[Teledermatology between two French hospitals: Two years of experience]. / Télédermatologie unissant deux hôpitaux : deux ans d'expérience.

BACKGROUND: Teledermatology is currently booming. Due to the shortage of dermatologists in hospitals access to dermatological consultations is very limited in some hospitals. We present our experience of collaboration between an expert center, the dermatology department of the Victor-Dupouy Hospital Centre in Argenteuil, and all medical structures under the André-Mignot Hospital in Versailles (CHV), including 2 prison medical centers (UCSA), traditional departments and emergency department. PATIENTS AND METHODS: Teledermatology, developed in the form of tele-expertise, began at the UCSA in November 2013. This expertise was then extended in June 2014 to the Internal Medicine department of CHV, and in December 2014 to all departments, including the emergency department. The rules and ethics of teledermatology were strictly adhered to. While UCSA could file all expertise dossiers, only urgent or difficult cases could be filed by other CHV departments. RESULTS: In 26 months, 347 expertise requests were filed: 231 by prisons and 116 by the other departments of the CHV. No patients refused teledermatology. The quality of information and photographs was considered good or excellent in over 95% of cases. A response was given within 3hours in more than 50% of cases and in all cases within 24hours (on working days). Analysis of diseases diagnosed illustrates the wide variety of conditions encountered in dermatology, with different structures having their own specific features. CONCLUSION: Our example illustrates the possibility of developing such an inter-hospital platform. However, it does not yet cater for requests made by patients to dermatologists, by dermatologists to dermatologists, or by dermatologists to the hospital teledermatology department. Acceptability was considered excellent by patients (with no refusals), physicians at the CHV, and the expert center.

CFTR pharmacological modulators: A great advance in cystic fibrosis management.

Cystic fibrosis is a severe monogenic disease that affects around 7400 patients in France. More than 2100 mutations in the cystic fibrosis conductance transmembrane regulator (CFTR), the gene encoding for an epithelial ion channel that normally transports chloride and bicarbonate, lead to mucus dehydration and impaired bronchial clearance. Systematic neonatal screening in France since 2002 has enabled early diagnosis of cystic fibrosis. Although highly demanding, supportive treatments including daily chest physiotherapy, inhaled aerosol therapy, frequent antibiotic courses, nutritional and pancreatic extracts have improved the prognosis. Median age at death is now beyond 30 years. Ivacaftor was the first CFTR modulator found to both reduce sweat chloride concentration and improve pulmonary function in the rare CFTR gating mutations. Combinations of modulators such as lumacaftor + ivacaftor or tezacaftor + ivacaftor were found to improve pulmonary function both in patients homozygous for the F508del mutation characterized by the lack of CFTR protein and those heterozygous for F508del with minimal CFTR activity. The triple combination of ivacaftor + tezacaftor + elexacaftor was recently shown to significantly improve pulmonary function and quality of life, to normalize sweat chloride concentration, and to reduce the need for antibiotic therapy in patients with at least one F508del mutation (83% in France). These impressive data, however, need to be confirmed in the long term. Nevertheless, it is encouraging to hear treated patients testify about their markedly improved quality of life and to observe that the number of lung transplants for cystic fibrosis decreased dramatically in France after 2020, despite the COVID pandemic, with no increase in deaths without lung transplant.

Children and screens: A survey by French pediatricians.

INTRODUCTION: Screens are increasingly prevalent within families. The excessive use of screens by children has negative consequences. To measure the use of screens, we undertook an investigation among children being followed by pediatricians. METHODS: An invitation to participate was sent electronically to 1460 private practice pediatricians. They were asked to complete the questionnaire on screen use by children under 12 years of age during a consultation, according to statements made by parents. RESULTS: One hundred and forty-four pediatricians submitted completed questionnaires involving 428 children. Among the 197 children under 3 years of age, 92 had played with an interactive screen for a median duration of 30min during the preceding week; 29% of the children were alone at the time. One hundred and thirty-nine children had watched television for a median weekly duration of 75min. Of the 231 children 3-11 years of age, 108 had played with an interactive screen for a median time of 30min the day before the consultation, and 50% of them were alone at the time. One hundred and seventy-two children watched television for a median daily duration of 45min. There was a correlation between these children's screen time and their mother's (r=0.36). The television was on during meals and continuously in 35% and 21% of the families, respectively. CONCLUSIONS: Children start looking at screens early, too often watching unsuitable programs, and too often without a parent's present. Regardless of the child's age, pediatricians must ask parents how much time their children are viewing screens, advise them accordingly, and warn them of the consequences of excessive use.

