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Bronchiolitis is a common cause of hospitalization in infants. The long-lasting impact of hygiene and social behavior changes during the pandemic on this disease is debated. We investigated the prevalence of hospitalized cases, clinical severity, and underlying risk factors before and during pandemic. The study was conducted in 27 hospitals in Italy and included infants hospitalized for bronchiolitis during the following four periods: July 2018-March 2019, July 2020-March 2021, July 2021-March 2022, and July 2022-March 2023. Data on demographics, neonatal gestational age, breastfeeding history, underlying chronic diseases, presence of older siblings, etiologic agents, clinical course and outcome were collected. A total of 5330 patients were included in the study. Compared to 2018-19 (n = 1618), the number of hospitalizations decreased in 2020-21 (n = 121). A gradual increase was observed in 2021-22 (n = 1577) and 2022-23 (n = 2014). A higher disease severity (need and length of O2-supplementation, need for non-invasive ventilation, hospital stay) occurred in the 2021-22 and, especially, the 2022-23 periods compared to 2018-19. This tendency persisted after adjusting for risk factors associated with bronchiolitis severity. Conclusions: Compared to adults, COVID-19 in infants is often asymptomatic or mildly symptomatic and rarely results in hospitalization. This study indicates that the pandemic has indirectly induced an increased burden of bronchiolitis among hospitalized infants. This shift, which is not explained by the recognized risk factors, suggests the existence of higher infant vulnerability during the last two seasons. What is known: ⢠The pandemic led to a change in epidemiology of respiratory diseases ⢠Large data on severity of bronchiolitis and underlying risk factors before and during COVID-19 pandemic are scarce What is new: ⢠Compared to pre-pandemic period, hospitalizations for bronchiolitis decreased in 2020-21 and gradually increased in 2021-22 and 2022-23 ⢠Compared to pre-pandemic period, higher disease burden occurred in 2021-22 and, especially, in 2022-23. This tendency persisted after adjusting for risk factors associated with bronchiolitis severity ⢠The interplay among viruses, preventive measures, and the infant health deserves to be further investigated.
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Bronquiolite , COVID-19 , Infecções por Vírus Respiratório Sincicial , Recém-Nascido , Lactente , Adulto , Humanos , Pandemias , COVID-19/epidemiologia , Hospitalização , Bronquiolite/epidemiologia , Tempo de Internação , Infecções por Vírus Respiratório Sincicial/epidemiologiaRESUMO
BACKGROUND: The accurate assessment of resting energy expenditure (REE) is essential for personalized nutrition, particularly in critically ill children. Indirect calorimetry (IC) is the gold standard for measuring REE. This methodology is based on the measurement of oxygen consumption (VO2) and carbon dioxide production (VCO2). These parameters are integrated into the Weir equation to calculate REE. Additionally, IC facilitates the determination of the respiratory quotient (RQ), offering valuable insights into a patient's carbohydrate and lipid consumption. IC validation is limited to spontaneously breathing and mechanically ventilated patients, but it is not validated in patients undergoing non-invasive ventilation (NIV). This study investigates the application of IC during NIV-CPAP (continuous positive airway pressure) and NIV-PS (pressure support). METHODS: This study was conducted in the Pediatric Intensive Care Unit of IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, between 2019 and 2021. Children < 6 years weaning from NIV were enrolled. IC was performed during spontaneous breathing (SB), NIV-CPAP, and NIV-PS in each patient. A Bland-Altman analysis was employed to compare REE, VO2, VCO2, and RQ measured by IC. RESULTS: Fourteen patients (median age 7 (4; 18) months, median weight 7.7 (5.5; 9.7) kg) were enrolled. The REE, VO2, VCO2, and RQ did not differ significantly between the groups. The Limits of Agreement (LoA) and bias of REE indicated good agreement between SB and NIV-CPAP (LoA +28.2, -19.4 kcal/kg/day; bias +4.4 kcal/kg/day), and between SB and NIV-PS (LoA -22.2, +23.1 kcal/kg/day; bias 0.4 kcal/kg/day). CONCLUSIONS: These preliminary findings support the accuracy of IC in children undergoing NIV. Further validation in a larger cohort is warranted.
