[Covid-19 and adolescence: Clinical findings and psychopathological thoughts about some immediate or differed impacts]. / Covid-19 et adolescence : constats cliniques et réflexions psychopathologiques à propos de quelques incidences immédiates ou différées.

This pandemic has profoundly changed our lives for many months and its long-term consequences remain largely hypothetical. The containment measures, the threats to the health of relatives, the constraints limiting social openings have left no one indifferent, but may have particularly impeded "adolescent separation work". Most of adolescents have been able to deploy their adaptation capacities, while for others this exceptional situation has triggered stressful reactions for those around them. Some were immediately overwhelmed by the direct or indirect manifestations of their anxiety or by their intolerance of governmental instructions, others revealed their difficulties only when the schools reopened, or even in the distant "aftermath", as shown by some studies carried out at a distance revealing a clear increase in suicidal ideation. We will not be surprised by the problems of adaptation of the most fragile, of those suffering from psychopathological disorders, but it is necessary to note an increase in the needs for psychological care. Teams dealing with the suffering of adolescents are puzzled by the increase in self-vulnerable acts, anxious school refusals, eating disorders or various forms of addiction to screens. However, everyone agrees on the key role of parents and the impact of their own suffering on that of their children, even if they are young adults. Of course, it is important that caregivers do not forget the parents in the support they aim to provide to their young patients.

[Perception of adolescent medicine among French pediatric residents]. / Représentations de la médecine de l'adolescent chez les futurs pédiatres.

PURPOSE: The perception of adolescent medicine (AM) among future pediatricians in France has scarcely been explored although adolescent health care is an integral part of the pediatrician's job. Moreover, pediatric residents seem to have a lack of enthusiasm for this field. The aim of this study was to assess the beliefs and perceptions of fourth-year French pediatric residents regarding adolescents and AM. METHODOLOGY: We conducted a national electronic survey among French pediatric residents in their last year of residency. An original 51-item, open-ended declarative questionnaire was sent out including questions on demographics, career expectations, AM block rotation experiences, and perceptions and beliefs regarding adolescents and AM. Difficulties and barriers experienced in this field were investigated. Queries about residents' specific AM courses and about their educational needs were also explored. RESULTS: The survey was conducted online between January and March 2015. There were 121 respondents, achieving a 43% response rate. The majority of respondents perceived teens as interesting (75%), vulnerable (83%), and time-consuming (84%). Up to four fifths of respondents (81%) considered AM to be a skill that all pediatricians should acquire. A subgroup analysis showed that the residents who had not experienced an AM block rotation did not seem to be convinced of the need for training in this field (P=0.09). The following issues were reported as major difficulties by residents: providing care for teens reluctant to seek health care (65%), managing violent behavior among adolescents in the emergency ward (98%), and managing adolescents who attempt suicide (80%). Less than half (45%) of the residents reported their residency program had a specific AM course. Among them, 73% attended the lectures and 57% found them useful. One third (32%) of the respondents had experienced a 2-month block rotation in the field of AM during their residency. DISCUSSION: This is the first nationwide study in France in this field. Although the response rate is below 50%, it exceeded our expectations. Our results are in line with previous studies showing that pediatric residents report a high interest in working with adolescents and yet their educational needs in AM are unmet. The limitations of this study include the self-selection bias and implicit limitations carried by the phrasing of the survey questions. CONCLUSIONS: There is a need to devise a better educational approach combining a broader proposal of AM block rotations together with a specific competency framework in adolescent health, since we know it improves the quality of health care delivered to adolescents. Moreover, training pediatricians in AM is a public health priority so as to comply with medical schools' principles of social accountability and address the priority health needs for an efficient, equitable, and sustainable health system. At a time when postgraduate reform is being made, the inclusion of an AM curriculum in the general pediatrician course is necessary.

[Neonatal renal venous thrombosis following an electrical shock in pregnancy]. / Thrombose néonatale de la veine rénale suite à une électrisation in-utero accidentelle.

