Giorgio Cozzi

Analgesia by cooling vibration during venipuncture in children with cognitive impairment.

Children with cognitive impairment experience pain more frequently than healthy children and are more likely to require venipuncture or intravenous cannulation for various procedures. They are frequently unable to report pain and often receive poor pain assessment and management. This study assessed the effectiveness of physical analgesia during vascular access in children with cognitive impairments.

Anti-transglutaminase 6 autoantibody development in children with celiac disease correlates with duration of gluten exposure

Objectives: Antibodies against transglutaminase 6 (anti-TG6) have been implicated in neurological manifestations in adult patients with genetic gluten intolerance, and it is unclear whether autoimmunity to TG6 develops following prolonged gluten exposure. We measured the anti-TG6 in children with celiac disease (CD) at the diagnosis time to establish a correlation between these autoantibodies and the duration of gluten exposure. We investigated a correlation between anti-TG6 and the presence of neurological disorders. Methods: Anti-TG6 (IgA/IgG) were measured by ELISA in sera of children with biopsy-proven CD and of children experiencing gastrointestinal disorders. CD patients positive for anti-TG6 were retested after 2 years of gluten-free diet (GFD). Results: We analyzed the sera of 274 CD children and of 121 controls. Anti-TG6 were detected in 68/274 (25%) CD patients and in 19/121 (16%) controls, with significant difference between the 2 groups (P = 0.04). None of the CD patients and of the controls testing positive for anti-TG6 were experiencing neurological disorders. Eleven of 18 (61%) CD patients with other autoimmune diseases were positive for anti-TG6. In CD patients, a significant correlation between the gluten exposure before the CD diagnosis and anti-TG6 concentration was found (P = 0.006 for IgA; P < 0.0001 for IgG). After GFD anti-TG6 concentrations were significantly reduced (P < 0.001). No significant correlation was observed between anti-TG6 and anti-TG2 serum concentrations. Conclusions: Anti-TG6 are more prevalent in children with untreated CD in the absence of overt neurological disorders. The synthesis of the anti-TG6 is related to a longer exposure to gluten before the CD diagnosis, and the autoimmunity against TG6 is gluten dependent and disappeared during GFD.

Somatic symptom disorder was common in children and adolescents attending an emergency department complaining of pain

The aim of this study was to quantify the prevalence of somatic pain in a paediatric emergency department (ED).

Hand-held computers can help to distract children undergoing painful venipuncture procedures

Needle‐related procedures can be painful for children, and distraction provides ideal pain relief in blood‐drawing centres. This study assessed the effectiveness of playing a computer game during venipuncture, compared with low‐tech distraction by a nurse.

Intranasal Dexmedetomidine for Procedural Sedation in Children, a Suitable Alternative to Chloral Hydrate

Sedation is often required for children undergoing diagnostic procedures. Chloral hydrate has been one of the sedative drugs most used in children over the last 3 decades, with supporting evidence for its efficacy and safety. Recently, chloral hydrate was banned in Italy and France, in consideration of evidence of its carcinogenicity and genotoxicity. Dexmedetomidine is a sedative with unique properties that has been increasingly used for procedural sedation in children. Several studies demonstrated its efficacy and safety for sedation in non-painful diagnostic procedures. Dexmedetomidine’s impact on respiratory drive and airway patency and tone is much less when compared to the majority of other sedative agents. Administration via the intranasal route allows satisfactory procedural success rates. Studies that specifically compared intranasal dexmedetomidine and chloral hydrate for children undergoing non-painful procedures showed that dexmedetomidine was as effective as and safer than chloral hydrate. For these reasons, we suggest that intranasal dexmedetomidine could be a suitable alternative to chloral hydrate.

Combination of intranasal dexmedetomidine and oral midazolam as sedation for pediatric MRI

passage of the ETT, the length of the bougie should be long enough to accommodate the full length of the ETT as well as extend beyond the proximal end of the tube, so that an assistant can hold it firmly while threading the ETT. In children, one of the commonly used introducer is Cook’s 8 French Frova introducer with a length of 35 cm. It is recommended for ETTs with an internal diameter of 3.5 to 5 mm. The length of a pediatric Frova is adequate when used with endotracheal tubes of internal diameter up to 4.5 mm ID but its length falls short with larger tubes. The average length of 5 mm ID ETT from various manufacturers varies from 24 to 25 cm with the exclusion of the universal circuit adaptor, which makes it impossible to hold the proximal end of introducer once the ETT is railroaded over it (Figure 1). This necessitates discontinuing the current attempt of intubation. As the intubation attempts increase, the risk of airway trauma and desaturation also increases. To ensure smooth railroading of the ETT, the pediatric airway introducer should be at least twice the length of the ETT. Otherwise one simple solution to avoid these problems would be to use a preshortened tube cut to the length appropriate for the age and height of the child. The shortened ETT provides an additional benefit of reducing the airway resistance. Another option is to preload the regular length ETT on the introducer with its bent tip extending just beyond the bevel of ETT. The manufacturer recommends preloading of the ETT over Frova while using as an intubation aid. This technique provides ample length of the introducer beyond the proximal end of the tube but if tube exchange is needed due to improper size, the same problem of inadequate length will crop up; therefore, a shortened tube should be kept standby. This simple step of shortening the ETT while using pediatric Frova introducer can avoid unwanted stress while managing a difficult airway in children and smoothen the process of intubation.

