Hematological Markers in Children and Adults with Atopic Dermatitis: A Retrospective Cohort Study.

INTRODUCTION: Atopic dermatitis (AD) is a common chronic skin disease with an inflammatory pathophysiology that includes the activation of the innate and adaptive immune systems. We aimed to investigate the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), eosinophil-to-lymphocyte ratio (ELR), and eosinophil-to-neutrophil ratio (ENR) in AD patients, according to age and disease severity. METHODS: This is a retrospective, population-based cohort study conducted between the years 2005 and 2020, comparing hematological markers of AD patients and sex-age-ethnicity-matched controls. AD patients were further divided by age and disease severity (mild, moderate-to-severe AD). We created a decision tree to predict moderate-severe AD. RESULTS: A total of 13,928 patients with AD were included in this study: 6,828 adults and 7,100 children, with 13,548 controls. NLR, PLR, and ELR were lower in children compared to adults (p values <0.001). NLR, PLR, ELR, and ENR were increased in moderate-severe AD patients compared to mild AD patients (p values <0.001). PLR, ELR, and ENR were increased in AD patients versus controls (p values <0.001), with an additional increase in the NLR of moderate-to-severe AD patients. Patients with an ELR <0.21, a PLR >161, and ENR ≤0.016 should be considered high risk for developing severe AD, as well as patients with an ELR >0.21 and age at diagnosis <30 or age >30 years and mean platelet volume ≤9. CONCLUSION: Hematological ratios were significantly higher in moderate-to-severe AD patients, compared to mild AD patients. Hematological markers were lower in children with AD compared to adults, except for ENR, likely reflecting age-related changes in blood count parameters. These markers can assist in the management and follow-up of AD patients.

Increased Neutrophil-Lymphocyte Ratio and Platelet-Lymphocyte Ratio in Chronic and Severe Urticaria.

Chronic spontaneous urticaria (CSU) is a disturbing skin condition often severely detrimental to quality of life. Haematological markers of inflammation such as neutrophil-to-lymphocyte and platelet-to-lymphocyte may be used in the assessment of inflammatory skin diseases. Their usefulness in urticaria is unknown. Neutrophil- to-lymphocyte, platelet-to-lymphocyte, and total serum IgE were investigated in urticaria patients: acute spontaneous urticaria (ASU) versus CSU, children versus adults with CSU, and patients with mild-to-moderate versus severe CSU. This retrospective cohort study included patients of all ages diagnosed with urticaria between 2005 and 2020 and blood counts within 30 days of diagnosis. Patients with comorbidities influencing blood cells (infection, surgery, malignancy) were excluded. Neutrophil-to-lymphocyte and platelet-to-lymphocyte were evaluated in patients with ASU vs CSU and mild-to-moderate CSU vs severe CSU (defined by the use of systemic medications or hospitalizations). A total of 13,541 urticaria patients were included in the study. CSU patients (n = 5,021) had higher neutrophil-to-lymphocyte and platelet-to-lymphocyte, as well as serum IgE levels compared with ASU patients (n = 8,520). Adults had higher neutrophil-to-lymphocyte and platelet-to-lymphocyte than children. Severely affected patients (n = 53) had higher neutrophil-to-lymphocyte and platelet-to-lymphocyte compared with mild-to-moderately affected patients (n = 4,968). Patients with higher neutrophil-to-lymphocyte and platelet-to-lymphocyte had higher odds of having CSU rather than ASU and severe urticaria rather mild-to-moderate. In conclusion, neutrophil-to-lymphocyte and platelet-to-lymphocyte are simple and available markers that can be used to predict and assess severe and chronic urticaria.

Does weight influence the course of RSV bronchiolitis in hospitalized infants?

