Maria Alessia Mesturino

In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions and pleural and pericardial effusions, but less to evaluate fluid depletion. The main aim of this review is to analyze the current literature on the assessment of dehydration in pediatric patients by using POCUS. The size of the inferior vena cava (IVC) and its change in diameter in response to respiration have been investigated as a tool to screen for hypovolemia. A dilated IVC with decreased collapsibility (< 50%) is a sign of increased right atrial pressure. On the contrary, a collapsed IVC may be indicative of hypovolemia. The IVC collapsibility index (cIVC) reflects the decrease in the diameter upon inspiration. Altogether the IVC diameter and collapsibility index can be easily determined, but their role in children has not been fully demonstrated, and an estimation of volume status solely by assessing the IVC should thus be interpreted with caution. The inferior vena cava/abdominal aorta (IVC/AO) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS could be a valuable supplementary tool in the assessment of dehydration in several clinical scenarios, enabling rapid identification of life-threatening primary etiologies and helping physicians avoid inappropriate therapeutic interventions.    Conclusion: POCUS can provide important information in the assessment of intravascular fluid status in emergency scenarios, but measurements may be confounded by a number of other clinical variables. The inclusion of lung and cardiac views may assist in better understanding the patient’s physiology and etiology regarding volume status. What is Known: • In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions (like pneumonia and bronchiolitis) and pleural and pericardial effusions, but less to evaluate fluid depletion. • The size of the IVC (inferior vena cava) and its change in diameter in response to respiration have been studied as a possible screening tool to assess the volume status, predict fluid responsiveness, and assess potential intolerance to fluid loading. What is New: • The IVC diameter and collapsibility index can be easily assessed, but their role in predicting dehydration in pediatric age has not been fully demonstrated, and an estimation of volume status only by assessing the IVC should be interpreted carefully. • The IVC /AO(inferior vena cava/abdominal aorta) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS can be a valuable supplementary tool in the assessment of intravascular volume in several clinical scenarios.

Background: Aggregatibacter actinomycetemcomitans (Aa), previously known as Actinobacillus actinomycetemcomitans, is a slow-growing Gram-negative coccobacillus, member of the HACEK group of bacteria colonizing oral flora. Besides causing infectious diseases in the oral cavity such as dental caries and periodontitis, it is responsible for severe extra-oral infections secondary to hematogenous spread or aspiration, such as endocarditis, soft tissue abscesses and osteomyelitis. The diagnosis depends on prolonged bacterial culture of biological material obtained through biopsy. Aa is susceptible to most antibiotics but complete eradication often requires a long term treatment. Case presentation: We report the case of a 15-year-old previously healthy boy diagnosed with both pulmonary empyema and subphrenic chest wall abscess caused by Aa. He was admitted to our Pediatric Emergency department for evaluation of a right mass associated with marked asthenia and dry cough. After radiological findings etiological diagnosis was made by culture of fluid drainage of pleural empyema. He started empirical antibiotic therapy with intravenous piperacillin/tazobactam, whose sensibility was confirmed by the antibiogram, then, for occurrance of hepatopathy it was switched to ciprofloxacin: the patient almost completely recovered after 6-month therapy. Conclusions: Extra-oral infections caused by Aa are extremely rare, especially in children, and not well described yet. To our knowledge, there is only another similar case described in literature. However, the case described in our manuscript represents the only one presenting with pulmonary empyema without involvement of lung parenchyma in children. We also conducted a brief review of published cases of Aa infection in the pediatric population. This case report reminds us the importance of an accurate inspection of the oral cavity during the examination of pediatric patients.

Background: To date, there are no data regarding the systematic application of Point-of-Care Lung Ultrasound (PoC-LUS) in children with Multisystem Inflammatory Syndrome in Children (MIS-C). The main aim of this study is to show the role of Point-of-Care Lung Ultrasound as an additional aid in the diagnosis of COVID-19-related Multisystem Inflammatory Syndrome in Children (MIS-C). Methods: Between April 2020 and April 2021, patients aged 0–18 years referred to our emergency department for fever, and later hospitalized without a specific diagnosis, underwent PoC-LUS. Ultrasound images of patients with a final diagnosis of MIS-C were retrospectively evaluated. Results: Ten patients were enrolled. All were described to have pleural irregularities and B-lines. In particular: 8/10 children presented with isolated B-lines in at least half of the lung areas of interest; 8/10 presented with multiple B-lines and 3/8 had them in at least 50% of lung areas; 5/10 had a white lung appearance in at least one lung area and 1/5 had them in half of the areas of interest. Pleural effusion was described in 9/10. Conclusions: During the ongoing COVID-19 pandemic, we suggest performing PoC-LUS in febrile patients with high levels of inflammatory indices and clinical suspicion of MIS-C, or without a certain diagnosis; the finding of many B-lines and pleural effusion would support the diagnosis of a systemic inflammatory disease.

Bronchiolitis is the most common cause of hospitalization of children in the first year of life. The lung ultrasound is a new diagnostic tool which is inexpensive, non-invasive, rapid, and easily repeatable. Our prospective study was conducted in the emergency department and all patients underwent a routine clinical evaluation and lung ultrasound by the pediatricians who defined the clinical and the ultrasound score. We enrolled 76 infants (median age 90 days [IQR 62–183], 53.9% males). In nasopharyngeal aspirates, the respiratory syncytial virus was isolated in 33 patients. Considering the clinical score, children with higher score had a higher probability of requiring respiratory support (p 0.001). At the ultrasound evaluation, there was a significant difference on ultrasound score between those who will need respiratory support or not (p 0.003). Infants who needed ventilation with helmet continuous positive airway pressure had a more severe ultrasound score (p 0.028) and clinical score (p 0.004), if compared with those who did not need it.

The child obesity and its complications are associated with an alarming increased health care use, including the emergency department (ED). We evaluated the effects of the obesity and overweight in children admitted to ED, especially in patients with injury diagnosis. A retrospective study of patients aged 6–18 years was conducted. Patients were categorized into normal weight (body mass index, BMI < 85th); overweight (BMI ≥ 85th e < 95th); obesity (BMI ≥ 95th). Multiple logistic analysis was used for estimation of risk factors associated with the BMI and to explore the association between injury diagnosis and BMI. The predictive factors associated with obesity and overweight were school age (p < 0.001), male gender (p < 0.001) and number of visits for year (obesity: p < 0.001 and overweight: p < 0.05). Obese children were less at injury risk than normal weight (p < 0.05). In injury subset, fractures in school age were more likely to occur in obesity (p < 0.01). Dislocated fractures (p < 0.01) and fractures at lower extremity were more likely to occur in obesity and overweight (p < 0.05). School age children presenting to ED are more at risk of excess body weight than adolescents and are at higher fracture risk if obese and overweight. This has clear implication to support the efforts to reduce the obesity in childhood. The ED may represent a crucial setting for the early identification of these children and of co-morbidities related BMI ≥ 85th, and for a timely specialist referral of these children, especially if school age.

Coeliac disease is diagnosed by means of jejunal biopsy, an invasive procedure. Anti-gliadin antibodies (AGA) have therefore been used in the first screening of the disease. On the other hand, low...