Analysis of Psychiatric Disorders by Age Among Children Following a Mass Terrorist Attack in Nice, France, on Bastille Day, 2016.

This cross-sectional study examines psychiatric disorders among children after a mass terrorist attack in Nice, France, in 2016.

A 3-year retrospective study of 866 children and adolescent outpatients followed in the Nice Pediatric Psychotrauma Center created after the 2016 mass terror attack.

Background: The mass terrorist attack in Nice, France, in July 2016 caused deaths and injuries in a local population, including children and adolescents. The Nice Pediatric Psychotrauma Center (NPPC) was opened to provide mental health care to the pediatric population (0-18 years) who experienced traumatic events. Objectives: This study describes the specificity of the care pathway for young trauma victims, with an explanation of how the NPPC works during the first three years. Methods: In this retrospective study, we conducted quantitative and qualitative data collection about new and follow-up consultations, primary and comorbid diagnoses, and the kind of trauma (terrorist attack versus other kinds of trauma). Ethics approval was obtained from the local Ethics committee. Results: 866 children and adolescents were followed in the NPPC. We found a high rate of Post-Traumatic Stress Disorder (PTSD; 71%) in this population with a high rate of comorbidities (67%), mainly sleep disorders (34.7%) and mood and anxiety disorders (16.2%). A high number of children and adolescents impacted by the terrorist attack required follow-up consultations after exposure to the mass terrorist attack, the first care-seeking requests continued to occur three years later, although at a slower rate than in the first and second years. New consultations for other kinds of trauma were observed over time. Discussion: This study supports previous findings on the significant impact of mass trauma in the pediatric population showing even a higher level of PTSD and a high rate of comorbidities. This may be explained by the brutality of the traumatic event, particularly for this age group. The findings of this study have implications for early interventions and long-term care for children and adolescents to prevent the development of chronic PTSD into adulthood.

Remote training as a common tool for the different professionals involved in the acute phase after terror attacks across Europe: Perspectives from an expert panel.

The acute response after a terror attack may have a crucial impact on the physical and psychological wellbeing of the victims. Preparedness of the professionals involved in the acute response is a key element to ensure effective interventions, and can be improved through trainings. Today in Europe there is a recognized lack of inter-professional and international trainings, which are important, among others, to respond to the needs and the rights of victims affected by a terrorist attack in another country than their home country. In this paper we report the perspectives of an expert panel composed by different categories of professionals on the possible role of interprofessional trainings provided remotely. The experts discussed the pertinence of remote trainings for professionals involved in the acute response of a terror attack, and highlighted their Strengths, Weaknesses, Opportunities and Threats (SWOT analysis). We concluded that, while remote trainings cannot replace in-person trainings, they may be useful to share knowledge about the role and the organization of the different categories of professionals, thus potentially improving response coordination, and to easily share good practices across professionals and countries.

Storm Alex: acute stress responses in the pediatric population.

Introduction: On 2 October 2020, a violent storm (Alex) reached the French Riviera and caused significant damage in three inhabited valleys in the hinterland of the city of Nice. Entire populations were exposed to prolonged stress (no means of communication, electricity nor water) and were particularly at risk of suffering from psychological consequences. We first hypothesized that a majority of children would experience an acute stress reaction. However, we also hypothesized that their clinical expression would differ depending on their developmental age. Thus, we aimed to evaluate, according to the child's level of development, the presence of acute stress symptoms. Methods: Consecutive interviews with the child/adolescent and his/her parents were conducted by child and adolescent psychologists and psychiatrists to assess symptomatology following storm Alex (from day 1 to day 3). Each interview assessed nine classes of symptoms that have been compared according to age-groups. Results: 116 children have been evaluated (0.2-17.6 years, mean 9.1). The 0-5-years-old showed more agitation as well as developmental regression than children aged 6-11 (p = .011, p = .045) and 12-18 years (p < .001, p < .001). Anxiety was reported more frequently among the 6-11 years old than the 0-5 years children (p = .018). Overall, the interviewed children presented at least one manifestation of acute stress after the storm (94% for the 0-5 years; 83% for the 6-11 years and 74% for the 12-18 years). Discussion: The results highlight the high rate of acute stress symptoms in a natural disaster context, their specificity depending on children's age. Therefore; it emphasizes the need to develop, improve and validate specific assessment tools. Scheduled follow-up evaluations will help to understand, after a natural disaster, the long-term stress response in children, paving the way for targeting early, intensive, specific and multidisciplinary symptomatic treatment approaches.Trial registration: ClinicalTrials.gov identifier: NCT04850924. HIGHLIGHTS: Acute stress symptoms in children and adolescents are very frequent in the context of exposure to a natural disaster with specifications depending on the developmental age.

