Optimized workflow to minimise intra-fractional motion during stereotactic body radiotherapy of spinal metastases.

Background and purpose: This study evaluated translational and rotational intra-fractional patient movement during spinal stereotactic body radiotherapy (SBRT) using 6D positioning based on 3D cone beam computerized tomography (CBCT) and stereoscopic kilovoltage imaging (ExacTrac). The aim was to determine whether additional intra-fractional image verification reduced intra-fractional motion without significantly prolonging treatment time, whilst maintaining acceptable imaging related dose. Materials and methods: A retrospective analysis of 38 patients with 41 primary tumour volumes treated with SBRT between September 2018 and May 2021 was performed. Three different image-guided radiotherapy (IGRT) workflows were assessed. The translational and rotational positioning errors for the different imaging workflows, 3D translational vectors and estimates of imaging dose delivered for the different imaging workflows were evaluated. Results: As the frequency of intra-fractional imaging increased from workflow 1 to 3, the mean intra-fraction 3D translational vector improved from 0.91 mm (±0.52 mm), to 0.64 (±0.34 mm). 85 %, 83 % and 97 % of images were within a tolerance of 1 mm/1° for workflows 1, 2 and 3 respectively, based on post treatment CBCT images. The average treatment time for workflow 3 was 13 min, as compared to 12 min for workflows 1 and 2. The effective dose per treatment for IGRT workflows 1, 2 and 3 measured 0.6 mSv, 0.95 mSv and 1.8 mSv respectively. Conclusion: The study demonstrated that the use of additional intra-fractional stereoscopic kilovoltage image-guidance during spinal SBRT, reduced the number of measurements deemed "out of tolerance" and treatment delivery could be optimized within a standard treatment timeslot without applying substantial additional radiation dose.

From the original SARS-CoV-2 strain to the Omicron variant: Predictors of COVID-19 in ambulatory symptomatic children.

OBJECTIVES: To determine the predictors of a positive SARS-CoV-2 test in a pediatric ambulatory setting. PATIENTS AND METHODS: We performed a cross-sectional prospective study (November 2020-February 2022) of 93 ambulatory settings in France. We included symptomatic children < 15 years old tested for SARS-CoV-2. For each period corresponding to the spread of the original strain and its variants (period 1: original strain; period 2: Alpha, period 3: Delta; period 4: Omicron), we used a multivariate analysis to estimate adjusted odds ratios (aORs) associated with COVID-19 among age, signs, symptoms or contact, and 95 % confidence intervals (95CIs). RESULTS: Of 5,336 children, 13.9 % (95CI 13.0-14.8) had a positive test. During the first three periods, the positivity rate ranged from 5.6 % (95CI 4.6-6.7) to 12.6 % (95CI 10.8-14.6). The main factors associated with a positive test were contact with an infected adult at home or outside the home (aOR 11.5 [95CI 4.9-26.9] to 38.9 [95CI 19.3-78.7]) or an infected household child (aOR 15.0 [95CI 4.8-47.1] to 28.4 [95CI 8.7-92.6]). By contrast, during period 4, aORs for these predictors were substantially lower (2.3 [95CI 1.1-4.5] to 5.5 [95CI 3.2-7.7]), but the positivity rate was 45.7 % (95CI 42.3-49.2). CONCLUSIONS: In pediatric ambulatory settings, before the Omicron period, the main predictor of a positive test was contact with an infected person. During the Omicron period, the odds of these predictors were substantially lower while the positivity rate was higher. An accurate diagnostic strategy should only rely on testing and not on age, signs, symptoms or contact.

Training of pediatricians in infectious diseases in France: survey among pediatricians enrolled in the French infectious diseases training program: Training of pediatricians in infectious diseases in France.

The French infectious diseases (ID) program was accessible to all medical trainees enrolled in postgraduate training for other specialties until 2017, when it became an independent specialty. Therefore, the national ID training is no longer accessible to pediatricians, and a specific program for pediatric ID (PID) is under development. We conducted a survey among French pediatric trainees enrolled in the former ID training to assess their satisfaction and describe the barriers they may have faced during the training. A questionnaire was sent in October 2018 to all pediatricians enrolled in this curriculum. Among the 17 trainees who replied, almost half (8/17) described the ID training as being hardly accessible to pediatricians, and six reported difficulties in finding a mandatory one-year position in an ID department to complete their training. Future training in PID should address these issues.

