Recurrent (or episodic) fever of unknown origin (FUO) as a variant subgroup of classical FUO: a French Multicenter Retrospective study of 170 patients

BACKGROUND

Recurrent-FUO (fever of unknown origin) is a rare subtype of FUO for which diagnostic procedures are ill-defined and outcome data are lacking.

METHODS

We performed a retrospective multicentre study of patients with recurrent-FUO between 1995 and 2018. By multivariate analysis, we identified epidemiological, clinical, and prognostic variables independently associated with final diagnosis and mortality.

RESULTS

Of 170 patients, 74 (44%) had a final diagnosis. Being ≥ 65 years of age (OR=5.2; p<0.001), contributory history (OR=10.4; p < 0.001), and abnormal clinical examination (OR=4.0; p=0.015) independently increased the likelihood of reaching a diagnosis, whereas lymph node and/or spleen enlargement decreased it (OR = 0.2; p=0.004). The overall prognosis was good; 58% of patients recovered (70% of those with a diagnosis). Twelve (7%) patients died; patients without a diagnosis had a fatality rate of 2%. Being ≥ 65 years of age (OR = 41.3; p < 0.001) and presence of skin signs (OR = 9.5; p = 0.005) significantly increased the risk of death.

CONCLUSION

This study extends the known yield of recurrent-FUO and highlights the importance of repeated complete clinical examinations to discover potential diagnostic clues during follow- up. Moreover, their overall prognosis is excellent.

Blister Beetle Dermatitis Outbreaks in Mali

INTRODUCTION

Meloidae are distributed in temperate and arid regions but are also common in subtropical and tropical savannahs. These insects contain cantharidin, a vesicant substance that can cause poisoning by ingestion and dermatitis by direct contact.

MATERIAL AND METHODS

We describe recurrent Meloidae-related dermatitis outbreaks and their health impact by analyzing medical consultation records and meteorological data.

RESULTS

Between 2015 and 2019, dermatitis outbreaks took place at a French military base at the end of the rainy season, from July to August, with 100 cases reported in 2015, 74 in 2017, 100 in 2018, and 36 in 2019. In 2017, the incidence rate was 4.4% for the base's population. Initial medical consultations represented 31.5% of total medical care activity. Meloidae were identified as Cyaneolytta fryi.

CONCLUSIONS

These outbreaks of burn-like lesions, although clinically benign, can place a considerable burden on the medical activity of health care facilities. The diagnosis of Meloidae dermatitis is exclusively anamnestic and clinical and requires reported contact with the insect. The treatment protocol is that of standard burn care, and the best preventive measure is to avoid bright white lights. Military personnel, foreign workers, and travelers venturing into the Sahel should be warned of the risks associated with these beetles.

[Naftidrofuryl in arterial obstructive disease: A systematic revue of the literature]

INTRODUCTION

Arterial obstructive disease is a disease affecting 11 % of the general population. This prevalence is constantly increasing. Nafronyl is still prescribed despite a decreasing reimbursement rate since 2005. The objective of this study was to summarize data from the scientific literature on the efficacy and safety of nafronyl used for the treatment of peripheral arterial obstructive disease.

METHOD

A systematic review was made on EMBASE, MEDLINE and the Cochrane Library. Randomized controlled trials, systematic reviews and meta-analyses comparing naftidrofuryl with placebo were included. The main outcome was an improvement in the maximum walking distance or pain free walking distance. The quality of the reviews was analysed using a standardised reading grid. Only the best study was retained.

RESULTS

Among 193articles, one meta-analyses were selected. Naftidrofuryl improved the initial pain free walking distance by 60 % at six months, without a demonstrated increase in the risk of adverse reactions.

CONCLUSION

The efficacy of naftidrofuryl over the maximum walking distance in peripheral arterial obstructive disease appears similar to physical exercise or simvastatin.

Healthy worker, healthy citizen: the place of occupational health within public health research in Switzerland

OBJECTIVES

To assess the state of Swiss occupational health (OH) research over the period 2008-2017.

METHODS

Two types of indicators were constructed, focused, respectively, on resources available for OH research and its output. Data for their assessment were gathered from specialized research institutions, professional associations, and the Swiss Federal Statistical Office.

