[Overview of hospital city repay for paediatric preparations initiated within the Marseille Public University Hospital system]

OBJECTIVES

Hospital internal-use pharmacies are required to make pharmaceutical preparations in order to obtain a medication in a dosage and/or Galenic form (FG) suitable for pediatric use. The aim of this study is to assess the procedures for continuing pharmaceutical preparations initiated within the Assistance Publique des Hôpitaux de Marseille in an outpatient setting.

METHODS

Hospital discharge prescriptions and/or consultation prescriptions involving paediatric magistral preparations and issued by our Hospital Centre were collected from two pharmacies with significant preparation activity at national level. An analysis of regulatory compliance was carried out, as well as a comparison of the formulation of preparations made in the outpatient setting and in the hospital.

RESULTS

Au total, 45 prescriptions were collected, representing 52 preparation lines. The regulatory analysis revealed that all the prescriptions contained at least one non-conformity, 60.8% of which related to drug treatments. The prepared FG differed in the outpatient setting compared to the hospital in 46.2% of cases, and in 56% of cases, the vehicle and concentration of the active ingredient used differed when the FG was a liquid oral form.

CONCLUSIONS

The lack of clear and complete hospital prescriptions makes it difficult to carry out treatment initiated in hospital in the outpatient setting. The multiplicity of information systems between hospitals and outpatient settings are obstacles to the interoperability needed to coordinate patient treatment, particularly in paediatrics. The quality of discharge prescriptions needs to be improved to optimise the patient care pathway.

[Chemotherapy-induced nausea and vomiting in pediatric oncology patients: 2023 recommendations from the Supportive Care Committee of the French Society of Cancer in Children and Adolescents]

Chemotherapy-induced nausea and vomiting (CINV) are frequent and dreaded side effects in cancer treatments. CINV has a major impact on patient's condition and quality of life. Prophylaxis is tailored to patient's profile and the emetogenic level of their chemotherapy. The aim of this study is to update the recommendations for CINV prevention and management in pediatric onco-hematology for use in France, by adapting the guidelines of the Pediatric Oncology Group of Ontario (POGO). Clinical practice guideline adaptation is a recognized method for tailoring existing clinical practice guidelines to local context. A multidisciplinary French-speaking panel was formed to discuss about POGO guideline recommendations for the acute and delayed phases, breakthrough, refractory and anticipatory CINV and the evidence supporting them. Panel members were asked whether they wanted to adopt, modify or reject each of the POGO guideline recommendations. Panel members translated each recommendation and adapted recommendations for an implementation in France. Their acceptance required agreement at least 80 % of panel members. Algorithms and tables were created, listing all the recommendations and providing a better overview for decision-making process adapted to the patient's profile. These recommendations should be reviewed for implementation at French institutions caring for pediatric cancer patients and once implemented, the rates of adherence to recommendations and CINV control should be reported.

Intraocular foreign bodies in children: A retrospective case series

INTRODUCTION

Open globe injuries are a major cause of visual impairment in children, related to the severity of the trauma or secondary to induced amblyopia. Intraocular foreign bodies (IOFB) have been reported in approximately one third of cases of open globe injuries. As clinical presentation and management may differ between adults and children, data is lacking about IOFBs in children under 18years of age. The purpose of this study was to assess the clinical characteristics and visual prognosis of ocular trauma associated with intraocular foreign bodies in children.

MATERIALS AND METHODS

This single-center retrospective study included patients under 18years of age treated for ocular trauma with IOFB. Demographic characteristics, complete initial and final ophthalmological examination, imaging data and details of medical and surgical management were collected.

RESULTS

Fourteen patients were included (78.6% boys), with a mean age of 10.3years (min 7months-max 17years). In 92.9% of cases, patients were found to have a single IOFB, mostly metallic (71.4%). Posterior segment IOFBs were found in 50% of cases, anterior segment IOFBs in 28.6% and orbital IOFBs in 21.4%. The clinical examination permitted detection of the IOFBs in 50% of cases, while they were visible on CT scan in all cases. The mean initial visual acuity was 20/320, and the mean final visual acuity was 20/125. Endophthalmitis occurred in 2 cases (14%).

DISCUSSION

Open globe injuries associated with IOFB are severe and sight-threatening. Localization of the IOFB in the posterior segment has a worse prognosis. CT scan is mandatory, especially in children, as the trauma history is often missing. Retinal detachment and endophthalmitis appear to be the main prognostic factors requiring urgent specialized pediatric ophthalmology management.

[A severe unilateral corneal ectasia in children]

PURPOSE

We report a case of unilateral Terrien's marginal degeneration in a 14-year-old girl.

CLINICAL CASE

Slit-lamp examination of the affected eye revealed 360° circumferential lipid deposits with 6mm of superior limbal distension, superficial neovascularization, a zone of corneal thinning from 3:00 to 9:00 with a zone of corneomalacia at 11:00. The remainder of the cornea was clear, without fluorescein staining or anterior chamber reaction.

DISCUSSION

Terrien's marginal degeneration (TMD) is typically known to occur bilaterally in men over the age of 40. Terrien's degeneration must be differentiated from other causes of peripheral corneal thinning; the primary differential diagnosis is Fuchs' marginal keratitis. Other causes of corneal thinning must be ruled out, including Mooren's ulcer. In Terrien's degeneration, there is no central mined edge in the thinning sulcus, the epithelium remains intact, and affected patients do not present with pain. Other differential diagnoses include pellucid marginal degeneration and sulcus degeneration, which are characterized by the absence of lipid infiltrates associated with the central region of the thinning zone, thus distinguishing them from TMD.

CONCLUSION

It is important to keep in mind that Terrien's marginal degeneration can occur in children.

[Juvenile myelomonocytic leukemia and pediatric myelodysplastic syndromes]

Juvenile myelomonocytic leukemia (JMML) and myelodysplastic syndromes (MDS) of children are rare and aggressive diseases. They both have the particularity of being very frequently associated with an underlying predisposition syndrome, which must be systematically investigated by meticulous clinical exam completed by molecular analysis on fibroblasts, in order to guarantee the best therapeutic management. New generation sequencing techniques have made it possible to better define the landscape of constitutional predisposing pathologies, to understand the clonal evolution that leads to the development of hematological malignancies and to identify new prognostic markers. In these two diseases, the only curative treatment is allogeneic hematopoietic stem cell transplantation, for which the appropriate timeframe, the type of donor and the conditioning must be decided in consultation with the expert teams in each entity.

Radial nerve lesion after medial epicondyle osteosynthesis in a pediatric patient: A rare complication of surgery

Fractures of the medial epicondyle are relatively common in children and may be associated with nerve lesion, especially in case of displacement. Incarceration of the ulnar nerve in the fracture site is feared in Watson-Jones stage II, rarely directly related to osteosynthesis. Depending on the degree of fracture displacement, various osteosynthesis techniques may be used; nerve injuries are a rare but known complication of these procedures. We report a case of radial nerve injury related to pinning osteosynthesis of a medial epicondyle fracture.

[Outpatient surgery for penile hypospadias in pediatric urology: A monocentric experience with a mean follow-up of 3 years]

INTRODUCTION

Hypospadias is one of the most common congenital anomalies in men. Outpatient surgery has been proposed but is not widespread. The aim of this study was to evaluate our experience of outpatient surgery for penile hypospadias repair and to specify the constraints for a result similar to a conventional inpatient procedure.

