Evaluation of a CIAP session for students in Medicine, Pediatrics module.

BACKGROUND: Teaching by the Clarification, Illustration, Application and Participation of Students (CIAP) approach is a method of participatory pedagogy that helps active learning to help the learner understand and integrate the new Knowledge to be able to apply them. The objectives of this work were to describe the conduct of a CIAP session and to evaluate this method of learning among students. METHODS: The session took place in a room in the Forensic Medicine Department of the Charles Nicolle Hospital in Tunis on April 18, 2017 for 60 minutes. Our population was made up of DCEM2 students undergoing pediatrics and neonatology at the Charles Nicolle Hospital. The chosen topic was post-infectious acute glomerulonephritis. The assessment consisted in a written test given at baseline before the teaching sessions and repeated immediately afterwards. Students were also asked to grade the quality of the teaching received. RESULTS: In total, 13/22 students were present. Clarifications were given at the request of the students. The illustration showed capillary proliferation and extra-capillary proliferation. Clinical cases have sparked a lot of interaction. All the students participated in the session: seven of them participated actively, the other six were solicited to participate. Pre-test scores varied from 2/10 to 7/10. Post-test scores ranged from 4/10 to 10/10. The mean score for the pre-test was 4.61 ± 1.6 and, the mean score for the post-test was 8.23 ± 2.31 / 10, the difference being statistically significant (p = 0.03). For students, the choices of educational objectives were relevant and were achieved, the session was coherent with the professional reality and brought new knowledge. The majority of students felt that there was good interaction. All students were satisfied with listening to the teacher and her answers to their questions. All students reported that the CIAP session provided them with a better clarification of the theoretical course, a sufficient illustration, and enabled them to participate actively in teaching. The students reported that there was a good application of the theoretical course. CONCLUSION: The CIAP session improved student knowledge. The students were generally satisfied with this teaching.

Infantile cystinosis: From dialysis to renal transplantation.

Cystinosis is an autosomal recessive, lysosomal storage disease characterised by the accumulation of the amino acid cystine in different organs and tissues. It is a multisystemic disease that can present with renal and extra-renal manifestations. In this report, we present the first case of transplanted nephropathic cystinosis in a Tunisian child. A 4-year-old Tunisian boy born to nonconsanguineous parents, was treated in our medical services in 1990 for cystinosis. Since the age of five months, he developed symptoms of severe weight loss, vomiting, dehydration, and polyuria. He manifested the Toni Debré Fanconi syndrome. Slit lamp examination of the anterior segment of both eyes revealed fine, shiny crystal-like deposits diffusely distributed in the corneal epithelium and the stroma. Our patient had renal failure. At the age of seven, he reached terminal chronic renal failure and was treated with peritoneal dialysis. Hemodialysis was started at the age of nine years. At the age of 13 years, he received a renal transplantation and was started on cysteamine 1999, five months after the renal transplantation. Currently, the patient is 28-year-old. The graft has survived 15 years after the transplantation. Renal functions were stable with a serum creatinine of 123 µmol/L at last follow-up.

Focal segmental glomerulosclerosis in children.

Background Focal segmental glomerulosclerosis (FSGS) represents 20% of nephrotic syndrome in children. The clinical course and prognosis is heterogeneous in children. The aim of this study was to analyze treatment and outcome of children with FSGS. Methods This retrospective study was conducted in the Department of Pediatrics in Charles Nicolle Hospital during a 15-year period (1996-2010). Results There were 30 children, 16 boys and 14 girls. The mean age was 7 ± 4 years. Nephrotic syndrome was observed in 26 patients, hematuria was noticed in 2 patients and renal insufficiency was detected in 2 patients at presentation. FSGS, not otherwise specified, was the predominant variant. All patients with nephrotic syndrome were treated with steroids. Only three patients responded to it. Twenty one patients were treated with cisclosporin A and this resulted in a 57% complete remission and a 24% partial response. Cyclophosphamide was administered to 6 patients and engendered a 50% complete remission. Six patients were treated with mycophenolate mophetil and showed no response in all cases. Renal insufficiency has been developed in 12 children. Conclusion Results from this study showed that the majority of children with FSGS achieve a high sustained remission rate with ciclosporine A.

Peritoneal dialysis: Experience of the department of pediatrics of the hospital Charles Nicolle of Tunis.

Introduction Peritoneal dialysis (PD) is still the most common modality used in treatment for children with End Stage Renal Disease (ESRD). The objective of this study was to identify the epidemiological, clinical, and microbiological factors affecting the outcome of PD. Methods In this study, we retrospectively reviewed the records of 85 patients who were treated with DP for the last ten years (from January 2004 to December 2013) in the Department of Pediatrics in Charles Nicolle hospital, Tunis. Results The mean duration of PD was 18.1±12 months (3.5-75 months). The average age of PD onset was 9.3±5.7 years (29 days-23 years). The sex ratio was 1.5. In a significant number of cases with ESRD, the primary cause is Congenital Anomalies of the Kidneys and Urinary Tract (CAKUT). Seventy-four of our patients (87%) had been treated with Automated PD. The average time between catheter placement and PD commencement was 3.9±4.6 days. Catheter change was 1.62 (1-5). Sixty-one patients (71.8%) had experienced at least one episode of peritonitis. The most frequently isolated organisms was the Gram-positive bacteria (61%). Survival rates without peritonitis at 12th, 24th and 36th months were 40%, 32% and 18%, respectively. Transition to permanent hemodialysis was required in 66% of patients. Conclusion Considering the important incidence of peritonitis in our patients, it is imperative to establish a targeted primary prevention.

