How Can Specialist Advice Influence the Neuroimaging Practice for Childhood Headache in Emergency Department?

Differentiating between primary and secondary headaches can be challenging, especially in the emergency department (ED). Since symptoms alone are inadequate criteria for distinguishing between primary and secondary headaches, many children with headaches undergo neuroimaging investigations, such as brain CT and MRI. In various studies, the frequency of neuroimaging utilization is influenced by several factors, including teaching status, ownership, metropolitan area, insurance status, and ethnicity of patients. However, only a few studies have considered the role of specialist consultations in ordering neuroimaging studies on childhood headaches. We report the contributions of different specialists to the evaluation of children with headaches admitted to the ED and their influence on neuroimaging decisions. We retrospectively reviewed the medical reports of paediatric patients who presented with headaches to the paediatric ED of the Ospedale Maggiore Policlinico of Milano between January 2017 and January 2022. Overall, 890 children with headaches were evaluated (mean age: 10.0 years; range: 1 to 17 years). All patients were examined by the ED paediatricians, while specialist consultations were required for 261 patients, including 240 neurological (92.0%), 46 ophthalmological (17.6%), and 20 otorhinolaryngological (7.7%) consultations. Overall, 173 neuroimaging examinations were required, of which 51.4 and 48.6% were ordered by paediatricians and neurologists, respectively. In particular, paediatricians required 61.4% of brain CT scans, and neurologists required 92.0% of brain MRI scans. In conclusion, paediatricians were responsible for the management of most children with headaches admitted to the ED, while specialist consultations were required only in about a third of the cases. Although there was no significant difference in the number of neuroimaging studies ordered by specialists, brain CT scans were most often used by paediatricians, and MRI scans by neurologists.

Impact of COVID-19 Pandemic on Headache Evaluations in the Pediatric Emergency Department.

BACKGROUND: To evaluate the impact of COVID-19 on evaluations in the pediatric emergency department (ED) because of headache as main symptom. METHODS: Number and clinical features of patients evaluated in the pediatric ED of a single site in Milan, Italy, were collected between January 2017 and January 2022. The impact of COVID-19 on evaluation rates was quantified by using the incidence rate ratio (IRR) and 95% confidence intervals (CI) between the pandemic (March 2020 to January 2022) and the prepandemic period (January 2017 to February 2020). RESULTS: During the study period, 890 evaluations were registered: 689 over the prepandemic period and 201 over the pandemic period. Mean age at evaluation was 10 years (range: 1 to 17 years). Evaluation rates per month were 18.1 during the prepandemic period and 8.7 during COVID-19 pandemic, with peaks in autumn and winter months and considerable drops in the summer. The IRR was 0.49 (95% CI, 0.40-0.61). The reduction in evaluation rate was higher for secondary headache (IRR, 0.31; 95% CI, 0.23-0.42) when compared with primary headache (IRR, 0.56; 95% CI, 0.40-0.78). CONCLUSIONS: We found a remarkable reduction in the number of evaluations in the pediatric ED for headache during the pandemic period.

Has Otitis Media Disappeared during COVID-19 Pandemic? A Fortuitus Effect of Domestic Confinement.

BACKGROUND: To measure patient flow at our Pediatric Emergency Department (PED) during the Italian lockdown, with particular care in terms of otolaryngological (ENT)-related diagnoses. METHODS: A retrospective evaluation of electronic charts of children admitted to our PED in the City Center of Milan (Italy) for any disease. The outcome was to compare distribution of diagnoses performed at our PED during 21 February-3 May 2019 (period 1) to 21 February-3 May 2020 (period 2). RESULTS: A total of 4538 children were evaluated during period 1 compared to 1310 during period 2. A statistically significant overall effect on diagnosis between the study periods was attested (p-value < 0.001; pseudo R2 = 0.010), ENT-related diagnoses being more frequently documented in period 1 (80.4% vs. 19.5%; p-value < 0.001), as well as those related to middle ear infections (92.8% vs. 7.2%; p-value < 0.001). Non-complicated acute otitis media more frequently occurred in period 1 (92.0% vs. 8.0%; p-value < 0.001); no significant difference in the number of complicated middle ear infections occurred (95.8% vs. 4.2%). CONCLUSIONS: The exceptional circumstances of the Italian lockdown resulted in a significant decrease in patients' attendance to our PED, especially when considering diagnoses related to any ENT disorder, middle ear disease, and non-complicated middle ear infection.

