Effects of Relaxed Lockdown on Pediatric ER Visits during SARS-CoV-2 Pandemic in Italy.

Previously, we demonstrated an 81% reduction in pediatric Emergency Room (ER) visits in Italy during the strict lockdown due to the SARS-CoV-2 pandemic. Since May 2020, lockdown measures were relaxed until 6 November 2020, when a strict lockdown was patchily reintroduced. Our aim was to evaluate the impact of the relaxed lockdown on pediatric ER visits in Italy. We performed a retrospective multicenter study involving 14 Italian pediatric ERs. We compared total ER visits from 24 September 2020 to 6 November 2020 with those during the corresponding timeframe in 2019. We evaluated 17 ER specific diagnoses grouped in air communicable and non-air communicable diseases. We recognized four different triage categories: white, green, yellow and red. In 2020 total ER visits were reduced by 51% compared to 2019 (16,088 vs. 32,568, respectively). The decrease in air communicable diseases was significantly higher if compared to non-air communicable diseases (-64% vs. -42%, respectively). ER visits in each triage category decreased in 2020 compared to 2019, but in percentage, white and red codes remained stable, while yellow codes slightly increased and green codes slightly decreased. Our results suggest that preventive measures drastically reduced the circulation of air communicable diseases even during the reopening of social activities but to a lesser extent with regard to the strict lockdown period (March-May 2020).

Colour Preference of the Deer Ked Lipoptena fortisetosa (Diptera: Hippoboscidae).

Lipoptena fortisetosa, a deer ked native to Japan, has established itself in several European countries and was recently recorded in Italy. This hippoboscid ectoparasite can develop high density populations, causing annoyance to animals and concern regarding the potential risk of transmitting pathogens to humans. No monitoring or control methods for L. fortisetosa have been applied or tested up to now. This research evaluated the possible response of L. fortisetosa winged adults to different colours as the basis for a monitoring and control strategy. In the summer of 2020, a series of six differently coloured sticky panels were randomly set as traps in a wooded area used by deer for resting. The results indicated a clear preference of the deer ked for the blue panels that caught the highest number of flies during the experimental period. Lower numbers of flies were trapped on the red, green, black, and white panels, with the yellow panels recording the fewest captures. The response clearly demonstrates that this species displays a colour preference, and that coloured traps might be useful for monitoring and limiting this biting ectoparasite in natural areas harbouring wildlife and visited by people.

Safety of anti-inflammatory drugs in children with asthma.

PURPOSE OF REVIEW: Inhaled corticosteroids (ICS) are widely used as the first-line treatment of asthma. When the disease is not controlled by standard doses of ICS, other anti-inflammatory drugs should be considered. The aim of this report is to review the main adverse events induced by anti-inflammatory drugs in children with asthma and discuss possible actions to prevent or mitigate these effects. RECENT FINDINGS: Proper interpretation of ICS safety studies requires knowledge of the pharmaceutical properties and delivery device systems of the different ICS available. Genetic variants affecting susceptibility to corticosteroid-induced adrenal suppression were found in children and adults who use ICS to treat their asthma. There is evidence of the association between montelukast use and neuropsychiatric events. SUMMARY: Benefits of ICS, properly prescribed and used, outweigh their potential adverse effects. There is substantial evidence that the combination of ICS with long-acting beta2 agonists is safe for asthmatic children. Awareness of the potential risks of neuropsychiatric events in children taking montelukast should inform the clinicians' prescribing practices. Omalizumab is generally well-tolerated, but the evidence on the safety of other biologic agents in children is scanty. The risk of systemic adverse events with anti-inflammatory drugs must be balanced against the risks of uncontrolled asthma and/or frequent oral steroid use.

Dog bite injuries in a tertiary care children's hospital: A seven-year review.

