Biomedical subjects
Publications and source records attributed to D Floret.
Three children presented with an association of pains, infectious syndrome, acute renal failure, hepatitis and meningitis, that lead to the diagnosis of leptospirosis. The clinical spectrum of this rare disease are recalled.
Systematic restricted fluid administration (800 to 1,000 ml/m2/day) as usually recommended at the initial phase of bacterial meningitis (BM) has been revisited. Fluid restriction is now only proposed when the evidence of ADH hypersecretion has been documented. A careful attention to this syndrome should be paid by close monitoring of diuresis, body weight, plasma electrolytes and urinary density. In the absence of patent ADH hypersecretion, normal fluid intake should be provided. Seizures occur in 20-30% of cases of BM. Isolated seizures can be treated with phenytoïne or phenobarbital, while active seizures must be treated with diazepam. A low incidence of seizures (13%) has been documented in one study using a preventive administration of barbiturates; however, this needs to be confirmed before in order to be recommended. The evolution of fever is a good index of the efficacy of the antibiotic treatment. In addition, fever has been demonstrated to decrease bacterial growth rate in experimental meningitis. Thus, the administration of antipyretic drugs should be limited to the cases with a fever higher than 39 degrees C. Neurologic forms include coma, seizures, motor deficits and neurovegetative disturbances. Intracranial hypertension due to cerebral oedema is the usual mechanism of these manifestations. Coning occurs in approximately 5% of BM, causing 30% of deaths. Lumbar puncture (but not the onset of the antibiotic treatment) should be delayed in any clinical situation suggesting the possibility of coning. The patient should be admitted to the pediatric intensive care unit for aggressive treatment of cerebral oedema with mechanical hyperventilation, sedation and mannitol infusion. Barbiturates are not recommended since they have deleterious hemodynamic effects.(ABSTRACT TRUNCATED AT 250 WORDS)
BACKGROUND: Subglottal stenosis following intubation of children is infrequent, but significant. It is therefore necessary to know more about predisposing factors. MATERIAL AND METHODS: The files of all the 1,006 children who were intubated from 1982 to 1989 were studied. The following data were analysed: weight, height, locality of intubation, type and diameter of tube, reason for intubation, duration of intubation, delay and type of clinical signs of subglottal stenosis, treatment of this complication. RESULTS: Twelve children (1.5%) developed subglottal stenosis; 9 were 5 months to 7 years old; the other 3 were neonates, 2 of them with a very low birth weight. The disease responsible for intubation was neurologic in origin in 6 cases, respiratory in 4 and hemodynamic in 2. The tube used for 4 children was too large, based on standards for age and weight. The mean duration of intubation was 21.1 days (1-129 days). Primary failure to extubate usually revealed subglottal stenosis, which was assessed by laryngoscopy. It was necessary to reinsert a tube for a mean duration of 20.2 days (4-41 days) in 11 of the 12 children; all patients received corticosteroids. 6 children required tracheostomy for 37 to 365 days. Dilation was necessary in 7 children. Finally, 9 children fully recovered, 1 has an asymptomatic persistent stenosis, 1 is still intubated with severe neurologic sequellae and 1 died accidentally, probably as a result of obstruction by tube dilation. CONCLUSION: Stenosis remains a severe complication of intubation. The diameter of the tube is probably the most aggressive factor. It seems preferable to use a smaller, therefore cuffed tube and to secure the airways, if necessary, by inflating the cuff.
High proximity in daycare centers is a well established risk factor for upper respiratory tract infections as well as Haemophilus influenza meningitis. Many studies have also reported the development of gastroenteritis as well as hepatitis A outbreaks in daycare centers; however, because of lack of controls, these studies do not provide enough information about the excess of risk attributable to daycare attendance. Main risk factors such as age, or seasons, are still very important in daycare centers and studies have also shown that a protection occurs rapidly after the beginning of attendance, may be in relation to the stimulation of the non-specific immunity. All these results do not provide enough data to implement a rational intervention project. More studies have to be carried out to assess the long term consequences (at school age for instance) of these infections. In order to make a rational decision regarding daycare attendance, it is important to have a global assessment of all the effects related to attendance (which are numerous and sometimes opposite); studies focusing on a single aspect of daycare attendance, or on its short term effect, may result in partial and misleading conclusions.
