Inter-society consensus for the use of inhaled corticosteroids in infants, children and adolescents with airway diseases

Background: In 2019, a multidisciplinary panel of experts from eight Italian scientific paediatric societies developed a consensus document for the use of inhaled corticosteroids in the management and prevention of the most common paediatric airways disorders. The aim is to provide healthcare providers with a multidisciplinary document including indications useful in the clinical practice. The consensus document was intended to be addressed to paediatricians who work in the Paediatric Divisions, the Primary Care Services and the Emergency Departments, as well as to Residents or PhD students, paediatric nurses and specialists or consultants in paediatric pulmonology, allergy, infectious diseases, and ear, nose, and throat medicine. Methods: Clinical questions identifying Population, Intervention(s), Comparison and Outcome(s) were addressed by methodologists and a general agreement on the topics and the strength of the recommendations (according to the GRADE system) was obtained following the Delphi method. The literature selection included secondary sources such as evidence-based guidelines and systematic reviews and was integrated with primary studies subsequently published. Results: The expert panel provided a number of recommendations on the use of inhaled corticosteroids in preschool wheezing, bronchial asthma, allergic and non-allergic rhinitis, acute and chronic rhinosinusitis, adenoid hypertrophy, laryngitis and laryngospasm. Conclusions: We provided a multidisciplinary update on the current recommendations for the management and prevention of the most common paediatric airways disorders requiring inhaled corticosteroids, in order to share useful indications, identify gaps in knowledge and drive future research

Sindrome di Ehlers-Danlos: un raro caso di ischemia intestinale e renale

Caso clinico:Un uomo di 52 anni giunge alla nostra osservazioneper dolore epigastrico irradiato ai fianchi ed alvo chiuso a feci egas da alcuni giorni; ipertrofia prostatica all\u2019anamnesi patologicaremota. Obiettivamente addome trattabile, non dolorabile,peristalsi vivace; PA 180/100 mmhg. Gli esami ematochimicimostravano leucocitosi neutrofila (WBC 17,95), incremento ditroponina I (0,108 ng/ml), D-dimero 1207 (ng/ml), LDH (513U/l), CPK (1102 U/l), AST (96 U/l) e ALT (120 U/l) ed elevatiindici biologici di flogosi (PCR 18,9 mg/dl). La TC addomeevidenziava ectasie, dissezione e microaneurismi di tronco celiaco,aa mesenteriche, arcata pancreatico-duodenale ed ileocolica consegni di ischemia intestinale diffusa e lesioni infartuali renalibilaterali per dissezione di vari tratti delle arterie renali. Presenteinoltre dissezione dell\u2019arteria carotide interna destra extracranicaalla TC vasi epicranici. Negativa risultava la sierologia immunitaria;la ricerca genetica per malattia del collagene confermava ladiagnosi di sindrome di Ehlers-Danlos di tipo IV. Il paziente \ue8 stato trattato con eparina ev, antiipertensivi ev con buona rispostaclinica e laboratoristica. Dimesso e seguito in regimeambulatoriale con discrete condizioni cliniche, decedevaimprovvisamente a sette mesi dalla diagnosiConclusioni:La S. di Ehlers-Danlos \ue8 una malattia ereditariadovuta ad alterazioni del collagene e del tessuto connettivo conquadri clinici eterogenei. La forma vascolare (tipo IV) \ue8 la pi\uf9 gravepotendo determinare rottura di grossi vasi e perforazioni visceralifino all\u2019exitus

CHA2DS2-VASC and HAS-BLED scores in the prediction of NVAF-related events in a population of critically ill patients