PATIENTS AND METHODS

Observational, retrospective and single-center study, including all the patients operated on hypospadias for the first time by one of the 3 senior surgeons, between January 2011 and March 2018. Peno-scrotal and perineal hypospadias were excluded because systematically hospitalized.

RESULTS

One hundred sixty-six patients were included. 67 patients (40,4%) were treated on an outpatient basis. The mean age at the time of procedure was 15.6 (6-51) months. Forms with curvature were almost exclusively hospitalized (1 vs. 25, P<0.001). There was no significant difference for anterior penile forms (60 vs. 81, P=0.06). Middle and posterior hypospadias were more often hospitalized, although outpatient experience exists. There were no more complications in the outpatient group.

CONCLUSION

Outpatient hypospadias surgery seems to be achievable in most of the cases, provided that medical care is standardized and multidisciplinary, the staff is trained and involved and a specific organization is put in place in the department. Evaluation of the socio-family environment is therefore fundamental.

LEVEL OF EVIDENCE: 4

Ultrasonography in the assessment of hand injuries in children: A systematic review

Despite the frequency of paediatric hand injuries, recommendations for diagnostic investigations are limited due to paucity of published guidelines. This has led to inappropriate diagnoses and therefore inappropriate management. Ultrasonography is a portable, non-ionising imaging modality that allows rapid real-time evaluation of anatomical structures at a low cost and without sedation. In the adult population, ultrasonography has already been shown to improve accuracy in hand injury diagnoses. However, in the paediatric population, only one narrative review focuses on the application of ultrasonography to diagnose hand injury. A systematic search using PubMed, Google Scholar, EMBASE, Scopus, Cochrane database of systematic reviews and University Library of York, Keele, Edinburgh and King's College London was conducted to assess literature surrounding use of ultrasonography as a diagnostic tool for paediatric hand injuries. The literature search yielded 11,860 articles and 21 studies were identified with a total of 30 patients. Ultrasonography was observed to be an accurate tool for diagnosing bone, tendon, ligament and nerve injuries in children. The results of our study suggest that ultrasonography should be considered as an early diagnostic step for paediatric hand injuries.

Comparison of the iCare rebound tonometer and the Perkins applanation tonometer in children under general anesthesia

INTRODUCTION

The goal of the study was to compare Perkins applanation tonometry and iCare rebound tonometry, evaluating their correlation and agreement in a diverse pediatric population under general anaesthesia (GA).

MATERIALS AND METHODS

Children undergoing an eye examination under GA between November 2019 and March 2020 were included. Intraocular pressure (IOP) was measured successively using the Perkins applanation tonometer and the iCare IC200 rebound tonometer. Ultrasonic central pachymetry and axial length were measured.

RESULTS

One hundred and thirty-eight eyes of 72 children were included. The mean age was 2.87years. IOP measurements obtained with the two tonometers were statistically and significantly highly correlated (r=0.8, P<0.001), although the iCare overestimated IOP by an average of 3.37mmHg (SD±4.48). The agreement between the two methods was moderate; the 95% agreement limits ranged from -5.41 to +12.15mmHg (r=0.5, P<0.001). The IOP difference between the two tonometers was weakly but significantly correlated with mean IOP (r=0.52; P=0.006). No correlation was found with axial length and pachymetry.

CONCLUSION

In this study, the IOP values obtained using the Perkins applanation tonometer and the iCare IC200 rebound tonometer were well correlated. The iCare tended to overestimate the IOP, especially for high IOP values. However, no underestimation of IOP was found with this device, hence its potential for glaucoma screening in children.

[Pediatric medical evacuations from Reunion Island to metropolitan France]

BACKGROUND

The only French center for pediatric oncology and hematology outside of the metropolitan territory is in the Indian Ocean, in Saint Denis, on Reunion Island. It welcomes children from Reunion Island but also from Mayotte and neighboring countries. A quarter of them requires a secondary medical transfer to metropolitan France for specific technic care.

METHOD

We conducted a retrospective single-center study of all pediatric medical evacuations that occurred between 2015 and 2019 from the pediatric oncology and hematology department of Reunion Island. The purpose of this study is to describe these transfers and the consequences of these care pathways for families and care teams.

RESULTS

A total of 189 transfers took place for 105 children: 66 from Reunion Island, 17 from Mayotte and 22 were foreigners. In total, 92 % of the children received the medical care for which they were transferred to metropolitan France. Difficulties were reported: family for 26 % of them, social in 11 % of cases and medical in 10 % of medical records.

CONCLUSIONS

This organization allows children in the Indian Ocean to benefit from similar care than metropolitan children. Many difficulties arise in connection with family and societal breakdowns caused by these transfers. These differences and difficulties are important to know to better accompany patients, families and caregivers in this stage of their medical pathways.

Uveitis in children: Epidemiological, clinical and prognostic characteristics

PURPOSE

The purpose of this study is to describe the characteristics and prognostic factors of pediatric uveitis in a French university referral hospital.

METHODS

We performed a retrospective study of all cases of all pediatric uveitis seen at our institution over a 7-year period.

RESULTS

A total of 141 eyes of 86 children were included. The mean age was 10.7 years, and 61.6% were girls. The uveitis was bilateral in 64.0% of cases. Anterior uveitis (41.0%) and intermediate uveitis (32.0%) were the most frequent forms. The most frequent etiologies were idiopathic (27.9%), juvenile idiopathic arthritis (25.6%) and pars planitis (18.6%). During the follow-up period, systemic corticosteroids were received by 43.0% of children, immunosuppressive drugs by 31.4% and biological agents by 18.6%. At the final examination, complications were present in 67.0% of patients: 18.0% had cataracts, and 11.3% had intraocular hypertension. Posterior synechiae were present in 27.6% of eyes, optic disc edema in 10.5% and macular edema in 16.2%. At the last visit, visual acuity was better than 20/200 in 97.0% of cases. The presence of band keratopathy, cataract or glaucoma was an independent predictor of impaired visual outcomes at follow-up.

CONCLUSION

Juvenile idiopathic arthritis is one of the most frequent and severe pediatric uveitides. Close monitoring and early treatment could prevent complications.

[Antineoplastic drug-induced nausea and vomiting in pediatric onco-hematology: 2022: Guidelines from the supportive care committee of the French Society of Childhood Cancer (SFCE)]

Nausea and vomiting induced by cancer treatment (CINV) remain one of the most common and feared side effects in children despite the use of new drugs to prevent them. The existing recommendations for the prophylaxis and treatment of CINV are based on adult patients in Anglo-Saxon societies. Based on a recent review of the literature, we focused on specific pediatric issues in order to offer recommendations validated by the supportive care committee of the French society for childhood cancer.

[Practical management during maintenance therapy of pediatric acute lymphoblastic leukemia: Recommendations of the French Society for Childhood and Adolescent Cancer and Leukemia (SFCE)]

Maintenance therapy is the last phase of treatment for acute lymphoblastic leukemia in children and adolescents. Although maintenance therapy is associated with toxicities and specific management issues, it is an essential phase of treatment that reduces the risk of relapse. The objective of this work is to propose a guide for the initiation, administration, and monitoring of maintenance therapy, and for the management of food, schooling, leisure, community life, risk of infection and links with family medicine.

