Irene Raffaldi

Drug use and upper gastrointestinal complications in children: a case-control study

Objective To evaluate the risk of upper gastrointestinal complications (UGIC) associated with drug use in the paediatric population. Methods This study is part of a large Italian prospective multicentre study. The study population included children hospitalised for acute conditions through the emergency departments of eight clinical centres. Patients admitted for UGIC (defined as endoscopically confirmed gastroduodenal lesions or clinically defined haematemesis or melena) comprised the case series; children hospitalised for neurological disorders formed the control group. Information on drug and vaccine exposure was collected through parental interview during the childrens hospitalisation. Logistic regression was used to estimate ORs for the occurrence of UGIC associated with drug use adjusted for age, clinical centre and concomitant use of any drug. Results 486 children hospitalised for UGIC and 1930 for neurological disorders were enrolled between November 1999 and November 2010. Drug use was higher in cases than in controls (73% vs 54%; p<0.001). UGICs were associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) (adjusted OR 2.9, 95% CI 2.1 to 4.0), oral steroids (adjusted OR 2.9, 95% CI 1.7 to 4.8) and antibiotics (adjusted OR 2.3, 95% CI 1.8 to 3.1). The duration of use of these drug categories was short (range 1–8 days). Paracetamol showed a lower risk (adjusted OR 2.0, 95% CI 1.5 to 2.6) compared to ibuprofen (adjusted OR 3.7, 95% CI 2.3 to 5.9), although with partially overlapping CIs. Conclusions NSAIDs, oral steroids and antibiotics, even when administered for a short period, were associated with an increased risk of UGIC.

Effectiveness and safety of the A-H1N1 vaccine in children: A hospital-based case - Control study

Objective To verify whether vaccination against the A-H1N1 virus in the paediatric population was effective in preventing the occurrence of influenza-like illness (ILI) or was associated with adverse events of special interest. Design, setting and patients A case–control analysis was performed as part of surveillance of children hospitalised through the emergency departments of eight paediatric hospitals/wards for ILI, neurological disorders, non-infectious muco-cutaneous diseases and vasculitis, thrombocytopaenia and gastroduodenal lesions. Results Among 736 children enrolled from November 2009 to August 2010, only 25 had been vaccinated with the pandemic vaccine. Out of 268 children admitted for a diagnosis compatible with the adverse events of special interest, six had received the A-H1N1 vaccine, although none of the adverse events occurred within the predefined risk windows. Only 35 children out of 244 admitted with a diagnosis of ILI underwent laboratory testing: 11 were positive and 24 negative for the A-H1N1 virus. None of the A-H1N1 positive children had received the pandemic vaccine. The OR of ILI associated with any influenza vaccination was 0.9 (95% CI 0.1 to 5.5). Conclusions The study provides additional information on the benefit–risk profile of the pandemic vaccine. No sign of risk associated with the influenza A-H1N1 vaccine used in Italy was found, although several limitations were observed: in Italy, pandemic vaccination coverage was low, the epidemic was almost over by mid December 2009 and the A-H1N1 laboratory test was performed only during the epidemic phase (in <10% of children). This study supports the importance of the existing network of hospitals for the evaluation of signals relevant to new vaccines and drugs.

Moxifloxacin for the treatment of pulmonary tuberculosis in children: A single center experience

To report our experience on the safety and tolerability of moxifloxacin for treating children affected by pulmonary TB.

An uncommon cause of seizures in children living in developed countries: neurocysticercosis -a case report

Neurocysticercosis represents an important cause of seizures in children in endemic countries, such as Latin America, Asia and sub-Saharan Africa, while in Europe, especially in Italy, the cases of neurocysticercosis are anectodal. We report the case of a 6 year old boy, born and lived for four years in Cameroon, who presented a right emiconvulsion. The diagnosis was neurocysticercosis. This case accentuates the need to consider neurocysticercosis in a child presenting with non febrile seizures, mainly if he emigrated from an area of high prevalence or if he had long-term stay in endemic regions.

How to manage neonatal tuberculosis

This article reports the recommendations for managing neonatal tuberculosis (TB) drawn up by a group of Italian scientific societies. The Consensus Conference method was used, and relevant publications in English were identified through a systematic review of MEDLINE and the Cochrane Database of Systematic Reviews from their inception until 31 December 2014. Group experts concluded that if suspicion is aroused, it is necessary to undertake promptly all of the investigations useful for identifying the disease not only in the newborn, but also in the mother and family contacts because a diagnosis of TB in the family nucleus can guide its diagnosis and treatment in the newborn. If the suspicion is confirmed, empirical treatment should be started. Breast-fed newborns being treated with isoniazid should be given pyridoxine supplementation at a dose of 1 mg kg−1 day−1. Mothers with active-phase TB can breast-feed once they have become smear negative after having received appropriate treatment.

