[Impact of the healthcare pathway on the rate of obstetrical interventions in small for gestational age fetuses (IATROPAG Study)]

BACKGROUND

While previous studies have demonstrated an improvement in implementation of clinical practices and an improved neonatal prognosis when growth restricted fetuses were followed within a standardized healthcare pathway, the objective of this study was to assess the prevalence of obstetric interventions in small-for-gestational-age (SGA) fetuses followed within a standardized care pathway compared to a traditional care pathway.

METHODS

We conducted a retrospective study between 2015 and 2017, in a type III maternity hospital in Lyon, in a population of SGA fetuses, considered as such in case of antenatal diagnosis of fetal weight<10th percentile but>3rd centile without umbilical Doppler abnormality during antenatal surveillance and without ultrasound argument suggesting intrauterine growth retardation (IUGR). We collected the gestational age at diagnosis, obstetrical events and prevention of preterm delivery (antenatal corticosteroids), gestation age at birth, the method of delivery (spontaneous or induced), indication of induction, the method of birth (spontaneous, instrumental extraction or caesarean section), and the immediate neonatal outcome including cord pH, Apgar score at 5minutes, birth weight and fetal sex. After diagnosis, the choice of the pathway was left to the practitioner depending on their habit, their ability to manage the follow-up and their organizational constraints.

RESULTS

Over the study period, and after exclusion of IUGR, 96 SGA were followed up in the traditional pathway and 106 SGA were followed up in the standardized pathway P=0.75. The traditional pathway showed in multivariate analysis a higher prevalence of antenatal corticosteroid therapy for SGA (16,6%) between 2015 and 2017 with OR 7.3 95% CI [1.41-38.43] when compared to the standardized pathway (3,7%). Similarly, the traditional pathway proposes a higher prevalence of induction of labor (54,1%) than the standardized pathway (33,9%) between 2015 and 2017 with OR 3.19 95% CI [1.70-7.80]. The "a posteriori" post-hoc power of the study is 82.9%.

CONCLUSION

This study confirms the absence of excessive obstetrical intervention in the SGA population when followed in a standardized healthcare pathway. The latter would reduce unnecessary obstetrical interventions while respecting the intrinsic neonatal prognosis of small for gestational age fetuses.

[Evaluation of the Follow-Up and State of Adolescents with Sickle-Cell Disease in Brazzaville (Congo)]

The experience of the adolescent with homozygous sickle-cell disease is influenced by several factors that differentiate it from the older child entirely dependent on his parents. The objective of this study was to describe the state of health and to assess the quality of follow-up and to identify the determinants of poor monitoring of adolescent sickle-cell followed in Brazzaville for an average of 12 ± 9.6 years, starting from a cross-sectional study carried out at the Brazzaville University Hospital from March to September 2016. It is based on a questionnaire composed of elements of assessment of the state of health and the quality of the follow-up. The vaccination coverage of adolescents was low, 81.3% for DTCP, 66.5% for Typhim Vi, 50.2% for viral hepatitis B, 76.4% for pneumococcus, and 59.1% for the ROR. In the last two years prior to the survey, 99 (48.7%) adolescents had only 2 follow-up visits instead of 4 planned per year. Therapeutic compliance was good in 132 (65%). No hospitalizations were reported during this period in 23 adolescents (11.3%); in 180 cases (88.7%), however, adolescents were hospitalized one to three times apart from regular follow-up visits. Since the discovery of the disease, 177 (87.2%) adolescents had already been transfused, more than three times in 89 cases. A history of neurovascular seizures was found in 10 cases (5.2%) and priapism in 35 cases (18.2%). Paraclinical examinations were not systematic during follow-up visits. The socioeconomic level of the family and the level of education of the father had a negative impact on monitoring and adherence (P < 0.01). On clinical examinations, stunting, undernutrition, pubertal delay, tooth decay, enuresis were found in 45.3%, 36%, 53.7%, 27.6%, 15.3%, respectively. The biological examinations carried out during the investigation showed an average inter-critical hemoglobin level between 7 and 8 g/dl, creatinine level was normal in all cases, ferritinemia was elevated in 93.6%, a negative proteinuria was found in 71.4% of the cases, and hematuria in 26.6%. Systematic abdominal ultrasound revealed vesicular lithiasis in 8 cases, hepatomegaly in 10 cases, and splenomegaly in 102 cases. Echocardiography performed in all subjects showed cardiomyopathy in 9 cases. The follow-up of the adolescent sickle-cell in Brazzaville still faces enormous difficulties. The improvement of the standard of living, the therapeutic education and the introduction of a total free of charge of the global management of sickle-cell disease would make it possible to minimize these difficulties which also would improve the future of these teenagers, adults of tomorrow.

