The role of lung ultrasound in the management of acute bronchiolitis

Introduzione: Nonostante l’esistenza di linee guida che scoraggiano il ricorso routinario alla radiografia (Rx) toracica nella bronchiolite acuta, essa è ancora eseguita in oltre il 50% dei soggetti ricoverati, perlopiù nel sospetto di infezione batterica polmonare, con conseguente esposizione non giustificata a radiazioni ionizzanti. Obiettivo primario dello studio è stato valutare sensibilità e specificità dell’ecografia nella diagnosi di polmonite batterica in corso di bronchiolite. Obiettivi secondari sono stati calcolare la concordanza inter-operatore (pediatra versus radiologo) nella diagnosi ecografica di tale complicanza e indagare l’esistenza di indicatori ecografici predittivi del decorso clinico. Materiali e metodi: Sono stati arruolati i pazienti con bronchiolite ricoverati presso la Pediatria d’Urgenza del S.Orsola negli anni 2016-2019 e sottoposti a Rx toracica per sospetta polmonite batterica. Ciascun soggetto è stato sottoposto ad ecografia polmonare da parte di un pediatria. I primi 30 arruolati hanno ricevuto una seconda ecografia eseguita in cieco da un radiologo. Il riscontro di consolidamento con broncogramma è stato considerato indicativo di polmonite batterica. Il gold standard diagnostico utilizzato è stata la diagnosi finale posta da un pediatra esperto all’oscuro dell’ecografia. Risultati: 33/115 pazienti hanno ricevuto la diagnosi finale di bronchiolite complicata da polmonite batterica. Sensibilità e specificità dell’ecografia rispetto alla Rx nella diagnosi di tale complicanza sono risultate rispettivamente 97.0% e 82.9% versus 87.9% e 76.8%. La concordanza ecografica inter-operatore radiologo/pediatra è risultata ottima (K 0.93). Negli 82 pazienti con bronchiolite semplice la presenza di linee B confluenti è risultata correlare con il Clinical Score (p 0.037) e la necessità di ossigenoterapia (p 0.015), il riscontro di consolidamenti subpleurici con una durata maggiore della degenza (p 0.026). Conclusioni: L’inclusione dell’ecografia polmonare nel work-up diagnostico della bronchiolite sembra uno strumento promettente per guidare il clinico nella gestione di tale patologia e ridurre il ricorso alla Rx toracica, limitando l’esposizione alle radiazioni ionizzanti.Background: Guidelines currently do not recommend the routine use of chest x-ray (CXR) in acute bronchiolitis (AB). However, CXR is still performed in a high percentage of cases, mainly to rule out bacterial pneumonia, resulting in children exposure to ionizing radiations. The purpose of this study was to assess the diagnostic accuracy and reliability of LUS for the detection of pneumonia in AB and to assess the correlation between LUS findings and AB severity. Methods: We enrolled children admitted to our hospital in 2016-2019 with a diagnosis of AB and undergone CXR because of clinical suspicion of bacterial pneumonia. LUS was performed in each child by a pediatrician. An exploratory analysis was done in the first 30 patients to evaluate the inter-observer agreement between a pediatrician and a radiologist who independently performed LUS. The diagnosis of pneumonia was established by an expert clinician based on the recommendations of the British Thoracic Society guidelines. Results: A final diagnosis of concomitant bacterial pneumonia was made in 33/115 patients with AB. Sensitivity and specificity of LUS and CXR for the diagnosis of pneumonia were respectively 97.0% and 82.9% versus 87.9% and 76.8%. Cohen's kappa between pediatrician and radiologist sonologists showed a high agreement (K 0.93). A significant correlation emerged between the LUS findings and the severity of AB. Confluents B lines correlate with clinical score (p 0.037) and need for oxygen therapy (p 0.015), and subpleural consolidations correlate with longer hospital stay (p 0.026). Conclusions: This study shows the good accuracy of LUS in diagnosing bacterial pneumonia in children with AB, together with a high inter-observer agreement. Moreover, if confirmed in future studies, LUS may emerge as a useful technique to predict the clinical course of AB and to help clinician in the management of this disease