Primary sternal osteomyelitis in paediatric age: a case report with review of the literature

Osteomyelitis of the sternum is a rare clinical entity, mostly described in adults following cardiothoracic surgery, sternotomy, blunt chest traumas, intravenous line insertion and mediastinitis. When no predisposing factors can be demonstrated and no focus of infection other than sternal localization can be found, a diagnosis of primary sternal osteomyelitis (PSO) can be made. To date, slightly more than 20 cases of PSO have been documented in children: sternum ossification points are in their maximal activity phase in earlier paediatric age, representing a privileged area for bacterial growth after haematogenous bacterial spread. 1‐3 A healthy 15-month-old male came to our attention for midsternal swelling. He had a 20-day history of nocturnal awakening and weeping, with a febrile episode treated with paracethamol one week before hospital admission. Thenceforward he looked nervous and presented respiratory difficulties. No local traumas were reported. Upon examination, the child was afebrile, easily irritable and without apparent respiratory disturbances. An ill-defined midsternal swelling of 3 cm in diameter was palpable: it was tender, warm, painful, with reddening of the upper skin. White cell count was elevated (16.31610 3 /ml) with neutrophilia (53.7%, 8.76610 3 /ml); erythrocyte sedimentation rate and C-reactive protein were increased (120 mm/hour and 66.4 mg/l, respectively). No sternum alteration at X-rays was evident. Ultrasounds revealed a hypoecogen colliquating mass, with underlying cartilage and periosteum alterations. The magnetic resonance imaging (MRI) showed capsular exudate and synovial hyperplasia, with manubrium sterni joint’s arthritis and osteomyelitis of the underlying bone. As osteonecrosis and skeletal abnormalities were also sorted out, a diagnosis of PSO was made. Blood cultures performed at admission were sterile, even though the child had not been treated with antimicrobials. An increased antistaphylolysin titer (.8 U/ml, normal value ,2 U/ml) was documented, suggesting a possible staphylococcal infection. The child was given empiric antibiotic therapy with IV teicoplanin (10 mg/kg/day following a loading dose of 20 mg/kg/ day) and ceftriaxone (80 mg/kg/day), which lead to a prompt decrease in white cells, neutrophil count, inflammation indices and clinical improvement. Given the clinical and laboratory findings, fine needle aspiration of the mass was deemed unnecessary. After 10 days of antimicrobial therapy, due to the onset of a febrile maculopapular rash, teicoplanin and ceftriaxone were replaced by IV meropenem (60 mg/kg/day) and oral rifampicin (20 mg/kg/day). The child was discharged after 31 days in good general conditions, with a sensible reduction of the midsternal swelling. Oral rifampicin and trimethoprim/sulfamethoxazole (TMP/SMX, 10 mg/kg/day of TMP) were administered as outpatient for a total antibiotic course of 6 weeks. No relapses were found at follow-up: in particular, the MRI test of the sternum performed 3 months later showed complete bone resolution. In spite of its rarity, PSO should be considered in the differential diagnosis of sternal swelling in paediatric patients. Unfortunately, clinical symptoms are not specific, and history of trauma is absent in the majority of cases. Sickle cell disease is the sole predisposing condition clearly identified in paediatric age, 4 as these

Quantiferon Tb Test in Children With Miliary Tuberculosis.

W report 2 cases of miliary tuberculosis (TB) with late development of a positive result in tuberculin skin test (TST) and QuantiFERON TB In Tube (QFT-GIT) test. The first case was a 2-year-old female of Romanian origin with a recent history of fever and cough. The chest radiograph showed blurred interstitial thickening in the right lung field and the thoracic computed tomography scan confirmed the presence of diffuse nodular opacities. Both TST and QFT-GIT tests had negative results. The screening of family members did not show any case of active TB, but the mother was diagnosed with latent TB. Three samples of gastric aspirate and urine were collected for microscopic identification of acid-fast bacilli, culture and real-time polymerase chain reaction for identification of Mycobacterium tuberculosis. They were all negative. Congenital and acquired immunodeficiencies were excluded. Despite the absence of a known source of infection and the negativity of the TST and interferon-gamma releasing assay tests, because of the epidemiologic data and the strong radiologic suspicion of miliary TB, the patient was started on TB treatment with first-line drugs, with rapid clinical improvement. Two months later, TST and QFT-GIT were repeated and were positive. The computed tomography scan had improved. The girl has been given a total of 12-month anti-TB therapy. She is currently in follow-up. The second case was a Senegalese male, 8 years old, in Italy since 2 years of age. He presented to our hospital with 1 week of fever and fatigue. The chest radiograph showed a bilateral basal nonhomogeneous density. The computed tomography scan highlighted the presence of multiple areas of increased pulmonary parenchymal density with increased bilateral hilar lymph nodes, one of which calcified. No immune deficiencies were found. Because of suspected miliary TB, TST and QFT-GIT were performed and were negative. Nonetheless,

Surveillance Study of Healthcare-Associated Infections in a Pediatric Neurosurgery Unit in Italy

Background: This prospective surveillance study was designed to estimate the incidence of healthcare-associated infections (HAIs) and to analyze the risk factors for their development in a pediatric neurosurgical unit. Methods: The study was performed in an Italian teaching hospital from October 2008 through March 2010. All children (0–18 years) undergoing neurosurgery were included and monitored daily for the development of HAIs. Results: The study included 260 patients, with a mean age of 4.3 ± 4.7 years. Thirty-six HAIs were detected in 25 patients; catheter-related infections were the most frequent. Etiological identification was available in 22 cases; Gram-negative bacteria were the most commonly isolated pathogens. The incidence density was 11.0/1,000 patient days, and the incidence rate was 13.8/100 patients. The crude mortality was 0%. The risk of developing HAIs was related to the length of hospital stay, while the higher the age of the patients, the lower the risk of developing HAIs. Conclusion: To our knowledge, this survey is the first study to evaluate the overall incidence of HAIs and to explore the risk factors implicated in their development in neurosurgical pediatric patients. The most effective strategies to prevent these infections are reduction of the length of the hospital stay and improvement in device management.