[Malignant pertussis and exchange transfusion]

CASE REPORT

Malignant pertussis is a critical clinical state associated with fatal outcome in 70% of cases. The severity criteria are a lung infection with pulmonary hypertension and hyperleukocytosis usually above 50 G/L. We report the case of a 2.5-month-old girl hospitalized with critical pertussis in a pediatric intensive care unit. She had acute respiratory distress syndrome with pulmonary hypertension complicated by a bacterial secondary infection with Enterobacter cloacae managed by high-frequency oscillatory ventilation associated with pulmonary vasodilatation therapy. In the absence of clinical improvement and before considering extracorporeal life support, exchange transfusion was performed at day 9 to reduce hyperleukocytosis at 70 G/L. Exchange transfusion was successfully performed with a reduction of leukocytes to under 40 G/L followed by steady improvement of pulmonary function. Weaning from mechanical ventilation and discharge took place at day 23 and 38, respectively.

COMMENTS

Exchange transfusion should be considered in infants suffering from malignant pertussis with extreme leukocytosis before hemodynamic failure to improve the survival prognosis.

[Intervention of psychological and ethical professionals of human science in obstetrical morbidity and mortality conferences]

OBJECTIVE

To identify the defence mechanisms manifested by medical staff which could disturb the decision making, revealed by professionals of human science (PHS) in morbidity and mortality conferences (MMC).

MATERIALS AND METHODS

Application of two methods of psychological intervention in MMC, conducted between March 1st, 2009 and November 30, 2010, in 20 randomized maternity among five perinatal networks: the method of inter-active problem solving targeted at the functioning of the teams and the method for developing professional practice centred on individual. The data collection was realized during analyse of case in MMC, with note-taking by two pair PHS. The oral expressions of RMM' participant were secondarily re-written, analyzed and classed by theme.

RESULTS

Fifty-four MMC were performed. The mechanisms of defence have been identified by PHS intervention in MMC: denial of situation, pact of denegation, rift and overprotection. They were be identified by two PHS intervention methods, this consolidates these results. This intervention began staff medical to transformation at different level, in particular to improve the capacity of cooperation.

CONCLUSION

The identification of the mechanisms of defence in MMC enables staff medical to improve communication and quality relationship between healthcare professionals. This could constitute an actual factor of practices improvement. However, complementary studies must be performed to confirm this hypothesis.

[Atrial chaotic tachycardia during a respiratory tract infection due to NL63 coronavirus]

We report the case of a 3-month-old boy hospitalized with acute bronchiolitis. Respiratory distress was associated with cardiogenic shock caused by chaotic atrial tachycardia. The cause of bronchiolitis was a coronavirus NL63 viral infection, confirmed in nasopharyngeal aspirations. The patient required intensive care including diuretics (furosemide), anti-arrhythmic drugs (amiodarone and digoxin), and inotropic drugs (milrinone and levosimendan) associated with mechanical ventilation. The outcome was favorable in 10 days and the sinusal cardiac rhythm was completely restored at discharge.

Visceral and mucosal involvement in neonatal haemangiomatosis

BACKGROUND

Two types of neonatal haemangiomatosis (NH) are distinguished: diffuse which is associated with a high rate of mortality linked to mucosal/visceral involvement, and benign.

OBJECTIVES

First, this study aimed to examine the frequency of mucosal and visceral (especially hepatic) involvement in NH, according to skin extension, and second, it aimed to examine clinical, pathological (with glucose transporter 1 (GLUT-1) immunostaining), and imaging features of NH, including follow-up data.

METHODS

This was a descriptive retrospective study carried out in the University Hospital Center of Tours, France.

RESULTS

The study included 19 patients with cutaneous NH (number of skin haemangiomas ranging from 5 to >100). Mucosal involvement was observed in 32% of all cases (100% and 19% in diffuse and other cutaneous cases respectively) and hepatic involvement in 42% (67% and 38% respectively). The number of hepatic haemangiomas ranged from 1 to >10. Half of the hepatic haemangiomas cases exhibited increased hepatic arterial blood flow.

CONCLUSIONS

Mucosal and hepatic involvement was frequent in cases with a high number of cutaneous haemangiomas (>100), but only frequency of mucosal involvement was statistically significant (P = 0.021).

[Clinical variability and diagnosis steps in childhood mitochondrial disease]

OBJECTIVES

Mitochondrial respiratory chain deficiencies are known for their high clinical variability. Difficult to diagnose, the prevalence of these diseases is probably underestimated.

METHODS

We report 18 children diagnosed with respiratory chain deficiency at the Tours University Hospital over the past 10 years.

