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Obstructive sleep apnea syndrome (OSAS) and nonalcoholic fatty liver disease (NAFLD) are frequently encountered in obese children. Whether OSAS and intermittent hypoxia are associated with liver injury in pediatric NAFLD is unknown. To assess the relationship of OSAS with liver injury in pediatric NAFLD. Sixty-five consecutive children with biopsy-proven NAFLD (age, mean ± SD, 11.7 ± 2.1 yr; 58% boys; body mass index z score, 1.93 ± 0.61) underwent a clinical-biochemical assessment and a standard polysomnography. Insulin sensitivity, circulating proinflammatory cytokines, markers of hepatocyte apoptosis (cytokeratin-18 fragments), and hepatic fibrogenesis (hyaluronic acid) were measured. Liver inflammatory infiltrate was characterized by immunohistochemistry for CD45, CD3, and CD163, surface markers of leukocytes, T cells, and activated macrophage/Kupffer cells, respectively. OSAS was defined by an apnea/hypopnea index (AHI) greater than or equal to 1 event/h, and severe OSAS was defined by an AHI greater than or equal to 5 events/h. Fifty-five percent of children with NAFLD had nonalcoholic steatohepatitis (NASH), and 34% had significant (stage F ≥ 2) fibrosis. OSAS affected 60% of children with NAFLD; the presence and severity of OSAS were associated with the presence of NASH (odds ratio, 4.89; 95% confidence interval, 3.08-5.98; P = 0.0001), significant fibrosis (odds ratio, 5.91; 95% confidence interval, 3.23-7.42; P = 0.0001), and NAFLD activity score (β, 0.347; P = 0.029), independently of body mass index, abdominal adiposity, metabolic syndrome, and insulin resistance. This relationship held also in nonobese children with NAFLD. The duration of hemoglobin desaturation (Sa(O2) < 90%) correlated with increased intrahepatic leukocytes and activated macrophages/Kupffer cells and with circulating markers of hepatocyte apoptosis and fibrogenesis. In pediatric NAFLD, OSAS is associated with biochemical, immunohistochemical, and histological features of NASH and fibrosis. The impact of hypoxemia correction on liver disease severity warrants evaluation in future trials.

The gold standard for the diagnosis of sleep apnoea (SA) is polysomnography, consisting of overnight in-lab tests, which are expensive for both patients and healthcare systems. Airflow and pulse/oximetry signals contain most of the necessary information for detecting SA and widely simplify the data acquisition process, hence holding the promise to increase the availability of SA diagnosis and reduce waitlists. Deep learning has recently shown some interesting steps forward in analysing these signals in paediatric patients. Here we introduce a novel platform, REST, that is able to simultaneously detect the presence of apnoea, desaturation, and artefacts in input signals. To achieve this goal, we developed a novel 1D deep neural network architecture that leverages prior knowledge of the information distribution across signals, allowing for the concurrent detection and interpretation of target events. The platform was trained, validated, and tested on data from 86 paediatric patients. We show that our approach outperforms other three approaches from the literature, reaching 92.50% (1.10%), 98.30% (0.43%), and 97.59% (0.28%) balanced classification accuracies for apnoea, desaturation, and artefact, respectively (mean and standard deviation, in brackets). Notably, the REST platform also gives a confidence score as output, highlighting to the doctor the samples that need to be reviewed and further boosting the performances of the other samples. Lastly, based on gradient-weighted class activation mapping (grad-CAM) heatmaps, our platform allows the explanation of the decision process, pointing out the regions of the input signals in which events occur, increasing the reliability of the whole process for a human user.

Background During the pandemic, the pneumology team at Bambino Gesù Children’s Hospital highlighted that telemedicine was a valuable tool for remotely managing the medical needs of children with medical complexity (CMC). Following the telemedicine experience during the emergency phase, a telemedicine service was established, and new tools were tested to optimize televisits and the overall eHealth approach for patients. In this context, the TytoHome™ device was tested for performing objective examinations remotely. This pilot study, conducted at our hospital, explored the management of CMC patients on long-term mechanical ventilation via the telemedicine platform and the TytoHome™ device. Methods This study involved the treatment of 10 pediatric patients over one year using this approach. The patients were already receiving care at our hospital and were undergoing long-term mechanical ventilation (LTV) at home—4 on invasive mechanical ventilation (IMV) and 6 on non-invasive ventilation (NIV). A database was developed to collect patient data, including personal details, vital parameters, objective examinations, audio quality, and patient satisfaction. A descriptive analysis was subsequently performed using the data collected during the earlier stages of the study. Results The utility of the TytoCare device for medically complex children was evaluated. The families were “satisfied” with the remote follow-up visits, and healthcare personnel rated the audio quality of the visits as “good.” Conclusions In conclusion, the remote management of these patients using the Tyto device offered several advantages. In our experience, Tyto proved to be a useful tool for the remote medical management of complex patients.

