Régulation médicale de la dyspnée de l’enfant : intérêt d’une régulation pédiatrique

Introduction :L’évaluation téléphonique du patient pédiatrique peut être difficile à la régulation médicale du Samu-Centre 15 (aide médicale urgente [AMU] ou permanence de soins [PDS]). La dyspnée est un motif d’appel fréquent dans cette population et présente des particularités importantes comparée à la population adulte. Nous avons voulu évaluer la pertinence de l’évaluation téléphonique de la dyspnée en pédiatrie selon la qualification du médecin régulateur (urgentiste, généraliste ou pédiatre).

Matériel et méthode :Il s’agit d’une étude observationnelle rétrospective monocentrique menée au Samu de Haute-Garonne entre le 1er décembre 2018 au 31 janvier 2019. Les critères d’inclusion étaient un appel pour tout patient avec un âge inférieur à dix ans pour dyspnée. Le critère de jugement principal était le surtriage.

Résultats : Nous avons analysé 717 appels pour dyspnée pédiatrique sur la période. La non-adéquation entre la décision médicale et le devenir du patient était retrouvée chez 174 patients (24 %) : 173 patients (99 %) étaient surtriés et un patient était sous-trié (< 1 %). En analyse multivariée, les facteurs protecteurs de surtriage étaient l’âge de six mois à trois ans (OR = 0,56 ; IC 95 % = [0,36–0,86]) comparé à un âge jeune (≤ 6 mois ; référence) et l’évaluation par un régulateur de PDS (OR = 0,38 ; IC 95 % = [0,23–0,62]) ou pédiatre (OR = 0,54 ; IC 95 % = [0,34–0,86]) comparé à un régulateur de l’AMU (référence). L’appel nocturne était un facteur de risque de surtriage (OR = 1,98 ; IC 95 % = [1,39–2,84]).

Conclusion : La régulation par un pédiatre ou un médecin de la PDS permet de réduire le surtriage dans un centre où les régulateurs AMU n’ont pas d’activité pédiatrique clinique.

[Surgical treatment of Obstructive Sleep Apnea Syndrome. Functional assessment]

INTRODUCTION

Obstructive Sleep Apnea Syndrome (OSAS), when associated with adverse skeletal dysmorphia, can be managed by curative surgery i.e. advanced maxillomandibular associated with genioplasty and uvulopalatoglossoplasty ("6 in 1"). The purpose of this study was to assess the functional impact of this procedure.

MATERIALS AND METHODS

This retrospective study was made on 27 patients with OSAS surgically treated between 1998 and 2009. The functional results were considered satisfactory when postoperative apnea/hypopnea index (AHI) was <15/h and/or at least decreased by 50%.

RESULTS

After surgical treatment, the AHI dropped below 15/h for 70.4%, and for 92.6% it was at least decreased by 50%, one year after surgery. A significant concomitant decrease of the body mass index (BMI) was also observed.

DISCUSSION

This "6 in 1" surgical management seemed to effectively treat OSAS in the selected cases.

[Guillain-Barré syndrome in a child with normal tendon reflexes]

We describe the case of a 10-year-old child with the acute motor axonal neuropathy (AMAN) form of Guillain-Barré syndrome (GBS) with preserved tendon reflexes, 6 days after a bout of gastroenteritis. The child quickly showed weakness of the distal muscles of his four limbs, with preserved tendon reflexes and a raised CSF protein concentration with no cells. Nerve conduction studies showing motor axonal degeneration confirmed the diagnosis of GBS in spite of preserved tendon reflexes. The serum was positive for IgG antibodies to gangliosides GM1 and GD1b. The child received intravenous immunoglobulins, which resulted in a favorable progression. This case proves that GBS with normal tendon reflexes exists. The other cases of SGB with preserved tendon reflexes already described in the literature were the AMANs form with antibodies to gangliosides in the serum and only adults were affected.

[Treatment and prognosis of idiopathic intracranial hypertension in children. Retrospective study (1995-2009) and literature review]

AIM

Idiopathic intracranial hypertension (IIH) may cause severe visual loss due to the optic nerve damage. Routine management involves mainly medical treatment. The aim of this study was to improve diagnosis and management of IIH in children.