[Contribution of teledermatology in a hospital pediatrics department]. / Apport de la télédermatologie dans un service de pédiatrie hospitalière.

The hospital of Versailles no longer has a dermatologist; consequently the pediatrics department suggested assess to the system put in place in 2015 based on the telemedicine software platform WebDCR developed throughout the hospital. The acceptability of this was based on its implementation as well as speed and ease of use. METHODS: In 2015, 47 reviews were submitted. RESULTS: No patient refusal was noted. The answer was obtained in 100 % of cases on the day the requests were made, during the week. A diagnosis was made in 36 % of cases and one or more hypotheses were formulated in the 64 % of the remaining cases. The review resulted in a further consultation in 28 % of cases, and in one case to transfer to the dermatology department. The quality of the data collected was considered good or excellent in 96 % of cases. DISCUSSION: This first teledermatology experiment seems to show its utility in terms of the services provided. Given the successful deployment of the system, it was extended to the pediatric emergency department. The response time was reduced to 1h. CONCLUSION: This first teledermatology experiment seems to show its real value in terms of services rendered. However, it is necessary to have more experience to confirm the contribution of this tool, and to reassess the sustainability and economic relevance of the device.

Children and screens: Groupe de Pédiatrie Générale (Société française de pédiatrie) guidelines for pediatricians and families.

The Groupe de Pédiatrie Générale (General Pediatrics Group), a member of the Société française de pédiatrie (French Pediatrics Society), has proposed guidelines for families and doctors regarding children's use of digital screens. A number of guidelines have already been published, in particular by the French Academy of Sciences in 2013 and the American Academy of Pediatrics in 2016. These new guidelines were preceded by an investigation into the location of digital screen use by young children in France, a survey of medical concerns on the misuse of digital devices, and a review of their documented benefits. The Conseil Supérieur de l'Audiovisuel (Higher Council on Audiovisual Technology) and the Union Nationale de Associations Familiales (National Union of Family Associations) have taken part in the preparation of this document. Five simple messages are proposed: understanding without demonizing; screen use in common living areas, but not in bedrooms; preserve time with no digital devices (morning, meals, sleep, etc.); provide parental guidance for screen use; and prevent social isolation.

[Seasonal outbreak of enteroviral meningitis during summer 2005: experience of a French pediatric unit]. / Epidémie estivale de méningites à entérovirus en 2005: expérience d'un service de pédiatrie générale.

OBJECTIVE: To describe the clinical and biological characteristics of children presenting with enteroviral (EV) meningitis in a French paediatric unit during summer 2005. METHODS: Retrospective study of children with EV meningitis from May to September 2005, diagnosed by PCR and/or viral culture in cerebrospinal fluid (CSF), serum or throat. RESULTS: We reported 99 cases of EV meningitis (96 confirmed and 3 probable). The sex ratio was 2/1, and the median age was 5 years. Peak incidence was reached during the second week of July. The predominant symptom was meningism. ENT (16%), digestive (10%), cutaneous (15%) or respiratory (4%) symptoms were rare. Blood leucocyte count found a predominance of neutrophils (73%), and lymphopenia in half of the children. The mean value of CRP was 25,5 mg/l. The median leukocyte count in CSF was 65 cells/mm(3), with a prevalence of neutrophils in 60% of cases. Pleiocytosis was absent in 20 children. CSF protein level was increased in 20% of cases. The rate of hospitalization was 57,5%. Intravenous antibiotic treatment, initiated among 18 patients, was stopped in 66,6% of the cases on reception of PCR result. The latter result was obtained in 2,3 days on average. CONCLUSION: The epidemic of 2005 EV meningitis was as widespread as that of summer 2000. Characteristics of these meningitis are strong proportion of CSF without pleiocytose and high prevalence of neutrophils in blood and CSF.