[The Script Concordance Test: A multimodal teaching tool]. / Le test de concordance de script : un outil pédagogique multimodal.

In recent years, there has been a major interest in assessing learners during their medical education. The core of medical competence is the clinical reasoning that should be acquired by all medical actors. Its assessment includes the ability to integrate and apply different types of knowledge, weigh critical evidence and think about the process used to have a diagnosis. French faculties of medicine will have to include it in the training and evaluation of students during 2017. It should therefore be part of the new docimological modalities of the computerized "Épreuves Classantes Nationales" from 2020 onwards. In this article, we did a specific review of the literature concerning the theoretical foundations, methodology and use of Script Concordance Test (SCT) in the field of health. To do so, we used the PubMed, EMBASE and PsycINFO databases and selected articles in English and French language using the following keywords alone or in combination: script, concordance, script concordance test, medical studies, validity, fidelity, psychometric properties. We have found 62 articles that matched our search. Built on a well-targeted methodology, the SCT is a reliable and valid pedagogical tool. It can discriminate the levels of practice between medical students, residents and medical doctors, evaluate the progression and skills of clinical reasoning. It can be administered online, in multicentric centers, at a national or international level. There are, however, limitations that teachers must take into account.

[Evaluating a child after a febrile seizure: Insights on three important issues]. / Évaluation d'un enfant après une crise fébrile : focus sur trois problèmes de pratique clinique.

Febrile seizures (FS) are the most common seizures seen in the paediatric population in the out-of-hospital and emergency department settings, and they account for the majority of seizures seen in children younger than 5 years old. An FS is a seizure accompanied by fever, without central nervous system infection, occurring in children between 6 months and 5 years old. Five criteria have been used and taught to classify any FS as simple or complex FS. These factors do not bear the same significance for clinical practice, in particular, the decision to perform a lumbar puncture for cerebrospinal fluid analysis to rule out an intracranial infection. Moreover, epidemiological studies have illustrated that some factors are predictive of febrile seizure recurrence while others are predictive of epilepsy occurrence. On this basis, a workshop was organized to provide an answer to three clinical practice questions: when should a lumbar puncture be performed in a child who has experienced a seizure during a fever episode, is the prescription of a rescue drug required with a risk of a prolonged febrile seizure recurrence, when should a neurological consultation be requested (risk of later epilepsy)? Based on a review of the literature and on a 1-day workshop, we report here the conclusion of the working group. A lumbar puncture is required in any child with meningitis symptoms or septic signs or behaviour disturbance. A lumbar puncture should be discussed based on the clinical symptoms and their progression over time when a child has experienced a focal FS or repetitive FSs without signs of meningitis or sepsis or behaviour disturbance. The lumbar puncture is not necessary in case of simple FS without signs of meningitis, including in infants between 6 and 12 months old. An early clinical evaluation (at least 4 h after the first clinical assessment) could be helpful, in particular in infants younger than 12 months of age. A rescue drug might be prescribed when there is a high risk of prolonged FS (i.e., risk higher than 20%): age at FS<12months OR a history of a previous febrile status epilepticus OR if the first FS was a focal seizure OR abnormal development/neurological exam/MRI OR a family history of nonfebrile seizure. A neurological consultation should be requested for any child who has experienced a prolonged FS before the age of 1 year, for children who have experienced prolonged and focal FS or repetitive (within 24h) focal FS, for children who have experienced multiple complex (focal or prolonged or repetitive) FS, for children with an abnormal neurological exam or abnormal development experiencing a FS. Although childhood febrile seizures in most cases are benign, witnessing such seizures is always a terrifying experience for the child's parents. Most parents feel that their child is dying or could have severe brain injury related to the episode. Therefore, the group also suggests a post-FS visit with the primary care physician.

[Teaching pediatrics to residents via conventional lectures in France: A national survey from students]. / Enseignement théorique du Diplôme d'études spécialisées de pédiatrie en France : évaluation nationale par les internes.

