Solid Organ Transplant Litigation at One of Europe's Largest University Hospitals.

Due to its intrinsic complexity and the principle of collective solidarity that governs it, solid organ transplantation (SOT) seems to have been spared from the increase in litigation related to medical activity. Litigation relating to solid organ transplantation that took place in the 29 units of the Assistance Publique-Hôpitaux de Paris and was the subject of a judicial decision between 2015 and 2022 was studied. A total of 52 cases of SOT were recorded, all in adults, representing 1.1% of all cases and increasing from 0.71% to 1.5% over 7 years. The organs transplanted were 25 kidneys (48%), 19 livers (37%), 5 hearts (9%) and 3 lungs (6%). For kidney transplants, 11 complaints (44%) were related to living donor procedures and 6 to donors. The main causes of complaints were early post-operative complications in 31 cases (60%) and late complications in 13 cases (25%). The verdicts were in favour of the institution in 41 cases (79%). Solid organ transplants are increasingly the subject of litigation. Although the medical institution was not held liable in almost 80% of cases, this study makes a strong case for patients, living donors and their relatives to be better informed about SOT.

Comparing Dynamics and Determinants of Severe Acute Respiratory Syndrome Coronavirus 2 Transmissions Among Healthcare Workers of Adult and Pediatric Settings in Central Paris.

BACKGROUND: Healthcare workers (HCWs) have paid a heavy toll during the coronavirus disease 2019 (COVID-19) outbreak. Routes of transmission remain to be fully understood. METHODS: This prospective study compared a 1500-bed adult and 600-bed pediatric setting of a tertiary-care university hospital located in central Paris. From 24 February until 10 April 2020, all symptomatic HCWs were screened for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on a nasopharyngeal swab. HCWs screened positive were questioned on their profession, symptoms, and occupational and nonoccupational exposures to SARS-CoV-2. RESULTS: Among 1344 HCWs tested, 373 were positive (28%) and 336 (90%) corresponding questionnaires were completed. Three hospitalizations and no deaths were reported. Most HCWs (70%) had patient-facing occupational activities (22% in COVID-19 dedicated units). The total number of HCW cases peaked on 23 March, then decreased slowly, concomitantly with a continuous increase of compliance to preventive measures (including universal medical masking and personal protective equipment [PPE] for direct care to COVID-19 patients). Attack rates were of 3.2% and 2.3% in the adult and pediatric settings, respectively (P = .0022). In the adult setting, HCWs more frequently reported exposure to COVID-19 patients without PPE (25% vs 15%, P = .046). Report of contacts with children attending out-of-home care facilities dramatically decreased over the study period. CONCLUSIONS: Universal masking, reinforcement of hand hygiene, and PPE with medical masks for patients' care allowed protection of HCWs and containment of the outbreak. Residual transmissions were related to persistent exposures with undiagnosed patients or colleagues and not to contacts with children attending out-of-home care facilities.

Hair analysis does not allow to discriminate between acute and chronic administrations of a drug in young children.

There are many differences between the hair from children and that of adult subjects, the hair being thinner, more porous with a different growth rate from the usual 1 cm/month observed in adults. In order to determine whether hair analysis could discriminate between chronic use and acute administration of a drug in children like in adults, we analyzed hair from 18 children aged between 1 day and 15 years in whom the administration of different drugs was known (single therapeutic administration or acute intoxication). A strand of hair was sampled within 1 to 45 days after treatment or intoxication. Analysis was conducted using LC/MS/MS. In the 10 youngest children, aged between 1 day and 29 months, the compounds administered in hospital or responsible for intoxication (lidocaine, ropivacaine, diazepam, midazolam, levetiracetam, morphine, ketamine, methadone, buprenorphine, THC, MDMA) were found in all segments of the hair independently of the time of sampling (1-45 days after ingestion). The concentrations detected were similar along the hair shaft, showing a radial diffusion and incorporation of the analytes in the hair of young children from the sebum. Concentrations could be very high when sampled shortly after administration (72 ng/mg for methadone, 75 ng/mg for MDMA after 3 days) and lower when sampling later (1.2 ng/mg for MDMA after 45 days). In these cases, hair analysis allowed to highlight the compounds responsible for intoxication even when they had disappeared from the blood or urine but should not be used to discriminate long-term exposure to a drug. In the eight remaining children aged from 34 months to 15 years, the drugs used in hospital (lidocaine, diazepam, morphine) or responsible for intoxication (THC, codeine, buprenorphine) were not found in any analyzed segments sampled 1 to 5 days after administration of the drugs, in agreement with the non-incorporation of the drugs from the sebum into the hair. For those children aged over 34 months, hair analysis allows to determine the chronic administration of a drug, like in adults.

