Loss-of-function variants affecting the STAGA complex component SUPT7L cause a developmental disorder with generalized lipodystrophy

Generalized lipodystrophy is a feature of various hereditary disorders, often leading to a progeroid appearance. In the present study we identified a missense and a frameshift variant in a compound heterozygous state in SUPT7L in a boy with intrauterine growth retardation, generalized lipodystrophy, and additional progeroid features. SUPT7L encodes a component of the transcriptional coactivator complex STAGA. By transcriptome sequencing, we showed the predicted missense variant to cause aberrant splicing, leading to exon truncation and thereby to a complete absence of SUPT7L in dermal fibroblasts. In addition, we found altered expression of genes encoding DNA repair pathway components. This pathway was further investigated and an increased rate of DNA damage was detected in proband-derived fibroblasts and genome-edited HeLa cells. Finally, we performed transient overexpression of wildtype SUPT7L in both cellular systems, which normalizes the number of DNA damage events. Our findings suggest SUPT7L as a novel disease gene and underline the link between genome instability and progeroid phenotypes.

[Evaluation of a referral protocol to primary health care for patients eligible for health service access points following hospitalization]

INTRODUCTION

PASS is a hospital care unit that provides access to health care for precarious persons and supports them as soon as they have obtained primary health care insurance. No details of this support had previously been described. A Hospital-to-Community protocol for referral to the public health system has been developed at the adult PASS unit of the Marseille public hospitals (AP-HM). The objectives of this study are to describe how this protocol is applied, to evaluate at six months the inclusion in general practice of patients having benefited (or not) from this protocol and to determine the key influencing factors.

MATERIAL AND METHOD

This two-arm prospective observational study collected data on the primary care pathways of precarious patients six months after their having obtained health coverage, and found out whether or not the newly existing protocol had been effectively implemented. It was carried out on a cohort of people included in the PASS-MULTI study who had acquired complete health coverage.

RESULTS

Sixty patients were included between November 2020 and August 2022, 35 of whom had availed themselves of the Hospital-to-Community protocol. Among them, 68.8% in the interventional group had consulted their referring general practitioner within six months, vs. 40% in the control group (p = 0.04). The initiation of follow-up in general medicine was associated with application of the protocol (p = 0.04).

CONCLUSION

This study described an initial Hospital-to-Community protocol for referral to the primary healthcare system of patients followed up in the PASS unit and found an association between application of this protocol and initiation of follow-up in primary healthcare.

Non-invasive cell-free DNA prenatal screening for trisomy 21 as part of primary screening strategy in twin pregnancy

OBJECTIVES

The performance of non-invasive prenatal screening using cell-free DNA testing of maternal blood in twin pregnancy is underevaluated, while serum marker-based strategies yield poor results. This study aimed to assess the performance of non-invasive prenatal screening for trisomy 21 in twin pregnancy as a first-tier test. Secondary objectives were to assess its failure rate and factors associated with failure.

METHODS

This retrospective cohort study included twin pregnancies in which non-invasive prenatal screening using cell-free DNA was performed as the primary screening strategy between May 2017 and October 2019. We used the NIPT VeriSeq® test for in-vitro diagnosis and set a fetal fraction cut-off of 4% for monochorionic pregnancies and 8% for dichorionic ones. Clinical data and pregnancy outcome were collected from physicians or midwives via a questionnaire or were retrieved directly on-site. We calculated the performance of non-invasive cell-free DNA screening for trisomy 21, analyzed its failure rate and assessed potentially associated factors.

RESULTS

Among 1885 twin pregnancies with follow-up, there were six (0.32%) confirmed cases of trisomy 21. The sensitivity of non-invasive prenatal screening for trisomy 21 was 100% (95% CI, 54.1-100%) and the false-positive rate was 0.23% (95% CI, 0.06-0.59%). The primary failure rate was 4.6%, with 4.0% being due to insufficient fetal fraction. A successful result was obtained for 65.4% of women who underwent a new blood draw, reducing the overall failure rate to 2.8%. Maternal body mass index, gestational age at screening as well as chorionicity were significantly associated with the risk of failure.