OBJECTIVE: To assess the point of view of young physicians training in pediatrics in France on their theoretical courses during residency. METHODS: A free-access electronic anonymous survey was sent three times by e-mail to the 1215 residents in pediatrics, from July to October 2015. RESULTS: Fifty-seven percent of French residents in pediatrics responded to the survey. It was established that they took part in six (range, 3-10) half-days of specific theoretical teaching in pediatrics from November 2014 to mid-April 2015. Only 54% participated in more than 75% of regional theoretical training. The main self-declared reason for their absence was that they could not leave their clinical activities. Fifty-three per cent of the residents took part in additional training, 45% of them because they found the primary theoretical training insufficient. The overall quality of the theoretical teaching was rated 5 (range, 3-7) out of 10. Eighty-five percent of residents expected to be evaluated on their knowledge during their residency. CONCLUSION: In pediatrics, additional training is individually undertaken because they deemed their initial training insufficient during their residency. An evaluation of knowledge is requested by residents. The reform of the national residency program must take into account these results in redesigning the theoretical training in pediatrics, integrating innovative teaching techniques to daily practice, for example.

A midstream urine collector is not a good alternative to a sterile collection method during the diagnosis of urinary tract infection.

AIM: Guidelines recommend collecting urine with suprapubic aspiration or urethral catheterisation in infants with a suspected urinary tract infection (UTI), but the invasiveness of these methods continues to drive research on new urine collection devices. We studied children with a suspected UTI, who had not been toilet trained, to compare a new midstream urine collector and catheterisation. METHOD: During this prospective controlled diagnosis study of 94 children, urine collection was performed using the midstream collector and then controlled via catheterisation when the urine dipstick was positive. RESULTS: When end stream samples collected by the midstream collector were compared to catheter samples, the results were inconsistent in 23.4% of cases, similar to the inconsistent results between first stream samples discarded by the device and the catheter samples (21.3%). Interestingly, the overall rate of sample contamination in the bag of the midstream collector was lower than that reported in previously published studies and there were no false positive bag results. CONCLUSION: The midstream collector did not appear to provide additional benefits to classic collection bags. A sterile collection method, such as suprapubic aspiration, catheterisation or clean catch, is still mandatory for diagnosing urinary tract infections in children who are not toilet trained.

Impact of 2011 French guidelines on antibiotic prescription for acute otitis media in infants.

OBJECTIVE: In 2011, new guidelines on antibiotic prescription for acute otitis media (AOM) were published in France to decrease the use of third generation cephalosporins that promote the carriage of extended-spectrum beta-lactamase producing Escherichia coli. Our objective was to assess the impact of the 2011 French recommendations on the type of antibiotics prescribed for AOM. METHODS: Fourteen thousand six hundred and sixty-one children, 6 to 24 months of age, presenting with AOM were included in 2 studies, between November 1, 2009 and October 31, 2012. The first one was conducted with the support of 62 private practice pediatricians; the second one was conducted in 7 pediatric emergency departments. Three periods of 1 year each were defined. RESULTS: Antibiotics were prescribed in 12,471 (85.1%) of cases of AOM during the study period. Amoxicillin prescriptions was multiplied by 25, between the first year (2.6%) and the last year (66.1%). Conversely, prescriptions of cefpodoxime proxetil and amoxicillin-clavulanic acid decreased from 33.6% and 62.0% in the first year to 5.2% and 27.7% in the last year, respectively. This trend was observed in both private practices and in the pediatric emergency departments. CONCLUSION: Amoxicillin became the most frequently prescribed antibiotic for AOM in 2012, complying with the 2011 French guidelines, while the proportion of prescribed broad-spectrum antibiotics decreased. Our study highlights the importance of guidelines to decrease the prescription of broad-spectrum antibiotics, a crucial factor in the prevention of antibiotic resistance.

Survey of vaccination policies in French healthcare institutions.

