Telephone consultation during Coronavirus outbreak in a Pediatric Emergency Department: methodological approach of a tertiary care center in a COVID-19 hospital setting.

OBJECTIVE: A computerized system of telephone consultation has been experimented at the Pediatric Emergency Department (ED) of Policlinico Gemelli Hospital in Rome during the outbreak of Coronavirus Disease 2019 (COVID-19). MATERIALS AND METHODS: Twenty monothematic items with a series of questions to evaluate child's clinical conditions have been set up in order to evaluate the different situations according to their severity. All items were highlighted according to conventional scores corresponding to the different answers (yes/no) given by the child's parents. This system has been implemented with large diffusion of computer programs and applications by the availability of a computer station in every ED room. RESULTS: The system allows healthcare workers to establish the medical check-up urgency which may be immediate, within the next 24 hours or scheduled in the pediatric ward. Therefore, it has been implemented a telephone triage consultation with a standardized method. CONCLUSIONS: Telephone consultation during outbreaks, considering the risks of contagion, allows healthcare workers to decrease the concern of families and to reduce indiscriminate access to ED. The remote approach will not solve logistic and setting problems related to COVID-19 outbreak17, but it would be a valid tool to improve medical evaluation without deep change in infrastructure and clinical organization.

Toxoplasma gondii infections in sheep in Sicily, southern Italy.

The aim of the study was to determine the burden of Toxoplasma gondii-infections in sheep in Sicily, southern Italy and the risk factors for infection. Sera from 1961 sheep were collected just before slaughtering from 62 farms located in 8 out of 9 Sicilian administrative districts. The sera were analysed for Toxoplasma-specific IgG antibodies using commercially available enzyme-linked immunosorbent assay. Sheep less than 4 weeks old were further analysed by ELISA for Toxoplasma-specific IgM-antibodies. Data on farm size and location were obtained from slaughterhouse sanitary reports and through structured telephone interviews of the veterinary officers from public health districts. The overall seroprevalence of Toxoplasma-specific IgG-antibodies were 49.9% (937/1876) by ELISA. Eighty-seven (54/62) percent of the farms had at least one Toxoplasma-positive animal. All the farms fed the animals outdoor on pasture and only one was claiming organic farming. Having cats on the farm, age of the animals, farm size and the use of surface water sources for drinking were all significantly associated with T. gondii-infected animals on the farm. T. gondii infection in mutton used for human consumption is very prevalent, and eating unprocessed sheep and lamb meat has a high risk of transmitting infections to humans. The presence of cats on the farm, farm size and using surface water as drinking water for the animals were risk factors for infection in sheep, with age as a significant confounder.

Functionality of the ARPIA ambulatory information system.

Although database-based medical information systems are becoming popular, experiments done by researchers tell us that physicians still do not fully accept them. Key factors for changing physicians' practice habits are the availability of more powerful methods and tools for interactive data acquisition and retrieval. Problems involving human engineering usually require the identification of and experimentation with many novel approaches before the most suitable answer is discovered. ARPIA is an ambulatory information system experimenting on the effectiveness and acceptability (by medical users) of new intelligent and friendly interaction techniques and tools. In particular, it tests a novel flexible dialogue-based man-machine interface offering physical and logical data 'independence' during retrieval operations. Other features of the system are: a fast and robust data acquisition environment; a text- and picture-based data presentation and report generation facility; finally, a set of modules offering the ambulatory staff effective assistance in some extra complex interactive tasks. A user-oriented description of the main functionality of ARPIA is given; users' feedback summarizing almost 2 years of usage of the system is also reported.

[Reproducibility of pediatric information collected with various methods: postal/telephone questionnaire and direct interview]. / Riproducibilità di informazioni pediatriche rilevate con modalità diverse: questionario postale/telefonico e intervista diretta.