RESULTS

Three clinical profiles can be distinguished depending on the age at onset of the first symptoms: the neonatal period (4 cases), between 1 month and 2 years of age (10 cases), and after 10 years (4 cases). However, no clinical feature appears specific of any age group. In contrast, respiratory chain analysis on liver biopsy was very informative for all our patients at any age and with any clinical presentation, even with predominant neurological symptoms.

CONCLUSIONS

These biochemical analyses support the diagnosis of mitochondrial disorders in view of molecular analysis, which nevertheless frequently remains inconclusive. These investigations should benefit from the new molecular screening technologies based on DNA chips that can identify the genomic mutations responsible for these severe and relatively frequent diseases.

[Neonatal onset of Menkes disease: diagnosis interest of cupremia and microscopic examination of the hairs]

BACKGROUND

Menkes disease is a rare X-linked disorder due to a defect in intracellular copper transport. Clinical symptoms appear during the first months of life, with a progressive developmental delay leading to death within a few years. Diagnosis is confirmed by the demonstration of copper retention in fibroblasts and/or DNA testing. However, these investigations are complexes and time consuming.

CASE REPORT

We report 1 case of Menkes disease with neonatal onset, diagnosed on multiple organ failure, hypothermia, and major central nervous system damage, leading to death in a few weeks. The diagnosis, suggested by the clinical features, was rapidly supported by the microscopic examination of the hairs, showing pili torti, and the demonstration of severely decreased levels of plasma copper and ceruloplasmin. Diagnosis was further confirmed by the demonstration of an increased copper uptake and retention in fibroblasts.

CONCLUSION

This report highlights the clinical variability of Menkes disease with the possibility of a neonatal onset. Microscopic examination of the hairs and the determination of copper and ceruloplasmin plasma levels are simple and inexpensive investigations, which can provide rapidly valuable information to support this diagnosis.

Effects of oral stimulation and oral support on non-nutritive sucking and feeding performance in preterm infants

This study compared the effects of oral stimulation with those of oral support on non-nutritive sucking and feeding parameters in preterm infants. Preterm infants (23 males, 20 females) born between 29 and less than 34 weeks' gestational age (GA; mean GA 31.2wks [standard error of mean{SEM} 0.39]; mean birth-weight 1580g [SEM 120]) were allocated to one of three experimental groups: (Stimulation+support [five males, four females]; Stimulation [four males, seven females]; and Support [seven males, five females]) or a control group. Non-nutritive sucking pressure and sucking activity were quantified in the gavage and transition periods. Oral support minimizes fluid loss, stabilizes the jaw, and organizes deglutition. The time of transition, the quantity of milk ingested per day, and the number of bottle feeds per day were recorded. Variables were analyzed by repeated-measures analysis of variance, with birth-weight as covariate (ANCOVA). Transition time was reduced (p<0.0001) for the Stimulation+support and Support groups. ANCOVA computed during gavage showed increased non-nutritive sucking pressure and sucking activity (p<0.001) for the Stimulation and Stimulation+support groups. ANCOVA computed during transition revealed increases in non-nutritive sucking pressure and daily bottle feeds (p<0.001) for the three experimental groups and in daily milk ingested (p=0.002) for the Stimulation+support and Support groups. We demonstrated that oral support is the result of both the action of chin and cheek support, and the aid to deglutition. An analysis of the organization of sucking patterns should be undertaken to provide better understanding of the mechanisms involved in oral support.

Étude épidémiologique de la rétinopathie du prématuré : les facteurs de risque au CHU de Tours

BACKGROUND

A prospective analysis of the incidence of retinopathy of prematurity (ROP) by documenting clinical perinatal characteristics of affected infants, in an attempt to describe risk factors for ROP.

MATERIALS AND METHODS

Between March 2002 and April 2004, 161 infants, with a gestational age under 31 weeks and/or a birth weight under 1500 g, were screened according to CRYO-ROP guidelines, using direct ophthalmoscopy with a Layden contact lens. Risk factors for ROP were analyzed with the Student and Fischer tests.

RESULTS

ROP developed in 15% of the cases studied, with one out of five at prethreshold or threshold levels of ROP. Gestational age at birth (p<0.0001), low birth weight (p<0.0001), the length of the infant's stay in the neonatal intensive care unit (p<0.0001), the duration of mechanical ventilation (p<0.0001), the duration of oxygen provided (p<0.0001), blood transfusions (p<0.0001), hyaline membrane disease (p=0.0257), and bronchodysplasia (p=0.0012) were significant risk factors for ROP.

