Triage of children with headache at the ED: a guideline implementation study.

UNLABELLED: We present a multicenter validation of a modified Manchester Triage System (MTS) flowchart for pediatric patients who present with headache to the emergency department. A prospective observational study was conducted across 5 European pediatric emergency departments. The standard MTS headache flowchart and a modified MTS headache flowchart were tested in the participating centers, and results were compared with triage categories identified by either the physician at the end of the clinical examination or the reference classification matrix (RCM). Fifty-three patients were enrolled in the preimplementation phase and 112 in the postimplementation phase. When compared with physician's triage and RCM, the modified MTS flowchart demonstrated good sensitivity (79% and 70%, respectively), specificity (77% and 76%, respectively), and a high positive likelihood ratio (9.14 and 16.75, respectively) for the identification of low-risk children. CONCLUSIONS: Our modified headache flowchart is safe and reliable in pediatric emergency settings, especially for lower classes of urgency.

Factors influencing neurological outcome of children with bacterial meningitis at the emergency department.

We performed a cohort study of children who survived bacterial meningitis after the neonatal period at a single pediatric center in France over a 10-year period (1995-2004) to identify predictors of death and long-term neurological deficits in children with bacterial meningitis. We performed multivariate regression to determine independent predictors of death and neurologic deficits. We identified 101 children with bacterial meningitis of which 19 died during initial hospitalization. Need for mechanical ventilation [hazard ratio (HR) 11.5, 95 % confidence interval (CI) 2.4-55.5)] and thrombocytopenia defined as a platelet count <150 × 10(9) per liter (HR 0.6, 95 % CI 0.4-0.9) at presentation were associated with death during initial hospitalization. At final assessment, 42 of the 70 survivors had no neurologic deficits identified; 20 had a single deficit, and eight had multiple deficits. A delay in initiation of antibiotics (HR 1.3, 95 % CI 1.1-1.7) and hydrocephalus on computed tomographic scan (HR 2.6, 95 % CI 1.1-6.0) were associated with having one or more long-term neurologic deficits. Identification of children at risk of death or long-term neurologic sequelae may allow therapeutic interventions to be directed to children at the highest risk.

Aetiology and epidemiology of fever in children presenting to the emergency department of a French paediatric tertiary care centre after international travel.

OBJECTIVE: As few data are available on the causes of fever in children returning from international travel, the authors studied children presenting to a French tertiary care centre with fever. METHODS: Children presenting to the emergency department of the Robert Debré Paediatric Hospital, Paris, France between July and December 2007 with fever that occurred within 3 months of a stay abroad were included in this retrospective study. RESULTS: The children (n=538) had most commonly visited North Africa (NA) (n=214), sub-Saharan Africa (SSA) (n=185) and Europe (n=67). Their median age was 2.8 years (IQR 1.4-5.8). The median time between their return to France and the onset of fever was 5 days (IQR 0-18). Cosmopolitan infections represented 85% of the established diagnoses (97.8% and 63.9% in the children returning from NA and SSA, respectively). Fever of unknown origin accounted for 19.3% of cases. Malaria was the leading tropical infection. Excluding malaria, diarrhoeal diseases were more frequent in the children returning from NA (38.5%) than in those returning from SSA (24.5%). Malaria was associated with stays in endemic countries that exceeded 30 days (OR 3.13, 95% CI 1.02 to 9.59). CONCLUSION: Cosmopolitan infections are the leading cause of fever in French children returning from tropical and subtropical areas. However, all febrile children who have returned from an endemic area should be tested for malaria.

Cost effectiveness of sirolimus-eluting stents compared with bare metal stents in acute myocardial infarction: insights from the TYPHOON trial.