Neonatal renal venous thrombosis may result in severe morbidity. Predisposing conditions are well known. We report the case of an unusual and early neonatal renal venous thrombosis. The mother received an electrical shock at 34 weeks gestation. This case demonstrates that maternal electrical shock effect on the fetus should be early investigated.

[Chronic intestinal pseudo-obstruction complicated by an eating disorder]. / Pseudo-obstruction intestinale chronique compliquée d'un trouble des conduites alimentaires chez une adolescente.

Chronic idiopathic intestinal pseudo-obstruction is a rare and serious chronic disease starting in childhood, which can affect the entire digestive tract. It is caused by a peristalsis intestinal disorder that leads to occlusions without any obvious obstruction. Few studies have been carried out regarding the prognosis of this illness. This disease is often diagnosed by a process of elimination, but some histological anomalies have been present in the digestive wall of certain patients. This clinical case concerns a 17-year-old girl affected by CIPO and eating disorders. It seems difficult to discriminate between digestive disorders and eating disorders. What psychological effects can this severe pathology have? Are eating disorders induced by CIPO? These questions are raised in this article through the example of this patient's somatopsychic complexity and the ensuing difficulties in her overall care.

Longitudinal study of plasma testosterone in male pseudohermaphrodites during early infancy.

Plasma testosterone was longitudinally studied during the first months of life in 7 XY infants with male pseudohermaphroditism. In two, the physiological postnatal rise of plasma testosterone was absent or blunted. A combined adrenal and testicular enzymatic defect was demonstrated in these two boys. In 5, a normal postnatal testosterone rise demonstrated a normal Leydig cell function. The longitudinal study of the physiologic postnatal rise of testosterone may be useful to distinguish secretory defects from responsiveness abnormalities thus improving the choice of gender in male pseudohermaphrodites.

Comparison of intact, midregion, and carboxy terminal assays of parathyroid hormone for the diagnosis of bone disease in hemodialyzed patients.

The predictive value of three different RIAs of PTH for the diagnosis of the histological type of bone disease has been compared in 24 asymptomatic patients on chronic hemodialysis who had never been exposed to aluminum intoxication and who agreed to have a bone biopsy after double tetracycline labeling. The serum concentrations of PTH were measured using a two-site immunoradiometric assay for intact PTH(1-84) and region specific assays directed against the C-terminal (53-84) fragment or the midregion (44-68) of the molecule. The bone histomorphometric analysis showed that six patients had nonaluminic adynamic bone disease with low bone formation rate (BFR), eight had mild hyperparathyroidism characterized by increased bone resorption and normal BFR, nine had severe hyperparathyroidism with increased BFR, and only one had true osteomalacia with increased osteoid seam thickness. All PTH assays correlated with the various parameters of bone resorption and bone formation and were able to differentiate the histological type of bone disease only when groups of patients were considered. For classifying individual patients into severe hyperparathyroidism and adynamic bone disease groups, the intact PTH assay had the best predictive value with a sensitivity of 100% and a specificity of at least 70%. A nonaluminic adynamic bone disease was observed in more than 50% of the patients who had normal intact PTH levels (6/11). It is concluded that the intact PTH measurement is superior to C-terminal and midregion assays for the prediction of the histological type of bone disease in hemodialyzed patients and should be of considerable value to adapt their treatment in order to avoid the emergence of both severe hyperparathyroidism and adynamic bone disease. In the absence of aluminum intoxication it seems that maintaining intact PTH concentrations 1 to 1.5 times the upper limit of normal would correspond to the best bone histology.

Non-aluminic adynamic bone disease in non-dialyzed uremic patients: a new type of osteopathy due to overtreatment?