BACKGROUND: Dog bites are a major cause of traumatic injury in children. The aim of this study was to determine the experience, management, and outcome of dog bite injuries in our department. METHODS: We retrospectively reviewed the clinical records for 127 patients (mean age 7.15 ± 4.24 years, range 1 to 17 years; 68 males) affected by dog-related injuries, from 2012 to 2018. Characteristics of patients and dogs, type and severity of injuries, circumstances of the accidents, treatment and outcome were analyzed. RESULTS: Of 141 wounds, 73 (51.8%) affected the head and neck, 62 (44%) the limbs, and six (4.2%) affected the trunk. According to the Mcheik classification, 107 lesions (75.9%) were stage 1, 26 (18.4%) stage 2, and eight (5.7%) stage 3. Seventy-eight percent of the cases involved known dogs. The breed of the dog was recorded in 62/127 cases (48.8%) and the most common were mongrels (23/62, 37.1%). Seventy-five percent of the attacks occurred during spring and summer. All patients underwent antibiotic prophylaxis and immediate surgical repair. Wound infection was observed in two patients. Three unsightly scars required rectification, with good cosmetic results in all cases. CONCLUSIONS: Our results are consistent with previous data showing that the typical dog-related injury occurs from a known dog, during spring and summer, and in younger boys, who are frequently exposed to head and neck wounds. Our experience showed the feasibility and safety of primary repair and antibiotic prophylaxis in all patients, with very low incidence of infection and good cosmetic results.

Question 4: Is there a role for antibiotics in infantile wheeze?

Acute wheezing episodes are frequent in young children and are associated with high morbidity and healthcare utilization. The role of respiratory viruses in triggering acute wheezing is well known. There is also accumulating evidence that airway bacteria, either alone or as part of bacteria-virus interaction, are important determinants of acute asthma exacerbations. Targeting airway bacteria with antibiotics to reduce the severity of acute wheezing episodes and prevent recurrent wheezing among preschool children has been recently evaluated in three randomized, double-blind, placebo-controlled trials. The results of these studies are controversial. An interventional approach with azithromycin in young children during acute wheezing episodes cannot be generically incorporated into clinical practice, due to the potential consequences of widespread use of antibiotics in such a common clinical setting. This intervention may be reserved for children with really severe, recurrent wheezing episodes. Future research should focus on risk factors that facilitate acquisition of bacterial airway infection in young children and better understanding how virus and bacteria interact with each other during wheezing attacks. Identifying objective biomarkers that may direct the treatment to specific groups of children may represent a significant step forward in the clinical approach of acute wheezing.

Olive fruit fly rearing procedures affect the vertical transmission of the bacterial symbiont Candidatus Erwinia dacicola.

BACKGROUND: The symbiosis between the olive fruit fly, Bactrocera oleae, and Candidatus Erwinia dacicola has been demonstrated as essential for the fly's larval development and adult physiology. The mass rearing of the olive fruit fly has been hindered by several issues, including problems which could be related to the lack of the symbiont, presumably due to preservatives and antibiotics currently used during rearing under laboratory conditions. To better understand the mechanisms underlying symbiont removal or loss during the rearing of lab colonies of the olive fruit fly, we performed experiments that focused on bacterial transfer from wild female flies to their eggs. In this research, eggs laid by wild females were treated with propionic acid solution, which is often used as an antifungal agent, a mixture of sodium hypochlorite and Triton X, or water (as a control). The presence of the bacterial symbiont on eggs was evaluated by real-time PCR and scanning electron microscopy. RESULTS: DGGE analysis showed a clear band with the same migration behavior present in all DGGE profiles but with a decreasing intensity. Molecular analyses performed by real-time PCR showed a significant reduction in Ca. E. dacicola abundance in eggs treated with propionic acid solution or a mixture of sodium hypochlorite and Triton X compared to those treated with water. In addition, the removal of bacteria from the surfaces of treated eggs was highlighted by scanning electron microscopy. CONCLUSIONS: The results clearly indicate how the first phases of the colony-establishment process are important in maintaining the symbiont load in laboratory populations and suggest that the use of products with antimicrobial activity should be avoided. The results also suggest that alternative rearing procedures for the olive fruit fly should be investigated.

Horizontal transfer and finalization of a reliable detection method for the olive fruit fly endosymbiont, Candidatus Erwinia dacicola.