The Role of HDACs Inhibitors in Childhood and Adolescence Acute Leukemias

Acute leukemia is the most common type of childhood and adolescence cancer, characterized by clonal proliferation of variably differentiated myeloid or lymphoid precursors. Recent insights into the molecular pathogenesis of leukemia have shown that epigenetic modifications, such as deacetylation of histones and DNA methylation, play crucial roles in leukemogenesis, by transcriptional silencing of critical genes. Histone deacetylases (HDACs) are potential targets in the treatment of leukaemia, and, as a consequence, inhibitors of HDACs (HDIs) are being studied for therapeutic purposes. HDIs promote or enhance several different anticancer mechanisms, such as apoptosis, cell cycle arrest, and cellular differentiation and, therefore, are in evidence as promising treatment for children and adolescents with acute leukemia, in monotherapy or in association with other anticancer drugs. Here we review the main preclinical and clinical studies regarding the use of HDIs in treating childhood and adolescence leukemia

Impact of Guidelines Publication on Acute Bronchiolitis Management: 10-Year Experience from a Tertiary Care Center in Italy

Bronchiolitis is the most common lower respiratory tract infection in infants. According to evidence-based guidelines, diagnosis is clinical, there is no need for routine use of laboratory or instrumental tests and therapy is primarily supportive, based on oxygen and adequate fluid supplementation. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. The aim of this retrospective cohort study was to evaluate how the management of bronchiolitis has changed in the last ten years in a Tertiary Care Center in Italy, assessing adherence to national guidelines. Considering the publication of the Italian inter-society consensus document in 2014, we compared patients admitted in the prior four epidemic seasons with patients admitted in the latter six epidemic seasons. The comparison between the two groups showed a significant reduction in the prescription of systemic corticosteroids (58.9% vs. 41.8%, p < 0.001), nebulized epinephrine (73.8% vs. 38.3%, p < 0.001) and antibiotics (59.5% vs. 42.3%, p < 0.001), together with a drastic decrease in the use of chest X-ray (92.2% vs. 54.4%, p < 0.001). On the contrary, the use of inhaled salbutamol remained substantially stable over time (39.4% vs. 37.6%, p = 0.505). Despite the encouraging results, further efforts are needed to limit the prescription of ineffective therapies like antibiotics and inhaled salbutamol

Effect of Adherence to Mediterranean Diet during Pregnancy on Children’s Health: A Systematic Review

The traditional Mediterranean diet has been shown to be a healthy eating pattern that protects against the development of many diseases in adults and children. Pregnancy is a critical period of plasticity during which foetal development may be significantly influenced by different environmental factors, including maternal nutrition. In this context, several studies have examined the potential benefits of adherence to a Mediterranean diet during pregnancy on birth outcomes, considering the Mediterranean diet as a whole rather than focusing on the effect of its individual components. In this review, we systematically summarized and discussed results of studies investigating the protective role of Mediterranean diet against foetal growth, prematurity, neural tube defects and other congenital pathologies, asthma and allergy, body weight and metabolic markers. Although current data are insufficient and randomized control trials are needed, growing evidence suggests the beneficial effect of the Mediterranean diet during pregnancy on children’s health. In this sense, strategies aiming to promote adherence to this dietary pattern might be of considerable importance to public health

Different Pediatric Acute Care Settings Influence Bronchiolitis Management: A 10-Year Retrospective Study

Bronchiolitis is the main cause of hospitalization in infants. Diagnosis is clinical, and treatment is based on hydration and oxygen therapy. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. This retrospective study aimed to evaluate whether the setting of bronchiolitis care influences diagnostic and therapeutic choices. The management of 3201 infants, referred to our Italian Tertiary Care Center for bronchiolitis between 2010 and 2020, was analyzed by comparing children discharged from the pediatric emergency department (PEDd group) undergoing short-stay observation (SSO group) and hospitalization. Antibiotic use in PEDd, SSO, and ward was 59.3% vs. 51.6% vs. 49.7%, respectively (p < 0.001); inhaled salbutamol was mainly administered in PEDd and during SSO (76.1% and 82.2% vs. 38.3% in ward; p < 0.001); the use of corticosteroids was higher during SSO and hospitalization (59.6% and 49.1% vs. 39.0% in PEDd; p < 0.001); inhaled adrenaline was administered mostly in hospitalized infants (53.5% vs. 2.5% in SSO and 0.2% in PEDd; p < 0.001); chest X-ray use in PEDd, SSO, and ward was 30.3% vs. 49.0% vs. 70.5%, respectively (p < 0.001). In a multivariate analysis, undergoing SSO was found to be an independent risk factor for the use of systemic corticosteroid and salbutamol; being discharged at home was found to be a risk factor for antibiotic prescription; undergoing SSO and hospitalization resulted as independent risk factors for the use of CXR. Our study highlights that different pediatric acute care settings could influence the management of bronchiolitis. Factors influencing practice may include a high turnover of PED medical staff, personal reassurance, and parental pressure