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Ventilação não Invasiva , Respiração Artificial , Criança , Humanos , Calorimetria Indireta , Estudos Cross-Over , Respiração , Estudo de Prova de ConceitoRESUMO
In the realm of emergency medicine, the swift adoption of lung ultrasound (LU) has extended from the adult population to encompass pediatric and neonatal intensivists. LU stands out as a bedside, replicable, and cost-effective modality, distinct in its avoidance of ionizing radiations, a departure from conventional chest radiography. Recent years have witnessed a seamless adaptation of experiences gained in the adult setting to the neonatal and pediatric contexts, underscoring the versatility of bedside Point of care ultrasound (POCUS). This adaptability has proven reliable in diagnosing common pathologies and executing therapeutic interventions, including chest drainage, and central and peripheral vascular cannulation. The surge in POCUS utilization among neonatologists and pediatric intensivists is notable, spanning economically advanced Western nations with sophisticated, high-cost intensive care facilities and extending to low-income countries. Within the neonatal and pediatric population, POCUS has become integral for diagnosing and monitoring respiratory infections and chronic and acute lung pathologies. This, in turn, contributes to a reduction in radiation exposure during critical periods of growth, thereby mitigating oncological risks. Collaboration among various national and international societies has led to the formulation of guidelines addressing both the clinical application and regulatory aspects of operator training. Nevertheless, unified guidelines specific to the pediatric and neonatal population remain lacking, in contrast to the well-established protocols for adults. The initial application of POCUS in neonatal and pediatric settings centered on goal-directed echocardiography. Pivotal developments include expert statements in 2011, the UK consensus statement on echocardiography by neonatologists, and European training recommendations. The Australian Clinician Performed Ultrasound (CPU) program has played a crucial role, providing a robust academic curriculum tailored for training neonatologists in cerebral and cardiac assessment. Notably, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) recently disseminated evidence-based guidelines through an international panel, delineating the use and applications of POCUS in the pediatric setting. These guidelines are pertinent to any professional tending to critically ill children in routine or emergency scenarios. In light of the burgeoning literature, this paper will succinctly elucidate the methodology of performing an LU scan and underscore its primary indications in the neonatal and pediatric patient cohort. The focal points of this review comprise as follows: (1) methodology for conducting a lung ultrasound scan, (2) key ultrasonographic features characterizing a healthy lung, and (3) the functional approach: Lung Ultrasound Score in the child and the neonate. Conclusion: the aim of this review is to discuss the following key points: 1. How to perform a lung ultrasound scan 2. Main ultrasonographic features of the healthy lung 3. The functional approach: Lung Ultrasound Score in the child and the neonate What is Known: ⢠Lung Ultrasound (LUS) is applied in pediatric and neonatal age for the diagnosis of pneumothorax, consolidation, and pleural effusion. ⢠Recently, LUS has been introduced into clinical practice as a bedside diagnostic method for monitoring surfactant use in NARDS and lung recruitment in PARDS. What is New: ⢠Lung Ultrasound (LUS) has proven to be useful in confirming diagnoses of pneumothorax, consolidation, and pleural effusion. ⢠Furthermore, it has demonstrated effectiveness in monitoring the response to surfactant therapy in neonates, in staging the severity of bronchiolitis, and in PARDS.
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Pneumopatias , Derrame Pleural , Pneumotórax , Recém-Nascido , Adulto , Criança , Humanos , Austrália , Pulmão/diagnóstico por imagem , Ultrassonografia/métodos , Pneumopatias/diagnóstico por imagem , Derrame Pleural/diagnóstico por imagem , Radiografia , TensoativosRESUMO
Infant botulism is a rare and underdiagnosed disease caused by BoNT-producing clostridia that can temporarily colonize the intestinal lumen of infants less than one year of age. The diagnosis may be challenging because of its rareness, especially in patients showing atypical presentations or concomitant coinfections. In this paper, we report the first infant botulism case associated with Cytomegalovirus coinfection and transient hypogammaglobulinemia and discuss the meaning of these associations in terms of risk factors. Intending to help physicians perform the diagnosis, we also propose a practical clinical and diagnostic criteria checklist based on the revision of the literature.
