Paediatric long term continuous positive airway pressure and noninvasive ventilation in France: A cross-sectional study

OBJECTIVE

To describe the characteristics of children treated with long term continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) in France.

DESIGN

Cross-sectional national survey.

SETTING

Paediatric CPAP/NIV teams of 28 tertiary university hospitals in France.

PATIENTS

Children aged <20 years treated with CPAP/NIV since at least 3 months on June 1st, 2019.

INTERVENTION

An anonymous questionnaire was filled in for every patient.

RESULTS

The data of 1447 patients (60% boys), mean age 9.8 ± 5.8 years were analysed. The most frequent underlying disorders were: upper airway obstruction (46%), neuromuscular disease (28%), disorder of the central nervous system (13%), cardiorespiratory disorder (7%), and congenital bone disease (4%). Forty-five percent of the patients were treated with CPAP and 55% with NIV. Treatment was initiated electively for 92% of children, while 8% started during an acute illness. A poly(somno)graphy (P(S)G) was performed prior to treatment initiation in 26%, 36% had a P(S)G with transcutaneous carbon dioxide monitoring (PtcCO₂), while 23% had only a pulse oximetry (SpO₂) with PtcCO₂ recording. The decision of CPAP/NIV initiation during an elective setting was based on the apnea-hypopnea index (AHI) in 41% of patients, SpO₂ and PtcCO₂ in 25% of patients, and AHI with PtcCO₂ in 25% of patients. Objective adherence was excellent with a mean use of 7.6 ± 3.2 h/night. Duration of CPAP/NIV was 2.7 ± 2.9 years at the time of the survey.

CONCLUSION

This survey shows the large number of children treated with long term CPAP/NIV in France with numerous children having disorders other than neuromuscular diseases.

Dynamic Popliteal Phlebography

Phlebography of the popliteal vein is reviewed. An anatomical summary considers the superficial and deep venous systems, perforating veins and the gastrocnemius veins. Techniques and methods are described. Results of 2500 investigations are reported To date the puncture failure rate is only 0.3%. The method is useful in identifying incompetence in a wide variety of veins, varicose veins and post-phlebitic disease. The system is compared to other types of investigation. It is concluded that the technique enables a rapid evaluation of venous pathology in many instances and is ideal for use on out-patients.

Investigation of Popliteal Fossa Venous Reflux

Objective:

To assess the relative diagnostic merits of duplex scanning (DS) and dynamic popliteal phlebography (DPP) in the investigation of popliteal fossa venous reflux.

Design:

Prospective single patient study.

Setting:

Departments of Vascular Surgery, Radiology and Angiology, Jean Kunlin Unit of Vascular Pathology, Clinique du Grand-Large, Declines Charpieu, France.

Patients:

Eighteen consecutive patients with venous reflux in the popliteal fossa as demonstrated by hand-held Doppler insonation.

Interventions:

All limbs were investigated by DS and DPP before undergoing surgical exploration of the Popliteal fossa.

Main outcome measures:

The findings of the two modes of investigation were compared with the operative findings.

Results:

Both tests showed good specificity (98% DPP, 96% DS), but only moderate sensitivity (83% DPP, 87.5% DS). Both tests were wrong in two limbs.

Conclusion:

Phlebography can be reserved for cases where duplex scanning is inconclusive. Unsuspected anomalies will occasionally be found at operation despite exhaustive investigation.

Bacterial colonization status of cystic fibrosis children's toothbrushes: A pilot study

BACKGROUND

Pseudomonas aeruginosa and Staphylococcus aureus toothbrush contamination in cystic fibrosis (CF) is unknown. This pilot study aimed to determine their prevalence and the potential involvement of toothbrushes in pulmonary infection.

METHODS

Toothbrush bacteriological analysis for children aged 8-18 years was conducted on 27 CF patients, 15 healthy siblings, and 15 healthy children from the general population.

RESULTS

S. aureus was detected on 22% of the patients' toothbrushes, and 13% of healthy children's toothbrushes and P. aeruginosa on 15% of patients' toothbrushes and 0-13% of healthy children's toothbrushes. There was no statistical correlation between pulmonary colonization and toothbrush contamination. P. aeruginosa genotyping showed two identical clones on the patients' toothbrushes and in their sputum, and between one patient's sputum and his sibling's toothbrush.

