The position during urine sample collection from young precontinent children through a bag does not limit contamination rates: Results from a randomized controlled trial: Does infant position influence quality of urine collection?

AIM: Despite its limitation, bag collection is still widely used for a preliminary urine screening test in non-toilet-trained children suspected of febrile urinary tract infection. A previous study conducted by our group raised the hypothesis that the absence of direct contact between urine and the perinea during urine collection could limit urine contamination by perineal flora. The aim of this study was to evaluate the impact of the patient's position during urine collection (upright standing position versus free position) on the rate of contaminated urine samples in non-toilet-trained children with suspected febrile urinary tract infection. METHODS: This prospective, randomized, controlled study took place in seven pediatric emergency departments. Two groups were compared: the intervention group (infants held in an upright standing position during urination) and the control group (free position during urination). RESULTS: Among the 800 pediatric patients randomized to the study, 124 had a urine culture, 60 in the intervention group and 64 in the control group. Among the 124 urine cultures, 12 (9.7%) were contaminated: eight (13.3%) in the intervention group and four (6.3%) in the control group (p = 0.1824). CONCLUSION: The results show that the patient's position does not have a significant impact on the quality of urine samples collected by bag.

Parental presence during painful or invasive procedures in neonatology: A survey of healthcare professionals.

BACKGROUND: Newborns in neonatology are exposed to invasive and painful procedures. The absence of parents during procedures revealed significantly high pain scores. OBJECTIVE: The aim of this study was to assess practices regarding the role of parents during painful and invasive procedures. METHODS: This was a prospective, observational, multicenter study in France in which 471 caregivers participated. Professional practices regarding the role of parents during painful procedures on their child were assessed. Univariate and multivariate analyses were performed to identify factors associated with parental presence during painful procedures. RESULTS: Parental presence was most often allowed during capillary blood sampling, nasogastric tube insertions, and vein punctures, whereas it was mostly restricted during central line insertions, extubations, lumbar punctures, and intubations. However, we found discrepancies depending on the type of facility and caregiver seniority. CONCLUSION: An important variability in practices concerning the role of parents during painful and invasive procedures on their child was reported.

[Treatments of steroid-dependent nephrotic syndrome in children]. / Traitements du syndrome néphrotique cortico-dépendant de l'enfant.

Primary nephrotic syndrome (NS) is the most common glomerular disease in children. It is characterized by massive proteinuria and hypoalbuminemia. It typically has a sudden onset and more than 70% of patients will experience at least one relapse. An immunological origin has long been postulated, although the precise molecular mechanisms underlying the disease remain debated. Steroids are the first-line therapy with cumulative dose and duration of initial treatment varying among countries. Steroid-sparing agents may be indicated in case of steroid-dependency or frequent relapses. However, no consensus exists regarding the different treatment options. These treatments are mostly suspensive and therefore, need to be prolonged for several months. Levamisole, an antihelminthic drug, also has an immunomodulatory function, and alone or in combination with steroids, it can decrease cumulative steroid dose and relapses. It is usually well tolerated, and its principal side effects are cytopenia and elevated liver enzymes. Mycophenolate mofetil is an immunosuppressive agent whose reported side effects are cytopenia and diarrhea. Calcineurin inhibitors (cyclosporine or tacrolimus) have long been used in steroid-dependent patients. Their major side effects are hirsutism, gum hypertrophy, and nephrotoxicity, leading to interstitial kidney fibrosis and chronic kidney disease. Cyclophosphamide is an efficient treatment but its gonadal toxicity is a major drawback to its use. More recent drugs such as rituximab are very effective but require hospitalization for the infusion and induce an increased risk of opportunistic infection, prolonged neutropenia, and anaphylaxis. In this review, we present the available treatments, their indications, and the side effects.

[Idiopathic nephrotic syndrome]. / Aspects cliniques du syndrome néphrotique idiopathique de l'enfant.

