Evaluating the Increased Burden of Cardiorespiratory Illness Visits to Adult Emergency Departments During Flu and Bronchiolitis Outbreaks in the Pediatric Population: Retrospective Multicentric Time Series Analysis

BACKGROUND

Cardiorespiratory decompensation (CRD) visits have a profound effect on adult emergency departments (EDs). Respiratory pathogens like respiratory syncytial virus (RSV) and influenza virus are common reasons for increased activity in pediatric EDs and are associated with CRD in the adult population. Given the seasonal aspects of such challenging pathology, it would be advantageous to predict their variations.

OBJECTIVE

The goal of this study was to evaluate the increased burden of CRD in adult EDs during flu and bronchiolitis outbreaks in the pediatric population.

METHODS

An ecological study was conducted, based on admissions to the adult ED of the Centre Hospitalier Universitaire (CHU) of Grenoble and Saint Etienne from June 29, 2015 to March 22, 2020. The outbreak periods for bronchiolitis and flu in the pediatric population were defined with a decision-making support tool, PREDAFLU, used in the pediatric ED. A Kruskal-Wallis variance analysis and a Spearman monotone dependency were performed in order to study the relationship between the number of adult ED admissions for the International Classification of Diseases (ICD)-10 codes related to cardiorespiratory diagnoses and the presence of an epidemic outbreak as defined with PREDAFLU.

RESULTS

The increase in visits to the adult ED for CRD and the bronchiolitis and flu outbreaks had a similar distribution pattern (CHU Saint Etienne: χ²₃=102.7, P<.001; CHU Grenoble: χ²₃=126.67, P<.001) and were quite dependent in both hospital settings (CHU Saint Etienne: Spearman ρ=0.64; CHU Grenoble: Spearman ρ=0.71). The increase in ED occupancy for these pathologies was also significantly related to the pediatric respiratory infection outbreaks. These 2 criteria gave an idea of the increased workload in the ED due to CRD during the bronchiolitis and flu outbreaks in the pediatric population.

CONCLUSIONS

This study established that CRD visits and bed occupancy for adult EDs were significantly increased during bronchiolitis and pediatric influenza outbreaks. Therefore, a prediction tool for these outbreaks such as PREDAFLU can be used to provide early warnings of increased activity in adult EDs for CRD visits.

Strategy using a new antigenic test for rapid diagnosis of Streptococcus pneumoniae infection in respiratory samples from children consulting at hospital

Background

Despite vaccination programs, Streptococcus pneumoniae remains among the main microorganisms involved in bacterial pneumonia, notably in terms of severity. The prognosis of pneumococcal infections is conditioned in part by the precocity of the diagnosis. The aim of this study was to evaluate the impact of a Rapid Diagnostic Test (RDT) targeting cell wall polysaccharide of Streptococcus pneumoniae and performed directly in respiratory samples, on the strategy of diagnosis of respiratory pneumococcal infections in children.

Results

Upper-respiratory tract samples from 196 children consulting at hospital for respiratory infection were tested for detecting S. pneumoniae using a newly-designed RDT (PneumoResp, Biospeedia), a semi-quantitative culture and two PCR assays. If positive on fluidized undiluted specimen, the RDT was repeated on 1:100-diluted sample. The RDT was found highly specific when tested on non-S. pneumoniae strains. By comparison to culture and PCR assays, the RDT on undiluted secretions exhibited a sensitivity (Se) and negative predictive value (NPV) of more than 98%. By comparison to criteria of S. pneumoniae pneumonia combining typical symptoms, X-ray image, and culture ≥10⁷ CFU/ml, the Se and NPV of RDT on diluted specimens were 100% in both cases.

Conclusions

In case of negative result, the excellent NPV of RDT on undiluted secretions allows excluding S. pneumoniae pneumonia. In case of positive result, the excellent sensitivity of RDT on diluted secretions for the diagnosis of S. pneumoniae pneumonia allows proposing a suitable antimicrobial treatment at day 0.

