Do children and adolescents with type 1 diabetes suffer from a lack of resources in France? Results from a benchmark study in the New Aquitaine region.

BACKGROUND: A benchmark study was conducted in the southwest of France, in the New Aquitaine region, to investigate metabolic outcomes and availability of resources in pediatric diabetes units. We assessed whether the level of care was in accordance with the International Society for Pediatric and Adolescent Diabetes recommendations. METHODS: Demographic and clinical data were collected, as were all HbA1c tests for the 2017 calendar year. Pediatricians specialized in diabetes care were invited to complete an online survey concerning means allocated to the management of type 1 diabetes in their centers. RESULTS: Sixteen centers provided data for 1277 patients and 3873 clinical visits. A total of 1115 children suffering from diabetes for more than 1 year were studied. Median HbA1c was 8% (7.4-8.6) for the whole region. Only 29.2% of children had good metabolic control in accordance with the <7.5% target. We identified slight but significant variation in glycemic control among centers (P=0.029). The use of an insulin pump varied greatly among centers but did not explain HbA1c differences. We did not identify a correlation between medical or paramedical time dedicated to the follow-up of diabetic patients and the mean HbA1c of each center. For 100 diabetic patients, follow-up was provided by 0.42 physicians (0.23-1.50), 0.15 nurses (0-0.56), 0.12 dietitians (0-0.48), and 0.07 psychologists (0-0.30). CONCLUSION: This study demonstrates a lack of human resources allocated to the management of type 1 diabetes in the region that is far below international recommendations. The proportion of children achieving the international glycemic target is low. There is a clear need to improve glycemic control in children, which will only be possible with improved professional practices, encouraged by benchmark studies, and by increasing the size of our multidisciplinary teams.

[Treatment of homozygous familial hypercholesterolemia with LDL-apheresis on a 4-year-old child]. / Traitement d'une hypercholestérolémie familiale homozygote par LDL-aphérèse chez un enfant de 4 ans.

Homozygous familial hypercholesterolemia (HFH) is a rare genetic disease associated with increased atherosclerosis, resulting in premature death near the age of 20 years. Treatment requires the LDL-apheresis system. M, born from a consanguineous union, suffers from HFH (total-cholesterol=12.29 g/l, LDL-cholesterol=9.65 g/l). Diet and drug treatment was not associated with decreased LDL-cholesterol. At the age of 4.5 years (body weight: 16.7 kg), M began treatment with LDL-apheresis. Apheresis treatment was given every 2 weeks using the Direct Adsorption of LIpoprotein (DALI system, a process that involves total-blood filtration. During the first 26 sessions, the mean reduction in LDL-cholesterol was 67+/-12%, while HDL-cholesterol decreased by only 17+/-11%. Mean LDL-cholesterol concentration decreased from 6.54+/-0.93 g/l (before apheresis) to 2.21+/-0.95 g/l (after apheresis). Apart from iron deficiency anemia, no major side effects were observed. LDL-apheresis using the DALI system is associated with significant reductions in LDL-cholesterol (similar to reports from the literature) without major side effects, even in a child weighing less than 20 kg. A long term, multinational (European) study is needed to confirm these results.

[Bacteroides fragilis meningitis revealing a meningorectal fistula]. / Méningite à Bacteroides fragilis révélatrice d'une fistule rectoméningée.

UNLABELLED: Cases of meningitis due to Bacteroides fragilis are rare; we report a case revealing a meningorectal fistula. CASE REPORT: A 2-month-old infant developed a severe sepsis syndrome following a rectosigmoidoscopy for rectal bleeding. Lumbar puncture diagnosed bacterial meningitis. Cerebrospinal fluid (CSF) culture evidenced B fragilis with betalactamase. The initial antibiotherapy was changed for imipenem-metronidazole, which is at present the recommended antibiotherapy. Malformation including pre-spinal tumor and meningorectal fistula was evoked on magnetic resonance imaging (MRI) and confirmed by surgery. The outcome was favorable after surgery and antibiotherapy. CONCLUSION: B fragilis meningitis are usually associated with sepsis, whose origin is obvious. In our case, meningitis was isolated, revealing a meningorectal fistula.

[Why pediatric consultations increase in the centers for the socially excluded?]. / Pourquoi les consultations pédiatriques augmentent-elles dans les structures de soins pour exclus?

Studies done by Médecins du Monde indicate that sanitary exclusion is a growing phenomenon in France, children included. Paediatricians must be concerned by this phenomenon, which is related to the social precarity of many families who do not use the standard health care structure. They must understand the reasoning behind the choices of these families, and be involved in the care of their children in places that they accept to visit. Paediatricians should also be present in institutions, conferences and debates where public health policy is discussed in order to defend the place of paediatrics in the sanitary organisation.

t(3;17)(q21;q25) in Epstein-Barr virus associated peripheral T-cell lymphoma: a paediatric case.

We describe an immunocompetent 8-year-old boy with a serological profile indicating chronic infection by Epstein-Barr virus (EBV) who developed subcutaneous and pulmonary lesions related to a peripheral T-cell proliferation. No clonal rearrangement of T-cell receptor or immunoglobulin genes was seen. However, the finding of a t(3;17)(q21;q25) in 44 metaphases from one skin lesion demonstrated a clonal origin. We also showed that the proliferative T cells contained EBV genome leading to the diagnosis of EBV-associated peripheral T-cell lymphoma. Further cytogenetic and molecular studies are needed to identify genes implicated in the pathogenesis of this haematological malignancy.