Hemodynamic Shock Caused by Tension Pneumoperitoneum in a 5-Year-Old Girl.

Tension pneumoperitoneum is a relatively rare occurrence in the pediatric population. However, tension pneumoperitoneum is associated with significant morbidity and mortality if it is not promptly diagnosed and treated. A 5-year-old girl was admitted to emergency department with abdominal pain. She was in shock, and the radiograph film of the abdomen revealed a voluminous tension pneumoperitoneum. Aggressive fluid challenges were performed in intensive care followed by urgent laparotomy. Primary abdominal compartment due to trapped gas caused a decreased venous return and visceral perfusion. In the absence of hemodynamic improvement after vascular filling, needle decompression was performed before surgery.

Impact of Implementing National Guidelines on Antibiotic Prescriptions for Acute Respiratory Tract Infections in Pediatric Emergency Departments: An Interrupted Time Series Analysis.

BACKGROUND: Many antibiotics are prescribed inappropriately in pediatric emergency departments (PEDs), but little data are available in these settings about effective interventions based on guidelines that follow the antimicrobial stewardship principle. Our aim was to assess the impact of implementing the 2011 national guidelines on antibiotic prescriptions for acute respiratory tract infection (ARTI) in PEDs. METHOD: We conducted a multicentric, quasiexperimental, interrupted time series analysis of prospectively collected electronic data from 7 French PEDs. We included all pediatric patients who visited a participating PED during the study period from November 2009 to October 2014 and were diagnosed with an ARTI. The intervention consisted of local protocol implementation, education sessions, and feedback. The main outcome was the antibiotic prescription rate of discharge prescriptions for ARTI per 1000 PED visits before and after implementation, analyzed using the segmented regression model. RESULTS: We included 242534 patients with an ARTI. The intervention was associated with a significant change in slope for the antibiotic prescription rate per 1000 PED visits (-0.4% per 15-day period, P = .04), and the cumulative effect at the end of the study was estimated to be -30.9%, (95% CI [-45.2 to -20.1]), representing 13136 avoided antibiotic prescriptions. The broad-spectrum antibiotic prescription relative percentage decreased dramatically (-62.7%, 95% CI [-92.8; -32.7]) and was replaced by amoxicillin. CONCLUSION: Implementation of the 2011 national French guidelines led to a significant decrease in the antibiotic prescription rate for ARTI and a dramatic drop in broad-spectrum antibiotic prescriptions, in favor of amoxicillin.

Extended-spectrum ß-lactamase-producing bacteria caused less than 5% of urinary tract infections in a paediatric emergency centre.

AIM: The last decade has seen a significant increase in extended-spectrum ß-lactamase (ESBL) secreting organisms responsible for paediatric urinary tract infections (UTIs), particularly in community-acquired infections. These expose patients to the risks of antibiotic treatment failure and renal scarring. This prospective study examined the prevalence and risk factors of febrile ESBL UTIs and their treatment in the paediatric emergency department of a university hospital. METHODS: In this prospective observational study, all children from 0 to 16 years of age with febrile UTIs were included from May 2012 to April 2013. Cases with and without ESBL involvement were compared. RESULTS: Of the 474 diagnosed febrile UTIs, 22 (4.6%) with a 95% confidence interval (95% CI) of 2.9-6.9 were due to an ESBL-producing organism. Escherichia coli was found in 85% of cases. Significant odds ratios (OR) for ESBL urinary tract infections were prior hospitalisation (OR 4.1, 95% CI 1.6-10.8), urinary tract abnormalities (OR 3.9, 95% CI 1.5-10.2) and previous antibiotic treatment (OR 3.1, 95% CI 1.2-8.8). All ESBL urinary tract infections had positive outcomes. CONCLUSION: The prevalence of febrile ESBL urinary tract infections was less than 5% in a paediatric emergency department. This low rate was not high enough to justify changing our guidelines.

