Management of obstructive sleep apnea syndrome type 1 in children and adolescents - A French consensus.

This document is the outcome of a group of experts brought together at the request of the French Society of Sleep Research and Medicine to provide recommendations for the management of obstructive sleep apnea syndrome type 1 (OSA1) in children. The recommendations are based on shared experience and published literature. OSA1 is suspected when several nighttime respiratory symptoms related to upper airway obstruction are identified on clinical history taking. A specialist otolaryngologist examination, including nasofibroscopy, is essential during diagnosis. A sleep study for OSA1 is not mandatory when at least two nighttime symptoms (including snoring) are noted. Therapeutic management must be individualized according to the location of the obstruction. Ear, nose, and throat (ENT) surgery is often required, as hypertrophy of the lymphoid tissues is the main cause of OSA1 in children. According to clinical findings, orthodontic treatment generally associated with specialized orofacial-myofunctional therapy might also be indicated. Whatever treatment is chosen, follow-up must be continuous and multidisciplinary, in a network of trained specialists.

How do the FIFA World Cup 2018 and the 2016 UEFA championships impact a pediatric emergency department?

INTRODUCTION: In France, soccer is the most popular sport, which today attracts a huge television audience with millions of spectators in the case of international competitions. During certain games with European top clubs, the attendance of adult emergencies is impacted. However, the impact of international soccer competitions on pediatric emergency department (PED) activity has not been evaluated. METHODS: We performed a retrospective analysis of attendance in the PED of a tertiary university hospital in Nancy (France) during the UEFA 2016 championship and the FIFA 2018 World Cup. Games were represented by 2.5-h blocks and the tournament period was compared with the same period in the previous year. RESULTS: Considering all games, we did not observe an impact of PED attendance. The admission rate was significantly lower during the final phase (11.1 patients per match vs. 13.9, P=0.037). We observed a decrease in consultations for trauma (4.9 vs. 6.7, P=0.006). The effects were higher during games involving the national French team, with a decrease in less severe admissions (P=0.034), attendance of older children (P=0.016), and the presence of the father as accompanying adult (P=0.002). During the two final matches, we observed a decrease of 14% in the total activity. CONCLUSION: We found significant differences in PED attendance during two international soccer tournaments. It would be interesting to study this effect in countries other than France or in countries with different sport habits.

Localization of interleukin-6 signaling complex in epithelialized apical lesions of endodontic origin.

OBJECTIVES: We aimed to determine the immunolocalization patterns of the interleukin (IL)-6 signaling complex in epithelialized and non-epithelialized apical lesions of endodontic origin (ALEOs). MATERIALS AND METHODS: Epithelialized (n = 8) and non-epithelialized (n = 7) ALEOs were obtained from teeth with indication of extraction in patients with clinical diagnosis of apical periodontitis. All tissues were subjected to routine processing for histopathologic examination and primary antibodies for IL-6, IL-6 receptor (R), and glycoprotein (gp)-130 were used for immunohistochemistry and double immunofluorescence co-localization. RESULTS: IL-6, IL-6R, and gp-130 were immunolocalized in endothelial cells and mononuclear leukocytes in a diffuse pattern within the connective tissue of epithelialized and non-epithelialized ALEOs. In the epithelialized lesions, two different patterns were identified: IL-6 signaling complex was localized within the proliferating epithelium in a diffuse intracellular pattern and in a cell membrane localization pattern within the mature epithelial lining, showing a decreased intensity towards the surface layers. CONCLUSIONS: IL-6, IL-6R, and gp-130 localized to mononuclear inflammatory cells, vascular endothelial cells, and immature proliferating epithelia in a diffuse pattern and in mature lining epithelia in a localized cell membrane pattern, supporting a role for epithelial proliferation during cyst formation. Additional cell membrane co-localization of IL-6 receptor complex suggests classic signaling involvement in addition to trans-signaling.

Assessment of antibiotic prescriptions in pediatric care units in a regional university hospital.