[Acute hemorrhagic edema of infancy associated with Coxsackie virus infection]. / Œdème aigu hémorragique du nourrisson associé à une infection à Coxsackie virus.

Acute hemorrhagic edema of infancy is a rare but benign vasculitis occurring in infants aged from 4 to 24 months. Skin lesions can take various forms, including extensive hemorrhagic purpura, and can therefore be mistaken for purpura fulminans if associated with fever, which leads to initiating broad-spectrum antibiotic treatment. In the present case, we describe a 7-month-old boy with acute hemorrhagic edema of infancy and rapidly extensive purpura lesions that led to intravenous cefotaxime and amikacin treatment. Diagnosis was made on the next day by a dermatologist, based on the typical aspect of skin lesions, hemodynamic stability, and negative bacteriological samples. Coxsackie virus B5, a pathogenic enterovirus, was found by specific PCR in cerebrospinal fluid. The outcome was spontaneously favorable after discontinuation of antibiotics on day 2. We discuss the imputability of the enterovirus in triggering this case of acute hemorrhagic edema of infancy.

[Pseudomonas aeruginosa and cystic fibrosis: non-antibiotic strategy]. / Pseudomonas aeruginosa et mucoviscidose: stratégie non antibiotique.

The Pseudomonas aeruginosa bronchopulmonary infection is, when chronical, a poor prognosis factor for cystic fibrosis children. The higher life expectancy is partly linked to the progresses of the antipseudomonal antibiotherapy: treatment modulated to the stage of infection; possible use of nebulized and oral (ciprofloxacin) antibiotics. But the antipseudomonal strategy does not limit to the antibiotherapy. The preventive approach includes: preservation of a good nutritional status; daily chest physiotherapy with combined use of aerosolized recombinant human DNase for more than 5 years old children with significative bronchorrea; early anti-infammatory treatment with inhaled corticosteroids, despite a poor efficacy proof level; hygiene measures to reduce the environmental and domestic reservoirs and to avoid nosocomial infections. The development of vaccines for the prevention of P. aeruginosa infection is a promising way but stays in the field of clinical research. In case of chronical infection, long-term macrolids reduce the virulence factors expression of the bacteria, leading to antibiofilm properties in spite of subinhibitory concentrations.

[Post lumbar puncture headache in general pediatrics: a prospective multicenter study]. / Les céphalées après ponction lombaire en pédiatrie générale: étude prospective multicentrique.

PURPOSE: To investigate the frequency of post lumbar puncture headaches (PLPH) after diagnostic lumbar puncture (LP) and to search for influence factors. PATIENTS AND METHODS: Conducted over 6 months into 8 paediatric services, the study concerned 2 to 15 years old children. The LP technic (cannula gauge, bevel orientation, child position, reinsertion of the stylet) was standardised. For each child questionnaires were filled with the parents 3 and 8 days after LP for inquiring headaches, postural characteristics, length and clinical consequences. RESULTS: Among 84 charts, 71 were exploitable. PLPH were observed in 25% of children. The mean duration was 5.9 days, mean bed rest was 1.4 day and mean antalgic treatment 1.7 day. The frequency of PLPH was not significantly influenced by age and sex, neither by the qualification of the physician performing the LP. The frequency was significantly lower when LP execution was easy (19.6 vs. 46.7%; P < 0.05), and when the child had viral meningitis (8 vs. 34.8%; P < 0.05). CONCLUSION: We have found a more important frequency of PLPH than in previous paediatric studies. Clinical consequences justify other researches to precise influence factors and reduce the frequency of this complication.