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Agamaglobulinemia , Botulismo/diagnóstico , Infecções por Citomegalovirus/diagnóstico , Botulismo/terapia , Lista de Checagem , Clostridium botulinum/isolamento & purificação , Coinfecção , Citomegalovirus/isolamento & purificação , Humanos , Lactente , Masculino , Fatores de RiscoRESUMO
BACKGROUNDS: Pediatric noninvasive neurally adjusted ventilatory assist (NIV-NAVA) has been shown to improve patient-ventilator interaction but no data on clinical outcomes are available. Aim of this study was to compare NIV-NAVA with noninvasive pressure support (NIV-PS) in children with acute hypoxemic respiratory failure (AHRF), in a single-center before-after study. A cohort of thirty-four NIV-PS patients (before group) admitted to our PICU within the 2 years prior NAVA introduction was compared with a cohort of thirty children treated with NIV-NAVA during implementation phase (after group). The primary end-point was intubation rate between groups. Days on mechanical ventilation, number of invasive devices, nosocomial infections, PICU/hospital length of stay (LOS), and physiological parameters at 2 and 24 h after admission were considered. RESULTS: Intubation rate was lower in the NIV-NAVA group as compared to the NIV-PS group (p = 0.006). Patients treated with NIV-NAVA required fewer invasive devices (p = 0.032) and had lower incidence of ventilator-acquired pneumonia (p = 0.004) and shorter PICU (p = 0.032) and hospital LOS (p = 0.013). At 2 h, NIV-NAVA compared with NIV-PS resulted in higher paO2:FIO2 (p = 0.017), lower paCO2 (p = 0.002), RR (p = 0.026), and HR (p = 0.009). CONCLUSIONS: Early NIV-NAVA vs NIV-PS was associated to lower intubation rate and shorter PICU and hospital LOS. Further studies are needed in order to confirm these preliminary data.
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BACKGROUND: Fluid therapy is a cornerstone of pediatric intensive care medicine. We aimed at quantifying the load of water, sodium and chloride due to different fluid indications in our pediatric intensive care unit (PICU). We were particularly interested in the role of fluid creep, i.e. fluid administered mainly as the vehicle for drugs, and the association between sodium load and water balance. METHODS: Critically ill children aged ≤3 years and invasively ventilated for ≥48 h between 2016 and 2019 in a single tertiary center PICU were retrospectively enrolled. Need for renal replacement therapy, plasmapheresis or parenteral nutrition constituted exclusion criteria. Quantity, quality and indication of fluids administered intravenously or enterally, urinary output and fluid balance were recorded for the first 48 h following intubation. Concentrations of sodium and chloride provided by the manufacturers were used to compute the electrolyte load. RESULTS: Forty-three patients (median 7 months (IQR 3-15)) were enrolled. Patients received 1004 ± 284 ml of water daily (153 ± 36 ml/kg/day), mainly due to enteral (39%), creep (34%) and maintenance (24%) fluids. Patients received 14.4 ± 4.8 mEq/kg/day of sodium and 13.6 ± 4.7 mEq/kg/day of chloride, respectively. The majority of sodium and chloride derived from fluid creep (56 and 58%). Daily fluid balance was 417 ± 221 ml (64 ± 30 ml/kg/day) and was associated with total sodium intake (r2 = 0.49, p < 0.001). CONCLUSIONS: Critically ill children are exposed, especially in the acute phase, to extremely high loads of water, sodium and chloride, possibly contributing to edema development. Fluid creep is quantitatively the most relevant fluid in the PICU and future research efforts should address this topic in order to reduce the inadvertent water and electrolyte burden and improve the quality of care of critically ill children.