Background Children with chronic respiratory failure and/or sleep disordered breathing due to a broad range of diseases may require long-term ventilation to be managed at home. Advances in the use of long-term non-invasive ventilation has progressively leaded to a reduction of the need for invasive mechanical ventilation through tracheostomy. In this study, we sought to characterize a cohort of children using long-term NIV and IMV and to perform an analysis of those children who showed significant changes in ventilatory support management. Methods We performed a retrospective cohort study of pediatric (within 18 years old) patients using long-term, NIV and IMV, hospitalized in our center between January 1, 2000 and December 31, 2017. A total of 432 children were included in the study. Long Term Ventilation (LTV) was defined as IMV or NIV, performed on a daily basis, at least 6 h/day, for a period of at least 3 months. Results 315 (72.9%) received non-invasive ventilation (NIV); 117 (27.1%) received invasive mechanical ventilation (IMV). Children suffered mainly from neuromuscular (30.6%), upper airway (24.8%) and central nervous system diseases (22.7%). Children on IMV were significantly younger when they start LTV [NIV: 6.4 (1.2–12.8) years vs IMV 2.1 (0.8–7.8) years] ( p  < 0.001)]. IMV was likely associated with younger age at starting ventilatory support (aOR 0.9428; p  = 0.0220), and being a child with home health care (aOR 11.4; p  < 0.0001). Overtime 39 children improved (9%), 11 children on NIV (3.5%) received tracheostomy; 62 children died (14.3%); and 74 children (17.1%) were lost to follow-up (17.8% on NIV, 15.4% on IMV). Conclusions Children on LTV suffered mainly from neuromuscular, upper airways, and central nervous system diseases. Children invasively ventilated usually started support younger and were more severely ills.

Background Long-term mechanical ventilation (LTV) with non-invasive ventilation (NIV) prolongs survival in patients with Neuromuscular Diseases (NMDs). Transition from paediatric to adult healthcare system is an undervalued and challenging issue for children with chronic conditions on mechanical ventilation. Methods this retrospective study aims to compare issues of young adults in age to transition to adult care (≥ 15 years old) affected by NMDs on NIV in two different Paediatric Respiratory Units in two different countries: Bambino Gesù Children’s Hospital, Research Institute, (Rome, Italy) (BGCH) and the Paediatric Respiratory Unit of the Royal Brompton Hospital (London, UK) (RBHT). Results The median (min-max) age at starting ventilation was significantly different in the two groups (16 years old vs 12, p  = 0.0006). We found significant difference in terms of median age at the time of observation (18 (15–22) vs 17 (15–19) years, p  = 0.0294) and of type of referral (all the patients from the BGCH group were referred to paediatric services ( n  = 15, 100%), median age 18 (15–22); only 6 patients, in the RBHT group, with a median age 15.50 (15–17) years, were entirely referred to paediatric service). We found different sleep-disordered breathing assessments 6 full Polysomnographies, 7 Cardio-Respiratory Polygraphies and 2 oximetry with capnography (SpO 2 -tcCO 2 ) studies in the BCGH group, while all patients of RBHT group were assessed with an SpO 2 -tcCO 2 study. All patients from both groups underwent multidisciplinary assessment. Conclusions In conclusion, patients with NMDs on NIV in age to transition to adult require complex multidisciplinary management: significant efforts are needed to achieve the proper transition to adult care.