Frequency of asymptomatic carriers of SARS-CoV-2 among children and adults after school reopening.

BACKGROUND: Children often develop an asymptomatic form of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), but it is debated if children are at higher risk than adults to be asymptomatic carriers of SARS-CoV-2, especially during the school reopening. The main aim of this study was to investigate the frequency of SARS-CoV-2 asymptomatic carriers in children and adults during the reopening of the schools in Milan, Italy. METHODS: We conducted a cross-sectional study at the pediatric and adult Emergency Department (ED) of the Ca' Granda Ospedale Maggiore Policlinico (Milan) between October 1 and 31, 2020, i.e. 3 weeks after the reopening of schools. Patients admitted to the ED short stay observation and without any sign or symptom consistent with a SARS-CoV-2 were eligible. These patients underwent a nasopharyngeal swab specimen for the detection of SARS-CoV-2. The odds ratio and its 95% confidence interval (CI) was calculated to assess the risk of asymptomatically carrying the SARS-CoV-2 infection in children and adults. RESULTS: A total of 69 (27 females, median age 8.7 years) children and 251 (107 females, median age 71 years) adults were enrolled. Pediatric and adult subjects tested positive for SARS-CoV-2 with a similar frequency (1/69 [1.4%] vs 4/251 [1.6%]). Children had an odds ratio to be a carrier of 0.91 (CI 0.02- 9.38) compared to adults. CONCLUSIONS: The frequency of asymptomatic SARS-CoV-2 carriers was similar among children and adults. Considering the emerging diffusion of new SARS-CoV-2 variants, the asymptomatic spread of SARS-CoV-2 infection among children and adults should be monitored.

Diagnosis of SARS-CoV-2 in children: accuracy of nasopharyngeal swab compared to nasopharyngeal aspirate.

The tests currently used for the identification of SARS-CoV-2 include specimens taken from the upper and lower respiratory tract. Although recommendations from the World Health Organization prioritise the usage of a nasopharyngeal swab (NS), nasopharyngeal aspirates (NPA) are thought to be superior in identifying SARS-CoV-2 in children. To our knowledge, however, no paediatric study has been published on the subject. The aim of this study is to evaluate the diagnostic performances of NS referred to NPA for SARS-CoV-2 in children. We calculated the sensitivity and specificity of the NS referred to the NPA of the whole sample and considered both age and collection period as covariates in different analyses. We collected 300 paired samples. The NS had a specificity of 97.7% and a sensitivity of 58.1%. We found similar results for the group of subjects ≥ 6 years old, while for subjects < 6 years old, the sensitivity was 66.7% and the specificity 97.8%. Considering period as a covariate, the sensitivity and specificity for patients hospitalised in March (31 patients, 52 records) were 70.0% and 97.6%, while for patients involved in the follow-up (16 patients, 57 records), they were 57.2% and 89.7%. The NS has a low sensitivity in detecting SARS-CoV-2 in children when referred to the NPA, whereas its specificity is high. Our results suggest that in children under 6 years of age, NSs should be preferred whenever possible. Though statistically not significant, the sensitivity of the NS rises when performed before the NPA.

Three months of COVID-19 in a pediatric setting in the center of Milan.