[Treatment of exacerbation of asthma: what are today's issues?]. / Traitement de la crise d'asthme: où sont aujourd'hui les enjeux?

During past decades, major progress has been accomplished in the management of acute asthma. Most recent recommendations include evidence-based rationale. The improved quality of clinical guidelines makes them efficient models for medical education. The pediatric pharmacopoeia provides a great variety of choices of drugs as well as for asthma medical devices. These innovations dramatically facilitated the medical management of asthmatic children, but they did not solve all problems. Physicians now use higher doses of salbutamol, but the early prescription of systemic glucocorticoids for moderate exacerbation of asthma is still underused, given the most recent clinical guidelines and meta-analysis. Furthermore, repeated emergency department visits to the wards and lack of primary care physician should systematically be appraised when evaluating severity, as they are both major risk factors for severe exacerbations, even though they are not considered in acute asthma severity scores. Finally, initiating (or reinforcing) patient education at the time of exacerbation also presents important challenges, as emergency visits are a favorable moment to commence the therapeutic education of the child and his family. Indeed, framing the controller medications and educating families about how to manage the disease and to improve their domestic environment are the genuine tools available for the prevention of asthma exacerbations, and particularly those most severe.

[Recurrent respiratory tract infections: how should we investigate and treat?]. / Infections respiratoires récidivantes: quels bilans, quels traitements ?

Recurrent respiratory tract infections are a common reason for visits to primary care practitioners or hospital physicians. They are placed at the junction of several medical specialities: paediatrics, ENT, pneumology, allergology, immunology, infectiology. The great diversity of the laboratory tests requested and on the other hand the proposed treatments, are the consequences of the diversity of the patients encountered and the paucity of the evidence based-medicine studies in this setting. The dilemma is how to identify the child for which recurrent respiratory tract infections are the witness of underlying condition, without performing repeated medical examinations, laboratory tests and treatments for normal children for which immunologic development occurs normally. The essential tools are the history analysis, physical examination and few laboratory tests. The other questions are how to include, for these patients, influenza and pneumococcal vaccines in the immunization program and how to assess the benefit/risk ratio and the cost of surgical treatments. This paper presents the thought of an expert group trying to define the situations where biological tests or treatments are useful.

[Prognostic value of VZV PCR in cerebrospinal fluid in neurological manifestations of varicella]. / Manifestations neurologiques associées à la varicelle : apport de l'amplification génique dans le liquide céphalo-rachidien.

Varicella-zoster virus (VZV) is, like other alphaherpes viruses, neurotropic. Of the admissions to hospital for varicella, 7.6-25% are due to neurologic manifestations. Most of the time, the concomitant skin lesions facilitate the diagnosis. The justification of qualitative PCR (polymerase chain reaction) for VZV DNA in cerebrospinal fluid in the management of these patients is not clear. The aim of this study was to evaluate the prognostic value of qualitative PCR for VZV DNA in cerebrospinal fluid and to assess its impact on patient management. We conducted a retrospective monocentric study in Versailles Hospital (France). It included every child admitted for neurologic manifestations associated with varicella and compared the patients with positive PCR for VZV DNA to those with a negative PCR in the cerebrospinal fluid. Seven patients with positive PCR and 16 patients with negative PCR were included. The median age of the children included was 3 years (range, 1.6-12 years) and 2 years (range, 0.6-5 years), respectively. In the positive PCR group, 86% of the children had fever on first examination and the average time between the onset of skin lesions and neurological signs was +1.28 days (range, -2 to +5 days). In comparison, in the negative PCR group, 81% of the children had fever and the average time delay was +1.75 days (-2 to +7 days). There was no significant difference in terms of length of hospitalization; 3 days (range, 0-6 days) and 3 days (range, 2-7 days), respectively. All patients discharged from our department went home. In addition, there was no significant difference between the two groups in terms of treatment with acyclovir; two children (28.5%) were treated in the positive PCR group versus four (25%) in the negative PCR group. Our study showed no prognostic value for qualitative PCR for VZV DNA in the cerebrospinal fluid of patients with neurologic manifestations of varicella. Therefore, its relevance can be questioned in clinical practice. However, in case of encephalitis and meningitis during primary infection with VZV, quantitative PCR for VZV DNA might have a prognostic value and therefore requires further study.