Autonomic Cardiac Reactivity to Painful Procedures Under Hypnosis in Pediatric Emergencies: A Feasibility Study

Pain sensation is characterized by abrupt changes in central nervous system activity producing autonomic reactivity. While clinical hypnosis has demonstrated its benefits for children in pain management, it is not clear whether hypnosis modulated autonomic pain response in children in clinical conditions. Here, we studied autonomic responses under hypnosis to sutures in pediatric emergencies. For that, 42 children (mean age: 6.5 years, range 1.5 to 13) were divided into two groups consecutively (hypnosis and control groups), according to their choice. Time-frequency analysis was applied on RR intervals (heart rate interbeat intervals, or RRI) to estimate parasympathetic reactivity based on high frequency power (HF) and the Analgesia Nociception Index (ANI®) and on sympathetic reactivity (low frequency power [LF]) and LF/HF ratio). We observed that RRI and LF/HF ratio varied according to suture and hypnosis (p < 0.05): RRI was higher and LF/HF ratio was lower during sutures in the hypnosis group in comparison to the control group whereas HF and ANI® increased only during hypnosis. To conclude, hypnosis in pediatric emergencies reduces sympathetic cardiac pain reactivity and could be a marker of pain relief under hypnosis, while parasympathetic activity seems to be a better marker of hypnosis.

Analytical performances of the BD Veritor™ System for the detection of respiratory syncytial virus and influenzaviruses A and B when used at bedside in the pediatric emergency department

This study aims to evaluate the analytical performance of the BD Veritor™ rapid diagnostic assays (RDTs) for respiratory syncytial virus (RSV) and influenzaviruses when performed 24/7 at bedside by nurses in the pediatric emergency department (PED). The study was performed between 14/10/2015 and 19/03/2016 on nasopharyngeal aspirates (NPAs) collected from children consulting at the PED of the University Hospital of Saint-Etienne for bronchiolitis (RSV detection) or flu-like syndrome (influenzaviruses A/B detection). NPAs were tested 24/7 at the PED with the RDT and then sent to the Infectious Agents Department for routine analyses, first by immunofluorescence assay (IFA), then by nucleic acid amplification test (NAAT) considered as the gold standard in case of discrepancy between RDT and IFA results. For RSV detection, 205 NPAs was analyzed; the overall concordance between RDT and routine assays was of 97.6% (200/205). The sensitivity (Se), specificity (Sp), negative predictive value (NPV) and positive predictive value (PPV) were of 97.6% (160/164), 97.6% (40/41), 90.9% (40/44) and 99.4% (160/161), respectively. A total of 419 NPA was tested for influenzaviruses. For influenzavirus A, the overall concordance was of 98.8% (414/419); Se, Sp, NPV and PPV were of 100% (41/41), 98.7% (373/378), 100% (373/373) and 89.1% (41/46), respectively. For influenzavirus B, the overall concordance was of 97.9% (410/419); Se, Sp, NPV and PPV were of 96.6% (172/178), 98.8% (238/241), 97.5% (238/244) and 98.3% (172/175), respectively. Due to their excellent performances and their easy handle by non-laboratory personnel, these RDTs can be warmly recommended as point of care assays at the PED.

Clinical severity and molecular characteristics of circulating and emerging rotaviruses in young children attending hospital emergency departments in France

Group A rotavirus (RVA) is the leading cause of acute gastroenteritis in young children worldwide. A prospective surveillance network has been set up to investigate the virological and clinical features of RVA infections and to detect the emergence of potentially epidemic strains in France. From 2009 to 2014, RVA-positive stool samples were collected from 4800 children <5 years old attending the paediatric emergency units of 16 large hospitals. Rotaviruses were then genotyped by RT-PCR with regard to their outer capsid proteins VP4 and VP7. Genotyping of 4708 RVA showed that G1P[8] strains (62.2%) were predominant. The incidence of G9P[8] (11.5%), G3P[8] (10.4%) and G2P[4] (6.6%) strains varied considerably, whereas G4P[8] (2.7%) strains were circulating mostly locally. Of note, G12P[8] (1.6%) strains emerged during the seasons 2011-12 and 2012-13 with 4.1% and 3.0% prevalence, respectively. Overall, 40 possible zoonotic reassortants, such as G6 (33.3%) and G8 (15.4%) strains, were detected, and were mostly associated with P[6] (67.5%). Analysis of clinical records of 624 hospitalized children and severity scores from 282 of them showed no difference in clinical manifestations or severity in relation to the genotype. The relative stability of RVA genotypes currently co-circulating and the large predominance of P[8] type strains may ensure vaccine effectiveness in France. The surveillance will continue to monitor the emergence of new reassortants that might not respond to current vaccines, all the more so as all genotypes can cause severe infections in infants.

