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Background - In the last few years care for children with severe chronic conditions is a topic of increasing interest. Children with chronic illness often require a high complexity of care and a high level of coordination among health services. Objective - The primary aim of this study is the assessment of children with chronic disease and high complexity of care (children with medical complexity), discharged from the Neonatal Intensive Care Unit (NICU) of Modena University-Hospital. The secondary aim is to assess the outcome of these patients. Methods - Patients with chronic diseases and high complexity of care (children with medical complexity), aged 0-6 months, and admitted to the NICU of Modena in the years 2009-2019 were recruited. Results - 59 subjects were included, of which 15 (25.4%) were born preterm, 11 (18.6%) suffered from hypoxic-ischemic encephalopathy, 33 (56%) had genetic diseases or malformations. All patients were discharged home, except for one patient who was discharged to hospice. The average hospital length of stay was 116.0 ± 63.4 days. Follow-up visits showed that 25 cases (42.4%) remained unchanged, 18 (30.5%) improved and 16 (27.1%) died. Conclusion - This study allows an assessment of patients with early diagnosis of chronic disease with high complexity of care, showing that some of these patients could be eligible for palliative care. The management of children with medical complexity requires diagnostic-therapeutic programmes that focus on them and their families and connect hospital and territorial health services.

Therapeutic hypothermia is the standard care for asphyxiated newborns. Discomfort and pain during treatment are common and may affect therapeutic efficacy of hypothermia. Opioid analgosedation is commonly used in the clinical setting, but its effects in the cooled newborns is poorly investigated.The aim of this study was to assess the safety of fentanyl analgosedation during therapeutic hypothermia, by evaluating severe adverse effects and possible correlation with the neurodevelopmental outcome.We analyzed asphyxiated newborns treated with hypothermia receiving fentanyl intravenous infusion (years 2013-2018). Severe neurodevelopmental outcome was defined as cerebral palsy or Griffith's developmental quotient70 or major sensorineural deficit. Severe brain lesions were defined as cortical or/and basal ganglia extensive involvement.Fentanyl cumulative dose was variable (61.7 ± 18.5 µg/kg; range 34.3-120.3 µg/kg) among 45 enrolled patients. Respiratory depression was recorded in 13.3% cases of 30 spontaneously breathing patients. Severe brain lesions and severe neurodevelopmental disability were found in 24.4 and 11.1% of all included cases, respectively. Higher cumulative fentanyl dose was not associated with poor outcome.Fentanyl treatment during therapeutic hypothermia does not negatively affect the neurodevelopmental outcome, thus on the contrary, it may contribute to ameliorate neuroprotection in the asphyxiated cooled newborns.

Aim The aim of this study was to carry out a literature review and develop clinical guidelines for pain prevention and control during screening and laser photocoagulation for retinopathy of prematurity (ROP) in neonatal intensive care units (NICUs). Methods The Italian Society of Neonatology assessed papers published between 1986 and June 2017 and used the Grading of Recommendations, Assessment, Development and Evaluation approach, to develop new guidelines on pain and ROP. Results The Society's pain experts assessed the full texts of 47 papers, including randomised or quasi-randomised controlled trials and case-control studies on nonpharmacological and pharmacological measures used in NICUs during the screening and laser photocoagulation of neonates for ROP. The literature suggested methods for reducing the stress and pain associated with ROP screening procedures. The panel concluded that the literature showed that it was feasible to provide laser photocoagulation for ROP in spontaneously breathing patients with adequate analgesia. Conclusion This literature review on managing pain in infants with ROP in NICUs led to the development of national guidelines, which will help physicians and nurses to reduce the stress and pain experienced by premature newborn infants during unavoidable screening and treatment for ROP.

The aim of this literature review was to develop clinical guidelines for the prevention and control of needle-related pain in newborn infants. The guidelines were developed by the Italian Society of Neonatology, using the Grading of Recommendations, Assessment, Development and Evaluation approach, based on the assessment of 232 papers published between 1986 and 2015. The quality of the evidence was high or moderate for some behavioural and nonpharmacological interventions. Conclusion There was sufficient evidence to strongly support the use of nonpharmacological interventions for common needle-related procedures in newborn infants. Combined interventions seemed to be more effective in relieving procedural pain.

