Activity of a Pediatric Emergency Department of a Tertiary Center in Bologna, Italy, during SARS-CoV-2 Pandemic

Round 1

Reviewer 1 Report

The submitted article by Zama et al describes the main changes in the organization and in the attendances to a pediatric ED of Bologna, Emilia-Romagna during the COVID-19 pandemic. The paper is well written. However, the paper would be further strengthened by addressing the following major and minor issues:

 

Page 5- Line 148 and 157: You may have written VRS instead of RSV by mistake.

 

Page5- Figure 4: In the top graph, the attendance in ED is consistently lower than the number of admissions. Typically, in my experience, most admissions are through ED in which case, the number of admissions should be less than the attendance in ED. Please explain if you get most of the admissions bypassing the ED in your hospital.

 

Page7-line 240: ‘a high peck in November – December’’. Please correct the spelling from peck to peak.

Author Response

Reviewer #1: The submitted article by Zama et al describes the main changes in the organization and in the attendances to a pediatric ED of Bologna, Emilia-Romagna during the COVID-19 pandemic. The paper is well written. However, the paper would be further strengthened by addressing the following major and minor issues:

Specific comment:

1) Page 5- Line 148 and 157: You may have written VRS instead of RSV by mistake.

We would like to thank Reviewer #1 for the constructive report. Firstly, we would like to apologize for having forgot during the submitting phase to correct this typing mistake. We now provided to correct the reported part.

2) Page5- Figure 4: In the top graph, the attendance in ED is consistently lower than the number of admissions. Typically, in my experience, most admissions are through ED in which case, the number of admissions should be less than the attendance in ED. Please explain if you get most of the admissions bypassing the ED in your hospital.

 

We would like to thank Reviewer #1 for the report. Figure 4 presents with two different numeric scales on the ordinate axis: on the right the number of accesses is represented in the range of 10², whereas on the left side the number of admissions in the range of 10¹. The reason for this representation is for trying to compare this to different variables and show their changes in time. Keeping the same numeric scale in our opinion would have increased the difficulty of the visualization of the figure. If it is possible, we would like to make it appear clearer so if any suggestions would be welcome.

 

3) Page7-line 240: ‘a high peck in November – December’’. Please correct the spelling from peck to peak.

We would like to thank Reviewer #1 for the constructive report. Also this time we would like to apologize for having forgot during the submitting phase to correct this typing mistake. We now provided correct the reported part.

Author Response File: Author Response.pdf

Reviewer 2 Report

The analysis and description of the changes in the activity of the pediatric emergency department during the SARS-CoV-2 pandemic it’s quite interesting. The COVID-19 pandemic has led to many different types of data. The retrospective observational study was well done and the results are quite interesting, but there are some questions that should be clarified.

 

1.       How many children tested positive? In Abstract and pag 4 line 123 “…796…” instead to the pag 4 line 134 :”…976 patients who resulted positive…”

2.       In order to better understand the usefulness of molecular and rapid test. Did the children perform rapid antigen swab before or pending the molecular result? How many of them tested positive for both tests?

3.       How many parents or family members of positive children were also positive?

4.       Did you change something from the first to the second year that improve the management of the access to the emergency department? It would be interesting to include a few sentences in the discussion.

5.       There are few grammar mistakes. Examples of these errors are present in the following sentences: pag. 4 line 131”…Covid-10..”

Author Response

Reviewer #2: The analysis and description of the changes in the activity of the pediatric emergency department during the SARS-CoV-2 pandemic it’s quite interesting. The COVID-19 pandemic has led to many different types of data. The retrospective observational study was well done and the results are quite interesting, but there are some questions that should be clarified.

Specific comment:

1. How many children tested positive? In Abstract and pag 4 line 123 “…796…” instead to the pag 4 line 134 :”…976 patients who resulted positive…”

We would like to thank Reviewer #2 for the constructive comments and kind words. We would like to apologize for the typing mistakes and we wanted really to thank you for the precious report. The correct number of positive patients in that period of time was actually 796. We now provided to also insert the missing sentence.

2. In order to better understand the usefulness of molecular and rapid test. Did the children perform rapid antigen swab before or pending the molecular result? How many of them tested positive for both tests?

 

Thank you for the interesting question. Actually our centre already published a paper on the effectiveness of antigenic swab screening using the data coming from our pediatric ED. ( Lanari M, Biserni GB, Pavoni M, Borgatti EC, Leone M, Corsini I, Lazzarotto T. Feasibility and Effectiveness Assessment of SARS-CoV-2 Antigenic Tests in Mass Screening of a Pediatric Population and Correlation with the Kinetics of Viral Loads. Viruses. 2021 Oct 14;13(10):2071. doi: 10.3390/v13102071. PMID: 34696501; PMCID: PMC8537025.)