The paper reports on a research aimed to evaluate the repeatability of some paediatric data obtained from the parents by using different collection instruments: telephone interview, mail questionnaire, in-person interview. The study included 699 children consecutively born in the Policlinico Universitario "A. Gemelli" from September to November 1983. After 3 years a questionnaire containing questions about measles, anti measles immunization, age at which the baby started to walk, disease delaying the walking, and orthopaedic examinations was sent by mail to 149 families; the other 550 families were searched for by telephone and, if found, asked the same questions. All the contacted families were invited for a paediatric check-up, during which the same data were collected through direct interview. For each question crude agreement and K statistic (which controls for the agreement attributable to chance) were computed with respect to both the phone/direct and mail direct comparisons. 391 families (56%) were traced for the first interview, due to the high number of them which had moved home. Among these 289 (74%) attended the paediatric check-up. On the whole, rather high values of K statistic were observed, ranging from 0.59 (question on diseases delaying the walking, comparison phone/direct) to 0.93 (question on anti-measles immunization, comparison mail/direct). Due to the small sample size, the estimates concerning the comparison mail/direct are rather imprecise. Although its potential is limited by the low response rate, the study brings good evidence that the information considered is not sufficiently reliable when reported retrospectively by parents. However, the keeping of a prospective individual record containing data of medical interest should be encouraged.

[The early diagnosis of congenital hip dysplasia: a proposal for a differentiated echographic screening]. / Diagnosi precoce della displasia congenita dell'anca: proposta per uno screening ecografico differenziato.

Prevention of congenital hip dislocation is one of the main goals of pediatric activity. 839 newborn outpatients, with six months follow-up at least, were recruited at the Pediatric Clinic of the Catholic University of Rome, from January 1991 to December 1992. Every newborn baby was clinically examined for congenital hip dysplasia (CHD) at nursery and afterwards in the ambulatory. Hip sonography was performed, according to Graf's technique, in 504 babies (60%): 17 resulted pathological (3.3%), 30 borderline (6%) and 457 normal (90.7%). Ultrasonographic and clinical findings were compared. Clinical examinations at nursery and ambulatory have shown low sensitivity (21.3% and 34% respectively) in detecting dysplastic hips. Present experience confirms ultrasonography value in the diagnosis of CHD and the utility of its use in a general screening programme.

[Neonatal sepsis and perinatal risk factors]. / Sepsi neonatale e fattori di rischio perinatali.

Numerous studies have identified perinatal risk factors of neonatal sepsis. Some authors have attempted to develop a score system and have shown that babies with septicemia usually had a significantly higher score than healthy newborns and infants with other diseases. The aim of our study is to verify the validity of a scoring method based on the following items: maternal disease; e.g. diabetes, severe toxemia, infection; rupture of the membranes more than 24 hours before the delivery; foul-smelling amniotic fluid; complicated delivery; Apgar score less than 7; umbilical catheterization; respiratory distress and other neonatal diagnoses leading to operative procedures. We have evaluated four groups of babies, full-term AGA and SGA and preterm AGA and SGA, 84 with septicemia, 105 with other diseases and 210 healthy newborn infants. None of the perinatal risk factors or neonatal diseases was sufficiently predictive of neonatal septicemia. Only the incidence of umbilical catheterization was significantly higher (p less than 0.01) in preterm AGA (37.1%) and SGA (64.7%) babies with septicemia than in preterm healthy AGA (2.8%) and SGA (7.7%) babies; on the contrary, no statistical differences were found between preterm AGA (37.1%) and SGA (64.7%) infants with septicemia and preterm AGA (42.8%) and SGA (66.6%) infants with other neonatal diseases. A score of 1 was assigned for each of the considered items. In the full-term infants a score of 1 or less was found in 100% of the healthy infants. A score of 2-3 was found in 26% of the septicemic infants and in 42% of the infants with other diseases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Correlations between blood pressure values, familial hypertension and anthropometric parameters in a sample of 3-year-old children]. / Correlazione tra valori di pressione arteriosa, familiarità ipertensiva e parametri antropometrici in un campione di bambini di tre anni.

Nowadays evaluation of blood pressure in children is almost routine. In fact hypertension in adults may be preceded by high blood pressure values in childhood. In this study the authors examined systolic blood pressure (SBP) and diastolic blood pressure (DBP), height, weight, ponderosity index and family history of hypertension, in 261 3-year-old children, 139 boys and 122 girls. Average values of SBP were slightly but not significantly higher in males. Coefficients of linear regression and correlation for any pair of the different parameters (SBP-DBP and weight, SBP-DBP and height, SBP-DPB and ponderosity index) were all significantly positive for males, but not for females. The most significant value (r = 0.43) was in the correlation DBP-weight. In studying the family history of hypertension all children were divided into three groups: negative (F.I.-), positive with brothers and/or parents affected (F.I. I+) and positive with other relatives affected (F.I. II+). Average SBP and DPB in the second group were higher than in the third, and much higher than in the first group. These results suggest the importance of prevention in early childhood with alimentary education and serial blood pressure measurements. The individuation of borderline values is also very important.