Respiratory syncytial virus: The influence of serotype and genotype variability on clinical course of infection

Respiratory syncytial virus (RSV) belongs to the recently defined Pneumoviridae family, Orthopneumovirus genus. It is the leading cause of acute bronchiolitis and one of the most common causes of infant viral death worldwide, with infection typically occurring as recurrent seasonal epidemics. There are two major RSV subtypes, A and B, and multiple genotypes, which can coexist during RSV epidemic season every year and result in different disease severity. Recently, new RSV genomic sequences and analysis of RSV genotypes have provided important data for understanding RSV pathogenesis. Novel RSV strains do spread rapidly and widely, and a knowledge of viral strainspecific phenotypes may be important in order to include the more virulent strains in future therapeutical options and vaccine development. Here we summarize recent literature exploring genetic and molecular aspects related to RSV infection, their impact on the clinical course of the disease and their potential utility in the development of safe and effective preventive and therapeutic strategies

Obesity and the Mediterranean Diet: A Review of Evidence of the Role and Sustainability of the Mediterranean Diet

Several different socio-economic factors have caused a large portion of the population to adopt unhealthy eating habits that can undermine healthcare systems, unless current trends are inverted towards more sustainable lifestyle models. Even though a dietary plan inspired by the principles of the Mediterranean Diet is associated with numerous health benefits and has been demonstrated to exert a preventive effect towards numerous pathologies, including obesity, its use is decreasing and it is now being supplanted by different nutritional models that are often generated by cultural and social changes. Directing governments’ political actions towards spreading adherence to the Mediterranean Diet’s principles as much as possible among the population could help to tackle the obesity epidemic, especially in childhood. This document intends to reiterate the importance of acting in certain age groups to stop the spread of obesity and proceeds with a critical review of the regulatory instruments used so far, bearing in mind the importance of the scientific evidence that led to the consideration of the Mediterranean Diet as not just a food model, but also as the most appropriate regime for disease prevention, a sort of complete lifestyle plan for the pursuit of healthcare sustainability

The Management and Treatment of Acute Bronchiolitis in Infants

Acute bronchiolitis (AB) is the most common lower respiratory tract infection in young infants. It usually has viral etiology, being Respiratory Syncytial Virus (RSV) most frequently involved. The diagnosis is based on clinical history and physical examination, whereas diagnostic studies \u2013 including chest radiograph and blood tests \u2013 are generally not recommended in routine evaluation. To date, no etiologic antiviral drug is regularly used for the treatment of AB. Ribavirin is the only drug approved for RSV infection but its use is limited by the adverse side effects in patients and by the potential toxic risks it poses to health care providers. Other new antiviral agents are now object of ongoing studies. While these trials are still progressing, the current management of AB is essentially supportive, including oxygen therapy and hydration. Supplemental oxygen is the mainstay of treatment.in infants with respiratory distress and hypoxia; it can be administered with several techniques according to the severity of the respiratory impairment, starting from low-flow nasal cannula up to mechanical ventilation. The use of intravenous or nasogastric fluids supplementation is recommended to avoid dehydration in patients with AB and impaired feeding. Although several pharmacological treatments (nebulized hypertonic saline or bronchodilators, systemic corticosteroids or antibiotics) have been routinely administered in infants with AB over the past decades, at present their real efficacy is highly debated and their indication is controversial. Despite the existence of several clinical practice guidelines, many children with AB continue to undergo unnecessary tests and ineffective therapies worldwide. In the present chapter, we summarize the most recent literature about AB to provide an evidence-based approach to the management and treatment of this disease

Personalized Medicine for Pediatric AML: New Targeted StrategiesTopics in Anti-Cancer Research

Acute myeloid leukemia is a heterogeneous group of diseases accounting for 15- 20% of all tumors diagnosed in children under 15 years of age. The past few decades have yielded remarkable improvements in long-term outcomes for children with acute myeloid leukemia. A better risk-group stratification of patients based upon clinical and biologic features, a more effective use of anti-leukemic agents and enormous improvements in supportive care have increased the probability of cure by approximately 60%. The increase in our understanding of the biology of this disease has resulted in the development of molecularly targeted therapies that are potentially more effective and less toxic than the standard approaches. We here review novel molecularly targeted drugs for the treatment of childhood acute myeloid leukemia such as monoclonal antibodies, inhibitors of signalling molecules, proteasome inhibitors and epigenetic agents. For these recently patented agents, we also provide a detailed analysis of the published preclinical data and the clinical trials that have been completed