CONCLUSION

This study provides further evidence of the high performance, at an extremely low false-positive rate, of non-invasive prenatal screening in twins as part of a primary screening strategy for trisomy 21. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Role of chromosomal imbalances in the pathogenesis of DSD: A retrospective analysis of 115 prenatal samples

Differences of sex development (DSDs) are a group of congenital conditions characterized by a discrepancy between chromosomal, gonadal, and genital sex development of an individual, with significant impact on medical, psychological and reproductive life. The genetic heterogeneity of DSDs complicates the diagnosis and almost half of the patients remains undiagnosed. In this context, chromosomal imbalances in syndromic DSD patients may help to identify new genes implicated in DSDs. In this study, we aimed at describing the burden of chromosomal imbalances including submicroscopic ones (copy number variants or CNVs) in a cohort of prenatal syndromic DSD patients, and review their role in DSDs. Our patients carried at least one pathogenic or likely pathogenic chromosomal imbalance/CNV or low-level mosaicism for aneuploidy. Almost half of the cases resulted from an unbalanced chromosomal rearrangement. Chromosome 9p/q, 4p/q, 3q and 11q anomalies were more frequently observed. Review of the literature confirmed the causative role of CNVs in DSDs, either in disruption of known DSD-causing genes (SOX9, NR0B1, NR5A1, AR, ATRX, …) or as a tool to suspect new genes in DSDs (HOXD cluster, ADCY2, EMX2, CAMK1D, …). Recurrent CNVs of regulatory elements without coding sequence content (i.e. duplications/deletions upstream of SOX3 or SOX9) confirm detection of CNVs as a mean to explore our non-coding genome. Thus, CNV detection remains a powerful tool to explore undiagnosed DSDs, either through routine techniques or through emerging technologies such as long-read whole genome sequencing or optical genome mapping.

Gene Editing Corrects In Vitro a G > A GLB1 Transition from a GM1 Gangliosidosis Patient

Ganglioside-monosialic acid (GM1) gangliosidosis, a rare autosomal recessive disorder, is frequently caused by deleterious single nucleotide variants (SNVs) in GLB1 gene. These variants result in reduced β-galactosidase (β-gal) activity, leading to neurodegeneration associated with premature death. Currently, no effective therapy for GM1 gangliosidosis is available. Three ongoing clinical trials aim to deliver a functional copy of the GLB1 gene to stop disease progression. In this study, we show that 41% of GLB1 pathogenic SNVs can be replaced by adenine base editors (ABEs). Our results demonstrate that ABE efficiently corrects the pathogenic allele in patient-derived fibroblasts, restoring therapeutic levels of β-gal activity. Off-target DNA analysis did not detect off-target editing activity in treated patient's cells, except a bystander edit without consequences on β-gal activity based on 3D structure bioinformatics predictions. Altogether, our results suggest that gene editing might be an alternative strategy to cure GM1 gangliosidosis.

Impact of COVID-19 pandemic on child abuse and neglect: A cross-sectional study in a French Child Advocacy Center

OBJECTIVE

This study aimed to describe the impact of the first COVID-19 lockdown in France on the activity of a Child Advocacy Center.

METHODS

This cross-sectional, observational study included all children involved in the activity of the CAC during the first lockdown, from March 16 to May 10, 2020 and the next 3 months and the corresponding periods in 2018 and 2019. Cases were considered severe when a hospitalization, social alert and/or judicial report to the prosecutor was decided.

RESULTS

Data for 1583 children were analyzed. During the lockdown, the global center activity decreased with 26.4 consultations per 100.000 children in 2018, 46 in 2019 and 20.7 in 2020 (p < 0.001). Judicial activity decreased (forensic examinations and child forensic interview recordings), whereas assessment consultations increased. Cases were more severe during the lockdown than in 2019 and 2018 (12.3, 9.4 and 6.04/100.000 children, respectively, p < 0.0001). The global activity of the center increased in the 3 months after the lockdown as compared with during the lockdown (38.2/100.000 versus 20.7/100.000, respectively, p < 0.001) but did not differ from activity in 2018 and 2019. Severe cases were more frequent in the 3 months after the lockdown than the previous years (13.7/100.000 in 2020, 9.62 in 2019 and 8.17 in 2018, p = 0.0002).

CONCLUSION

The CAC activity decreased during the lockdown in France but the increase in incidence of severe abuse cases during the lockdown and the next 3 months confirm the need for optimal screening, care and support of child abuse and neglect victims even in the context of health crisis.