Efficacy and safety of recombinant growth hormone treatment in children with growth retardation related to long-term glucocorticosteroid therapy

OBJECTIVE

To evaluate safety and efficacy of recombinant human growth hormone treatment in children on long-term glucocorticoid therapy.

METHODS

A 5-year prospective open-label study included children on glucocorticoid therapy with either standard deviation score (SDS)<-2 for height for chronological age (CA) if naïve to growth hormone treatment, or annual growth rate≥0 SDS for CA if currently receiving growth hormone.

RESULTS

Ninety-eight patients began treatment, 63 discontinued; 59 were analyzed for safety and 58 for efficacy. There was male predominance (78.0%). Median age was 13.0 years. Median height screening was 136.0cm (range, 95.1-159.7cm). Mean SDS for height for CA in the efficacy analysis set was -2.91±1.19 (range, -7.49 to -0.96). Mean growth hormone dose was 0.4, 0.4, 0.4 and 0.3mg/kg/week at month 0, M12, M24, and M36, respectively. Primary analysis of change in SDS for height for CA from baseline to M36 showed a significant increase of 0.80±1.03. Twenty patients in the safety analysis set had≥1 treatment-emergent adverse event (TEAE) related to study treatment. Two patients experienced serious treatment-related TEAEs: 1 case of poor compliance, and 1 of mild hyperglycemia, both already observed under growth hormone treatment.

CONCLUSION

This study suggests that growth hormone treatment could be effective in increasing height in children on long-term glucocorticoid treatment with a safety profile comparable to that in approved rhGH treatment indications.

CLINICAL TRIAL REGISTRATION

NCT00163189.

[Not Available]

Zusammenfassung. Epidemiologische sowie tierexperimentelle Studien erbrachten den Nachweis, dass ein zu niedriges Geburtsgewicht ein Risikofaktor für kardiovaskuläre Erkrankungen im Erwachsenenalter darstellt. Die Diagnose einer intrauterinen Wachstumsretardierung (IUGR) erfolgt vorgeburtlich mittels Ultraschall. Bei einem Neugeborenen ist die Differenzierung zwischen einer Wachstumsretardierung und einem konstitutionell kleinem Kind schwierig. Hierfür, wie auch für die pathophysiologische Verbindung zwischen einer IUGR und einer späteren kardiovaskulären Erkrankung, ist die Erforschung der physiologischen, endokrinen und morphologischen Anpassungen des Föten an eine Mangelversorgung essenziell.

Challenges of malnutrition care among HIV-infected children on antiretroviral treatment in Africa

More than 90% of the estimated 3.2 million children with HIV worldwide, at the end of 2013, were living in sub-Saharan Africa. The management of these children was still difficult in 2014 despite the progress in access to antiretroviral drugs. A great number of HIV-infected children are not diagnosed at 6 weeks and start antiretroviral treatment late, at an advanced stage of HIV disease complicated by other comorbidities such as malnutrition. Malnutrition is a major problem in the sub-Saharan Africa global population; it is an additional burden for HIV-infected children because they do not respond as well as non-infected children to the usual nutritional care. HIV infection and malnutrition interact, creating a vicious circle. It is important to understand the relationship between these 2 conditions and the effect of antiretroviral treatment on this circle to taking them into account for an optimal management of pediatric HIV. An improved monitoring of growth during follow-up and the introduction of a nutritional support among HIV-infected children, especially at antiretroviral treatment initiation, are important factors that could improve response to antiretroviral treatment and optimize the management of pediatric HIV in resource-limited countries.