Background: non-valvular atrial fibrillation (NVAF) is the most common arrhythmia in clinical practice. Its risk increases with age and the presence of comorbidities. NVAF-related morbility is associated to thromboembolic events and, among patients undergoing to anticoagulant therapy, to haemorrhagic complications. Guidelines suggest stratifying the thrombotic risk with CHA2DS2-VASc score and the haemorrhagic risk with HAS-BLED score before initiating any anticoagulant treatment. These two scores share several items, and it is common to observe patients with both an increased thrombotic and haemorrhagic risk. This area represents a \u201cgrey zone\u201d where guidelines are not able to suggest any evidence-based approach. Patients and Methods: we enrolled 519 consecutive, critically-ill subjects affected by permanent NVAF admitted to our Subintensive Medicine department. CHA2DS2-VASc score and HAS-BLED score were calculated at admission. For each patient, we evaluated age, sex, admission diagnosis, comorbidities, thromboembolic and haemorrhagic events. Results: mean age was 75.61(\ub111.92) years; males represented 50.3% of the sample; patients had a median of 2(0-6) comorbidities. We observed 38 haemorrhagic events and 80 thromboembolic events; HAS-BLED had a median of 2(0-5), CHA2-DS2-VASc score had a median of 3(0-6); CHA2DS2-VASc had an AUC of 0.56;95%CI:0.50-0:63(p=0.06); HAS-BLED had an AUC of 0.53;95%CI:0.44-0:62(p=0.53). Discussion: in this population of elderly patients admitted for critical illnesses, CHA2DS2-VASc and HAS-BLED scores have a limited predictive value for both thromboembolic and haemorrhagic events. Newer approaches based on machine learning and topological data analysis could better discriminate the risk factors of NVAF-related complications and give a more reliable prediction of thrombotic or haemorrhagic events

The role of procalcitonin in emergency medicine

evaluate its efficacy. Informations regarding the diagnostic and prognostic role of PCT in the critically ill subject are lacking. Aim of this study was to evaluate the value of PCT in the diagnosis of bacterial infections and its prognostic weight in the unstable patient. Methods: we enrolled 1063 consecutive, critically ill subjects admitted to our Internal Subintensive Medicine Department in the period 2008-2010, evaluating age, sex, haemodynamic parameters, blood exams, PCT and blood cultures. In particular we collected the absolute number of peripheral white blood cells, troponin I (TnI) and serum creatinine. Among hemodynamic parameters, we evaluated the presence of shock (defined as systolic blood pressure < 90 mmHg, low urine output, < 0.5 ml/kg/h and reduced cutaneous perfusion). The degree of severity of the pathology was assessed with the SAPS-II score. We\u2019ve set as outcomes mortality or intensive therapy transfer, overall survival and length of hospital admission. Results: We observed positive cultures in 375 subjects, whose mean PCT levels were significantly higher than in patients without positive cultures (0,84 ng/ml versus 0,20 ng/ml; p<0,0001). ROC curve analysis, however, underlined a sub-optimal role of PCT in predicting bacterial isolation (AUC:0,58;95% CI: 0,54-0,62). 172 patients died, and their mean PCT values were significantly higher than survivors (2,62 ng/ml versus 0,17 ng/ ml; p<0,05). Calculating an optimal cutoff of 0,50 ng/ml, mean time without events among subjects with lower PCT was 44 days compared with 26 days observed in patient with high PCT. The prognostic weight of PCT was superior than TnI, and PCT was correlated with prognosis independently from bacterial infection. A model including SAPS2, troponin I and PCT had a good AUC (0,734; 95%CI: 0,667-0,775) in predicting in-hospital events, such as death or transfer to intensive-care unit. Discussion: Procalcitonin is now a widely used marker of bacterial infection, despite several papers confirmed its low diagnostic yeld. In our population, we confirmed this observation by showing a low correlation between increased PCT and positive bacterial isolates (blood, sputum or urine cultures). However, an increased PCT value was associated, independently from the presence of sepsis or infection, to an increased rate of adverse events and a lower event-free survival. When combined in a model including clinical and serologic markers of severity, such as SAPS2 and troponin I, PCT showed a good prognostic value for in-hospital death or complications by increasing the AUC of the model. This derived model was able to predict adverse event in all the critically ill patients enrolled, independently from the cause of admission. Conclusion: Among critically ill patients PCT has a low diagnostic yeld, with a poor predictive value for positive bacterial cultures. PCT, however, maintains a good prognostic significance in predicting both event-free survival and adverse events during the hospitalization. In particular, PCT increases the prognostic value of commonly used scores, such as SAPS2, and well-recognised prognostic markers, as troponin I. A model including SAPS2, troponin I and PCT is highly predictive for in-hospital adverse events among critically ill patients, and could be used to predict the risk of in-hospital mortality and the probability of transfer to intensive therapy unit

CHA2DS2-VASc and HAS-BLED scores do not predict NVAF-related events in a population of critically ill patients