Vaccine coverage in CF children: A French multicenter study.

BACKGROUNDS: Recent reports have pointed the low vaccine coverage in patients with chronic diseases. Data are lacking in patients with cystic fibrosis (CF). Gaining more information on coverage both for mandatory vaccines and those more specifically recommended would help to optimize care of these patients. METHODS: Data were extracted from the "MucoFlu" study, which was a prospective study performed in 2009 in the 5 cystic fibrosis centers of the Paris metropolitan area. Data on mandatory and recommended vaccines in CF were collected in the health booklet and compared to the coverage of the general population. RESULTS: A total of 134 CF children were included. Vaccination coverage for mandatory vaccines was insufficient (DTPCaHi, conjugate pneumococcal, BCG, MMR and hepatitis B) at 1year of age with no catching-up with age in contrast to the general population. Approximately 66% of the children had immunization for seasonal influenza and 91% for 2009 pandemic flu. Coverage for vaccines specifically recommended in CF was low for hepatitis A, non conjugate pneumococcal and varicella. CONCLUSION: This study shows a defect in vaccine coverage for both routine immunization and vaccines more specifically recommended in CF.

Gastric pepsin and acid secretion during total parenteral nutrition and constant-rate enteral nutrition in infancy.

Total Parenteral Nutrition (TPN) and constant rate enteral nutrition (CREN) are widely used: their effects on gastric function, especially pepsin secretion, are unknown. Basal and pentagastrin-stimulated pepsin (BPO, MPO) and acid (BAO, MAO) secretions were measured in three groups of infants: controls (14 infants fed normally), TPN groups (seven infants on TPN), CREN groups (14 infants on CREN). The MAO and MPO of the TPN group were significantly lower than controls (p less than 0.02), and the ratio of pentagastrin-stimulated PO/AO did not change, suggesting a large decrease of acid gastric function in the TPN group. BPO was not different from controls and BAO was significantly higher because of amino acids perfusion. The data for CREN group were not different from those of the control group, despite the fact that 11 infants were on TPN before CREN. These results demonstrate that TPN causes decreases in both acid and pepsin secretions in human infants. When TPN children are placed on CREN, these secretions return to normal.

[Pediatric imported malaria. Experience of the hospital center of Versailles (1997-2001)]. / Paludisme d'importation de l'enfant. Expérience du centre hospitalier de Versailles (1997-2001).

UNLABELLED: Few data are available about pediatric imported malaria, whereas the number of cases seems in constant increase. PATIENTS AND METHODS: all pediatric malaria cases diagnosed by a positive thin or thick blood film at the Versailles Hospital, from January 1997 to December 2001, were studied retrospectively. RESULTS: sixty cases of pediatric imported malaria were studied. They were 58 cases of uncomplicated malaria and 2 cases of severe malaria; 85% of the children had travelled to sub-Saharan Africa and 15% to Oceania; 90% of the children were of African origin. Plasmodium falciparum was found alone in 84% of the cases. The anti-malarial chemoprophylaxis was inappropriate in 92% of the cases. No child had profited from preventive measures against mosquitos. Fever > 37,5 degrees C was observed in 100% of the cases. The other clinical signs were present in less than 50% of the cases. The median of haemoglobin and platelet was 10.5 g/dL and 141,000/mm(3), respectively. After treatment, the evolution was good in all the cases, without relapse or any consequences. DISCUSSION/CONCLUSION: our study, in agreement with the national data, confirms the increase in the number of case of pediatric imported malaria, and underlines the mediocrity of the prevention, in particular in term of anti-malarial chemo-prophylaxis. These data, in a context of regular increase of international travels to endemic areas, suggest the necessity to improve the information of the general public, and the urgency of a better staff training of health care workers concerning malaria, in order to improve the prevention and the treatment of this potentially fatal disease.