[Announcing treatment resistance in pediatric oncology: A qualitative study of nurses' experiences]

INTRODUCTION

The announcement of treatment resistance is a key moment in the management of children treated for cancer. Although nurses are present at various stages of this announcement, few studies have examined their role and experience. This study proposes to enhance understanding of the experience of nurses at this time of the pediatric cancer trajectory in France.

METHOD

A qualitative study was conducted in two pediatric oncology departments. Semi-structured research interviews were conducted with seven pediatric nurses (five women) with an average age of 36.9 years.

RESULTS

Nurses report not being systematically present during announcements of treatment resistance but being present with the families before and after these announcements. Nurses described their role at this point in the management process as multifaceted. The emotional burden associated with these announcements is significant: nurses must manage their own emotions when faced with the discovery of resistance to treatment, those of the families, and must often answer difficult questions about the prognosis or end of life. In this context, teamwork is an important support.

DISCUSSION

Better awareness and recognition of the role of nurses and the associated emotional burden would enable them to fully carry out their missions.

[Respiratory physiotherapy in pediatric practice]

Congestion of the upper (URT) and lower respiratory tracts (LRT) is a common symptom in several acute and chronic respiratory diseases that occur in childhood. To eliminate these secretions, airway clearance techniques (ACT) directed to the URT and LRT are frequently prescribed. The rationale for the application of these techniques is the same as in adults, but they need to be adapted to be transposed to children. The physiotherapist will be able to choose among a wide range of techniques, of which the most adequate will depend not only on the age of the child and the indication, but also on the basis of his preferences or habits, as well as those of the child. Upper airway clearance, including nasal irrigation, is now recommended for acute and chronic rhinosinusitis in children. It is also one of the symptomatic treatments recommended for infants with acute bronchiolitis. For LRT clearance, several indications, such as cystic fibrosis, primary ciliary dyskinesia and neuromuscular disease, are now widely advocated. Conversely, other indications, such as for infants with acute viral bronchiolitis, are highly controversial. Thoughtful application of these techniques is lacking in robust and precise tools to objectively assess the presence of bronchial congestion, and to treat it accordingly. Similarly, no precise and reliable evaluation of the effectiveness of these ACTs is available to date. This review is designed to explore the ACTs used by physiotherapists, to provide an overview of their current indications, and to consider complementary approaches.

[Kidney injury in children and adolescents with leptospirosis in France]

INTRODUCTION

Leptospirosis is an anthropozoonosis with polymorphic clinical symptoms and a high variability of severity, ranging from flu-like syndrome to severe acute kidney injury. This disease is highly incident in tropical regions but there is a trend towards increasing incidence in metropolitan France and in Reunion Island. The objective of this study was to describe the epidemiological, clinical, laboratory and therapeutic characteristics of the pediatric leptospirosis in metropolitan France and in Reunion Island.

PATIENTS AND METHODS

We performed a retrospective analysis of leptospirosis cases hospitalized in University hospitals where members of the Paediatric Nephrology Society work in France between January 2008 and December 2020, 6 centers reported leptospirosis cases, one center had one patient in consultation but lack of available data and 10 centers did not find any case.

RESULTS

A total of 21 cases were reported (mean age 13.4±3.4years), mostly boys (ratio 6:1). Out of 21 patients, 95% had fever, 71% were presenting with myalgia, 81% with thrombocytopenia, and 76% with gastrointestinal symptoms. Regarding kidney impairment, 18 patients (86%) had acute kidney injury, including 4 (19%) with oligoanuria, but none of them required acute dialysis. About 30% of patients had biological signs of tubulopathy including hypophosphatemia, hypokalemia, or tubular proteinuria. No death due to the disease occurred. The therapeutic management followed the current guidelines with the use of antibiotic therapy by amoxicillin or 3rd generation cephalosporins with symptomatic treatment. When there was biological control after exit, creatinine decreased.

DISCUSSION

In this multicenter retrospective study, we report 21 children with leptospirosis with a significant proportion of acute kidney injury, the outcome was favorable. Children do not seem to be at high risk of chronic kidney disease progression but nephrology follow-up has not been systematically carried out. Compared to studies performed in adults, the prognosis was better and hepatic impairment was rare. Compared to other pediatric studies, conjunctivitis was not a common symptom but kidney injury and survival appeared to be similar. Children were presenting with anicteric renal presentation. The casebook wasn't exhaustive and didn't include the other overseas territories, which account for the highest proportion of leptospirosis infection.

CONCLUSION

Leptospirosis is an infection which may lead to multivisceral failure with kidney involvement conditioning the outcome. Despite a better prognosis in children, it remains important to quickly diagnose this infection in order to start appropriate antibiotic therapy and perform a kidney function monitoring.

[Antimicrobial resistance patterns in pediatric febrile urinary tract infection and empirical antibacterial therapy. An epidemiological study in secondary and tertiary care centers in the north-east of France in 2019-2020]

BACKGROUND

Febrile urinary tract infection (UTI) is a common health issue in pediatrics that can lead to serious infectious and renal complications, it requires early diagnosis and a targeted use of antibiotics. The aim of our study was to describe local bacterial agents causing febrile UTIs and their resistance patterns and confront the results with currently used empirical antibacterial therapy in pediatrics emergency departments in Strasbourg and Saverne.

PATIENTS AND METHODS

We used billing codes (international classification of diseases) to identify all inpatients treated for febrile UTIs in two French pediatric emergency departments between January 2019 and December 2020. Microbial results of urine cultures were retrieved from the laboratory information system.

RESULTS

Among 214 microbial results from 208 patients, the distribution of uropathogens was 82% Escherichia coli, with extended-spectrum beta-lactamase in 2.8%, 7% Enterococcus faecalis, 5% Klebsiella, 2% Proteus mirabilis. E. coli was resistant respectively to amoxicillin, amoxicillin/clavulanic acid and cotrimoxazol in 43, 33 and 14% of samples. A third-generation cephalosporin administered intravenously was mainly used (98%) as empirical treatment. Less than 2% of patients were treated with oral cephalosporin from the start.

CONCLUSION

We present the spectrum of uropathogens and susceptibility test results in pediatric UTIs as well as the susceptibility pattern of E. coli, a local treatment protocol was designed based on our results in conformity with national guidelines.

[Chronic aqueous diarrhea in children: An unusual etiology]

Peripheral neuroblastic tumors are the most common extracranial solid tumors in children. On the other hand, diarrheal neuroblastic tumors are quite rare and not easy to diagnose in the early stage. We report a case of neuroblastic tumor in a 2-year old girl presenting with aqueous diarrhea caused by paraneoplasic secretion of VIP.

Physical activity and aerobic fitness in children with inherited cardiac diseases

BACKGROUND

Because of sports and exercise restrictions, children with inherited cardiac disease are at risk of physical deconditioning. Guidelines on sports participation in cardiovascular disease have become less restrictive over time, but their real-life application and behavioural impact have seldom been evaluated in children.

AIMS

We aimed to evaluate adherence to the 2020 European Society of Cardiology guidelines on sports and exercise in children with inherited cardiac arrhythmia and inherited cardiomyopathy; we also sought to evaluate their aerobic fitness, and the behavioural impact of inherited cardiac diseases on physical activity in children.

METHODS

Children aged 6-18 years with inherited cardiomyopathy or inherited cardiac arrhythmia were eligible for this cross-sectional study. Clinical, demographic and qualitative data were analysed.