Validation of the French Version of the Child Posttraumatic Stress Checklist in French School-Aged Children.

Background: The child posttraumatic stress disorder checklist (CPC) updated to DSM-5 is a questionnaire aimed to assess posttraumatic stress disorder (PTSD) symptoms in children. It is available in both parents and child versions. The back-translation method has been used for the French translation of the CPC. It has not been yet validated in French-speaking populations. The aim of this study was to assess the psychometric properties and the validity of the CPC in a sample of French-speaking schoolchildren and their parents. Methods: The sample was composed by 176 children outpatients implicated in the Nice terrorist attack (14 July 2016) aged 7-17 (mean = 11.68 years, SD = 2.63 months) and 122 parents. Cronbach's alpha was used to test CPC internal consistency. The Spearman-correlation coefficient was performed between the French version of the CPC and the Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime version (K-SADS-PL) to assess the convergent validity. An ROC curve was constructed to verify the validity of the cutoff scores. An evaluation of the sensitivity and specificity of each score and a comparison with the diagnosis of the K-SADS-PL were made. Finally, a principal component analysis with varimax rotation was computed to analyze the structure of the French version of the CPC. Results: Cronbach's alpha coefficient was 0.90 for child version and 0.91 for parent version of the CPC. There was a statistical correlation between the K-SADS-PL for PTSD and the total score of CPC for the child version (r = 0.62; p < 0.001) and for the parent version (r = 0.55; p < 0.001). The sensitivity and specificity of the children version with a threshold of >20 were 73.1 and 84.7%, respectively, using the K-SADS-PL as the diagnostic reference for PTSD. Concerning the parent version, using the same recommended cutoff score, the sensitivity, and specificity were 77 and 80.5%, respectively. Conclusions: The psychometric properties of the French CPC are good. This questionnaire appears to be valid and should be used in French-speaking children.

CoCo20 protocol: a pilot longitudinal follow-up study about the psychiatric outcomes in a paediatric population and their families during and after the stay-at-home related to coronavirus pandemic (COVID-19).

INTRODUCTION: In the context of a viral outbreak and the stay-at-home measures, a significant increase in psychological distress, such as stress or fear behaviours, has previously been reported in adult and paediatric population. Children and adolescents seem to be particularly at risk of developing psychiatric disorders during and after the stay-at-home but evidences are lacking. The main objective of this article is to present the methodology of Coronavirus Confinement 2020 (CoCo20) Study, which aims to assess the impact of the coronavirus pandemic (COVID-19) and stay-at-home on the development of psychiatric disorders, including post-traumatic stress disorder (PTSD), in children and adolescents. METHODS AND ANALYSIS: We describe a longitudinal and multicentre study in the paediatric population during and after stay-at-home related to COVID-19 pandemic. Inclusions started on 30 March 2020 for 6 months. This study is proposed to all consecutive paediatric outpatients consulting during and after stay-at-home related to COVID-19 pandemic in medical-psychological centres and in a paediatric psychotrauma centre and/or calling the emergency COVID-19 hotline. We perform standardised and internationally validated psychiatric assessments (Diagnosis Infant and Preschool Assessment, Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version) together with anxiety, attention deficit hyperactivity disorder, PTSD, parenting stress and somatic symptoms scales during five visits (baseline, 1 week after baseline, 1 month after baseline, 1 week after the end of the containment and 1 month after the end of the containment) in patients and their families enrolled during the containment and during three visits in case of enrolment after the containment. The inclusion period will end in 30 November 2020. ETHICS AND DISSEMINATION: The protocol has been approved by the Ethics Committee of Cote d'Azur University « CERNI ¼ (number 2020-59). All patients and their legal caregivers provide a written informed consent on enrolment in the study. We will submit the results of the study to relevant journals and offer national and international presentations. This study will enable better characterisation of the impact of the stay-at-home (related to COVID-19 pandemic) on the mental health of children and adolescents. TRIAL REGISTRATION NUMBER: NCT04498416.