CONCLUSION

S. aureus and P. aeruginosa can colonize CF patients' toothbrushes. The impact on pulmonary colonization remains unknown. Toothbrush decontamination methods need to consider these bacteria in CF patients.

[MR-galactography: a new way to explore nipple discharges]

Nipple discharge is a common breast complaint that justifies an etiologic check-up in order to identify and characterize the underlying intraductal lesion. The low sensitivity and specificity of the existing imaging exams led to the search of new, more efficient ways to explore nipple discharge. MR-Galactography is one of these emerging techniques. Recent literature tends to prove that MR-Galactography could be an interesting technique for localizing and characterizing lesions causing nipple discharge.

Fatal haemoptysis in a case of lymphomatoid granulomatosis treated with rituximab

Lymphomatoid granulomatosis is a rare angiocentric and angiodestructive disease, which commonly involves the lungs but also the brain, kidneys, liver and skin. This report describes the case of a 33-yr-old female with an aggressive form of lymphoid granulomatosis treated with an anti-CD20 antibody. Dramatic radiological improvement was seen at the fourth week. However, the patient died at home 1 month after the last rituximab administration from a massive haemoptysis.

[Low grade pulmonary sarcoma preceding the discovery of a uterine primary]

INTRODUCTION

Low grade pulmonary sarcomas are very rare tumours. We report the case of a low grade sarcoma of the lung occurring two years prior to the finding of a uterine primary.

CASE REPORT

Complete surgical excision of a low grade pulmonary sarcoma was performed. The initial search for dissemination was negative. Two years later a follow-up scan discovered a uterine mass as well as a para-aortic shadow that proved to be the primary tumour (low grade uterine sarcoma) and a metastasis.

CONCLUSION

This is the second case of a pulmonary metastasis discovered before a primary low grade uterine sarcoma. The first was found during the investigation of a pulmonary sarcoma. The main differential diagnosis to consider is metastatic leiomyosarcoma. In both cases their finding justifies the search for a uterine primary by immunohistochemical examination for oestrogen and progesterone receptors as well as pelvic ultrasound or even magnetic resonance imaging.

Influence of medical speciality and experience on interpretation of helicoidal thoracic computed tomography in blunt chest trauma

OBJECTIVE

To compare the quality of interpretation of chest helicoidal computed tomography (HCT) by physicians with different levels of experience and medical specialty.

DESIGN

Prospective observational study.

SETTING

Trauma critical care unit at a French university hospital (US equivalent: level 1).

PATIENTS

HCT of 50 consecutive patients with blunt chest trauma were assessed by four groups of physicians [residents in anaesthesiology (n=5), residents in radiology (n=5), senior anaesthesiologists (n=5), and senior radiologists (n=5)]. Interpretation from each physician was compared with a grid obtained from an expert interpretation by a senior radiologist and a senior anaesthesiologist.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

No group of observers performed better than another in their interpretation of lung and parietal injuries on HCT. In contrast, senior radiologists were better than anaesthesiologists for the diagnosis of pneumomediastin. However, residents in radiology performed better than other physicians in detecting the presence of gastric and tracheal tubes.

CONCLUSIONS

Compared with anaesthesiologists, senior radiologists seem more expert in the diagnosis of HCT mediastinal injuries whereas residents in radiology were better at detecting resuscitation materials in thoracic trauma patients. This article reinforces the usefulness of the interpretation of the HCT by a senior radiologist in the case of blunt chest trauma. This also reinforces the usefulness of an aspect team of radiologists and anaesthesiologists in the case of trauma. The logical usefulness of a systematic interpretation of the images should be borne in mind.

[Imaging of the endometrium]

During genital activity, physiological and pathological modifications can be observed; Pre- and postmenopausal menometror-rhagia are the principle clinical signs of various endometrial pathologies: benign (polyp, atrophy or endometrial hypertrophy), malignant (cervical or endometrial carcinoma) or neighboring pathologies (myometrium or ovary). The value and methods of various imaging techniques (B-mode and Doppler abdominal and endovaginal ultrasonography, hysterosonography, computed tomography, MR imaging and hysteroscopy) are described together with symptomatological features permitting identification of the endometrial pathology.