Assessing respiratory epidemic potential in French hospitals through collection of close contact data (April-June 2020).

The transmission risk of SARS-CoV-2 within hospitals can exceed that in the general community because of more frequent close proximity interactions (CPIs). However, epidemic risk across wards is still poorly described. We measured CPIs directly using wearable sensors given to all present in a clinical ward over a 36-h period, across 15 wards in three hospitals in April-June 2020. Data were collected from 2114 participants and combined with a simple transmission model describing the arrival of a single index case to the ward to estimate the risk of an outbreak. Estimated epidemic risk ranged four-fold, from 0.12 secondary infections per day in an adult emergency to 0.49 per day in general paediatrics. The risk presented by an index case in a patient varied 20-fold across wards. Using simulation, we assessed the potential impact on outbreak risk of targeting the most connected individuals for prevention. We found that targeting those with the highest cumulative contact hours was most impactful (20% reduction for 5% of the population targeted), and on average resources were better spent targeting patients. This study reveals patterns of interactions between individuals in hospital during a pandemic and opens new routes for research into airborne nosocomial risk.

Do parents understand the medical information provided in paediatric emergency departments? A prospective multicenter study.

AIM: We evaluated the extent to which parents understood the medical information about hospitalization of their child in an emergency department and looked for characteristics likely to increase the risk of poor comprehension. METHODS: Prospective multicenter study in thirteen paediatric emergency departments. The parents and doctors completed questionnaires based on closed-ended questions with a common core of four items: reasons of hospitalization, diagnosis, treatment and seriousness of child condition. We evaluated concordance between parents and doctor answers for these items by comparing their responses. RESULTS: This study included 380 parents. Percentage of concordance was 55% for the reason of hospitalization, 78% for the diagnosis, 92% for the treatment, 48% for the seriousness of the condition and 19% for all four items. The mean number of concordant items was 2.76 (CI 95%, 2.66-2.86). Parents whose children seemed not in pain and parents who received additional information from the nurse showed significantly slightly higher levels of concordance with doctor's answers (2.98 vs 2.66, p = 0.006 and 2.89 vs 2.60, p = 0.004, respectively). CONCLUSION: This study shows that improvements are required in the clarity of the information delivered to the parents. The assistance of nurses and optimal pain management may help to improve communication.

The European Paediatric Life Support course improves assessment and care of dehydrated children in the emergency department.

We tested the hypothesis that application of the principles learned from the European Paediatric Life Support (EPLS) course improves child health assessment and care. In a retrospective study, residents from five paediatric emergency departments were included. For each of them, we analysed five medical records of infants and children suffering from diarrhoea; three were in ambulatory care and two were in-hospital care with IV hydration. Two independent observers analysed the records using a standardized checklist of 14 clinical points, as well as three items to evaluate the adequacy of treatment according to hydration status. Agreement between readers was evaluated the kappa coefficient of concordance. Statistical associations between each item and the EPLS course status was assessed by logistic regression taking into account the clustered data structure. Fifty residents and 240 medical records were included. Twenty-six residents were EPLS trained (intervention group) and 24 residents were not (control group). The results of the analyses of the medical records by the observers were concordant (kappa >0.91). Medical records in the intervention group contained more clinical information on circulatory status (P < 0.0001). Residents in the intervention group prescribed goal-directed therapy more often (P = 0.006). For children with shock, they administered volume resuscitation (P = 0.01) with goal-directed therapy more often (P = 0.003). This is the first evaluation of an educational program focusing on the actions of "learners" in the clinical environment. Our findings highlight that the EPLS course is associated with a better clinical analysis of hydration and circulation status as well as with goal-directed therapy.