Acute bronchiolitis is among the most common causes of hospitalizations in infants worldwide. Associations between weight and severity of respiratory syncytial virus (RSV) bronchiolitis remain unclear. The aim of this study was to evaluate this association. A single-center, retrospective cohort study of infants aged under 24 months, who were hospitalized between 2018 and 2022 for RSV bronchiolitis. Data from computerized medical records were extracted using the MDclone platform. Participants were divided into three groups according to weight percentiles: underweight (below 5th percentile), normal-weight, and overweight (above 85th percentile). A total of 1936 infants (mean age 6.3 months, 55% males) were included, comprising 274 infants who were underweight, 1470 with normal weight, and 192 with overweight. Underweight infants had a higher rate of admission to the pediatric intensive care unit (PICU) (9.1% vs. 3.5%, P < 0.005) and prolonged length of stay (LOS) in the hospital (3.13 vs. 2.79 days P < 0.001) compared to those with normal weight. Hyponatremia was also more common in the underweight group (23% vs. 15%, P < 0.001). A multivariable model accounting for prematurity and birthweight predicted a relative risk of 2.01 (95% CI 1.13-3.48, P = 0.015) for PICU admission and 1.42 (95% CI 1.17-1.7, P < 0.001) for a prolonged LOS. Being overweight was not associated with a more severe disease.  Conclusion: Underweight infants, hospitalized for RSV bronchiolitis, had a more severe disease course with a higher complication rate, including PICU admission and prolonged LOS. Thus, careful attention and supervision should be given to this subgroup of infants. What is Known: • Established risk factors for severe bronchiolitis include prematurity, BPD, CHD, and compromised immunity. • Abnormal weight status has been associated with an increased risk for morbidity and mortality from infectious diseases, proposedly due to the effects on endocrine and immunologic systems. What is New: • Underweight infants hospitalized with RSV bronchiolitis face an independent risk of PICU admission and prolonged hospital stay. • Conversely, overweight infants did not display associations with severity measures in our study.

Neonatal diagnosis of primary ciliary dyskinesia in a high consanguinity population: a single tertiary center experience.

Though PCD usually presents after birth in term neonates, diagnosing PCD during the neonatal and infancy stages is uncommon, particularly in children who do not exhibit laterality defects. We report our recent experience with the diagnosis of PCD in the neonatal and early infantile period in a highly consanguine population. This was achieved by implementing a novel genetic-based diagnostic approach based on direct testing for recognized regional genetic variants. We conducted a retrospective analysis of children diagnosed with PCD at Soroka University Medical Center during the neonatal or early infantile period between 2020 and 2023. We included children under 3 months of age who had a genetic confirmation of PCD, as evidenced by the presence of two pathogenic variants in recognized genes. Genetic testing targeted regional genetic variants in previously identified PCD genes. Eight patients were included. The median age at diagnosis was 12.5 days. Three (38%) were born prematurely < 34 weeks gestational age. All patients were presented with respiratory distress and hypoxemia after birth. The median duration of oxygen support was 23 days, and upper lobe atelectasis was present in five patients (63%). Congenital cardiac malformation was present in four patients. Organ laterality defects were present in four patients. Genetic mutations identified were in the DNAAF5, DNAL1, DNAAF3, and DNAH1 genes.     Conclusion: Neonatal diagnosis of PCD is uncommon, especially in atypical presentations such as children without laterality defects or preterms. Focusing on a genetic diagnosis of the local tribal pathogenic variants promotes a potential cost-efficient test leading to earlier diagnosis. There is a need for a standardized protocol for earlier diagnosis of PCD in high-consanguinity areas. What is Known: • Primary ciliary dyskinesia (PCD) typically presents after birth in term neonates. • Diagnosing PCD during neonatal and infancy stages is challenging, particularly in children without laterality defects. What is New: • A novel genetic-based diagnostic approach was implemented on the neonatal population in a highly consanguine community, focusing on direct testing for regional genetic variants, leading to early and rapid diagnosis of PCD.

Foreign body aspiration score (FOBAS)-a prospectively validated algorithm for the management and prediction of foreign body aspiration in children.