From November 2020 to April 2021 to every child who required a molecular swab, an antigenic swab was performed as well. Two rapid antigen detection kits Point of care were tested:  The COVID-19 Ag FIA kit and the AFIAS COVID-19 Ag kit. The COVID-19 Ag FIA kit showed a baseline sensitivity of 53.8%, baseline specificity 99.7% and overall accuracy of 80%; the AFIAS COVID-19 Ag kit, baseline sensitivity of 86.4%, baseline specificity 98.3% and overall accuracy of 95.3%.

 

 

3. How many parents or family members of positive children were also positive?

 

Also in this case family members received a molecular swab only in case of prolong observation or hospitalization. Therefore unfortunately we can not access to this information for all the children that presented to our pediatric ED. Surely also this topic would be of interest for a future discussion.

 

4. Did you change something from the first to the second year that improve the management of the access to the emergency department? It would be interesting to include a few sentences in the discussion.

 

Actually there haven’t been substantial changes in the management of the accesses between the two years, because we continue to screen every child with Covid-19 related symptoms. We therefore focused the attention on the changes of the disease presentations and its incidence throughout the year.

 

5. There are few grammar mistakes. Examples of these errors are present in the following sentences: pag. 4 line 131”…Covid-10..”

 

We would like to apologize for the typing mistake. We now provided to also insert the missing sentence.

Author Response File: Author Response.pdf

Reviewer 3 Report

Manuscript well written. It describes the changes made in pediatric emergency room to better manage the pandemic. 

Author Response

Reviewer #3: Manuscript well written. It describes the changes made in pediatric emergency room to better manage the pandemic. 

 

We would like to thank Reviewer #3 for the kind and supportive words.

Author Response File: Author Response.pdf

Reviewer 4 Report

REVIEW REPORT

Activity of a Pediatric Emergency Department of a Tertiary Center in Bologna, Italy, during SARS-CoV-2 Pandemic

 

NO: pediatrrep-1797965

Journal: MDPI

Section: COVID-19: What Happens in Pediatric Research in the Era of Pandemic

 

Date: 07.08.2022

 

Conflict of interest statement for peer reviewer:

I declare that I do not have any competing interests

 

Language and formatting related comments:

-          The spelling of COVID-19 is different throughout the text. Please unify the vocabulary and stay consistent.

-          COVID-10? – line 131

-          Table 1 – a row with numbers would help the presentation, also, it is not fully formatted

-          Title 3.3 – VRS infection – typo; also – one should not use abbreviations in the titles (especially not if they haven’t been introduced up to that point)

-          Superior graph sounds quite odd –figure 4 “in the upper graph”

-          Line 157 – typo – VRS (multiple typos throughout the text)

-          Line 167 – bronchiolitis being the main cause …

-          Line 172 – odd spacing between numbers, also the number 151 – are those the cases?

-          Line 176 – spacing p-value…

-          MIS-C – since this is a new entity, I believe the readers would benefit from learning its diagnostic criteria; consider inclusion

-          Spacing between citations and text (e.g., line 238).

-          RSV diffusion ? – spread perhaps?

 

Moderate English revision.

 

Data presentation:

-          Data on RSV showed that the epidemic period 2020/2021 was totally abolished. – this sentence is not clear. What has been abolished?

-          Line 229 - … confirming the already demonstrated data of 229 the different clinical presentations between children and adults [9]. – this sentence has been thrown into the discussion without any introduction or explanation as to why it differs. The readers should be given a short explanation (e.g., lower severity and shorter hospitalisation).

 

The authors set out to do the following:

“In this paper, we describe the activity, its modulation and changes, during the pandemic waves in our pediatric department, the biggest tertiary pediatric center in the Emilia Romagna region in Italy.”

 

I fail to see how the activity and its modulation were performed at their department.

 

My questions regarding the activity modulation:

-          What concrete measures were implemented?

-          Was the workload divided?

-          What is the normal workflow protocol at admission?

-          Were there specific workflow protocols for COVID-19?

-          Did the work protocols change during the waves?

Some concerns:

-          Is there any follow-up data on the COVID-19 positive children?

-          Did any of the children experience any COVID-19 related side effects?

-          How many of the children were vaccinated?

 

I believe the article should undergo major revision.

 

With best regards.

Author Response

Reviewer #4:

 

1. Language and formatting related comments:

-          The spelling of COVID-19 is different throughout the text. Please unify the vocabulary and stay consistent.