Adynamic bone disease, characterized by a low bone formation rate with normal or reduced amount of unmineralized osteoid, is supposed to be the consequence of aluminum intoxication in uremic patients. However, the emergence of adynamic bone disease has been recently reported in hemodialyzed patients in the total absence of aluminum overload. This study was aimed to assess whether such a histological pattern of adynamic bone disease was already present in uremic patients not yet on dialysis. Twenty-seven asymptomatic uremic patients (mean age +/- SD 43 +/- 10 years, mean creatinine clearance 19 +/- 3 ml/mm) were studied and bone biopsies were repeated in 16 of them after 18 +/- 10 months of treatment with oral calcium carbonate (1-3 g of elemental calcium/day) and calcidiol (21 +/- 14 micrograms/day). None of the patients received aluminum hydroxide, and the search for bone aluminum deposits was negative in all patients both before and after treatment. Two patients fulfilled the criteria of adynamic bone disease on their post-treatment biopsies. They originated from patients classified as having normal bone histology before treatment. Comparison with the other patients showed that they had comparable plasma C-terminal PTH but higher plasma creatinine than patients with normal bone histology and lower plasma C-terminal PTH than patients with osteitis fibrosa but comparable plasma creatinine. The plasma levels of 1,25(OH)2D reached values above normal after treatment in these two patients. It is suggested that adynamic bone disease not related to aluminum intoxication can develop in uremic patients independently of dialysis, and is favored by a relative hypoparathyroidism for the degree of renal failure, possibly induced by elevated plasma concentrations of calcitriol.

Evaluation in patients with Alport syndrome of knowledge of the disease and attitudes toward prenatal diagnosis.

Cloning of the COL4A5 gene has now made possible prenatal testing for Alport syndrome with X-linked dominant inheritance. We interviewed 27 females and 24 males with Alport syndrome to evaluate their knowledge of the disease and its transmission, and their attitudes to prenatal testing. Twenty-two males and 8 females were on renal replacement therapy. In all cases transmission was compatible with X-linked disease. Only 59% of the interviewees (74% of women, 42% of men) knew that gender was the major determinant in progression of the disease. Knowledge of the mode of inheritance was adequate in only 25%, in both sexes. Seventy percent of the participants (78% of women, 63% of men) would use prenatal testing. Of the women in favor of prenatal diagnosis, 67% and 39% would terminate pregnancy in the case of an affected male or female fetus, respectively. Of the men in favor of prenatal diagnosis, 53% would consider termination of an affected fetus. In summary, a majority would use prenatal testing, but only one or two thirds of them wished to use selective abortion. As in other inherited disorders, there is a discrepancy between the demand for prenatal diagnosis and the decision to terminate pregnancy. Most of the participants who would terminate a pregnancy had, however, little knowledge of the clinical and genetic aspects of Alport syndrome on which to base such a decision. An important aspect of genetic counselling is to assist consultants in reaching a decision regarding future reproductive behaviour which is appropriate to their situation. This study underlines the need to improve education and counselling to assure appropriate use of prenatal testing.

Indirect clinical evidence that 1 alpha OH vitamin D3 increases the intestinal absorption of aluminum.

In a previous study we showed that 1 alpha OH vitamin D3 [1 alpha (OH)3] given to 16 hemodialyzed patients taking Al(OH)3 at a constant dose increased their plasma concentrations of aluminum [Demontis et al. 1986]. In order to choose between 2 possible mechanisms explaining this increase (increased intestinal absorption or decreased tissue storage of aluminum), we gave, in the present study, 1 alpha (OH)3 the same dose (6 micrograms per week) for the same period (4 weeks) to 15 stable hemodialyzed patients after their Al(OH)3 had been discontinued for 6 weeks. Under Al(OH)3 treatment they had a mean plasma aluminum (2.33 +/- 2.36 mumol/l) which was not significantly different from that of the patients in our former study (1.23 +/- 0.25 mumol/l). After Al(OH)3 discontinuation, plasma aluminum (measured by inductively coupled plasma emission spectrometry) decreased significantly as early as the 2nd week of the control period (1.39 mumol/l). The decrease was maintained at a plateau throughout the 5 weeks of the control period (1.38 mumol/l), the 4 weeks of 1 alpha OH vitamin (vit) D3 administration (1.40 mumol/l) and the 8 weeks of the post 1 alpha (OH)3 period (1.22 mumol/l). Plasma calcium and phosphate concentrations increased significantly with 1 alpha (OH)3 and decreased thereafter whereas plasma PTH concentrations decreased during 1 alpha (OH)2 D3 and increased after its discontinuation suggesting biological activity of 1 alpha (OH)3. Since 1 alpha (OH)3 increases plasma aluminum in hemodialyzed patients only when they are simultaneously taking Al(OH)3, it is suggested that this increase is explained by an increase of intestinal absorption of aluminum and not by a tissue redistribution of aluminum.

