Microvascular dysfunction in pediatric patients with SARS-COV-2 pneumonia: report of three severe cases.

The coronavirus 19 (COVID-19) pandemic has affected hundreds of millions of people worldwide: in most of cases children and young people developed asymptomatic or pauci-symptomatic clinical pictures. However authors have showed that there are some categories of childhood more vulnerable to COVID-19 infection such as newborns or children with comorbidities. We report for the first time to the best of our knowledge about microvascular dysfunction in three pediatric clinical cases who developed COVID-19 infections with need of pediatric critical care. We found that sublingual microcirculation is altered in children with severe COVID-19 infection. Our findings confirmed most of data already observed by other authors in adult population affected by severe COVID-19 infection, but with distinct characteristics than microcirculation alterations previous observed in a clinical case of MIS-C. However we cannot establish direct correlation between microcirculation analysis and clinical or laboratory parameters in our series, by our experience we have found that sublingual microcirculation analysis allow clinicians to report directly about microcirculation dysfunction in COVID-19 patients and it could be a valuable bedside technique to monitor thrombosis complication in this population.

Acute toxic exposures in children: analysis of a three year registry managed by a Pediatric poison control Center in Italy.

INTRODUCTION: Acute pediatric poisoning is an emerging health and social problem. The aim of this study is to describe the characteristics of a large pediatric cohort exposed to xenobiotics, through the analysis of a Pediatric Poison Control Center (PPCc) registry. METHODS: This study, conducted in the Pediatric Hospital Bambino Gesù of Rome, a reference National Pediatric Hospital, collected data of children whose parents or caregivers contacted the PPCc by phone (group "P"), or who presented to the Emergency Department (group "ED"), during the three-year period 2014-2016. Data were prospectively and systematically collected in a pre-set electronic registry. Comparisons among age groups were performed and multivariable logistic regression models used to investigate associations with outcomes (hospital referral for "P", and hospital admission for "ED"group). RESULTS: We collected data of 1611 children on group P and 1075 on group ED. Both groups were exposed to both pharmaceutical and non-pharmaceutical agents. Pharmaceutical agent exposure increased with age and the most common route of exposure was oral. Only 10% among P group were symptomatic children, with gastrointestinal symptoms. Among the ED patients, 30% were symptomatic children mostly with gastrointestinal (55.4%) and neurologic symptoms (23.8%). Intentional exposure (abuse substance and suicide attempt), which involved 7.7% of patients, was associated with older age and Hospital admission. CONCLUSIONS: Our study describes the characteristics of xenobiotics exposures in different paediatric age groups, highlighting the impact of both pharmacological and intentional exposure. Furthermore, our study shows the utility of a specific PPCc, either through Phone support or by direct access to ED. PPCc phone counselling could avoid unnecessary access to the ED, a relevant achievement, particularly in the time of a pandemic.

Dissection of the V3-V4 due to whiplash injury: description of a non-fatal case.

Whiplash injuries, a common sequel of road traffic accidents, may be defined as a musculo-ligamentous sprain resulting from forced acceleration/deceleration and flexion/ extension neck injury. We report a non-fatal case of vertebral right artery dissection after a minor rear-lateral collision. The injury was detected twenty-four days after trauma when a computerized tomography (CT) scan and cerebral angiography revealed multiple ischemic lesions of the right cerebellum. Digital subtraction angiography (DSA) has been the most sensitive imaging modality to describe the types and degree of vascular injury. The accuracy of such imaging allows linking several injuries with minor car crash avoiding patients seeking litigation for correct financial compensation.

Usefulness and limits of near infrared spectroscopy monitoring during endovascular neuroradiologic procedures.

BACKGROUND: Transcranial cerebral oximetry (TCCO) with near-infrared spectroscopy (NIRS) is a non-invasive, bedside technique, which allows the continuous measurement of regional cerebral oxygenation. The aim of this study was to evaluate TCCO monitoring during endovascular neuroradiologic procedures. METHODS: Adult patients undergoing elective endovascular embolization of cerebral aneurysms, arteriovenous malformations, dural arteriovenous fistulas and meningiomas under general anesthesia were included in the study, over a period of 12 months. Twenty-eight procedures in 25 patients were analyzed. RESULTS: Regional cerebral oxygenation rSO(2) readings were significantly different according to the different phases of the neuroendovascular procedure. An effect of the underlying cerebral pathology on regional cerebral oxygenation rSO(2) recording, in relation to the different stage of the interventional procedure, was also evident, the more invasive the procedure the greater the impact on rSO(2) reading. NIRS monitoring contributed to a prompt diagnosis and management of two adverse intraoperative events and helped in early evaluation of prognosis. CONCLUSION: TCCO with NIRS is a promising monitoring tool to assess the balance between oxygen supply and demand during neuroradiologic procedures. Nevertheless, some limits should be acknowledged, such as the study of the posterior circulation and artefacts related to contrast agent injection. A careful understanding of the undergoing step of the procedure as well of the possible influence of intrinsic and extrinsic factors affecting recording is important for interpretation of data.

Significance of hypoxemia screening in candidates for liver transplantation: our experience.

Hepatopulmonary syndrome (HPS) is recognized as one of the causes of hypoxemia in patients with chronic liver disease. This complication is responsible for increased mortality and increased perioperative risk in liver transplantation candidates. Recent data from the literature suggest extending the screening for HPS to all candidates for liver transplantation. The aim of this retrospective study was to evaluate the incidence of hypoxemia among a population of patients awaiting liver transplantation. Using pulse oximetry as a screening tool for hypoxemia, 39 of 198 patients (20%) were hypoxemic. The results of this study confirmed the importance of screening for hypoxemia among patients awaiting liver transplantation. In these patients, a more accurate evaluation of respiratory function should be performed to confirm or exclude the diagnosis of HPS.