Contamination of healthcare workers' mobile phones by epidemic viruses

Mobile phones (MPs) are potential reservoirs of nosocomial bacteria, but few data are available concerning viruses. We aimed to evaluate the presence of virus RNA from epidemic viruses including metapneumovirus, respiratory syncytial virus, influenza viruses, rotavirus (RV) and norovirus on the MPs used by healthcare workers (HCWs) and to relate it to hygiene measures. An anonymous behavioural questionnaire about MP use at hospital was administered to the HCWs of four adult and paediatric departments of a university hospital. After sampling personal (PMP) and/or professional MPs (digital enhanced cordless telephone, DECT), virus RNAs were extracted and amplified by one-step real-time reverse transcription–quantitative PCR. The molecular results were analysed in a masked manner in relation to the behavioural survey. Questionnaires from 114 HCWs (35 senior physicians, 30 residents, 32 nurses, 27 nurses' assistants) working either in adult (n = 58) or paediatric (n = 56) departments were analysed. Medical personnel used their PMP more frequently than paramedical HCWs (33/65 vs. 10/59, p <0.001). MPs were used during care more frequently in adult wards than in paediatric ones (46/58 vs. 27/56, p <0.001). Virus RNA was detected on 42/109 (38.5%) collected MPs, with RV found on 39, respiratory syncytial virus on three and metapneumovirus on one. The presence of virus RNA was significantly associated with MPs from the paediatric HCWs (p <0.001). MPs routinely used in hospital, even during care, can host virus RNA, especially RV. Promotion of frequent hand hygiene before and after MP use, along with frequent cleaning of MPs, should be encouraged.

[Infantile scurvy: Two cases]

BACKGROUND

Scurvy is the classic and most severe form of vitamin C deficiency. This condition has become extremely rare among children in the industrialized countries.

PATIENTS AND METHODS

We report the case of two boys presenting bone pain associated with haemorrhagic gingivitis, with perifollicular purpura of the lower limbs in one boy. The children had an unbalanced diet. Scurvy was associated with vitamin D and iron deficiency. The dermatological and radiological abnormalities seen were characteristic and a favourable outcome was rapidly obtained following supplementation.

DISCUSSION

The possibility of this forgotten historical illness should not be overlooked in the presence of these dermatological and rheumatologic signs, since this can help avoid unnecessary or excessively aggressive investigations.

[An epidemiological study of early consultations of newborns in pediatric emergency units]

BACKGROUND

The number of visits to the pediatric emergency services has increased in the past 20 years in France and around the world, especially for neonates (under 28 days of age).

OBJECTIVES

Determine for neonates the reasons requiring medical consultation in the emergency pediatric unit of Saint-Etienne University Hospital (France) and isolate the proportion of "non-urgent" preventable consultations that could be managed outside of emergency units.

METHOD

Epidemiological, retrospective study on computerized data on neonates who were referred to the pediatric emergency unit of the Saint-Étienne University Hospital from 1 January to 31 December 2011. Four composite criteria "child not addressed by a healthcare professional; severity score G1, G2, G3 based on an internal scale; no further review undertaken; and return home" were used to define "non-urgent" consultations.

RESULTS

A total of 419 infants were included in the study. The leading reasons for consultations were crying (14.1%), vomiting (11.9%), chest tightness (10.7%), fever (8.1%), and diarrhea (7%). The main diagnoses were acute nasopharyngitis (11.5%), gastroesophageal reflux (10%), colic (8.1%), and excessive parental anxiety (7.6%). The percentage of "non-urgent" consultations was 52.4%.

CONCLUSIONS

Final diagnoses are quite similar to the reasons for consultation. The baby's unexplained crying and the inexperience of young parents resulted in an irrational anxiety. This study highlights the need for parental support at home after discharge from the maternity ward and the use of large-scale educational initiatives.

Epidemiology and microbiological investigations of community-acquired pneumonia in children admitted at the emergency department of a university hospital

•

Systematic antimicrobials are recommended in community-acquired pneumonia of child.

•

A large panel of bacteria and viruses was detected in 85 children exhibiting CAP.

