Atraumatic Limping Child, a Challenge for Pediatricians: An Observational Age-Related Study in a Pediatric Emergency Department.

BACKGROUND: Atraumatic limping is a frequent cause of consultation in Pediatric Emergency Departments (PED) and often represents a challenge for pediatricians for its variability in etiology ranging from benign causes to potential crippling conditions. The aims of this research are to illustrate the clinical features of acute limping children (LC) and to identify the possible red flags that could help to make a diagnosis of severe pathologies. METHODS: We carried out a retrospective study about non-traumatic limping children referred to the PED of Bambino Gesù Children's Hospital over a 2-year period. We divided the cohort into three groups based on the patient's age: toddlers, children and adolescents. We considered crippling conditions: oncologic etiologies, bone or neurological infections, epiphysiolysis, Perthes disease, Guillain Barrè syndrome and non-accidental injuries. RESULTS: We analyzed 485 patients. At clinical evaluation, 19.5% of the patients presented at least one sign and/or symptom of red flags. Crippling conditions (6.2% of the total population) showed red flags in 36.7%. Transient synovitis of the hip was the most frequent diagnosis. We found crippling conditions in 30 patients, mostly represented by toddlers. CONCLUSIONS: Our data suggest that toddlers and patients presenting red flags should be evaluated with particular suspicion because they have an increased risk of underlying severe conditions.

Biallelic truncating variants in children with titinopathy represent a recognizable condition with distinctive muscular and cardiac characteristics: a report on five patients.

Background: Monoallelic and biallelic TTN truncating variants (TTNtv) may be responsible for a wide spectrum of musculoskeletal and cardiac disorders with different age at onset. Although the prevalence of heterozygous TTNtv is relatively high in the general population, cardiac phenotyping (mainly cardiomyopathies, CMPs) in biallelic titinopathy has rarely been described in children. Methods: We reviewed the medical records of pediatric patients with biallelic TTNtv and cardiac involvement. Clinical exome sequencing excluded pathogenic/likely pathogenic variants in major CMP genes. Results: Five pediatric patients (four male) with biallelic TTNtv were included. Major arthrogryposis multiplex was observed in four patients; no patient showed intellectual disability. At a cardiac level, congenital heart defects (atrial and ventricular septal defects, n = 3) and left ventricular non-compaction (n = 1) were reported. All patients had dilated cardiomyopathy (DCM) diagnosed at birth in one patient and at the age of 10, 13, 14, and 17 years in the other four patients. Heart rhythm monitoring showed tachyarrhythmias (premature ventricular contractions, n = 2; non-sustained ventricular tachycardia, n = 2) and nocturnal first-degree atrio-ventricular block (n = 2). Cardiac magnetic resonance (CMR) imaging was performed in all patients and revealed a peculiar late gadolinium enhancement distribution in three patients. HyperCKemia was present in two patients and end-stage heart failure in four. End-organ damage requiring heart transplantation (HT) was indicated in two patients, who were operated on successfully. Conclusion: Biallelic TTNtv should be considered when evaluating children with severe and early-onset DCM, particularly if skeletal and muscular abnormalities are present, e.g., arthrogryposis multiplex and congenital progressive myopathy. End-stage heart failure is common and may require HT.

Finger ischemia in a young lady: an unusual presentation of papillary fibroelastoma with intraventricular location.

An otherwise healthy 32-year-old woman suffered from finger ischemia. An echocardiogram and computed tomography scan revealed a mobile mass in the left ventricle that was attached to the anterior papillary muscle and did not involve the valve leaflets. The tumor was resected, and histopathology confirmed it to be a papillary fibroelastoma. Our case emphasizes the significance of a comprehensive diagnostic work-up for a peripheral ischemic lesion. This resulted in the discovery of an unusual intra-ventricular origin for a commonly benign tumor.

Fibrolipomatous hamartoma of the median nerve in a child with carpal tunnel syndrome: imaging findings and literature review.