RESULTS

A total of 32 children were included in the study (mean age 12.7±3.5 years). Most children (81.3%) complied with the 2020 European Society of Cardiology guidelines; they were physically active and had good overall aerobic fitness, with a mean peak oxygen uptake (VO₂) value of 36.5±8.0mL/kg/min (84.0±17.2% of theoretical value). As a result of personal or parental behaviour, some children at risk of sudden cardiac death did not comply with the recommended upper limit of physical activity intensity, whereas others at low risk did not comply with the lower limit.

CONCLUSION

Most children with inherited cardiac arrhythmia or inherited cardiomyopathy complied with current 2020 European Society of Cardiology guidelines on sports cardiology and exercise in cardiovascular disease.

[Development of a tool to help optimizing drug prescriptions in pediatric units in Côte d'Ivoire: GOPP tool]

OBJECTIVE

This study aims to develop a tool for optimizing drug management related to clinical and therapeutic contexts of pediatric units in Côte d'Ivoire.

METHODOLOGY

A list of Inappropriate prescribings (IPs) was developed from prescription review of inpatients and outpatients aged 1 month to 15 years and followed in pediatric units at 4 Teaching Hospitals of Abidjan during 16 months. A two-round Delphi method was used to validate a qualitative list of IPs by experts according to their level of agreement on a six-point Likert scale of 0-5 (0, no opinion; 5, strongly agree). Only propositions obtaining the agreement (rating 4 or 5) of>70% of experts who gave a non-zero rating for the first round and 80% for the second round were retained. Each IP of final list associated with "rationale", (justifying the inappropriateness of prescribing), and "recommendations and/or therapeutic alternative", used to elaborate items of a tool for helping to optimize drug prescriptions in pediatrics (GOPP tool).

RESULTS

A qualitative list of 54 IPs was drawn up from 267 Drug related problems detected after prescription review of 4992 prescription lines for 881 patients. Twenty-three (23) experts rated IPs on this list during two-round Delphi survey. At the end of survey, final list of 52 IPs was retained for development GOPP tool items. Malaria (15%), rhinitis (12%) and bacterial infectious (8%) are mainly pathologies concerned by these items.

CONCLUSION

GOPP tool developed in this study should help to improve drug management of patients in pediatric units in Côte d'Ivoire.

[Pediatric exposure to endocrine disruptors and carcinogenic, mutagenic or reprotoxic substances by pharmaceutical forms intended for the cutaneous route: Regulatory provisions in France, in Europe, and state of the art of scientific knowledge]

OBJECTIVES

The objective is to conduct a review of pediatric exposure to substances whose endocrine disrupting (ED), carcinogenic, mutagenic, or reprotoxic (CMR) character has been confirmed or remains controversial, through their use in pharmaceutical forms intended for the cutaneous route, as well as regulatory measures diligent at the national and European levels.

METHODS

A bibliographical search was carried out on the databases PubMed, Web of Science, Cochrane Library, supplemented by a search for recommendations from French and European authorities. References were selected following an assessment of their relevance to our topic.

RESULTS

Seventy-one references were selected. Pediatric exposure to endocrine disruptors and CMR substances remains through products formulated for their use, but also through indirect exposure to products commonly used by adults. Exposure arises both from the choice of excipients (parabens, phenoxyethanol), packaging materials (bisphenols, phthalates) and the qualitative or quantitative nature of the active ingredients (iodine, boron, pyrethroids, organic sunscreens).

CONCLUSION

The health professional must be able to develop a critical mind on such substances in order to inform and promote therapeutic adherence, guaranteeing the safety of the child's care.

[Cancer in children with intellectual disabilities: Questioning and ethical issues]

The Parents and Caregivers group in the face of ethics in pediatrics of the Île-de-France Ethics Area wondered about the association of the words Disability and Cancer by focusing on the study of the course of children with intellectual disability, treated for cancer. These situations are exceptional, the number of cases in France must not be more than fifty per year. We gathered the testimony of five families of children using a semi-directive survey taking up the journey from birth, announcement of the handicap, the diagnosis of cancer and its treatment. The verbatim show that each story is unique and rich in lessons, despite the feeling of "double penalty": "He did not deserve this, a handicap plus cancer is a lot for one person", "the shot moreover." A healthcare team was also interviewed and raised an additional question: "First, the double penalty… then, what's the point?" Through these testimonies, we sought to question the ethical principles of care, which can be shaken up in these extraordinary supported.

[Intellectual disability and cancer in children: An analysis of the decision-making process]

AIM

The aim was to describe and to analyze the ethics of decision-making in situations involving children with intellectual disability and cancer, from the referent-doctor's point-of-view, in pediatric oncology units in France.

METHODS

Pediatricians working in pediatric oncology units were interviewed through an online questionnaire and a semi-directive interview was systematically proposed. We analyzed the ethical issues that arose during the process of decision-making and we made suggestions in order to address them.

RESULTS

Sixteen doctors reported twenty-one clinical cases. Of these cases, one third of the children had a change in their oncologic treatment, with a risk of pejorative outcome on the prognosis. Despite the fact that ethical issues appeared in 80 % of the cases, there were few consultations with ethical committees. Decision-making process showed no difference compared to children without intellectual disability, thus raising ethical issues in the medical team. Our study showed discrepancy between frequently reported ethical issues, high consensus rate regarding treatment decision and lack of consultation with ethical committees.

DISCUSSION

We propose three steps to guide the decision-making process in situations involving children with intellectual disability and cancer: 1/deeper understanding of the child through reinforced interactions with their caregivers, 2/better cross-boundary discussions, to improve the effectiveness of the multidisciplinary staff, and 3/more systematic ethical committees consultation.

Forearm reconstruction by induced-membrane technique after sarcoma resection in children: technique and functional outcome in three cases

Forearm sarcoma is rare in children. Here, we report three cases. One child presented undifferentiated soft-tissue sarcoma involving the ulna, another had Ewing's sarcoma of the ulna, and the third had Ewing's sarcoma of the proximal radius. In the first case, there were episodes of iterative aseptic nonunion, treated surgically. At last follow-up (respectively 11, 9 and 8 years postoperatively), the mean Musculoskeletal Tumor Society (MSTS) score was 80%, 90% and 77% respectively, and all cases were in remission. The induced membrane technique to reconstruct bone defect after sarcoma resection in children is a possible limb-salvage strategy.

[Chemo-induced mucositis in pediatric oncology: Perspectives?]

Mucositis is defined as inflammatory and/or ulcerative lesions of the oral and/or gastrointestinal tract. It occurs in approximately 40% to 50% of adults patients receiving conventional chemotherapy and up to 75% of patients receiving high dose chemotherapy as conditioning for hematopoietic stem cell transplantation. It is a toxic side effect, which strongly impairs quality of life and leads to refractory pain, increasing risk of infection and even therapeutic modifications. Despite improvements made, the management of mucositis remains a challenge and is still not consensual. A multicentric survey of practices concerning the preventive and curative management of chemo-induced mucositis in pediatric oncology department in France was carried out using a standardized questionnaire. Results confirm heterogeneous practices and the small progress made during the last decade. This national survey and an analysis of the recent literature leads to propose guidelines for the prevention and treatment of oral mucositis in children receiving treatment for cancer.