Foreign body aspiration (FBA) is a common cause of pediatric morbidity, but a standardized protocol to guide decision-making about bronchoscopy is lacking. We aimed to validate a new Foreign body aspiration score (FOBAS) for the pediatric emergency department (ED). Patients aged 0-18 years referred to the ED for suspected FBA were prospectively enrolled. FOBAS was calculated according to clinical features of a choking episode, sudden cough, exposure to nuts, absence of fever and rhinitis, stridor, and unilateral auscultatory and radiological findings. FBA risk was evaluated based on the total score (low, 1-3; moderate, 4-6; high, 7-10). Low-risk children were discharged from the ED and followed clinically. Moderate-risk children were hospitalized and evaluated by a pediatric pulmonologist, and high-risk children were referred directly for therapeutic bronchoscopy. Among the 100 enrolled children (59% males; median age 20 [interquartile range 11-39] months), a foreign body was diagnosed in 1/49 (2%), 14/41 (34.1%), and 9/10 (90%) with low, moderate, and high FOBAS, respectively (P < .001). Logistic regression indicated a higher risk for FBA with higher scores. The odds ratio for each additional point was 2.75 (95% confidence interval 1.78-4.24), and FOBAS showed a high predictive value for FBA (area under the curve 0.89). FOBAS implementation significantly reduced the rate of negative bronchoscopies, from 67.4% annually during 2016-2019 to 50% in 2020 (P = .042). CONCLUSION: FOBAS reliably predicts FBA in cases of suspected FBA and improves management and in-hospital decision-making. WHAT IS KNOWN: • Foreign body aspiration is a major cause of pediatric morbidity and mortality. • Currently, there is no unified protocol for children referred to the emergency department for suspected FBA, therefore, a well-defined algorithm is needed to improve the decision-making process. WHAT IS NEW: • The pediatric Foreign body aspiration score (FOBAS) is a new, prospectively validated clinical score that shows high sensitivity and specificity for the presence of FBA in children. • FOBAS reduces unnecessary admissions and invasive procedures and leads to better clinical outcomes.

Viral load in hospitalized infants with respiratory syncytial virus bronchiolitis: a three-way comparative analysis.

Viral load measurement of Respiratory syncytial virus (RSV) in acute bronchiolitis depends on specimen collection, viral load quantification, and transport media. The aim of this study was to investigate viral load in three-way-comparative analyses; nasal swab versus nasal wash, quantitative real-time polymerase chain reaction (RT-PCR) versus cell tissue culture, and various transport media. A prospective cohort study of infants aged < 12 months, admitted to the Soroka Medical Center, due to acute bronchiolitis, was conducted. Two nasal swabs and two nasal wash samples (in UTM and VCM) were collected from each infant upon admission and after 48 h. Samples were immediately stored at -80 °C and tested at Viroclinics DDL (Rotterdam, Netherlands). Quantitative RT-PCR and quantitative virus culture were performed using tissue culture infective dose (TCID50). Spearman's correlation coefficient test assessed the correlation between the different methods, viral load, and clinical severity score. One hundred samples were collected from 13 infants (mean age 5.7 ± 3.8 months, 46% males). Twelve patients were RSV-A positive, and one was RSV-B positive. A high correlation was found between transport media- UTM and VCM (0.92, P < 0.001) and between nasal swabs and nasal wash samples (0.62, P = 0.02). RSV signals were higher in nasal wash than in swabs. PCR signals were lower in the second collection compared to the first. No correlation was found between viral load and clinical severity.    Conclusion: RSV viral load is comparable across nasal wash, nasal swabs, and various transport media. However, it did not correlate with clinical severity, probably due to the limited sample size. Broader analyses are warranted. What is Known: • Viral load measurement in Respiratory Syncytial Virus (RSV) bronchiolitis depends on specimen collection, viral load quantification, and transport media. • The COVID-19 pandemic underscored the paramount significance of proper specimen collection, notably through nasal swabs. What is New: • RSV viral load was investigated in three-way-comparative analyses. • RSV viral load correlated well across PCR and tissue culture, nasal wash and swabs, and various transport media. RSV viral load did not correlate with clinical severity.

Pediatric thermal epiglottitis: insights from a tertiary center experience.

Thermal epiglottitis, a non-infectious cause of epiglottitis, is a rare entity that shares some clinical features with infectious epiglottitis. This study presents 16 years of experience in diagnosing and managing thermal epiglottitis. A retrospective descriptive study in a tertiary center in southern Israel included confirmed cases of thermal epiglottitis in children (0-18 years) between 2004 and 2020 by endoscopy. Of approximately 600,000 pediatric ER admissions between 2004 and 2020, seven children were diagnosed by endoscopy with thermal epiglottitis (mean age 24 months, 71% males). Clinical presentation included stridor, respiratory distress, and drooling. Four children had fever and elevated inflammatory markers at presentation and were treated with systemic antibiotics. All were treated with systemic steroids. The median length of stay in the PICU was five days, and four patients required intubations. All fully recovered without experiencing any sequelae.  Conclusion: Thermal epiglottitis stands as a potential contributor to acute upper airway obstruction. Although it's rarity, it should be discussed in any child with acute upper airway obstruction. It is essential to inquire directly about the accidental intake of hot beverages, particularly in cases lacking fever or elevated inflammatory markers. What is Known: • Thermal epiglottitis is a rare, non-infectious condition sharing clinical features with infectious epiglottitis. • Common presentations include stridor, respiratory distress, and drooling. What is New: • Thermal epiglottitis is a potential contributor to acute upper airway obstruction, urging consideration even in the absence of fever or elevated markers. • Direct inquiry about hot beverage intake for diagnosis is essential for diagnosis.