Comparison of a morphine and midazolam combination with morphine alone for paediatric displaced fractures: a randomized study.

AIM: To compare the efficacy of sublingual midazolam with oral morphine versus that of oral morphine with placebo in a paediatric population attending an emergency department (ED) with acute long-bone fractures. METHODS: A sample of children aged 5-16 years with clinically deformed closed long-bone fractures was randomized to groups receiving either oral morphine (0.5 mg/kg)/sublingual placebo or oral morphine (0.5 mg/kg)/sublingual midazolam (0.2 mg/kg). The main exclusion criteria were narcotic or benzodiazepine use, significant head injury, multiple organ failure, femoral fracture and allergy. Pain scores were rated on a 100-mm visual analogue scale (VAS) at 0, 15, 30, 60, 90 and 120 min. RESULTS: Fifty-eight children were enrolled (mean age: 10.5 years, SD 2.7). Fractures concerned the radius or ulna in 43 cases (74.1%), the humerus (22.4%) and the tibia or fibula (3.5%). No significant difference in VAS scores was observed between the two treatment arms (p = 0.72). Drowsiness was significantly more frequent in the midazolam group (p = 0.007) during the first 2 h after administration. No serious adverse event was observed. CONCLUSION: The analgesic performances of morphine and the combination of morphine with midazolam assessed by VAS were similar in children presenting at the ED with a long-bone fracture.

Bleeding complications after ritual circumcision: about six children.

Circumcision is the most common surgical procedure in boys. Even if the procedure is frequent, circumcision can have tragic complications. We report the cases of six children, seen over 1 year at the emergency department for bleeding complication or mutilation after ritual home circumcision. To avoid such complications, it is recommended that circumcision should be performed by doctors trained in this procedure. Parents have to be cautioned about the risks of possible complications after this procedure.

An unusual cause of extensive edema.

Edema of nutritional origin is quite rare in industrialized countries. We report the case of an 8-month-old boy with a history of kwashiorkor. Even if the diagnosis is not obvious, there is a need to perform a proper diagnosis at admission to avoid inappropriate management.

Healthcare trajectory of children with rare bone disease attending pediatric emergency departments.

BACKGROUND: Children with rare bone diseases (RBDs), whether medically complex or not, raise multiple issues in emergency situations. The healthcare burden of children with RBD in emergency structures remains unknown. The objective of this study was to describe the place of the pediatric emergency department (PED) in the healthcare of children with RBD. METHODS: We performed a retrospective single-center cohort study at a French university hospital. We included all children under the age of 18 years with RBD who visited the PED in 2017. By cross-checking data from the hospital clinical data warehouse, we were able to trace the healthcare trajectories of the patients. The main outcome of interest was the incidence (IR) of a second healthcare visit (HCV) within 30 days of the index visit to the PED. The secondary outcomes were the IR of planned and unplanned second HCVs and the proportion of patients classified as having chronic medically complex (CMC) disease at the PED visit. RESULTS: The 141 visits to the PED were followed by 84 s HCVs, giving an IR of 0.60 [95% CI: 0.48-0.74]. These second HCVs were planned in 60 cases (IR = 0.43 [95% CI: 0.33-0.55]) and unplanned in 24 (IR = 0.17 [95% CI: 0.11-0.25]). Patients with CMC diseases accounted for 59 index visits (42%) and 43 s HCVs (51%). Multivariate analysis including CMC status as an independent variable, with adjustment for age, yielded an incidence rate ratio (IRR) of second HCVs of 1.51 [95% CI: 0.98-2.32]. The IRR of planned second HCVs was 1.20 [95% CI: 0.76-1.90] and that of unplanned second HCVs was 2.81 [95% CI: 1.20-6.58]. CONCLUSION: An index PED visit is often associated with further HCVs in patients with RBD. The IRR of unplanned second HCVs was high, highlighting the major burden of HCVs for patients with chronic and severe disease.

Neurological consequences of vitamin B12 deficiency and its treatment.