[Possible pathogenetic factors in hypocalcemia of low birth weight newborn infants (author's transl)]. / L'ipocalcemia del neonato di basso peso: aspetti etiopatogenetici.

The Authors studied the possible pathogenetic factors in hypocalcemia of 66 low birth weight healthy newborn infants, 28 preterm and 38 small for gestational age babies. To clarify the pathogenesis of neonatal hypocalcemia, the Authors determined daily in the first week of life serum calcium, phosphorus and magnesium concentrations, the serum natrium and kalium level and E.A.B. on capillary blood. Total serum proteins was determined on the 2nd and on the 7th day of age. The incidence of hypocalcemia was 25.7% for all considered babies: 32.1% for preterm infants and 21% for small for gestational age babies. The hypocalcemia of preterm babies appears early during the first three days of life and it results not correlated with the serum phosphorus and the serum magnesium concentrations. On the contrary the small for gestational age babies show a "late" hypocalcemia directly related with an elevated serum concentration of phosphorus and with a reduced serum magnesium level. Both the preterm and the small for gestational age newborn infants had asymptomatic hypocalcemia and the orally administration of high doses of calcium gluconate 10% was able to normalize rapidly the serum calcium level.

[Computerized prototype of a screening test for the assessment of psychomotor development in childhood]. / Prototipo automatizzato di un test di screening per la valutazione dello sviluppo psicomotorio dell'infanzia.

The aim of Denver's screening test is to study the psychomotor development of normal or supposed normal children aged from 0 to 6 years and to suggest further investigation when an abnormal development is noticed. The test is divided into 4 sections: social behavior, fine motility, language, gross motility. The results are valid only if the test is done in a standardized manner. The aim of this paper is to describe the computerized prototype of the Denver test in use at the Divisional Pediatric Ambulatory of "A. Gemelli" University Policlinic in Rome. This test is used in the context of an automatized ambulatory management system called ARPIA, capable of interacting and guiding "non expert" user. The program performs the following functions: 1) General instructions for the execution and interpretation of the test. The original instructions of the test (1975 version) have been used. 2) Input, modification, exclusion of questions. The archive is organized in the following manner: questions are divided in the above four sections, according to the child, undergoing the test, age limit; the questions regarding information that can be asked directly to the parents or the display of a picture that better explains the test are marked. During the test the questions may be modified using a menu with a certain number of options to facilitate the use of the system. The questions to eliminate from the test may be appropriately marked and removed. The text is not physically deleted from the archive. The inverse operation of inclusion of a formerly removed question may be performed too.(ABSTRACT TRUNCATED AT 250 WORDS)

[Congenital dysplasia of the hip. Preliminary results of a longitudinal study in the first 6 months of life]. / La displasia congenita dell'anca (DCA). Risultati preliminari di uno studio longitudinale nei primi 6 mesi di vita.

The authors report their experience of a serial follow-up for congenital dysplasia of the hip (CDH). 699 babies born during a three-months period were examined on their first day of life, on the forth and at the age of 1 and 6 months. 2 dislocated hips, 222 clicking hips were discovered in the neonatal period. At the first month 1 dislocated hip and only 6 clicking hips were detected. At the sixth month all babies were normal with the exception of two clicking hips. X-ray examination confirmed clinical dislocation diagnosis and showed pathological signs (subluxation and acetabular dysplasia) also in normal and clicking hips. According to their results the authors suggest that clinical examination during the first 6 months of life and X-ray can decrease the incidence of late diagnosis of CDH.

[Otitis media in childhood: a critical review of the literature]. / L'otite media nell'età pediatrica: revisione critica della letteratura.

