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Mollet A, Rousselet L, Tristram D, Kalach N, Pelzer MM, Charkaluk ML, Delebarre M. Comparison between local and three validated triage systems in an emergency department for 2126 children under 3 months. Acta Paediatr 2023; 112:1986-1994. [PMID: 37222311 DOI: 10.1111/apa.16858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 05/25/2023]
Abstract
AIM Triage of patients less than 3 months old was not already studied. The aim was to evaluate Paediatric Emergency Department triage in patients less than 3 months old and newborns using a local system in comparison with three validated paediatric triage systems (Canadian Triage and Acuity Scale, Manchester Triage System and Emergency Severity Index) and to determine inter-system agreement. METHODS All admissions of patients less than 3 months old admitted to the Emergency Department of the Saint Vincent University Hospital between April 2018 and December 2019 were included. The local triage system level was determined prospectively for comparison with retrospectively calculated triage levels of the validated systems. Hospitalisation rates were compared and inter-system agreements determined. RESULTS Among emergency admissions, 2126 were included (55% males, mean age 45 days). Hospitalisation rate increased with priority severity as determined by all triage systems studied. Cohen's kappa showed slight agreement between the local triage system and the Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System (weighted kappa = 0.133, 0.185 and 0.157 respectively). CONCLUSION Whether prospective or retrospective triage used, the systems studied exhibited good association with hospitalisation rate for patients aged less than 3 months and newborn infants.
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Affiliation(s)
- Agathe Mollet
- Lille Catholic hospitals, Paediatric Department, Lille Catholic University, Lille, France
| | - Louis Rousselet
- Lille Catholic hospitals, Medical Information Department, Lille Catholic University, Lille, France
| | - Domitille Tristram
- Lille Catholic hospitals, Research Department, Lille Catholic University, Lille, France
| | - Nicolas Kalach
- Lille Catholic hospitals, Paediatric Department, Lille Catholic University, Lille, France
| | - Marie Moukagni Pelzer
- Lille Catholic hospitals, Paediatric Department, Lille Catholic University, Lille, France
| | - Marie-Laure Charkaluk
- Lille Catholic hospitals, Neonatology Department, Lille Catholic University, Lille, France
| | - Mathilde Delebarre
- Lille Catholic hospitals, Paediatric Department, Lille Catholic University, Lille, France
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Givone A, Duval-Destin J, Delebarre M, Abou-Chahla W, Lervat C, Dubos F. Consensus survey on the management of children with chemotherapy-induced febrile neutropenia and at low risk of severe infection. Pediatr Hematol Oncol 2023; 41:172-178. [PMID: 37293777 DOI: 10.1080/08880018.2023.2218406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/21/2023] [Indexed: 06/10/2023]
Abstract
Our aim was to identify national consensus criteria for the management of children with chemotherapy-induced febrile neutropenia (FN), for evidence-based step-down treatment approaches for patients classified at low risk of severe infection. In 2018, a five-section, 38-item survey was e-mailed to all pediatric hematology and oncology units in France (n = 30). The five sections contained statements on possible consensus criteria for the (i) definition of FN, (ii) initial management of children with FN, (iii) conditions required for initiating step-down therapy in low-risk patients, (iv) management strategy for low-risk patients, and (v) antibiotic treatment on discharge. Consensus was defined by respondents' combined answers (somewhat agree and strongly agree) at 75% or more. Sixty-five physicians (participation rate: 58%), all specialists in pediatric onco-hematology, from 18 centers completed the questionnaire. A consensus was reached on 22 of the 38 statements, including the definition of FN, the criteria for step-down therapy in low-risk children, and the initial care of these patients. There was no consensus on the type and duration of antibiotic therapy on discharge. In conclusion, a consensus has been reached on the criteria for initiating evidence-based step-down treatment of children with FN and a low risk of severe infection but not for the step-down antimicrobial regimen.