RESULTS

Thirty-two of 317 Ph.D./M.D.-Ph.D. theses delivered were in the field of OH. The number of OH physicians progressed substantially, but the density of OH professionals per number of active workers showed important variations between OH disciplines and geographical regions. The number of yearly peer-reviewed publications increased substantially but represented 6% of publications in public health in 2017. Psychological and respiratory health conditions were the most studied topics, while papers on cancers accounted for only 10%.

CONCLUSIONS

This study suggests a limited place of OH research in the Swiss public health landscape and the need for a national research effort in OH. This requires an improved collaboration between regional and federal authorities and communication/coordination between public health authorities and OH executive institutions belonging to the economic sector.

Management of otitis media with effusion in children. Société française d'ORL et de chirurgie cervico-faciale clinical practice guidelines

The Société française d'ORL et de chirurgie cervico-faciale clinical practice guidelines concern the management of otitis media with effusion (OME) in children under the age of 12 years. They are based on extensive review of MEDLINE and Cochrane Library publications in English or French from 1996 to 2016 concerning the methods of diagnosis and assessment of otitis media with effusion, as well as the efficacy of tympanostomy tubes and medical and surgical treatments of OME.

Morning blisters: cantharidin-related Meloidae burns

We report several cases of Meloidae-related blisters in French soldiers deployed to Mali. Blister beetles of the Meloidae family produce cantharidin, a blistering agent, for defensive purposes. These virtually cosmopolitan Coleoptera can cause significant nuisance to travellers and deployed soldiers especially during the rainy season in the Sahel region.

Mind the eye-squirter! An Anthia sexmaculata sexmaculata-related necrotic burn

We report the case of an Anthia sexmaculata sexmaculata-associated necrotic burn in a French expatriate in Mauritania. Anthia spp.-related injury is a common though underreported health issue in the Sahelo-Saharan area. Deployed soldiers and travellers should be aware of these beetles when adventuring in this region.

The economic burden of urinary tract infections in women visiting general practices in France: a cross-sectional survey

Background

Urinary tract infections (UTIs) are among the most common bacterial infections. Despite this burden, there are few studies of the costs of UTIs. The objective of this study was to determine the costs of UTIs in women over 18 years of age who visit general practitioners in France.

Methods

The direct and indirect costs of clinical UTIs were estimated from societal, French National Health Insurance and patient perspectives. The study population was derived from a national cross-sectional survey entitled the Drug-Resistant Urinary Tract Infection (Druti). The Druti included every woman over 18 years of age who presented with symptoms of UTI and was conducted in France in 2012 and 2013 to estimate the annual incidence of UTIs due to antibiotic-resistant Enterobacteriaceae in women visiting general practitioners (GPs) for suspected UTIs.

Results

Of the 538 women included in Druti, 460 were followed over 8 weeks and included in the cost analysis. The mean age of the women was 46 years old. The median cost of care for one episode of a suspected UTI was €38, and the mean cost was €70. The annual societal cost was €58 million, and €29 million of this was reimbursed by the French National Health Insurance system. In 25 % of the cases, the suspected UTIs were associated with negative urine cultures. The societal cost of these suspected UTIs with negative urine cultures was €13.5 million. No significant difference was found between the costs of the UTIs due to antibiotic-resistant E. coli and those due to wild E. coli (p = 0.63).

Conclusion

In the current context in which the care costs are continually increasing, the results of this study suggests that it is possible to decrease the cost of UTIs by reducing the costs of suspected UTIs and unnecessary treatments, as well as limiting the use of non-recommended tests.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1620-2) contains supplementary material, which is available to authorized users.

Schooling of hearing-impaired children and benefit of early diagnosis

OBJECTIVE

To assess the impact of moderate-to-severe bilateral hearing loss on schooling and the factors influencing this impact, and to evaluate special schooling needs in addition to speech therapy.

MATERIAL AND METHODS

Retrospective study including children with moderate-to-severe bilateral hearing loss, born between 1992 and 2006, diagnosed and managed in our institution. The age and degree of hearing loss in the better ear, the type of schooling and the level of schooling at the time of the last visit were recorded for each patient.

RESULTS

Two hundred and twenty-five hearing-impaired children were included: 161 attended a regular school (58% of the 55 children with severe hearing loss and 76% of the 170 children with moderate hearing loss). The percentage of children with moderate hearing loss attending a regular school increased over time. This study did not demonstrate any difference in terms of grade retention according to the age at diagnosis for children with moderate hearing loss. No child with comorbidity affecting intellectual capacities attended a regular school.