Two children with toxic shock-like syndrome due to streptococcal infection are reported. In both cases (one fatal) the site of infection was in the soft tissues. Both strains of group A hemolytic streptococci isolated from blood culture produced large amounts of erythrogenic toxin B (ET B) small amounts of ET C but no ET A. This report confirms the implication of Streptococcus pyogenes in toxic shock like syndromes. When ET A seems to be responsible for most cases observed in the USA, our cases and others observed in Europe could be related to strains producing large amounts of ET B.
Tracheotomy in children has two main fields of indication: 1) obstructions of the upper respiratory tract, the main cause being today the post-intubation stenosis; 2) long term mechanical ventilation. When performed in good conditions, with adapted care, there are few complications, among them the accidental denaculation being the most worrying. When long-term tracheotomy is needed, parent-education, together with special equipment and adapted environment may allow the return of the tracheotomised child at home in secure conditions. Special attention with preventive measures during intubation is recommended in order to reduce the number of tracheotomies for post-intubation stenosis.
The French public day-care system is intended for children under the age of 3. All structures are under the supervision of the "protection maternelle et infantile" (mother and child health service) and, before opening, must have the agreement of the Conseil général (department council). In the Rhône department (main town: Lyon) in 1990, 5020 children under the age of 3, from a total of 67,500, were in public daycare. The public daycare system complies with about 21% of all requests for child care. Recently, family day nurseries have developed more rapidly than collective daycare, being more flexible and less expensive. The costs for running a day nursery are shared between parents (28%), municipality (50%), national social support (20%) and other fundings (2%).
A 17 day-old neonate with no history of broncho-pulmonary disease presented with a severe respiratory distress which was found to be related to a congenital tracheal diverticulum. An excision of the diverticulum was performed. Histologically it was characterized by a lining wall of stratified columnar ciliated epithelium and the presence of smooth muscle and cartilage in the wall. This rare entity was reported only once in the pediatric literature. It gives a history of chronic respiratory tract infections or acute respiratory distress. Bronchoscopy or bronchography and CT scan are necessary for the diagnosis. The treatment is surgical.
A 8.5-month prospective study was performed in the Rhône area of France to study the incidence of infectious diseases in children in day care, and the qualitative and quantitative aspects of drug prescriptions for young children. The families of 1.359 children agreed to participate (98.5% of those selected). During the follow-up period 3.605 infections episodes were reported and 10.706 medications were used, an average of 3.0 medications per episode. Antibiotics were used in the treatment of 2.333 infectious episodes (65%) amoxycillin (36%), cephalosporin (23%), macrolide (17%) and trimethoprim-sulphamethoxazole (9%). Acetylsalicylic acid and paracetamol were used 865- and 1.568-times, respectively. Drugs with multi-active components represented 11.3% of the total number of systemic medicines reported. Paracetamol was prescribed in 59% of cases in a multi-active component drug, whereas this type of product accounted for 83.5% of the antihistamines (used 932-times). The rationale behind the paediatric prescribing habits of French medical doctors is discussed in relation to results previously obtained in other European countries.
Recombinant interleukin-2 (rIL-2) is a new promising treatment for cancer, but is associated with severe renal toxicity. This study is the first to analyse the renal effects of rIL-2 in children. Twenty-one cycles of continuous rIL-2 infusion were studied in 15 patients; mean age was 6.9 years and average weight 18.9 kg. Interstitial fluid retention and oliguria (baseline, 1.7 ml/kg per hour; nadir, 0.5 mg/kg per hour) were associated with hypotension (baseline, 101/56 mm Hg; nadir, 85/43 mm Hg) and decreased intravascular volume (plasma renin activity increased x 10). Weight gain (+7.9%) was observed in 13 cycles whereas weight loss (-6.3%) was shown in 8 cycles because of digestive and cutaneous losses, mainly in the youngest patients. This prerenal azotaemia was characterized by a decrease in creatinine clearance (from 101 to 36 ml/min per 1.73 m2) and a low fractional excretion of sodium (FENa) (from 0.70% to 0.09%). Hypotension and hypovolaemia needed vascular filling (n = 12), dopamine (n = 7) and interruption of rIL-2 (n = 2). Most abnormalities occurred as early as day 2 of therapy and were always reversible after a short period with sodium leakage (diuresis = 2.2 ml/kg per hour, FENa = 2.01%). Hypophosphataemia was associated with low urinary excretion of phosphorus, suggesting an increased uptake of inorganic phosphorus by rapidly proliferating lymphoid cells.