The neurodevelopmental impact of fentanyl given to preterm newborns for pain control is still unknown. The aim of this study was to assess the neurodevelopmental impact of 2 regimens of fentanyl administration by a prospective follow-up evaluation. In our previous multicenter, double-blind, randomized controlled trial, 131 mechanically ventilated newborns (gestational age ≤32 weeks) were randomized to fentanyl (continuous infusion of fentanyl + open label boluses of fentanyl) or placebo (continuous infusion of placebo + open label boluses of fentanyl). Infant development was evaluated using Griffiths Mental Developmental Scales (Griffiths, 1996) until 24 months of corrected age by trained psychologists who were not aware of the group allocation. 106/131 infants survived at discharge; 3 died after discharge, 25 were lost to follow-up (12 in the fentanyl and 13 in the placebo group). Seventy-eight patients were evaluated at 2 years of corrected age. Children in the fentanyl group, compared with those in the placebo group, obtained significantly lower Griffiths general developmental quotient (mean [SD]: 89.95 [13.64] vs 97.18 [12.72], P = 0.024) together with the scores on the eye-hand coordination (mean [SD]: 89.09 [12.13] vs 99.19 [13.19], P = 0.002) and performance skills (mean [SD]: 79.71 [15.80] vs 90.09 [15.28], P = 0.009) scales. After adjustment for clinical confounders (gestational age, CRIB score, and sex) only eye-hand co-ordination was associated with fentanyl infusion. This study demonstrates that continuous infusion of fentanyl in very preterm infants, given at 1 mcg·kg·h during mechanical ventilation, is associated with a significant decrease in eye and hand co-ordination skills. Longer follow-up is needed to evaluate the impact on future motor, cognitive, and behavioral functions.

Aim This review informed pain control guidelines for clinicians performing mechanical ventilation, nasal continuous positive airway pressure and endotracheal intubation on term and preterm newborn infants. Methods We reviewed literature published between 1986 and June 2017 on analgesia and sedation during assisted ventilation and before endotracheal intubation in newborn infants admitted to neonatal intensive care units. The subsequent guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation approach. Results Our review produced five strong standard of care recommendations. One, reduce neonatal stress and use nonpharmacological analgesia during invasive ventilation. Two, favour intermittent boluses of opioids, administered after pain scores and before invasive procedures, during short expected periods of mechanical ventilation, mainly in preterm infants affected by respiratory distress syndrome. Three, do not use morphine infusion in preterm infants under 27 gestational weeks. Four, always use algometric scores to titrate analgesic drugs doses. Five, use premedication before endotracheal intubation for a more rapid, less painful, less traumatic and safer manoeuvre. We also developed 30 conditional recommendations on therapeutic options. Conclusion Our review produced 35 recommendations on standard care and therapeutic options relating to the analgesia and sedation of newborn infants during ventilation and before endotracheal intubation.

Despite accumulating evidence that procedural pain experienced by newborn infants may have acute and even long-term detrimental effects on their subsequent behaviour and neurological outcome, pain control and prevention remain controversial issues. Our aim was to develop guidelines based on evidence and clinical practice for preventing and controlling neonatal procedural pain in the light of the evidence-based recommendations contained in the SIGN classification. A panel of expert neonatologists used systematic review, data synthesis and open discussion to reach a consensus on the level of evidence supported by the literature or customs in clinical practice and to describe a global analgesic management, considering pharmacological, non-pharmacological, behavioural and environmental measures for each invasive procedure. There is strong evidence to support some analgesic measures, e.g. sucrose or breast milk for minor invasive procedures, and combinations of drugs for tracheal intubation. Many other pain control measures used during chest tube placement and removal, screening and treatment for ROP, or for postoperative pain, are still based not on evidence, but on good practice or expert opinions. Conclusion: These guidelines should help improving the health care professional's awareness of the need to adequately manage procedural pain in neonates, based on the strongest evidence currently available.

Material and methods To assess efficacy and safety of PIs for procedural pain in neonate, a literature search covering the period 20002015 via Medline and Cochrane Library database, was undertaken. PIs were evaluated in relation to intubation (INT), mechanical ventilation (MV)and postoperative analgesia (POp) in preterm and fullterm infants. Efficacy of PIs in controlling procedural pain and distress was assessed on validated pain scores as PIPP, DAN, CRIES, EDIN etc. Safety of PIs was evaluated in relation to reduced morbidity and on the Adverse Effects (AEs) reported. The authorsratedthe level of evidence (LOE) and strength of recommendations, according with GRADE system.

To ascertain the extent to which neonatal analgesia for invasive procedures has changed in the last 5 years since the publication of Italian guidelines.We compared survey data for the years 2004 and 2010 on analgesia policy and practices for common invasive procedures at Italian Neonatal Intensive Care Units (NICUs); 75 NICUs answered questionnaires for both years and formed the object of this analysis.By 2010 analgesia practices for procedural pain had improved significantly for almost all invasive procedures (p0.05), both non-pharmacological and pharmacological methods being adopted by the majority of NICUs (unlike the situation in 2004). The routine use of medication for major invasive procedures was still limited, however (35% of lumbar punctures, 40% of tracheal intubations, 46% during mechanical ventilation). Postoperative pain treatment was still inadequate, and 41% of facilities caring for patients after surgery did not treat pain routinely. Pain monitoring had definitely improved since 2004 (p0.05), but not enough: only 21% and 17% of NICUs routinely assess pain during mechanical ventilation and after surgery, respectively.There have been improvements in neonatal analgesia practices in Italy since national guidelines were published, but pain is still undertreated and underscored, especially during major invasive procedures. It is mandatory to address the gap between the recommendations in the guidelines and clinical practice must be addressed through with effective quality improvement initiatives.

