.

Clustering spatio-temporal series of confirmed COVID-19 deaths in Europe.

The impact of the COVID-19 pandemic varied significantly across different countries, with important consequences in the definition of control and response strategies. In this work, to investigate the heterogeneity of this crisis, we analyse the spatial patterns of deaths attributed to COVID-19 in several European countries. To this end, we propose a Bayesian nonparametric approach, based on mixture of Gaussian processes coupled with Dirichlet process, to group the COVID-19 mortality curves. The model provides a flexible framework for the analysis of time series data, allowing the inclusion in the clustering procedure of different features of the series, such as spatial correlations, time varying parameters and measurement errors. We evaluate the proposed methodology on the death counts recorded at NUTS-2 regional level for several European countries in the period from March 2020 to February 2021.

Catheter salvage strategies in children with central venous catheter-related or -associated bloodstream infections: a systematic review and meta-analysis.

BACKGROUND: Optimal management of central venous catheter-related, or -associated, bloodstream infections (CRBSI or CLABSI) in children is not established. AIM: To evaluate success of catheter salvage strategies in paediatric patients. METHODS: Studies were retrieved from medical databases and article reference lists. Data were collected relating to clinical outcomes of two treatments: systemic antibiotics alone or in association with antimicrobial lock therapy (ALT). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated from a mixed logistic effects model. Heterogeneity was summarized using I2 statistics. Publication bias was investigated by Egger's regression test and funnel plots. FINDINGS: From 345 identified publications, 19 met inclusion criteria (total of 914 attempted salvage strategies). To achieve successful catheter salvage, in CRBSI the addition of ALT was superior to systemic antibiotics alone (OR: -0.40; 95% CI: -1.41, 0.62): 77% (95% CI: 69, 85; I2 = 42.5%; P = 0.12) and 68% of success (95% CI: 59, 77; I2 = 0; P < 0.05), respectively. CRBSI recurrence was less common in studies that used ALT compared with systemic antibiotics alone: 5% (95% CI: 0, 13; I2 = 59.7%; P = 0.03) and 18% of recurrence (95% CI: 9, 28; I2 = 0; P < 0.05), respectively. Recurrences were low with both antibiotic locks and ethanol lock. No clear benefits of ALT addition compared to systemic antibiotic only were found in CLABSI (OR: -0.81; 95% CI: -0.80, 2.43). CONCLUSION: The addition of an antimicrobial lock solution to systemic antibiotic may be beneficial for successful catheter salvage in paediatric patients with CRBSI, depending on aetiology, whereas no statistically significant difference between systemic antibiotic with or without addition of an antimicrobial lock solution was found regarding CLABSI.

Molecular characterization of adenovirus from clinical samples through analysis of the hexon and fiber genes.

Human adenoviruses (HAdVs) are common pathogens associated with a variety of clinical manifestations. Although most infections are self-limiting, HAdVs can cause severe or lethal infections in immunocompromised as well as in healthy individuals. Several HAdVs have recently been characterized as emerging pathogens. In Italy, epidemiological, and especially molecular epidemiological, information on this pathogen is scarce. This study describes the characterization by cell culture, PCR and phylogenetic analysis of HAdV strains originating from a small collection of clinical samples gathered between 2008 and 2009. The distribution of different HAdV species was studied and the possible presence of newly emerging types was ascertained. A broad-range primer pair was used, targeting a portion of the hexon gene, in combination with species-specific primer pairs targeting a portion of the fiber gene. Human and animal reference AdV strains were included in the study. The broad-range assay identified all HAdV strains (study and reference samples), as well as three out of four animal AdV reference strains. Seven different types belonging to three HAdV species (B, C and F) were identified in the study samples. Species C was by far the most frequent. Two co-infections were detected, each with two serotypes within species C (types 1/2 and 2/6). The combined use of these two PCR assays--allowing not only the identification of known types but also, potentially, the discovery of newly emerging ones--can provide valuable epidemiological information on the spread of HAdVs.