•

More than 60% of children with CAP exhibited an exclusive viral infection.

•

A co-infection with at least 2 viruses was observed in >40% of the children.

•

Data suggest that the use of antimicrobials in child's CAP should be revisited.

Background

The management of children with community-acquired pneumonia (CAP) is largely influenced by the development of new molecular diagnostic tests that allow the simultaneous detection of a wide range of pathogens.

Objectives

Evaluation of a diagnostic approach including multiplex PCR assays for revisiting the epidemiology and etiology of CAP in children at hospital.

Study design

Children of all ages consulting at the Emergency Department of the University hospital of Saint-Etienne, France, during the 2012–2013 winter period were included. In addition to bacterial cultures, the following pathogens were detected using biplex commercially-available rt-PCR tests: adenovirus, respiratory syncytial virus, human metapneumovirus, bocavirus, rhinovirus/enterovirus, coronavirus, influenza viruses A and B, parainfluenza viruses, Mycoplasma pneumoniae and Chlamydophila pneumonia.

Results

From 85 patients with CAP, at least one pathogen was identified in 81 cases (95.3%), including 4 bacterial exclusive infections (4.7%), 53 viral exclusive infections (62.4%) and 24 mixed infections (28.2%). Coinfection by at least two viruses was observed in 37 cases (43.5%). Mean age was higher in the case of documented bacterial infection (P < 0.05). In the subgroup of viral exclusive infection, the mean age of severe cases was 2.0 years vs 3.8 years in mild and moderate cases (P < 0.05).

Conclusions

These findings highlight the huge proportion of CAP of viral origin, the high number of co-infection by multiple viruses and the low number of bacterial CAP, notably in children under 5 years, and address the need to re-evaluate the indications of empiric antimicrobial treatment in this age group.

[Incidence of rotavirus gastroenteritis among children under 5 years consulting a paediatrician or a general practitioner in France]

BACKGROUND

Rotavirus (RV) is the main infectious agent of severe acute gastroenteritis (AGE) in infants and children under 5 years. Given the recent availability of new vaccines, it is important to accurately assess the incidence of rotavirus gastroenteritis (GERV) and their medical and epidemiological consequences.

METHODS

This work is the French part of study program called SPRIK, a multicenter, prospective, observational study conducted from October 2005 to May 2007 to estimate the annual incidence of GERV within children under 5 years visiting a general practitioner or pediatrician. It presents data collected by 41 general practitioners and 36 paediatricians located throughout the French metropolitan territory. A stool sample was taken for every child. Rotavirus presence was sought by the physician using a rapid immunochromatographic test. French results are presented in this article.

RESULTS

A total of 1648 GEA episodes corresponding to 1463 eligible patients were included in the study mainly from December to May (peak in February-March). The incidence rate of GERV leading to consultations in general practice was 1357 cases per 100,000 patient-years (PY) (1.36%), with a 95% confidence interval of [1345-1368]. The peak incidence occurs before 2 years. GERV accounted for 21% of all GEA cases seen by paediatricians and general practitioners. Patients with GERV were younger (14.1 ± 10.8 versus 18.4 ± 13.9 months for other GEA, P<0.0001) and had more severe clinical symptoms: presence of fever (32.6% versus 20.0%, P<0.0001), behavioural symptoms (45.6% versus 20.8%, P<0.0001) and dehydration (48.7% versus 21.2%, P<0.0001). GERV episodes were considered severe in 79.7% of cases, using the Vesikari scale. More than 86% patients received oral rehydration during the episode and 13 patients (5.8%) were hospitalized. Nearly 80% GERV episodes were considered severe using the Vesikari scale. Main genotypes were G1P[8] rotavirus (44%) and G9P[8] rotavirus (35%) types.

CONCLUSION

The incidence rate reported in this study is close to results of previous studies done in Europe. The frequency and severity relative to GERV support vaccination in very young children to reduce the burden associated with this pathology.

Hospital-based surveillance to estimate the burden of rotavirus gastroenteritis among European children younger than 5 years of age

OBJECTIVES

Rotavirus is the leading cause of acute gastroenteritis requiring hospitalization in young children. Data on the burden of rotavirus gastroenteritis are needed to guide recommendations for rotavirus vaccine use. This study was undertaken to estimate the burden of rotavirus gastroenteritis in European children <5 years of age.