Infants receiving respiratory assistance may feel pain due to underlying disease or ventilation itself. Pain control during neonatal respiratory care reduces morbidity. This article summarizes the main scientific evidence about the use of drugs during ventilatory assistance, and provides some practical suggestions on pain management in neonates with respiratory support.

As part of the ACTS CONVAIR project, experts from seventeen major telecommunication companies and institutions have generated foresights and visions of the evolution of the ICT sector in Europe in the next years. Key goals for a sustainable information economy have been selected and critical issues identified preventing the accomplishment of the set goals. While it is accepted that developments in technology will play an important part in advancing the information society, there will be many other influences, just as important, that will dictate the shape and functionality of the future. This paper analyses these influences and their interactions with the technology innovation and lists expected users needs evolution. Some relevant conclusions are then drawn.

Basic requirements for asynchronous-transfer-mode (ATM) switching network architecture and sizes are assured. An evolutionary switching system approach is outlined to withstand the foreseeable evolution of the telecommunications service scenario from the narrowband ISDN to an integrated broadband communication network. State-of-the-art ATM switching techniques are examined against previous requirements. The need for further research on modularity and expandability is consequently deduced. Finally, an interesting research field is identified, namely, multistage structure with path-finding algorithms. >

The relation between Centrex service and integrated services digital network (ISDN) technology is discussed. The advantages and the synergies arising in the introduction of Centrex in ISDN are described, with particular emphasis on the access/network signaling and on the offered services aspects. In addition, two different ways of providing ISDN users with Centrex services and relevant ISDN-based central office local area network (CO-LAN) issues are analyzed. >

Background Acute pain and distress during medical procedures are commonplace in newborn admitted to Intensive Care Unit and can have detrimental effects, if uncontrolled. Accumulating evidence suggests that neonate, as older children, could benefice of non pharmacological interventions (NPIs) to relive mild to moderate pain, anxiety and discomfort from minor invasive procedures. [1] These therapies include nonnutritive sucking (NNS) both with and without sucrose, swaddling, positioning, facilitated tucking (FT), kangaroo care or skin to skin contact (KMC), multi-sensorial stimulation (SS) and music therapy.

A very low birth weight female infant developed a systemic infection by Candida albicans. Her clinical conditions were very poor; involvement of CNS was demonstrated my multifocal hyperechogenic images, spreading to the periventricular and subcortical areas of brain, confirmed by CT as circumscribed hyperdense punctiform granulations suggesting initial cerebritis. The introduction of liposomal Amphotericin-B in the therapy resulted in a marked improvement of clinical conditions together with the disapparance of pathological brain images. Longitudinal examinations carried out every three months during the first year, and every six months during the second, have shown adequate psychomotor development. The results of late cerebral nuclear magnetic resonance (NMR) imaging were within the norm. The patient is now seven-years-old and shows a well-balanced neuropsychological development. Systemic Candida infections of VLBW infants with CNS involvement have usually a very poor prognosis in terms of death or residual brain damage. The use of liposomal Amphotericin-B allowed us to achieve the complete cure of our patient, suggesting an high efficacy together with at a lower toxicity in respect of traditional treatments.

A 14-month-old female infant with chronic diarrhea, recurrent respiratory infections and stunted growth was diagnosed as celiac disease with AGA detection and a positive intestinal biopsy. A gluten-free diet was introduced with a poor response. A sweat test was positive and heterozygosis for mutation of CFTR gene (both F508 and G542X) was found, demonstrating an association in the infant between cystic fibrosis and celiac disease. Fifteen cases of such association have been previously described in literature, but only three have been genetically studied. The co-existence of cystic fibrosis and celiac disease in the same subject has to be considered till now a casual finding, but are also discussed hypothesis of a non-casual linkage, formulated by some authors.

pQCT is a method which allows the separate determination of cortical and trabecular bone mineral density in the peripheral skeleton. 21 thalassaemic patients (8 females, 13 males) aged from 10 to 32 years, were examined using pQCT at the ultra distal radius to evaluate SSI (Stress-Strain Index). ALP, serum calcium, hydroxyproline, magnesium, IGF-I, and body surface were determined. The results show a good correlation between cortical BMD and age, concentration of hydroxyproline in urine, serum bone Gla protein, body surface index, bone density of trabecular bone and SSI. Good correlation was found between trabecular bone density and age, IGF-I, BGP and PTH, and between SSI and cortical BMD, age and BSI. The linear relationships between age and cortical and trabecular density show an increase of cortical BMD with age and a decrease of trabecular density with age. The same results were obtained considering trabecular and cortical density versus SSI.

