The management of pediatric severe traumatic brain injury: Italian Guidelines.

INTRODUCTION: The aim of the work was to update the "Guidelines for the Management of Severe Traumatic Brain Injury" published in 2012, to reflect the new available evidence, and develop the Italian national guideline for the management of severe pediatric head injuries to reduce variation in practice and ensure optimal care to patients. EVIDENCE ACQUISITION: MEDLINE and EMBASE were searched from January 2009 to October 2017. Inclusion criteria were English language, pediatric populations (0-18 years) or mixed populations (pediatric/adult) with available age subgroup analyses. The guideline development process was started by the Promoting Group that composed a multidisciplinary panel of experts, with the representatives of the Scientific Societies, the independent expert specialists and a representative of the Patient Associations. The panel selected the clinical questions, discussed the evidence and formulated the text of the recommendations. The documentarists of the University of Florence oversaw the bibliographic research strategy. A group of literature reviewers evaluated the selected literature and compiled the table of evidence for each clinical question. EVIDENCE SYNTHESIS: The search strategies identified 4254 articles. We selected 3227 abstract (first screening) and, finally included 67 articles (second screening) to update the guideline. This Italian update includes 25 evidence-based recommendations and 5 research recommendations. CONCLUSIONS: In recent years, progress has been made on the understanding of severe pediatric brain injury, as well as on that concerning all major traumatic pathology. This has led to a progressive improvement in the clinical outcome, although the quantity and quality of evidence remains particularly low.

Role of eculizumab in a pediatric refractory gemcitabine-induced thrombotic microangiopathy: a case report.

BACKGROUND: The incidence of gemcitabine-induced hemolytic uremic syndrome has already been described in adults. Several approaches have been employed in the treatment of gemcitabine-induced hemolytic uremic syndrome with different outcomes. One of the most promising agents is eculizumab, which is a monoclonal antibody directed against C5 complement protein. CASE PRESENTATION: We reported the case of a 3-year-old white boy with medulloblastoma who underwent high-dose chemotherapy and craniospinal irradiation. Afterwards he started maintenance chemotherapy with gemcitabine and oxaliplatin. After five courses he presented a progressive clinical worsening, which resulted in a systemic thrombotic microangiopathy. Initially he was treated with rituximab without clinical improvement. Therefore he started therapy with repeated cycles of eculizumab. After seven infusions he showed a gradual improvement and finally a complete remission of gemcitabine-induced hemolytic uremic syndrome. CONCLUSIONS: Eculizumab prevents serious complement-mediated vascular damage for chemotherapy-induced thrombotic microangiopathy in pediatric cases.

"Synthetic" comets: a new look at lung sonography.

Ultrasound interstitial syndrome is an echographic pattern of the lung characterized by the presence of multiple acoustic artifacts called "comets" or B-lines. It correlates to increase in extravascular lung water and to interstitial lung disease. From the physical and genetic point of view, the characteristics and the entity of this correlation have not yet been studied. The purpose of this study was to extrapolate past observations and demonstrate how comets or B-lines are artifactual images whose formation is linked to ultrasound interactions on discretely aerated tissues of variable density. Echographic comets were studied by scanning a wet synthetic, partially aerated polyurethane sponge (phantom). Density of the phantom in different drying phases was measured and correlated to the presence of echographic artifacts. Artifacts (comets) showed a different concentration from a completely white artifactual field to presence of rare comets. Their density correlates with porosity and geometry of the phantom. In our opinion, comets represent superficial, artifactual, density and geometry correlated phenomenon due to the acoustic permeability of a broken (collapsed) specular reflector, normally present when the phantom is dry.