Background Seasonal variability on obstructive sleep apnea has already been studied by polysomnography in children. Winter and spring season emerged as critical periods. No data are currently available for pulse oximetry performed at home. The aim of our study was to evaluate the effect of seasonality and age on the results of at-home pulse oximetry performed in children referred for suspected OSA. Methods We retrospectively studied 781 children (64.3% Males), aged 4.9 ± 2.5 years. For all patients, we evaluated both pulse oximetry metrics and the McGill Oximetry Score. Variables for seasonal groups were assessed using Kruskal-Wallis test. A logistic regression model was performed to assess the relationship between patients’ main characteristics, season period and the likelihood to have an abnormal McGill Oximetry Score. Results Patients recorded during winter were significantly younger ( p  < 0.02), nadir SpO 2 was significantly lower ( p  < 0.002) and DI 4 significantly higher than during others seasons ( p  < 0.005). Moreover, patients recorded during winter were nearly 2 times more likely to have an abnormal MOS (aOR 1.949). The logistic regression showed that also younger age ( p  < 0.0001) was associated with a higher risk to find an abnormal pulse oximetry. Conclusions In our study, the winter season confirms to be a critical period for pulse-oximetry and it should be taken into account by clinicians for a correct interpretation of tests. Our data show that also younger age affects the prevalence of abnormal at-home pulse oximetry in children.

To identify subgroups regarding paediatricians' awareness, attitude, practice and satisfaction about management of Sleep-Disordered Breathing (SDB) in Italy using Latent Class Analysis (LCA). A cross-sectional study was conducted on a large sample of Italian paediatricians. Using a self-administered questionnaire, the study collected information on 420 Paediatric Hospital Paediatricians (PHPs) and 594 Family Care Paediatricians (FCPs). LCA was used to discover underlying response patterns, thus allowing identification of respondent groups with similar awareness, attitude, practice and satisfaction. A logistic regression model was used to investigate which independent variables influenced latent class membership. Analyses were performed using R 3.5.2 software. A p-value<0.05 was considered statistically significant. Two classes were identified: Class 1 (n = 368, 36.29%) \"Untrained and poorly satisfied\" and Class 2 (n = 646, 63.71%) \"Trained and satisfied.\" Involving paediatric pneumologists or otorhinolaryngologists in clinical practice was associated with an increased probability of Class 2 membership (OR = 5.88, 95%CI [2.94-13.19]; OR = 15.95, 95% CI [10.92-23.81] respectively). Examining more than 20 children with SDB during the last month decreased the probability of Class 2 membership (OR = 0.29, 95% CI [0.14-0.61]). FCPs showed a higher probability of Class 2 membership than PHPs (OR = 4.64, 95% CI [3.31-6.55]). These findings suggest that the LCA approach can provide important information on how education and training could be tailored for different subgroups of paediatricians. In Italy standardized educational interventions improving paediatricians' screening of SDB are needed in order to guarantee efficient management of children with SDB and reduce the burden of disease.

Nocturnal pulse oximetry has a high positive predictive value for polysomnographically diagnosed obstructive sleep apnoea (OSA) in children. When significant adenotonsillar hypertrophy is diagnosed, adenotonsillectomy (T&A) represents a common treatment for OSA in children. We investigated the role of pulse oximetry in predicting those patients, referred for suspected OSA, who subsequently needed T&A. At-home nocturnal pulse oximetry was performed on 380 children (65.7% males), median age 4.1(IRQ 3.0–5.6) years, referred for suspected OSA, and data were retrospectively analysed. For each recording McGill Oximetry Score (MOS) was categorized. Mean pulse rate (PR) z -score and pulse rate variability (PRV)-corrected (PRSD/meanPR) were significantly higher in children with abnormal MOS. Both parameters were significantly higher in subjects who underwent T&A compared with those not surgically treated. Both DI 4 and PRV corrected showed a negative correlation with the elapsed time between pulse oximetry recordings and T&A. The logistic regression model showed a strong effect of an abnormal MOS as a predicting factor for T&A (adjusted odds ratio 19.7). Conclusions : In our study, children with OSA who subsequently needed T&A showed higher PRV compared to those without surgical indication. Children with abnormal MOS were nearly 20 times more likely to undergo T&A. What is Known: • Nocturnal pulse oximetry has a high positive predictive value for polysomnographically diagnosed obstructive sleep apnoea in children. • When significant adenotonsillar hypertrophy is diagnosed, adenotonsillectomy represents a common treatment for OSA in children. What is New: • An abnormal pulse oximetry highly predict the indication for adenotonsillectomy. • We suggest the use of at-home pulse oximetry as method to predict prescription of adenotonsillectomy, and this may be useful in contexts where polysomnography is not readily available.