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Affiliation(s)
- Aude Givone
- Pediatric Emergency Unit & Infectious Diseases, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean Duval-Destin
- Pediatric Emergency Unit & Infectious Diseases, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Mathilde Delebarre
- Pediatric Emergency Unit & Infectious Diseases, Centre Hospitalier Universitaire de Lille, Lille, France
- Pediatric Emergency Unit, Saint-Vincent-de-Paul Hospital, GHICL, Lille, France
| | - Wadih Abou-Chahla
- Pediatric Hematology Unit, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Cyril Lervat
- Pediatric Oncology Unit, Oscar Lambret Cancer Center, Lille, France
| | - François Dubos
- Pediatric Emergency Unit & Infectious Diseases, Centre Hospitalier Universitaire de Lille, Lille, France
- ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Université de Lille, Lille, France
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Delebarre M, Gonzales F, Behal H, Tiphaine A, Sudour-Bonnange H, Lutun A, Abbou S, Pertuisel S, Thouvenin-Doulet S, Pellier I, Mansuy L, Piguet C, Paillard C, Blanc L, Thebaud E, Plantaz D, Blouin P, Schneider P, Guillaumat C, Simon P, Domenech C, Pacquement H, Le Meignen M, Pluchart C, Vérite C, Plat G, Martinot A, Duhamel A, Dubos F. Decision-tree derivation and external validation of a new clinical decision rule (DISCERN-FN) to predict the risk of severe infection during febrile neutropenia in children treated for cancer. Lancet Child Adolesc Health 2022; 6:260-268. [PMID: 34871572 DOI: 10.1016/s2352-4642(21)00337-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/11/2021] [Accepted: 10/18/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND In 2017, international guidelines proposed new management of febrile neutropenia in children with cancer, adapted to the risk of severe infection by clinical decision rules (CDRs). Until now, none of the proposed CDRs has performed well enough in high-income countries for use in clinical practice. Our study aimed to build and validate a new CDR (DISCERN-FN) to predict the risk of severe infection in children with febrile neutropenia. METHODS We did two prospective studies. First, a prospective derivation study included all episodes of febrile neutropenia in children (aged <18 years) with a cancer diagnosis and receiving treatment for it who were admitted for an episode of febrile neutropenia, excluding patients already treated with antibiotics for this episode, febrile neutropenia not induced by chemotherapy, those receiving palliative care, and those with a stem cell allograft for less than 1 year, from April 1, 2007, to Dec 31, 2011 from two paediatric cancer centres in France. We collected the children's medical history, and clinical and laboratory data, and analysed their associations with severe infection. Sipina software was used to derive the CDR as a decision tree. Second, a prospective, national, external validation study was done in 23 centres from Jan 1, 2012, to May 31, 2016. The primary outcome was severe infection, defined by bacteraemia, a positive bacterial culture from a usually sterile site, a local infection with a high potential for extension, or an invasive fungal infection. The CDR was applied a posteriori to all episodes to evaluate its sensitivity, specificity, and negative likelihood ratio. FINDINGS The derivation set included 539 febrile neutropenia episodes (270 episodes in patients with blood cancer [median age 7·5 years, IQR 3·7-11·2; 158 (59 %) boys and 112 (41%) girls] and 269 in patients with solid tumours [median age 6·6 years, IQR 2·9-14·2; 140 (52 %) boys and 129 (48%) girls]). Significant variables introduced into the decision tree were cancer type (solid tumour vs blood cancer), age, high-risk chemotherapy, level of fever, C-reactive protein concentration (at 24-48 h after admission), and leucocyte and platelet counts and procalcitonin (at admission and at 24-48 h after admission). For the derivation set, the CDR sensitivity was 98% (95% CI 93-100), its specificity 56% (51-61), and the negative likelihood ratio 0·04 (0·01-0·15). 1806 febrile neutropenia episodes were analysed in the validation set (mean age 8·1 years [SD 4·8], 1014 (56%) boys and 792 (44%) girls), of which 332 (18%, 95% CI 17-20) were linked with severe infection. For the validation set, the CDR had a sensitivity of 95% (95% CI 91-97), a specificity of 38% (36-41), and a negative likelihood ratio of 0·13 (0·08-0·21). Our CDR reduced the risk of severe infection to a post-test probability of 0·8% (95% CI 0·2-2·9) in the derivation set and 2·4% (1·5-3·9) in the validation set. The validation study is registered at ClinicalTrials.gov, NCT03434795. INTERPRETATION The use of our CDR substantially reduced the risk of severe infection after testing in both the derivation and validation groups, which suggests that this CDR would improve clinical practice enough to be introduced in appropriate settings. FUNDING Ligue Nationale Contre le Cancer.
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Affiliation(s)
- Mathilde Delebarre
- ULR 2694-METRICS: Évaluation des technologies de santé et des pratiques médicales, Université de Lille, Lille, France; Paediatric Emergency Unit & Infectious Diseases, Lille, France; Paediatric Haematology Unit, CHU Lille, Lille, France
| | | | - Hélène Behal
- ULR 2694-METRICS: Évaluation des technologies de santé et des pratiques médicales, Université de Lille, Lille, France
| | - Aude Tiphaine
- Paediatric Emergency Unit & Infectious Diseases, Lille, France
| | | | - Anne Lutun
- Paediatric Haematology-Oncology Unit, CHU Amiens, Amiens, France
| | - Samuel Abbou
- Paediatric Oncology Unit, Gustave-Roussy Institute, Villejuif, France
| | - Sophie Pertuisel
- Paediatric Haematology-Oncology Unit, CHU Rennes, Rennes, France
| | | | - Isabelle Pellier
- Paediatric Haematology-Oncology Unit, CHU Angers, Angers, France
| | - Ludovic Mansuy
- Paediatric Haematology-Oncology Unit, CHU Nancy, Nancy, France
| | | | - Catherine Paillard
- Paediatric Haematology-Oncology Unit, CHU Strasbourg, Strasbourg, France
| | - Laurence Blanc
- Paediatric Haematology-Oncology Unit, CHU Poitiers, Poitiers, France
| | - Estelle Thebaud
- Paediatric Haematology-Oncology Unit, CHU Nantes, Nantes, France
| | - Dominique Plantaz
- Paediatric Haematology-Oncology Unit, CHU Grenoble, Grenoble, France
| | - Pascale Blouin
- Paediatric Haematology-Oncology Unit, CHU Tours, Tours, France
| | | | - Cécile Guillaumat
- Department of Paediatrics, Centre Hospitalier Sud Francilien, Corbeil-Essonne, France
| | - Pauline Simon
- Paediatric Haematology-Oncology Unit, CHU Besançon, Besançon, France
| | - Carine Domenech
- Institute of Paediatric Haematology and Oncology, Hospices Civils de Lyon, University-Lyon, Lyon, France
| | | | | | - Claire Pluchart
- Paediatric Haematology-Oncology Unit, Institut Jean Godinot, CHU Reims, Reims, France
| | - Cécile Vérite
- Paediatric Haematology-Oncology Unit, CHU Bordeaux, Bordeaux, France
| | - Geneviève Plat
- Paediatric Haematology-Oncology Unit, CHU Toulouse, Toulouse, France
| | - Alain Martinot
- ULR 2694-METRICS: Évaluation des technologies de santé et des pratiques médicales, Université de Lille, Lille, France; Paediatric Emergency Unit & Infectious Diseases, Lille, France
| | - Alain Duhamel
- ULR 2694-METRICS: Évaluation des technologies de santé et des pratiques médicales, Université de Lille, Lille, France
| | - François Dubos
- ULR 2694-METRICS: Évaluation des technologies de santé et des pratiques médicales, Université de Lille, Lille, France; Paediatric Emergency Unit & Infectious Diseases, Lille, France.