[Congenital toxoplasmosis treatment]

OBJECTIVES: Congenital toxoplasmosis is a particular manifestation of Toxoplasma gondii infection, which may present as a mild or severe neonatal disease. This pathology remains a difficult challenge in terms of therapy for the pediatrician and gynecologist. In this article we have set ourselves the objective to provide an overview of the main aspects of the disease, with particular attention to the treatment, based on the information in the literature. RESULTS: Two kinds of treatment are currently available: prenatal and postnatal. When pregnant women seroconvert, spiramycin is administered in order to prevent the mother-to-child transmission. When the fetal infection is confirmed the association of pyrimethamine and sulfadiazine is prescribed. After birth the specific therapy is based on the administration of pyrimethamine and sulfadiazine. However, to date, there is not strong evidence on the effectiveness of treatment, whether prenatal or postnatal. CONCLUSIONS: The studies undertaken so far have not given satisfactory answers. Double-blind randomized controlled trials would be required, but for obvious ethical reasons they cannot be achieved.

Pediatric hepatitis C infection: to treat or not to treat...what's the best for the child?

OBJECTIVES: Pediatric hepatitis C mainly occurs through mother to child transmission, to date. Children usually present a mild disease, but they are not spared from its long-term complications. Thus this infection cannot be underestimated in children and intervention is necessary. Current treatment is based on the administration of pegylated-interferon associated with ribavirin, but few studies evaluated the efficacy and safety of this therapeutic protocol. Moreover, there is still no clarity on who, when and how to treat pediatric patients. This article, based on the information in literature, provides an overview of the main aspects of the disease, with particular attention to treatment. METHODOLOGY AND RESULTS: We describe the different treatment options available. About the association peginterferon plus ribavirin, we analyze thirteen non-randomized studies and one trial, found in recent literature. These studies are not directly compared because of differences in age, type of infection (vertical or not), viral genotypes and duration of treatment, between groups enrolled. The overall sustained viral response rate ranges from 28.6% to 81.8%. The rate of treatment success is higher in children infected with genotypes 2 and 3 than with other genotypes. The therapy does not induce severe adverse effects and children present better tolerance to antiviral than adults. CONCLUSIONS: The pharmacological efficacy of peginterferon and ribavirin seems to be proven by data collected in studies cited, but there are different opinions about who, when and how to treat children infected. Thus, further research is needed to define the best management of vertical acquired hepatitis C.

Evaluation of Kisspeptin levels in prepubertal obese and overweight children: sexual dimorphism and modulation of antioxidant levels.

OBJECTIVE: Kisspeptin, neuropeptide involved in puberty beginning and regulation of pituitary-gonadal axis, has been shown to stimulate antioxidant defenses in murine models. Its levels are greater in females than males and also in obese prepubertal girls. Therefore, our aim was to evaluate sex-related differences in prepubertal obese patients and the relationships of Kisspeptin with metabolic/hormonal parameters. PATIENTS AND METHODS: We studied Kisspeptin concentrations in 54 children (22 males and 32 females, Tanner stage 1), 5-12 ys, classified according to Cole's criteria into 17 overweight and 37 obese; 25 normal-weight children, aged 6-12 years, were studied as controls. We evaluated metabolic (glucose and insulin levels after oral glucose load, total- LDL- HDL-cholesterol, triglycerides, uric acid) and hormonal (fT3, fT4, TSH, IGF-1, leptin) parameters. Moreover, total antioxidant capacity (TAC) was evaluated by spectrophotometric method, using the system H202-metmyoglobin-ABTS. Kisspeptin levels were measured by RIA. RESULTS: We did not find significant differences between obese and normal-weight children, but obese males presented significantly lower levels than females. Kisspeptin did not correlate with BMI, HOMA-IR, Insulin peak levels and TAC; a significant correlation was found between Kisspeptin and fT3 (r2=0.25; p=0.003) in the obese group; leptin levels, significantly greater in obese vs. overweight and control children, significantly correlated with TAC (r2=0.39; p=0.03). CONCLUSIONS: These data suggest that both hormones could modulate antioxidants, Kisspeptin indirectly via influence on thyroid hormones, and Leptin by a direct effect. This mechanism seems to be sex-related, not attributable to peripheral steroid levels. Further studies can clarify the complex interrelationship between central and peripheral Kisspeptin secretion and oxidative stress in children obesity.