Nephrotic syndrome (NS) is defined by massive proteinuria and hypoalbuminemia, with resulting hyperlipidemia and edema. The most common cause of NS in children is idiopathic nephrotic syndrome (INS), also called nephrosis. Its annual incidence has been estimated to 1-4 per 100,000 children and varies with age, race, and geography. Many agents or conditions have been reported to be associated with INS such as infectious diseases, drugs, allergy, vaccinations, and malignancies. The disease may occur during the 1st year of life, but it usually starts between the ages of 2 and 7 years. INS is characterized by a sudden onset, edema being the major presenting symptom, but may rarely be discovered during a routine urine analysis. The disease may also be revealed by a complication such as hypovolemia, infection (pneumonia and peritonitis due to Streptococcus pneumoniae), deep-vein or arterial thromboses, and pulmonary embolism. Renal biopsy is usually not indicated in a child aged 1-10 years with typical symptoms and a complete remission with corticosteroids. Conversely, it is indicated in children under 1 year in case of macroscopic hematuria, hypertension, low C3 levels, persistent renal failure, or steroid resistance. Steroid therapy is applied in all children whatever the histopathology. Initial prednisone therapy in France consists of 60mg/m2 administered daily for 4 weeks (maximum dose, 60mg/day), followed by alternate-day prednisone with tapering doses. Eight-five to 90 % patients are steroid-responsive and may relapse, but the majority still responds to steroids over the subsequent courses. Only 1-3 % of patients who are initially steroid-sensitive subsequently become steroid-resistant. Children with primary or secondary steroid-resistance are at risk of end-stage kidney disease. Symptomatic treatment includes salt restriction, fluid restriction when natremia is less than 125 meq/L, reduction of saturated fat and carbohydrates, calcium and vitamin D supplements, anticoagulation, and vaccination. Albumin infusions are only indicated in case of complications. Diuretics should be restricted to cases of severe edema, after hypovolemia has been corrected.

Efficacy of intralesional sodium thiosulfate injections for disabling tumoral calcinosis: Two cases.

INTRODUCTION: Tumoral calcinosis (TC) is a difficult-to-treat complication that can occur during several diseases such as dermatomyositis or genetic hyperphosphatemia. It is a painful and disabling condition that can lead to local complications including joint mobility reduction, cutaneous ulceration and superinfection. For the largest lesions, the treatment relies essentially on surgery. Intravenous sodium thiosulfate (STS) is efficient to treat calciphylaxis in patients undergoing hemodialysis. Local injections of STS seem efficient in superficial calcifications. OBJECTIVE: To report the efficacy and safety of intra-lesional injections of STS in tumoral calcinosis. RESULTS: We report two cases of successful intra-lesional injections of STS. A 44-year-old woman, with a history of dermatomyositis, presenting large subcutaneous calcifications in the right elbow, and a 42-year-old man, with a history of familial tumoral calcinosis, presenting large intramuscular calcifications in the right buttock, received weekly intra-lesional of 1-3g STS injections for 12 and 21 months, respectively. In both cases, the treatment relieved pain and greatly reduced the tumoral calcinosis with a very significant functional improvement without specific adverse effects. In case 1, TC size decreased from 28.7*56.0mm at baseline to 21.5*30.6mm at M12 treatment (59% reduction). In case 2, TC reduced from 167.5*204.3mm at baseline to 86.2*85.2mm at M21 treatment (79% reduction). CONCLUSION: Local injection of STS could be a promising therapeutic strategy for large and deep TC lesions and could therefore be an alternative to surgery.

Prospective evaluation of a cutaneous stimulation technique to induce on-demand urination in non-toilet-trained infants.

CONTEXT: When a urinary tract infection is suspected, it is recommended to capture a midstream sample of urine for analysis, but this strategy is difficult to apply before successful toilet training. A cutaneous stimulation technique has been reported to be effective in provoking micturition in newborns. OBJECTIVE: To evaluate the feasibility and the efficacy of this technique in a population of non-toilet-trained infants. DESIGN AND METHODS: Fifty infants were enrolled in this prospective non-controlled study in three pediatric emergency departments. The bladder was stimulated through suprapubic and paravertebral cutaneous stimulation as previously reported in newborns. The evaluation criterion was the proportion of patients from whom urine had been collected within the first 5min of the procedure. RESULTS: Forty-eight patients (21 boys) were evaluated. The procedure was successful in 27% of the cases overall, but reached 46% for children aged less than 3 months. Elevated weight was associated with failure of the procedure. CONCLUSION: Despite promising results in newborns, the cutaneous stimulation technique to provoke micturition appears to encounter limitations in older children. Nevertheless, the technique is an attractive alternative to urethral catheterization or suprapubic aspiration for infants younger than 3 months.