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Kalach N, Misak Z, Bontems P, Kori M, Homan M, Cabral J, Casswall T, Chong S, Cilleruelo ML, Faraci S, Megraud F, Papadopoulou A, Pehlivanoglu E, Raymond J, Rea F, Maria R, Roma E, Tavares M, Ugras M, Urbonas V, Urruzuno P, Gosset P, Creusy C, Delebarre M, Verdun S. Systematic Review and Meta-analysis of Histological Gastric Biopsy Aspects According to the Updated Sydney System in Children. J Pediatr Gastroenterol Nutr 2022; 74:13-19. [PMID: 34338237 DOI: 10.1097/mpg.0000000000003259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES A descriptive and comparative study of gastric histological aspects according to the updated Sydney classification (USC), obtained from Helicobacter pylori-positive versus H pylori-negative children referred for upper gastrointestinal endoscopy. METHODS The Prisma method was used to perform a systematic review and meta-analysis. Selection criteria were based on following key words USC, H pylori, children, endoscopy, or biopsy. Publication biases were assessed according to the Newcastle-Ottawa Scale, and a meta-regression analysis was done. The study was registered on the PROSPERO platform. RESULTS Between 1994 and 2017, 1238 references were found; 97 studies were retained for the systematic review with a total number of 25,867 children; 75 studies were selected for the meta-analysis concerning 5990 H pylori-infected and 17,782 uninfected children.H pylori-positive versus H pylori-negative children, according to the USC, showed significantly higher relative risk for gastric antral and corpus chronic inflammation, presence of neutrophils, and of lymphoid follicles, and gastric mucosa atrophy, whereas, intestinal metaplasia showed a significantly higher RR only in antral biopsies. The meta-regression analysis showed that H pylori-positive versus H pylori-negative children had significantly higher risk only for corpus activity according to age, recurrent abdominal pain, and geographical area of low H pylori prevalence. CONCLUSIONS H pylori infection in children was associated with higher relative risk for gastric antral and corpus chronic inflammation, presence of neutrophils, lymphoid follicles, and rare gastric mucosa atrophy, whereas, rare intestinal metaplasia was only significantly higher in the antral area.
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Affiliation(s)
- Nicolas Kalach
- Pediatric Clinic, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University of Lille, Lille, France
| | - Zrinjka Misak
- Department of Pediatrics, Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| | - Patrick Bontems
- Department of Gastroenterology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Belgium
| | - Michal Kori
- Kaplan Medical Center, Pediatric Gastroenterology Unit, Rehovot, Israel
| | - Matjaz Homan
- Department of Gastroenterology, Hepatology and Nutrition, Faculty of Medicine, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - José Cabral
- Hospital of Dona Estefania, CHLC, Pediatric Gastroenterology Unit, Lisbon, Portugal
| | - Thomas Casswall
- Karolinska University Hospital, Department of Pediatrics, Stockholm, Sweden
| | - Sonny Chong
- Queen Mary's Hospital for children Epsom & St Helier NHS Trust Carshalton, Surrey, United Kingdom
| | - Maria Luz Cilleruelo
- Hospital Universitario Puerta de Hierro-Majadahonda, Pediatric Gastroenterology Unit, Madrid, Spain
| | - Simona Faraci
- Bambino Gesù Children's Hospital, Digestive Endoscopy and Surgery Unit, Rome, Italy
| | - Francis Megraud
- INSERM U1053, University of Bordeaux, & National Reference Centre for Campylobacter and Helicobacter, Hospital Pellegrin, Bordeaux, France
| | - Alexandra Papadopoulou
- Division of Gastroenterology & Hepatology, First Department of Pediatrics, University of Athens, Agia Sofia Children's Hospital, Athens, Greece
| | - Ender Pehlivanoglu
- Department of Child Health & Nutrition, Istanbul Kent University, Istanbul, Turkey
| | - Josette Raymond
- Microbiology Department, Cochin Hospital, Assistances Publiques des Hôpitaux de Paris (AP-HP), University René Descartes Paris V, Paris, France
| | - Francesca Rea
- Bambino Gesù Children's Hospital, Digestive Endoscopy and Surgery Unit, Rome, Italy
| | - Rogalidou Maria
- Division of Gastroenterology & Hepatology, First Department of Pediatrics, University of Athens, Agia Sofia Children's Hospital, Athens, Greece
| | | | - Marta Tavares
- Unidade de Gastrenterologia Pediátrica do Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Meltem Ugras
- Yeditepe University Medical Faculty, Department of Pediatrics, Gastroenterology, Hepatology and Nutrition, Ataşehir, Istanbul, Turkey
| | - Vaidotas Urbonas
- Vilnius University Clinic of Children's Diseases, Vilnius, Lithuania
| | - Pedro Urruzuno