-          COVID-10? – line 131

-          Table 1 – a row with numbers would help the presentation, also, it is not fully formatted

-          Title 3.3 – VRS infection – typo; also – one should not use abbreviations in the titles (especially not if they haven’t been introduced up to that point)

-          Superior graph sounds quite odd –figure 4 “in the upper graph”

-          Line 157 – typo – VRS (multiple typos throughout the text)

-          Line 167 – bronchiolitis being the main cause …

-          Line 172 – odd spacing between numbers, also the number 151 – are those the cases?

-          Line 176 – spacing p-value…

-          MIS-C – since this is a new entity, I believe the readers would benefit from learning its diagnostic criteria; consider inclusion???

-          Spacing between citations and text (e.g., line 238).

-          RSV diffusion ? – spread perhaps?

 

We would really like to thank Reviewer #4 for the precious and useful reports. We provided to modify all the language segnalations and correct the typo mistakes. We agree that introducing the MIS-C diagnostic criteria would implement the exposure and therefore we inserted them in our paper.

 

2. Data presentation:

-          Data on RSV showed that the epidemic period 2020/2021 was totally abolished. – this sentence is not clear. What has been abolished?

-          Line 229 - … confirming the already demonstrated data of 229 the different clinical presentations between children and adults [9]. – this sentence has been thrown into the discussion without any introduction or explanation as to why it differs. The readers should be given a short explanation (e.g., lower severity and shorter hospitalisation).

 

Thank you again for the punctual and well expose report. We totally see your point and agree that those paragraphs could not appear as clear as we would have wanted to. We tried to solve the misunderstanding, hoping in a better clarity.

 

3. The authors set out to do the following:

“In this paper, we describe the activity, its modulation and changes, during the pandemic waves in our pediatric department, the biggest tertiary pediatric center in the Emilia Romagna region in Italy.” I fail to see how the activity and its modulation were performed at their department.

My questions regarding the activity modulation:

-          What concrete measures were implemented?

-          Was the workload divided?

-          What is the normal workflow protocol at admission?

-          Were there specific workflow protocols for COVID-19?

-          Did the work protocols change during the waves?

 

Regarding the reorganization of the activities in our pediatric ED the main changes are described in the paragraph 3.1. They consisted in separating from the triage the patients with Covid-19 related symptoms from the others and making sure there was no contact between them in order to try to reduce the spreading (two different waiting rooms and two different rooms for the medical visit). We also described our approach with the molecular swab screening in those patients. Actually, the organization did not change much during the different pandemic periods and so we agree in changing the introduction sentence of our paper.

 

4. Some concerns:

-          Is there any follow-up data on the COVID-19 positive children?

-          Did any of the children experience any COVID-19 related side effects?

-          How many of the children were vaccinated?

 

Thank you very much for your interesting questions. Unfortunately a follow-up of the Covid-19 positive children was not possible in our centre due to the high incidence and the high number of patients that made it difficult to organize.

Regarding the side effects in our clinical experience we encountered many minor side effects as ageusia, anosmia, dermatological manifestations, asthenia and many minor symptoms related to long covid as well. Unfortunately at the moment it is not possible for us to access to those data, but it would be a great idea for a future paper.

In Italy the vaccination campaign for children started at the beginning of December 2021. Before this data all patients were not immune. Unfortunately also for this question we do not have access to the data of the vaccinated patients to Sars-Cov2 in our centre, even if it would be really interesting to describe as you suggested.

Author Response File: Author Response.pdf

Round 2

Reviewer 4 Report

REVIEW REPORT

Activity of a Pediatric Emergency Department of a Tertiary Center in Bologna, Italy, during SARS-CoV-2 Pandemic

 

NO: pediatrrep-1797965

Journal: MDPI

Section: COVID-19: What Happens in Pediatric Research in the Era of Pandemic

 

Date: 15.08.2022

 

The authors answered all questions satisfactory.

 

There are still spelling and formatting mistakes:

·         Diffusion – consider using “spread” or “transmission”

·         Line 189 – citations after full stop

·         254 – peack – the authors probably meant peak

·         Literature – do you need to have all URLs in the citations?

 

Consider an additional language check.

 

With best regards.

Author Response

Reviewer #4:
The authors answered all questions satisfactory.

We would like to thank Reviewer #4 for having reviewed our paper.

 

There are still spelling and formatting mistakes:

Diffusion – consider using “spread” or “transmission”

We changed the manuscript accordingly.

 

Line 189 – citations after full stop

We changed the manuscript accordingly.

 

254 – peack – the authors probably meant peak

We changed the manuscript accordingly.

 

Literature – do you need to have all URLs in the citations?

We modified the references according to Journal’s requirements.

 

Consider an additional language check.

The manuscript has been checked by a native English-speaking colleague as recommended.

Author Response File: Author Response.pdf