[Pitfalls for renogram interpretation in pediatric urology]. / Biais d'interprétation de la scintigraphie rénale chez l'enfant.

Renograms are currently used for functional assessment by pediatric urologists. The aim of the present work was to focus on the potential pitfalls concerning renography. Potential confounding factors are described in reference to concrete cases. The main types of pitfalls concern venous or urinary catheters and background area definition. Protocols and renogram interpretation are critiqued in a bibliographic review. We propose a technical update and original data on the potential pitfalls in renography interpretation. Multidisciplinary discussion between nuclear medicine, pediatrics and pediatric surgery departments is required before drawing conclusions.

[Simulation training for urinary drainage improves skill retention]. / Simulation et rétention des acquisitions : application au drainage vésical.

INTRODUCTION: Urethral and suprapubic catheterizations are the two methods for urinary drainage. Systematic simulation training could improve the performance and reduce iatrogenic complications. The aim of the study was to evaluate the skills retention using simulation training. MATERIALS AND METHODS: It was an experimental study of the effect of urinary drainage simulation based skills on medical students in order to compare active and passive training methods. On the first session, randomization was proceeded. Then, the participant performed one of the two workshops (urethral or suprapubic catheterization) on a male mannequin. The maximal performance was 40 points on the assessment form. Both workshops were performed on the second (one month) and third sessions (six months). RESULTS: Eighteen participants were included. Main performance was 28.7/40 (23-34.2) at the first session. All the participants improved the performance on the second session with a significant difference (P<0.01) between passive 32.5 (26-36.5) and active participants 36.1/40 (34.5-39). On the third session, a similar difference was observed between passive and active participants (32.5 versus 30.4, P non significant). CONCLUSION: Simulation training seems to improve long-term skill retention of urinary drainage for inexperienced medical students. This preliminary study suggests to incorporate urinary drainage simulation training into all medical school curricula. LEVEL OF EVIDENCE: 4.

A midstream urine collector is not a good alternative to a sterile collection method during the diagnosis of urinary tract infection.

AIM: Guidelines recommend collecting urine with suprapubic aspiration or urethral catheterisation in infants with a suspected urinary tract infection (UTI), but the invasiveness of these methods continues to drive research on new urine collection devices. We studied children with a suspected UTI, who had not been toilet trained, to compare a new midstream urine collector and catheterisation. METHOD: During this prospective controlled diagnosis study of 94 children, urine collection was performed using the midstream collector and then controlled via catheterisation when the urine dipstick was positive. RESULTS: When end stream samples collected by the midstream collector were compared to catheter samples, the results were inconsistent in 23.4% of cases, similar to the inconsistent results between first stream samples discarded by the device and the catheter samples (21.3%). Interestingly, the overall rate of sample contamination in the bag of the midstream collector was lower than that reported in previously published studies and there were no false positive bag results. CONCLUSION: The midstream collector did not appear to provide additional benefits to classic collection bags. A sterile collection method, such as suprapubic aspiration, catheterisation or clean catch, is still mandatory for diagnosing urinary tract infections in children who are not toilet trained.

Analgesic interaction between ondansetron and acetaminophen after tonsillectomy in children: the Paratron randomized, controlled trial.