METHODS

This prospective, study was conducted in 12 hospitals in France, Germany, Italy, Spain, and the United Kingdom. A sample of all children aged <5 years presenting to emergency departments or hospitalized because of community-acquired acute gastroenteritis was enrolled for parental interview and stool collection. Acute gastroenteritis was defined as diarrhea (>/=3 loose stools per 24 hours) for <14 days. Rotavirus was detected by enzyme-linked immunosorbent assay and typed by reverse-transcriptase polymerase chain reaction.

RESULTS

Between February 2005 and August 2006, 3734 children with community-acquired acute gastroenteritis were recruited and retained for analysis (55.9% via the emergency department, 41.8% hospitalized). Of the 2928 community-acquired acute gastroenteritis cases for which stool samples were available, 43.4% were rotavirus-positive by enzyme-linked immunosorbent assay (32.8% emergency department, 56.2% hospitalized). Of these rotavirus gastroenteritis cases 80.9% occurred in children aged <2 years and 15.9% among infants aged <6 months. Acute gastroenteritis was more severe in rotavirus-positive subjects (Vesikari score >/= 11 in 53.3% compared with 31.0% of rotavirus-negative subjects). All 1271 rotavirus-positive strains were genotyped (G1P[8]: 40.3%; G9P[8]: 31.2%; G4P[8]: 13.5%; G3P[8]: 7.1%).

CONCLUSIONS

Rotavirus gastroenteritis places high demands on European health care systems, accounting for 56.2% of hospitalizations and 32.8% of emergency department visits because of community-acquired acute gastroenteritis in children aged <5 years. Most community-acquired rotavirus gastroenteritis occurs in children aged <2 years, and a high proportion occurs in infants aged <6 months. Cases were also observed among very young infants <2 months of age. Rotavirus vaccination is expected to have a major impact in reducing morbidity and the pressure on hospital services in Europe.

Trichobézoard : à propos de 5 observations

Trichobezoars are made up of concretions of ingested hair and food. A history of occlusive syndrome in a context of trichotillomania and psychological problems must lead to this diagnosis. Bezoars can be fortuitously recognised by palpation of an epigastric abdominal mass while investigating anemia or esophageal reflux. This deviance is particularly dangerous. The first case of this series illustrates the Rapunzel syndrome with many perforations and necrosis of the small bowel. The 4 others are strict intragastric bezoars, quickly identified by echography. Treatment is exclusively surgical, digestion by papain or endoscopic extraction being impossible. Psychological assistance is mandatory.

Development and evaluation of Chlamylege, a new commercial test allowing simultaneous detection and identification of Legionella, Chlamydophila pneumoniae, and Mycoplasma pneumoniae in clinical respiratory specimens by multiplex PCR

This study describes the development and evaluation of a new commercial test, Chlamylege (Argene Inc.), which allows the simultaneous detection in respiratory samples of Chlamydophila pneumoniae, Mycoplasma pneumoniae, and most Legionella species, as well as PCR inhibitors, by using a multiplex PCR and microplate hybridization. The sensitivities of Chlamylege were 1 x 10(-3) IFU, 5 x 10(-2) color-changing units, and 1 CFU per reaction tube for C. pneumoniae, M. pneumoniae, and Legionella pneumophila, respectively. A cohort of 154 clinical samples from patients with documented respiratory infections was analyzed by the kit, including 2 samples from patients with C. pneumoniae infection, 9 samples from patients with M. pneumoniae infection, 19 samples from patients with Legionella species infection, and 114 samples that tested negative for the three pathogens. All the positive specimens were correctly detected and identified by the Chlamylege kit, and no false-positive result was observed with the negative samples. The kit was then evaluated in a pediatric prospective study that included 220 endotracheal aspirates, and the results were compared with those obtained by three single in-house PCR assays. Four specimens were found to be positive for C. pneumoniae and six were found to be positive for M. pneumoniae by using both strategies. The Chlamylege kit detected two additional samples positive for M. pneumoniae and one additional sample positive for a Legionella species other than L. pneumophila; these three samples were shown to be true positive by other techniques. These overall results demonstrate that the Chlamylege assay is sensitive, specific, and convenient for the rapid detection and identification of atypical pathogens in clinical samples from patients with respiratory infections.