The health hazards of daycare attendance for the development of upper and lower respiratory tract infections have been well documented; however the importance and the mechanism of this association have not been well defined. In order to ascertain the risk associated with the beginning of daycare (DC) attendance we conducted a survey on 1263 children aged from 3 months to 3 years; the analysis focused on the risk of developing an initial episode of common cold with fever, a first otitis and a first wheezy bronchitis (WB) within the 2 month period following admission to DC. For each 2 month period, the risk of a first infectious event was much higher in children who had just begun attending DC than in children who remained at home; the risk ratio varied from 1.7 to 2.4 for common cold, from 1.5 to 1.9 for otitis and from 1.8 to 3.2 for WB. Because age at onset of the first infectious event may be related to a higher risk of repeated events we consider that admission to DC under 12 months of age should be questioned.
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A phase II trial using interleukin-2 (IL2) and lymphokine-activated killer (LAK) cells was carried out in an attempt to treat children with end-stage neuroblastoma. Fifteen patients (median age, 7 years) were enrolled in the study. Twelve were in relapse after massive chemotherapy and autologous bone marrow transplantation (ABMT), and three had a primary refractory disease after conventional chemotherapy. IL2 was administered as an 18 x 10(6) IU/m2/d continuous infusion. One course consisted of a double 5-day treatment period separated by a 6-day break. Cytapheresis to harvest LAK progenitor cells was performed during the rest period. After a 4-day in vitro culture, LAK cells were reinjected during the second cycle of therapy. A phenotypic and functional analysis of immunologic parameters was conducted along with the therapeutic protocol. Toxicity was significant with two toxic deaths (cardiotoxicity and respiratory distress). The reinfusion of large amounts of LAK cells was clearly involved in one case, but this particularly severe toxicity has to be related to the patient's status (ie, heavy pretreatment). No significant clinical response was seen. The immunologic monitoring showed phenotypic and functional modifications in these patients before initiation of treatment and an unexpected absence of evolution of these parameters during IL2 therapy. Although the origin of these immune dysfunctions is not clear, they could be involved in the failure of IL2 therapy. Future studies of IL2 therapy in neuroblastoma should be undertaken earlier in the course of the disease.
The authors report on the case of a 10 year-old girl who died suddenly after exercise. The autopsy showed abnormal origin of the left coronary trunk from the right sinus of Valsalva, with proximal course of the vessel between the aorta and pulmonary trunk. We discuss on the mechanism of myocardial ischemia; the opportunity to diagnose such an anomaly when the patient is alive is rare, and cause of death is most frequently determined by necropsy.
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Over a 4 yr-period, 60 children (aged 10 months to 17 yr) received 66 kidney transplants with the same surgical intensive care program, the fist 48 hr-period of which has been analysed in this study. Thirty percent of recipients were transplanted without previous dialysis and in 8%, body weight was below 10 kg at the time of surgery. The duration of anesthesia was 4.4 +/- 1.0 h and 32% received locoregional anesthesia. The mean duration for cold ischemia was 14.7 +/- 11.7 h and 26 +/- 7 min for warm ischemia; diuresis began during the operation in 79% of the patients. Routine vascular filling consisted of standard isotonic solute (11 +/- 4 ml/kg/h) associated with mannitol infusion; 59% of recipients required 20% human serum albumin and 42% blood transfusion. Post-operative diuresis was 7.4 +/- 6.0 ml/kg/h during the first 24 h, and sometimes resulted in hypovolemic episodes; 9% of the patients had primary non-functioning kidneys (4 transient acute tubular necrosis; 2 vascular thrombosis) and 4% required dialysis; the 1-yr survival rate was 82% for the grafts and 98% of the patients.
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