OBJECTIVE: The survey was implemented to describe vaccination policies for healthcare professionals in French healthcare institutions. METHODS: A cross-sectional survey based on questionnaires was sent to occupational physicians and chairpersons of hospital infection prevention and control committees (HIPC) of 38 institutions between November 2010 and January 2011. RESULTS: Twenty-nine occupational physicians and 26 hospital infection prevention and control committees chairpersons (HIPC), from 30 institutions answered (response rate: 79%), 70% of the institutions were university hospitals. Overall, 76% of occupational physicians and 85% of HIPC chairpersons reported that information and awareness campaigns about vaccination recommendations for healthcare professionals were usually conducted in their establishment. Fifty-nine percent of occupational physicians and 31% of HIPC chairpersons reported that they were aware of the vaccine coverage rates of professionals in their institution. The occupational physicians reported that they suggested diphtheria, tetanus, polio, influenza, and acellular pertussis vaccination to all staff at their annual visit in 100%, 97%, and 62% of cases, respectively. Varicella and measles vaccinations were never suggested in 31% and 17% of cases, respectively. Among respondents, 55% of physicians reported that they had already managed a pertussis epidemic, and 42% a measles epidemic, and in both of these cases an awareness campaigns were usually conducted (93% and 96%). CONCLUSIONS: The vaccine coverage rates of healthcare professionals in French healthcare institutions remain insufficiently documented and could be improved.

[Pertussis in adults in the maternity ward: management and prevention for protecting newborns and infants]. / Prise en charge de la coqueluche chez l'adulte en maternité pour préserver les nourrissons.

Pertussis is a potentially serious illness in very young infants. The growing number of cases encountered in the past few years is partly explained by the loss of immunity, either natural or post vaccinal. To prevent the occurrence of pertussis in newborns and very young infants, it is mandatory to ensure compliance with vaccination recommendations regarding the general population (vaccination of young adults likely to have a child, of fathers and siblings during pregnancies, of mothers soon after birth), as well as professionals in contact with infants too young to have received their three doses of primary vaccination (diphtheria-tetanus-polio-pertussis booster may be performed as soon as the latest is more than two years). Obstetricians, midwives and pediatricians are directly concerned by this vaccinal strategy, owing to their prominent place in both informing couples during pregnancy and after delivery, and performing maternal vaccines soon after birth.

[What evidence for chest physiotherapy in infants hospitalized for acute viral bronchiolitis?]. / Place actuelle de la kinésithérapie respiratoire dans la prise en charge de la bronchiolite aiguë du nourrisson hospitalisé

This article updates the respiratory physiotherapy technique used in France, and the rationale for its use. This paper reports the results of a recent randomized clinical trial that did not show any efficiency of respiratory physiotherapy (using increased expiratory acceleration) in infants hospitalized for a first episode of bronchiolitis. Further trials are necessary for evaluating this technique in infants who are not hospitalized.

Inter-observer agreement between physicians, nurses, and respiratory therapists for respiratory clinical evaluation in bronchiolitis.

Care providers for children with bronchiolitis use various tools to evaluate respiratory status. The use of a single tool by different types of care provider requires a high level of inter-observer agreement, an aspect rarely studied. This study, involving 82 physicians, nurses, and respiratory therapists aimed to evaluate inter-observer agreement for clinical evaluations in children hospitalized for a first episode of bronchiolitis. Respiratory evaluation included three frequently reported parameters of respiratory status: respiratory rate, retraction signs, and wheezing. The frequency of concordance for observers from the same and from different care provider groups was assessed using a weighted kappa statistic and considering all possible combinations of care providers. We also calculated inter-provider agreement as a function of patient age, regardless of care provider type. Overall inter-observer agreement for all provider pairs was 93.1%, with a weighted kappa statistic of 0.72 (95% CI, 0.66-0.78), indicating substantial agreement, with no difference as a function of pair composition. Inter-observer agreements for the various age groups ranged from 87% to 93%, with kappa scores ranging from 0.62 to 0.78. We conclude that a simple clinical evaluation for respiratory status assessment has a high level of inter-observer agreement within and between physicians, nurses and respiratory therapists. Thus, once the validity of this test has been confirmed in a large population sample, it should be possible to use this test to monitor children hospitalized with bronchiolitis and as an endpoint in clinical trials.

Detection of DNA damage: effect of thymidine glycol residues on the thermodynamic, substrate and interfacial acoustic properties of oligonucleotide duplexes.

