Long-Term Ventilation in Children with Medical Complexity: A Challenging Issue.

Children with medical complexity (CMCs) represent a subgroup of children who may have congenital or acquired multisystemic disease. CMCs are frequently predisposed to respiratory problems and often require long-term mechanical ventilation (LTMV). The indications for LTMV in CMCs are increasing, but gathering evidence about indications, titration, and monitoring is currently the most difficult challenge due to the absence of validated data. The aim of this review was to examine the clinical indications and ethical considerations for the initiation, continuation, or withdrawal of LTMV among CMCs. The decision to initiate long-term ventilation should always be based on clinical and ethical considerations and should be shared with the parents.

Evidence of disorientation towards immunization on online social media after contrasting political communication on vaccines. Results from an analysis of Twitter data in Italy.

BACKGROUND: In Italy, in recent years, vaccination coverage for key immunizations as MMR has been declining to worryingly low levels, with large measles outbreaks. As a response in 2017, the Italian government expanded the number of mandatory immunizations introducing penalties to unvaccinated children's families. During the 2018 general elections campaign, immunization policy entered the political debate with the government in-charge blaming oppositions for fuelling vaccine scepticism. A new government (formerly in the opposition) established in 2018 temporarily relaxed penalties and announced the introduction of forms of flexibility. OBJECTIVES AND METHODS: First, we supplied a definition of disorientation, as the "lack of well-established and resilient opinions among individuals, therefore causing them to change their positions as a consequence of sufficient external perturbations". Second, procedures for testing for the presence of both short and longer-term collective disorientation in Twitter signals were proposed. Third, a sentiment analysis on tweets posted in Italian during 2018 on immunization topics, and related polarity evaluations, were used to investigate whether the contrasting announcements at the highest political level might have originated disorientation amongst the Italian public. RESULTS: Vaccine-relevant tweeters' interactions peaked in response to main political events. Out of retained tweets, 70.0% resulted favourable to vaccination, 16.4% unfavourable, and 13.6% undecided, respectively. The smoothed time series of polarity proportions exhibit frequent large changes in the favourable proportion, superimposed to a clear up-and-down trend synchronized with the switch between governments in Spring 2018, suggesting evidence of disorientation among the public. CONCLUSIONS: The reported evidence of disorientation for opinions expressed in online social media shows that critical health topics, such as vaccination, should never be used to achieve political consensus. This is worsened by the lack of a strong Italian institutional presence on Twitter, calling for efforts to contrast misinformation and the ensuing spread of hesitancy. It remains to be seen how this disorientation will impact future parents' vaccination decisions.

Patterns of Presentation of SARS-CoV-2 Infection in Children. Experience at the Italian Epicentre of the Pandemic.

Background: COVID-19, a disease caused by the new coronavirus SARS-CoV-2, spread worldwide, and Bergamo was one of the most affected areas in Europe. Following the first outbreak, more than half of the population of the Bergamo province had been infected. We aimed to describe the patients admitted to our unit shortly after the first outbreak. Methods: we retrospectively reviewed the notes of all pediatric patients diagnosed with COVID-19. We enrolled patients with positive swabs or serology and classified them based on the pattern and the timing of presentation after the first outbreak. This setting was considered a reliable reflection of the consequences of unmitigated SARS-CoV-2 circulation. Results: We diagnosed 35 patients over a 3-month period and we identified six patterns presenting in two temporal phases: Early phase, Group 1 (median of 20 days from epidemic start, IQR: 15-27): neonatal sepsis (n.7), pneumonia (n.5), flu-like symptoms (n.2). Late phase, Group 2 (59:51-66 days, p < 0.001): MIS-C (n.18), neurological manifestations (n.3). Group 1 differed from Group 2 for younger age (1 vs. 8 years, p = 0.02), lower C-reactive protein (0.9 vs. 16.6 mg/dl, p = 0.008), procalcitonin (0.16 vs. 7.9 ng/ml, p = 0.008) and neutrophil count (3,765 vs. 6,780/µl, p = 0.006), higher rate of positive swabs (14/14 vs. 9/21, p < 0.001), higher lymphocyte count (3,000 vs. 930/µl, p = 0.006) and platelet count (323,000 vs. 210,000/µl, p = 0.009). Conclusions: Following an outbreak of unmitigated SARS-CoV-2 diffusion, infected children may present with clinical patterns suggesting two temporal clusters, the first characterized by markers of direct viral injury, the second suggesting an immune-mediated disease.

Impact of Ethnicity on COVID-19 Related Hospitalizations in Children During the First Pandemic Wave in Northern Italy.

There is increasing evidence that black people and other minorities have a higher incidence of severe COVID-19 disease, but little is known about the situation of children, especially in Europe. In general children are less infected and if so, frequently show mild or asymptomatic disease, making conclusions difficult. We collected data on SARS-CoV-2 associated hospitalizations in a well-defined population of 550,180 children up to 15 years in five hub-centers during the "first wave" at the heart of the pandemic in Northern Italy. Among the 451,053 Italian citizens 80 were hospitalized as compared to 31 out of 99,127 foreign citizens, giving a significantly higher risk (odds ratio 1.76; 95% CI: 1.16-2.66) for the foreign children. The risk was highest for children of African ethnicity as compared to Italians with an odds ratio of 2.76 (95% CI: 1.56-4.87). None of the patients deceased. There was no significant difference in age (thou infants regardless of ethnicity had a 10-fold higher risk), sex, length of hospitalization or comorbidities, namely overweight. As bureaucratic, cultural and information barriers mostly affect preventive and adult services and considering that in contrast to other countries, in Italy pediatric care is guaranteed free of (out-of-pocket) charge to all people <16 years, and hospitals are densely spaced, access to health care seems to be a minor problem. Thus, other possible root causes are discussed. We believe that this is an unbiased starting point to understand and overcome the reasons for the higher risk those children experience.

