Pediatric emergency room visits for neurological conditions: Description and use of pediatric neurologist advice.

INTRODUCTION AND OBJECTIVE: Information on the spectrum and frequencies of pediatric neurological presentations to emergency departments is vital to optimize quality of care. The objective of this study was to determine the incidence of pediatric neurological emergencies and to analyze the impact of specialist neurological advice in emergency care. PATIENTS AND METHODS: We performed a retrospective descriptive study of pediatric emergency room visits for neurological reasons at the Timone University Hospital in Marseille over a 6-month period (from October 2017 to March 2018). RESULTS: Of the 14,572 emergencies analyzed, 370 (2.5%) were for neurological conditions. These were most commonly seizures (56.7% of cases), headache (19.7%), and motor or sensory deficits (5.1%). The most frequent diagnosis was epileptic seizure (30%), followed by febrile seizure (26.1%) and migraine (15%). Around two in every five patients (37.6%) required hospitalization. Neurological emergencies requiring critical care occurred at a frequency of about one per month (1.6% of cases). A pediatric neurologist was consulted in 37.3% of cases, resulting in a modification of the diagnosis or treatment in 66% of these referrals. CONCLUSION: The results of this study suggest that a formal referral system between the emergency department and pediatric neurologists would be useful.

[Complementary exams in child abuse: A French national study in 2015]. / Explorations complémentaires face à une situation d'enfant en danger : état des lieux des pratiques en France en 2015.

INTRODUCTION: Even if there are HAS (French National Health Authority) guidelines on shaken baby syndrome, many other child abuse situations are not included in these recommendations. The aim of this study was to invent the complementary exams in cases of child abuse in France and compare the practice to existing guidelines. MATERIAL AND METHODS: This was a multicenter study by email to 128 French hospitals (35 university hospitals and 93 general hospitals) that receives children in emergency and hospitalization settings. Three child abuse clinical situations were included in a clinical case multiple-choice format concerning the further explorations. We described the main results and evaluated their adherence to the HAS protocol for case 1. RESULTS: Of 128 hospitals surveyed, 104 responded, for an 81 % response rate, which corresponded to 274 doctors. Analysis of the results showed great heterogeneity in practices. The majority of physicians (99 %) performed systematic explorations in the situation of physical abuse, while only 27 % undertook such exams in situations of serious neglect. The situation of sexual abuse was the most consensual in terms of diagnostic tests for the detection of sexually transmitted diseases, but other types of associated abuse were not sought. In the first case, the HAS guidelines were respected in less than half of the cases for all complementary exams except the eye fundus exam. Abdominal imaging was insufficiently performed (40 % of cases). Examinations that were not indicated were still prescribed. Moreover, siblings under 2 years of age were examined in only one-third of cases (n=88/274; 32 %). Practices were not influenced by the age of the child. CONCLUSION: This study illustrates the heterogeneity in the use of complementary exams in cases of child abuse in France. Common protocols throughout the country would be useful, standardizing the most relevant exams for potential medical-legal issues, and facilitating exchanges concerning practices between different centers.

[Bronchiectasis revealing triple A syndrome]. / Une dilatation de bronches révélant un syndrome du triple A.

We report on the case of a 3-year-old child presenting bilateral bronchiectasis due to recurrent pneumonia with esophageal achalasia. The final diagnosis was triple A syndrome. This presentation is particularly atypical and rare at this age.

[Acute viral bronchiolitis: a national study in pediatric emergency departments]. / Bronchiolite aiguë du nourrisson : enquête nationale dans les services d'accueil des urgences pédiatriques.