BACKGROUND: Drug-eluting stents have been shown to reduce the rate of repeat revascularization after percutaneous coronary intervention for acute myocardial infarction (AMI) as compared with bare metal stents (BMS). A few studies have reported the cost effectiveness of sirolimus-eluting stents (SES) in several countries, but none in the particular setting of AMI in France. OBJECTIVES: To assess the cost effectiveness of SES compared with BMS in a pre-specified subgroup of French patients with AMI in the randomized, multicentre TYPHOON trial. METHODS: A prospective economic evaluation was conducted for the 337 patients in the TYPHOON trial who were enrolled in the French centres. In the TYPHOON trial, patients with AMI with ST-segment elevation less than 12 hours after the onset of chest pain were randomized to undergo percutaneous coronary intervention with either SES or BMS. Data on clinical outcomes and resource use were collected prospectively over a 1-year follow-up period (from October 2003 to October 2005). Unit costs were applied to the resource utilization data. The main outcome measure was the incremental cost-effectiveness ratio (ICER) for additional cost per target-vessel revascularization (TVR) avoided. The perspective of the study was the French healthcare system and costs were expressed in 2007 values. RESULTS: SES significantly reduced the rate of TVR (6.6% vs 22.2% with BMS, p < 0.0001). There was no difference in the rate of death, recurrent myocardial infarction or stent thrombosis after 1 year of follow-up between the SES and BMS groups. Mean index admission costs, including the angioplasty procedure, were increased by 282 Euro per patient in the SES group, mostly driven by the price of the SES. Mean follow-up costs were 140 Euro per patient lower in the SES group. Mean aggregate 1-year costs showed a euro 1142 per-patient increase in the SES group compared with the BMS group. The ICER was 7321 Euro per TVR avoided. CONCLUSIONS: In this pre-specified subgroup analysis of the TYPHOON trial, the use of SES in patients with AMI with ST-segment elevation less than 12 hours after the onset of chest pain reduced the rate of TVR compared with BMS. However, SES had a debatable ICER for the payer if it was based only on the specific benefit of TVR avoided.

Consequences of being born small for gestational age on body composition: an 8-year follow-up study.

CONTEXT: Increased fat mass has been reported in children and adults born small for gestational age (SGA). However, the progression of anthropometric parameters have been poorly documented in SGA adults. OBJECTIVE: We hypothesized that SGA individuals would remain susceptible to gain more fat when adults beyond the period of postnatal catch-up growth. STUDY POPULATION AND DESIGN: From a community-based cohort, 389 subjects born full-term SGA (body weight < 10th percentile) were compared with 462 subjects born appropriate for gestational age (25th < body weight < 75th percentile). Anthropometric parameters were measured at 22 and 30 yr as well as body composition (by multifrequency bioelectrical impedancometry and skinfold thickness) at 30 yr. RESULTS: Both groups gained weight, body mass index (BMI), and waist circumference. Progression of BMI was significantly greater in SGA (1.8 +/- 2.6 vs. 1.4 +/- 2.6 kg/m(2); P = 0.03). At 30 yr, the proportion of obese individuals was significantly increased in SGA (12.1 vs. 6.5%; P = 0.02), and percent body fat was significantly higher (23.5 +/- 8.7 vs. 21.9 +/- 8.0%; P = 0.01), the observation of which was confirmed by skinfold measures. Similarly, waist circumference gain was significantly greater in SGA (6.4 +/- 7.6 vs. 5.5 +/- 7.9, P = 0.04 when adjusted for gender and age). CONCLUSION: Over 8-yr follow-up, adults born SGA gained more BMI than appropriate for gestational age, resulting in greater fat mass with more abdominal fat. These data suggest that the consequences of fetal growth restriction on body composition are evolving beyond the period of early postnatal catch-up.

The relationship between the GH/IGF-I axis and serum markers of bone turnover metabolism in healthy children.

CONTEXT: There is evidence to suggest that IGF-I plays a role in regulating bone turnover. OBJECTIVE: To evaluate the relationships between serum concentrations of IGF-I and IGF-binding protein-3 (IGFBP-3), and bone metabolism markers in healthy children. DESIGN AND SETTING: Prospective cross-sectional study. SUBJECTS AND METHODS: A cohort of 579 boys and 540 girls, all healthy Caucasian, were included in this study. Serum IGF-I and IGFBP-3 concentrations, bone alkaline phosphatase (BAP) and CrossLaps (markers of bone formation and bone resorption respectively) levels were evaluated as a function of age, gender, pubertal stage and body mass index. RESULTS: Serum IGF-I SDS levels were positively correlated with BAP and CrossLaps SDS levels before and after puberty, and also with CrossLaps during puberty (weak correlation). Serum IGFBP-3 SDS levels were positively correlated with BAP and CrossLaps levels before, during (weak correlation) and after puberty (for BAP levels only). CONCLUSIONS: This study demonstrated the independent association between serum IGF-I and IGFBP-3 concentrations with both serum bone formation and resorption markers in healthy children. Physiological differences before, during and after puberty in the association of serum IGF-I and IGFBP-3 levels with the serum bone metabolism markers were found. These differences may be related to differences in interactions between sex steroid hormones and the GH/IGF-I system, bone metabolism and growth during the pubertal transition. Improvements in our understanding of life course determinants of the IGF-I system and bone metabolism are required to shed further light on the role of the GH/IGF-I axis in bone remodelling.