Methodology of "14-7" Program: A Longitudinal Follow-Up Study of the Pediatric Population and Their Families Exposed to the Terrorist Attack of Nice on July 14th, 2016.

Introduction: After a traumatic event, children and adolescents may present several clinical consequences, the most common being Post-Traumatic Stress Disorder (PTSD). Most children and adolescents with PTSD have comorbid disorders, such Attention Deficit Hyperactivity Disorder, depression, attachment and anxiety disorders, sleep disturbances and behavior problems. However, epidemiological studies on the development of PTSD and other psychiatric disorders in children and adolescents as a consequence of a terrorist attack and mass murder are lacking. Long-term follow-up of exposed children and adolescents will help identify risk and protective factors of developing psychiatric and psychological conditions after exposure to traumatic events or situations. The main objective of this article is to present the methodology of "14-7" program. The aim of "14-7" program is to characterize the risk and protective psychosocial factors affecting the clinical evolution of a pediatric population sample, exposed to the terrorist attack of July 14th, 2016 in Nice. Method and Analysis: "14-7" program is a multicentre longitudinal cohort study. Major inclusion criteria are children and adolescents exposed to the terrorist attack and aged under 18 years on July 14th, 2016. These children and adolescents will be compared to a non-exposed to the "14-7" terrorist attack group, matched on age and gender. Participants will be assessed at baseline (T1), 2 years (T2) and 5 years (T3) after the initial assessment (T1), and every 5 years until they are 25 years old. Multiple domains are assessed: 1) mental health disorders, 2) intensity of PTSD symptoms, 3) intensity of comorbid symptoms, 4) quality of the parent-child relationship, 5) intelligence quotient, 6) parental symptoms. We will also establish a biological collection of saliva samples, magnetic resonance imaging (MRI) and actigraphy data collection. Main analyses comprise analyses of variance and regression analyses of predictors of clinical evolution over time. Ethics and Dissemination: The National Ethics Committee "NORD OUEST III" approved the "14-7" Program protocol (number 2017-A02212-51). All patients and their caregivers signed informed consent on enrolment in the "14-7" Program. Inclusions started on November 21st, 2017. Three hundred thirty-five individuals have been included (191 children and adolescents, 144 parents). Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03356028.

Early Phase Psychiatric Response for Children and Adolescents After Mass Trauma: Lessons Learned From the Truck-Ramming Attack in Nice on July 14th, 2016.

Recent years have seen a multiplication of terrorist attacks in public places across European and North American countries, thus heightening the need for public mental health planning and response strategies focused on the special needs of children and their families. The present article retrospectively analyzes the early phase psychiatric response for children and adolescents after the truck attack in Nice on July 14th, 2016. In addition, lessons which can be drawn from it will be discussed, with a focus on organizational challenges in the early phase. During the first 2 weeks after the attack, 668 individuals have been registered at the medico-psychological emergency unit of the Children's Hospitals of Nice, including 365 (54.6%) children and adolescents of all ages. Overall, 146 child and adolescent mental health care professionals participated in this specific facility, including 75 psychiatrists and psychologists. The implementation of the medico-psychological emergency unit dedicated to the pediatric population has been an indispensable and unprecedented public health challenge in our country. Future studies are needed in order to evaluate and to improve the efficiency of the individual as well as collective impact of early phase psychiatric interventions dedicated for children and adolescents after mass trauma.