Life-threatening complications of streptococcal sepsis: a PICU contemporary series.

BACKGROUND: Life-threatening streptococcal sepsis nowadays represents an uncommon event in previously healthy infants and children. Critically ill patients suffering from severe streptococcal sepsis complications may present with pre-antibiotic era clinical pictures and require a timely clinical approach to achieve restitutio ad integrum. RESULTS: We report a series of four patient groups affected by an uncommon life-threatening streptococcal sepsis, each of them exhibiting some distinct features. Streptococcus Agalactiae sepsis was associated with cerebral thrombotic/ischaemic lesions, whereas severe cardiogenic shock was prominent in the Streptococcus Viridans group; Streptococcus Faecalis and ß-hemolytic group A Streptococcus patients mostly reported lung complications. CONCLUSIONS: Previous antibiotic treatments should not delay aggressive treatment in the intensive care setting. Early diagnostic suspicion, as well as appropriate and aggressive treatment provided within an intensive care setting are crucial for the clinical outcome.

Measles-induced respiratory distress, air-leak and ARDS.

Young infants with measles requiring respiratory support have a significant risk for death and long-term complications. Even in developed countries, the occurrence of spontaneous air-leaks and acute respiratory distress syndrome (ARDS) still represent the most severe clinical presentation in early childhood, with a high fatality rate. A clinical series review from a tertiary university paediatric intensive care unit (PICU) was undertaken. During the 2006-2007 outbreak in Rome, Italy, a young infant presented with ARDS/spontaneous air-leak and needed aggressive ventilatory management and haemodynamic support. Both nebulised iloprost and intravenous pentoxifylline were administered during the acute hypoxaemic phase; the role of this pharmacologic approach in critically ill patients is still under debate. We observed four further cases of respiratory impairment requiring a non-invasive approach. Clinical-radiological findings ranged from interstitial pneumonia to bronchiolitis-like pictures. All patients were imported cases, representing an important epidemiological factor and future medical issue, though they were not malnourished nor affected by chronic diseases. We conclude that early respiratory assessment and timely PICU referral is of mainstem importance in the youngest infants with measles-induced respiratory failure. The protean nature of clinical presentation and the possibility of rapid respiratory deterioration should be highlighted, and infants from immigrant families may represent a susceptible high-risk group.

Management of central nervous system tuberculosis in children: light and shade.