Extracellular and intracellular fluid volume monitoring during dialysis by multifrequency impedancemetry.

Impedance techniques can, in principle, permit non-invasive monitoring of extracellular (Ve) and intracellular (Vi) fluid volumes during dialysis. The authors present a method that determines the resistances Re and Ri of extracellular and intracellular compartments, respectively, by extrapolating impedance measurement toward zero, as well as infinite frequencies, according to the Cole-Cole model of biologic issues. These measurements were made using a XITRON 4000 B impedance meter (Xitron Technologies Inc., San Diego, CA) at frequencies ranging from 5 kHz to 1 MHz. The fact that the body is not a cylindric, homogeneous conductor is taken into account by introducing shape factors ke and ki and different resistivities pe and pi for the extracellular and intracellular fluid compartments. Assuming that these four unknown parameters can be regarded as constant during dialysis, the authors obtain: [formula: see text] where subscript o denotes initial values at start of dialysis. Impedances were measured at 30 min intervals on 11 pediatric patients and two adults, whereas total body water volume was determined by measuring urea in collected dialysate. Without ultrafiltration, Ve and Vi do not change significantly in percentage whereas, in the presence of ultrafiltration, Ve decreased by 15% to 25%. In cases when Vi does not change, it is possible to determine Ve and its variation during dialysis.

Continuous measurements by impedance of haematocrit and plasma volume variations during dialysis.

A technique for continuous measurements of haematocrit and plasma volume in the arterial line of dialysed patients has been tested in vitro and in vivo. This method uses impedance measurements at 5 kHz and requires a single haematocrit measurement. It relies on two assumptions: that plasma resistivity does not change during dialysis and that blood resistivity obeys Hanai's model. Both assumptions are verified during in vitro tests. Haematocrits measured in vivo by this method are found to be in good agreement with direct measurements from blood samples. The haematocrit variation is then used to monitor changes in plasma volume, assuming conservation of erythrocyte volume. In addition, it is possible to obtain the variation in interstitial volume by combining these data with body impedance measurements.

Extra- and intracellular volume monitoring by impedance during haemodialysis using Cole-Cole extrapolation.

A method is presented for monitoring the relative variation of extracellular and intracellular fluid volumes using a multifrequency impedance meter and the Cole-Cole extrapolation technique. It is found that this extrapolation is necessary to obtain reliable data for the resistance of the intracellular fluid. The extracellular and intracellular resistances can be approached using frequencies of, respectively, 5 kHz and 1000 kHz, but the use of 100 kHz leads to unacceptable errors. In the conventional treatment the overall relative variation of intracellular resistance is found to be relatively small.

Urea, creatinine and phosphate kinetic modeling during dialysis: application to pediatric hemodialysis.

The kinetics of urea, creatinine and phosphate removal during dialysis were investigated in pediatric patients using a two-pool model taking into account fluid shifts and mass transfer between the two compartments. It is found that even urea must be described by a two-pool model since it presents a post dialysis rebound due to equilibration between the two compartments. Phosphate plasma concentration drops very sharply during the first hour of dialysis and rises rapidly during the rebound period. This pattern cannot be accounted for by the classical two-pool model with constant generation rate and mass transfer coefficients, but corresponds to a large time-dependent phosphate influx from the intracellular compartment in which phosphate is generated by biochemical reactions or liberated from the bones. This influx was calculated for four patients representing 8 dialysis sessions and was found to reach a plateau after 90 minutes of dialysis, dropping rapidly during the rebound period.

Trichomegaly, pigmentary degeneration of the retina and growth disturbances. A probable autosomal recessive disorder.