CONCLUSION

This study confirms that moderate-to-severe congenital bilateral hearing loss has an impact on the child's schooling, with grade retention that depends, but not exclusively, on the degree of hearing loss. A growing number of children with moderate bilateral hearing loss fitted with a hearing aid now attend a regular school.

Structural and magnetic properties of mixed Co–Ln (Ln = Nd, Sm, Eu, Gd and Ho) diethyleneglycolate complexes

Co–Ln diethyleneglycolates consisting of 1D-chains of [(Ln₂Co₂)(Cl)₂(deg)₄] tetramers were produced in degH₂. In the tetramers 5 and 7 Co²⁺ and Ln³⁺ coordinated cations are antiferromagnetically weakly interacting.

Pseudohypacusis in children: circumstances and diagnostic strategy

OBJECTIVES

The study attempts to specify the circumstances under which we should pay attention to children's pseudohypacusis. It evaluates the methods used to detect such cases and to determine hearing thresholds, according to the uni-or bilateralism of hearing loss. The study finally deals with the future of children diagnosed with pseudohypacusis.

METHODS

The study was retrospective from January 1993 to November 2011 and prospective from December 2011 to April 2012. We included all the children between 3 and 16 years who were diagnosed with pseudohypacusis. We observed the reasons for them to consult, whether they had already been tested or had treatment, and what kind of hearing loss they displayed. All children were tested using standard pure tone audiometry and speech audiometry. Depending on the first results, other tests were conducted. They included transient evoked otoacoustic emissions (TEOEs), auditory brainstem responses (ABR) and auditory steady state responses. Families were finally contacted by phone over April 2012 in order to let them know about their child's results.

RESULTS

Fifty-four children were included: 19 boys and 35 girls, with an average age of 10 year-old (±3). The simulated hearing loss (HL) was bilateral (36), unilateral (18), of perception (37), moderate HL (33), cophosis (5). Fifteen cases were linked to a family or personal history of hearing loss, while 27 cases were due to important events like adoption, abuse, verbal aggression, school problems. Before diagnosing a pseudohypacusis, 13 children had had imaging studies, 3 had been treated with corticosteroids, and 5 had hearing aids. Most of the time the presence of pseudohypacusis was suspected a discrepancy between speech reception and air-conduction pure tone thresholds, as shown by the medical test (answer on whispered voice). The diagnosis was confirmed by ABR or TEOEs, except in cases where clinic was obvious. Then family's patient and patient were reassured and informed. An audiological follow-up during either 6 months or 1 year was proposed, as well as a psychological consultation.

CONCLUSION

Complementary examinations have to be performed to rule out a pseudohypacusis case before suggesting an invasive or expensive treatment (surgery or hearing aids) of children.

Mycophenolate mofetil in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis: a prospective pharmacokinetics and clinical study

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) treatment strategy is based on immunosuppressive agents. Little information is available concerning mycophenolic acid (MPA) and the area under the curve (AUC) in patients treated for AAV. We evaluated the variations in pharmacokinetics for MPA in patients with AAV and the relationship between MPA-AUC and markers of the disease. MPA blood concentrations were measured through the enzyme-multiplied immunotechnique (C(0), C(30), C(1), C(2), C(3), C(4), C(6) and C(9)) to determine the AUC. Eighteen patients were included in the study. The median (range) MPA AUC(0-12) was 50·55 (30·9-105·4) mg/h/l. The highest coefficient of determination between MPA AUC and single concentrations was observed with C(3) (P < 0·0001) and C(2) (P < 0·0001) and with C(4) (P < 0·0005) or C(0) (P < 0·001). Using linear regression, the best estimation of MPA AUC was provided by a model including C(30), C(2) and C(4): AUC = 8·5 + 0·77 C(30) + 4·0 C(2) + 1·7 C(4) (P < 0·0001). Moreover, there was a significant relationship between MPA AUC(0-12) and lymphocyte count (P < 0·01), especially CD19 (P < 0·005), CD8 (P < 0·05) and CD56 (P < 0·05). Our results confirm the interindividual variability of MPA AUC in patients treated with MMF in AAV and support a personalized therapy according to blood levels of MPA.