[Safety and efficiency of epithelium-off accelerated corneal cross-linking for progressive keratoconus in pediatric patients]

In adults, the management of keratoconus has evolved in recent years to achieve a well-codified treatment algorithm. The technique of cross-linking (CXL) has allowed us to stabilize the progression of keratoconus and has been largely developed. It is very effective, with few postoperative complications. Currently, there is no specific keratoconus management protocol for children. As we already know that keratoconus usually evolves more rapidly in children, we might consider whether a stabilizing treatment should be proposed as first-line therapy at the time of diagnosis. We carried out a retrospective study including patients less than 18 years of age with keratoconus who consulted the ophthalmology department at Edouard Herriot hospital in Lyon between 2013 and 2017. The main study parameter was whether or not CXL was performed. The other parameters were gender, age, ethnicity, eye rubbing, presence or absence of atopic disease, maximum keratometry (Kmax), minimal pachymetry, best corrected visual acuity (BCVA) and spherical equivalent. Forty-eight eyes of 34 patients were included. We found that two-thirds of the patients were Caucasian boys. Half of the patients had allergies, and over 60% of patients rubbed their eyes regularly. Only six percent of patients had a family history of keratoconus. The mean age of the patients was 14 (7-18) years at the time of diagnosis. Thirty-four eyes of 22 patients underwent CXL, for a total of 71% of our cohort. No postoperative complications occurred. After CXL, there was no significant difference in minimum pachymetry (455.6±37.25μm vs. 453.45±42.6μm after treatment (P=0.71)) or Kmax (50.23±7.17D vs. 50.99±7.01D after treatment (P=0.058)). There was a significant improvement in BCVA (from 0.30±0.3LogMar to 0.17±0.17LogMar after CXL (P=0.024)) and spherical equivalent (-1.91±2.1D to -2.54±1.89D after treatment (P=0.009)). The mean duration of follow-up was 32.2 months (12-59). CXL shows long-term disease stabilization in children with keratoconus. Nevertheless, this technique is indicated only for progressive keratoconus. Early diagnosis and management are essential in this population where the disease is rapidly changing. Treatment of atopy and performance of corneal topography when a child has irregular astigmatism should become automatic for early detection of this disease.

[Enoxaparin and tinzaparin in pediatrics: Impact of recommendation on prescription quality and anti-Xa levels]

OBJECTIVES

A protocol has been written and distributed in May 2017 to all prescribers in a pediatric hospital to standardize and to secure the prescriptions of enoxaparin and tinzaparin considered as two high risk medications. The aim of this study is to evaluate the impact of the protocol on those prescriptions in a pediatric population.

METHODS

This is a monocentric retrospective study comparing prescriptions of this two low-molecular-weight heparins for patients under 18 years old in 2016 and 2018, thus before and after the protocol redaction.

RESULTS

In 2016, 2246 prescriptions of enoxaparin and tinzaparin were analyzed for 627 patients. Among them, 142 (22.6%) patients have had at least one anti-Xa level dosed. On the other hand, in 2018, 2061 prescriptions were written for 628 patients including 96 (15.3%) who have had at least one anti-Xa level dosed. The conformity rate of the first dose in IU/kg/administration of the first enoxaparin prescription goes from 36.3% before protocol to 52.1% after (P=0.03*). Concerning tinzaparin, the conformity rate goes from 69.2% to 83.3%. (P=0.19). The rate of first anti-Xa level in the range 0.4 to 1.2 IU/ml increase between 2016 and 2018 from 27.7% to 43.8% (P<0.001*).

CONCLUSION

This protocol enabled to improve the quality of prescriptions in terms of: dosage written in IU/kg/administration, frequency of administration, dilution conformity, and result of the first anti-Xa level. Some efforts must be made in writing the dose in IU not in mg or ml.

[Dermocorticoides and sun exposure: A misunderstanding?]

INTRODUCTION

Fear of dermocorticoids (DCs) or corticophobia is based on an overestimation of the risks of actual side effects and on unfounded beliefs such as DCs-induced photosensitivity among community pharmacists. The objective of this study was to assess the community pharmacy teams' fear of dermocorticoids in atopic dermatitis (DA) in sunny weather and its impact on drug use advice.

MATERIAL ET METHODS

A questionnaire as a real case (a summer prescription for atopic dermatitis for an 18-month-old child) was posted on Facebook via groups of pharmacists, technicians and students. Data collected concerned the health professional, his or her reluctance to DCs, advice associated with dispensation, detailed concerns about the DC and sun association, and sources of information.

RESULTS

In total, 126 participants responded (48.4% pharmacists, 40.5% technicians, 10.3% students): 12% were reluctant to DCs, 36% were reluctant to DCs and considered them photosensitizing, and 51% were not reluctant but considered them photosensitizing. The impact on the patient advice was: a suggestion to stop DC during sun exposure (28%), to stop or limit DC (dose, duration) (43%). Concerns about the association DC/sun were mainly due to UV rays (46%). Sources cited were: monographs (54%), Internet (6%), training courses (13%).

CONCLUSION

The false belief of DC/sun incompatibility in DA is strong among pharmacists and impacts on patients' advice. The role of the official team in dispensing dermocorticoids is essential: training and information for professionals helps to fight false information.

[Use of radiopharmaceuticals in pediatrics: Specificities and recommandations of SoFRa (Société française de radiopharmacie)]

Radiopharmaceuticals are commonly used in children in nuclear medicine. Because of physiological differences in growing children and their radiosensitivity, precautions must be taken throughout the medication use process. The aim of this work is to propose recommendations, under the aegis of the Société française de radiopharmacie (SoFRa), for each subsystem of the process, in order to ensure the safety of pediatric patients. Furthermore, an analysis of two surveys on diagnostic radiopharmaceuticals dosage used in different nuclear medicine departments in France is detailed. Recommendations for therapeutic radiopharmaceuticals are also provided. Specificities of the preparation for pediatric patients are discussed through the example of the radiopharmaceuticals for lung perfusion scintigraphy. The preparation of individual dose and administration are also described. In nuclear medicine, radiopharmacist's expertise is essential for patient safety. A multidisciplinary approach is necessary to secure pediatric radiopharmaceutical use process.

Health-related quality of life correlates with time in therapeutic range in children on anticoagulants with International Normalised Ratio self-monitoring

BACKGROUND

Managing oral anticoagulant therapy with vitamin K antagonists remains challenging in paediatric medicine.

AIMS

This study aimed to assess the correlation between time in therapeutic range and quality of life in children participating in a non-selective International Normalised Ratio self-monitoring and vitamin K antagonist education programme.

METHODS

Children aged from 2 to 18 years and receiving vitamin K antagonist therapy were eligible for this prospective multicentre study. Clinical and demographic data were collected. Health-related quality of life was assessed using the PedsQL™ 4.0 questionnaire. Correlations between quality of life scores and time in therapeutic range were measured.

RESULTS

A total of 121 children were included in the study (mean age 9.6±4.9 years). Cardiac conditions were the predominant indication for vitamin K antagonists. The mean time in therapeutic range was 0.78±0.15 overall, and 0.76±0.24 over the 3-month period before quality of life assessment. The mean total quality of life score was 76.2±18 in self reports, 71.4±22 in mother reports and 73.5±19 in father reports. The time in therapeutic range correlated with the total quality of life scores in self reports (r=0.22; P=0.04), mother reports (r=0.23; P=0.02) and father reports (r=0.28; P=0.02). The time in therapeutic range predominantly correlated with school functioning in self reports (r=0.38; P=0.002) and mother reports (r=0.40; P<0.001), and with physical functioning in father reports (r=0.28; P=0.03).