OBJECTIVES: The main objective was to assess the relevance of antibiotic prescriptions in the pediatric wards of a regional university hospital in France. Secondary objectives were to assess adequacy of the dose, administration frequency, administration route, treatment duration, adaptation to bacteriological results, and treatment reevaluation. PATIENTS AND METHODS: We assessed antibiotic prescriptions in pediatric settings. We included all patients under 18 years of age hospitalized in a pediatric ward who received a computerized prescription for antibiotic treatment between June 1st and June 30th, 2018; 163 clinical cases for 157 patients were analyzed. Patients hospitalized in neonatology, pediatric intensive care unit, and onco-hematology wards were excluded. RESULTS: The rate of relevance was 71%. The rates of adequacy for the other criteria were 60% for the dose, 99% for the administration frequency, 98% for the administration route, 72% for treatment duration, 98% for treatment adaptation to microbiological results, and 100% for treatment revaluation. All criteria combined, the overall rate of adequacy was 28%. CONCLUSIONS: Effort should be made regarding doses and treatment durations. Areas for improvement have been suggested to the wards: standardized prescription protocols, pediatric prescription guide, training of residents, setting up of the operational team in pediatric wards and a second clinical evaluation.

In Vivo Documentation of Stimulus Velocity Tuning of Mechanically Induced Reflex Cough.

In order to clear airways and lungs defensive reflexes are provoked rather by the dynamic phase of mechanical stimulus. It is speculated that provocation of defensive response depends not only on stimulus duration but also on stimulus velocity. Fourteen adult rabbits were anaesthetized and tracheotomized. Mechanical stimulus was provoked by a mechanical probe introduced through the tracheotomy and rotated by a small electrical motor using a rotational velocity of 40 rpm/s and 20 rpm/s. Threshold, incidence and intensity of cough reflex (CR) were analyzed for each animal. Statistical comparisons between two velocities were performed using Friedman nonparametric test for repeated measurements. Results are median (25-75 %). The threshold of CR was significantly increased (p=0.005) from 350 ms (300-500 ms) to 550 ms (350-1150 ms) and the incidence of cough reflex was significantly reduced (p=0.002) from 50 % (19 50 %) to 0 % (0-25 %) when the rotational velocity of the mechanical probe was reduced by half. The findings of this study are of interest as they show that protective reflex cough, an important mechanism that allows clearing airways even during sleep or anesthesia, is tuned by mechanical stimulus velocity.

Management of eosinophilic esophagitis in children according to atopic status: A retrospective cohort in northeast of France.

INTRODUCTION: Most children with eosinophilic esophagitis (EoE) are atopic, but the impact of atopy on the remission and development of EoE is still unclear. The aim of our study was to determine the impact of atopy on remission of EoE and to describe allergy tests and the choice of treatment for a cohort of EoE children in France. METHODS: All children diagnosed with EoE between January 2013 and June 2018 in the five pediatric centers in the northeast of France were included. Children were divided into two groups according to personal atopic disorders. Histological remission was defined on the basis of an eosinophilic count below 15 eosinophils per high-power field. RESULTS: Among the 49 children included, 38 (78%) were atopic. Allergy tests were performed for 45 children (92%). Rates of sensitization were similar in both groups: 64% had food sensitization and 64% had aeroallergen sensitization. The most commonly attempted first-line therapy was with proton pump inhibitors (63%), followed by swallowed topical steroids (STS) (18%). First-line therapy was not associated with atopic status (P=0.88). Atopic children had a nonsignificant tendency for a higher remission rate after STS (55% vs. 0%, P=0.24) and a higher global remission rate (54% vs. 33%, P=0.18) compared with non-atopic children. CONCLUSION: Allergy testing is relevant in the majority of children with EoE whether or not they have atopic disorders. Atopy seems to be associated with better response to STS. Further studies are needed to determine whether atopic status determines histological response.

Neonatal low respiratory tract chlamydia trachomatis infection: Diagnostic and treatment management.

Maternal infection during pregnancy by Chlamydia trachomatis (Chlamydia t.) can result in neonatal interstitial lung disease. It remains difficult for physicians to establish this diagnosis and to select the best treatment, as there is no recommendation. In these two cases of neonatal low respiratory tract Chlamydia t. infection, we proposed successfully a diagnosis method based on Chlamydia t. determination by PCR, on any type of sampling, but more specifically on urinary and pharyngeal specimens; and a management based on oral antibiotic therapy, Josamycin 50mg/kg/day during 14 days which is commonly well accepted and not invasive.

Exceptional preservation of mid-Cretaceous marine arthropods and the evolution of novel forms via heterochrony.