Thymidine glycol residues in DNA are biologically active oxidative molecular damage sites caused by ionizing radiation and other factors. One or two thymidine glycol residues were incorporated in 19- to 31-mer DNA fragments during automatic oligonucleotide synthesis. These oligonucleotide models were used to estimate the effect of oxidized thymidines on the thermodynamic, substrate and interfacial acoustic properties of DNA. UV-monitoring melting data revealed that modified residues in place of thymidines destabilize the DNA double helix by 8-22 degrees C, depending on the number of lesions, the length of oligonucleotide duplexes and their GC-content. The diminished hybridizing capacity of modified oligonucleotides is presumably due to the loss of aromaticity and elevated hydrophilicity of thymine glycol in comparison to the thymine base. According to circular dichroism (CD) data, the modified DNA duplexes retain B-form geometry, and the thymidine glycol residue introduces only local perturbations limited to the lesion site. The rate of DNA hydrolysis by restriction endonucleases R.MvaI, R.Bst2UI, R.MspR9I and R.Bme1390I is significantly decreased as the thymidine glycol is located in the central position of the double-stranded recognition sequences 5'-CC / WGG-3' (W = A, T) or 5'-CC / NGG-3' (N = A, T, G, C) adjacent to the cleavage site. On the other hand, the catalytic properties of enzymes R.Psp6I and R.BstSCI recognizing the similar sequence are not changed dramatically, since their cleavage site is separated from the point of modification by several base-pairs. Data obtained by gel-electrophoretic analysis of radioactive DNA substrates were confirmed by direct spectrophotometric assay developed by the authors. The effect of thymidine glycol was also observed on DNA hybridization at the surface of a thickness-shear mode acoustic wave device. A 1.9-fold decrease in the rate of duplex formation was noted for oligonucleotides carrying one or two thymidine glycol residues in relation to the unmodified analog.

[Awareness and application of vaccine recommendations for chickenpox in French Nurse Schools]. / Connaissance et application des recommandations vaccinales concernant la varicelle en institut de soins infirmiers en France.

Since 2004, the French High Committee on Public Hygiene has recommended chickenpox vaccination for first-year medical or paramedical students with no history of chickenpox and with negative serology. A survey was carried out among directors of nurse schools to evaluate both their awareness of these new recommendations and the way in which they had been applied. A questionnaire was sent by mail to each of the directors of the 332 nurse schools identified throughout France. Less than half (41%) of the 147 directors who responded said they were aware of recommendations, and 31% stated they had real knowledge of the recommendations. Only 21% enquire about chickenpox history of students enrolling in their school, and 9% undertake serological assessment of students with no known history of varicella or zoster. More needs to be done both to inform nurse school directors of the vaccine recommendations and to ensure their application.

[Factors predicting serious bacterial infections in febrile infants less than three months old: multivariate analysis]. / Facteurs prédictifs de la présence d'une infection bactérienne sévère chez les nourrissons fébriles âgés de moins de trois mois: analyse multivariée.

AIM: To identify predictive factors of the presence of a serious bacterial infection (SBI) in febrile infants less than three months old. METHODS: Retrospective analysis of the medical files of 315 consecutive consultations of febrile infants less than three months old in the pediatric emergency department of a French hospital, with logistic regression multivariate analysis of the different criteria routinely considered and C-reactive protein (CRP). RESULTS: SBI were diagnosed in 79 (25.1%) infants, primarily urinary tract infections (71; 22.5%). One of these 79 children had pneumococcal meningitis but met the classical criteria for low risk of SBI: he died because antibiotics were not prescribed sufficiently early. Factors significantly associated with SBI were: male sex; temperature >38.5 degrees C and lasting >24 hours; poor general condition; absence of ear, nose and throat symptoms; high white blood cell count with >50% neutrophils; and serum CRP concentration >20 mg/l. Multivariate analysis entering all these items retained only the latter two (respectively, OR: 13.5, 95% CI: [6.5-28.2] and OR: 2.9; 95% CI: [1.3-6.3]). CRP <20 mg/l and <50% neutrophils had a negative-predictive value of 93.1% for the absence of SBI. CONCLUSIONS: At present, no factor(s) is(are) able to predict with 100% accuracy the absence of SBI in febrile infants less than three months old. The risk of severe sequelae or death caused by untreated SBI would seem to justify the prescription of antibiotics until microbacterial culture results become available.