UNLABELLED: The 2000 French guidelines for acute viral bronchiolitis management underlined clinical criteria for hospitalization. We aimed to assess the impact of these guidelines on admission rates in pediatric emergency departments. METHODS: A prospective multicentric observational study was conducted over 24h in 66 pediatric emergency departments. Questions were asked about the structure, the course of care, clinical data, resource utilization, and hospitalization or discharge of every patient under 2 years of age with acute viral bronchiolitis. An open-ended question allowed clinicians to explain the reason for hospitalization. Multivariable logistic regression analyses were performed to identify independent risk factors for severe disease to assess potential clinical factors associated with hospitalization. Responses were compared using the Student t-test and the Chi(2) test. RESULTS: Of 338 patients enrolled, 145 (45.1%) were admitted. Clinical criteria were associated with hospitalization: clinical deterioration (OR: 3 [95% CI: 1.0-8.5], p=0.04), respiratory rate more than 60/min (OR: 3.4 [95% CI: 1.3-8.8], p=0.02), age under 6 weeks (OR: 29.8 [95% CI: 7.0-125.4], p<0.001), oxygen saturation less than 94% (OR: 15.8 [95% CI: 4.2-60.1], p<0.001), food intake less than 50% of the usual intake (OR: 4.9 [95% CI: 2.2-10.9], p<0.001), and age between 6 weeks and 3 months (OR: 3.2 [95% CI: 1.4-7.2], p=0.007). CONCLUSION: The clinical criteria of the 2000 French guidelines influence hospitalization for acute viral bronchiolitis in pediatric emergency departments. However, other criteria are cited in about one-third of the patients.

[Scurvy, an old disease still in the news: two case reports]. / Le scorbut, une vieille maladie toujours d'actualité: à propos de deux cas.

Scurvy is the clinical manifestation of a deficiency in vitamin C, which is present in fresh fruits and vegetables. It is historically linked to the era of great maritime expeditions. Manifestations are misleading in children, in contrast with adults: bone disease and hemorrhagic syndrome are the earliest and most frequent manifestations due to a collagen biosynthesis defect. Scurvy is an old, potentially fatal disease but is easily curable with ascorbic acid. It can be prevented with vitamin C treatment in pediatric populations with unusual eating habits. We describe two cases of pediatric scurvy in two 7-year-old boys who had dietary restrictions stemming from developmental disorders.

[Value of routine identification of respiratory infectious agents in children hospitalized with an acute asthma exacerbation]. / Intérêt de l'identification en routine des agents pathogènes respiratoires chez les enfants hospitalisés pour une exacerbation d'asthme.

BACKGROUND: Asthma is the most common chronic disease in childhood. With its high economic burden, it is considered a disease of major public health importance by the World Health Organization. The link between respiratory tract infections and acute exacerbation has been recognized for a long time. The aim of this retrospective study in routine care was to evaluate our practices concerning microbiological prescriptions in children hospitalized for asthma exacerbation. STUDY DESIGN: All children aged from 2 to 15 years hospitalized for asthma exacerbation between January 2010 and December 2011 in our unit were included in the study. Microbiological prescriptions, their indications, their results, and their cost were studied. RESULTS: One hundred ninety-seven children were included in the study. A potential causative agent was sought in 79.7% of the children (n=157) by immunofluorescence assay (IFA) and/or polymerase chain reaction (PCR). The main indications were upper airway infections, hypoxemia, and pneumonia. Viruses were detected in 23.8% of them (30/126). Mycoplasma pneumoniae was detected by PCR in only 3.2% of these patients (4/125). No other bacterial agent was identified. There was no correlation between the severity of asthma exacerbation and the microbiological diagnosis of infection. The results did not influence the therapy given. These prescriptions represented a substantial cost for each child. CONCLUSION: These analyses do not seem to have a real advantage for the patient except for epidemiology. It would be important to conduct a new study analyzing the role of rhinovirus, and of other viruses such as coronavirus, bocavirus, and enterovirus, not routinely investigated in our hospital, and to question the value of these costly microbiological tests.

[Infections of central venous catheters in home parenteral nutrition: a retrospective monocentric study over 2 years]. / Infections des voies veineuses centrales en nutrition parentérale à domicile : étude rétrospective monocentrique sur 2ans.

BACKGROUND AND STUDY AIMS: Infection of the central venous catheter (CVC) is the main aggravating factor of parenteral nutrition. The aim of this study was to determine the ecology of these infections in our home parenteral nutrition center and to evaluate our care protocol. PATIENTS AND METHODS: The present study was monocentric and retrospective, and was conducted in the parenteral nutrition service of the Marseille University Hospital between 1 January 2011 and 31 May 2012. During this period, all the children who presented fever and a positive hemoculture in a medical emergency were taken into account, and the characteristics of the infection were analyzed. RESULTS: After 17 months, 17 children had been subject to an infection in their central catheter: 47 bacteremia were identified, which is equivalent to 5.4 infections for 1000 days of CVC. An average 2.8 hemocultures were performed during this time. The most common bacterium was Staphylococcus hominis. The children affected by a digestive stoma or by a gastrostomy were not subject to more infections and their ecology was not different. All the children were referred to the hospital and treated with an intravenous antibiotic through the CVC. DISCUSSION: As expected during the time of the study, the infection rate was very high. This finding led us to reassess our prevention protocol. It is also very likely that the number of infections was overestimated due to the protocol for sampling in the hemocultures and their subsequent analysis. Lastly, some children relapsed easily, although no predisposing factor was found in the present study. The therapy chosen was in agreement with the best practices and the ecology recovered. CONCLUSION: The high number of infections observed during the study encourages a prospective evaluation of current practices.