[Which initial tests should be performed to evaluate meno-metrorrhagias? A comparison of hysterography, transvaginal sonohysterography and hysteroscopy]

OBJECTIVE

Evaluate the feasibility and the value of hysterography, sonohysterography and hysteroscopy for investigation of abnormal uterine bleeding. Method. Longitudinal blind study of thirty-eight patients consulting for abnormal uterine bleeding during pre- and post menopause. All patients underwent an hysterography and transvaginal sonohysterography, in random order, followed by an hysteroscopy with histological sample. The results were compared with the histo-pathological examination that was used for reference diagnosis. Statistical study of sensitivity, specificity and Positive and Negative Predictive Value (PPV-NPV) of each investigation; rate of agreement by the coefficient of Kappa.

RESULTS

The hysterography offers a PPV of 83% and a NPV of 100%. The interpretation errors were associated with the simple mucous hypertrophy interpreted as "hyperplasy". The limits correspond to a contrast agent allergy. The sonohysterography had a VPP of 89% and a VPN of 100%. The false positive is due to the difficulties of distinguishing the clots from the polyps. The limits correspond to the difficulties of cervix catheterization (13%). As regards the hysteroscopy, the VPP was 81.5% and the VPN of 75%. The interpretation mistakes were associated with mucous hypertrophy and the hyperplasy.

CONCLUSIONS

The most useful examination for abnormal uterine bleeding, in the first instance, is transvaginal sonography with saline instillation. A complement by Doppler study would probably make it possible to limit the false positives.

[Analysis of chest radiographs of patients with thoracic trauma is not influenced by a grid nor by the experience of the reader]

OBJECTIVE

To evaluate the interest of a grid and the experience of the interpreter to interpretate the chest radiographs (CRs) of patients with thoracic trauma, the reference is the helicoidal computed tomography (HCT).

STUDY DESIGN

Prospective observational study.

MATERIAL

CRs and HCT of 50 thorax trauma patients.

METHOD

CRs were analysed without a grid (L) and results were compared with those obtained in an anterior study with a grid (G). The interpreter were residents in anaesthesiology (DESAR; G: n = 6/L: n = 4), residents in radiology (DESR; G: n = 3/L: n = 5), senior anaesthesiologists (MAR; G: n = 5/L: n = 4), and senior radiologists (MR; G: n = 3/L: n = 5). The reference was the HCT. The lectors were compared.

RESULTS

The interpretation of the CRs was neither influenced by the experience and the specialty of the lector nor by the use of a grid. Perhaps the formation is sufficient for the anaesthesiologists to evaluate the essential lesions in the trauma patient and treat them.

[Endometrial imaging]

The diagnostic value of endovaginal sonography in benign or malignant endometrial pathology is high, increased by sonohysterography. Sonohysterography is useful in the diagnosis of endometrial thickness and to determine further investigations. MRI is accurate in the uterine adenomyosis diagnosis and is the imaging modality of choice for the preoperative endometrial cancer staging.

[Interpretation of standard chest x-rays in thoracic trauma: influence of the experience of the interpreter]

OBJECTIVE

To compare the quality of interpretation of chest radiographs (CRs) by physicians of different levels of experience, with reference to data obtained from helicoidal computed tomography (HCT).

STUDY DESIGN

Prospective observational study.

MATERIAL

CRs of 50 thorax trauma patients as recent to HCTs as possible obtained within the 48 h following admission to the intensive therapy unit.

METHOD

CRs were analyzed according to a grid by observers included in one of the four groups: residents in anaesthesiology (n = 6), residents in radiology (n = 3), senior anaesthesiologists (n = 5), and senior radiologists (n = 3). The inter-observer agreements, the specificity and sensibility of each group with reference to HCT, and their global performances were assessed.

RESULTS

Inter-observer agreements were poor and sensitivities low in comparison to specificities. No group of observers performed better than another one. These data substantiate the low sensitivity of CRs in comparison to HCT and show that the quality of interpretation of CRs of thorax trauma patients is not influenced by physicians' experience.

[MRI evaluation of placenta accreta treated by embolization. Apropos of a case. Review of the literature]

Placenta accreta results from an abnormal attachment of the placenta to the uterine myometrium. The reported incidence in literature is variable, with an average of 1/7000 pregnancies. This condition is associated with a significant risk of bleeding at the time of delivery, usually requiring hysterectomy. Sonography associated with color Doppler is useful for diagnosis, but MRI can be used successfully to evaluate the degree of placental tissue invading into the myometrium, the serosa, and for follow-up after conservative management. To our knowledge, only two cases of placenta accreta evaluated with MR and six cases of placenta accreta treated by embolization have been reported in the literature. The authors report one case of placenta accreta treated successfully by embolization, and followed-up by MRI.