BACKGROUND: The mechanism of action of acetaminophen remains unclear. One hypothesis involves an interaction with the serotoninergic system. Antagonists to serotonin (5-HT)3 receptors (setrons) have antiemetic properties. Therefore, co-administration of acetaminophen and a setron could lead to a decrease or a loss of acetaminophen analgesic effects. The aim of this study was to demonstrate such an interaction. METHODS: Paratron is a prospective, randomized, controlled, double-blind, parallel group trial. All children aged 2-7 years (n = 69) scheduled for a tonsillectomy ± adenoidectomy received intraoperative acetaminophen with ondansetron or droperidol. Pain scores [Children's Hospital of Eastern Ontario Pain Scale (CHEOPS)], morphine consumption and the incidence of post-operative nausea and vomiting (PONV) were measured for 24 h following surgery. RESULTS: Pain scores were not different at all times between the groups but median morphine consumption (µg) in recovery was 322.5 [interquartile range (IQR) 0.0-500.0] and 0 (IQR 0-0) in the ondansetron (n = 35) and droperidol (n = 34) groups, respectively (p = 0.004). The percentages of patients who received morphine titration were 57.1% and 20.6% in the ondansetron and droperidol groups, respectively (p = 0.008). No significant difference was found for PONV. CONCLUSIONS: An interaction between acetaminophen and ondansetron is suggested, with children receiving three times more morphine during pain titration in the recovery room. More studies are necessary to evaluate whether this finding is clinically relevant enough to preclude the simultaneous perioperative administration of both drugs in the future.

[New insights into perinatal hemochromatosis]. / Nouveaux concepts dans l'hémochromatose périnatale.

Perinatal hemochromatosis (PH) includes neonatal acute liver failure (ALF) with cirrhosis and extrahepatic iron overload sparing the reticuloendothelial system. This is the main cause of neonatal ALF. Prognosis is very poor, usually with neonatal death or neonatal orthotopic liver transplantation occurring in more than 70%. The recurrence rate is more than 90%. Diagnosis is hard to make and is proved after exclusion of other neonatal ALF causes. A recent physiopathological hypothesis proposed HP as a maternofetal alloimmune disease against the fetal liver. A maternal antibody may activate the terminal complement cascade, responsible for the membrane attack complex directed against fetal hepatocytes. Maternal prenatal treatment after a pregnancy complicated by PH modifies the course and the prognosis of this disease. In France, approval of prenatal IVIG treatment is required after analysis of clinical and pathological data by a national multidisciplinary committee.

[Parapneumonic pleural effusion incidence in a French region before and during the antipneumococcal vaccine era]. / Incidence des pleuropneumopathies à pneumocoque en Limousin à l'ère de la vaccination.

BACKGROUND AND AIMS: The aim of the study was to compare the incidence of parapneumonic pleural effusion in the Limousin region of France, based on the comparison of pre- and postvaccination periods. METHODS: Subjects, 0-18-years-old, were retrospectively identified by searching in computerized databases of coded discharge diagnosis for patients with a diagnosis of pleural effusion and/or empyema and/or pulmonary infection in all the pediatric departments in Limousin hospitals. Medical records were reviewed by one of the authors and those with parapneumonic effusion and confirmed or suspected pneumococcal infection were included in the study. Data from the children hospitalized for parapneumonic pleural effusion were collected for two periods: period A, from July 2000 to July 2006, and period B, from July 2006 to July 2009 (before and after the generalization of the antipneumococcal vaccination). The main endpoint was the number of parapneumonic pleural effusion cases in each period in order to calculate the incidence within each period. RESULTS: A total of 35 children were included: nine during period A and 26 during period B. The incidence was 1 per 100,000 children for period A and 5.8 per 100,000 for period B. Bacteriological tests allowed us to serotype eight S. pneumoniae over the two periods. All serotypes were non-vaccine serotypes (1, 3, and 19A). CONCLUSION: This study demonstrates the increase in parapneumonic pleural effusion in the Limousin region.

Development of a Bayesian estimator for the therapeutic drug monitoring of mycophenolate mofetil in children with idiopathic nephrotic syndrome.