- Hospital Universitario Doce de Octubre, Servicio de Pediatria, Madrid, Spain
| | - Pierre Gosset
- Pathology Department, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University of Lille
| | - Colette Creusy
- Pathology Department, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University of Lille
| | - Mathilde Delebarre
- Pediatric Clinic, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University of Lille, Lille, France
| | - Stephane Verdun
- Department of Medical Research, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Lille Catholic Hospital, Lille, France
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Butel T, Angoulvant F, Filipovic-Pierucci A, Milcent K, Teglas JP, Bellêttre X, Claudet I, Gras-le Guen C, de Pontual L, Minodier P, Dubos F, Brouard J, Soussan-Banini V, Degas-Bussiere V, Gatin A, Schweitzer C, Epaud R, Ryckewaert A, Cros P, Marot Y, Flahaut P, Saunier P, Babe P, Patteau G, Delebarre M, Titomanlio L, Vrignaud B, Trieu TV, Tahir A, Regnard D, Micheau P, Charara O, Henry S, Ploin D, Panjo H, Vabret A, Bouyer J, Durand-Zaleski I, Gajdos V. Clinical course and cost assessment of infants with a first episode of acute bronchiolitis presenting to the emergency department: Data from the GUERANDE clinical trial. Pediatr Pulmonol 2021; 56:3802-3812. [PMID: 34516722 DOI: 10.1002/ppul.25621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Bronchiolitis is the leading cause of hospitalization for infants but its economic burden is not well documented. Our objective was to describe the clinical evolution and to assess the 1-month cost of a first episode of acute bronchiolitis presenting to the emergency department (ED). METHODS Our study was an epidemiologic analysis and a cost study of the cohort drawn from the clinical trial GUERANDE, conducted in 24 French pediatric EDs. Infants of 6 weeks to 12 months of age presenting at pediatric EDs with a first episode of bronchiolitis were eligible. The costs considered were collected from a societal viewpoint, according to the recommendations of the French National Health Authority. RESULTS A total of 777 infants were included with a median age of 4 months. A total of 57% were hospitalized during the month following the first consultation in the ED, including 28 (3.6%) in an intensive care unit. The mean length of stay was 4.2 days (SD = 3.7). The average time to relief of all symptoms was 13 days (SD = 7). Average total cost per patient was €1919 (95% confidence interval: 1756-2138) from a societal perspective, mostly due to hospitalization cost. The estimated annual cost of bronchiolitis in infants was evaluated to be between €160 and €273 million in France. DISCUSSION Bronchiolitis represent a high cost for the health care system and broadly for society, with hospitalizations costs being the main cost driver. Thus significant investments should be made to develop innovative therapies, to reduce the number of hospitalizations and length of stay.
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Affiliation(s)
- Thibault Butel
- The Clinical Research Unit of Health Economics, APHP, Paris, France
| | - François Angoulvant
- Department of Pediatric Emergency, The Necker-Enfants Malades University Hospital, APHP, Paris, France
| | | | - Karen Milcent
- Department of Pediatric Emergency, Antoine Béclère University Hospital, APHP, Clamart, France.,CESP Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Jean-Paul Teglas
- CESP Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Xavier Bellêttre
- Department of Pediatric Emergency, Robert Debré University Hospital, APHP, Paris, France
| | - Isabelle Claudet
- Department of Pediatric Emergency, Toulouse University Hospital, Toulouse, France
| | | | - Loïc de Pontual
- Department of Pediatric Emergency, Jean Verdier University Hospital, APHP, Bondy, France
| | - Philippe Minodier
- Department of Pediatric Emergency, Marseille Nord University Hospital, APHM, Marseille, France
| | - François Dubos
- Department of Pediatric Emergency, Lille University Hospital, Lille, France
| | - Jacques Brouard
- Department of Pediatric Emergency, Caen University Hospital, Caen, France
| | - Valérie Soussan-Banini
- Department of Pediatric Emergency, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, France
| | | | - Amélie Gatin
- Department of Pediatric Emergency, Nancy University Hospital, Nancy, France
| | - Cyril Schweitzer
- Department of Pediatric Emergency, Nancy University Hospital, Nancy, France
| | - Ralph Epaud
- Department of Pediatric Emergency, Creteil Intercommunal Hospital, Creteil, France
| | - Amélie Ryckewaert
- Department of Pediatric Emergency, Rennes University Hospital, Rennes, France
| | - Pierrick Cros
- Department of Pediatric Emergency, Brest University Hospital, Brest, France