Pseudodicentric Chromosome Originating from an X-Autosome Translocation in a Male Patient with Cryptozoospermia

Genetic factors are responsible for 15% of male infertility conditions. Numerical and structural chromosomal anomalies are validated genetic factors leading to spermatogenic quantitative defects, with a frequency depending on the severity of the phenotype. Among the structural chromosomal rearrangements, dicentric chromosomes are generally observed in robertsonian translocations or in cases of Y chromosome isodicentrics. In X-autosome translocations, male carriers are generally infertile, regardless of the position of the breakpoint, due to interrupted spermatogenesis. We report an infertile man bearing an unusual balanced (X;22) translocation, with a centromeric X breakpoint generating a derivative pseudodicentric chromosome psu dic(22;X). Extensive cytogenetic analyses were necessary to determine the precise nature of the derivative chromosome. The likely cause of the reproductive phenotype of the patient is discussed based on meiotic chromosomal conformation.

Prenatal phenotype of 22q11 micro-duplications: A systematic review and report on 12 new cases

The 22q11 region is prone to generating recurring Copy Number Variations (CNVs) as a result of the large numbers of Low Copy Repeats (LCRs). Typical duplications encompass the LCR-A-to-D region but atypical duplications of various sizes have also been reported. These duplications are responsible for highly variable phenotypes with incomplete penetrance and expressivity, which is challenging for adequate genetic counselling, especially in the prenatal period. To better delineate prenatal phenotypes associated with these CNVs, we report here a clinical and molecular description of twelve cases (9 foetuses and 3 deceased new-borns babies) carrying recurrent 22q11 duplications (diagnosed via aCGH), along with a review of the existing literature. 22q11 duplications were inherited from an apparently healthy parent in almost 60% of the cases. Other CNVs were diagnosed for 8% of the cases. Increased nuchal translucency and cardiac anomalies (CHD) were the most prominent phenotypes observed, along with mild renal and skeletal anomalies. Duplications encompassing the LCR-C-to-D region (and the CRKL gene) seemed more likely to generate CHDs and renal malformations. Cleft lip/palate were observed in foetuses with duplications encompassing the LCR-A-to-B region or the SPECC1L gene, as previously suggested. However, genotype-phenotype correlations remain difficult to ascertain. Second-hit point variants, epigenetic or environmental variations could play a role in the phenotypic variability of 22q11 duplications, but remain a challenge for assessment in the short period of pregnancy.

Pediatric hospital care organization: Cross-sectional enquiry in four regions in France

OBJECTIVE

The aim of this study was to characterize conventional pediatric care capacities in French public hospitals and identify the main difficulties in guiding upcoming health policies. The secondary objective was to assess the quality of care by the implementation of the European Charter of the Rights of Children in Hospital.

METHOD

Multicenter cross-sectional study using a questionnaire survey sent by e-mail to the heads of conventional pediatric departments in four French regions identified on the French Hospital Federation's website. The survey was conducted between 25 September and 25 October 2018.

RESULTS

Fifty-six of 113 heads of departments participated in the survey. The mean annual number of admissions per unit in 2017 was 2066 (SD, 1433), with a median length of stay of 2.7 days (range, 1-10). Children were admitted up to age 18 years in 76% of the departments, and 83% of the departments had an individualized pediatric emergency department. The nurse care load was very high, specifically during the night shift (9.5 patients/nurse). Inpatient education and academic teaching were unavailable in 38% of the departments. Overall, 89% of department heads declared knowing the European Charter of the Rights of Children in Hospital, and a copy of it was posted in all units in 57% (95% confidence interval, 44-70) of the services/departments. At all times and in all departments, parents were allowed to be with their children, and for 34% (95% CI, 21-47) of the departments, an accommodation for parents was available close to the hospital.

CONCLUSION

Public hospital pediatric departments lack sufficient medical and nonmedical caregivers. Department heads were well aware of the European Charter, and it was well disseminated but should be updated to address today's challenges in pediatrics. An area of improvement would be to include parents in their child's care more effectively.