Effect of Paediatric Atopic Dermatitis on Parental Sleep Quality.

Data on the impact of paediatric atopic dermatitis on parental sleep are scarce. The aim of this study was to examine the effects of paediatric atopic dermatitis on the quality of parents' sleep. This cross-sectional study included parents of patients with atopic dermatitis and parents of healthy children who completed validated Pittsburgh Sleep Quality Index questionnaires. The study and control groups were compared, as were results for mild and moderate atopic dermatitis with severe atopic dermatitis, mothers and fathers, and different ethnic groups. A total of 200 parents were enrolled. Sleep latency was significantly longer in the study group compared with the control group. Sleep duration was shorter in the parents of the mild AD group compared with the moderate-severe and control groups. Parents in the control group reported more daytime dysfunction than parents in the AD group. Fathers of children with AD reported more sleep disturbance than mothers.

Pediatricians' confidence level in diagnosing and treating children with atopic dermatitis in Israel, based on a self-efficacy survey.

Atopic dermatitis (AD) is one of childhood's most common skin conditions. Although pediatricians often diagnose and manage it, more than half refer even mild cases to dermatologists. In this study, we aimed to evaluate pediatric residents' and pediatricians' self-confidence regarding their ability to diagnose and manage AD. A cross-sectional questionnaire study was conducted with Israeli pediatric residents and pediatricians in 2022. The questionnaire was designed to distinguish participants with high vs. low self-confidence characteristics regarding their ability to diagnose and treat AD. In total, 171 participants completed the questionnaire (59.4% women; age, 41.1 ± 10.6 years); 39.1% of the participants were residents, while 60.9% were board-certified pediatricians. Overall, 64.4% of the responders reported below or average confidence (score ≤ 3, on a scale of 1-5) in diagnosing and treating AD in children. The group with higher self-confidence was significantly older (44.39 vs. 39.14 years, P = 0.003), had more years of experience in evaluating pediatric AD (P = 0.004), had trained in dermatology during their residency (P = 0.02) with a longer training period (P = 0.01), and with more than three training methods (P = 0.009). Multivariable logistic regression analysis showed that high self-confidence was associated with age older than 40 years and training in dermatology during residency (odds ratios = 5.63 [P = 0.04] and 3.36 [P = 0.05], respectively).  Conclusion: Most pediatric residents and pediatricians were not particularly confident in treating children with AD. Those with high self-confidence were older, had been exposed to more patients, and had been trained in dermatology during their residency with various methods and for longer periods. Therefore, we encourage the implementation of a training program in dermatology during pediatric residency programs. What is Known: • Atopic dermatitis (AD) is one of childhood's most common skin conditions and often presents to pediatricians for diagnosis and management. • Many pediatricians refer children with even mild cases of AD to dermatologists. What is New: • Most pediatric residents and pediatricians report low confidence in diagnosing and treating pediatric AD. • Physicians with high self- confidence were older, exposed to more AD patients, and had been trained in dermatology during their residency with various methods and for longer periods. Therefore, the implementation of a training program in dermatology during pediatric residency programs is warranted.

Evaluation of Foreign body aspiration score (FOBAS) in children- A retrospective cohort study.