In developed countries, the vitamin B12 deficiency usually occurs in children exclusively breast-fed, whose mothers are vegetarians, causing low stores of vitamin B12. Symptoms of vitamin B12 deficiency appear during the second trimester of life and include failure to thrive, lethargy, hypotonia, and arrest or regression of developmental skills. A megaloblastic anemia can be present. One half of the infants exhibit abnormal movements before the start of treatment with intramuscular cobalamin, which disappear 1 or 2 days after. More rarely, movement disorders appear a few days after treatment, whereas neurological symptoms are improving. These abnormal movements can last for 2 to 6 weeks. If not treated, vitamin B12 deficiency can cause lasting neurodisability. Therefore, efforts should be directed to preventing deficiency in pregnant and breast-feeding women on vegan diets and their infants by giving them vitamin B12 supplements. When preventive supplementation has failed, one should recognize and treat quickly an infant presenting with failure to thrive and delayed development.

Acute acalculous cholecystitis in a child returning from the Ivory Coast.

Acute cholecystitis is an uncommon occurrence in children. Acute acalculous cholecystitis (AAC) has various etiology; among them are a wide variety of infectious agents. We report the case of a 7-year-old child who presented AAC due to plasmodium falciparum infection. The causes of AAC are discussed.

Retrospective study of imported falciparum malaria in French paediatric intensive care units.

OBJECTIVE: The World Health Organization (WHO) severity criteria for paediatric Plasmodium falciparum (Pf) malaria are based on studies in countries of endemic malaria. The relevance of these criteria for other countries remains unclear. We assessed the relevance of these criteria in an industrialised country. DESIGN: Retrospective case-control study. SETTING: Eight French university hospitals, from 2006 to 2012. PATIENTS: Children with Pf malaria admitted to paediatric intensive care units (cases: n=55) or paediatric emergency departments (controls: n=110). MAIN OUTCOME MEASURES: Descriptive analysis of WHO severity criteria and major interventions (mechanical ventilation, blood transfusion, fluid challenge, treatment of cerebral oedema, renal replacement therapy). Thresholds were set by receiver operating characteristics curve analysis. RESULTS: Altered consciousness (71% vs 5%), shock (24% vs 1%), renal failure (20% vs 1%), anaemia <50 g/L (7% vs 2%), acidosis (38% vs 0%), bilirubin level >50 µmol/L (25% vs 8%) and parasitaemia >10% (30% vs 8%) were more frequent in cases (p<0.01). All these criteria were associated with major interventions (p<0.001). Respiratory distress (six cases), and hypoglycaemia (two cases) were infrequent. Thrombocytopenia <50 000/mm3 (46% vs 7%) and anaemia (haemoglobin concentration <70 g/L (41% vs 13%)) were more frequent in cases (p<0.0001). CONCLUSIONS: The WHO severity criteria for paediatric Pf malaria are relevant for countries without endemic malaria. The infrequent but severe complications also provide a timely reminder of the morbidity and mortality associated with this condition worldwide. In non-endemic countries haemoglobin <70 g/L and platelet count <50 000/mm3 could be used as additional criteria to identify children needing high level of care.

The accuracy of renal point of care ultrasound to detect hydronephrosis in children with a urinary tract infection.

The objective of this study was to investigate the accuracy of renal point of care ultrasound (POCUS) for the detection of hydronephrosis in children with a urinary tract infection (UTI). We prospectively included all patients with a final diagnosis of UTI who visited our pediatric emergency department between November 2009 and April 2011. Emergency physicians were encouraged to perform a renal POCUS during these visits, and a follow-up renal ultrasonography was performed by a radiologist who was blinded to the results of POCUS. We calculated the accuracy of POCUS to detect hydronephrosis (renal pelvis enlargement ≥10 mm). We included 433 UTI visits, and 382 (88.2%) POCUS were performed. The sensitivity and the specificity were 76.5% (95% confidence interval: 58.1-94.6%) and 97.2% (95.2-99.2%), respectively. The positive and the negative predictive values were 59.1% (36.4-79.3%) and 98.8% (97.7-99.9%), respectively. Renal POCUS might be used to rule out hydronephrosis in pediatric UTI.