Contribution of ultrasound scans in the first episode of urinary tract infection in children.

Background - Vesicoureteral reflux (VUR) is a common pediatric urologic disorder. After the first urinary tract infection (UTI), imaging studies are recommended, starting with a renal ultrasound (US) and voiding cystourethrography (VCUG). We propose to determine whether abnormalities found on US can help indicate the necessity of VCUG in children after the first urinary tract infection. Methods - A retrospective study included all children admitted with their first episode of urinary tract infection from January 2007 to December 2012. Results - A total of 311 children were included. The median age was 2.5 years, 72.3% were female. VUR Prevalence was 14%.  Forty-four patients were found to have VUR on VCUG, giving a prevalence of 14%. Of these 44 patients, 11 had grade I reflux, 6 had grade II reflux, 3 had grade III reflux, 15had grade IV reflux, and 9 had grade V reflux. Ultrasound findings were positive for VUR in 43 patients, 19 of them had RVU. Twenty five patients had a normal ultrasound but showed VUR on VCUG (11 had grade I reflux, six grade II reflux, three grade III reflux and five grade IV reflux).  The sensitivity and specificity of ultrasound in suggesting VUR were 43% and 91%, respectively. The positive predictive value of ultrasound in suggesting VUR was 44%; the negative predictive value was 91%. Conclusion - Renal ultrasound findings are specific for VUR in children with a first UTI, but no sensitive. Clinicians should consider renal ultrasound results to take decision on whether or not to proceed with a VCUG in the investigation of a first episode UTI in young children.

Nephrotic syndrome in children: risk factors for steroid dependence.

Background - Most patients with idiopathic nephrotic syndrome are steroid-responsive, about 50% relapse and often become steroid-dependent and exposed to long-term steroid complications. The aim of this study was to determine predictive risk factors for steroid dependence using clinical and biological variables present at onset of the disease. It may be useful to adapt the therapeutic strategy. Methods - Retrospective hospital-based cohort study in the department of pediatric nephrology of Charles Nicolle, Tunis, between 2002 and 2012 included 52 children with idiopathic steroid-responsive nephrotic. Results - Risk factors for steroid dependency identified from univariate analysis were season of the first episode (winter or autumn) (p=0.008), hyperalpha2globulinemia>16g/l (p=0.028), hyperbeta2globulinemia >3g/l (p=0.003), hypercholesterolemia>10mmol/l (p=0.001), proteinuria>110mg/kg/day (p=0.05), time to achieve remission>9 days (p=0,0001). Logistic regression revealed that time to first remission and hypercholesterolemia>10mmol/l at first presentation were independent risk factors for steroid dependency. Conclusion - Time to first remission, hypercholesterolemia more than 10mmol/l at first presentation and a respiratory tract infection at first relapse are independent risk factors for steroid dependency.

[Peritonitis in pediatric patients receiving peritoneal dialysis]. / Péritonite infectieuse sur cathéter de dialyse péritonéale chez l'enfant.

BACKGROUND: Peritonitis on catheter of dialysis represents the most frequent complication of the peritoneal dialysis (PD) in the pediatric population. It remains a significant cause of morbidity and mortality. In this study, we investigated the risk factors for peritonitis in children. METHODS: In this study, we retrospectively collected the records of 85 patients who were treated with PD within the past ten years in the service of pediatrics of the University Hospital Charles-Nicolle of Tunis. RESULTS: Peritonitis rate was 0.75 episode per patient-year. Notably, peritonitis caused by Gram-positive organisms were more common. Analysis of infection risk revealed three significant independent factors: the poor weight (P=0.0045), the non-automated PD (P=0.02) and the short delay from catheter insertion to starting PD (P=0.02). The early onset peritonitis was significantly associated with frequent peritonitis episodes (P=0.0008). The mean duration between the first and second episode of peritonitis was significantly shorter than between PD commencement and the first episode of peritonitis. We revealed a significant association between Gram-negative peritonitis and the presence of ureterostomy (0.018) and between Gram-positive peritonitis and the presence of exit-site and tunnel infections (0.02). Transition to permanent hemodialysis was needed in many children but no death occurred in patients with peritonitis. CONCLUSION: Considering the important incidence of peritonitis in our patients, it is imperative to establish a targeted primary prevention. Nutritional care must be provided to children to avoid poor weight. The automated dialysis has to be the modality of choice.