Foreign Body Aspiration (FBA) is a common medical emergency among young children, but the evaluation and management of a suspected FBA case can vary across physicians and centers. We aimed to identify which clinical, laboratory, and radiological findings can predict FBA in children and to evaluate a clinical score to improve FBA prediction. This is a retrospective cohort study of patients aged 0-18 years admitted to Soroka University Medical Center between 2010 and 2020 with suspected FBA. All patients underwent flexible bronchoscopy and were divided into positive and negative FBA groups. A newly developed foreign body aspiration score (FOBAS), based on medical history, physical examination, and chest X-ray findings, was evaluated for its predictability. The study included 412 children (median age 21 months, 56.8% females), of whom 154 (37.4%) had FBA and 258 (62.6%) did not. Multivariate regression analysis showed exposure to nuts/seeds, unilateral wheezing or decreased breath sounds, stridor, and suggestive findings on chest X-ray were significant risk factors for FBA (OR [95%CI] -1.994[1.290-3.082], 1.487[1.206-1.832], 1.883 [1.011-3.509] and 2.386[1.917-2.970], respectively). However, a choking episode, acute cough, and absence of fever and rhinorrhea did not predict FBA. FOBAS showed an increased risk of FBA for each additional point of the score, with an odds ratio of 1.572 (95% CI-1.389-1.799).  Conclusion: FOBAS is a good predictor for the presence of FBA in children. Once prospectively validated, FOBAS could aid in decision-making at the emergency department, enabling more standardized care, reducing unnecessary procedures, and leading to better clinical outcomes. What is Known: • The evaluation and management of a child with suspected foreign body aspiration (FBA) vary across physicians and centers, without a consensus regarding the indications and criteria for performing bronchoscopy. • Flexible bronchoscopy is the standard procedure for the diagnosis and sometimes treatment of FBA in children, but it may hold potential complications. What is New: • We propose a newly developed foreign body aspiration score (FOBAS), based on medical history, physical examination, and chest X-ray findings, for the prediction of FBA in children at the emergency department. • The FOBAS is a good predictor of FBA in children. The score enables more standardized care and may reduce unnecessary procedures.

Comparison of chest X-ray interpretation by pediatric pulmonologists, pediatric radiologists, and pediatric residents in children with suspected foreign body aspiration-a retrospective cohort study.

Chest X-ray (CXR) is an important tool in the assessment of children with suspected foreign body aspiration (FBA), although it can falsely be interpreted as normal in one-third of the cases. The aim of this study is to evaluate the positive predictive value of CXR in children hospitalized with suspected FBA, when interpreted by three disciplines: pediatric pulmonology, pediatric radiology, and pediatric residents. This is a retrospective study that included children aged 0-18 years, admitted with suspected FBA, between 2009 and 2020 in one tertiary center. All patients underwent CXR and a flexible/rigid bronchoscopy for the definitive diagnosis of FBA, up to 1 week apart. Two physicians from each discipline interpreted the CXR, independently. Intra-raters' and inter-raters' agreements were assessed. Sensitivity, specificity, and area under the curve (AUC) were calculated for each discipline. Four hundred seventy-three children were included in the study, 175 (37%) with FBA and 298 (63%) without FBA on flexible/rigid bronchoscopy. The most common radiological findings, as interpreted by a pediatric pulmonologist, were unilateral hyperinflation (47%), radiopaque FB (37.6%), lobar atelectasis (10.3%), unilateral hyperinflation with atelectasis (3.4%), and lobar consolidation (1.7%). Intra-raters' agreement ranged from 0.744 (p < 0.001) among pediatric pulmonologists to 0.326 (p < 0.001) among pediatric radiologists. AUC for predicting FBA based on a CXR was 0.81, 0.77, and 0.7 when interpreted by pediatric pulmonologists, pediatric residents, and radiologists, respectively (p < 0.001). CONCLUSIONS: CXR has a high positive predictive value and independently predicts FBA in children; however, normal CXR should not rule out FBA. Predictability is variable among different disciplines. WHAT IS KNOWN: • Chest X-ray is an important tool in the assessment of children with suspected foreign body aspiration (FBA). • Chest X-ray can be interpreted as normal in one-third of the cases. WHAT IS NEW: • Chest X-ray independently predicts FBA in children, with a high positive predictive value. • The ability of chest x-ray to predict FBA in children differs between pediatric residents, pediatric radiologists, and pediatric pulmonologists.

Pediatric psoriasis negatively influences parental sleep quality.