Fibrolipomatous hamartoma of the median nerve is an uncommon benign tumour of the childhood, which usually manifests in adolescents or adulthood with signs of compressive neuropathy at wrist. Symptomatic tumour is unusual in children below 5 years age and can be underdiagnosed. Magnetic resonance imaging provides pathognomonic features for the diagnosis, obviating the need for biopsy. Although standard ultrasonography is frequently the first-line imaging approach in the evaluation of soft-tissue masses, sonographic findings of this lesion are less frequently reported and have to be kept in mind by radiologist. We report the unusual case of carpal tunnel syndrome secondary to fibrolipomatous hamartoma of the median nerve in a 4-year-old child successfully treated with surgical carpal tunnel release.

Machine Learning Algorithm: Texture Analysis in CNO and Application in Distinguishing CNO and Bone Marrow Growth-Related Changes on Whole-Body MRI.

OBJECTIVE: The purpose of this study is to analyze the texture characteristics of chronic non-bacterial osteomyelitis (CNO) bone lesions, identified as areas of altered signal intensity on short tau inversion recovery (STIR) sequences, and to distinguish them from bone marrow growth-related changes through Machine Learning (ML) and Deep Learning (DL) analysis. MATERIALS AND METHODS: We included a group of 66 patients with confirmed diagnosis of CNO and a group of 28 patients with suspected extra-skeletal systemic disease. All examinations were performed on a 1.5 T MRI scanner. Using the opensource 3D Slicer software version 4.10.2, the ROIs on CNO lesions and on the red bone marrow were sampled. Texture analysis (TA) was carried out using Pyradiomics. We applied an optimization search grid algorithm on nine classic ML classifiers and a Deep Learning (DL) Neural Network (NN). The model's performance was evaluated using Accuracy (ACC), AUC-ROC curves, F1-score, Positive Predictive Value (PPV), Mean Absolute Error (MAE) and Root-Mean-Square Error (RMSE). Furthermore, we used Shapley additive explanations to gain insight into the behavior of the prediction model. RESULTS: Most predictive characteristics were selected by Boruta algorithm for each combination of ROI sequences for the characterization and classification of the two types of signal hyperintensity. The overall best classification result was obtained by the NN with ACC = 0.91, AUC = 0.93 with 95% CI 0.91-0.94, F1-score = 0.94 and PPV = 93.8%. Between classic ML methods, ensemble learners showed high model performance; specifically, the best-performing classifier was the Stack (ST) with ACC = 0.85, AUC = 0.81 with 95% CI 0.8-0.84, F1-score = 0.9, PPV = 90%. CONCLUSIONS: Our results show the potential of ML methods in discerning edema-like lesions, in particular by distinguishing CNO lesions from hematopoietic bone marrow changes in a pediatric population. The Neural Network showed the overall best results, while a Stacking classifier, based on Gradient Boosting and Random Forest as principal estimators and Logistic Regressor as final estimator, achieved the best results between the other ML methods.

Clinical report and predictors of sequelae of 319 cases of pediatric bacterial osteomyelitis.

Pediatric osteomyelitis is an insidious disease that can lead to permanent sequelae, the management of which still relies on lengthy intravenous antibiotic therapy. The purpose of this study is to report and describe the clinical course and outcome of pediatric bacterial osteomyelitis in our experience. We reported the clinical, diagnostic, and treatment characteristics of all cases of osteomyelitis in children younger than 18 years of age who were hospitalized between January 2010 and December 2021 at the Bambino Gesù Children's Hospital in Rome, Italy, we compared patients with and without complications at follow-up, to identify any predictive factor for sequelae. The study sample included 319 cases of pediatric bacterial osteomyelitis. The median age was 7.77 years. Males (60.8%) were more affected than females. The most affected bones were the femur, tibia, and spine. Etiology was identified in 40.1% of cases, with S.aureus as the most common causative agent. Sequelae were reported in 43 cases (13.5%). The main predictors of sequelae were sepsis on admission and hypergammaglobulinemia. Our results show that a severe presentation with sepsis and hypergammaglobulinemia on admission may be associated with a higher frequency of late sequelae. Early recognition and aggressive treatment of this subgroup of patients may lead to a reduction in complications.