The treatment of streptococcal pharyngitis with azithromycin (10 mg/kg orally once daily for 3 days) or clarithromycin (7.5 mg/kg orally twice daily for 10 days) was compared in a randomized observer-blind study carried out in 174 children with documented Streptococcus pyogenes infection. The observed cure rate 10 days after the beginning of treatment was 61/63 (96.8%) in the clarithromycin group and 71/74 (95.9%) in the azithromycin group. At days 17 – 20 the bacteriological eradication rate was 95.2% for clarithromycin and 94.6% for azithromycin. When children who did not complete treatment were included in the analysis the eradication rate was higher for azithromycin (93.6% compared with 82.9%; P < 0.05); the difference was due to better compliance with the azithromycin regimen.

To evaluate the analgesic superiority and the safety equivalence of continuous fentanyl infusions versus fentanyl boluses in preterm infants on mechanical ventilation.In this multicenter, double-blind, randomized controlled trial, mechanically ventilated newborns (≤ 32(+6) weeks gestational age) were randomized to fentanyl (continuous infusion of fentanyl plus open-label boluses of fentanyl) or placebo (continuous infusion of placebo plus open-label boluses of fentanyl). The primary endpoint was analgesic efficacy, as evaluated by the Echelle Douleur Inconfort Nouveau-Né (EDIN) and Premature Infant Pain Profile scales. Safety variables were evaluated as well.Sixty-four infants were allocated to the fentanyl group, and 67 were allocated to the placebo group. The need for open-label boluses of fentanyl was similar in the 2 groups (P = .949). EDIN scores were comparable in the 2 groups; 65 of 961 (6.8%) EDIN scores were6 in the fentanyl group and 91 of 857 (10.6%) in the placebo group (P = .003). The median Premature Infant Pain Profile score was clinically and statistically higher in the placebo group compared with the fentanyl group on days 1, 2, and 3 of treatment (P.05). Mechanical ventilation at age 1 week was required in 27 of 64 infants in the fentanyl group (42.2%), compared with 17 of 67 infants in the placebo group (25.4%) (P = .042). The first cycle of mechanical ventilation was longer and the first meconium passage occurred later in the fentanyl group (P = .019 and .027, respectively).In very preterm infants on mechanical ventilation, continuous fentanyl infusion plus open-label boluses of fentanyl does not reduce prolonged pain, but does reduce acute pain and increase side effects compared with open-label boluses of fentanyl alone.

Hypergammaglobulinemic purpura is a rare disease in children. We report a case of a 12 year-old girl with a history of frequent infections. We found the presence of IgG2 deficiency despite polyclonal hypergammaglobulinemia. An IgG subclass determination should be obtained in every child with polyclonal hypergammaglobulinemia and features of immunodeficiency.

Switching techniques for packetized data and for video communications are a key element in the evolution of the central office from IDN, to ISDN, and to broadband ISDN. An evolutionary scenario, based both on a short-term and on a longterm reference architecture for the switching system, is proposed, and two advanced switching techniques for labeled switching and for diffusive video switching, respectively, are analyzed which match the above scenario well. Plans and preliminary results are also reported on experimental research through laboratory demonstrators of the two switching techniques.

The problem of optimizing the organization of fixed-point implementations for first- and second-order digital filters is discussed. The direct and canonical forms are analyzed in detail and compared with each other with regard to the input quantization and roundoff noise effects. A summary of the computation results is plotted in some diagrams depicting on the z plane the zones of greater convenience of either solution.

To ascertain the extent to which neonatal analgesia for invasive procedures has changed in the last 5 years since the publication of Italian guidelines.We compared survey data for the years 2004 and 2010 on analgesia policy and practices for common invasive procedures at Italian Neonatal Intensive Care Units (NICUs); 75 NICUs answered questionnaires for both years and formed the object of this analysis.By 2010, analgesia practices for procedural pain had improved significantly for almost all invasive procedures (p0.05), with both non-pharmacological and pharmacological methods being adopted by the majority of NICUs (unlike the situation in 2004). The routine use of medication for major invasive procedures was still limited, however (35% of lumbar punctures, 40% of tracheal intubations, 46% during mechanical ventilation). Postoperative pain treatment was still inadequate, and 41% of facilities caring for patients after surgery did not treat pain routinely. Pain monitoring had definitely improved since 2004 (p0.05), but not enough: only 21 and 17% of NICUs routinely assess pain during mechanical ventilation and after surgery, respectively.There have been improvements in neonatal analgesia practices in Italy since national guidelines were published, but pain is still undertreated and underscored, especially during major invasive procedures. It is mandatory to address the gap between the recommendations in the guidelines and clinical practice must be addressed through with effective quality improvement initiatives.