Transcatheter versus surgical treatment for isolated superior sinus venosus atrial septal defect.

BACKGROUND: The superior sinus venosus atrial septal defect is a congenital communication between the left and right atria. Open surgical approach by patch closure has historically been the only treatment option. Recently, a transcatheter approach has been developed. This study aims to compare the efficacy and safety of surgical and transcatheter approach in treatment of sinus venosus atrial septal defect. METHODS: Between March 2010 and December 2020, 58 patients (median age: 45.4, range 14.8-73.8) underwent either surgical or transcatheter correction of superior sinus venosus atrial septal defect with partial anomalous pulmonary venous drainage. RESULTS: Twenty-four patients (median age: 35.4, range 14.8-66.8) underwent surgery while 34 patients (median age: 46.8, range 15.5-73.8) had a transcatheter treatment. During the catheterization era, 41 patients was considered suitable for a transcatheter closure. In 5 patients, surgery was the patient's or referring physician's choice. In 2 cases, the procedure was unsuccessful; the remaining 34 were successfully closed (94.4% of cases). Intensive care unit stay (median of 1 day, range 0.5-4, vs. 0, range 0-2, p < 0.0001) and hospital stay (median 7 days, range 2-15 vs. 2 days, range 1-12, p < 0.0001), were significantly longer in the surgery group. Total early complication rate, consisted on procedural and in-hospital complication, were higher in the surgical group (62.5% vs. 23.5%; p = 0.005). However, complications in both groups were clinically mild. At follow-up, a small residual shunt was present in 6 patients (surgery group: 2 pts; catheterization group: 4 pts; p: NS). Imaging studies showed significant improvement of right ventricular size and unobstructed pulmonary venous return in all patients. No late complications occurred at follow-up. CONCLUSIONS: Transcatheter correction of sinus venosus atrial septal defect is effective and safe in selected patients and may be considered as a valid alternative to surgery.

PECARN Rule in diagnostic process of pediatric patients with minor head trauma in emergency department.

This study aims to evaluate the efficacy of the PECARN Rule (PR) in reducing radiological investigations in children with mild traumatic head injury in comparison with current clinical practice. A retrospective study was performed in our hospital between July 2015 and June 2020. Data of all children < 18 years of age admitted to the emergency department (ED), within 24 h after a head trauma with GCS ≥ 14, were analyzed. PECARN Rule was retrospectively applied to all patients. In total, 3832 patients were enrolled, 2613 patients ≥ 2 years and 1219 < 2 years. In the group of children ≥ 2 years, 10 presented clinically important traumatic brain injury (ciTBI) and were hospitalized, 7/10 underwent neurosurgery, and 3/10 clinical observation in the pediatric ward for more than 48 h. In children < 2 years, only 3 patients presented ciTBI, 2 underwent neurosurgery and 1 hospitalized. Applying the PR, no patient with ciTBI would have been discharged without an accurate diagnosis and we would have avoided 139 CT scans in patients ≥ 2 years, and 23 in those < 2 years of age (29% less). CONCLUSION: We demonstrated the safety and validity of the PR in our setting with 100% sensitivity in both age groups in identifying patients with ciTBI and theoretically in reducing performed CT scans by 29%. Therefore, in patients classified in the low-risk category, it is a duty not to expose the child to ionizing radiation. WHAT IS KNOWN: • CT is the gold standard to identify intracranial pathology in children with head injury but CT imaging of head-injured children expose them to higher carcinogenic risk. • PECARN Rules support doctors in identifying children with ciTBI in order to reduce exposure to ionizing radiation. WHAT IS NEW: • We demonstrate the safety and validity of the PR with 100% sensitivity in both age groups in identifying patients with ciTBI. • In our setting, the application of PECARN Rule would theoretically have allowed us to reduce the CT scan by 29%.

Oral allergy syndrome by fruit and vegetable PR-10 allergy: Accuracy of in vivo diagnosis.