BACKGROUND: The olive fly, Bactrocera oleae, is the most important insect pest in olive production, causing economic damage to olive crops worldwide. In addition to extensive research on B. oleae control methods, scientists have devoted much effort in the last century to understanding olive fly endosymbiosis with a bacterium eventually identified as Candidatus Erwinia dacicola. This bacterium plays a relevant role in olive fly fitness. It is vertically transmitted, and it benefits both larvae and adults in wild populations; however, the endosymbiont is not present in lab colonies, probably due to the antibiotics and preservatives required for the preparation of artificial diets. Endosymbiont transfer from wild B. oleae populations to laboratory-reared ones allows olive fly mass-rearing, thus producing more competitive flies for future Sterile Insect Technique (SIT) applications. RESULTS: We tested the hypothesis that Ca. E. dacicola might be transmitted from wild, naturally symbiotic adults to laboratory-reared flies. Several trials have been performed with different contamination sources of Ca. E. dacicola, such as ripe olives and gelled water contaminated by wild flies, wax domes containing eggs laid by wild females, cages dirtied by faeces dropped by wild flies and matings between lab and wild adults. PCR-DGGE, performed with the primer set 63F-GC/518R, demonstrated that the transfer of the endosymbiont from wild flies to lab-reared ones occurred only in the case of cohabitation. CONCLUSIONS: Cohabitation of symbiotic wild flies and non-symbiotic lab flies allows the transfer of Ca. E. dacicola through adults. Moreover, PCR-DGGE performed with the primer set 63F-GC/518R was shown to be a consistent method for screening Ca. E. dacicola, also showing the potential to distinguish between the two haplotypes (htA and htB). This study represents the first successful attempt at horizontal transfer of Ca. E. dacicola and the first step in acquiring a better understanding of the endosymbiont physiology and its relationship with the olive fly. Our research also represents a starting point for the development of a laboratory symbiotic olive fly colony, improving perspectives for future applications of the Sterile Insect Technique.

Emigration Effects Induced by Radio Frequency Treatment to Dates Infested by Carpophilus hemipterus.

The dried fruit beetle (Carpophilus hemipterus) is considered a key pest of dates, infesting fruits both in the field and during storage. Control measures against the species rely on the use of chemicals or heat treatments based on sunlight, hot air or radio frequency (RF) applications. Previous investigations that have aimed to define control procedures for a total disinfestation using RF treatments with different exposure durations have shown the typical behavior of adults in some trials, which, under the influence of temperature increases, started to escape from infested fruits. We focused on the application of different RF voltage-time combinations to induce the emigration of C. hemipterus adults from dates in order to produce a complete disinfestation. The results showed that the application of 2500 V RF for 8-10 min to infested dates resulted in nearly 100% of adults escaping from fruits, thereby cleaning the commodity with low or no mortality inside and outside the dates. These achievements provide a new strategy for controlling key insect pests of dates that could be applied at an industrial scale, allowing for the quick disinfestation of fruits without affecting the fruit with harmful substances, such as residues from chemical treatments, and without unwanted side effects on date quality.

Macronodular hepatosplenic tuberculosis.

Hepatosplenic involvement is a rare manifestation of abdominal tuberculosis in children. We describe the case of a 7-year-old girl with persistent fever, cough, and hepatosplenomegaly. Typical lesions were shown in the liver and spleen by ultrasound and computed tomography. Colonoscopy showed a nodular, ulcerated mass that partially obstructed the cecum. Microbiological and histopathological findings of intestinal and liver biopsy confirmed the clinical suspicion of tuberculosis.

Endpoints in respiratory diseases.

A wide range of outcome measures or endpoints has been used in clinical trials to assess the effects of treatments in paediatric respiratory diseases. This can make it difficult to compare treatment outcomes from different trials and also to understand whether new treatments offer a real clinical benefit for patients. Clinical trials in respiratory diseases evaluate three types of endpoints: subjective, objective and health-related outcomes. The ideal endpoint in a clinical trial needs to be accurate, precise and reliable. Ideally, the endpoint would also be measured with minimal risk and across all ages, easy to perform, and be inexpensive. As for any other disease, endpoints for respiratory diseases must be viewed in the context of the important distinction between clinical endpoints and surrogate endpoints. The association between surrogate endpoints and clinical endpoints must be clearly defined for any disease in order for them to be meaningful as outcome measures. The most common endpoints which are used in paediatric trials in respiratory diseases are discussed. For practical purposes, diseases have been separated into acute (bronchiolitis, acute viral-wheeze, acute asthma and croup) and chronic (asthma and cystic fibrosis). Further development of endpoints will enable clinical trials in children with respiratory diseases with the main objective of improving prognosis and safety.