CONCLUSIONS

Time in therapeutic range correlated with quality of life in children participating in a non-selective International Normalised Ratio self-monitoring and vitamin K antagonist education programme. Regular assessment of quality of life in patient education programmes contributes towards understanding the concerns and needs of patients.

[Proton pump inhibitors in pediatrics: Review of the prescriptions' relevance for hospitalised children in a university hospital]

INTRODUCTION

Proton Pump Inhibitors (PPIs) are a pharmacological class designed to reduce the acidity of gastric secretions. They are prescribed for 11 % of the children in our institution.

AIMS

To assess the relevance of PPI prescriptions in pediatrics.

MATERIAL AND METHOD

A clinical audit according to the methodology proposed by the High Authority of Health was carried out between August 27 and August 31, 2018 in the pediatric departments of our institution. The main judgement criteria were the indication of the PPI. The main guidelines are the recommendations of the European society of pediatric gastroenterology, hepatology and nutrition.

RESULTS

Thirty patients were included. The average age was 8.6 years. The indication was compliant in 19 patients. The non-compliant indications were: two ulcer risk preventions related to the prescription of non-steroidal anti-inflammatory drugs (NSAIDs), one endoscopic biopsy, four ulcer risk preventions related to corticosteroid therapy, one hematopoietic stem cell transplantation and three mucositis.

DISCUSSION

The sample of patients included in the study was representative of the pediatric population with PPIs in our institution. The non-conformities identified could be justified in some cases. Only one study reported a compliance rate for PPI indications in pediatrics in the literature. This rate, in the order of 34 %, was much lower than that found in our institution (P<0.01).

CONCLUSION

The respect of the latest recommendations for the prescription of PPIs is quite good. A usage sheet will be diffused to improve the practices.

[Diagnostic strategy in pediatrics soft tissue sarcomas]

Soft tissue sarcomas in children are rare tumor, representing around 6 to 7% of children cancer. They spread mostly sporadically (90%) and therefore are rarely associated to an underlying constitutional genetic disease (10%). About half of those sarcomas are rhabdomyosarcomas and the others are a very heterogenous histologic group with various bio-pathologies and prognosis. Clinical presentation is mainly a soft tissue lump often difficult to distinguish from more frequent benign causes (malformative, infectious, benign, or pseudotumor). Inappropriate initial diagnosis work-up has a strong impact on soft tissue sarcomas' prognosis. Adapted complementary investigations (first ultrasound and MRI) are important to compile arguments for a malign origin and to indicate a biopsy. However, predictive value of imaging exams still remains imperfect, and histological analysis by percutaneous image-guided biopsy and sometimes by surgical biopsy is often necessary. Authors realize an update on optimal diagnostic pathway including molecular tests in presence of a soft tissue mass in a child.

Daily Life Physical Activity and Concussion Symptoms in Adolescents

BACKGROUND.

Concussion is a common injury in an adolescent population with up to 30% experiencing persistent symptoms. Rehabilitation programs that include aerobic exercises can reduce persistent postconcussion symptoms. However, it is unclear if daily life physical activities can also reduce symptoms.

PURPOSE.

To investigate whether the level of daily life physical activity reduces postconcussion symptoms in the adolescent population.

METHODS.

Ten adolescents aged 11-18 years with a concussion self-reported their postconcussion symptoms and level of physical activity during the first, third, and sixth months after injury. The extent to which physical activity explained postconcussion health was analyzed using linear mixed-effects modeling.

FINDINGS.

Higher levels of daily life physical activity were associated with fewer somatic and cognitive symptoms.

IMPLICATIONS.

These findings suggest that daily life physical activity, including engagement in sports, physical education, or active games, should be encouraged by occupational therapists to promote concussion recovery.

[Low grade glioma with MYBL1 alteration: Case report of an uncommon pediatric neoplasm]

Diffuse gliomas with MYB or MYBL1 alterations are rare tumours mostly affecting children or young adults with long-term epilepsy. This category of glioma includes two morphological subtypes. The angiocentric subtype is characterized by an angiocentric pattern of growth and a frequent MYB:QKI fusion. The isomorphic subtype corresponds to a highly differentiated astrocytic glioma with low cellularity, low proliferation and no specific microscopic features. The diagnosis is based on the imaging, demonstrating a supratentorial tumor, associated with the confirmation of a MYB or MYBL1 rearrangement. Here, we report the case of a 7-year-old child who presented a right frontal brain lesion corresponding to an isomorphic diffuse glioma with MYBL1 alteration.

[Case report of an infant hyperkalemia: Suggestion of a hospital procedure for the milk pretreatment with sodium polystyrene sulfonate resin]

Sodium polystyrene sulfonate (SPS) is used to reduce intestinal potassium absorption in hyperkalemia during conservative management of chronic renal failure in infants. Milk can be pretreated by SPS to reduce the risk of enteropathy associated with oral or rectal administration. We report the case of an infant for whom this pre-treatment has been implemented. The objective of this work was to define the hospital procedure for the pre-treatment of milk by the SPS. This pre-treatment involves both a drug and infant milk. Each product has its own regulation and their processes do not normally cross each other. The roles of each contributor were therefore defined: prescription of pre-treated milk (dose of SPS and volume of milk) by the physician, dispensing of SPS by the pharmacist, delivery of milk by the milk kitchen staff, pre-treatment by a nurse and administration by a nursing auxiliary. The preparation of the bottles is as follows: placing approximately 1g of SPS per 100mL of milk in contact, stirring, resting in the refrigerator for one hour, taking the supernatant to be administered. In the reported case, serum potassium levels were reduced from 5.57mmol/L before treatment to 4.53mmol/L after treatment, in line with the 20% decrease found in the literature. This method of administration is beneficial in terms of tolerance and acceptability. The preparation is simple and allows going back home under treatment.

Complication risk factors related to central venous catheter in pediatric

BACKGROUND

A prospective epidemiological study was carried out in the pediatric intensive care unit (ICU), at the Mayotte Hospital Center (MHC). The purpose of the study was to identify and to evaluate complications risk factors related to central venous catheterization. Improving side effects prevention and patients care was the second goal.

METHOD

Data collection took place over a period of 10 months. The central approaches followed in the study were femoral, jugular and subclavian. Since the database is composed of qualitative and quantitative variables, the Chi² test has been used to measure the association between two variables.

RESULTS

The study was carried out on 101 patients. Five infectious risk factors on the 10 variables evaluated have been significantly highlighted: the number of punctures, the number of repair of the dressing, the duration of the catheterization, the exposure time and the parenteral nutrition administration.

CONCLUSIONS

Evaluation of practices through audits, an appropriate training for the staff, the update and the standardization of procedures, development of standardized assembly of the devices should lower the incidence of complications related to the venous approach.

[Antibiotic strategy in pleural empyema in children: Consensus by the DELPHI method]

INTRODUCTION

The evolution of the microbial epidemiology of pleuropulmonary infections complicating community-acquired pneumonia has resulted in a change in empirical or targeted antibiotic therapy in children in the post Prevenar 13 era. The three main pathogens involved in pleural empyema in children are Streptococcus pneumoniae, Staphylococcus aureus and group A Streptococcus.

METHODS

A questionnaire according to the DELPHI method was sent to experts in the field (paediatric pulmonologists and infectious disease specialists) in France with the purpose of reaching a consensus on the conservative antibiotic treatment of pleural empyema in children. Two rounds were completed as part of this DELPHI process.