The second epicenter of the global COVID-19 epidemic following Wuhan, and the first in the Western world, occurred unexpectedly in the Lombardy region of Italy, whose capital city is Milan. The aggressive nature of the outbreak in the region was dramatic, leading to a 2-month period of lockdown. Within the Policlinico, the historic hospital in the center of Milan, many units were rapidly converted into intensive care units or semi-intensive units for adult patients. During lockdown, the pediatric inpatient units had to face daily reorganization caused by the necessary logistic and structural transformations, thus restricting routine care pathways for chronic patients, while the Pediatric Emergency Unit had to develop a system able to effectively separate the children and caregivers infected with COVID-19 from those who were not affected. These 2 months enhanced resilience among both doctors and nurses, and facilitated the transversal transmission of data aimed at helping colleagues and patients in any way possible, in spite of the restrictive measures limiting the rate of activity in pediatric care. The reorganization of the current phase of decreasing epidemic activity still leaves us with unanswered questions regarding the further possible changes to implement in the event of a potential reoccurrence of epidemic peaks.

Predictive value of EEG for febrile seizure recurrence.

OBJECTIVE: To define the role of the EEG in predicting recurrence of febrile seizures (FS) in children after a first FS. METHODS: Children with a first simple or complex FS who underwent EEG at our hospital were retrospectively enrolled. EEG recordings were classified in three groups: normal, abnormal (slow activity or epileptiform discharges), and pseudo-petit mal discharge (PPMD) pattern. Children were followed-up for at least three years. RESULTS: A total of 126 patients met the entry criteria, and 113 of them completed the follow-up. Risk of FS recurrence decreased linearly with increasing age (-2% per month). The risk was higher among patients with PPMD pattern (absolute risk 86%, adjusted relative risk 2.00) and abnormal EEG (epileptiform discharges: absolute risk 71%, adjusted relative risk 2.00; slow activity: absolute risk 56%, adjusted relative risk 1.44), compared with those with normal EEG (absolute risk 41%). CONCLUSIONS: PPMD and abnormal EEG should be considered as an independent risk factor for FS recurrence.

Recurrent Focal Myositis in Childhood: A Case Report and Systematic Review of the Literature.

BACKGROUND: Recurrent focal myositis in adulthood has been documented in case reports and case series. Existing textbooks and reviews do not mention or mention only in passing this entity in childhood. We present a patient with recurrent focal myositis and summarize available clinical, laboratory, management, and outcome data on this entity in the pediatric ages. METHOD: We describe a nine-year-old patient with recurrent myositis of the left biceps. The terms "myositis" and "relapsing" or "recurrent" or "recurrence" were searched using the United States National Library of Medicine and the Excerpta Medica Database. Pertinent secondary references were also screened. RESULTS: Another seven pediatric patients (five males and two females, median age ten years, interquartile range 7-14 years) with recurrent focal myositis were identified. In children, the calf was the most frequently involved muscle. Unlike adults, the myositis in children was usually painful. Episodes could be associated with normal or elevated erythrocyte sedimentation rate and blood levels of C-reactive protein, creatine kinase, and aspartate aminotransferase. Abnormalities of the creatine kinase value did not seem to be associated with a higher risk of recurrences. CONCLUSIONS: Focal myositis has a favorable outcome in children. Recurrent focal myositis is rare and usually benign in childhood. More data are needed to improve the understanding of this condition.

Treatment of Severe Hypervolemic Hyponatremia in a Child With Pneumonia.

A 21-month-old boy came to our attention because of pneumonia. His weight increased before presentation, and his blood test results showed hyponatremia (116 mEq/L), low plasma osmolarity (241 mOsm/L), and high urine osmolarity (435 mOsm/L). He was treated with 0.9% sodium chloride solution and intravenous furosemide, and sodium levels rose up to 135 mEq/L in 36 hours. No standard treatment is available for severe hyponatremia in children. The use of vaptans in pediatric patients is described in literature, but it lacks evidence about safety and effectiveness. We suggest that furosemide administration plus salt replacement is effective in restoring normal values of plasma sodium concentration in severe euvolemic and hypervolemic hyponatremia.