Leptin, free leptin index, insulin resistance and liver fibrosis in children with non-alcoholic fatty liver disease.

OBJECTIVE: Prevalence of non-alcoholic fatty liver disease (NAFLD) among children is increasing dramatically. It is unclear why some patients develop steatohepatitis (NASH), fibrosis and cirrhosis from steatosis, and others do not. A role for leptin has been claimed. This study aims to evaluate the relationship between leptin, insulin resistance (IR) and NAFLD in children. DESIGN AND METHODS: In 72 biopsy-proven NAFLD children (aged 9-18 years; 51M/21F), fasting leptin and its soluble receptor (sOB-R) were measured; free leptin index (FLI) was calculated as leptin/sOB-R; IR was estimated by homeostasis model assessment (HOMA-IR) and insulin sensitivity index (ISI-comp); glucose tolerance by oral glucose tolerance test (OGTT). Percentage of total body fat (TBF) by dual-energy X-ray absorptiometry (DXA) was available in 65 patients. RESULTS: Prevalence of diabetes, impaired fasting and/or after load glucose tolerance was 11%. HOMA-IR and ISI-comp values were 2.55 +/- 1.39 and 4.4 +/- 2. NASH was diagnosed in 38 and simple steatosis in 25 children; diagnosis was indeterminate in 29 children. Increased fibrosis, mostly of mild severity, was observed in 41 patients. Median NAFLD activity (NAS) score was 3.42 +/- 1.60. According to histology, levels of leptin and FLI increased as steatosis (leptin from 11.9 +/- 6.3 in score 1 to 17.4 +/- 6.9 in score 2 (P = 0.01) and 22.2 +/- 6.8 ng/ml in score 3 (P < 0.001); FLI 2.56 +/- 1.40, 3.57 +/- 0.34, 4.45 +/- 0.64 respectively (P = 0.05)); ballooning (from 13.7 +/- 6.7 in score 1 to 17 +/- 7.5 in score 2 (P = 0.001) and 22.1 +/- 7.1 ng/ml in score 3 (P = 0.01); FLI 2.81 +/- 1.50, 3.40 +/- 1.65, 4.57 +/- 1.67 (P = 0.01 between 0 and 2)); fibrosis (from 14.3 +/- 7 to18.3 +/- 6.9; P = 0.03; FLI 3.03 +/- 1.57 vs 3.92 +/- 077; P < 0.05) and NAS score (score 1-2: 12.9 +/- 6.9; score 3-4: 17 +/- 6.9 (P = 0.01); score 5-7: 22.9 +/- 7.5 ng/ml (P = 0.03); FLI 2.70 +/- 1.53, 3.12 +/- 1.53, 4.58 +/- 1.57 P = 0.01 and P = 0.05 between 1-2 vs 3-4 and 3-4 vs 5-7 respectively) worsened. Higher leptin correlated with more severe steatosis, ballooning and NAS score (r(0) = 0.6, 0.4 and 0.6 respectively; for all P < 0.001); FLI with ballooning (r(0) = 0.4, P < 0.0001), steatosis (r(0) = 0.5, P < 0.0001) and NAS score (r(0) = 0.5, P < 0.0001). CONCLUSIONS: Leptin and liver injury correlated independently of age, BMI and gender in the present study. Nevertheless, any causative role of leptin in NAFLD progression could be established. Thus, studies are needed to define whether the hormone plays a major role in the disease.

Foreign body aspiration in children.