[Vitamin K deficiency bleeding: a case secondary to transient neonatal cholestasis]. / Maladie hémorragique par déficit en vitamine K : à propos d'un cas secondaire à une cholestase néonatale transitoire.

We report the case of late vitamin K deficiency bleeding (VLDB), with appropriate but insufficient prophylaxis, secondary to extrahepatic cholestasis. Late VKDB is rare today but serious, with a risk of intracranial hemorrhage in more than half of the cases. The diagnosis, causes and prevention of this disease are discussed.

[Chest radiographs in infants hospitalized for acute bronchiolitis: real information or just irradiation?]. / La radiographie de thorax chez le nourrisson hospitalisé pour bronchiolite aiguë : réelle information ou simple irradiation ?

OBJECTIVE: To describe the chest radiographs of infants hospitalized for acute bronchiolitis and to assess whether patient management changed after radiography. STUDY DESIGN: All infants hospitalized in our pediatric unit with a first episode of acute bronchiolitis from October 2010 to March 2012 were included in the study. Infants with chronic disease or transferred from a pediatric intensive care unit were excluded. The following data were collected: sex, age, neonatal history, atopy, tobacco exposure, admission criteria, treatment, laboratory parameters, ultrasonography and its outcome, results of chest radiography on admittance, the reason for a second chest radiograph, change in management as a result of the radiograph. RESULTS: The study comprised 232 infants (median age 2.2 months, boys 56%, positive respiratory syncytial virus 73.4%). Among them, 227 children had a routine chest radiograph revealing distension and/or bronchial wall thickening (n=141, 62.4%), focal opacity (19.9%), or atelectasis (17.7%). This radiograph led to the prescription of antibiotics in six patients (2.6%) and allowed the diagnosis of vascular abnormality to be made in one case (0.4%). Thirty-five patients (15.4%) had a second chest radiograph during their hospitalization owing to oxygen dependency (n=21), respiratory distress (n=11), persistent fever (n=2), or no reason specified (n=1). Pneumonia (n=7) and/or atelectasis (n=15) were then found in 62.9%. Patient management (antibiotics, postural maneuvers) was modified in six patients (17.1%). CONCLUSIONS: Routine chest radiographs contribute only partially to the treatment of infants hospitalized for acute bronchiolitis. However, radiography is useful when the hospitalized child does not improve at the expected rate or if the disease is severe. The indication of chest radiography in infants hospitalized for acute bronchiolitis should be discussed on a case by a case basis.

[Subdural empyema complicating meningococcal meningitis: a pediatric observation]. / Empyème sous-dural compliquant une méningite à méningocoque : une observation pédiatrique.

Postmeningitis subdural empyema is rare in infants. It can have a severe clinical course with possible serious long-term consequences and 10% mortality. Diagnosis is often difficult. Postmeningitis subdural empyema must be discussed in cases of atypical progression of well-treated meningitis. We report the case of an 18-month-old infant presenting subdural empyema with an insidious course following Neisseria meningitidis group C meningitis.

[Nebulized hypertonic saline and acute viral bronchiolitis in infants: current aspects]. / Sérum salé hypertonique nébulisé et bronchiolite aiguë du nourrisson : données actuelles.

Acute viral bronchiolitis affects infants, is frequent, and can be severe. Its treatment is only based on symptoms. Hypertonic saline (HS) may act favorably in this situation by fighting virus-induced dehydration of the airway liquid surface. Because of an osmotic action, HS attracts the water from the epithelial cells and improves mucociliary clearance. Five double-blind placebo-controlled studies concerning hospitalized infants with acute viral bronchiolitis showed that repeated nebulizations of 3% HS induce a 20% improvement in the clinical severity score and reduced the hospital length of stay by 24h. Tolerance is excellent. On the other hand, a few questions remain unresolved: what is the optimal salt concentration? What is the recommended nebulizer? What is the best frequency for nebulizer use? Can nebulized HS be used at home? What are the results with systematic physiotherapy when HS is used?