Evolutionary origins of novel forms are often obscure because early and transitional fossils tend to be rare, poorly preserved, or lack proper phylogenetic contexts. We describe a new, exceptionally preserved enigmatic crab from the mid-Cretaceous of Colombia and the United States, whose completeness illuminates the early disparity of the group and the origins of novel forms. Its large and unprotected compound eyes, small fusiform body, and leg-like mouthparts suggest larval trait retention into adulthood via heterochronic development (pedomorphosis), while its large oar-like legs represent the earliest known adaptations in crabs for active swimming. Our phylogenetic analyses, including representatives of all major lineages of fossil and extant crabs, challenge conventional views of their evolution by revealing multiple convergent losses of a typical "crab-like" body plan since the Early Cretaceous. These parallel morphological transformations may be associated with repeated invasions of novel environments, including the pelagic/necto-benthic zone in this pedomorphic chimera crab.

[Refractive outcomes and precision in toric intraocular lens alignment using an automated alignment system]. / Résultats réfractifs et évaluation de la précision du positionnement des implants toriques à l'aide d'un système d'alignement automatisé.

PURPOSE: To compare precision in toric intraocular lens (TIOL) alignment and refractive outcomes between an intraoperative automated digital marker system and the conventional manual-ink marking. MATERIALS AND METHODS: Prospective single center study including consecutive patients undergoing uneventful cataract surgery with corneal astigmatism greater than 1 diopter. Total corneal astigmatism was measured using a placido-dual Scheimpflug system (GalileiG4®, Ziemer). Acrysof® SN6AT (Alcon) TIOL's were implanted, and patients were divided into 2 groups, the digital group (Verion®, Alcon) and the ink-marking group (Pendular marker, AMO). Mean error in TIOL axis, visual acuity and residual astigmatism were analyzed at 3 days, one month and 6 months after surgery. RESULTS: In total, 45 eyes of 30 patients were included (n=25 digital group, n=20 ink-marking group). The mean preoperative total corneal astigmatism was 1.71±0.53 diopters. At one month, there was a significantly lower mean average error in TIOL axis in the digital group compared to the ink-marking group (2.6±2.3° and 6.4±2.8° respectively, P=0.009). At 6months, these results remained statistically significant. Mean residual astigmatism was 0.7±0.4 diopters at one month, without significant difference between the two groups (P=0.9). The rate of misalignment less than or equal to 5° was 86 % (n=25) in the digital group and 63 % (n=20) in the ink-marking group (P=0.05). CONCLUSION: Intraoperative digital marker system is associated with better TIOL alignment accuracy and better reproducibility than the manual ink-marking method.

[Drug administration to pediatric patients: Evaluation of the nurses' preparation habits in pediatric units]. / Préparation et administration des médicaments dans les services de pédiatrie. Évaluation des pratiques des soignants.

In hospitals, the nursing staff is often confronted with the problem of the preparation and administration of drugs for their pediatric patients because of the lack of indication, pediatric dosage, and appropriate galenic form. The goal of this study was to give an overview of the nurses' preparation habits in pediatric units and highlight their daily problems. This single-center prospective study was conducted through an observation of the nursing staff during the drug preparation process in medicine, surgery and intensive care units. We included 91 patients (55 boys and 36 girls), with an average age of 6.3 years (youngest child, 10 days old; oldest child, 18 years old). We observed a mean 2.16 drug preparations per patient [1-5]. We collected 197 observation reports regarding 66 injectable drugs and 131 oral drugs (71 liquid forms and 60 solid forms). The majority of these reports concerned central nervous system drugs (63/197), metabolism and digestive system drugs (50/197), and anti-infective drugs (46/197). The study highlights the nurses' difficulties: modification of the solid galenic forms, lack of knowledge on oral liquid form preservation or reconstitution methods, withdrawal of small volumes, and vague and noncompliant labeling. This study led to the creation of a specific working group for pediatrics. This multidisciplinary team meets on a regular basis to work toward improving the current habits to both simplify and secure drug administration to hospitalized children.

[Pseudoexfoliation syndrome and pseudoexfoliation glaucoma]. / Syndrome pseudo-exfoliatif et glaucome exfoliatif.

