Respiratory syncytial virus (RSV) bronchiolitis is a very common infection in infants and, after the acute phase, a number of patients develop a reactive airway disease that lasts for years. Although the pathogenesis of the lung damage after RSV bronchiolitis is still largely unknown, previous studies suggest that leukotrienes may play an active part in it. The aim of this study was to measure leukotriene levels in the nasal lavage fluid (NLF) collected in infants during RSV bronchiolitis and 1 month later. Cysteinyl leukotrienes (Cys‐LTs) and leukotriene B 4 (LTB 4 ) were measured in the NLF of 22 infants with their first episode of RSV bronchiolitis and 16 healthy infants. A second NLF sample was collected to measure leukotriene levels 1 month after the acute disease. NLF Cys‐LT levels were significantly higher in infants with RSV bronchiolitis than in healthy controls [950 pg/ml (285.5–2155.9) vs. 110.5 pg/ml (66.5–451.3), p = 0.01], and they remained so a month after the acute infection (p = 0.02). A subanalysis showed no difference in Cys‐LTs concentrations, either between bronchiolitis infants with and without a family history of atopy, or between those with and without passive exposure to cigarette smoke. No significant difference was found between the LTB 4 levels measured in the bronchiolitis cases and the control children. Cys‐LTs are significantly increased in the NLF of infants with acute RSV bronchiolitis, and remain so at 1‐month follow‐up, suggesting a possible role of these eicosanoids in the pathogenesis of the disease.
Risultati.Dopo 24 ore, erano presenti sulle piastre di Agar Sangue, piccole colonie grigiastre con zona di beta -emolisi intorno, che alla ricerca antigenica risultavano positive per lo streptococco gruppo B. L'identificazione biochimica eseguita con sist.API della Ditta bioMérieux, evidenziava la presenza di Streptococcus agalactiae.La paziente, veniva trasferita in Malattie Infettive, dove il sospetto di meningite non veniva confermato, ma sottoposta ad ulteriori accertamenti (RNM) si evidenziava l'esistenza di un ascesso epidurale localizzato tra D10 ed L5.Trattata con terapia antibiotica mirata, dopo 25 giorni veniva dimessa guarita.Conclusioni.
Pour reduire la morbidite et la mortalite des enfants gravement malades et blesses, il faut les prendre en charge d’une maniere complete. Cela implique des soins efficaces et un traitement precoce de la maladie ou de la blessure jusqu’a l’intervention des medecins specialises en medecine pediatrique d’urgence (MPU). La medecine pediatrique d’urgence est en train d’emerger comme une sous-specialite unique et independante aux Etats-Unis, au Canada et en Australie. En Europe, le nombre des pediatres s’interessant a la MPU et le nombre d’hopitaux se consacrant aux maladies aigues des enfants ont augmente depuis les dix dernieres annees, mais la croissance de la MPU n’a pas ete la meme dans tous les pays, ce qui explique les differences parfois importantes que l’on peut observer au niveau professionnel ou scientifique d’un pays a l’autre. Il faut esperer que les pediatres auront de plus en plus un role-cle dans le developpement, l’amelioration et l’evaluation des progres des services de medecine pediatrique d’urgence et qu’ils seront impliques de maniere croissante dans le controle de la qualite, la redaction des protocoles cliniques, le soutien et la recherche en MPU.
Background: the number of children affected by chronic diseases and in need for complex health care assistance is markedly increased in the last years. The management of these children is a complex issue in which the continuity of health assistance and the coordination among clinical structures are a mainstay.
Outcomes: describe the reality of clinical assistance in children with complex health care needs in the ULSS 9 area of Treviso; analyse the existing welfare network to highlight its eventual strenghts and weaknesses; suggest modalities to improve quality and efficiency of the current health care assistance network.
Materials and methods: Population: children (under 18 years of age) affected by severe functional impairment requiring complex health care assistance and living in the ULSS 9 area of Treviso. Phase 1: identify children affected by severe functional impairments employing multiple sources such as: Registry of Rare Diseases of the Venetian Region (i.e. Registro Malattie Rare Regione del Veneto, MR), hospital discharge certificates (Schede di Dimissione Ospedaliera, SDO), lists of patients attending rehabilitation centers (ex art. 26) and/or requiring home health care assistance (i.e. Assistenza Domiciliare Integrata, ADI). Phase 2: perform a record-linkage analysis to identify patients acknowledged by a single source or by two or more sources. Phase 3: identify a sample group of patients to whom distribuiting house-to-house a questionnaire investigating: the characteristics of the patient, the underlying disease, the family profile and needs, the frequency of school attendance, the health care assistance organization, the perceived quality of the provided health services. Statistical Analysis: Descriptive analysis and multivariate analysis were conducted. Logistic analysis was used to determine the presence of association with: 1) child’s presence in more than one source; 2) negative judgements on health care assistance. The commercial statistical software package used was “The SAS System”.