COVID-19 and children with Down syndrome: is there any real reason to worry? Two case reports with severe course.

BACKGROUND: Down syndrome (DS) is characterized by a series of immune dysregulations, of which interferon hyperreactivity is important, as it is responsible for surging antiviral responses and the possible initiation of an amplified cytokine storm. This biological condition is attributed to immune regulators encoded in chromosome 21. Moreover, DS is also characterized by the coexistence of obesity and cardiovascular and respiratory anomalies, which are risk factors for coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). CASE PRESENTATION: A total of 55 children were admitted to the pediatric ward in Bergamo, between February and May 2020 for COVID-19. Here, we describe the cases of two children with DS and a confirmed COVID-19 diagnosis who had a severe course. In addition, both cases involved one or more comorbidities, including cardiovascular anomalies, obesity, and/or obstructive sleep apnea. CONCLUSIONS: Our observations indicate that children with DS are at risk for severe COVID-19 disease course.

A Pediatric Emergency Department Protocol to Avoid Intrahospital Spread of SARS-CoV-2 during the Outbreak in Bergamo, Italy.

The pandemic of coronavirus SARS-CoV-2 disease affected Northern Italy, spreading from the Bergamo province to the entire country. During reorganization of our emergency department to support patients presenting with coronavirus SARS-CoV-2 disease, we aimed to evaluate whether children play a role in intrahospital spread of the infection.

An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study.

BACKGROUND: The Bergamo province, which is extensively affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic, is a natural observatory of virus manifestations in the general population. In the past month we recorded an outbreak of Kawasaki disease; we aimed to evaluate incidence and features of patients with Kawasaki-like disease diagnosed during the SARS-CoV-2 epidemic. METHODS: All patients diagnosed with a Kawasaki-like disease at our centre in the past 5 years were divided according to symptomatic presentation before (group 1) or after (group 2) the beginning of the SARS-CoV-2 epidemic. Kawasaki- like presentations were managed as Kawasaki disease according to the American Heart Association indications. Kawasaki disease shock syndrome (KDSS) was defined by presence of circulatory dysfunction, and macrophage activation syndrome (MAS) by the Paediatric Rheumatology International Trials Organisation criteria. Current or previous infection was sought by reverse-transcriptase quantitative PCR in nasopharyngeal and oropharyngeal swabs, and by serological qualitative test detecting SARS-CoV-2 IgM and IgG, respectively. FINDINGS: Group 1 comprised 19 patients (seven boys, 12 girls; aged 3·0 years [SD 2·5]) diagnosed between Jan 1, 2015, and Feb 17, 2020. Group 2 included ten patients (seven boys, three girls; aged 7·5 years [SD 3·5]) diagnosed between Feb 18 and April 20, 2020; eight of ten were positive for IgG or IgM, or both. The two groups differed in disease incidence (group 1 vs group 2, 0·3 vs ten per month), mean age (3·0 vs 7·5 years), cardiac involvement (two of 19 vs six of ten), KDSS (zero of 19 vs five of ten), MAS (zero of 19 vs five of ten), and need for adjunctive steroid treatment (three of 19 vs eight of ten; all p<0·01). INTERPRETATION: In the past month we found a 30-fold increased incidence of Kawasaki-like disease. Children diagnosed after the SARS-CoV-2 epidemic began showed evidence of immune response to the virus, were older, had a higher rate of cardiac involvement, and features of MAS. The SARS-CoV-2 epidemic was associated with high incidence of a severe form of Kawasaki disease. A similar outbreak of Kawasaki-like disease is expected in countries involved in the SARS-CoV-2 epidemic. FUNDING: None.

Bivariate discrete beta Kernel graduation of mortality data.

Various parametric/nonparametric techniques have been proposed in literature to graduate mortality data as a function of age. Nonparametric approaches, as for example kernel smoothing regression, are often preferred because they do not assume any particular mortality law. Among the existing kernel smoothing approaches, the recently proposed (univariate) discrete beta kernel smoother has been shown to provide some benefits. Bivariate graduation, over age and calendar years or durations, is common practice in demography and actuarial sciences. In this paper, we generalize the discrete beta kernel smoother to the bivariate case, and we introduce an adaptive bandwidth variant that may provide additional benefits when data on exposures to the risk of death are available; furthermore, we outline a cross-validation procedure for bandwidths selection. Using simulations studies, we compare the bivariate approach proposed here with its corresponding univariate formulation and with two popular nonparametric bivariate graduation techniques, based on Epanechnikov kernels and on P-splines. To make simulations realistic, a bivariate dataset, based on probabilities of dying recorded for the US males, is used. Simulations have confirmed the gain in performance of the new bivariate approach with respect to both the univariate and the bivariate competitors.

[A ten-year risk evaluation study in Catania hospital operating rooms]. / Dal monitoraggio alla valutazione del rischio in sala operatoria: risultati di un'indagine decennale negli ospedali catanesi.

Previous studies conducted in Catania hospitals have revealed a high burden of contamination in the air of operating rooms and have recommended measures to improve air quality. In this study we verified the effectiveness of the undertaken measures. Furthermore we evaluated the possibility of using microclimatic parameters as "markers" of operating room contamination. Changes made to ventilation systems and to waste gas scavenging systems in the monitored operating rooms were remarkably effective. Microclimatic conditions and degree of chemical contamination improved over time; nevertheless airflow velocity values were found to be insufficient and nitrous oxide values, in some cases, remained slightly elevated. A significant correlation was observed only between some nitrous oxide values and relative humidity. Monitoring important marker levels is useful for correctly evaluating operating room thermal, chemical and microbiological air quality.