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Cloretos , Preparações Farmacêuticas , Criança , Pré-Escolar , Estado Terminal/terapia , Hidratação , Humanos , Unidades de Terapia Intensiva Pediátrica , Respiração Artificial , Estudos Retrospectivos , Sódio , ÁguaRESUMO
BACKGROUND: Neurally adjusted ventilatory assist (NAVA) is an innovative mode for assisted ventilation that improves patient-ventilator interaction in children. The aim of this study was to assess the effects of patient-ventilator interaction comparing NAVA with pressure support ventilation (PSV) in patients difficult to wean from mechanical ventilation after moderate pediatric acute respiratory distress syndrome (PARDS). METHODS: In this physiological crossover study, 12 patients admitted in the Pediatric Intensive Care Unit (PICU) with moderate PARDS failing up to 3 spontaneous breathing trials in less than 7 days, were enrolled. Patients underwent three study conditions lasting 1 h each: PSV1, NAVA and PSV2. RESULTS: The Asynchrony Index (AI) was significantly reduced during the NAVA trial compared to both the PSV1 and PSV2 trials (p = 0.001). During the NAVA trial, the inspiratory and expiratory trigger delays were significantly shorter compared to those obtained during PSV1 and PSV2 trials (Delaytrinspp < 0.001, Delaytrexpp = 0.013). These results explain the significantly longer Timesync observed during the NAVA trial (p < 0.001). In terms of gas exchanges, PaO2 value significantly improved in the NAVA trial with respect to the PSV trials (p < 0.02). The PaO2/FiO2 ratio showed a significant improvement during the NAVA trial compared to both the PSV1 and PSV2 trials (p = 0.004). CONCLUSIONS: In this specific PICU population, presenting difficulty in weaning after PARDS, NAVA was associated with a reduction of the AI and a significant improvement in oxygenation compared to PSV mode. TRIAL REGISTRATION: ClinicalTrial.gov Identifier: NCT04360590 "Retrospectively registered".
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Suporte Ventilatório Interativo , Síndrome do Desconforto Respiratório , Criança , Estudos Cross-Over , Humanos , Respiração com Pressão Positiva , Respiração Artificial , Síndrome do Desconforto Respiratório/terapia , Estudos RetrospectivosRESUMO
The outbreak of SARS-CoV-2 is the worst healthcare emergency of this century, and its impact on pediatrics and neonatology is still largely unknown. The European Society for Pediatric and Neonatal Intensive Care (ESPNIC) launched the EPICENTRE (ESPNIC Covid pEdiatric Neonatal Registry) international, multicenter, and multidisciplinary initiative to study the epidemiology, clinical course, and outcomes of pediatric and neonatal SARS-CoV-2 infections. EPICENTRE background and aims are presented together with protocol details. EPICENTRE is open to centers all over the world, and this will allow to provide a pragmatic picture of the epidemic, with a particular attention to pediatric and neonatal critical care issues.Conclusions: EPICENTRE will allow researchers to clarify the epidemiology, clinical presentation, and outcomes of pediatric and neonatal SARS-CoV-2 infection, refining its clinical management and hopefully providing new insights for clinicians. What is Known: ⢠COVID19 is the new disease caused by SARS-CoV-2 infection and is spreading around the globe. ⢠Majority of data available about SARS-CoV-2 infections originates from adult patients. What is New: ⢠EPICENTRE is the first international, multicenter, multidisciplinary, meta-data driven, hospital-based, online, prospective cohort registry dedicated to neonatal and pediatric SARS-CoV-2 infections. ⢠EPICENTRE will allow to understand epidemiology and physiopathology of COVID19.
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Betacoronavirus , Infecções por Coronavirus , Pandemias , Pneumonia Viral , Vigilância em Saúde Pública/métodos , Sistema de Registros , COVID-19 , Criança , Pré-Escolar , Protocolos Clínicos , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Europa (Continente)/epidemiologia , Humanos , Lactente , Recém-Nascido , Pediatria , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Prognóstico , SARS-CoV-2RESUMO
The antisense oligonucleotide Nusinersen has been recently licensed to treat spinal muscular atrophy (SMA). Since SMA type 3 is characterized by variable phenotype and milder progression, biomarkers of early treatment response are urgently needed. We investigated the cerebrospinal fluid (CSF) concentration of neurofilaments in SMA type 3 patients treated with Nusinersen as a potential biomarker of treatment efficacy. The concentration of phosphorylated neurofilaments heavy chain (pNfH) and light chain (NfL) in the CSF of SMA type 3 patients was evaluated before and after six months since the first Nusinersen administration, performed with commercially available enzyme-linked immunosorbent assay (ELISA) kits. Clinical evaluation of SMA patients was performed with standardized motor function scales. Baseline neurofilament levels in patients were comparable to controls, but significantly decreased after six months of treatment, while motor functions were only marginally ameliorated. No significant correlation was observed between the change in motor functions and that of neurofilaments over time. The reduction of neurofilament levels suggests a possible early biochemical effect of treatment on axonal degeneration, which may precede changes in motor performance. Our study mandates further investigations to assess neurofilaments as a marker of treatment response.