BACKGROUND: One-third of psoriasis cases occur in the pediatric population. Pediatric psoriasis has a negative long-term impact on the quality of life of children and their families. However, data regarding the impact of pediatric psoriasis on parental sleep quality are scarce. OBJECTIVES: This study examined the effects of pediatric psoriasis on the quality of parents' sleep compared to parents of healthy, non-psoriatic children. METHODS: A cross-sectional questionnaire study was conducted from September 2020 to November 2021, using the validated Pittsburgh Sleep Quality Index (PSQI). The study population included parents of patients aged 2-18 years diagnosed with psoriasis and parents of healthy children of the same gender and ethnicity. We further compared sleep quality between parents of children with mild and moderate-to-severe psoriasis, and fathers to mothers. RESULTS: A total of 301 parents were enrolled; 151 parents of 83 children diagnosed with psoriasis and 150 parents of 124 healthy controls. Parents of children with psoriasis had significantly longer sleep latency (p = 0.031), worse subjective sleep quality (p = 0.043), and greater use of sleep medications (p < 0.001). The comparison between parents of moderate-severe with mild psoriatic children as well as mothers with fathers showed no statistical significance. CONCLUSION: Poor sleep quality was demonstrated among parents of children diagnosed with psoriasis compared to parents of healthy children. This finding is crucial for the direction of treatment efforts regarding parental well-being and functioning.

The effect of a coaching program on asthma control and health care utilization in children with asthma.

ABSRACTObjective: Poor adherence to asthma therapy is a major problem in the management of asthma. We aimed to assess if a designed coaching program in children with asthma, coming from low socioeconomic background, will reduce respiratory morbidity and health care utilization.Methods: A prospective interventional pilot study enrolling children aged 3-18 years, admitted to Soroka University Medical Center (SUMC) between October 2015 and May 2016 due to asthma exacerbation. The intervention group was part of a coaching program, which was conducted by medical and paramedical personnel and included a diagnostic and personal educational office visit and a house visit by a nurse educator for asthma. The control group comprised of demographically matched children with asthma, who were admitted to the SUMC, but did not go through any intervention. Medications purchase and health care utilization were extracted from the participants' HMO databases, during 1-year of follow-up.Results: 41 children were enrolled to the intervention group, with 63 children as a control group. No differences were found in asthma-related drugs purchase, number of clinic visits, ER admissions and hospitalizations during the follow-up year, although the intervention group showed a trend towards having a shorter length of stay (2.3 vs. 4.5 days, Cohen's D = 0.44, p = 0.06). The intervention group demonstrated subjective improvement in asthma control, as reflected in Asthma Control Test questionnaires.Conclusions: In this pilot study of coaching program for children with asthma coming from low income families, no decrease in health care utilization was shown. Larger and longer intervention programs are needed.

From rigid to flexible bronchoscopy: a tertiary center experience in removal of inhaled foreign bodies in children.

Rigid bronchoscopy is the procedure of choice for removal of inhaled foreign bodies. In this retrospective study, we assessed the safety and efficacy of flexible bronchoscopy use in the removal of inhaled foreign bodies in children. One hundred eighty-two patients (median age of 24 months, 58% males) underwent an interventional bronchoscopy for the removal of inhaled foreign body between 2009 and 2019, 40 (22%) by flexible, and 142 (78%) by rigid bronchoscopy. 88.73% of rigid and 95% of flexible bronchoscopies were successful in foreign bodies removal (p value = 0.24). Complication rate was higher among rigid bronchoscopy (9.2% vs. 0%, p = 0.047). From 2017 onwards, following the implementation of flexible bronchoscopy for foreign bodies removal, 64 procedures were performed, 33 (51.6%) flexible, and 31 (48.4%) rigid. Procedure length was shorter via flexible bronchoscopy (42 vs 58 min, p = 0.016). Length of hospital stay was similar.Conclusion: In our hands, flexible bronchoscopy is an efficient and safe method for removal of inhaled foreign bodies in children, with shorter procedure time and minimal complication rate. Flexible bronchoscopy could be considered as the procedure of choice for removal of inhaled foreign bodies in children, by an experienced multidisciplinary team. What is Known: • Rigid bronchoscopy is currently the gold standard for removal of inhaled foreign bodies in children. • Rigid bronchoscopy has a relatively high complication rate compared to flexible bronchoscopy. What is New: • Flexible bronchoscopy is a short, safe, and efficient procedure to remove inhaled foreign bodies in children, compared to rigid bronchoscopy. • Flexible bronchoscopy could be proposed as the procedure of choice for removal of inhaled foreign bodies in children, if an experienced operator is available.