Infection of the middle ear is one of the most common childhood illnesses accounting for one-third of the pediatrics practice during the first five years of life. Therefore treatment and prevention of the otitis media are of considerable importance. A review of the literature of the otitis media during the pediatric age is reported. In fact in the last years a large amount of knowledge, sometimes referring discordant opinions, has been acquired. The Authors report epidemiology, anatomy, pathology, physiology, microbiology, classification, clinical data diagnosis and therapy of the otitis media. Common conditions of the middle ear (normal, acute otitis media, chronic otitis media, recurrent otitis media) are described. In particular acute otitis media, otitis media with effusion, perforation of the tympanic membrane, fluid level in the middle ear, severe retraction or bulging of the tympanic membrane are pointed out in color-photographs.

[The catarrhal child]. / Il bambino catarrale.

The first seven years of a child's development are often described as the catarrhal stage. This is because of the increased incidence of upper respiratory tract infections. Nasal obstruction in the children is common and symptoms are often distressing. The authors report a rational approach to this problem to produce effective treatment of recurrent nasal obstruction. In particular clinical features, diagnosis, and therapy of recurrent rhinitis, adenoid hypertrophy, and tonsillar obstruction are described. The indications for adenoidectomy, tonsillectomy or adenotonsillectomy has been questioned.

[Physiologic hyperbilirubinemia in low birth weight newborn infants: relation to gestational age, neonatal weight and intra-uterine growth]. / L'iperbilirubinemia fisiologica del neonato di basso peso: relazione con l'età gestazionale, il peso neonatale e l'accrescimento intrauterino.

Neonatal hyperibilirubinaemia is a real problem for its possible repercussion on the psychomotor development, mainly in low birth weight infants. The Authors studied the physiologic course of bilirubinaemia in 513 low birth weight newborns and then related it to gestational age, birth weight and intrauterine growth. Results obtained show that neonatal hyperbilirubinaemia is strictly depending on gestational age, while both the birth weight and the intrauterine growth have no significant influence on its course. Certainly the very low birth weight infants run the higher risk of Kernicterus and brain injury due to hyperbilirubinaemia; they need therefore a quicker therapeutic approach, though the treatment of physiologic hyperbilirubinaemia must always be planned on the basis of gestational age.

[Hypothyroxinemia in the low birth-weight infant in the screening of congenital hypothyroidism]. / L'ipotiroxinemia del neonato di basso peso nello screening dell'ipotiroidismo congenito.

Inside a pilot screening program for Congenital Hypothyroidism, T4 and TSH have been tested in sick and healty preteam and fullterm low birth weight (LBW) newborns during the first two months of life, 36 newborns affected by respiratory distress syndrome and 15 by sepsis have been included in the study. Blood samples were collected by heel puncture on 3rd, 10th, 20th, 40th and, in some cases, up to 60th day of life, and adsorbed on filter paper. Our findings show that hypothyroxinaemia in LBW newborns is strictly related to gestational age. In fact, among preterm infants with GA less than or equal to 33 weeks, 25 subjects (69,44%) showed T4 levels less than or equal to 6 micrograms/dl and 5 infants (13,88%) had T4 concentrations less than or equal to 2 micrograms/dl. The incidence of subjects with T4 values less than or equal to 6 micrograms/dl falls to 42,18% in the group of infants with GA = 34-36 weeks and to 17,27% in the group of fullterm LBW infants. None of these newborns showed thyroxine levels less than or equal to 2 micrograms/dl. All the examined infants showed normal TSH levels. The low T4 values may appear soon after birth or later (3rd-20th day of life) and sometimes persist up to 40th or 60th day, despite of always normal TSH levels. The mean of low T4 values at each sampling time is strictly and directly related to gestational age. (ABSTRACT TRUNCATED AT 250 WORDS)

[Implementation of a computerized pharmacological database for pediatric use]. / Realizzazione di un archivio farmacologico computerizzato ad uso pediatrico.

The authors present a pharmacological database to support teaching and care activity carried out in the Divisional Paediatric Ambulatory of the Catholic University of Rome. This database is included in a integrated system, ARPIA (Ambulatory and Research in Pediatric by Information Assistance), devoted to manage ambulatory paediatric data. ARPIA has been implemented by using a relational DBMS, very cheap and highly diffused on personal computers. The database specifies: active ingredient and code number related to it, clinical uses, doses, contra-indications and precautions, adverse effects, besides the possible wrapping available on the market. All this is showed on a single for that appears on the screen and allows a fast reading of the most important elements characterizing every drug. The search of the included drugs can be made on the basis of three different detailed lists: active ingredient, proprietary preparation and clinical use. It is, besides, possible to have a complete report about the drugs requested by the user. This system allows the user, without modifying the program, to interact with the included data modifying each element of the form. In the system there is also a fast consultation handbook containing for every active ingredient, the complete list of italian proprietary medicines. This system aims to give a better knowledge of the most commonly used drugs, not only limited to the paediatrician but also to the ambulatory health staff; an improvement of the therapy furthering, a more effective use of several pharmacological agents and first of all a training device not only to specialists but also to students.