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Proteínas de Neurofilamentos/líquido cefalorraquidiano , Oligonucleotídeos Antissenso/administração & dosagem , Oligonucleotídeos/administração & dosagem , Atrofias Musculares Espinais da Infância/tratamento farmacológico , Adolescente , Adulto , Idade de Início , Idoso , Biomarcadores/líquido cefalorraquidiano , Pré-Escolar , Feminino , Humanos , Filamentos Intermediários/metabolismo , Masculino , Pessoa de Meia-Idade , Oligonucleotídeos/efeitos adversos , Oligonucleotídeos Antissenso/efeitos adversos , Atrofias Musculares Espinais da Infância/líquido cefalorraquidiano , Atrofias Musculares Espinais da Infância/patologia , Resultado do TratamentoRESUMO
Acute respiratory distress syndrome (ARDS) represents a rare complication of miliary tuberculosis (TB) in the adult setting, and it is even less common in the pediatric population. The presence of comorbidities and the possibility of a delayed diagnosis may further impair the clinical prognosis of critically ill patients with disseminated TB and acute respiratory failure. In this report, we present a case series of five pediatric patients with miliary TB and ARDS, where rescue and multimodal respiratory support strategies have been applied with a favorable outcome in more than half of them. The burden of miliary TB over time on a general pediatric intensive care unit-including two ARDS patients-is also illustrated.
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Síndrome do Desconforto Respiratório/etiologia , Tuberculose Miliar/complicações , Criança , Comorbidade , Cuidados Críticos , Feminino , Humanos , Unidades de Terapia Intensiva Pediátrica , Masculino , Prognóstico , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/terapia , Tuberculose Miliar/diagnóstico , Tuberculose Miliar/terapiaRESUMO
BACKGROUND: Neurally adjusted ventilatory assist (NAVA) is an alternative to pressure support ventilation (PSV) potentially improving patient-ventilator interaction. During NAVA, diaphragmatic electrical activity (EAdi) is used to trigger the ventilator and perform a proportional respiratory assistance. We present a case in which the presence of severe bilateral diaphragmatic dysfunction led to a failure of NAVA. On the contrary, the preserved activity of the accessory inspiratory muscles allowed a successful respiratory assistance using PSV. CASE PRESENTATION: A 10-year-old girl developed quadriplegia after neurological surgery. Initially, no spontaneous breathing activity was present and volume controlled ventilation was necessary. Two months later spontaneous inspiratory efforts were observed and a maximal negative inspiratory force of - 20 cmH2O was recorded. In addition, a NAVA nasogastric tube was placed. The recorded EAdi signal, despite showing a phasic activity, had a very low amplitude (1-2 µV). Two brief (15 min) breathing trials to compare PSV (pressure support = 8 cmH2O) with NAVA (Gain = 5 cmH2O/µV, inspiratory trigger = 0.3 µV) were performed. On PSV, the patient was well adapted with stable tidal volumes, respiratory rates, minute ventilation, end-tidal and venous carbon dioxide levels. When switched to NAVA, her breathing pattern became irregular and she showed clear sign of increased work of breathing and distress: tidal volume dropped and respiratory rate rose, leading to an increase in total minute ventilation. Nevertheless, end-tidal and venous carbon dioxide rapidly increased (from 49 to 55 mmHg and from 52 to 57 mmHg, respectively). An electromyographic study documented an impairment of the diaphragm with preserved activity of the accessory inspiratory muscles. CONCLUSIONS: We document the failure of mechanical assistance performed with NAVA due to bilateral diaphragmatic dysfunction in a critically ill child. The preserved activity of some accessory respiratory muscles allowed to support the patient effectively with pressure support ventilation, i.e. by applying a pneumatic trigger. The present case underlines (i) the importance of the integrity of the respiratory centers, phrenic nerves and diaphragm in order to perform NAVA and (ii) the possible diagnostic role of EAdi monitoring in complex cases of weaning failure.