| | - Yves Marot
- Department of Pediatric Emergency, Tours University Hospital, Tours, France
| | - Philippe Flahaut
- Department of Pediatric Emergency, Rouen University Hospital, Rouen, France
| | - Pascal Saunier
- Department of Pediatric Emergency, Fontainebleau Hospital, Fontainebleau, France
| | - Philippe Babe
- Pediatric Emergency Department, Lenval University Hospital, Nice, France
| | - Géraldine Patteau
- Department of Pediatric Emergency, The Necker-Enfants Malades University Hospital, APHP, Paris, France
| | - Mathilde Delebarre
- Department of Pediatric Emergency, Lille University Hospital, Lille, France
| | - Luigi Titomanlio
- Department of Pediatric Emergency, Robert Debré University Hospital, APHP, Paris, France
| | - Bénédicte Vrignaud
- Department of Pediatric Emergency, Nantes University Hospital, Nantes, France
| | - Thanh-Van Trieu
- Department of Pediatric Emergency, Jean Verdier University Hospital, APHP, Bondy, France
| | - Abdelilah Tahir
- Department of Pediatric Emergency, Limoges University Hospital, Limoges, France
| | - Delphine Regnard
- Department of Pediatric Emergency, Bicêtre University Hospital, APHP, Kremlin-Bicêtre, France
| | - Pascale Micheau
- Department of Pediatric Emergency, Toulouse University Hospital, Toulouse, France
| | - Oussama Charara
- Department of Pediatric Emergency, André Mignot Hospital, Le Chesnay, France
| | - Simon Henry
- Department of Pediatric Emergency, Laennec Hospital, Quimper, France
| | - Dominique Ploin
- Department of Pediatric Emergency, Mother Child University Hospital, HCL, Bron, France
| | - Henri Panjo
- CESP Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Astrid Vabret
- Department of Pediatric Emergency, Caen University Hospital, Caen, France
| | - Jean Bouyer
- CESP Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | | | - Vincent Gajdos
- Department of Pediatric Emergency, Antoine Béclère University Hospital, APHP, Clamart, France.,CESP Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
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Delebarre M, Dessein R, Lagrée M, Mazingue F, Sudour-Bonnange H, Martinot A, Dubos F. Differential risk of severe infection in febrile neutropenia among children with blood cancer or solid tumor. J Infect 2019; 79:95-100. [PMID: 31228471 DOI: 10.1016/j.jinf.2019.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To describe and analyze the differences between infections in children with febrile neutropenia (FN) treated for solid tumor or blood cancer. METHODS A prospective study included all episodes of FN in children from April 2007 to April 2016 in 2-pediatric cancer centers in France. Medical history, clinical and laboratory data available at admission and final microbiological data were collected. The proportion of FN, severe infection, categories of microorganisms and outcomes were compared between the two groups. The presumed gateway of the infection was a posteriori considered and evaluated. RESULTS We analyzed 1197 FN episodes (mean age: 8 years). 66% of the FN episodes occurred in children with blood cancer. Severe infections were identified in 23.4% of episodes overall. The rate of severe infection (28.4% vs. 10.4%), types of microorganisms and the need for a management in intensive care unit (2.6% vs. 0.5%) was significantly different between children with blood cancer and solid tumor. Digestive or respiratory presumed gateway of the infections was less frequent for patients with solid tumor. CONCLUSION Given these important microbiological and clinical differences, it may be appropriate to consider differently the risk of severe infection in these two populations and therefore the management of FN.
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Affiliation(s)
- Mathilde Delebarre
- Univ. Lille, CHU Lille, 2 avenue Oscar Lambret, F-59000 Lille, France; EA2694, Public Health, Epidemiology and Quality of Care, F-59000 Lille, France; CHU Lille, Pediatric Emergency Unit & Infectious Diseases, F-59000 Lille, France
| | - Rodrigue Dessein
- Univ. Lille, CHU Lille, 2 avenue Oscar Lambret, F-59000 Lille, France; CHU Lille, Microbiology Unit, Pathology-Biology Center, F-59000 Lille, France
| | - Marion Lagrée
- CHU Lille, Pediatric Emergency Unit & Infectious Diseases, F-59000 Lille, France
| | | | | | - Alain Martinot
- Univ. Lille, CHU Lille, 2 avenue Oscar Lambret, F-59000 Lille, France; EA2694, Public Health, Epidemiology and Quality of Care, F-59000 Lille, France; CHU Lille, Pediatric Emergency Unit & Infectious Diseases, F-59000 Lille, France
| | - François Dubos
- Univ. Lille, CHU Lille, 2 avenue Oscar Lambret, F-59000 Lille, France; EA2694, Public Health, Epidemiology and Quality of Care, F-59000 Lille, France; CHU Lille, Pediatric Emergency Unit & Infectious Diseases, F-59000 Lille, France.