METHODS

The medical records of all patients with definite IIH seen at the children's hospital of Toulouse between 1995 and 2009 were reviewed. Cases of secondary intracranial hypertension were included because they did not present any cerebral lesions and underwent a similar therapeutic approach. The clinical and ophthalmological data at the beginning and at the end of their treatment was collected.

RESULTS

Eighteen children were included in this study. The average age was 10 years and the sex-ratio was equal to 1. There were 3 cases of secondary idiopathic intracranial hypertension in this pediatric group. The main features encountered were headache (15 children) and diplopia (8 children). Abnormal neurological examination was found for 11 patients with abducens nerve paresis in 8 cases, rachialgia in 6 cases, and neurogenic pains (neuralgia, dysesthesia, paresthesia, hyperesthesia) in the other cases. Papilledema was noted in 16 patients. At the initial phase, loss of visual acuity was documented in 6 patients and altered visual field in nine patients. All patients had a medical treatment. When recurrence occurred, each new treatment was documented, for a total of 23 treatments analyzed. Lumbar puncture was the only treatment for 2 patients. In 16 cases, first-line treatment was acetazolamide and it was the second choice in 1 case, with an average dosage of 11.2mg/kg and a mean duration of 2.5 months (15 treatments could be analyzed). This treatment was effective in 11 cases out of 15. Steroids were the initial treatment in 4 cases and second-line treatment in 4 cases (after failed acetazolamide therapy). The dosage was 1.5-2mg/kg for a mean duration of 1.5 months (6 treatments could be analyzed). This treatment was effective in 5 patients out of 6. One patient had dual therapy. No surgical procedure was necessary in this pediatric cohort. Three patients presented relapses of IIH. The outcome was good with no residual visual impairment in the 13 patients analyzed. One patient was still under medication.

COMMENTS

Therapeutic management of IIH in a pediatric population is essentially medical, in some cases limited to lumbar puncture. The first-line treatment is acetazolamide, but this study shows that low doses and short duration are usually chosen. Doses must be increased and treatment prolonged to avoid the use of corticosteroids as a second-line treatment and prevent possible relapses that require close monitoring of visual function.

CONCLUSION

The visual prognosis is generally better for this age group compared to adults and no risk factors for visual sequelae were identified. A standardized protocol for management of IIH was proposed.

Relevance of Traditional CEA and CA15-3 and Bone Turnover Markers in Predicting Bone Relapse in Breast Cancer Patients

Background: Over 50% of breast cancer patients who relapse systemically develop bone metastases. The RANK/RANKL/OPG axis governs osteoclastogenesis and bone reabsorption. In particular, osteoprotegerin (OPG) is a decoy receptor of RANK-L (receptor activator of nuclear factor kappa B ligand) and seems to prevent bone destruction by blocking the binding of RANKL with its receptor. We studied the efficacy of circulating OPG compared to the traditional markers CEA and CA15-3 for the early detection of bone lesions.Methods: The study was carried out on peripheral blood from 72 patients with breast cancer, of whom 33 were disease-free and 39 had bone metastases. The OPG transcript was determined using quantitative PCR analysis, and the traditional markers were quantified by immunoenzymatic assays.Results: The OPG median value was higher in disease-free patients (median = 1.7, 0.4-8.9) than in bone-relapse patients (median = 0.6, 0.1-5.2) (p&lt;0.001). CEA and CA15-3 median values were 1.3 (0.0-8.3) ng/ml and 10.6 (0-45.7) U/ml, respectively, in disease-free patients and 4.8 (0.0-90.6) ng/ml and 69.8 (7-1538) U/ml, respectively, in patients with bone metastases (p&lt; 0.0001 for both markers). Considering 0.9 as cut off of OPG relative expression, our analyses revealed a specificity of 88% with respect to 97% for CEA and 94% for CA15-3. OPG sensitivity was 73% compared to only 49% for CEA and 67% for CA15-3. When OPG was considered in combination with the traditional markers, sensitivity increased from 49% to 83% for CEA and from 67% to 88% for CA15.3.Conclusions: Our results on a preliminary series of breast cancer patients indicate that the bone turnover marker OPG greatly increases CEA and CA15-3 sensitivity in predicting bone metastases.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3027.