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Craniotomia/efeitos adversos , Diafragma/fisiopatologia , Eletromiografia , Suporte Ventilatório Interativo , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Respiração com Pressão Positiva , Quadriplegia/fisiopatologia , Criança , Craniofaringioma/cirurgia , Craniotomia/métodos , Estado Terminal , Feminino , Humanos , Neoplasias Hipofisárias/cirurgia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Quadriplegia/etiologia , Músculos Respiratórios/fisiologia , Volume de Ventilação Pulmonar , Falha de Tratamento , Desmame do RespiradorRESUMO
Shigatoxin Escherichia coli-related hemolytic uremic syndrome (eHUS) is a severe thrombotic microangiopathy (TMA) burdened by life-threatening complications and long-term sequelae. Since hemoconcentration is associated with worse outcome, we tried to develop a reliable and easy-to-calculate index for predicting complications and sequelae based on hemoglobin (Hb) at presentation. The first laboratory examinations with signs of TMA in eHUS patients were analyzed in relation to the outcomes with the receiver operating characteristic curves and their areas under the curve (AUC) for Hb and creatinine (sCr). A total of 197 eHUS patients were identified of whom 24% did not have anemia at presentation. Hb level was the best predictor of a poor outcome (AUC 0.67) but the combination of Hb with sCr, in the formula [(Hb in g/dL + (sCr in mg/dL × 2)], showed an even better AUC of 0.75. The described scoring system was also strongly associated and predictive of all complications and health care needs (8% of patients with scoring > 13 died or entered a permanent vegetative state compared with 0% of those with ≤ 13).Conclusion: The presented score is a simple and early predictor of both short- and long-term outcomes and identifies patients who should undergo rapid volume expansion to counteract hemoconcentration, the spreading of microvascular thrombosis, and the consequent increased organ damage. What is Known: ⢠In eHUS, hemoconcentration is associated with worse short- and long-term outcome. ⢠A prognostic index to identify patients at higher risk for complications at presentation is not available. What is New: ⢠We developed a simple and early prognostic index for eHUS outcome with the combination of Hb and sCr at onset, in the following formula [(Hb in g/dL + (sCr in mg/dL × 2)]. ⢠The proposed HUS Severity Score can promptly identify patients with good outcome and those with high risk of worse short- and long-term outcome.
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Infecções por Escherichia coli/complicações , Síndrome Hemolítico-Urêmica/diagnóstico , Toxina Shiga/efeitos adversos , Área Sob a Curva , Criança , Pré-Escolar , Creatinina/sangue , Feminino , Hemoglobinas/análise , Síndrome Hemolítico-Urêmica/complicações , Síndrome Hemolítico-Urêmica/etiologia , Humanos , Lactente , Masculino , Prognóstico , Curva ROC , Índice de Gravidade de Doença , Escherichia coli Shiga ToxigênicaAssuntos
Terapia Genética/métodos , Transplante de Células-Tronco Hematopoéticas/métodos , Leucodistrofia Metacromática/tratamento farmacológico , Leucodistrofia Metacromática/terapia , Inibidores da Agregação Plaquetária/uso terapêutico , Polidesoxirribonucleotídeos/uso terapêutico , Condicionamento Pré-Transplante/métodos , Humanos , Leucodistrofia Metacromática/patologia , Masculino , Inibidores da Agregação Plaquetária/farmacologia , Polidesoxirribonucleotídeos/farmacologia , GêmeosRESUMO
BACKGROUND: Acute myeloid leukemia (AML) accounts for more than two thirds of leukemia during pregnancy and has an incidence of 1 in 75,000 to 100,000. Its clinical management remains a challenging therapeutic task both for patient and medical team, given to the therapy-attributable risks for mother and fetus and the connected counseling regarding pregnancy continuation. METHODS: We provided a review of updated literature and a comprehensive description of five maternal/fetal outcomes of AML cases diagnosed concomitantly to pregnancy and treated at our Institution from 2006 to 2012. RESULTS: Median age at AML diagnosis was 32 years (31-39). One diagnosis was performed in first trimester and the patient asked for therapeutic abortion before starting chemotherapy. Three cases were diagnosed in second/third trimester; in one case leukemia was diagnosed concomitantly with intrauterine fetal death, while the remaining two patients continued pregnancy and delivered a healthy baby by cesarean section. In only one of these two cases chemotherapy was performed during pregnancy (at 24 + 5 weeks) and consisted of a combination of daunorubicine and cytarabine. Therapy was well tolerated and daily fetus monitoring was performed. After completion of 30 weeks of gestation a cesarean section was carried out; the newborn had an Apgar score of 5/1'-7/5'-9/10', oxygen therapy was temporarily given and peripheral counts displayed transient mild leukopenia. One patient had diagnosis of myelodysplastic syndrome rapidly progressed to AML after delivery. Four out of the 5 described women are currently alive and disease-free. Three children were born and long-term follow-up has shown normal growth and development. CONCLUSIONS: The treatment of AML occurring during pregnancy is challenging and therapeutic decisions should be taken individually for each patient. Consideration must be given both to the immediate health of mother and fetus and to long-term infant health. Our series confirmed the literature data: fetal toxicity of cytostatic therapy clusters during the first trimester; while chemotherapy can be administered safely during second/third trimester and combination of daunorubicin and cytarabine is recommended for induction.