[What is the choice of training in neonatal intensive care? Analysis of wishes from 106 neonatologists]. / Quels choix pédagogiques pour la formation à la réanimation du nouveau-né? Analyse des souhaits de 106 néonatologues.

BACKGROUND: Improvement of the care to the neonate relys on an increased number of pediatricians in nurseries and adequate neonatal resuscitation training. METHODS: A questionaire about the optimal modes of neonatal resuscitation training was sent to 132 pediatricians in charge of a neonatal unit or a neonatal intensive care unit. Response rate was 80.3%. RESULTS: The training program was targeted to be regional for the organization and for the evaluation. Nevertheless, 41% of answers also favored local evaluation. Duties in neonatal intensive care unit or transportation system, with differences among areas, were the proposed training choices. The pediatrician was considered to be the first person as an instructor and also as a learner in a multidisciplinary training program. Cooperation between primary and tertiary centers physicians was proposed as the best way for training. Proposed criteria for evaluating training efficacy included neonatal mortality and meconium aspiration syndrome rates. Government funding was suggested in 92% of answers. CONCLUSION: It seems necessary to perform a wide neonatal resuscitation training program. This multidisciplinary approach should be regional and follow the guidelines of the neonatal study group.

[Helicobacter pylori gastritis manifested by acute anemia]. / Anémie aiguë révélatrice d'une gastrite à Helicobacter pylori.

Helicobacter pylori gastritis usually manifests as recurrent abdominal pain but is sometimes discovered upon evaluation for digestive tract bleeding with severe anemia. An 11-year-old who was not under medication and had no history of pain was admitted for isolated regenerative anemia (5.6 g/dl) due to digestive tract bleeding. Laboratory tests showed only low serum iron and ferritin levels. Endoscopy disclosed hemorrhagic inflammation of the duodenal cap and antritis with a hillocky appearance. The diagnosis of H. pylori infection was established on the basis of the finding of curved Gram-negative rods on the smears and of a positive urea test. There was moderate interstitial antritis. The patient was given an H2 antagonist (ranitidine) and amoxicillin with tinidazole for six weeks. Serum IgG antibodies against H. pylori were found in the child's parents and siblings, with the exception of a 7 month old infant. A ten year old sister had been hospitalized two years earlier for hemorrhagic duodenitis ascribed at the time to use of acetylsalicylic acid. H. pylori has been reported in 40% to 95% of pediatric patients with primary gastritis. Physicians should be familiar with this frequent, often familial disease. Management rests on concomitant administration of two antimicrobials and an acid secretion inhibitor to the index patient and family members. Endoscopy is too invasive to be appropriate for monitoring the outcome. In practice, recovery is affirmed on the basis of resolution of clinical manifestations and decreased levels of anti-H. pylori antibodies.

[Mycoplasma pneumoniae pneumopathies in children: clinical, biological and radiological study]. / Pneumopathies à Mycoplasma pneumoniae chez l'enfant: étude clinique, biologique et radiologique.

Clinical, radiological and biological features of 19 cases of serologically proven Mycoplasma pneumoniae pneumonia were compared with those of 21 cases of other types of pneumonia. Some clinical features were more frequent in M pneumoniae: patients older than 5 years, association with upper respiratory tract infection, skin rashes, acute course, unsuccessful treatment with penicillin. There were no specific radiological features. When compared with the complement fixation method, the serological diagnosis using agglutination technique appears to be more sensitive.

Human low density lipoprotein subfractions separated by gradient gel electrophoresis: composition, distribution, and alterations induced by cholesteryl ester transfer protein.

Low density lipoprotein (LDL) subfractions were studied in sera from 208 normolipidemic, 22 hypercholesterolemic, and 33 hypertriglyceridemic subjects. Whole serum without preliminary ultracentrifugation was submitted to electrophoresis in a nondenaturing polyacrylamide gel. Three main LDL patterns were observed in normolipidemic sera: type 1, characterized by the presence of only one major band; type 2, characterized by the presence of two close major bands; and type 3, where LDL were more dispersed and presented at least three distinct bands. Type 1 was more frequent in men (43%) than in women (19%). The tendency for a higher potential coronary disease risk profile sera, namely higher triglyceride level, higher very low density lipoprotein + LDL fraction and lower high density lipoprotein (HDL) fraction, was type 3 less than type 2 less than type 1. The LDL patterns found in hypercholesterolemic sera were of type 1. Hypertriglyceridemic sera were characterized by the presence of a major band of small size. Separated LDL subfractions were collected by electroelution and analyzed for composition. In all subspecies, the mass ratio of core to surface components was constant as well as the molar ratio of the two lipid surface components, phospholipids and free cholesterol. Surface lipid to apolipoprotein B ratio, cholesteryl ester to triglyceride ratio, and cholesteryl ester to apoB ratio increased with particle size increment. Incubation of LDL with HDL and purified cholesteryl ester transfer protein induced a transfer of lipids, mainly cholesteryl esters and phospholipids, to LDL and an increase of the sizes of LDL subfractions. This suggests that lipid transfers from HDL to LDL might be a process of intravascular LDL remodeling and a factor of LDL polymorphism.

Acute pancreatitis from a duodenal foreign body in a child.

A 14-month-old child was admitted to the hospital with acute pancreatitis, abdominal pain, and shock. An abdominal radiograph revealed a paper clip standing out at the duodenal level. The foreign body was removed by endoscopy, revealing an edematic and hemorrhagic duodenal papilla. The patient progressed favorably after the foreign body was removed. This observation underlines the necessity of digestive transit surveillance of a foreign body that has not been endoscopically removed and the relevancy of duodenal endoscopy for acute pancreatitis of indefinite etiology.