Potential usefulness of OPG, a member of the tumor necrosis factor receptor superfamily, for the early diagnosis of bone metastasis in breast cancer patients

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Background: Breast cancer is the most frequent tumor in women. About 80% of patients with metastatic disease present bone involvement, in which the OPG/RANKL/RANK system would seem to play an important role. Our aim was to evaluate the potential usefulness of OPG bone marker for the early diagnosis of bone metastases. Methods: The study was carried out on 120 individuals: 30 healthy donors, with a median age of 40 years (21–76) and 90 breast cancer patients, with a median age of 57 years (30–86). Among patients, 49 were disease-free (median age 52 years) and 41 were at first diagnosis of bone metastases (median age 63 years). OPG transcript was determined in peripheral blood samples using quantitative PCR analysis. A receiver operating characteristic (ROC) curve was used to calculate the diagnostic accuracy of the marker. Results: OPG values were not correlated with age in any of the subgroups. The OPG median value was not statistically different in healthy donors (median=1.9; range 0.6–4.7) and disease-free patients (median=1.7; range 0.4–8.9), whereas it was threefold higher than that observed in relapsed patients (median=0.6; range 0.1–5.2; p<0.001), regardless of the number of metastatic sites. The area under the curve (AUC) in disease-free patients was 0.82 for OPG, with 71% sensitivity and 88% specificity, using a cut off ≤ 0.8. In a parallel analysis of 37 patients (14 disease-free and 23 with bone metastases) for whom CEA and CA15.3 information was available, specificity for each marker was 100%, whereas sensitivity was only 61% and 59%, respectively. When these markers were considered in combination with OPG, an increase in sensitivity, albeit not statistically significant, was observed for CEA (83%) and CA15.3 (82%). Conclusions: Our preliminary data show a potential role of the OPG bone turnover marker for the early diagnosis of bone metastases. Results now need to be confirmed in a larger case series.

No significant financial relationships to disclose.

Survey of the sociodemographic and motivational profile of volunteers in oncology

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Background: The volunteer sector developed rapidly in Italy throughout the 1980s, especially in the areas of cancer and palliative care. Istituto Oncologico Romagnolo (IOR), a non profit organization based in Forlì, actively supports the public health sector in the fight against cancer by funding scientific research, organizing voluntary work, promoting education campaigns, and setting up prevention and screening programs. The aim of the present work is to trace a sociodemographic and motivational profile of IOR volunteers. Methods: In May 2005, all IOR volunteers were invited to complete an anonymous questionnaire composed of 12 structured questions designed to collect sociodemographic data, information on type of voluntary work done and the reasoning behind such a choice. Results: Of IOR’s 1043 volunteers, 471 completed the questionnaire, of whom 70% were female and about one-third over 65 years of age. The majority of professions were represented, even though about two-thirds of men and half of the female volunteers were retired. About 40% of the group had been doing voluntary work for more than 10 years. Although fund-raising proved to be the most frequent activity (80%), there is a growing number of volunteers, especially those of a younger age group, involved in home- and hospital-based care. Various reasons were given for becoming a IOR volunteer: ethical considerations (35 % males and 28% females), personal experiences (24% and 38%, respectively), high regard held for IOR and its work (31 and 26%, respectively), and involvement directly through other volunteers (29 and 36%, respectively). Conclusions: The major involvement in fund-raising and perseverance over time of volunteers indicate a favorable social perception of medical research. It also emerged that the decision to start voluntary work was often closely linked to a previous personal experience of loss or disease, especially in female volunteers, who tend to react more constructively and develop a more active and concrete solidarity than men. We can therefore conclude that volunteers in the area of cancer act out of a sense of responsibility and awareness rather than out of pity or a desire for self-gratification.

No significant financial relationships to disclose.

Breast cancer (BC): May intra-arterial (IA) chemotherapy (CT) play a role in the treatment of locally advanced disease or liver metastases? Report of our experience