The use of mycophenolate mofetil (MMF) in children with idiopathic nephrotic syndrome (INS) is increasing. However, the clinical benefit of its monitoring has been scarcely studied, and little is known about its pharmacokinetics in this context. The objectives of the present study were: (i) to study and model the pharmacokinetics of mycophenolic acid (MPA; the active moiety of MMF) in paediatric patients with INS given MMF, at all stages of the disease; (ii) to develop a Bayesian estimator (MAP-BE) for individual inter-dose area under the concentration-time curve (AUC) prediction in this population, using a limited blood sampling strategy (LSS). Full-pharmacokinetic (PK) profiles of MPA collected in paediatric inpatients with INS already treated with a maintenance immunosuppressive therapy based on MMF (with no calcineurin inhibitors; CNI) were studied. A classical iterative two-stage (ITS) method was applied to model the data and develop MAP-BEs using a one-compartment open model where the absorption is described by a double gamma law allowing the description of a potential enterohepatic recirculation. The performance of the MAP-BE developed for individual exposure assessment was evaluated by the bias and precision of predicted AUCs with respect to measured, trapezoidal AUCs (reference value), and by the proportion of predicted AUCs with absolute error >20%. These PK tools were tested in an independent group of patients. Sixty PK profiles of MPA from children receiving MMF in association to corticosteroids or given alone were included in the study. Forty-five of these PK profiles were used to develop a PK model and a MAP-BE, and 15 for their validation. In the building group, the PK model fitted accurately the PK profiles of MPA: mean residual error of modelled vs. reference AUC was m±SD=-0.015±0.092 (range: -0.153 to 0.204). The MAP-BE which allowed the estimation of MPA AUC on the basis of a 20 min-60 min-180 min LSS was then developed. In the independent group of patients, its mean residual error vs. reference AUCs was m±SD=-0.036±0.145 (range: -0.205 to 0.189). Thus, a PK model and its derived MAP-BE for MMF (without any associated CNI) when given to children with INS have been developed. Clinical trials using these PK tools could test the potential impact of the therapeutic drug monitoring of MMF based on the AUC on the clinical evolution of INS.

Successful anti-TNFalpha treatment in a child with posttransplant recurrent focal segmental glomerulosclerosis.

Posttransplant recurrence of focal and segmental glomulosclerosis (FSGS) occurs in approximately 30% of patients, and remains after uncontrolled despite increased immunosuppression and plasma exchanges (PE) in approximately 30% of cases. New immunosuppressive drugs might then be warranted. We report the case of a 15-year-old boy with FSGS leading to end-stage renal disease (ESRD) who presented with an early posttransplant recurrence of disease. Reinforced immunosuppression and PE resulted in partial and transient disease control, but proteinuria significantly decreased with anti-TNFalpha treatment (infliximab then etanercep). This is the first case report of successful anti-TNFalpha treatment despite a constant high activity of FSGS, as demonstrated by relapse after discontinuation of anti-TNFalpha agents.

Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study.

PURPOSE: Antibiotic prophylaxis is given to children at risk for urinary tract infection. However, evidence concerning its effectiveness in grade I to III vesicoureteral reflux is lacking. The objective of this study was to determine whether antibiotic prophylaxis reduces the incidence of urinary tract infection in young children with low grade vesicoureteral reflux. MATERIALS AND METHODS: Children 1 month to 3 years old with grade I to III vesicoureteral reflux were assigned randomly to receive daily cotrimoxazole or no treatment, and followed for 18 months. A urinary tract infection constituted an exit criterion. Infection-free survival rates were calculated using the Kaplan-Meier method and compared using the log rank test. RESULTS: A total of 225 children were enrolled in the study. Distribution of gender, age at inclusion and reflux grade were similar between the 2 groups. There was no significant difference in the occurrence of urinary tract infection between the 2 groups (17% vs 26%, p = 0.2). However, a significant association was found between treatment and patient gender (p = 0.017). Prophylaxis significantly reduced urinary tract infection in boys (p = 0.013), most notably in boys with grade III vesicoureteral reflux (p = 0.042). CONCLUSIONS: These data suggest that antibiotic prophylaxis does not reduce the overall incidence of urinary tract infection in children with low grade vesicoureteral reflux. However, such a strategy may prevent further urinary tract infection in boys with grade III reflux.