The importance of predicting the prognosis in patients with hepatopulmonary syndrome: a simple scoring system.

Hepatopulmonary syndrome (HPS) is a pulmonary vascular disorder, complicating hepatic diseases, and is responsible for an increased morbidity and mortality among patients awaiting liver transplantation. Nowadays, it is recognized as an independent risk factor for death in this patient population. The severity of hypoxemia and the advanced stage of the liver dysfunction are determinants for the prognosis. Therefore, the possibility to be successful, thus improving survival, consists of addressing HPS at an earlier stage, giving more attention to moderate evidences of this pathology instead of the severe ones. On the basis of scientific evidence, we suggest a simple scoring system to predict prognosis among patients with HPS, founded on the integration of two main factors: the severity of hepatic disease, expressed as class of Child-Pugh, and the severity of the hypoxemia. This model of prognostic evaluation has the objective of estimating the additional risk of these patients, thereby avoiding a deleterious underestimate of risk and an arbitrariness of management.

IgD multiple myeloma. A report of three cases.

Three patients suffering from IgD myeloma, which a rare variant of multiple myeloma which often has an aggressive course, were studied retrospectively in order to elucidate the existence of clinical or laboratory features in relationship to survival time. The patients were monitored in follow-up for a time variable for 8 to 52 months. All patients received courses of chemotherapy using an association of Melphalan and Prednisone (MP); one patient also received recombinant interferon alpha in association. Response to chemotherapy, with a > 50% reduction of serum M component, disappearance of Bence Jones proteinuria and permanent control of the disease was achieved in all patients. The median duration of survival in IgD myeloma is shorter than that currently observed in patients with other myeloma types: in our series one patient died 8 months after diagnosis but other two patients are still alive 8 and 52 months after diagnosis, respectively. Great difficulty was encountered in analysis of unfavourable prognostic clinical and laboratory data: in our series, in spite of the small number of cases, the Authors observe that only the relief of increased serum levels of Lactate Dehydrogenase (LDH) seem to be in relationship with a trend of shorter survival. The authors, confirming the particular clinical and laboratory aspects of this myeloma, stress that there may coexist cases in which standard chemotherapy failed to control the diseases: these seem to indicate neoplasia with fast growth kinetics. Further studies are necessary in order to identify new prognostic index which allows the identification of selected groups of patients who can profit from a combination chemotherapy regimen other than the standard MP association.

[Not Available]. / La polmonite da Rhodococcus equi nell'AIDS.

Rhodococcus equi is a facultative intracellular, obligate aerobe, partially acid fast, gram-positive pathogen that causes cavitary pneumonia in animals and immunocompromised humans. We describe 8 cases of R. equi pneumonia in patients with advanced HIV infection (CD4 counts less than 100/mm3), 7 males and 1 female (mean age 30.8 years), observed between 1991 and 1994. A history of exposure to farm animals was found in 4 patients. The most common presenting symptoms were fever, malaise, dyspnea, cough and hemoptysis, chest pain and weight loss. Chest x-rays showed tipical focal area of consolidation throughout the lung (3 upper, 3 lower and 2 middle fields) associated with cavitation in 4 cases. The definitive diagnosis in our hands was delayed only in the first case in which conflicting data resulted from blood culture (Bacillus sp. isolation) and sputum examen (acid-fast bacterium in the Ziehl-Neelsen stain). Final microbiological diagnosis depended on blood cultures (n=5), bronchoalveolar lavage (n=1), sputum (n=1), lung biopsy (n=1). All the patients were treated with prolonged courses of antibiotic therapy (259 days, range 120-340 in 6 dead patients; more than one year and two months respectively in two patients alive). According to microbial susceptibility TMP/SMX, vancomycin, imipenem, rifampin, aminoglycosides, macrolides and quinolons were more frequently used. Resistant R. equi mutants were selected during therapy with TMP/SMX (n=2), rifampin (n=1) and erythromycin (n=1). Five patient underwent pulmonary lobectomy after exclusion of metastatic bacterial lesions. Only 2 patients are alive, one after 365 days of antibiotic therapy and upper lung lobectomy, one after 60 days of antibiotic therapy. Optimal antimicrobial therapy and the role of surgery remain, in our experience, uncertain.

[Evaluation of interferences in electronic platelet count]. / Valutazione di interferenze nel conteggio elettronico delle piastrine.

A platelets count was performed on 100 subjects using both the electronic counter and a manual method; the results obtained concerning healthy subjects are overlapping. In subjects with structural alterations regarding platelets and red blood cells, the electronic counter method has overestimated the number, yet making note of it.

[Cardiac pacing during open heart surgery (author's transl)]. / L'elettrostimolazione nella chirurgia a cuore aperto.

Cardiac pacing by means of temporary wires inserted during open heart surgery is an established useful adjunct to post-operative care. Optimal rate can be imposed to the heart with transiently depressed function, arrhythmias can be suppressed by overdriving and atrioventricular synchronization sometimes can be reestablished, with a resulting improvement of cardiac output. We routinely insert wires on the right ventricle, and on the right atrium wherever excitable. Wires have been inserted in 383 consecutive patients, significantly contributing to the control of bradiarrhythmias, the suppression of PVCs, and the improvement of low cardiac output states.