Routine diagnostic methods for allergies to plant-derived foods are based on skin prick test (SPT) with commercial extracts, prick-by-prick (PbP) with fresh food, serum-specific IgE measurement, and oral food challenge.We discuss the possibility and the advantages of performing, in patients with oral allergy syndrome (OAS) by fruit and vegetables (excluding nuts) PR-10 allergy, component-resolved diagnosis (CRD) by SPT and PbP with raw and cooked vegetables, rather than performing a CRD with in vitro tests by drawing blood.Based on our clinical experience and the studies published in the literature, we believe that, at least for the OAS by fruit and vegetables (excluding nuts) PR-10 allergy, the search for sensitizing allergens and related cross-reactive allergens with SPT and PbP can be performed routinely in clinical practice, even at the primary-care level.

Role of Troponin Determination to Diagnose Chest Pain in the Pediatric Emergency Department.

OBJECTIVES: Chest pain is a common cause to admission to the pediatric emergency department and often leads to an extensive cardiac evaluation. The objective of this study was to evaluate the usefulness of the troponin (TN) plasma level determination in the initial phase of the differential diagnosis of chest pain in children. METHODS: This is a retrospective observational study on 107 patients, aged 0 to 19 years, admitted for chest pain to the pediatric emergency department of our institution. Demographics, clinical data, and patient outcomes were analyzed. Troponin values of >0.03 ng/mL but <0.1 ng/mL were considered suspected for cardiac pathology, whereas levels of >0.1 ng/mL were indicative of cardiac pathology. In these latter patients, an echocardiographic examination was also performed. RESULTS: Only 99 patients were evaluated with electrocardiogram (ECG). In 91 of 99 patients of our series, both TN determination and ECG recording were performed. Troponin was higher than the cutoff value (0.03 ng/mL) in 9 patients (9.1%). Only 2 of the 9 patients who presented high TN values showed a nonpathological ECG, whereas 16 (17.5%) of 91 patients in whom both ECG and TN determination were performed had ECG abnormalities without a simultaneous elevation of TN. Of the 26 patients who had medical history and suggestive targets of cardiac pathology, only in 6 (23.1%) of them the diagnosis was confirmed. The final diagnosis of the 99 patients was idiopathic chest pain in 45.4% of cases. CONCLUSIONS: Even with the low cost and the relatively easiness for the plasma level determination, TN should be measured only in children with chest pain associated to familiar history suggestive of cardiovascular disease and/or clinical symptoms and/or ECG alterations.

The Use of Lung Ultrasound to Monitor the Antibiotic Response of Community-Acquired Pneumonia in Children: A Preliminary Hypothesis.

Community-acquired pneumonia (CAP) is associated with high morbidity and mortality among children worldwide. Over the last 10 years, lung ultrasound (US) has been widely studied as an alternative diagnostic tool for adult and pediatric CAP with excellent results. In this case series, we describe clinical and laboratory results as well as detailed lung US findings in 6 children with CAP, showing the potential use of lung US in monitoring the response to antibiotic therapy.

Usefulness and Clinical Impact of Whole-Body MRI in Detecting Autoimmune Neuromuscular Disorders.

Autoimmune neuromuscular diseases are a group of heterogenous pathologies secondary to the activation of the immune system that damage the structures of the peripheric nerve, the neuromuscular junction, or the skeleton muscle. The diagnosis of autoimmune neuromuscular disorders comprises a combination of data from clinical, laboratory, electromyography, imaging exam, and biopsy. Particularly, the whole-body MRI examination in the last two decades has been of great use in the assessment of neuromuscular disorders. MRI provides information about the structures involved and the status of activity of the disease. It can also be used as a biomarker, detect the pattern of specific muscle involvement, and is a useful tool for targeting the optimal muscle site for biopsy. In this work, we summarized the most used technical protocol of whole-body MRI and the role of this imaging technique in autoimmune neuromuscular disorders.

Sensitivity of prick test with walnut commercial extracts and of prick by prick with raw walnut compared with open food challenge in walnut allergy.