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Angoulvant F, Bellêttre X, Milcent K, Teglas JP, Claudet I, Le Guen CG, de Pontual L, Minodier P, Dubos F, Brouard J, Soussan-Banini V, Degas-Bussiere V, Gatin A, Schweitzer C, Epaud R, Ryckewaert A, Cros P, Marot Y, Flahaut P, Saunier P, Babe P, Patteau G, Delebarre M, Titomanlio L, Vrignaud B, Trieu TV, Tahir A, Regnard D, Micheau P, Charara O, Henry S, Ploin D, Panjo H, Vabret A, Bouyer J, Gajdos V. Effect of Nebulized Hypertonic Saline Treatment in Emergency Departments on the Hospitalization Rate for Acute Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr 2017; 171:e171333. [PMID: 28586918 PMCID: PMC6583778 DOI: 10.1001/jamapediatrics.2017.1333] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Acute bronchiolitis is the leading cause of hospitalization among infants. Previous studies, underpowered to examine hospital admission, have found a limited benefit of nebulized hypertonic saline (HS) treatment in the pediatric emergency department (ED). OBJECTIVE To examine whether HS nebulization treatment would decrease the hospital admission rate among infants with a first episode of acute bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS The Efficacy of 3% Hypertonic Saline in Acute Viral Bronchiolitis (GUERANDE) study was a multicenter, double-blind randomized clinical trial on 2 parallel groups conducted during 2 bronchiolitis seasons (October through March) from October 15, 2012, through April 15, 2014, at 24 French pediatric EDs. Among the 2445 infants (6 weeks to 12 months of age) assessed for inclusion, 777 with a first episode of acute bronchiolitis with respiratory distress and no chronic medical condition were included. INTERVENTIONS Two 20-minute nebulization treatments of 4 mL of HS, 3%, or 4 mL of normal saline (NS), 0.9%, given 20 minutes apart. MAIN OUTCOMES AND MEASURES Hospital admission rate in the 24 hours after enrollment. RESULTS Of the 777 infants included in the study (median age, 3 months; interquartile range, 2-5 months; 468 [60.2%] male), 385 (49.5%) were randomized to the HS group and 387 (49.8%) to the NS group (5 patients did not receive treatment). By 24 hours, 185 of 385 infants (48.1%) in the HS group were admitted compared with 202 of 387 infants (52.2%) in the NS group. The risk difference for hospitalizations was not significant according to the mixed-effects regression model (adjusted risk difference, -3.2%; 95% CI, -8.7% to 2.2%; P = .25). The mean (SD) Respiratory Distress Assessment Instrument score improvement was greater in the HS group (-3.1 [3.2]) than in the NS group (-2.4 [3.3]) (adjusted difference, -0.7; 95% CI, -1.2 to -0.2; P = .006) and similarly for the Respiratory Assessment Change Score. Mild adverse events, such as worsening of cough, occurred more frequently among children in the HS group (35 of 392 [8.9%]) than among those in the NS group (15 of 384 [3.9%]) (risk difference, 5.0%; 95% CI, 1.6%-8.4%; P = .005), with no serious adverse events. CONCLUSIONS AND RELEVANCE Nebulized HS treatment did not significantly reduce the rate of hospital admissions among infants with a first episode of acute moderate to severe bronchiolitis who were admitted to the pediatric ED relative to NS, but mild adverse events were more frequent in the HS group. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01777347.
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Affiliation(s)
- François Angoulvant
- Service d'accueil des urgences pédiatriques, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France,Epidémiologie Clinique et Évaluation Économique Appliquées aux Populations Vulnérables, INSERM, Unité Mixte de Recherche 1123, Paris, France
| | - Xavier Bellêttre
- Service d'accueil des urgences pédiatriques, Robert Debré University Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Karen Milcent
- Service de Pédiatrie, Antoine Béclère University Hospital, Assistance Publique–Hôpitaux de Paris, Clamart, France,Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Jean-Paul Teglas
- Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Isabelle Claudet
- Service d'accueil des urgences pédiatriques, Toulouse University Hospital, Toulouse, France
| | | | - Loïc de Pontual
- Service de Pédiatrie, Jean Verdier University Hospital, Assistance Publique–Hôpitaux de Paris, Bondy, France
| | - Philippe Minodier
- Service d'accueil des urgences pédiatriques, Marseille Nord University Hospital, Assistance Publique–Hôpitaux de Marseille, Marseille, France
| | - François Dubos
- Service d'accueil des urgences pédiatriques, Lille University Hospital, Lille, France
| | - Jacques Brouard
- Service de Pédiatrie, Caen University Hospital, Caen, France
| | - Valérie Soussan-Banini
- Service de Pédiatrie, Ambroise Paré University Hospital, Assistance Publique–Hôpitaux de Paris, Boulogne-Billancourt, France
| | | | - Amélie Gatin
- Service de médecine infantile, Nancy University Hospital, Vandoeuvre-Lès-Nancy, France
| | - Cyril Schweitzer
- Service de médecine infantile, Nancy University Hospital, Vandoeuvre-Lès-Nancy, France
| | - Ralph Epaud
- Service d'accueil des urgences pédiatriques, Creteil Intercommunal Hospital, Creteil, France
| | - Amélie Ryckewaert
- Service d'accueil des urgences pédiatriques, Rennes University Hospital, Rennes, France
| | - Pierrick Cros
- Service de Pédiatrie, Brest University Hospital, Brest, France
| | - Yves Marot
- Service d'accueil des urgences pédiatriques, Tours University Hospital, Tours, France
| | - Philippe Flahaut
- Service d'accueil des urgences pédiatriques, Rouen University Hospital, Rouen, France
| | - Pascal Saunier
- Service de Pédiatrie, Fontainebleau Hospital, Fontainebleau, France
| | - Philippe Babe
- Service d'accueil des urgences pédiatriques, Lenval University Hospital, Nice, France
| | - Géraldine Patteau
- Service d'accueil des urgences pédiatriques, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Mathilde Delebarre
- Service d'accueil des urgences pédiatriques, Lille University Hospital, Lille, France
| | - Luigi Titomanlio
- Service d'accueil des urgences pédiatriques, Robert Debré University Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Bénédicte Vrignaud