RESULTS

Our work has shown that in the absence of clinical signs of severity, the prescription of an intravenous monotherapy is consensual but there is no agreement on the choice of drug to use. A consensus was also reached on treatment adjustment based on the results of blood cultures, the non-systematic use of a combination therapy, the need for continued oral therapy and the lack of impact of pleural drainage on infection control. On the other hand, after the second round of DELPHI, there was no consensus on the duration of intravenous antibiotic therapy and on the treatment of severe pleural empyema, especially when caused by Staphylococci.

CONCLUSIONS

The result of this work highlights the needed for new French recommendations based on the evolution of microbial epidemiology in the post PCV13 era.

Blood transfusion in children at a university hospital in a middle-income country: The need to reinforce adherence to current guidelines

OBJECTIVES

Blood component transfusion is a common procedure used during hospital admissions; however, it is not risk-free. The evaluation of correct use of blood products (BP) is of vast importance considering the risks and costs implied in their use. Our principal objective was to evaluate the adherence to national guidelines for blood transfusion in pediatric patients at a third level university hospital.

MATERIAL AND METHODS

A prospective and retrospective descriptive analytical study was conducted to report the incidence of incorrect use of BP in pediatric patients (1 month to 16 years of age). In a timeline period of 4 years, 579 medical records were randomly selected from a total of 6575 transfusions realized to create a statistically significant sample. The variables studied were volume, infusion time, and transfusion criteria. Indications were evaluated in patient's medical records according to national guidelines.

RESULTS

Of the transfusions analyzed, 54% were classified as incorrect mainly due to lack of transfusion criteria fulfillment. Blood transfusion indications in pediatric patients adhered poorly to national guidelines.

CONCLUSION

The implementation of effective programs for education and information on the use of BP are needed to increase compliance with current guidelines.

The Engaged Child in Occupational Therapy

BACKGROUND.

Achieving optimal outcomes for children in occupational therapy settings is influenced, in part, by their engagement. The nature of child engagement from the occupational therapy perspective remains relatively unexplored.

METHOD.

A qualitative research methodology was adopted, using an interpretive description approach. Thirty-two occupational therapists participated in five focus groups and six individual interviews that were thematically analyzed.

FINDINGS.

Four themes emerged from the data: (i) signs of child engagement and disengagement; (ii) it's about the child feeling safe; (iii) a sense of meaning and purpose; and (iv) service and therapist factors influencing child engagement.

IMPLICATIONS.

Helping the child feel safe; providing meaningful experiences; and being flexible and responsive were key means of connecting with, and supporting, child engagement. Strategies occupational therapists reportedly used to engage the child aligned with the tenets of self-determination theory (autonomy, relatedness, and competence).

[Evaluation of the care of the severe acute malnutrition in the service of pediatrics of the CHU Gabriel TOURE, Bamako, Mali]

OBJECTIVE

To study the care of children suffering from severe acute malnutrition with complications at the URENI of the pediatrics of the CHU (University Hospital) Gabriel TOURE.

PATIENTS AND METHOD

it was a comprehensive cross-sectional study with a retrospective collection of data on children monitored for the treatment of severe acute malnutrition from January 1st till December 31st, 2014. We, also, conducted a qualitative survey of staff and carers of children under treatment during the survey period.

RESULTS

490 patients were admitted directly to URENI. The 12-23 month age group was predominant (46.5%). The sex ratio was 1.09 in favor of the male sex. The success rate of treatment at the URENI was 51.40%. At the URENAS, the dropout rate was 27.50%. At the URENAM, the dropout rate was 72.70%. Almost all the carers interviewed during the individual interviews and focus groups were satisfied with nutritional care.

CONCLUSION

The lack of autonomous hospitalization rooms at the URENI and the inadequacies noticed at the level of performance indicators have to motivate the creation of an URENI answering the standards at the level of the pediatrics of the CHU (University Hospital) Gabriel TOURE.

Adverse transfusion reactions in transfused children

Transfusion in paediatrics requires specific guidelines, because child physiology and pathology differ significantly as compared to adults. Adverse transfusion reactions in transfused children also vary in type and frequency, but there is a better understanding of these reactions in adults than in children. However, for the most frequent adverse transfusion reactions, the overall prevalence is higher in children than in adults, with the exception of post-transfusion red blood cell alloimmunisation, which is lower, excluding patients with haemoglobinopathies. In several studies, allergic reactions were the most frequently reported adverse transfusion reaction in paediatrics, and the platelet concentrate the most frequently implicated blood product. Early diagnosis of certain adverse transfusion reactions such as haemosiderosis, is essential in order to initiate the best therapy and obtain a good clinical outcome. The prevention of adverse transfusion reactions in children is required, but needs further clinical studies in paediatrics. Lastly, changes in technology, policy and clinical practices will improve transfusion safety in children.

Evaluation of efficacy and feasibility of foot reflexology in children experiencing chronic or persistent pain

BACKGROUND

Complementary and Alternative Medicines (CAM) are increasingly used in the therapeutic arsenal, particularly for pain management. Foot reflexology (FR) is still poorly evaluated, specifically in the pediatric population. The aim of this study was to evaluate the effectiveness of FR sessions in children experiencing chronic or persistent pain.

METHODS

We conducted a prospective study in two pediatric centers from January 2011 to January 2014. Sessions of FR were offered to children regardless of their age, experiencing persistent pain (>72h) or chronic pain (>3 months). A form was completed by the patient before and after each FR sessions. The effectiveness of the session was evaluated using a Visual Analogue Scale (VAS) for both pain and anxiety.

RESULTS

One hundred and twenty-two patients suffering from persistent pain were included. We observed a significant decrease of mean VAS pain scores after each session (respectively P<0.001, P<0.001 and P=0.015) and of mean VAS anxiety scores (P<0.001) for all sessions). Seventy patients suffering from chronic pain were included. Decrease in VAS pain scores was statistically significant after each reflexology session for children suffering from headache and musculoskeletal pain (P<0.001). Anxiety was significantly lower after each session (P<0.001).

CONCLUSION

In 192 pediatric patients, FR significantly reduce pain and anxiety in children suffering from persistent or chronic pain. This CAM could have a place in pain management in children but needs to be evaluated in larger cohorts.

[Children and adolescents discharge guidelines after allogeneic stem cell transplantation for healthcare professionals: Recommendations of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]

Recommendations for visits or environment restrictions, and sometimes for food are usually well described for inpatient within HSCT unit procedures where those measures are less precise and detailed for outpatient from the discharge to the immune reconstitution achievement. The present paper main objective is to define risk patient groups depending on time, immune-suppressive drugs as well as graft-versus-host disease and immune reconstitution. We define here 3 risk patient groups and propose measures about house cleaning, pets, schools, social activities, hygiene, foods, sexual life and siblings.

Pediatric endonasal dacryocystorhinostomy and operative standardization

OBJECTIVE

The objective of this study was to confirm that the standardized endonasal dacryocystorhinostomy (DCR) technique routinely performed in adults can be used in children.

MATERIALS AND METHODS

A consecutive series of children undergoing endonasal DCR between 2003 and 2017 was analysed. The surgical procedure consisted of: preoperative CT scan, anatomical localization of the ideal surgical zone, access to the nasal cavity via an optional planned enlargement, creation of a mucoperiosteal flap, osteotomy with rongeurs and equatorial resection of the medial wall of the lacrimal sac. This pediatric series was compared to a series of adult patients operated according to the same standardized technique.