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Leucemia Mieloide Aguda/tratamento farmacológico , Leucemia Mieloide Aguda/epidemiologia , Complicações Neoplásicas na Gravidez/tratamento farmacológico , Complicações Neoplásicas na Gravidez/patologia , Aborto Terapêutico , Adulto , Cesárea , Criança , Citarabina/uso terapêutico , Daunorrubicina/uso terapêutico , Feminino , Morte Fetal , Humanos , Recém-Nascido , Leucemia Mieloide Aguda/patologia , Gravidez , Complicações Neoplásicas na Gravidez/epidemiologiaRESUMO
BACKGROUND: Reporting new cases of enterovirus (EV)-D68-associated acute flaccid myelitis (AFM) is essential to understand how the virus causes neurological damage and to characterize EV-D68 strains associated with AFM. CASE PRESENTATION: A previously healthy 4-year-old boy presented with sudden weakness and limited mobility in his left arm. Two days earlier, he had an upper respiratory illness with mild fever. At admission, his physical examination showed that the child was febrile (38.5 °C) and alert but had a stiff neck and weakness in his left arm, which was hypotonic and areflexic. Cerebrospinal fluid (CSF) examination showed a mild increase in white blood cell count (80/mm3, 41% neutrophils) and a slightly elevated protein concentration (76 gm/dL). Bacterial culture and molecular biology tests for detecting viral infection in CSF were negative. The patient was then treated with intravenous ceftriaxone and acyclovir. Despite therapy, within 24 h, the muscle weakness extended to all four limbs, which exhibited greatly reduced mobility. Due to his worsening clinical prognosis, the child was transferred to our Pediatric Intensive Care Unit; at admission he was diagnosed with acute flaccid paralysis of all four limbs. Brain magnetic resonance imaging (MRI) was negative, except for a focal signal alteration in the dorsal portion of the medulla oblongata, also involving the pontine tegmentum, whereas spine MRI showed an extensive signal alteration of the cervical and dorsal spinal cord reported as myelitis. Signal alteration was mainly localized in the central grey matter, most likely in the anterior horns. Molecular biology tests performed on nasopharyngeal aspirate and on bronchoalveolar lavage fluid were negative for bacteria but positive for EV-D68 clade B3. Plasmapheresis was performed and corticosteroids and intravenous immunoglobulins were administered. After 4 weeks of treatment, the signs and symptoms of AFM were significantly reduced, although some weakness and tingling remained in the patient's four limbs. MRI acquired after 3 weeks showed that the previously reported alterations were no longer present. CONCLUSION: This case suggests that EV-D68 is a neurotropic agent that can cause AFM and strains are circulating in Europe. EV-D68 disease surveillance is required to better understand EV-D68 pathology and to compare various strains that cause AFM.