First Case of Tricuspid Valve Surgery in a Neurofibromatosis Type 1 Patient.

The neurofibromatosis is a large class of different genetic disorders: Neurofibromatosis type 1, type 2, type 3 (or Schwannomatosys), which have different clinical characterization. Neurofibromatosis type 1 (NF1), also known as Von Recklinghausen disease, represents 95% of the total cases. It is a complex autosomal dominant disorder with multisystem involvement, frequently associated to cardiac malformation. We present the case of a 52-years-old male affected by NF-1 with severe tricuspid regurgitation and atrial septal defect (ASD). No previous report about tricuspid valve surgery in NF-1 are available in the literature. A complete perioperative assessment was performed, including dermatologist evaluation, angio-CT scan and transesophageal echocardiography. The patient underwent uneventfully tricuspid valve replacement and ASD closure, with no wound complication even at 6-months follow-up. Treating congenital malformation in patient with complex genetic disorders like NF-1 is safe and can be resolutive, permitting to reduce long-term risk of complications for the patients. Preoperative assessments are fundamental, as well as in-hospital care and expertise on congenital heart defects.

Italian consensus on the therapeutic management of uncomplicated acute hematogenous osteomyelitis in children.

BACKGROUND: Acute hematogenous osteomyelitis (AHOM) is an insidious infection of the bone that more frequently affects young males. The etiology, mainly bacterial, is often related to the patient's age, but it is frequently missed, owing to the low sensitivity of microbiological cultures. Thus, the evaluation of inflammatory biomarkers and imaging usually guide the diagnosis and follow-up of the infection. The antibiotic treatment of uncomplicated AHOM, on the other hand, heavily relies upon the clinician experience, given the current lack of national guidelines for the management of this infection. METHODS: A systematic review of the studies on the empirical treatment of uncomplicated AHOM in children published in English or Italian between January 1, 2009, and March 31, 2020, indexed on Pubmed or Embase search engines, was carried out. All guidelines and studies reporting on non-bacterial or complicated or post-traumatic osteomyelitis affecting newborns or children older than 18 years or with comorbidities were excluded from the review. All other works were included in this study. RESULTS: Out of 4576 articles, 53 were included in the study. Data on different topics was gathered and outlined: bone penetration of antibiotics; choice of intravenous antibiotic therapy according to the isolated or suspected pathogen; choice of oral antibiotic therapy; length of treatment and switch to oral therapy; surgical treatment. CONCLUSIONS: The therapeutic management of osteomyelitis is still object of controversy. This study reports the first Italian consensus on the management of uncomplicated AHOM in children of pediatric osteomyelitis, based on expert opinions and a vast literature review.

Improving burn depth assessment for pediatric scalds by AI based on semantic segmentation of polarized light photography images.

This paper illustrates the efficacy of an artificial intelligence (AI) (a convolutional neural network, based on the U-Net), for the burn-depth assessment using semantic segmentation of polarized high-performance light camera images of burn wounds. The proposed method is evaluated for paediatric scald injuries to differentiate four burn wound depths: superficial partial-thickness (healing in 0-7 days), superficial to intermediate partial-thickness (healing in 8-13 days), intermediate to deep partial-thickness (healing in 14-20 days), deep partial-thickness (healing after 21 days) and full-thickness burns, based on observed healing time. In total 100 burn images were acquired. Seventeen images contained all 4 burn depths and were used to train the network. Leave-one-out cross-validation reports were generated and an accuracy and dice coefficient average of almost 97% was then obtained. After that, the remaining 83 burn-wound images were evaluated using the different network during the cross-validation, achieving an accuracy and dice coefficient, both on average 92%. This technique offers an interesting new automated alternative for clinical decision support to assess and localize burn-depths in 2D digital images. Further training and improvement of the underlying algorithm by e.g., more images, seems feasible and thus promising for the future.

The Pediatric Spine.