- Service d'accueil des urgences pédiatriques, Nantes University Hospital, Nantes, France
| | - Thanh-Van Trieu
- Service de Pédiatrie, Jean Verdier University Hospital, Assistance Publique–Hôpitaux de Paris, Bondy, France
| | - Abdelilah Tahir
- Service d'accueil des urgences pédiatriques, Limoges University Hospital, Limoges, France
| | - Delphine Regnard
- Service d'accueil des urgences pédiatriques, Bicêtre University Hospital, Assistance Publique–Hôpitaux de Paris, Kremlin-Bicêtre, France
| | - Pascale Micheau
- Service d'accueil des urgences pédiatriques, Toulouse University Hospital, Toulouse, France
| | - Oussama Charara
- Service de Pédiatrie, André Mignot Hospital, Le Chesnay, France
| | - Simon Henry
- Service de Pédiatrie, Laennec Hospital, Quimper, France
| | - Dominique Ploin
- Service d'accueil des urgences pédiatriques, Mother Child University Hospital, Bron, France,Epidémiologie, Pharmacologie, Investigation Clinique, Information médicale, Mère-Enfant (EPICIME), Clinical Investigation Center, INSERM Clinical Investigation Center 1407, Bron, France
| | - Henri Panjo
- Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Astrid Vabret
- Service de Pédiatrie, Caen University Hospital, Caen, France
| | - Jean Bouyer
- Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Vincent Gajdos
- Service de Pédiatrie, Antoine Béclère University Hospital, Assistance Publique–Hôpitaux de Paris, Clamart, France,Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
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Delebarre M, Tiphaine A, Martinot A, Dubos F. Risk-stratification management of febrile neutropenia in pediatric hematology-oncology patients: Results of a French nationwide survey. Pediatr Blood Cancer 2016; 63:2167-2172. [PMID: 27569451 DOI: 10.1002/pbc.26121] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/31/2016] [Accepted: 06/06/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND In 2012, new international guidelines for children with chemotherapy-induced febrile neutropenia (FN) were issued, recommending reduced-intensity management strategy based on stratification of infectious risks. Some studies have highlighted practice disparities in different countries and within the same country. Our aim was to assess the current management strategies for the treatment of chemotherapy-induced FN in children in France. PROCEDURE This survey of all French pediatric oncology-hematology reference centers (n = 30) in late 2012 and early 2013 sent a standardized questionnaire to each center inquiring about their definition of an FN episode, its initial empiric treatment and ongoing management, use of management stratified by risk, and any criteria used for the risk assessment. Each center's management protocol was also analyzed. RESULTS All French reference centers participated in this survey, completing 88% of the questionnaire items. Definitions of both fever and neutropenia varied between centers. Ten centers used a risk-stratification strategy for initial management. In all, 42 probabilistic first-line antibiotic treatments were identified. After 48 hr of apyrexia, 17 units applied different forms of step-down therapy. CONCLUSIONS Most French centers already offered some form of reduced-intensity or step-down therapy, although they differed substantially in their management of FN episodes. Risk stratification with validated tools is essential to facilitate the implementation of the international recommendations, which would ultimately help to standardize practices in France.
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Affiliation(s)
- Mathilde Delebarre
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France. .,Univ. Lille, EA2694, Public Health, Epidemiology and Quality of Care, Lille, France.
| | - Aude Tiphaine
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France.,CHU Bordeaux, Pediatric Hematology-Oncology Unit, Bordeaux, France
| | - Alain Martinot
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France.,Univ. Lille, EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
| | - François Dubos
- Univ. Lille, CHU Lille, Pediatric Emergency Unit & Infectious Diseases, Lille, France.,Univ. Lille, EA2694, Public Health, Epidemiology and Quality of Care, Lille, France
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Dégrange M, Delebarre M, Turck D, Mestdagh B, Storme L, Deruelle P, Rakza T. [Is self-confidence a factor for successful breastfeeding?]. Arch Pediatr 2015; 22:708-17. [PMID: 26033192 DOI: 10.1016/j.arcped.2015.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 02/25/2015] [Accepted: 04/21/2015] [Indexed: 11/27/2022]
Abstract
CONTEXT Maternal self-confidence and self-efficacy in breastfeeding are recognized as factors positively associated with the initiation and duration of breastfeeding. OBJECTIVE To evaluate the importance of this association using the Breast Feeding Self-Efficacy Scale (BSES). METHOD This prospective study was conducted in 2012 in the Jeanne-de-Flandre maternity department in the Lille University Hospital (France). During their time in the maternity department, breastfeeding mothers who participated in the study completed the BSES, a brief self-assessment of their feelings of self-efficacy relating to breastfeeding. They then received follow-up telephone interviews at 1 and 3 months postpartum. RESULTS One hundred and forty-nine mothers were included in the study. Breastfeeding rates were 86.5% at 1 month and 60% at 3 months. The BSES score of mothers who continued to breastfeed at 1 and 3 months was significantly higher than the score of mothers who had already weaned their children, with an AUROC of 0.72 at 3 months. This confirmed the reliability of the BSES for predicting adherence to breastfeeding. The BSES score of mothers who had previously breastfed was significantly higher than for those breastfeeding for the first time. The threshold score for the BSES was determined as 116/165. CONCLUSION It is important that mothers who lack confidence in their ability to breastfeed be identified early, whether on the maternity ward or even before this point. The value of BSES-based breastfeeding support intervention needs to be evaluated through randomized trials.