STAG3 homozygous missense variant causes primary ovarian insufficiency and male non-obstructive azoospermia

Infertility, a global problem affecting up to 15% of couples, can have varied causes ranging from natural ageing to the pathological development or function of the reproductive organs. One form of female infertility is premature ovarian insufficiency (POI), affecting up to 1 in 100 women and characterised by amenorrhoea and elevated FSH before the age of 40. POI can have a genetic basis, with over 50 causative genes identified. Non-obstructive azoospermia (NOA), a form of male infertility characterised by the absence of sperm in semen, has an incidence of 1% and is similarly heterogeneous. The genetic basis of male and female infertility is poorly understood with the majority of cases having no known cause. Here, we study a case of familial infertility including a proband with POI and her brother with NOA. We performed whole-exome sequencing (WES) and identified a homozygous STAG3 missense variant that segregated with infertility. STAG3 encodes a component of the meiosis cohesin complex required for sister chromatid separation. We report the first pathogenic homozygous missense variant in STAG3 and the first STAG3 variant associated with both male and female infertility. We also demonstrate limitations of WES for the analysis of homologous DNA sequences, with this variant being ambiguous or missed by independent WES protocols and its homozygosity only being established via long-range nested PCR.

Enterobacter cloacae complex outbreak in a neonatal intensive care unit: multifaceted investigations and preventive measures are needed

We report the investigation to control an Enterobacter cloacae complex outbreak in a neonatal intensive care unit from November 2020 to February 2021. Pulsed-field gel electrophoresis showed that five of eight cases were infected with a clonal strain. Breast pumps, shared among mothers in the unit, could have contributed to the spread of the clonal spread.

Investigation of primary immune deficiency after severe bacterial infection in children: A population-based study in western France

BACKGROUND

Infectious diseases are still an important cause of morbidity and mortality in high-income countries and may preferentially affect predisposed children, especially immunocompromised children. We aimed to evaluate the frequency of recommended immunological tests in children with community-onset severe bacterial infection (COSBI) admitted to a pediatric intensive care unit. We also assessed the frequency and described the typology of diagnosed primary immune deficiency (PID).

METHODS

We conducted a retrospective observational epidemiological study in six university hospitals in western France. All children from 1 month to 16 years of age admitted to hospital for bacterial meningitis, purpura fulminans, or meningococcal disease between August 2009 and January 2014 were included. We analyzed the frequency, type, and results of the immunological tests performed on children with meningitis, purpura fulminans, or a meningococcemia episode.

RESULTS

Among the 143 children included (144 episodes), 84 (59%) and 60 (41%) had bacterial meningitis and purpura fulminans or meningococcemia, respectively: 72 (50%) had immunological tests and 8% had a complete immunological investigation as recommended. Among the 72 children examined for PID, 11 (15%) had at least one anomaly in the immunological test results. Two children had a diagnosis of PID (one with C2 deficit and the other with C8 deficit) and seven other children had possible PID. Thus, the prevalence of a definite or possible diagnosis of PID was 12% among the children examined.

CONCLUSION

PID is rarely investigated after COSBI. We raise awareness of the need for immunological investigations after a severe infection requiring PICU admission.

Multicolor-FISH Characterization of a Prenatal Mosaicism for a Chromosomal Rearrangement Undetected by Molecular Cytogenetics

Fetal mosaicism for chromosomal rearrangements remains a challenge to diagnose, even in the era of whole-genome sequencing. We present here a case of fetal mosaicism for a chromosomal rearrangement explored in amniocytes and fetal muscle, consisting of a major cell population (95%) with partial monosomy 4q and a minor population (5%) with additional material replacing the 4qter deleted segment. Molecular techniques (MLPA, array-CGH) failed to assess the origin of this material. Only multicolor-FISH identified the additional segment on chromosome 4 as derived from chromosome 17. Due to the poor prognosis, the couple chose to terminate the pregnancy. Because of low-level mosaicism, chromosomal microarray analysis (CMA), now considered as first-tier prenatal genetic analysis, did not allow the identification of the minor cell line. In case of large CNVs (>5 Mb) detected by CMA, karyotyping may be considered to elucidate the mechanism of the underlying rearrangement and eliminate mosaicism.

Severity of parechovirus infections in infants under 3 months of age and comparison with enterovirus infections: A French retrospective study