Pseudoexfoliation syndrome is an age-related systemic disease that mainly affects the anterior structures of the eye. Despite a worldwide distribution, reported incidence and prevalence of this syndrome vary widely between ethnicities and geographical areas. The exfoliative material is composed mainly of abnormal cross-linked fibrils that accumulate progressively in some organs such as the heart, blood vessels, lungs or meninges, and particularly in the anterior structures of the eye. The exact pathophysiological process still remains unclear but the association of genetic and environmental factors are thought to play a role in the development and progressive extracellular accumulation of exfoliative material. Hence, LOXL1 gene polymorphisms, responsible for metabolism of some components of elastic fibers and extracellular matrix, and increased natural exposure to ambient ultraviolet or caffeine consumption have been associated with pseudoexfoliation syndrome. Ophthalmological manifestations are commonly bilateral with an asymmetric presentation and can lead to severe visual impairment and blindness more frequently than in the general population, mainly related to glaucoma and cataract. Pseudoexfoliation glaucoma is a major complication of pseudoexfoliation syndrome and represents the main cause of identifiable glaucoma worldwide. Visual field progression is more rapid than that observed in primary open angle glaucoma, and filtering surgery is more frequently required. Nuclear cataract is more frequent and occurs earlier than in the general population. Owing to poorer pupil dilation and increased zonular instability, cataract surgery with pseudoexfoliation is associated with a 5- to 10-fold increase in surgical complications compared to cataract surgery without pseudoexfoliation. Some specific treatments targeting production, formation or accumulation of exfoliative material could improve the prognosis of this syndrome.

[Teaching pediatrics to residents via conventional lectures in France: A national survey from students]. / Enseignement théorique du Diplôme d'études spécialisées de pédiatrie en France : évaluation nationale par les internes.

OBJECTIVE: To assess the point of view of young physicians training in pediatrics in France on their theoretical courses during residency. METHODS: A free-access electronic anonymous survey was sent three times by e-mail to the 1215 residents in pediatrics, from July to October 2015. RESULTS: Fifty-seven percent of French residents in pediatrics responded to the survey. It was established that they took part in six (range, 3-10) half-days of specific theoretical teaching in pediatrics from November 2014 to mid-April 2015. Only 54% participated in more than 75% of regional theoretical training. The main self-declared reason for their absence was that they could not leave their clinical activities. Fifty-three per cent of the residents took part in additional training, 45% of them because they found the primary theoretical training insufficient. The overall quality of the theoretical teaching was rated 5 (range, 3-7) out of 10. Eighty-five percent of residents expected to be evaluated on their knowledge during their residency. CONCLUSION: In pediatrics, additional training is individually undertaken because they deemed their initial training insufficient during their residency. An evaluation of knowledge is requested by residents. The reform of the national residency program must take into account these results in redesigning the theoretical training in pediatrics, integrating innovative teaching techniques to daily practice, for example.

[Evaluation of corneal biomechanical properties in glaucoma and control patients by dynamic Scheimpflug corneal imaging technology]. / Évaluation des propriétés biomécaniques de la cornée de patients glaucomateux et témoins par la technologie dynamique Scheimpflug de visualisation cornéenne.

PURPOSE: To compare corneal biomechanical properties measured with Corvis Scheimpflug technology (Corvis ST) between a group of patients with chronic open-angle glaucoma and a group of control patients. DESIGN: Prospective observational case-control study. METHODS: This study enrolled 56 right eyes of 56 patients (G1 [chronic open-angle glaucoma] n=37/G2 [control] n=19). Each patient underwent measurement of corneal biomechanical properties by dynamic Scheimpflug (Corvis ST) camera and the Ocular Response Analyser (ORA), then a measurement of intraocular pressure (IOP) by Goldmann applanation tonometry (GAT) and measurement of central corneal thickness (CCT) by optical coherence tomography during the same visit, by a single clinician. The parameters determined by Corvis ST are: Corvis IOP (IOP Corvis ST), the corneal deformation amplitude (CDA), corneal velocity, the time at highest concavity (TIME CONCAV), the lengths of applanation and their corresponding applanation time. Those studied by ORA are: compensated IOP (IOPcc), non-compensated IOL (IOPg), corneal hysteresis (CH) and corneal resistance factor (CRF). RESULTS: IOP measured on all patients by Corvis ST was positively correlated to GAT (Spearman r=0.569, P<0.001) and PIOcc (Spearman r=0.531, P<0.001). After adjusting for age effect, CCT and GAT, the CDA was significantly lower in G1 than in G2, respectively 1.10 ± 0.12 mm and 1.15 ± 0.10mm (P<0.001). The TIME CONCAV is significantly shorter in G1 than in G2, respectively 16.88 ± 0.63 ms and 17.11 ± 0.29 ms, P=0.029. CH was significantly lower in G1 (G1: 9.58 ± 1.94 than G2: 10.89 ± 2.16, P=0.026). CONCLUSIONS: This study showed differences in corneal biomechanical properties between glaucoma and control patients. The cornea of glaucoma patients appears less deformable.