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Affiliation(s)
- M Dégrange
- Service de pédiatrie et néonatologie, hôpital de Tourcoing, 59200 Tourcoing, France
| | - M Delebarre
- Service des urgences pédiatriques, hôpital Roger-Salengro, CHRU de Lille, 59000 Lille, France
| | - D Turck
- Service de gastro-nutrition pédiatrique, hôpital Jeanne-de-Flandre, CHRU de Lille, 59000 Lille, France
| | - B Mestdagh
- Service de pédiatrie en maternité, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - L Storme
- Unité de réanimation néonatale, service médecine néonatale, hôpital Jeanne-de-Flandre, CHRU de Lille, 59000 Lille, France; EA 4489, faculté de médecine de Lille, 59000 Lille, France
| | - P Deruelle
- EA 4489, faculté de médecine de Lille, 59000 Lille, France; Service d'obstétrique, hôpital Jeanne-de-Flandre, CHRU de Lille, 59000 Lille, France
| | - T Rakza
- Service de pédiatrie en maternité, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France; EA 4489, faculté de médecine de Lille, 59000 Lille, France.
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Delebarre M, Macher E, Mazingue F, Martinot A, Dubos F. Which decision rules meet methodological standards in children with febrile neutropenia? Results of a systematic review and analysis. Pediatr Blood Cancer 2014; 61:1786-91. [PMID: 24975886 DOI: 10.1002/pbc.25106] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 04/23/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Clinical decision rules (CDRs) have sought to identify the few children with chemotherapy-induced febrile neutropenia (FN) really at risk of severe infection to reduce the invasive procedures and costs for those at low risk. Several reports have shown that most rules do not perform well enough to be clinically useful. Our objective was to analyze the derivation methods and validation procedures of these CDRs. PROCEDURE A systematic review using Medline, Ovid, Refdoc, and the Cochrane Library through December 2012 searched for all CDRs predicting the risk of severe infection and/or complications in children with chemotherapy-induced FN. Their methodological quality was analyzed by 17 criteria for deriving and validating a CDR identified in the literature. The criteria published by the Evidence Based Medicine Working Group were applied to the published validations of each CDR to assess their level of evidence. RESULTS The systematic research identified 612 articles and retained 12 that derived CDRs. Overall, the CDRs met a median of 65% of the methodological criteria. The criteria met least often were that the rule made clinical sense, or described the course of action, or that the variables and the CDR were reproducible. Only one CDR, developed in South America, met all methodological criteria and provided the highest level of evidence; unfortunately it was not reproducible in Europe. CONCLUSION Only one CDR developed for children with FN met all methodological standards and reached the highest level of evidence.
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Affiliation(s)
- Mathilde Delebarre
- Pediatric Emergency Unit and Infectious Diseases, UDSL, Lille University Hospital, Lille, France; EA2694, UDSL, Lille University Hospital, Lille, France; Pediatric Hematology Unit, UDSL, Lille University Hospital, Lille, France
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Tiphaine A, Delebarre M, Martinot A, Dubos F. SFCE P-06 - Prise en charge des neutropénies fébriles : Enquête nationale Française. Arch Pediatr 2014. [DOI: 10.1016/s0929-693x(14)71622-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Macher E, Dubos F, Garnier N, Delebarre M, De Berranger E, Thebaud E, Mazingue F, Leblond P, Martinot A. Predicting the risk of severe bacterial infection in children with chemotherapy-induced febrile neutropenia. Pediatr Blood Cancer 2010; 55:662-7. [PMID: 20806364 DOI: 10.1002/pbc.22586] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The prognosis of febrile neutropenia (FN) in childhood cancer has been considerably improved by the intensification of treatment, including systematic hospitalization and broad-spectrum antibiotics. As only few children present with a severe bacterial infection (SBI), clinical decision rules have been developed to distinguish those at risk for SBI. The aim of this study was to evaluate the reproducibility of six clinical decision rules proposed in the literature and to compare their performance. METHODS This retrospective two-center cohort study included all episodes of chemotherapy-induced FN in children admitted between January 2005 and December 2006. Each rule was applied to our patients. Their sensitivity (Se) and specificity (Sp) were calculated and compared with the authors' results, to assess reproducibility. The most predictive rule was defined in advance as that yielding 100% Se, the highest Sp, and the greatest simplicity for bedside application. RESULTS Three hundred seventy-seven episodes of FN in 167 patients were collected; 64 episodes were associated with SBI, including 36 with bacteremia. Four of the six rules were reproducible, but none were able to be validated. The most predictive rule for bacteremia had 96% Se (95% confidence interval (CI): 79-99%) and 25% Sp (95% CI: 19-33%), and the most predictive rule for SBI had 95% Se (95% CI: 87-98%), but no power of discrimination (Sp = 5%, 95% CI: 3-8%). CONCLUSION This study emphasizes the difficulty in identifying standardized decision rules in the management of a condition with numerous clinical variables like FN.
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Affiliation(s)
- Emilie Macher
- Pediatric Hematology Unit, Lille-Nord de France University Hospital, Lille, France
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Garnier N, Dubos F, Macher E, Delebarre M, De Berranger E, Thebaud E, Mazingue F, Leblond P, Martinot A. CL103 - Neutropénies fébriles post-chimiothérapie : identification des variables prédictives d’infections sévères. Arch Pediatr 2010. [DOI: 10.1016/s0929-693x(10)70315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Delebarre M, Leblond P. CL087 - Corticosurrénalomes de l’enfant : étude nationale rétrospective sur 15 ans. Arch Pediatr 2010. [DOI: 10.1016/s0929-693x(10)70300-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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