Prevalence of children witnessed violence in a pediatric emergency department.

Witnessed violence is a form of child abuse with detrimental effects on child wellbeing and development, whose recognition relies on the assessment of their mother exposure to intimate partner violence (IPV). The aim of this study was to assess the frequency of witnessed violence in a population of children attending a pediatric emergency department (ED) in Italy, by searching for IPV in their mother, and to define the characteristics of the mother-child dyads. An observational cross-sectional study was conducted from February 2020 to January 2021. Participating mothers were provided a questionnaire, which included the Woman Abuse Screening Tool (WAST) and additional questions about their baseline data and health. Descriptive analysis was reported as frequency and percentage for the categorical variables and median and interquartile range (IQR) for quantitative variables. Mothers and children screened positive and negative for IPV and witnessed violence, respectively, were compared by the chi-square test or the exact Fisher test for categorical variables, and by the Wilcoxon-Mann-Whitney test for continuous variables. Out of 212 participating mothers, ninety-three (43.9%) displayed a positive WAST. Mothers tested positive were mainly Italian (71%, p 0.003), had a lower level of education (median age at school dropout 19, p 0.0002), and a higher frequency of unemployment (p 0.001) and poor personal health status (8.6%, p 0.001). The children of mothers tested positive showed a higher occurrence of abnormal psychological-emotional state (38.7%, p 0.002) and sleep disturbances (26.9%, p 0.04). CONCLUSION: IPV was common in a population of mothers seeking care for their children in a pediatric ED. WHAT IS KNOWN: • Witnessed violence is a form of child abuse, usually inferred by their mothers' exposure to IPV. The latter is suffered by one in three women worldwide. WHAT IS NEW: • This study shows a 43.9% prevalence of IPV among mothers attending an Italian pediatric ED. • Positive mother-child dyads displayed a higher frequency of poor mothers' health status and children's abnormal emotional state and sleep disturbances.

Judicial outcome and follow up of abused child protection acts in a pediatric emergency department: 12-year experience in a third level pediatric hospital.

BACKGROUND: Italian laws allow the protection of a child who is suspected to be a victim of abuse through a procedure that can be put in motion by the attending physician in any Emergency Department (article nr. 403 Civil Code) with a temporarily suspension of parental authority. This study aims at evaluating both the appropriateness of the activation of the protection procedure by ED doctors in cases of suspected child abuse in terms of judicial confirmation and how it impacts children in the long-term. METHODS: We selected cases in which the procedure was activated due to suspected child abuse. The children were admitted to the ED of a tertiary children hospital from 2006 to 2018. We then reviewed the medical charts and collected data from the social services through a questionnaire concerning the long-term outcomes . RESULTS: Twenty-eight patients were included (75% females, mean age 13.8 years). In 90% of cases the activation of the procedure in the ED was followed by a Court confirmation. Evaluation of long term outcome was possible in 22 cases. Among them, a positive social outcome was achieved in 15 cases (68.2%). The remaining abandoned the program or had critical reintegration in the family. Eighteen percent of patients developed major issues such as aberrant behaviours, substance abuse or psychiatric disorders. CONCLUSIONS: This report identifies a good ability of ED doctors in the activation of an emergency procedure to protect the child. Overall, the social outcome was good for nearly 70% of the patients, highlighting the importance of activation of social support programs for child abuse.

Pain Intensity and Risk of Bone Fracture in Children With Minor Extremity Injuries.

OBJECTIVES: Injuries are one of the most common causes of pediatric emergency department (ED) visit. The aim of this study was to investigate the relationship between the intensity of pain at the ED visit of children presenting with an extremity injury and the risk of fracture. METHODS: We conducted a retrospective study, considering all patients presenting to the ED of a children's hospital in Italy, with an accidental extremity injury, between May and December 2015. We selected all children aged 8 to 17 years who underwent an x-ray. Children with major, multiple, or nonextremity injuries were excluded. Age, sex, spontaneous and palpation pain, local swelling, time between injury, and medical evaluation were recorded. Sensibility and specificity of spontaneous and palpation pain in detecting a fracture were calculated. RESULTS: We reviewed 994 medical records; of these, 344 (34.6%) reported a fracture. Children's median age was 12 years (interquartile range [IQR], 10-14). Median spontaneous pain at the ED visit was not significantly different between children with and without a fracture: 4.0 (1.0-6.0) and 5 (1.0-6.0), respectively (P = 0.129). Children with mild palpation pain and children without an increase of pain of at least 2 points between spontaneous and palpation pain were fractured in 3.2% and 0.97% of cases, respectively. CONCLUSIONS: In this series, pain intensity in children with a minor extremity injury was not a good marker of fracture. Nevertheless, children with mild palpation pain or with a mild increase of pain between spontaneous and palpation pain had a low risk of fracture.