While enteroviruses (EV) are a well-recognized cause of aseptic meningitis in children, human parechoviruses (HPeV), especially genotype 3, have been increasingly reported as a frequent cause of sepsis-like illness and meningitis among young infants. The aim of this study was to describe the epidemiological, clinical, and laboratory characteristics of HPeV infections in infants and to compare them with those of well-known EV infections. This monocentric retrospective study was carried out at the pediatric unit of Nantes University Hospital from January 2015 to August 2018. All patients under 18 years of age with diagnosis codes referring to fever, for whom viral infection was suspected and cerebrospinal fluid (CSF) specimens were collected, were included. All CSF specimens were screened by duplex real-time polymerase chain reaction (PCR) assay that allows for the simultaneous detection of EV and HPeV in clinical samples. During the study period, 1373 CSF specimens from patients under 18 were included. A total of 312 CSF samples were positive for HPeV (n=34) or EV (n=278). Among the 34 HPeV-positive patients, 97% (33/34) were under 3 months of age, whereas the rate was 54% (149/278) for EV-positive patients (P<0.001); thus, patients under 3 months of age were defined as the study population for the rest of this work. A review of the medical records was carried out for the positive cases. In this population, the HPeV detection rate was 5.6% versus 25.3% (P<0.001) for EV. All but one of the HPeV samples available for genotyping were HPeV-3. No seasonality was observed for HPeV infections. Length of hospital stay tended to be longer for children infected with HPeV compared with those infected by EV (3 days vs. 2 days, P=0.05). Clinicians reported more severe illness presentations among HPeV-infected infants, with more frequent administration of fluid bolus (P<0.02). Regarding laboratory characteristics, a significant lack of cellular reaction in the CSF (P=0.004) as well as lower C-reactive protein (CRP) levels (P=0.006) and neutrophil counts (P<0.001) were noted for HPeV infections compared with EV infections. Our results confirm the early onset of HPeV infections (more than 95% of patients aged under 3 months). The clinical presentation and laboratory characteristics of the two infections was similar. However, some higher clinical severity criteria and a lack of CSF pleocytosis were regularly observed in patients with HPeV infections. Considering the significant proportion (5.6%; 95% CI, 3.7-7.5) of all CSF samples in our series, HPeV detection should be systematically included in the microbiological diagnosis of febrile children under 3 months of age.

New insights into the genetic basis of premature ovarian insufficiency: Novel causative variants and candidate genes revealed by genomic sequencing

Ovarian deficiency, including premature ovarian insufficiency (POI) and diminished ovarian reserve (DOR), represents one of the main causes of female infertility. POI is a genetically heterogeneous condition but current understanding of its genetic basis is far from complete, with the cause remaining unknown in the majority of patients. The genes that regulate DOR have been reported but the genetic basis of DOR has not been explored in depth. Both conditions are likely to lie along a continuum of degrees of decrease in ovarian reserve. We performed genomic analysis via whole exome sequencing (WES) followed by in silico analyses and functional experiments to investigate the genetic cause of ovarian deficiency in ten affected women. We achieved diagnoses for three of them, including the identification of novel variants in STAG3, GDF9, and FANCM. We identified potentially causative FSHR variants in another patient. This is the second report of biallelic GDF9 and FANCM variants, and, combined with functional support, validates these genes as bone fide autosomal recessive "POI genes". We also identified new candidate genes, NRIP1, XPO1, and MACF1. These genes have been linked to ovarian function in mouse, pig, and zebrafish respectively, but never in humans. In the case of NRIP1, we provide functional support for the deleterious nature of the variant via SUMOylation and luciferase/β-galactosidase reporter assays. Our study provides multiple insights into the genetic basis of POI/DOR. We have further elucidated the involvement of GDF9, FANCM, STAG3 and FSHR in POI pathogenesis, and propose new candidate genes, NRIP1, XPO1, and MACF1, which should be the focus of future studies.

COVID-19 and schools. Guidelines of the French Pediatric Society

The educational and social benefits provided by school far outweigh the risks of a possible COVID-19 contamination of children in school environments or in daycare centers. Following summer break, the back-to-school period in France is taking place in the context of an increasing viral spread and requires strict adherence to health measures to limit the risk of outbreaks in communities. Based on a critical update of the role of children in the transmission of the infection, and of children's susceptibility to infection, the French Pediatric Society published practical guidelines for school re-entry and the management of COVID-19 infections in schools.

Epidemiology of invasive early-onset neonatal infection in a French administrative district: A 10-year population-based study

BACKGROUND

In light of the pending update of the French guidelines for the management of neonatal infections, knowing the current epidemiology of early-onset neonatal infection (EONI) is essential.

OBJECTIVES

The aim of this study was to assess the current epidemiology of a French administrative district population of proven EONI, including umbilical cord blood procalcitonin levels.

METHODS

We conducted a retrospective population-based study in the Nantes metropolitan area. We included all infants treated for proven EONI in the maternity, neonatology, and intensive care wards between 1 January 2006 and 31 December 2015 in the Nantes University Hospital.