An adolescent with disabling abdominal pain

A previously healthy teenager was taken to a paediatric emergency department with abdominal pain, nausea, and fatigue. The pain had started four months earlier and had increased in severity and frequency, occurring daily in the past month and resulting in her missing three weeks of school and preventing her from participating in other activities. Painkillers had not helped. The results of repeated diagnostic tests were all normal, including complete blood cell count; blood and faecal inflammatory markers; renal, hepatic, and pancreatic function; urine analysis; and serial abdominal ultrasound scans. Despite repeated medical evaluations, there was no defined diagnosis. The girl reported a dull discomfort in the periumbilical area. She had no fever, vomiting, stool alteration, weight loss, nocturnal pain, or sleep problems. Her parents were concerned that this was a serious illness, given the worsening of symptoms over the past month, the lack of response to drug treatment, and the absence of a clear diagnosis. On examination, the girl appeared well, although she rated her pain 8 out of 10. Vital signs were normal and cardiorespiratory and abdominal examinations were unremarkable.

Intranasal dexmedetomidine, as midazolam-sparing drug, for MRI in preterm neonates

1. Abraham M, Wadhawan M, Gupta V, Singh AK. Cardiopulmonary resuscitation in the lateral position: is it feasible during pediatric intracranial surgery? Anesthesiology. 2009;110(5):1185-1186. 2. Bengali R, Janik LS, Kurtz M, McGovern F, Jiang Y. Successful cardiopulmonary resuscitation in the lateral position during intraoperative cardiac arrest. Anesthesiology. 2014;120(4):1046-1049. 3. Travers AH, Rea TD, Bobrow BJ, et al. Part 4: CPR overview: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;18(suppl 3): S676-S684.

Facing somatic symptom disorder in the emergency department: Somatic symptom disorder

Somatic symptom disorder is a condition in which a patients subjective report of physical symptoms is associated with distress; disruption of day‐to‐day functioning; or disproportionate thoughts, feelings and behaviours regarding the symptoms, whether or not they are associated with an identified medical condition. While somatic symptom disorder affects a considerable proportion of children and adolescents presenting to the emergency department (ED), it has not been well investigated in the ED literature, nor is there much formal training in, or guidelines for, how to care for affected patients in the ED. The aim of this paper is to highlight the historical clues commonly reported by these patients in order to try to help the emergency physicians recognise patients affected by a somatic symptom disorder. Adolescent age, the presence of daily subjective symptoms presenting daily for weeks or months, a long medical history record, an extensive diagnostic workup and, most of all, disproportionate functional impairment related to the symptoms are all features strongly suggestive of this disorder. Emergency physicians should become used to taking advantage of these clues to formulate a positive diagnosis of somatic symptom disorder according to the most recent diagnostic criteria. Emergency physicians have the unique opportunity to contribute to the correct diagnosis and treatment of these patients and to have a positive impact on their prognosis.

Still toddler: A clinical clue for acute appendicitis: Still toddler

A previously healthy 30-month-old boy presented to the emergency department with a 2-days history of repeated non-bilious vomiting, low-grade fever and refusal to stand or walk. The day before admission, he had been evaluated by his general practitioner and a viral intestinal infection was suspected. The re-evaluation was prompt by the fact that in the next hours at home he was continuously lying in his bed, refusing to walk or play. On examination, he was alert, vital signs were normal, body temperature was 37.5 C and no signs of dehydration were noted. He was apparently not suffering, calm while lying on the table, trying to limit movements and to keep a still body position. He started crying after palpation of the right lower abdominal quadrant. No guarding or rebound tenderness were noted. Bowel sounds were present. An acute appendicitis was suspected and a diagnostic work-up was performed. Blood tests showed an increased white blood count (20.4 × 10/L) with neutrophilia (17.4 × 10/L) and an elevated C-reactive protein 5.26 mg/dL. Abdominal ultrasonography revealed a hypoanechoic dilated appendix (>1 cm) with peripheral hypervascularity at colour-Doppler analysis with a visible appendicolith (Fig. 1). The patient was admitted to the surgical department and an appendectomy was performed. He recovered without complications.