CONCLUSION

Despite progress in neonatal intensive care, ROP persists and can be explained by greater and greater prematurity and earlier screening. Effective screening, done between 4 and 6 weeks of life, taking risk factors into account, can improve prognosis.

Application of the French guidelines for preventing neonatal group B streptococcal disease in a university hospital

This study evaluated the application of the French guidelines for prevention of neonatal group B streptococcus (GBS) infections. The prevalence of GBS vaginal carriage by pregnant women during the study period was 6%. Less than 50% of pregnant women testing positive for GBS were treated with at least two doses of antibiotics during labour, and most received only one dose or no antibiotics. In addition, several neonates were colonised or infected by GBS although their mothers were GBS-negative. These results are consistent with vaginal screening having a poor sensitivity, as suggested by the low prevalence of GBS carriage.

Prise en charge précoce des enfants nés avec un liquide méconial: enquête dans les maternités françaises

The meconium aspiration syndrome is the first cause of respiratory distress in full term newborns. At birth, management includes systematical oropharyngeal suctioning, before and after shoulders delivery, followed by tracheal suction. During last 10 years, many trials were published which discuss again the value of this strategy.

AIM

To assess practices of the current management of births with a meconial amniotic liquid in the French maternities.

METHODS

Observational survey by written questionnaires sent to the 617 French maternities.

RESULTS

The rate of answers was of 54.3%. The incidence of the births presenting a meconial amniotic fluid was of 8.2%, complicated of meconium aspiration syndrome in 4.7%. In case of birth with presence of a meconial amniotic liquid, half of the maternities resorted systematically to oropharyngeal suctioning before shoulders delivery. A glottis exposition under laryngoscopy was practiced of principle for half of the newborn. Tracheal suctioning was achieved systematically in a quarter of the establishments. These techniques, with the exception of suctioning before clearing of the shoulders, were especially been achieved in a systematic way in the maternities of I and II A levels.

CONCLUSION

This survey shows the necessity of harmonization of the practices in France for the management of the births with a meconial amniotic liquid.

Nursing and medical staff knowledge regarding the monitoring and management of accidental or exposure hypothermia in adult major trauma patients

Recording a patient's vital signs is a basic requirement that in part informs clinical decision-making. Practice suggests that recording a trauma patient's temperature is occasionally overlooked in the emergency department. A staff survey was undertaken to gain an appreciation of knowledge and understanding of the issues that surround accidental or exposure hypothermia in trauma patients. Results demonstrate that nurses and doctors are unsure of how to define hypothermia and are not conversant with simple ways to prevent heat loss or rewarm patients. Complications from hypothermia such as coagulopathy and metabolic acidosis were seldom identified. Issues that limit staff recording temperature include patient access and acuity, lack of knowledge and confidence and access to temperature-measuring devices. These results emphasize the need for regular education. Implications for clinical practice were considered; an algorithm to guide staff on ways to improve the monitoring and management of temperature in trauma patients was developed. Opportunities for ongoing and further research were identified.

Toxicité fœtale du candesartan

We report a case of a newborn with an oligohydramnios, acute renal failure and ossification abnormalities. The role of maternal treatment of essential hypertension by angiotensin-II receptor antagonists is discussed in regard to the literature and pathophysiological data.

[Isolated tracheo-oesophageal fistula in neonates]

INTRODUCTION

Congenital isolated tracheo-oesophageal fistulae without oesophageal atresia account for about 4% of tracheo-oesophageal malformations. An Otolaryngologist, even with a paediatric practice, is unlikely to treat a lot of cases during his career. We report 3 cases and discuss the investigations and management of the fistulae.

PATIENTS AND METHODS

Three neonates with an isolated congenital tracheo-oesophageal fistula were treated between 1997 and 2002. We describe their presentation, investigation and treatment. We present radiology, endoscopic and surgical images for one case.

RESULTS

The mean age at diagnosis of congenital isolated fistula was 6.7 days. In retrospect, the symptoms were usually present from birth. A barium swallow had demonstrated the tracheo-oesophageal fistula in 2 infants. In all three cases the fistula was clearly visualized by tracheoscopy. The most distal fistula was 25 millimetres below the true vocal cords. The closure of the fistula was made by cervicotomy in all cases. Our results are discussed with regards to the literature.

CONCLUSION

Congenital tracheo-oesophageal fistulae are rare malformations. Diagnostic delay is common. Tracheo-oesophageal endoscopy is the investigation of choice. Good results are obtained with surgery treatment via a cervical approach. The management of such fistulae requires medical teams familiar with neonatal endoscopy and cervical surgery.