RESULTS

Among the 140,502 children born during the study period, 61 cases of EONI were documented. The overall incidence of confirmed EONI was 0.43/1000 live births, with 0.23/1000 GBS (group B streptococcus) infections and 0.08/1000 Escherichia coli infections. The majority of infected newborns were full-term or late-preterm infants (67% were≥34 weeks of gestation), 88% had symptoms of EONI in the first 24h of life, most of which were respiratory. The mortality rate was 8% (in premature infants). Available in 51% of the population, the cord blood PCT value could contribute to an earlier diagnostic screening in 10% of cases but with a very low sensitivity.

CONCLUSIONS

The incidence of confirmed EONI is low in this French district. The diagnostic value of PCT umbilical blood cord should be assessed based on further studies before confirming its value. We suggest that a national registry of these rare but serious cases of EONI could contribute to monitoring the epidemiological progression as well as to optimizing our diagnostic and therapeutic strategies.

Antiviraux chez l’enfant en pratique de ville : infections herpétiques, varicelle, grippe

Les infections liées à l’herpès virus humain (HSV), au virus de la varicelle et du zona (VZV) et au virus de la grippe (Influenza A et B) sont très fréquentes en pédiatrie et sont le plus souvent bénignes avec une guérison spontanée. L’utilisation des antiviraux antigrippaux (inhibiteurs de neuraminidase) a été étudiée dans de larges essais randomisés et fait l’objet de recommandations nationales et internationales. Celle des anti-HSV et anti-VZV n’a pas fait l’objet d’études de la même ampleur et de ce fait, leur prescription est plus discutée avec des bénéfices moins bien définis et variables (à l’exception des infections néonatales et/ou neuro-méningées). L’objectif de cette mise au point est donc de proposer une synthèse des données disponibles dans la littérature concernant les indications des antiviraux en pratique de ville pour les infections liées à l’HSV (gingivostomatite, herpès récurrent, faux panaris herpétique), au VZV (varicelle, zona) et à la grippe.

Catheter-related bloodstream infection due to Tsukamurella pulmonis identified by MALDI-TOF spectrometry, 16S rRNA gene sequencing, and secA1 gene sequencing in an immunocompromised child: a case report and literature review

Tsukamurella species are Gram-positive bacilli related to aerobic Actinomyces. Originally reported from the environment, Tsukamurella species have also been described in human infections, especially in bacteremia. A literature review analysis revealed that Tsukamurella spp. are often initially considered as contaminant microorganisms, especially due to bacterial identification issues. Here, we report a catheter-related bloodstream infection in an immunocompromised child caused by Tsukamurella pulmonis. Matrix-Assisted Laser Desorption/Ionization-Time Of Flight (MALDI-TOF) mass spectrometry allowed rapid genus-level identification and contributed to better patient care. However, accurate species-level identification required 16S rRNA gene sequencing and secA1 gene sequencing. Considering the increased number of Tsukamurella infections, the implementation of new Tsukamurella species in MALDI-TOF databases is required to be more discriminant.

Pseudodicentric Chromosome Originating from Autosomes 9 and 21 in a Male Patient with Oligozoospermia

Genetic factors are responsible for 15% of male infertility conditions. Numerical and structural chromosomal anomalies (related to the Y chromosome or to the autosomes) are validated genetic factors leading to spermatogenic quantitative defects with a frequency depending on the severity of the phenotype. The most frequent structural chromosomal rearrangements of autosomes are translocations and inversions, whereas dicentric chromosomes involving autosomes are rare. We report a man bearing a pseudodicentric chromosome (9;21) and presenting with oligozoospermia. Extensive cytogenetic analyses were necessary to determine the precise nature of the derivative chromosome and to discount the presence of interstitial telomeric sequences. Defects in spermatogenesis and abnormal segregation at meiosis for existing spermatozoa are proposed and are the likely cause of the reproductive phenotype of the patient.