Results: Phase 1 and 2: 5.6 out of 1000 children living in the ULSS 9 area of Treviso are affected by severe diseases (or by severe functional impairment) requiring complex health care assistance. Employing a record-linkage analysis, 421 children in need for complex health care assistance were identified, among these 361 were acknowledged by a single source and 60 by 2 or more sources (1 by 4 sources, 7 by 3 and 52 by 2 sources). A multivariate analysis showed that the presence in more than one source depended on the underlying disease (metabolic, malformative/genetic) and on the sources themselves (ADI or SDO). Phase 3: 80 children, aged 8 + 4.5 years, were interviewed; 56.3% were males and 43.7% females. 87% of the parents were married. Children were affected by neurological disorders and congenital malformations/syndromes more often, by metabolic diseases and tumors less frequently. Almost 100% of the fathers and 50% of the mothers were employed. Moreover, the majority of the fathers needed to reduce their work activity and the 47% of the mothers was forced to quit their job due to their child disease. In 80% of the cases the diagnosis was made in the first year after the onset of the symptoms. More than 30% of the families visited more than one medical center to ask for a secon opinion. The path to diagnosis was extremely difficult both for psychological and social reasons. The organization of the health care assistance resulted often extremely complex and shared among many professionals figures. Only in 20% of the cases the family pediatrician contributed to this organization, whyle in the other 80% of the cases the hospital pediatrician or the pediatric sub-specialist were primary involved. In 52% of the cases parents directly took care of their child performing health care procedures. Anger and lack of understanding as well as hope and peacefulness were the most common feelings in the sample group. Many parents declared to make life plans only on a daily base and not in a long-term perspective. More than 30% of parents would require more time for their personal relationships and their social life. Notwithstanding, 70% of the patients gave a positive judgement on the health care assistance. They required, however, a greater involvement of the Health Care Services concerning: family problems, organization of the health care assistance and training of the health care professional figures involved. The Institutions were mainly blamed for excess of burocracy and low availability in giving informations on rights, available services and diseases. Logistic analysis showed that negative judgements on health care assistance were positively related to the short duration of the disease (<1 year) and absence of offhand help, and negatively related to the number of health care professionals involved. Parents required: 1) more informations concerning their child disease, their rights and available health care services; 2) more coordination among Health Care Services and Medical Professionals; 3) an improvement in medical professional skills and abilities, especially concerning rare diseases and disorders requiring a complex health care assistance.
Pediatric Emergency Department, Department of Pediatrics, University of Padova, Padova, Italy Abstracts of Fourth European Congress on Emergency Medicine Herakilon, Crete: 4–8 October 2006
The identification of severe bacterial infection (SBI)in children with fever without source (FWS) remains a diagnostic problem. The authors previously developed in their Swiss population a risk index score, called the Lab-score, associating three independent predictors of SBI, namely C reactive protein (CRP), procalcitonin (PCT) and urinary dipstick. The objective of this study was to validate the Lab-score in a population of children with FWS different from the derivation model.
Methods
A prospective study, conducted in Padova, on 408 children aged 7 days to 36 months with FWS was recently published. PCT, CRP, white blood cell count (WBC) and urinary dipstick were determined in all children. The Lab-score was applied to this population and the diagnostic characteristics for the detection of SBI were calculated for the Lab-score and for any single variable used in the Italian study.
Results
For the identification of SBI, the sensitivity of a score ≥3 was 86% (95% CI 77% to 92%) and the specificity 83% (95% CI 79% to 87%). The area under the receiver operating characteristic curve for the Lab-score (0.91) was significantly superior to that of any single variable: 0.71 for WBC, 0.86 for CRP and 0.84 for PCT. The Lab-score performed better than other laboratory markers, even when applied to children of different age groups (<3 months, 3–12 months and >12 months). The results obtained in this validation set population were comparable with those of the derivation set population.
Conclusions
This study validated the Lab-score as a valuable tool to identify SBI in children with FWS.
