Pediatric private practice in the Nord-Pas-de-Calais region: Demographics, organization, and challenges

While the needs for pediatric care are increasing and becoming more diverse, pediatric private practice in France is encountering difficulties linked to a growing medical demographic deficit. The objective of this study was to give an overview of pediatric private practice in the Nord-Pas-de-Calais region and to describe the main challenges encountered.

METHODS

For this descriptive observational survey, private practice pediatricians in the Nord-Pas-de-Calais region filled out an online questionnaire between April 2019 and October 2020.

RESULTS

The response rate was 64%. Most respondents practiced in an urban area (87%) and shared the practice with other physicians (59%). A majority (85%) had previously worked in hospital; 65% reported training in a subspecialty. Overall, 48% had other professional activities; 28% worked night shifts and 96% accepted urgent requests for consultations. A total of 33% reported having difficulties contacting specialists for consults, and 46% had difficulties in obtaining written reports of their patients' hospitalizations. All respondents participated in a form of ongoing medical education. The main difficulties were: lack of information about how to found a private practice (68%), lack of personal time (61%), balance between medical and administrative work (59%), and an excess of patients to care for (57%). The main satisfactions were: trusting relationships with patients (98%), freedom in their choice of practice (85%), and the diversity of problems and situations encountered (68%).

CONCLUSION

Our study underlines that private practice pediatricians are involved in healthcare provision, in particular regarding ongoing medical training, subspecialties, and continuity of care. It also highlights the problems encountered and the possible improvements: developing better communication between private practice and hospitals, reinforcing training during residency, and highlighting the importance and complementarity of private practice in children's healthcare.

Cytokine storm induced coagulopathy in septic shock and critical Covid-19: head-to-head comparison

Background

Septic shock generates an important inflammatory reaction, endothelial activation and a procoagulant state leading to microvascular thrombosis and subsequent organ impairment [1].

Similarly, a severe inflammatory reaction and a coagulopathy with pulmonary micro-thrombosis eventually leading to acute lung injury, is a typical feature of critical form of Coronavirus disease 2019 (Covid-19) [2].

Our aim was to compare coagulation, platelet activation and platelets-neutrophils interplay between control, septic shock and critical Covid-19 patients.

Methods/Materials

A total of 118 patients were included in our prospective, monocentric, observational study between February 2019 and June 2020. Septic shock (n=48) and Covid-19 (n=22) patients were consecutively included at admission in our ICU department. Control patients (n=48) with matched gender and co-morbidities were recruited at central lab consultation.

Results

Septic shock patients had worse severity scores due to multiple organ failure (assessed by APACHE II and SOFA score) whereas Covid-19 patients had more severe respiratory failure and a longer ICU length-of-stay (Table 1).

At the time of inclusion, CRP and lymphocyte count were comparable between septic shock and Covid-19 patients. White cell count ad neutrophil count was higher for septic shock patients.

Analysis of coagulation showed a prolonged INR, TT and aPTT in septic shock although only INR was prolonged in Covid-19. Thrombin antithrombin complex (TATc) formation was similar in both pathologies, whereas consumption of antithrombin III (ATIII) and D-dimers formation was more pronounced in septic shock.

Platelet count was lower in septic shock and platelet activation, assessed via plasmatic levels of soluble P-selectin (sCD62P) and Trem-like transcript 1 (sTLT-1), was more important in septic shock.

Neutrophil activation and NETosis, evaluated by levels of circulating myeloperoxidase (MPO) and citrullinated histone 3 (H3-Cit), was similarly increased in both groups (Figure 1).

Conclusions

This study confirmed an activation of coagulation cascade, platelet activation and NETosis in both septic shock and critical Covid-19, compared with control patients. Importantly, the extent of these changes was similar or less pronounced in critical COVID-19 compared with septic shock.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Fondation Saint Luc

Artificial intelligence for the public sector: opportunities and challenges of cross-sector collaboration

Public sector organizations are increasingly interested in using data science and artificial intelligence capabilities to deliver policy and generate efficiencies in high-uncertainty environments. The long-term success of data science and artificial intelligence (AI) in the public sector relies on effectively embedding it into delivery solutions for policy implementation. However, governments cannot do this integration of AI into public service delivery on their own. The UK Government Industrial Strategy is clear that delivering on the AI grand challenge requires collaboration between universities and the public and private sectors. This cross-sectoral collaborative approach is the norm in applied AI centres of excellence around the world. Despite their popularity, cross-sector collaborations entail serious management challenges that hinder their success. In this article we discuss the opportunities for and challenges of AI for the public sector. Finally, we propose a series of strategies to successfully manage these cross-sectoral collaborations.This article is part of a discussion meeting issue 'The growing ubiquity of algorithms in society: implications, impacts and innovations'.

The effects of a home-based arm ergometry exercise programme on physical fitness, fatigue and activity in Polio survivors: a randomised controlled trial

Objective:

To investigate the effect of an eight-week home-based arm ergometry aerobic exercise programme on physical fitness, fatigue, activity and quality of life in Polio Survivors.

Design:

An assessor blinded randomised controlled trial.