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Enterovirus Humano D/isolamento & purificação , Infecções por Enterovirus/diagnóstico , Hipotonia Muscular/etiologia , Mielite/etiologia , Paralisia/etiologia , Pré-Escolar , Infecções por Enterovirus/patologia , Infecções por Enterovirus/virologia , Humanos , Itália , Masculino , Hipotonia Muscular/virologia , Mielite/virologia , Paralisia/virologiaRESUMO
OBJECTIVE: Neurally adjusted ventilatory assist has been shown to improve patient-ventilator interaction in children with acute respiratory failure. Objective of this study was to compare the effect of noninvasive neurally adjusted ventilatory assist versus noninvasive flow-triggered pressure support on patient-ventilator interaction in children with acute respiratory failure, when delivered as a first-line respiratory support. DESIGN: Prospective randomized crossover physiologic study. SETTING: Pediatric six-bed third-level PICU. PATIENTS: Eighteen children with acute respiratory failure needing noninvasive ventilation were enrolled at PICU admission. INTERVENTIONS: Enrolled children were allocated to receive two 60-minutes noninvasive flow-triggered pressure support and noninvasive neurally adjusted ventilatory assist trials in a crossover randomized sequence. MEASUREMENTS AND MAIN RESULTS: Primary endpoint was the asynchrony index. Parameters describing patient-ventilator interaction and gas exchange were also considered as secondary endpoints. Noninvasive neurally adjusted ventilatory assist compared to noninvasive flow-triggered pressure support: 1) reduced asynchrony index (p = 0.001) and the number of asynchronies per minute for each type of asynchrony; 2) it increased the neuroventilatory efficiency index (p = 0.001), suggesting better neuroventilatory coupling; 3) reduced inspiratory and expiratory delay times (p = 0.001) as well as lower peak and mean airway pressure (p = 0.006 and p = 0.038, respectively); 4) lowered oxygenation index (p = 0.043). No adverse event was reported. CONCLUSIONS: In children with mild early acute respiratory failure, noninvasive neurally adjusted ventilatory assist was feasible and safe. Noninvasive neurally adjusted ventilatory assist compared to noninvasive flow-triggered pressure support improved patient-ventilator interaction.
Assuntos
Cuidados Críticos/métodos , Suporte Ventilatório Interativo/métodos , Respiração com Pressão Positiva/métodos , Insuficiência Respiratória/terapia , Doença Aguda , Pré-Escolar , Estudos Cross-Over , Feminino , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica , Masculino , Estudos Prospectivos , Insuficiência Respiratória/fisiopatologia , Resultado do TratamentoRESUMO
BACKGROUND: In sedated and paralyzed children with acute respiratory failure, the compliance of respiratory system and functional residual capacity were significantly reduced compared with healthy subjects. However, no major studies in children with ARDS have investigated the role of different levels of PEEP and tidal volume on the partitioned respiratory mechanic (lung and chest wall), stress (transpulmonary pressure) and strain (inflated volume above the functional residual capacity). METHODS: The end-expiratory lung volume was measured using a simplified closed circuit helium dilution method. During an inspiratory and expiratory pause, the airway and esophageal pressure were measured. Transpulmonary pressure was computed as the difference between airway and esophageal pressure. RESULTS: Ten intubated sedated paralyzed healthy children and ten children with ARDS underwent a PEEP trial (4 and 12 cmH2O) with a tidal volume of 8, 10 and 12 ml/kgIBW. The two groups were comparable for age and BMI (2.5 [1.0-5.5] vs 3.0 [1.7-7.2] years and 15.1 ± 2.4 vs 15.3 ± 3.0 kg/m(2)). The functional residual capacity in ARDS patients was significantly lower as compared to the control group (10.4 [9.1-14.3] vs 16.6 [11.7-24.6] ml/kg, p = 0.04). The ARDS patients had a significantly lower respiratory system and lung compliance as compared to control subjects (9.9 ± 5.0 vs 17.8 ± 6.5, 9.3 ± 4.9 vs 16.9 ± 4.1 at 4 cmH2O of PEEP and 11.7 ± 5.8 vs 23.7 ± 6.8, 10.0 ± 4.9 vs 23.4 ± 7.5 at 12 cmH2O of PEEP). The compliance of the chest wall was similar in both groups (76.7 ± 30.2 vs 94.4 ± 76.4 and 92.6 ± 65.3 vs 90.0 ± 61.7 at 4 and 12 cmH2O of PEEP). The lung stress and strain were significantly higher in ARDS patients as compared to control subjects and were poorly related to airway pressure and tidal volume normalized for body weight. CONCLUSIONS: Airway pressures and tidal volume normalized to body weight are poor surrogates for lung stress and strain in mild pediatric ARDS. TRIAL REGISTRATION: Clinialtrials.gov NCT02036801. Registered 13 January 2014.