RESULTS

A total of 20 DCRs (17 patients, with a mean age of 8 years (range: 4-16)) were included. Anatomical localization was effective in 100% of cases without the need for transillumination. With a mean follow-up of 4 years, the success rate was 95%, and no major complications were observed. Comparison with the same surgical technique in adults revealed similar results.

DISCUSSION

Our experience suggests that standardized endonasal DCR can be adapted to the nasal cavities of children. Anatomical localization is effective. The physiologically narrow nasal cavity does not constitute a major obstacle with the use of slightly smaller instruments. The results and complications are similar to those observed in adults.

CONCLUSION

The same standardized endoscopic endonasal DCR surgical technique can be used in adults and children with a similar good success rate.

Prognosis of severe congenital heart diseases: Do we overestimate the impact of prenatal diagnosis?

BACKGROUND

Prenatal diagnosis of congenital heart disease (CHD) is controversial because of unclear benefits in terms of morbidity and mortality, and issues with healthcare costs and organization.

AIM

To compare, in children with severe CHD, 1-year morbidity and mortality between prenatal and postnatal diagnosis groups.

METHODS

All pregnancies and children aged<1 year with a diagnosis of severe CHD were collected over a 5-year period from our database. Severe CHDs were defined as lethal cases, cases leading to medical termination of pregnancy, or children requiring surgery and/or interventional catheterization and/or hospitalization during their first year of life. The primary endpoint was 1-year mortality rate among live births.

RESULTS

Overall, 322 cases of severe CHD were identified; 200 had a prenatal diagnosis and there were 97 terminations of pregnancy. Of the 225 live births, 34 died before the age of 1 year. The 1-year mortality rate was not significantly different between prenatal and postnatal groups (16.7% vs. 13.9%; p=0.13). In the prenatal group, prostaglandin use was more important and precocious, duration of hospitalization stay was longer, extracardiac complications were less common and cardiac surgery was performed more frequently and later. An association with chromosomal or syndromic anomalies was a risk factor for 1-year mortality.

CONCLUSIONS

Prenatal diagnosis of severe CHD had an impact on the decision regarding termination of pregnancy, but not on the 1-year prognosis among live births. We should now use large multicentre CHD registries to determine the impact of prenatal diagnosis on postnatal management, neurological prognosis and quality of life.

[Human Resources for Unplanned Activities in Obstetrics and Gynecology. Consensus statements by the CNGOF, CARO, CNSF, FFRSP, SFAR, SFMP and SFN]

OBJECTIVE

To determine a minimum threshold of human resources (midwives, obstetricians and gynecologists, anesthesiology and intensive care units, pediatricians) to ensure the safety and quality of unplanned activities in Obstetrics and Gynecology.

MATERIALS AND METHODS

Consultation of the MedLine database, the Cochrane Library and the recommendations of authorities. Meetings of representative members in different modes of practice (university, hospital, liberal) under the aegis of and belonging to the French College of Obstetricians and Gynecologists (CNGOF), the French Society of Anesthesia and Resuscitation (SFAR), the French Society of Neonatalogy (SFN), the French Society of Perinatal Medicine (SFMP), the French College of Midwives (CNSF), the French Federation of Perinatal Care Networks (FFRSP) with elaboration of a re-read text by external experts, in particular by the members of the Boards of Directors of these authorities and of Club of Anesthesiology-Intensive Care Medicine in Obstetrics (CARO).

RESULTS

Different minimum thresholds for each category of caregivers were proposed based on the number of births/year. These proposed minimum thresholds can be modulated upwards according to the types (level I, IIA, IIB or III) or the activity (existence of an emergency reception service, maternal-fetal and/or surgical activity of resort or referral). Due to peak activity and the possibility of unpredictable concomitance of urgent medical procedures, it is necessary that organizations plan to use resource persons. The occupancy rate of the target beds of a maternity ward must be 85%.

CONCLUSION

These proposed minimum thresholds are intended to help caregivers providing non-scheduled perinatal as well as Obstetrics and Gynecology care to make the most of the human resources allocated to institutional bodies to ensure their safety and quality.

Acceptability of children's testing for HIV infection during routine care activities in the Pediatrics Department of Sourô Sanou Teaching Hospital in Bobo-Dioulasso (Burkina Faso)

BACKGROUND

In order to contribute to the fight against the pediatric HIV infection, we have assessed, through a study in which we have systematically proposed to carry out children's testing, the rate of acceptability and the feasibility of children's HIV testing during the routine activities of the department. We have also analyzed the reasons for the acceptability or the refusal of the child's HIV testing by the accompanying person.

METHODS

The study took place from May to September 2015 including all the parents/legal guardians of any child aged 0 to 14 years coming for a consultation or who was hospitalized in the Pediatric Department of Souro Sanou Teaching Hospital. Counseling sessions conducted by community health workers focused on informing and proposing the principle of child testing. After obtaining the verbal and informed consent of the accompanying person, the first test was performed with Determine® by a hospital health worker. A second SD Bioline®/ImmunoCombII® test was performed if the first test was positive. With children aged less than 18 months, after a positive antibody test, we resorted to PCR for confirmation.

RESULTS

A total of 848 accompanying persons, 568 of whom were female, underwent a pre-test interview during which the HIV test was offered to them. The mean age of accompanying persons was 30 (25.5 to 38) years; 747 accompanying persons (88.1%) accepted the testing of their child. We have found an influence of the accompanying person's religion (P=0.02) and the type of accompanying person on the acceptability of children's testing. Mothers were more willing to accept the test compared to other accompanying persons (P=0.002). The main reason for refusing the child's testing was the absence of one of the child's parents, mainly the father whose opinion was needed. The test was positive for HIV1 in 10 children.

CONCLUSION

In health centers, getting the informed consent from parents to test their children is a big challenge. However, our study shows that this is possible, through the high rate of acceptability obtained.

[Ovarian Sertoli-Leydig tumor: A tricky tumor]

We report the case of a 15 years old teenage girl presenting with a primary amenorrhea and hypervirilisation symptoms. The clinical assessement found a 16cm wide heterogenous ovarian mass testosteronemia and alpha-foeto protein levels were increased. On gross exam the tumor was solid and cystic, multilocular containing serous and mucinous liquids. Microscopically, there was a sertoli cells rich solid area in which the cells had a trabecular and nested organization with Leydig cells between them and there was also a cystic area made of glandular structures lined with an intestinal muco-secreting epithelium. Next to these area, there were Sertoli cells and an oedematous stroma. The immunostaining showed that the Sertoli cells expressed, among others, the inhibine and the glands expressed the cytokeratins 7 and 20. A Sertoli and Leydig cells tumor of intermediate differentiation with heterologous elements diagnostic was made. This is a rare tumor, representing less than 0.5% of ovary tumors. Well differentiated tumors are not frequent. In one third of the cases, there are hypervirilisation symptoms, the imaging exams will serve to narrow the diagnosis and to do a full work-up to establish an extension. There are several histologic sub types caracterised by the existence of retiforms structures or heterologous elements. There are no specific immunostainings, this will only help to narrow the diagnosis and rule out some hypothesis. There are no guidelines for the management of the patients, indeed each center has its own practices. Those tumors have quite a good prognosis thanks to their early diagnosis at a stade where they are still confined to the ovary.