Setting:

Home-based exercise.

Subjects:

Fifty-five Polio survivors randomised to exercise or control groups.

Intervention:

Home-based arm ergometry at an intensity of 50%-70% maximum heart rate, compared with usual physiotherapy care.

Main measures:

The Six-minute Arm Test, Fatigue Severity Scale, Physical Activity Scale for Individuals with Physical Disabilities and SF-36. Assessments were completed at baseline and at eight weeks.

Results:

There was no significant difference in the primary outcome, exercising heart rate during the Six-minute Arm Test, between the groups at follow-up [97.6 (SD10.1) compared to 102.4 (SD13.7) beats per minute ( P=0.20)]. Blood pressure was significantly lower in the intervention group at follow-up [systolic blood pressure 132(18.6)mmHg compared to 144.1(14.6)mmHg ( P=0.002)]. There were no between group differences in the Fatigue Severity Scale ( P=0.25) or Physical Activity Scale for Individuals with Physical Disabilities ( P=0.49), with a small difference in SF-36 physical component score ( P=0.04).

Conclusions:

This home-based arm ergometry programme successfully facilitated aerobic exercise in Polio Survivors, but did not result in a significant change in physical fitness, measured by the Six-minute Arm Test.

Ventilation non invasive des nourrissons ayant une infection respiratoire sévère présumée à virus respiratoire syncitial : faisabilité et critères d'échec

Beneficial effect of continuous positive airway pressure (CPAP) during non invasive ventilation (NIV) has been reported in infants with respiratory syncytial virus (RSV) infection, but no study has analyzed the predictors of its failure.

OBJECTIVE

To evaluate the feasibility of NIV and to determine NIV failure criteria.

POPULATION AND METHODS

All infants hospitalized in one PICU with presumed RSV infection between 2002 and 2006 were prospectively included. When respiratory support was needed, NIV was first started according to a pre-established protocol.

RESULTS

One hundred and one infants, 43 females, 58 males, median age 49 days (range: 10-334), median weight 3.9 kg (range: 2,4-12) were included. RSV infection was confirmed in 84/101. Sixty-seven infants were transported by the paediatric medical transport system, 27 with NIV and 15 with invasive ventilation (IV). Fifteen infants were in IV at admission, 69 received NIV during their PICU stay (12 secondarily requiring IV) and 17 were never ventilated. A significant decrease in PCO2 with increase in pH was observed within 2 hours of NIV. Parameters associated with NIV failure were apneas, high values of admission PCO2 and H24 PRISM score. The 17 non-ventilated infants were older and had a lower severity score than those who were ventilated.

CONCLUSION

In infants with RSV and needing respiratory support, NIV represented the sole method of respiratory support in 68% of cases. NIV failure criteria were apneas, high values of admission PCO2 and H24 PRISM score.

[Analysis of delay in diagnosis of extrahepatic biliary atresia]

Prognosis of extrahepatic biliary atresia depends on an early surgical treatment. This survey studied the delay to surgery of infants treated for biliary atresia and analysed the causes of late diagnosis and referral.

MATERIAL AND METHODS

Medical files of 21 infants treated for biliary atresia between 1988 and 1998 were retrospectively analysed.

RESULTS

Median age at biliary operation was 57 days and did not change during time. In only 3/21 cases, surgery was performed before 45 days of age. The first clinical or biological sign of cholestasis was noted at a median age of 12 days. In eight cases, the first medical visit for cholestasis (median age of 21 days) was not followed by a blood test. In 11 cases, infants presenting with biological cholestasis were referred to hospital more than seven days later. False diagnosis was noted in seven cases and delayed significantly the operation.

CONCLUSION

The delay to surgical treatment is too long and does not decrease whereas a majority of infants visit their physician early. Medical information is mandatory for all physicians taking care of infants.

Resonance Raman kinetic spectroscopy of bacteriorhodopsin on the microsecond time scale

Using a rotating disk with a slit of variable width, a continuous wave argon ion laser, and an Optical Multichannel Analyzer for detection, a new technique is reported which should, in principle, be capable of recording resonance Raman spectra with time resolution of 100 ns. The resonance Raman spectra of the intermediates of the photosynthetic cycle of bacteriorhodopsin are recorded on the microsecond time scale. Both the kinetic results and the resonance enhancement profile suggest that deprotonation results in an intermediate preceding bM412 that has an optical absorption maximum at a wavelength longer than that of bM412.

Time-resolved resonance Raman spectroscopy of bacteriorhodopsin on the millisecond timescale

A simple technique is described that uses a continuous wave laser with electromechanical modulation to obtain time-resolved Raman spectra of transient species on the millisecond timescale. The time behavior of the vibrational bands of the intermediates involved in the proton pumping of bacteriorhodopsin is determined. From these results, along with resonance enhancement and power dependence studies, the bands that appear in the continuous wave Raman spectrum of bacteriorhodopsin can be assigned to three intermediates in the photochemical cycle of bacteriorhodopsin, bR570, bL550, and bM412. The Raman spectra of bR570 and bM412 are compared with published spectra of model Schiff bases of all-trans and 13-cis retinal.