The spine, a frequently investigated site in children, has a complex development in relation to both nervous and bone/cartilaginous structures and shows several particular features in children compared with adults. We report the main normal variants and pathologies of the pediatric spine, from the prenatal period to adolescence, focusing on a multimodality imaging approach.

Neonatal osteomyelitis: an Italian multicentre report of 22 cases and comparison with the inherent literature.

OBJECTIVE: The primary objective of this study is to report and compare our data with the most relevant literature of the past decade about neonatal osteomyelitis. STUDY DESIGN: We retrospectively review the data of 22 subjects aged 35 days or less who were admitted to three different sites in Italy with a radiological diagnosis of osteomyelitis. The inherent literature was searched and reviewed: five studies were considered for comparison with our data. RESULTS: All the neonates, except three (two pre-term and one post-term), were born at term. The male to female ratio was 1.75 (14 males and 8 females). The mean age at presentation was 19.5 days. The most common presenting signs of the infection were local swelling and reduced mobility of the affected segment. The most common sites of infection were the femur, humerus, and tibia. The mean duration of intravenous antibiotic therapy was 29.5 days. In most neonates the diagnosis was prompt and the antibiotic treatment immediate. A low rate of sequelae was reported. All infants survived through follow up. The data from the inherent literature showed a wide variability, probably owing to the setting and the historical period of the different studies. CONCLUSION: Neonatal osteomyelitis is an alarming yet poorly understood disease. Nonetheless, our report suggests that a quick diagnosis and treatment can be easily achieved, with good outcome on the remarkably plastic structure of neonatal bones.

Recommendations for early diagnosis of Developmental Dysplasia of the Hip (DDH): working group intersociety consensus document.

This consensus document has been prepared by a multidisciplinary group of experts (Paediatricians, Radiologists, Paediatric Orthopaedics) and it is mainly aimed at paediatricians, hospitals and primary care providers. We provide recommendations for the early diagnosis and treatment of Developmental Dysplasia of the Hip (DDH) and indications on its management.

Exploring Personal Protection During High-Risk PCI in a COVID-19 Patient: Impella CP Mechanical Support During ULMCA Bifurcation Stenting.

The correct management of patients with coronavirus disease-2019 (COVID-19) and acute coronary syndrome is still uncertain. We describe the percutaneous treatment of an unprotected left main coronary artery in a patient who is positive for COVID-19 with unstable angina, dyspnea and fever. Particular attention will be dedicated to the measures adopted in the catheterization laboratory to protect the staff and to avoid further spread of the infection. (Level of Difficulty: Intermediate.).

Time-Independent Prediction of Burn Depth Using Deep Convolutional Neural Networks.

We present in this paper the application of deep convolutional neural networks (CNNs), which is a state-of-the-art artificial intelligence (AI) approach in machine learning, for automated time-independent prediction of burn depth. Color images of four types of burn depth injured in first few days, including normal skin and background, acquired by a TiVi camera were trained and tested with four pretrained deep CNNs: VGG-16, GoogleNet, ResNet-50, and ResNet-101. In the end, the best 10-fold cross-validation results obtained from ResNet-101 with an average, minimum, and maximum accuracy are 81.66, 72.06, and 88.06%, respectively; and the average accuracy, sensitivity, and specificity for the four different types of burn depth are 90.54, 74.35, and 94.25%, respectively. The accuracy was compared with the clinical diagnosis obtained after the wound had healed. Hence, application of AI is very promising for prediction of burn depth and, therefore, can be a useful tool to help in guiding clinical decision and initial treatment of burn wounds.

Tensor Decomposition for Colour Image Segmentation of Burn Wounds.

Research in burns has been a continuing demand over the past few decades, and important advancements are still needed to facilitate more effective patient stabilization and reduce mortality rate. Burn wound assessment, which is an important task for surgical management, largely depends on the accuracy of burn area and burn depth estimates. Automated quantification of these burn parameters plays an essential role for reducing these estimate errors conventionally carried out by clinicians. The task for automated burn area calculation is known as image segmentation. In this paper, a new segmentation method for burn wound images is proposed. The proposed methods utilizes a method of tensor decomposition of colour images, based on which effective texture features can be extracted for classification. Experimental results showed that the proposed method outperforms other methods not only in terms of segmentation accuracy but also computational speed.