Antibiotic therapy of bone and joint infections in children: proposals of the French Pediatric Infectious Disease Group

Acute hematogenous bone and joint infections (osteomyelitis, septic arthritis, osteoarthritis, and spondylodiscitis) affect more frequently children younger than 5 years of age. Early diagnosis and prompt treatment are needed to limit the risk of complications. Children with suspected bone and joint infections (BJI) should be hospitalized at the beginning of treatment. Surgical drainage is indicated in patients with septic arthritis and in those with periosteal abscess. Staphylococcus aureus is involved in BJIs in children at all ages; Kingella kingae is a very common causative pathogen in children under 4 years of age. The French Pediatric Infectious Disease Group recommends in children > 3 months of age empirical antibiotic therapy with appropriate coverage against methicillin-sensitive S. aureus with high doses (150mg/kg/day) of intravenous amoxicillin-clavulanate, cefuroxime or cefazoline. In most children with uncomplicated BJI, short intravenous antibiotic therapy for 3 days can be followed by oral therapy. The minimum total duration of antibiotic therapy should be 10 days for septic arthritis and 3 weeks for osteomyelitis.

Surgical and medical antibiotic prophylaxis

Surgical site infections are the leading cause of perioperative morbidity and mortality as well as increased costs following surgery. Among preventive measures, antibiotic prophylaxis, when indicated, significantly decreases these risks. Adult and pediatric guidelines have recently been published (1,2). Specific pediatric data are scarce, but adult recommendations can be used by extrapolation except for neonates. For procedures that may warrant antimicrobial prophylaxis, agents of choice are frequently first-generation cephalosporins such as cefazolin, that are not currently used in curative treatment, with an appropriate dosage. Administration of an antimicrobial agent within 1 hour before surgery is often sufficient. Continuation for more than 24 hours is exceptionally advised.

A prospective observational study of medication errors in a pediatric emergency department

We present a prospective, observational study evaluating the incidence of medication errors (ME) in a university hospital pediatric emergency department and describe their characteristics and determinants. A systematic analysis of the handwritten prescriptions was conducted by a clinician and pharmacist. Of 11,573 consecutively studied prescriptions in children under 15 years of age, the ME incidence was 0.9% (n=102). The incidence of errors found was statistically significantly higher in children older than 5 years (OR=2.05; P=0.026). There was no significant difference regarding the time of admission (P=0.544), the day of the week (P=0.940), or the affluence of people in attendance at the emergency department. The errors observed were all prescription errors. Most errors were related to analgesic (51%) and antibiotic (30%) treatments. No serious errors were reported.

CONCLUSION

We found a low incidence of medication errors in this study. The validation of prescriptions by a senior multidisciplinary staff could contribute to limited medication errors. Measures should be continued to further reduce the incidence of drug errors by calling the attention of prescribers to the most common situations at risk of ME.

Validation of the PECARN clinical decision rule for children with minor head trauma: a French multicenter prospective study

BACKGROUND

To date, the Pediatric Emergency Care Applied Research Network (PECARN) rule for identifying children who are at very low risk of clinically-important traumatic brain injuries after minor head trauma has not been validated prospectively in an independent population. Our goal was to evaluate the diagnostic performance of the PECARN clinical decision rule in a French pediatric population in multiple clinical settings.

METHODS

We conducted a multicenter, prospective, non-interventional cohort study of patients with minor head trauma who presented to three emergency departments in France. We enrolled patients younger than 16 years of age seeking a consultation within 24 h of head trauma with Glasgow Coma Scale scores of 14-15.

RESULTS

During the study period, we included 1499 children of which 421 (28 %) were under 2 years of age, and 955 (64 %) were male. A cranial computed tomography (CT) scan was performed on 76 patients (5.1 %). Of the 1499 included patients, 9 children (0.6 %) had a clinically-important traumatic brain injury, and none were classified as very low risk by the PECARN rule. In our study, the sensitivity of this clinical decision rule was 100 % (95 % CI 66.4 to 100 %), the specificity was 69.9 % (95 % CI 67.5 to 72.2 %) and the negative predictive value was 100 % (95 % CI 99.7 to 100 %).

DISCUSSION

Our study confirmed the good predictive performances of the PECARN clinical decision rule for minor head trauma in children. The PECARN rule performed similarly to our study and to its internal validation study.

CONCLUSIONS

We conducted an external validation study of the PECARN clinical decision rule for the detection of clinically-important traumatic brain injuries in children with minor head trauma, according to the methodological standards. The PECARN rule successfully identified all patients with clinically-important traumatic brain injuries, with a limited use of CT scans. Conducting a broad validation study with a large cohort is a prerequisite to provide sufficient statistical power before authorizing its implementation and generalization.

TRIAL REGISTRATION

This study has been registered in ClinicalTrials.gov with identifier number: NCT02752711 on April 27, 2016.