BACKGROUND AND AIM: Diagnosis of walnut allergy includes the evaluation of IgE sensitization by skin prick tests (SPT) with standardized commercial extracts. When assuming the loss of relevant allergens due to extract preparation and storage, it is possible to perform SPT with fresh foods, i.e., prick by prick (PbP). To our knowledge, there is no published comparison between SPT with commercial extracts and PbP with fresh food about their sensitivity to the diagnosis of walnut allergy. Therefore, we describe our experience. METHODS: We observed seven children (mean age + SD 6.8 years + 5.2, range 2 - 15 years; male 85%) with an history of immediate adverse reaction following walnut ingestion. All but one the patients underwent SPT with at least two out of three walnut commercial extracts (Lofarma, Milan, Italy; ALK-Abellò, Milan, Italy; Allergopharma, Rome, Italy). It has also been performed PbP with raw walnut. IgE-mediated walnut allergy was diagnosed based on suggestive history, positivity of PbP and failed open food challenge with walnut. RESULTS: The SPT with Lofarma extract was never positive (sensitivity = 0%), that performed with ALK extract was positive in 2/5 cases (sensitivity 40%) and that of Allergopharma extract was positive in 1/5 cases (sensitivity 20%). PbP was positive in 7/7 cases (sensitivity 100%). CONCLUSIONS: In the specific case of walnut allergy in pediatric age, the execution of SPT alone with commercial extract may not be sufficient and clarifying in the diagnostic iter. We suggest to always associate the execution of PbP test.

Complications associated with myocardial bridging in four children without underlying cardiac disease: a case series.

BACKGROUND: Myocardial bridging is largely considered to be a benign, symptomless congenital anomaly of the coronary arteries in which the intramyocardial coronary course is partially 'tunnelled' and leads to vessel compression during ventricular systole. There are few data regarding children. OBJECTIVE: To report on myocardial bridging observed in children seeking medical help in the paediatric emergency room. CASE PRESENTATION: A series of four children aged 6-13 years with symptomatic myocardial bridging but no other underlying cardiac abnormalities is reported. They were admitted to the paediatric emergency department during 2013-2016, three with chest pain after physical activity and one with septic shock. RESULTS: Heart computed tomography scan in the first three demonstrated myocardial bridging of the left anterior descendent coronary artery's branches; their 2-year follow-up was uneventful. The fourth patient presented with ventricular fibrillation 24 hours after admission and at autopsy there was an intramyocardial tract 4 cm long on the left anterior descendent coronary artery. CONCLUSIONS: This case series demonstrates that myocardial bridging can be symptomatic in children with no underlying cardiac disorders and should be included in the differential diagnosis of exertional chest pain and/or arrhythmias.Abbreviations: CRP, C-reactive protein; CT, computed tomography; D1, diagonal 1 artery; ECG, electrocardiogram; ED, emergency department; KD, Kawasaki disease; LAD, left anterior descending coronary artery; MB, myocardial bridging; RI, ramus intermedius artery; TN, troponin.

Resolution of Giant Coronary Aneurisms in a Child With Refractory Kawasaki Disease Treated With Anakinra.

Kawasaki disease (KD) is an acute, febrile illness of unknown etiology that mainly affects children under 5 years of age. intravenous immunoglobulin (IVIG), the standard treatment, has reduced coronary involvement to <5%. Patients who do not improve after an initial IVIG have a higher risk of developing coronary arteries aneurysms, and its optimal treatment remains controversial. We present a case of IVIG, steroids, and infliximab-resistant KD in a 9-month-old child, which developed giant aneurysms and was successfully treated with anakinra, a recombinant antagonist of the IL-1 receptor. In our case, the introduction of IL-1 receptor antagonist therapy seems to have blocked the disease from both a clinical and a laboratory point of view. We also noted a very rapid regression of coronary aneurysms passed from giant aneurysms to small ones, or, as in the case of the anterior descending artery, the complete disappearance of the aneurysm formation. We think that our case adds more evidences to the potential role of IL-1RA as therapy in some selected cases of refractory KD, in particular with severe involvement of coronary arteries, although new efficacy trials are needed to better understand the role of Anakinra in these patients.