Sutureless aortic valve replacement in high risk patients neutralizes expected worse hospital outcome: A clinical and economic analysis.

BACKGROUND: Aortic valve replacement (AVR) by sutureless prostheses is changing surgeon options, although which patients benefit most, as well as their possible economic impact is still to be defined. METHODS: Perceval-S prosthesis (LivaNova) is reserved, at the documented Institution, for patients at perceived high surgical risk. This retrospective analysis of outcome and resource consumption compared Perceval with other tissue valves. To clarify the comparison, only patients respecting 'instructions-for- use' of Perceval were reviewed. INCLUSION CRITERIA: > 65 years, +/- coronary artery bypass grafting, patent foramen ovale closure or myectomy. EXCLUSION CRITERIA: bicuspid, combined valve or aortic sur- gery. Costs were calculated per patient on a daily basis including preoperative tests, operating costs (hourly basis), disposables, drugs, blood components and personnel. RESULTS: The sutureless group (SU-AVR) had a higher risk profile than the sutured group (ST-AVR). Cardiopulmonary bypass (CPB) and cross-clamp times were significantly shorter in SU-AVR (isolated AVR: cross-clamp 52.9 ± 12.6 vs. 69 ± 15.3 min, p < 0.001; CPB 79.4 ± 20.3 vs. 92.7 ± 18.2 min, p < 0.001). Hospital mortality was 0.9% in SU-AVR and nil in ST-AVR, p = 0.489; intubation 7 (IQR 5-10.7) and 7 h (IQR 5-9), p = 0.785; intensive care unit 1 (IQR 1-1) and 1 day (IQR 1-1), p = 0.258; ward stay 5.5 (IQR 4-7) and 5 days (IQR 4-6), p = 0.002; pacemaker 5.7% (6/106) and 0.9% (1/109), p = 0.063, respectively. Hospital costs (excluding the prosthesis) were $12,825 (IQR 11,733-15,334) for SU-AVR and $12,386 (IQR 11,217-14,230) in ST-AVR, p = 0.055. CONCLUSIONS: Despite higher operative risks in SU-AVR, hospital mortality, morbidity and resource consumption did not differ. Operative times were shorter with the sutureless device and this improve- ment, along with more frequent ministernotomy, may have improved many postoperative aims.

Reply to the Comment on: Marco Cirillo The Memory of the Heart. J. Cardiovasc. Dev. Dis. 2018, 5, 55.

I was disappointed by Anderson's comment on my recent review, a comment that I think derives from a too quick reading of the article. [...].

Imaging of the limping child.

Limping is a challenging symptom in the pediatric patient as the diagnosis can range from traumatic, malformative, infectious/inflammatory and neoplastic diseases. In this paper, we propose a schematic imaging algorithm to the limping child in three different age groups (Toddler: 1-3years, child: 4-10 years; adolescent: 11-16 years) based on presence of signs of infection, any specific localization of pain, and history of trauma. In this setting, the most common imaging pitfalls are also summarised. Finally, a literature review of the main differential causes of limping in the pediatric patient is reported.

The Memory of the Heart.

The embryological development of the heart is one of the most fascinating phenomena in nature and so is its final structure and function. The various ontogenetic passages form the evolutive basis of the final configuration of the heart. Each key step can be recognized in the final features, as the heart maintains a kind of "memory" of these passages. We can identify the major lines of development of the heart and trace these lines up to the mature organ. The aim of this review is to identify these key parameters of cardiac structure and function as essential elements of the heart's proper functioning and bases for its treatment. We aim to track key steps of heart development to identify what it "remembers" and maintains in its final form as positively selected. A new vision based on the whole acquired knowledge must guide an in-depth scientific approach in future papers and guidelines on the topic and a complete, farsighted therapeutic conduct able to ensure the physiological correction of cardiac pathologies. The application of this modern, functional vision of the heart could improve the clinical treatment of heart disease, filling the gaps still present.