Nonpareil Yb behavior in YbMn6Ge(6-x)Sn(x)

We investigate the temperature dependence of the Yb valence in YbMn6Ge1.8Sn4.2 and YbMn6Ge1.6Sn4.4 using resonant inelastic x-ray scattering experiments. Yb is found to be in an intermediate valent state in the whole investigated temperature range (10-450 K). We thus prove that the unusually high magnetic ordering temperature of Yb (∼60 and 90 K for x=4.2 and 4.4, respectively) involves an intermediate valent Yb, an unprecedentedly observed phenomenon. Further, an anomalous increase in the Yb valence is observed upon cooling. A scenario is proposed to explain this unusual behavior. It is based on the presence of magnetically ordered Mn moments and on an Anderson Hamiltonian with a Zeeman term modeling the magnetic interactions.

[Opioid-sparing effect of ketamine during tonsillectomy in children]

INTRODUCTION

In the adult population, Ketamine is currently used as an antihyperalgesic and opioid-sparing agent during the perioperative period. However, for doses of ketamine up to 0.5mg/kg, these effects have not been found in pediatric population. The aim of the present study was to evaluate the efficacy of a preoperative bolus of 1mg/kg of ketamine on postoperative pain intensity and morphine consumption in children undergoing tonsillectomy.

METHODS

We have undertaken a retrospective comparison of 60 consecutive children operated for tonsillectomy in our institution before (first 30 patients) and after (last 30 patients) the introduction of a preoperative bolus of 1mg/kg of ketamine. Data collected were: age, ASA score, dose of intraoperative sufentanil, OPS score during PACU stay and the first postoperative day, morphine consumption during PACU stay and the first postoperative day, psychodysleptic manifestations, pain at first solid oral intake and postoperative respiratory complications or haemorrhage.

RESULTS

No difference was found between the two groups in terms of demographic characteristics. Perioperative doses of sufentanil, postoperative opioid consumption or pain score in PACU or during 24hours were similar between the two groups. The two groups did not differ in terms of pain at first oral intake, or other adverse effects.

CONCLUSION

These results suggest that 1mg/kg of ketamine administered right after anaesthesia induction in children undergoing tonsillectomy did not result in an opioid sparing effect.

Osteochondritis dissecans van de knie bij een Duitse herder

Kreupelheid ten gevolge van orthopedische problemen in de achterhand komt frequent voor bij de hond. De belangrijkste oorzaak van manken bij jongvolwassen dieren van grote hondenrassen is heupdysplasie. Indien het probleem zich in de knie situeert, dan moet naast patellaluxatie en vroege voorste kruisbandrupturen steeds aan osteochondritis dissecans gedacht worden. Aan de hand van een klinisch geval van osteochondritis dissecans bij een jonge Duitse herder worden de diagnostische bevindingen en de behandeling geïllustreerd.

[Congenital buried penis in children]

PURPOSE

Congenital buried penis in children is an uncommon and poorly known entity. The aims of this study were to report an original technique for correction of buried penis and to evaluate its results.

PATIENTS AND METHODS

It is a retrospective study of buried penis operated between November 1998 and May 2009. The acquired concealed penis and hypospadias were excluded from this study. The procedure includes several stages: degloving of the penis through a ventral anchor-like incision; division of the adherent layers surrounding the corpora cavernosa; anchorage of the Buck's fascia to the corporeal albuginea at the base of the penis; and ventral cutaneous coverage. The long-term results were evaluated by the parents and the surgeon according to anatomical, functional and aesthetic criterion.

RESULTS

Twenty-five boys were evaluated. The mean age at surgery was 27 months (seven days-120 months). Two children required an additional plasty. Results were satisfactory in 24 cases (96%). One child required a redo procedure for unsatisfactory outcome. Of seven children with redundant skin (28%), three underwent a complementary cutaneous excision.

CONCLUSION

Congenital buried penis remains a controversial issue. Our technique was simple and easily reproducible. Voiding difficulties, urinary tract infection or strong parental request were the main indications of this surgery in our experience.

Traumatisme du testicule chez l’enfant

Introduction

Les traumatismes du testicule sont rares chez l’enfant, et la littérature est très pauvre sur ce sujet. Le but était de les analyser à partir d’une étude multicentrique rétrospective.

Matériel et méthodes

Un questionnaire sur les traumatismes du testicule survenus entre 2000 et 2009 a été envoyé dans les différents centres de chirurgie pédiatrique français. L’analyse a été effectuée à l’aide du questionnaire et du compte rendu opératoire, et n’ont été retenus que les dossiers de traumatisme vrai du testicule, excluant les plaies simples du scrotum, les traumatismes « révélateurs » d’une torsion de testicule ou d’hydatide, ou encore les dossiers incomplets.