Glucose Metabolism Evaluated by Glycated Hemoglobin and Insulin Sensitivity Indices in Children Treated with Recombinant Human Growth Hormone

Objective: To evaluate glucose metabolism and insulin sensitivity in children with idiopathic growth hormone (GH) deficiency, treated with recombinant human GH (rhGH), and to identify possible risk factors for the development of glucose abnormalities in this population. Methods: We retrospectively collected data from 101 patients (60 males, median age 10.4 years, 77 prepubertal), with confirmed GH deficiency, enrolled before starting rhGH and followed up during the first three years of treatment. Glucose metabolism was evaluated annually by oral glucose tolerance test (OGTT) and glycated hemoglobin A1c (HbA1c). OGTT was used to calculate insulin sensitivity (HOMA-S) and insulin resistance (HOMA-IR), defined as HOMA-IR >3. Results: RhGH was effective in improving growth and dosages significantly reduced after the first year of therapy. No patient developed diabetes mellitus. After one year of therapy, a significant increase in HbA1c (p=0.0042) and insulin levels (fasting p<0.0001, 60 min p=0.0018, 120 min p=0.0003) was observed, with a higher prevalence of IR (p<0.05). These indices did not alter further during the follow-up and were not related to GH dose or to family history of diabetes. A significant correlation was found only for IR indices and pubertal status, weight and age (p<0.05). Conclusion: In this retrospective study on a large GH deficient pediatric population, conventional use of replacement therapy resulted in an increase in HbA1c and IR after one year of therapy, regardless of rhGH dosage. These alterations did not worsen significantly in the following two years and were not associated with overt diabetes.

An adolescent with acute abdominal pain and bowel wall thickening.

: A 15-year-old girl was admitted with acute crampy abdominal pain and repeated vomiting over the preceding 2 hours; no fever, diarrhoea or abdominal trauma was reported. She had started oestrogen-progestin contraception 3 months ago. She had sought medical advice twice in the previous weeks for self-limiting episodes of right hand swelling, without urticaria. On examination, she was unwell and in pain, with severe tenderness in the right lower quadrant, without guarding or rebound tenderness. Bowel sounds were diminished. Blood tests were unremarkable. Two hours after admission, an abdominal ultrasound scanning showed an impressive wall thickening (>1 cm) of the terminal ileum, caecum and ascending colon (figure 1). Abundant free intraperitoneal fluids in the pelvis and in the hepatorenal recess were present.edpract;103/1/22/EDPRACT2016311823F1F1EDPRACT2016311823F1Figure 1Marked caecal wall thickening evidenced at the ultrasound scanning. QUESTIONS: Which of the following is the most likely diagnosis in this patient? Ileocolic intussusceptionGastrointestinal manifestation of Henoch-Schönlein purpuraAbdominal attack of hereditary angioedema (HAE)Acute pancreatitisWhich of the following blood tests may help to confirm the diagnosis? Erythrocyte sedimentation rateC4Serum amylase: 36 IU/LC1-inhibitorHow should this patient be evaluated and treated?Answers are on page ▪▪▪.

Acute lobar nephritis in children: Not so easy to recognize and manage.

Acute lobar nephritis (ALN) is a localized non-liquefactive inflammatory renal bacterial infection, which typically involves one or more lobes. ALN is considered to be a midpoint in the spectrum of upper urinary tract infection, a spectrum ranging from uncomplicated pyelonephritis to intrarenal abscess. This condition may be difficult to recognize due to the lack of specific symptoms and laboratory findings. Therefore the disease is probably underdiagnosed. Computed tomography scanning represents the diagnostic gold standard for ALN, but magnetic resonance imagine could be considered in order to limit irradiation. The diagnosis is relevant since initial intravenous antibiotic therapy and overall length of treatment should not be shorter than 3 wk. We review the literature and analyze the ALN clinical presentation starting from four cases with the aim to give to the clinicians the elements to suspect and recognize the ALN in children.

Appendicitis in children less than five years old: A challenge for the general practitioner.