[Kawasaki disease in older children and young adults: 10 years of experience in Marseille, France]. / Maladie de Kawasaki chez le grand enfant et l'adulte jeune : expérience marseillaise sur 10 ans.

Kawasaki disease is a well-known disease in young children. However, it can also affect older children. The aim of this study was to determine the different characteristics of Kawasaki disease in older children and young adults. This is a descriptive, retrospective, and multicenter study including all cases of Kawasaki disease occurring in children over 8 years and adults hospitalized at children's or adult Hospitals, in Marseille, France, between 1999 and 2009. The clinical, biological, prognostic, and therapeutic data were reviewed for each case. Over a 10-year period, 98 patients were hospitalized for Kawasaki disease. Six cases were aged between 8 years and 1 month and 21 years and 7 months. All patients showed a classic form of the disease with associated organ damage in 5 patients. A cardiac problem was present in 5 cases with 2 patients needing intensive care. The median time to diagnosis and treatment was 11.2 days, with all patients initially diagnosed erroneously. Current treatment guidelines were applied in 2 patients. Kawasaki disease in children over 8 years and adults under 30 years has a worse prognosis than in young children even though clinical features are atypical. It is rarely seen by clinicians in this age group, causing a delay in diagnosis, the main factor of the poor prognosis. The diagnosis of Kawasaki disease must be raised when predisposing factors are present in this group.

[Botulism and pregnancy]. / Botulisme et grossesse.

Botulism during pregnancy is uncommon and raises concern due uncertainty about fetal impairment. This type of situation has not been reported to date. Treatment is basically symptomatic and based on nursing care. The prognosis is tightly correlated with the maternal status. Dietary hygiene is the basis of prevention. We describe a case of botulism occurring during the second quarter of pregnancy.

Critical limits to define a lab adverse event during phase I studies: a study in 1134 subjects.

OBJECTIVE: The first goal of phase I drug development is the determination of maximal tolerated dose, which must be established by case-by-case analysis, sometimes using a laboratory adverse event. Since no accurate rule defining lab adverse events, has been validated yet, we propose a new "combined method" based on combination of two thresholds: inclusion values and magnitude of variation. Using this combined method, the label "lab adverse event" is applied if any lab value exceeds the inclusion threshold and is associated with a variation from baseline exceeding the variation threshold defined from reference change limit. Thus, this study aimed to test this combined method on a large healthy volunteer population, studied in 19 phase I centres worldwide, and on five lab parameters: alanine amino transferase, aspartate amino transferase, alkaline phosphatases, creatinine and polymorphonuclear leukocytes. METHODS: The inclusion threshold from each center was used. Reference change limits were defined from volunteers previously included in comparable studies and were expressed as absolute values: increases of 10 IU.l-1 for alanine amino transferase or aspartate amino transferase, 15 IU.l-1 for alkaline phosphatases, 15 mumol.l-1 for creatinine and a 0.34 10(9).l-1 decrease for polymorphonuclear leukocytes. Comparison between the "combined method" and a normal range method was made using positive predictive value and a ratio between relevant and irrelevant results. This application was implemented in all young healthy volunteers (1134) included in 38 phase I studies sponsored by Rhone Poulenc Rorer from 1991 to 1993. RESULTS: Seventy seven subjects (6.7%) were indicated in final study reports as having a lab adverse event (reference group). Of 179 subjects with lab abnormalities defined by the normal range method, 77 belonged to the reference group, inducing a poor 0.43 positive predictive value. Of ninety subjects with lab adverse events defined by the "combined method", seventy-five belonged to the reference group, inducing a two-fold higher 0.83 positive predictive value. The combined method produced a high ratio of relevant/irrelevant results (5 = 75/15) compared with the low ratio (0.76 = 77/102) achieved using the normal range method. CONCLUSION: This new "combined method", leading to a better definition of lab adverse event, seems an accurate and useful tool for routine case-by-case analysis within phase I drug development studies.