Subnormal serum insulin-like growth factor-I levels in young adults with childhood-onset nonacquired growth hormone (GH) deficiency who recover normal gh secretion may indicate less severe but persistent pituitary failure.

CONTEXT: The unexpected observation of a normal GH peak in 22% of young adults with childhood-onset GH deficiency (GHD) and ectopic neurohypophysis has raised questions about the criteria defining GHD in young adults and whether patients with subsequent increases in GH secretion nonetheless have a subtle form of GHD. OBJECTIVE: Our objective was to determine the characteristics of patients with childhood-onset nonacquired GHD who recover normal peak GH secretion when adult height has been achieved. DESIGN AND SETTING: We conducted a university hospital-based observational follow-up study. PARTICIPANTS: Sixty-two patients with ectopic neurohypophysis (n = 24), isolated hypoplastic anterior pituitary (n = 14), or normal hypothalamic pituitary area (n = 24) on magnetic resonance imaging (MRI) at the time of GHD diagnosis underwent reevaluation of the GH-IGF-I axis at a mean age of 16.8 +/- 1.6 yr. MAIN OUTCOME MEASURES: Outcome measures included clinical and MRI findings and serum IGF-I and peak GH levels. RESULTS: On retesting, peak GH exceeded 10 microg/liter in 31 patients (50%): six (20%) patients with ectopic neurohypophysis, 10 (32%) patients with initially isolated hypoplastic anterior pituitary, and 15 (48%) patients with normal MRI findings. Among these patients, serum IGF-I levels were significantly lower in patients with ectopic neurohypophysis than in those without structural abnormalities of the hypothalamic pituitary axis (n = 25), but patients without structural abnormalities also had significantly lower serum IGF-I levels than control subjects, after controlling for age, sex, and body mass index (mean serum IGF-I levels of 374 +/- 83 vs. 446 +/- 108 microg/liter; beta-coefficient = -72; P = 0.003). CONCLUSIONS: The severity of the disease seems to have decreased over time in these patients, who may nonetheless present persistent pituitary failure. The natural history and clinical implications of these findings remain to be clarified. The possibility of a deterioration in the secretion of GH and other pituitary hormones later in life in a subset of these patients warrants the careful long-term follow-up of this population.

Predictors of late menarche and adult height in children with anorexia nervosa.

OBJECTIVES: The onset of anorexia nervosa (AN) during childhood can affect the timing of puberty and adult height. The aim of the study was to evaluate the determinants of late menarche and adult height in children with AN. PATIENTS AND METHODS: We carried out a retrospective, longitudinal, university hospital-based study. All prepubertal or early pubertal girls diagnosed with AN between 1998 and 2002 were selected for the study. Participants (n = 33) were studied at a median age of 21 (19.8-24.3) years. AN was diagnosed at 11.8 (10.7-12.3) years. RESULTS: Patients with AN reached menarche at significantly greater ages than their mothers [15.4 (13.5-16.8) vs. 13.2 (12.0-14.5) years, P < 0.01]. Chronological age at onset of AN and lowest body mass index (BMI) were important independent predictive factors for delayed menarche (P < 0.01). Adult height was 165.0 (163.0-172.0) cm, 2.5 (-1.5 to 5.0) cm above target height. Twelve patients (36%) did not reach their target height and had a median height deficit of -3.9 cm with respect to their target height. The duration of hospitalization, a marker of disease severity and chronicity, was an independent predictor of the difference between adult height and target height for a given individual (beta coefficient = -0.07; P = 0.01). The other factors studied (i.e. age at onset of AN, pubertal stage at diagnosis of AN, lowest BMI reached, associated comorbidity if any, type of AN, age at menarche) had no significant effect on adult height. CONCLUSION: The intensity of the disease affects the timing of menarche but not adult height in most patients. Hospitalization, despite often being an effective means of managing AN, does not reduce the impact of AN on growth.