Acute appendicitis is one of the most common indications for abdominal surgery in pediatrics with peak incidence in the second decade of life. Acute appendicitis in the first years of life is an uncommon event. The clinical presentation is often varied and the diagnosis may be overshadowed by other medical conditions. Gastroenteritis is the most common misdiagnosis, with a history of diarrhea present in 33% to 41% of patients. Pain is the most common presenting symptom in children less than 5 years old, followed by vomiting, fever, anorexia and diarrhea. The most common physical sign is focal tenderness (61% of the patients) followed by guarding (55%), diffuse tenderness (39%), rebound (32%), and mass (6%). Neonatal appendicitis is a very rare disease with high mortality; presenting symptoms are nonspecific with abdominal distension representing the main clinical presentation. The younger the patient, the earlier perforation occurs: 70% of patients less than 3 years develop a perforation within 48 h of onset of symptoms. A timely diagnosis reduces the risk of complications. We highlight the epidemiology, pathophysiology, clinical signs and laboratory clues of appendicitis in young children and suggest an algorithm for early diagnosis.

Acquired long QT syndrome: a focus for the general pediatrician.

Acquired long QT syndrome (LQTS) is a disorder of cardiac repolarization most often due to specific drugs, hypokalemia, or hypomagnesemia that may precipitate torsade de pointes and cause sudden cardiac death. Common presentations of the LQTS are palpitations, presyncope, syncope, cardiac arrest, and seizures. An abnormal 12-lead electrocardiogram obtained while the patient is at rest is the key to diagnosis. The occurrence of drug-induced LQTS is unpredictable in any given individual, but a common observation is that most patients have at least 1 identifiable risk factor in addition to drug exposure. The cornerstone of the management of acquired LQTS includes the identification and discontinuation of any precipitating drug and the correction of metabolic abnormalities, such as hypokalemia or hypomagnesemia. Most of the episodes of torsade de pointes are short-lived and terminate spontaneously. We propose a management protocol that could be useful for the daily practice in the emergency pediatric department to reduce the risk of acquired QT prolongation.

¿Es eficaz el tratamiento con hidroxicloroquina en el déficit de proteína C surfactante? / Is Treatment With Hydroxychloroquine Effective in Surfactant Protein C Deficiency?

Presentamos el caso de 2 hermanos gemelos con déficit de proteína C surfactante que fueron tratados mediante el empleo de hidroxicloroquina durante 3 años, con aparente éxito. La fisiopatología exacta de esta enfermedad no se conoce, y no disponemos de ningún tratamiento específico para ella; tan solo tenemos noticia de unas pocas descripciones previas en la literatura sobre el uso de hidroxicloroquina para el déficit de proteína C surfactante con resultados satisfactorios. Dos años después de la retirada del tratamiento se volvió a evaluar a los gemelos: no presentaron nuevas infecciones, el crecimiento y el estado general fueron normales, y la TC de tórax mostró una notable reducción adicional de la neumopatía intersticial. Estos datos parecen poner en duda la eficacia de la hidroxicloroquina, y sugieren que la mejoría clínica fue simplemente la evolución natural de la enfermedad (AU)

We present the case of two twin brothers with surfactant protein C deficiency who were treated with hydroxychloroquine for three years, with apparent success. The exact physiopathology of this disease is not known and there is no specific treatment for it. There is merely news from a few previous descriptions in the literature about the use of hydroxychloroquine for surfactant protein C deficiency with satisfactory results. Two years after the treatment was withdrawn, the twins were evaluated once again: they presented no new infections, growth and general state were normal and chest CT showed a notable additional reduction in the interstitial pneumopathy. These data seem to cast some doubt on the efficacy of hydroxychloroquine, and they suggest that the clinical improvement was simply the natural evolution of the disease (AU)

Is treatment with hydroxychloroquine effective in surfactant protein C deficiency?

We present the case of two twin brothers with surfactant protein C deficiency who were treated with hydroxychloroquine for three years, with apparent success. The exact physiopathology of this disease is not known and there is no specific treatment for it. There is merely news from a few previous descriptions in the literature about the use of hydroxychloroquine for surfactant protein C deficiency with satisfactory results. Two years after the treatment was withdrawn, the twins were evaluated once again: they presented no new infections, growth and general state were normal and chest CT showed a notable additional reduction in the interstitial pneumopathy. These data seem to cast some doubt on the efficacy of hydroxychloroquine, and they suggest that the clinical improvement was simply the natural evolution of the disease.