BACKGROUND: The aim was to investigate the role of physical and radiological findings before bronchoscopy in the diagnosis of foreign body aspiration (FBA). METHODS: We retrospectively reviewed the clinical records for 82 patients (mean age 26.4 +/- 21.4 months, range 9 months to 13.5 years; 49 males) with a history suggestive of foreign body aspiration. RESULTS: The presence of a foreign body in the airways was confirmed in 70 children (85.4%) (mean age 25 +/- 14.1 months, 45 boys). Of the 70 children, 63 patients (90%) were under 3 years of age, with a peak incidence during the second year. Of the 70 foreign bodies retrieved, 46 (60%) were vegetable and 35 (76%) of these were nuts. In 42% of the patients the foreign body was located in the right bronchial tree. The most frequent physical findings observed in our patients were persistent cough (75%), localized decreased breath sound (62.8%) and localized wheezing (30%). The clinical triad (concomitant cough, localized wheezing and decreased breath sound) was present in 11 patients (15.7%). All clinical findings had a high positive predictive value with poor sensitivity. In 11 patients (20%) chest X-rays were normal. Five foreign bodies (9.1%) were radiopaque. The most frequent radiological findings observed were localized air trapping (43.6%), followed by atelectasis (40%). The diagnostic sensitivity was 80% and the specificity 33% for the presence of a single positive radiological finding. CONCLUSIONS: Our study confirmed that clinical symptoms and radiological findings before bronchoscopy have a low diagnostic value in children with a history of FBA.

Microaspiration in infants with laryngomalacia.

OBJECTIVES/HYPOTHESIS: Laryngomalacia is the most common congenital laryngeal anomaly and the most frequent cause of stridor in infants. Infants with laryngomalacia may have associated respiratory symptoms other than stridor. In this study, we evaluated whether infants with laryngomalacia have episodes of microaspiration by calculating the amount of lipids present in the alveolar macrophages. STUDY DESIGN: We reviewed bronchoalveolar lavage (BAL) findings obtained in 14 infants with laryngomalacia and in 11 control children. METHODS: BAL was performed during flexible fiberoptic bronchoscopy (FFB) to diagnose persistent stridor. The presence of microaspiration was determined by evaluating the amount of lipid per single macrophage, assigning each cell a score from 0 to 4 according to the amount of lipid in the cytoplasm. RESULTS: The lipid-laden macrophage index was similar in patients and controls (31.5, range 12-177 vs. 45, range 35-106). In 5 of the 14 (36%) patients the index exceeded 100, and more than 25% of the cells were graded 3 and 4, indicating the presence of microaspiration. The lipid-laden macrophage index correlated significantly with the number and percentage of BAL neutrophils (Pearson correlation test, r = 0.83, P < .001 and r = 0.925, P < .001) as a marker of lung inflammation. CONCLUSIONS: Infants with laryngomalacia may have episodes of microaspiration. BAL performed during FFB to evaluate stridor may add helpful therapeutic information without increasing the risks of the procedure.

Bronchial adenoma: an unusual cause of recurrent pneumonia in childhood.

Primary lung tumors are rare in childhood and often overlooked owing to the nonspecific presentation. We report the case of a 15-year-old boy with a 3-year history of recurrent pneumonia always involving the right lower lobe due to bronchial mucinous adenoma. After endoscopic removal the tumor recurred locally, necessitating open surgical resection of the tumor. In a child with localized recurrent pneumonia of uncertain pathogenesis, the differential diagnosis should include a primary lung tumor. Bronchial adenomas should not be removed endoscopically; patients must undergo open thoracotomy for surgical excision.

Nutritional status in childhood malignancies.

In children affected by tumor, nutritional status is important to sustain aggressive chemotherapy and to support normal growth during and after therapy. The aim of this study was to investigate the prevalence of nutritional status disorders in a sample of pediatric oncology day-hospital patients. We measured weight and height in patients affected by solid tumors on or off therapy at short-term follow-up (1-24 mo). The study was performed at a pediatric oncology day-hospital over a period of 20 consecutive days. A suitable computer package was used to estimate relative body weight (%RBW) and body mass index (BMI) for each patient. Thereafter, the same sample was divided into four weight classes (underweight, normal weight, overweight, and obese) according to %RBW and BMI. Moreover, patients were divided into two groups: on and off therapy. In the off-therapy group, no patient was underweight; in the on-therapy group, 26.3% and 15.8% of patients were underweight (not significant) according to %RBW and BMI, respectively. The prevalence of overweight (overweight ++obese) according to %RBW was 36.9% in the on-therapy group and 52.9% in the off-therapy group (P < 0.05); whereas the prevalence of overweight according to BMI was 21% in the on-therapy group and 35.3% in the off-therapy group (P = 0.05). These preliminary data suggest that, in pediatric oncology, nutritional assessment is required to provide nutritional strategies in on-therapy patients whose underweight status prevalence is impressive or in off-therapy children in whom the causes of overweight should be explored.