[Urolithiasis in cystic fibrosis]. / Lithiase urinaire et mucoviscidose.

The prevalence of urolithiasis is higher in patients with cystic fibrosis than in the normal population. We report on a case of a 12-year-old child with cystic fibrosis who presented flank pain which revealed a calcium oxalate urolithiasis. Evolution was satisfactory with pharmacological and dietary treatment. The principal mechanisms of lithogenesis in patients with cystic fibrosis are described and preventive treatment is discussed.

[Psychosomatic approach to encopresis]. / Abord psychosomatique de l'encoprésie.

Encopresis most often results from functional constipation and a behaviour disorder characterised by retention of faeces. Rarely it is a passive or active expulsion of normal faeces. It indicates a failure in the education of sphincter control, often with a preferential development of autoerotic versus relational investments. A depressive component is frequent. We propose a bidisciplinary approach with a somatic and psychological evaluation of the encopretic child from the first visit. The physical examination assesses constipation and stercoral stasis. Associated psychopathological symptoms or a pathogenic psychosocial situation must be sought. The therapeutic means must be directed towards the different etiologic features. Explanations of the physiopathology of the symptom and discussion with the child and the parents on the origin of the dysfunction must be accomplished first. A medical treatment of the constipation is generally indicated. Psychotherapy is initiated according to the background and associated psychopathological symptoms.

[Trismus and tetanus vaccine]. / Trismus et vaccination antitétanique.

BACKGROUND: Tetanus immunization, mandatory in France before the age of 18 months, is usually well tolerated. Fever and local reaction at the site of injection are the most common side effects. We report a case of trismus associated with tetanus immunization. CASE REPORT: A 12-year-old boy was hospitalized for a trimus which occurred 22 h after a booster dose of tetanus polio vaccine. The spasm of masticator muscles was so severe that the patient had difficulties in elocution and feeding. A moderate fever and a hypertonia of the lower limbs were associated. The trismus resolved itself within about 5 min after diazepam intravenous infusion. After examination of the buccal cavity, a local cause was discarded. The outcome was favorable and the clinical status of the boy was still normal six months later. DISCUSSION: Although no similar cases have been published, 13 other comparable adverse events associated with four vaccines containing tetanus toxoid were reported to the manufacturer within a period of 12 years. During the same period, more than 66 millions doses of vaccines containing tetanus toxoid were distributed. Trisms appeared to be more likely reported in adults after booster doses. Onset of the symptoms was between a few hours to 15 days. Outcome was always favorable. CONCLUSION: Although trimus associated to tetanus toxoid immunization is rare and remains unexplained, physicians should be aware of this adverse event.

[Severe parvovirus B19 infection in an immunocompetent child with hemophilia A]. / Infection sévère à parvovirus B19 chez un enfant hémophile A immunocompétent.

BACKGROUND: B19 parvovirus is a widespread virus whose typical manifestations in immunocompetent children are erythema infectiosum, acute erythroblastopenia and fetal anemia. CASE REPORT: An 11 year-old immunocompetent patient with hemophilia A was referred for an hemorrhagic syndrome. Forty days after a pasteurized coagulation factor concentrates treatment, and after 12 days of treatment with solvent/detergent factor VIII concentrates, he developed fever, consciousness disorders, pancytopenia, liver cytolysis and probably minor haemophagocytic syndrome, associated with human parvovirus B19 infection. His clinical state returned to normal within 15 days. A retrospective study revealed that the patient had received every day for 12 days, one parvovirus B19 polymerase chain reaction positive batch before the occurrence of symptoms. CONCLUSION: This case highlights the possibility of severe parvovirus B19 infection transmitted by clotting factors prepared from large pools of plasma. The use of recombinant factors would allow to reduce human virus contamination, even if immune risk has to be more accurately assessed.