Two brothers are described with trichomegaly, early pigmentary degeneration of the retina, growth retardation, anterior pituitary deficiencies and peripheral neuropathy. This syndrome, initially reported in a boy by Olivers and Mac Farlane in 1965 (6), and thereafter in six sporadic cases of both sexes, is not associated with a recognizable chromosomal defect. The present report of two brothers of healthy parents with negative familial history suggests an autosomal recessive mode of inheritance of this entity.

[Long-term follow-up of abused children (apropos of 65 cases)]. / Surveillance lointaine des sévices chez l'enfant (à propos de 65 cas).

The authors work in an area located north of Paris, which contains roughly a population of .75 million, of which 82,000 are children less than 3 years of age. The center and main city of the area is the town of Amiens. The recruitment of their cases under study was essentially hospital based, which explains the relative severity of the trauma observed. The children were followed by various observation systems. Seventy-four children, of which more than two-thirds were less than 3 years of age were followed for a period varying from two to ten years. Forty-three percent of these children have been maintained in their biological families; the others have been placed. With this system only nine recurrences of abuse have been observed (12%), and only two instances of death have been observed. Other studies have demonstrated higher proportions. However, in two-thirds of the children observed, there were minor or major psychological or even psychiatric sequelae. Protection services have tried to stay away from institutional placement as much as possible; when necessary, the foster home system or adoption has been used. Striking is the lack of means available to help abusing families. Efforts should be made to assist the abusing families stay together.

[Adolescent obesity: guidelines for the management]. / Obésité au temps de l'adolescence: repères pour une prise en charge.

The increasing prevalence of adolescent obesity justifies widespread effort and attention of the paediatrician. In order to manage, following points are to be documented: (I) weight status assessed on the basis of body mass index (BMI)split in two levels: obesity grade I: >or=97 ème centile, obesity grade 2: level IOTFC 30; (2) complete anamnesis including age at adiposity rebound and existence of overweight in family; (3) research of associated morbidity and medical risks;(4) assessment of food intake and feeding practice; (5) assessment of physical activity; (6) talk with the adolescent to assess the psychological status, looking after depressive symptoms, anxiety, loss of self esteem. Once the items are documented, it allowed making a plan to manage the obesity in alliance with the adolescent and his family.

[Change in management of ureteropelvic junction obstruction]. / Evolution de la prise en charge du syndrome de la jonction pyélo-urétérale.

PURPOSE: The aim of this study was to evaluate the change in ureteropelvic junction management, from surgical correction to observation of the hydronephrosis. We checked wether or not it was deleterious for kidney. MATERIALS AND METHODS: We retrospectively reviewed 96 charts between 1988 and 1998. Initial ultrasonography, and voiding cystourethrogram were available for all cases. Intravenous urography and diuretic renography were studied when available. Minimal follow-up of patients was one year. Patients were divided into three groups: surgery right away, surgery after observation, and observation only. RESULTS: Later was the diagnosis, more significant were the hydronephrosis and impairment of renal function (p < 0.01). In group operated on right away (69 cases), drainage improved, hydronephrosis decreased, but renal function did not improve significantly (p = 0.37). Sixteen patients were operated on after observation without deleterious effect for kidney. Eleven patients were only observed: hydronephrosis progressively decreased. Initial radiological results were not different between the last two groups (p > 0.05), and were not predictive of their course. CONCLUSION: Initial non operative management of hydronephrosis was not dangerous for renal function. It is advisable to detect at the earliest all signs of obstruction, because surgery improves renal drainage but not renal function.

[Comparison between scintigraphy, B-mode, and power Doppler sonography in acute pyelonephritis in children]. / Imagerie comparative entre techniques scintigraphique et echographiques en mode B et Doppler energie dans la pyelonéphrite aigüe de l'enfant.