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Background: IA infusion of CT increases drug concentrations within a tumor. We investigated if it is effective in BC patients (pts) with locally advanced disease or liver metastases. Methods: Twenty-five pts were treated with IA CT using angiographic technique in the Department of Medical Oncology, Morgagni-Pierantoni Hospital in Forlì. Pts received a short IA infusion through the proper hepatic artery (liver metastases) or the internal mammary artery (locally advanced disease). Drugs were: Epirubicin (EPI) 30 mg/m2, Mitomycin-c (MMC) 7 mg/m2 and 5-fluoruracil (5FU) 1000 mg on day 1 every 21 days. EPI was not administered in anthracycline pretreated pts. Results: Median age was 54.3 years (31–75 years) and ECOG Performance Status (PS) was ≤2. Nine pts had liver metastases and 16 had locally advanced disease. Twenty-three (96%) of the 25 pts had received adjuvant treatment (21 CT, 7 endocrine therapy), 20 (80%) had had at least one treatment for metastatic disease (20 CT, 11 endocrine therapy, 8 radiotherapy), and 11 pts (40%) had received concomitant therapy (3 CT and 8 endocrine). Fifteen pts were anthracycline-naïve. A total of 88 angiographic sessions were carried out, with a median number of 3.5 cycles per patient (1–8 cycles). One transitory ischaemic attack occurred during angiographic procedure . No other serious complications were observed. The only cases of toxicity higher than grade 2 were one grade III neutropenia and one grade IV thrombocytopenia. A dose reduction was necessary in 4 pts (2 due to PS, 1 to toxicity and 1 to pre-treatment) and treatment was interrupted in 4 pts (2 due to PS, 1 to early progression and 1 to technical problems). Among the 19 pts assessable for response, 13 (68%) had a partial response, 2 (11%) showed stable disease and 4 (21%) progressed. Median time to progression and median overall survival will be given. Conclusions: Our results suggest that IA CT may play a role in the treatment of advanced pre-treated BC pts.

No significant financial relationships to disclose.

Intra-arterial chemotherapy for liver metastases from colorectal cancer

The aim was to investigate whether intra-arterial infusion of chemotherapy improves response to treatment in unresectable liver metastases from colorectal cancer. We treated 14 patients (pts) with intra-arterial chemotherapy. Arterial catheters were placed via percutaneous access. Treatment schedule was: 5-FU and mitomycin-C on day 1 every 21 days. Six pts also received from day 3 for 5 days, a continuous intra-arterial 24-hr infusion of interleukin-2 (IL-2). We had only one case of toxicity drug-related > grade 2 (neutropenia). We observed 2 partial response (PR) and 5 stable disease (SD). Median time to disease progression (TTP) and median survival (OS) were, respectively 4 and 15 months.

[Bilateral compartment syndrome after colorectal surgery in the lithotomy position]

Lower limb compartment syndrome is an unusual but severe complication of prolonged surgery more than four hours in lithotomy position. It is usually a consequence of hypoperfusion of the lower extremities and muscle necrosis may occur. Several risk factors are pointed out: trendelenburg, the hardness of operating table, hypothermia, control hypotension, occlusion of arterial blood flow of the lower extremity, arteritis (and smoking), diabetes, obesity, arterial hypertension, myopathy and an important muscle mass. The symptoms are postoperative pain with neurological signs. A rapid diagnosis and aggressive management (i.e. resuscitation and aponevrotomy) is recommended. Neurological sequelae are sometimes invalidating. Reporting a case of bilateral syndrome, we reviewed the literature and describe the present diagnosis and therapeutic management as well as prevention modalities of this iatrogenic complication.

[Cystic dystrophy of heterotopic duodenal pancreas]

Cystic dystrophy of heterotopic pancreas is characterized by the presence of cystic formations in the duodenal wall with or without associated pancreatitis. The mechanism by which the cystic dystrophy develops in heterotopic pancreatic pancreas is poorly understood. These lesions are found in young men (40-50 years old) with abusive alcohol intake. The patients are referred for suspected pancreatic neoplasm or for acute pancreatitis. Endoscopic ultrasonography features allow preoperative diagnosis. First line, treatment is medical with parenteral nutrition and octreotide. Then, if the lesions are complicated, surgery (pancreatoduodenectomy or bypass procedure) is indicated.

[Video-laparoscopic diagnosis and follow-up of a peritoneal tuberculosis]

A 21-year-old woman suffering from abdominal pain and a fever of 39 degrees C was hospitalized. Ultrasonography and computed tomographic scan showed a large amount of ascites and one hepatic node. The serum CA 125 level was elevated. Protein Chain Reaction (PCR) searching tuberculosis antigen in ascitic fluid was normal. A diagnosis of peritoneal tuberculosis was supposed and an exploratory laparoscopic procedure performed. Peroperative observation of the ascites, with multiple sites of adhesion, and pathological examination of the hepatic nodule and peritoneum confirmed initial diagnosis. Antituberculous treatment was given for one year. A second laparoscopic procedure was performed and found no disease remaining.