A study of long-term survival, functional outcome and quality of life in patients with polymyositis or dermatomyositis

There have been few studies of long-term functional outcomes and quality of life in patients with polymyositis or dermatomyositis.

PATIENTS

28 patients, 16 female and 12 male, meeting Bohan's and Peter's criteria and admitted between 1970 and 1993, were studied retrospectively; nine had polymyositis and 19 dermatomyositis (with onset during childhood in five cases); mean age was 43.5 years.

METHODS

we reevaluated 18 of the 28 patients, after a mean interval of eight years; among the ten remaining patients, eight had died, one could not be traced and one declined reevaluation. Survival, muscle function, joint function, respiratory function and quality of life (AIMS 1) were determined. Factors predicting the value of these parameters were looked for.

RESULTS

significant excess mortality was observed as compared with the general population in the Seine Maritime region of France. Easy fatigability and decreased exercise tolerance were found in 50% of evaluated patients; Ritchie's index was 0 in 67% of patients and between 1 and 7 in 33%; 55% of patients had dyspnea and 50% had abnormal respiratory function parameters; quality of life items were usually rated "fairly good" or "very good", except for "physical activities", which were given "poor" or "very poor" ratings by one third of patients. We found no factors associated with survival or any of the above-mentioned functional parameters, except for male gender, which predicted better muscle function.

DISCUSSION

polydermatomyositis is associated with excess mortality; alterations in muscle function persist in half the cases and the ability to carry out physical activities is often reduced. The retrospective design of our study, small sample size and heterogeneity of our population precluded identification of factors predictive of survival, loss of function, or poor quality of life.

[Heart injury following closed thoracic injury]

A 60-year-old man, was admitted in the emergency ward, following a motor vehicle accident. At the time of arrival his clinical state was stable. The initial investigations showed a moderate left haemopneumothorax and fractured ribs. After insertion of a thoracostomy tube into the left pleural cavity he had to undergo surgery for an open fracture of the left arm. Following induction of anaesthesia, a cardiovascular collapse occurred rapidly. An emergency thoracotomy was performed which showed a right ventricular perforation by a rib fragment. The authors discuss the role of possible changes in heart position produced by induction of general anaesthesia. Indeed the decrease in functional residual capacity following induction of anaesthesia with a cephalad diaphragmatic shift may have secondarily exposed the right ventricle to the bevel of a fractured rib.

Intrapulmonary haematoma complicating mechanical ventilation in patients with chronic obstructive pulmonary disease

Intrapulmonary haematomas occurred during mechanical ventilation of two patients with advanced chronic obstructive pulmonary disease and bullous dystrophy. In both cases, the haematomas were revealed by blood-stained aspirates, a fall in haemoglobin level, and the appearance of radiological opacities. Haematoma occurrence in the area of a bulla which recently has rapidly increased in size, suggests that the haematoma is due to the rupture of stretched vessels embedded in the wall of the bulla.

[Dynamic popliteal phlebography]

Since 1984, dynamic popliteal phlebography is an investigative fundamental technique in chronic venous insufficiency of the lower extremities. Our experience includes more than 2,500 examinations. After an anatomical reminder, the technique and methodology of this examination are described. Then its indications are specified: a) in essential varicose veins when a surgical procedure is contemplated in the popliteal fossa: insufficient external saphenous vein, insufficient gemellar veins, etc... b) before repeated surgery for essential varicose veins, c) in the pre-operative evaluation of some post-phlebitic syndromes. Finally, the informations provided by this examination are compared with those provided by clinical examination, Doppler and ultrasonography.

[Phlebography in chronic venous insufficiency of the lower extremities. Technic and value of different tests]

Remainder of the various phlebographic procedures in chronic venous insufficiency of the lower extremities: peripheral phlebography, popliteal phlebography, femoral phlebography, varicography. The techniques and the informations they provide are presented for each one of these examinations.

[Late empyema after pneumonectomy. Demonstration in x-ray computed tomography]

The authors describe CT signs of a thoracic empyema, developed several years after a pneumonectomy. The disappearance of the concavity of post-pneumonectomy space in contact with mediastinum, associated to the absence of retraction of the hemithorax are the main signs of the diagnosis.