PURPOSE: Comparing Power Doppler imaging versus technetium-dimercapto-succinic-acid (Tc-DMSA) scintigraphy in acute pyelonephritis of childhood. INCLUSION CRITERIA: First episode of urinary tract infection, clinical and biological findings suggesting an upper lesion, absence of urological malformation or obstruction, absence of reflux (or vesico-ureteral reflux inferior to grade 3). Number of patients: 49, length of the study: 26 months (from November 95 to January 98). METHODS: Tc99m-DMSA scintigraphy (after five days), B mode and Power Doppler imaging (on the day of admission or the following day). Systematic cystography (day 5 to day 30). RESULTS: In terms of positive diagnosis, scintigraphy was superior to Power Doppler, and the latter was superior to B mode ultrasonography. Sensitivity (scintigraphy being the gold standard) was equal for both B mode and Power DopplerUS imaging, but combined Power Doppler and B mode US provided improved results. CONCLUSION: Currently, the results with Power Doppler imaging are insufficient to replace DMSA scintigraphy. However, Power Doppler is a good complement to B mode US.

[Cardiac involvement during classic hemolytic uremic syndrome]. / Atteinte cardiaque au cours du syndrome hémolytique et urémique typique.

BACKGROUND: Cardiac involvement rarely occurs in classic hemolytic uremic syndrome (HUS); it is often fatal. CASE REPORTS: The first patient, a 21-month-old boy, developed classic HUS with acute renal failure. Peritoneal dialysis was performed for 20 days. On the 10th day of dialysis, myocardial infarction occurred, probably related to coronary thrombus. The patient was given heparin and antibiotics because of an unexplained fever. The outcome was favorable despite antero-apical cardiac necrosis, and moderated chronic renal failure. The second patient, a 24-month-old girl, also showed a classic HUS, which required peritoneal dialysis for 10 days. Dilated cardiomyopathy with cardiac failure appeared on the 4th day of dialysis, not related to the volume overload and metabolic consequences of the acute renal failure, such as systemic hypertension or ineffective dialysis. On the 5th day of dialysis neurological involvement appeared. Neurological, cardiac and renal outcome was favorable. The third patient, a 25-month-old girl, developed a classical HUS, requiring peritoneal dialysis for 25 days. No cardiac insult appeared during the acute phase of the disease. After dialysis, the child had chronic renal failure (creatinine clearance: 15 mL/min/1.73 m2). Dilated cardiomyopathy appeared 3 months later, without definite etiology. The outcome was favorable with digoxin treatment. CONCLUSION: A cardiac involvement should also be searched for in the acute phase of HUS and several months later.

[Prevention of vitamin D deficiency in adolescents and pre-adolescents. An interventional multicenter study on the biological effect of repeated doses of 100,000 IU of vitamin D3]. / Prophylaxie de la carence en vitamine D chez l'adolescent et le préadolescent. Etude interventionnelle multicentrique sur les effets biologiques d'un apport répété de 100,000 UI de vitamin D3.

UNLABELLED: Recent studies have shown a high prevalence of calcium and vitamin D deficiencies in adolescents. The aim of this present study was to follow the changes in calcium status and 25 hydroxyvitamin D (25[OH]D) and parathyroid hormone (iPTH) levels during winter in preadolescents and adolescents from four university hospitals in northern France. SUBJECTS AND METHODS: Two groups of teenagers and adolescents (range: 10-15 years) were followed from October 1996 to June 1997. They were given either 100,000 IU of vitamin D (treated group n = 33) or a placebo (control group n = 35) in October, January and April. Serum calcium, phosphate, 25(OH)D and iPTH levels were measured at inclusion and every three months thereafter. RESULTS: At inclusion, plasma or serum 25(OH)D levels were < or = 10 ng/mL in 16 subjects and < 6 ng/mL in six. In control children, no significant change in 25(OH)D occurred during the study, while plasma or serum iPTH levels increased to 34 +/- 11 pg/mL. In the treated groups, 25(OH)D levels remained > 20 ng/mL in every subject; no hypercalcemia was observed; and the mean plasma or serum iPTH level was 25 +/- 14 pg/mL at the end of the study. CONCLUSION: Teenagers presented with a high prevalence of biological vitamin D deficiency at the end of summer. The increase of iPTH during winter in the unsupplemented group suggests that this has secondary consequences on their calcium homeostasis unless they are supplemented with vitamin D. We advocate a sufficient calcium supply and a 100,000 IU vitamin D supplement given two or three times during winter to preadolescents and adolescents living in northern France.