[The psychologist in paediatric intensive care, liaison and separation]. / Le psychologue en réanimation pédiatrique, liaison et séparation.

The relationship between the interventions of liaison psychiatry and those of general medicine is essential. The psychologist, notably, plays an important role in a paediatric intensive care unit. A double temporality, somatic and psychological, is to be taken into account in order to hear, beyond the individual, what the subjet has to say.

Pharmacoresistant Severe Mental Health Disorders in Children and Adolescents: Functional Abnormalities of Cytochrome P450 2D6.

BACKGROUND: Severe mental health disorders in children and adolescents represent a major public health problem. Despite adequate drug treatment, some patients develop pharmacoresistant disease. As a consequence, physicians are confronted with prescribing challenges, prolonged hospitalization and increased risk of adverse events, thus aggravating short-, medium-, and long-term prognosis. The majority of psychotropic treatments, particularly antipsychotics and antidepressants, are metabolized at hepatic level by cytochrome P450 (CYP), particularly by CYP3A4 and CYP2D6. Several CYP2D6 genetic polymorphisms are described to be associated with ultrarapid (UM) or poor drug metabolism (PM), inducing clinical resistance and/or adverse events, and might therefore be related to pharmacoresistant severe mental health disease. CASE PRESENTATION: A total of nine pharmacoresistant patients (four females, five males) aged 11-16 (mean 14.1) years have been genotyped for CYP2D6 between January, 2015 and April, 2016. Patients were diagnosed with schizophrenia (n = 5), autism spectrum disorders (n = 2), intellectual disability with challenging behavior (n = 2), oppositional defiant disorder (n = 1), and post-traumatic stress and borderline personality disorders (n = 1). They had a treatment history with on average 6.1 (3-9) psychotropic, 5 (3-7) antipsychotic, and 3.4 (2-5) CYP2D6-metabolized antipsychotic and antidepressant molecules. Five patients (56%) presented functional anomalies of the CYP2D6 gene: three patients were UM metabolizers with gene duplication and two patients were PM with *4/*41 and *3/*4 polymorphisms. CONCLUSION: Functional anomalies of CYP2D6 concerned more than half of our pediatric inpatient sample with pharmacoresistant disease. However, our case reports are limited by the low sample size. Nevertheless, knowledge of individual metabolism and in particular CYP2D6 genotyping should be considered for clinical workup and therapy adjustment in resistant patients in child and adolescent psychiatry and might permit better treatment outcome, increased treatment adherence and diminished adverse events.

[What if it is not an acute pyelonephritis? A monocentric experience of renal infarcts]. / Quando non è una pielonefrite acuta: esperienza monocentrica di infarti renali.

BACKGROUND: Often the reduced contrast enhancement on CT renal imaging is radiologically interpreted as acute pyelonephritis (PNA), but it is the task of the clinician to assess a possible differential diagnosis such as a renal infarct and look for a cause. METHODS: In our experience (2010-2013), we hospitalized 51 patients with radiological imaging consistent with acute pyelonephritis in native kidneys. However, three of these cases result, after a second look, to be ischemic lesions, only sometimes complicated by over-infections (Tabella 1). FIRST CASE: a woman hospitalized for fever and flank pain with blood culture positive for Klebsiella Pneumoniae. Antibiotic therapy allowed a clinical-laboratory improvement, but after 45 days persisted a focal wedge to the CT scan. The labs showed a anemia due to a sickle cell disease (SLC). The overview was finally interpreted as a renal infarct secondary to a sickle cell anemia, initially complicated by over-infection. SECOND CASE: a men hospitalized for a acute flank pain. The CT scan showed a left renal infarct and a partial renal artery thrombosis, resulting in abuse of cannabinoids and LAC positivity.Third case: a woman hospitalized for flank pain and slight movement of inflammatory markers. CT showed a cuneiform area in the right kidney not vascularized, that did not resolved after prolonged antibiotic therapy. The labs evidence a heterozygous mutation of prothrombin and MTHFR causing the renal infarction. CONCLUSIONS: 6% of radiographic imaging consistent with acute pyelonephritis concealed an underlying infarct, due to a unknown state of thrombophilia. The presence of hypovascular imaging to the TC scan, therefore, requires a differential diagnosis between PNA and infarct, especially in the case of atypical development.