[Evaluation of the locomotor system during pediatric health examinations and elements of kinesitherapy]. / La valutazione dell'apparato locomotore durante i bilanci di salute pediatrici ed elementi di chinesiterapia.

The pediatrician, being a primary health care physician, has the task of bringing the small patient and his parents to the resolution of all those problems which are erroneously referred to a subspecialist. With this in mind, the authors believe that even common orthopedic problems must be evaluated by the pediatrician. He would decide if and when to refer the child to an orthopedic specialist. Certain problems such as congenital hip dysplasia or scoliosis require specific treatment, whereas others (tibial bowing, genu varum-valgum, flatfoot, metatarsus varus) resolve themselves over time. The authors therefore emphasize the role of the pediatrician in preventing any iatrogenic pathology due to inappropriate treatment.

[Therapy of neonatal infection caused by group B beta-hemolytic Streptococcus]. / La terapia dell'infezione neonatale da streptococco beta-emolitico di gruppo B.

Expectant therapy for early Group B Streptococcus onset septicemia must provide coverage against other microorganism, such as L. Monocytogenes, H. Influenzae and S. Pneumoniae. It is possible to administer a combination of antimicrobial agents with activity against all or the most likely pathogens. Thus initial expectant therapy includes a broad spectrum semisynthetic penicillin (e.g. ampicillin) and an aminoglycoside (e.g. netilmicin). Vancomicin, teicoplanin and cefotaxime may also be used. Supportive therapy consists on temperature control, i.v. administration of fluids, acid-base balance and electrolytes monitoring, seizures control and ventilation. IV immunoglobulins, granulocyte and serum transfusion are also used. The G-Colony Stimulating Factor (G-CSF, filgastrim) usage is also reported.

[Neonatal sepsis caused by coagulase-negative staphylococci]. / Sepsi neonatale da stafilococchi coagulasi-negativi.

All cases of neonatal bacteremia occurring at Neonatal Department of Pediatric Clinic, Catholic University of Rome, from January 1976 to December 1983 were examined retrospectively. Twenty-seven (30%) newborn infants with positive blood cultures for coagulase-negative staphylococcus were identified. Seven (25.9%) of the 27 infants were born at term, 4 AGA and 3 SGA; mean birth weight was 2,804 gm (range 2,280-3,670). All of these neonates had clinical evidence and laboratory signs of sepsis, and one had the cerebrospinal-fluid culture positive for coagulase-negative staphylococcus. In the remaining 20 infants (74.1%) the mean birth weight was 1,445 gm (range 810 - 2,400) and mean gestational age was 32 weeks (range 27 - 36). In 15 of the 20 preterm infants clinical signs of septicemia were associated with positive blood culture, and sixty percent of these had received an umbilical artery catheter. An half of coagulase-negative staphylococci isolated from our neonatal sepsis were DNAse-positive and/or phosphatase-positive and/or mannitol-positive. Two full-term infants, one with Down syndrome and one with cardiac malformation, died at 9 days and at 2 weeks of age, respectively. Three of 15 preterm infants with coagulas-negative staphylococcal septicemia died; deaths were among infants of very low birth weights and immature gestations who had severe respiratory syndrome. These data show that coagulase-negative staphylococcus can be important cause of septicemia in patients with compromised host defenses as newborn infants, and especially in the premature babies receiving invasive procedures.

Hand dermatoglyphics in trisomy 4p.

A dermatoglyphic analysis of the hands of 16 patients with trisomy for the short arm of chromosome 4 has revealed an increased frequency of whorl patterns on fingertips, presence of axial triradii in position t' on palms and an increase of the main line index. Although of little diagnostic value these changes must be included in the constellation of major signs which characterize the 4p trisomy syndrome.