Vitamin D deficiency in children with acute bronchiolitis: a prospective cross-sectional case- control study.

BACKGROUND: 25(OH) vitamin D levels are inversely associated with respiratory infections and childhood wheezing. OBJECTIVE: To evaluate serum 25(OH) vitamin D levels in infants and toddlers with acute bronchiolitis, compared to subjects with non-respiratory febrile illness. METHODS: A prospective cross-sectional case-control study which compared serum 25(OH) vitamin D levels between infants and toddlers diagnosed with acute bronchiolitis to subjects with non-respiratory febrile illness. Multivariate logistic regression, adjusted for age, sex, ethnicity and nutrition was performed. Correlation between serum vitamin D levels and bronchiolitis severity was assessed via Modified Tal Score and length of hospital stay (LOS). RESULTS: One hundred twenty-seven patients aged < 24 months were recruited; 80 diagnosed with acute bronchiolitis and 47 patients with non- respiratory febrile illnesses. Both groups had similar demographics aside from age (median [IQR] 5 [3-9] vs. 9 [5-16] months in the bronchiolitis group compared to control group (p = 0.002)). Serum 25(OH) vitamin D levels were significantly lower in the bronchiolitis group; median [IQR] 28[18-52] vs. 50[25-79] nmol/L, respectively, (p = 0.005). Deficient vitamin D levels (< 50 nmol/L) was found more frequently in the bronchiolitis group than controls; 73% vs. 51% (p = 0.028). Multivariate logistic regression showed vitamin D deficiency was more probable in bronchiolitis patients; OR [95% CI] 3.139[1.369-7.195]. No correlation was found between serum vitamin D levels and bronchiolitis severity, which was assessed via Modified Tal Score and by length of hospital stay. CONCLUSION: Children with acute bronchiolitis displayed significantly lower vitamin D levels than children with non-respiratory acute febrile illnesses.

Massive Pneumomediastinum and Subcutaneous Emphysema Secondary to Foreign Body Aspiration.

BACKGROUND: Spontaneous pneumomediastinum (SPM) occurs in cases of mediastinal leaks that are not caused by trauma, mechanical ventilation, or other surgical procedures. In most cases, in the pediatric population a trigger can be identified, most commonly asthma. SPM caused by foreign body aspiration is not a common entity. It is usually a benign condition that generally resolves without severe sequela, but in some cases, severe morbidity and mortality have been documented. Treatment is usually conservative and includes rest, analgesics, and treatment of any underlying pathologies. CASE REPORT: We report a case of a 19-month-old boy who presented to the emergency department with acute facial swelling and wheezing with no history of foreign body aspiration. This misleading presentation led the medical staff in the emergency department to initially treat the patient for anaphylaxis. The diagnosis was made only after imaging modalities demonstrated SPM with a suspected foreign body in the right main stem bronchus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Providers should consider SPM from an aspirated foreign body in young children with respiratory distress and acute facial swelling, especially when crepitus is present. © 2021 Elsevier Inc.

[HYPERTONIC SALINE FOR HOSPITALIZED INFANTS WITH ACUTE BRONCHIOLITIS IN ISRAEL IN 2018].

INTRODUCTION: Inhalations of hypertonic saline is a known therapy for infants diagnosed with acute bronchiolitis. Recent meta-analysis has shown that it can reduce the length of hospitalization and decrease the chances of admission. AIMS: To assess the extent of use of hypertonic saline inhalations in the pediatric wards in Israel in 2018. METHODS: During October 2018 a detailed questionnaire was emailed to all the managers of pediatric wards in Israel. The questions related to treatments given to infants with acute bronchiolitis in pediatric wards and emergency departments in 2018. All results underwent statistical analysis. RESULTS: A total of 22/28 (78%) of all pediatric wards managers completed the questionnaire; 17/22 (77%) routinely use hypertonic saline in their wards. In 15 out of the 17 wards the hypertonic saline is also provided at their emergency department. In 12 wards (70%) the saline is provided together with a bronchodilator, in 4 (24%) with inhaled steroids, and in 2 (12%) with adrenaline. CONCLUSIONS: In most pediatric wards and their emergency departments in Israel, hypertonic saline with bronchodilators is routinely used to treat infants with acute bronchiolitis.