Background: Non-valvular atrial fibrillation(NVAF) is commonamong critically-ill subjects and is associated to worseoutcomes.NVAF-related morbility is associated to thromboembolicand haemorragic complications.Guidelines suggest stratifying thethrombotic risk with CHA2DS2-VASc and the haemorrhagic risk withHAS-BLED. These scores are not validated for the critically-ill, andguidelines are not able to suggest any evidence-based approach.Patients and Methods: Single-cohort, perspective study enrollingall the consecutive patients admitted to our department for a crit-ical illness and affected by NVAF. We excluded patients admittedfor trauma or surgical pathologies. Embolic outcome(TE) was de-fined as the occurrence of embolic manifestations at the admis-sion or during the hospitalization. Haemorragic outcome(MH) wasdefined as the occurrence of major haemorrhage according toISTH criteria during the hospitalization or at the 12-months follow-up. For each patient, we evaluated age, sex, admission diagnosis,comorbidities, CHA2DS2-VASc, HAS-BLED, TE and MH. Results: 519 subjects[age:75.6(\ub111.9);males:50.3%;comorbidi-ties:2(0-6)].38 MH(7,3%),80 TE(15,4%).HAS-BLED: median of2(0-5),CHA2-DS2-VASc:median of 3(0-6);among MH, HAS-BLED:median of 3(1-4), CHA2-DS2-VASc:median of 2(1-3);amongTE,HAS-BLED: median of 2(1-3), CHA2-DS2-VASc:median of 3(1-4);CHA2DS2-VASc had an AUC of 0.56[95%CI:0.50-0:63(p=0.06)] for TE;HAS-BLED had an AUC of 0.53 [95%CI:0.44-0:62(p=0.53)] for MH. Discussion: In this population, CHA2DS2-VASc and HAS-BLEDhad limited predictive value for TE and MH

AIDS related neoplasms in Genoa, Italy

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A case of fever in emergency medicine: the importance of clinical evaluation

A 38-years-old woman was referred to our subintensive medicine department for persistent fever associated to epigastric pain, nausea and vomiting. At the arrival, blood exams showed severe pancytopenia and increase of AST. Her clinical history did not reveal any significant associated pathology, but she complained of a recent history of three months of persistent fever, relapsing despite different antibiotic treatments and oral steroid treatment given by her general practitioner. Physical examination showed a marked increase of haepatic and splenic volume, signs of bilateral pleural effusion and the presence of continuous fever. Our first diagnostic hypotheses ranged between a subacute viral infection to a severe haematologic disorder. In the second day, blood examinations showed EBV-DNA positivity. Serum antibodies were not suggestive for autoimmunity. Despite this finding, we also observed markedly increased ferritin (> 500 ng/ml) and trygliceride levels (> 1000 mg/dl), a positive beta2-microglobilin and a markedly reduced serum haptoglobin and fibrinogen levels. A total body CT-scan showed diffuse lymphadenopathy and confirmed the bilateral pleural effusion and the marked hepato-splenomegaly observed clinically at the admission. For this reason, we proceeded with a peripheral blood cell immunophenotypization, which resulted suggestive for a chronic lymphoproliferative T-cell disorder. At this point, we felt confident in restricting our diagnostic hypotheses: particularly, the presence of a markedly increased serum ferritin and trygliceride levels and hypofibrinogenemia were strongly suggestive for lymphoma-associated haemophagocytic syndrome. For this reason, we evaluated serum IL-6 levels, which resulted markedly raised, and performed a bone marrow biopsy, showing "aspects of haemophagocytosis in perypheral T-cell lymphoma", confirming the diagnosis of haemophagocytic syndrome complicating a T-cell lymphoma. We started immediately both specific and supportive therapy for haemophagocytic syndrome, starting with high-dose metilprednisolone (1000 mg/die) and continuous haemodiafiltration to reduce rapidly serum cytokine levels. However, after an initial improvement in her clinical conditions, in the fifth day she developed acute respiratory failure and was urgently transferred to the intensive care unit, where she died the day after for multi-organ failure. Haemophagocytic lymphoistiocytosis, or haemofagocytic syndrome, is a rare group of pathologies commonly associated to several conditions, ranging from infections to autoimmunity and malignancies, characterized by a poor prognosis. Early recognition and aggressive treatment of this syndrome are essential to increase the survival probabilities, which still remain very low despite optimal medical treatment