Impact of pre-transplant antiaggregant and anticoagulant therapies on early hemorrhagic and cardiovascular events after kidney transplantation.

BACKGROUND: Oral anticoagulation with vitamin K antagonists (VKA) and antiaggregant therapy (AAT) are common among dialysis patients, but it is not known if they increase the risk of hemorrhagic (HE) or cardiovascular events (CVE) in the early post-transplant weeks. METHODS: We conducted a retrospective analysis on 911 consecutive kidney transplants (KTxs) in order to analyze the impact of AAT and VKA on early HE and CVE-which might be related to their withdrawal-and to identify the main risk factors for these complications. RESULTS: We observed 21/911 HE (2.3%; 1 death, 4 allograft loss); risk factors for HE at multivariate analysis were: KTx before 2004 (when anti-factor Xa activity measurement was not available; odds ratio, OR 5.835, [95% confidence interval, 1.241-27.436], p = 0.026), and VKA (OR 7.090 [2.030-24.772], p = 0.002), while AAT was not a risk factor. CVE were 32/911 (3.5%; 3 deaths, 11 allograft loss): risk factors for CVE at multivariate analysis were: previous cardiovascular events (OR 4.180 [1.615-10.948], p = 0.0032) and cinacalcet use (OR 7.930 [3.002-20.945], p < 0.0001), while neither VKA nor AAT had any impact. CONCLUSIONS: In conclusion, HE and CVE are relatively rare but can be severe, but there are no pre-KTx modifiable risk factors. If an anticoagulant therapy with low molecular weight heparins has to be started soon after surgery, monitoring of anti-Xa activity is highly recommended.

Influence of weight loss on outcomes in patients with head and neck cancer undergoing concomitant chemoradiotherapy.

BACKGROUND: The purpose of this study was to determine the influence of weight loss on outcome in patients with head and neck cancer undergoing concomitant chemoradiotherapy (CCRT): treatment interruption, infections, mortality, and hospital readmission rate. METHODS: Forty patients with head and neck cancer were enrolled. All patients were counseled to follow a nutritional program during CCRT. Body weight was evaluated at baseline, at the end, and 30 days after radiochemotherapy. RESULTS: Ninety percent of compliant patients with nutritional program maintained body weight (mean, 1 +/- 2.4 kg) and 100% of noncompliant patients continued to lose weight (mean, -9 +/- 4 kg; p < .001). A reduction greater than 20% of prediagnosis weight significantly correlated with treatment interruption (p = .003), infections (p = .002), early mortality (p = .011), hospital readmission rate (p = .001), and survival (log-rank test: z = -2.722, p = .006). CONCLUSION: In patients with head and neck cancer undergoing CCRT, the early nutritional management reduces weight loss and improve outcome.

Retro-orbital granulocytic sarcoma: case report.

Granulocytic sarcomas (chloromas) are rare extra-medullary tumors arising from primitive granulocytic cells. The term "chloroma" is derived from the Greek word chloros (green), and it refers to the frequently greenish color of the tumor, which is due to the presence and oxidation of the myeloperoxidase enzyme. These tumors can arise de novo or can be associated with other myeloid disorders, such as acute or chronic myeloid leukemia, myeloproliferative or myelodysplastic conditions. Presentation can occur prior to, in association with the underlying myeloid disorder, or upon relapse. The location of the tumor can vary: sub-periosteal bone, skull, pelvis, ribs, sternum or lymph nodes. We report the case of a 58-year-old man who presented right exophthalmos and ophthalmoplegy with computerized tomography (CT) evidence of a retro-orbital mass, which histology confirmed to be a granulocytic sarcoma.