BACKGROUND: Pediatric tuberculosis of the central nervous system (CNS-TB) is a severe form of extrapulmonary TB. It is most common in children between 6 months and 4 years of age. CNS-TB can present as meningitis and/or tuberculoma. In both situations, brain damage results from a cytokine-mediated inflammatory response, which causes vasculitis, obstructive hydrocephalus and cranial nerve palsy. Tumor necrosis factor alpha (TNF-alpha) is an important cytokine in this response. The prognosis of tuberculous meningitis (TBM) correlates most closely with the clinical stage of illness at the time treatment is started. Most patients in the 1st stage have a good outcome, whereas the management of patients in the 2nd and 3rd stage is still a clinical challenge, and the few patients who survive have permanent severe disabilities. Due to the important role of inflammation in CNS-TB pathogenesis, corticosteroids are routinely used in TBM or tuberculomas, in order to reduce death and disabling residual neurological deficits among survivors. Nevertheless, not all patients show a good response to standard anti-inflammatory treatment. Thalidomide is a drug with pleiotropic effects: it appears to downregulate production of TNF-alpha and other proinflammatory cytokines. Due to its anti-inflammatory effects, thalidomide has been evaluated as an adjunctive drug in the management of difficult-to-treat CNS-TB. MATERIALS AND METHODS: A literature review was carried out based on MEDLINE/pubmed database (1997/2010) searching for the following descriptors: corticosteroids and tuberculous meningitis (limits: review, all child); thalidomide and tuberculosis treatment; and tuberculous meningitis; and CNS-TB; and brain abscess; and TB clinical trial. AIMS: Literature review on the use of corticosteroids and thalidomide in the treatment of CNS-TB. RESULTS: The Cochrane review for randomized-controlled trials evaluating the use of steroids in TBM showed significantly reduced overall mortality, reduced death and severe residual disability in children. Regarding the use of thalidomide, a randomized controlled trial published in 2004 do not support the use of adjunctive high-dose thalidomide therapy in the treatment of TBM in children, but results from four case reports, one clinical trial and one placebo-controlled trial suggest the use of thalidomide in CNS-TB not responding to standard therapy. CONCLUSION: "Adjuvant" treatment with dexamethasone improves survival in patients with TBM but probably does not prevent disability. Thalidomide should not be used for the routine treatment, but it may be helpful as a "salvage therapy" in patients with TBM and tuberculomas not responding to anti-TB drugs and high dose corticosteroids. More studies should evaluate its not completely conclusive role.

Role of spiramycin/cotrimoxazole association in the mother-to-child transmission of toxoplasmosis infection in pregnancy.

The purpose of this report is to evaluate the efficacy and safety of spiramycin/cotrimoxazole in the mother-to-child transmission of Toxoplasma gondii infection. We retrospectively analysed 76 infants born to mothers with toxoplasmosis during pregnancy and estimated the risk of mother-to-child transmission considering the gestational age at the time of infection. Seventy-six mothers were given spiramycin, cotrimoxazole and folinic acid; only two babies (2.6%) were infected by Toxoplasma and none of them showed signs or symptoms of congenital infection or interference of sulphamid on tetrahydrofolate reductase (THFR) either at birth or during follow-up. Treatment did not need to be stopped in any mother because of adverse drug effects. Our results seem to encourage the use of spiramycin/cotrimoxazole in women with toxoplasmosis during pregnancy.

Molecular epidemiology of Legionella pneumophila serogroup 1 isolates following long-term chlorine dioxide treatment in a university hospital water system.

This paper describes the results of a five-year monitoring programme applied to the water distribution system of the University Hospital of Pisa (Italy). The purpose of the programme was to evaluate the efficacy of an integrated water safety plan in controlling Legionella spp. colonisation of the potable water system. The impact of the safety plan on the ecology of legionella in the water network was evaluated by studying the genetic variability and the chlorine susceptibility of the strains isolated prior to, and throughout, the application of continuous chlorine dioxide treatment. After 45 months of water hyperchlorination, Legionella spp. were still present but the positive supply points were reduced by 79.4%. The samples exceeding 10(3)cfu/L were reduced by 83.8% and the mean counts showed a decrease of 94.6%. The majority of the isolates belonged to Legionella pneumophila serogroup 1 (overall positivity rate: 161/423; 38%). Molecular typing was performed on 61 isolates (37.9% of the positive samples) selected on spatial and temporal criteria. This revealed the circulation and the persistence in the hospital environment of three prevalent types of L. pneumophila Wadsworth, demonstrating allelic and electrophoretic characteristic profiles and different chlorine susceptibility. Two of these, one predominant and pre-dating the sanitation regimen, and one other isolated after three years of water treatment, were chlorine tolerant. Despite the ineffectiveness of chlorine dioxide in eradicating L. pneumophila, the risk management plan adopted appeared to discourage further cases of nosocomial legionellosis.