Résultats

Quinze centres ont bien voulu nous transmettre leurs observations et parmi ceux-ci, deux ont répondu n’avoir opéré aucun cas; cette étude n’est pas exhaustive, car beaucoup d’équipes ont envoyé des dossiers d’enfants opérés et aucun cas de traumatisme bénin. Parmi les 60 observations reçues, 45 ont été retenues. L’âge moyen était de 12,3 ans (2 jours–18 ans). Les circonstances du traumatisme étaient 23 coups (pied, genou, poing), 13 chutes (vélo, banc, luge), quatre accidents de la voie publique, quatre traumatismes de nature inconnue et un traumatisme obstétrical. Le traumatisme était fermé 41 fois et ouvert quatre fois. L’échographie-doppler couleur a été réalisée dans 34 cas sur 45 (75,5 %); un diagnostic exact a été possible 30 fois, alors qu’il y a eu trois faux-positifs (deux fractures du testicule et un hématome intratesticulaire non confirmés à l’intervention) et un faux-négatif (contusion de l’épididyme non vue à l’échographie). Les lésions testiculaires étaient les suivantes: 15 fractures, huit hématomes intratesticulaires, six contusions testiculaires bénignes (dont une associée à une tumeur), six hématomes du cordon, six contusions de l’épididyme, trois hématocèles isolées et une avulsion. Le traitement a été chirurgical 33 fois et non opératoire 12 fois. Parmi les 15 fractures du testicule, 13 ont été opérées (huit sutures et cinq orchidectomies partielles) et deux ont été surveillées avec de bons résultats, sans atrophie secondaire. Pour les hématomes intratesticulaires, trois ont été surveillés et cinq opérés. Seuls 20 enfants ont été suivis au-delà de quatre mois, essentiellement les fractures testiculaires, et aucune atrophie secondaire n’a été constatée.

Conclusion

Les traumatismes du testicule chez l’enfant sont rares, mais leur pronostic est plutôt bon. L’échographie-doppler permet désormais de faire un diagnostic précis dans un grand nombre de cas, devant permettre d’éviter certaines explorations chirurgicales systématiques; mais l’intervention reste indispensable en cas de doute.

[Outpatient tonsillectomy in children]

Tonsillectomy may be performed as an outpatient procedure because post-tonsillectomy hemorrhages occur during the first few hours, and therefore are diagnosed before discharge, or occur after the sixth day. Nevertheless, not all patients are eligible for outpatient tonsillectomy. Both the ENT surgeon and the anesthesiologist must identify children who cannot be operated as outpatients because they do not satisfy the social criteria for discharge on the day of surgery (their parents do not speak French, they live too far from the hospital, etc.) or because they have individual risk factors for complications unrelated to their tonsils, such as bleeding disorders or related to their tonsils, such as a history of obstructive sleep apnea due to enlarged tonsils, particularly for young children. The anesthetic protocol must minimize the risk of postoperative nausea and vomiting. After tonsillectomy, the child may be discharged from the recovery room if he is fully awake, with no dyspnea and no oral bleeding, and is able to swallow liquids, without repeated vomiting.

[Epidemiology of acute otitis media caused by Streptococcus pneumoniae: emergence of serotype 19A]

In this study, the authors report the distribution of serogroups/serotypes and their susceptibility profiles of Streptococcus pneumoniae causing recurrent and difficulties to treat acute otitis media (AOM) in children obtained at the ENT outpatient clinic of Robert Debré Hospital in Paris, between 2002-2008 after the implementation of the 7-valent pneumococcal conjugate vaccine. In this retrospective study, 126 S. pneumoniae isolates were obtained by tympanocentesis from 126 children with AOM during three different periods: 2002-2003 (period 1), 2004-2005 (period 2), and 2006-2008 (period 3). In period 1, the most common serotype was 19F. Between period 1 and period 3, the proportion of serotype 19F decreased from 39 to 13% (P=0.03). In contrast, the proportion of serotype 19A increased from 25 to 60% (P=0.03). So, they observed that vaccine-related serotype 19A became dominant among young children with AOM in 2006-2008. Overall, 15.1% of the isolates were penicillin susceptible, 73.8% intermediate and 11.1% were resistant. Most (94%) of the S. pneumoniae serotype 19A were penicillin intermediate.