Management of febrile infants aged 1 month and less than 3 months in a French university hospital: Clinical practice evaluation.

BACKGROUND: Management of febrile infants is challenging due to the increased risk of serious bacterial infections and it varies among physicians and hospitals. The goals of this study were to describe and compare the management of febrile infants aged 1-2 months in a hospital in 2011 and 2016. METHODS: We conducted a retrospective study in the Bordeaux Pellegrin University Hospital, France, in 2011 and 2016. All infants aged 1-2 months with diagnosis codes referring to fever were included. Data on infant characteristics, fever episodes, clinical symptoms, and management were collected from medical charts. Univariate analyses and multivariate logistic models were used. RESULTS: A total of 530 infants were included; 89.2% had blood testing and 81.1% urine testing; 79.6% of the infants were hospitalized, three of them in the pediatric intensive care unit. The median hospitalization duration was 3 days. In the sample investigated, 59.8% of the infants received antibiotic therapy and 128 (24.1%) had bacterial infections with no difference between 2011 and 2016. The main bacterial infection was pyelonephritis (86.7%). Urethral catheterization was implemented in 2016, whereas a urine bag was utilized for 174 out of 177 infants in 2011. The percentage of contaminated urine cultures was higher in 2011 (35.9%) than in 2016 (19.6%, P<0.001). The hospitalization rate was higher in 2016. CONCLUSIONS: Management of febrile infants changed between 2011 and 2016. The hospitalization rate and antibiotic therapy use remained high regarding the rate of bacterial infection. Use of urethral catheterization decreased the level of contamination.

[Development of a self-administered questionnaire to assess women's satisfaction with maternity care]. / Développement d'un auto-questionnaire évaluant la satisfaction des femmes à l'égard des maternités.

OBJECTIVES: We describe the development and the validation of a French self-administered questionnaire which measures women satisfaction concerning care given during pregnancy. The analysis includes pregnancy monitoring, hospitalization for delivery and homecoming. METHODS: We considered the content validity, internal-consistency and the reproducibility by test-retest estimates. This survey also compared the characteristics of respondents and non-respondents. RESULTS: Response rate was 61% and the rate of reply per question was greater than 90%. Eleven dimensions are identified by principal-components analysis. Ten of them had good Cronbach's alpha coefficients (0.58 to 0.83). The convergence between open comments and questions and between the different methods to measure satisfaction was good. The test-retest estimates for each dimension were correct. CONCLUSION: This questionnaire is reliable. It is a valid tool for evaluation of satisfaction after pregnancy. Designed to be sent to the woman's residence 2 months after childbirth, it can be easily used in common practice.

Laryngeal afferents activated by phenyldiguanide and their response to cold air or helium-oxygen.

In anesthetized cats, sensory neurons in the superior laryngeal nerves (SLN) were identified with respect to their response to (1) phenyldiguanide (PDG) i.v., (2) mechanical stimulation and (3) lowering temperature in an isolated tracheolaryngeal segment. The activity originating from 107 SLN afferent units activated by PDG was recorded using glass microelectrodes advanced in the nodose ganglion. All tested afferent units increased their discharge rate during direct touching of the airway mucosa. None showed flow or pressure related activity during abrupt changes in constant laryngeal flow or transmural pressure in the isolated segment. Fifteen units were inhibited by cold air. Sixty-two units significantly increased their firing rate when the temperature approached 18 degrees C, reached a peak discharge near 15 degrees C, then their activity decreased or stopped. The response to cold air was compared to cold heliox (79% He-21% O2), which enhanced the respiratory heat loss by conduction. The peak firing rate was significantly higher with heliox (+356% compared to +246% with air), the temperature threshold higher (25 degrees C +/- 1.0 degree C) and the temperature range broader (25-11.5 degrees C). Present results show that a large proportion (58%) of afferent SLN fibres activated by PDG are likely non-proprioceptive units, which are stimulated by cooling the inspired gas. Thermosensitive units in the upper airways may act as sensors of the thermal flux through the airway wall more than as detectors of the absolute value of temperature in the airway lumen.

Increased ventilatory chemosensitivity induced by domperidone, a dopamine antagonist, in healthy humans.

Respiratory and cardiovascular effects of domperidone (0.1 mg X kg-1 i.v.) and placebo given on separate test days to eleven healthy volunteers were assessed in a double-blind study. Domperidone caused no significant change in ventilation, heart rate and blood pressure while they were resting and breathing room air. However, it produced an increase in the slope of the hypoxia-induced ventilatory response, from 2.35 +/- 1.10 to 3.71 +/- 2.91 1 X min-1 per 1% decrease in SaO2 (mean +/- SD; p less than 0.05). We conclude that domperidone augments hypoxic responsiveness in humans, presumably by blocking the dopaminergic receptors that modulate the activity of carotid body chemoreceptors, as it does not readily cross the blood-brain barrier.

Breathing discomfort in asthma: role of adaptation level.

In asthmatic patients, Helson's adaptation level theory was applied to breathing discomfort to investigate the discrepancy between the subjective severity of breathlessness and their objective airflow obstruction. The data from a signal detection methodology show a considerable loss of sensitivity in twelve asthmatic patients with permanent airflow obstruction compared to the high sensitivity of six normal subjects to the same four external resistive loads (range 2.5 to 8.0 cmH2O X l-1 X s). Furthermore, when subjective ratings are examined, the absence of any contrast effect between adjacent load intensities in asthmatics suggests that these subjects evaluate the discomfort induced by the loads with reference to a strong internal comparison (adaptation level) rather than to the experimental stimuli. There was no relationship between physiological parameters and the low sensitivity of asthmatics. Also salbutamol-induced bronchodilation in six asthmatics did not improve sensitivity or induce any contrast effect. These two observations bring out the necessity to consider the role of past experience of breathing discomfort on adaptation level and sensitivity.

Role of vagal and spinal sensory pathways in diaphragmatic response to resistive loading.

The effects of severe inspiratory (I) or expiratory (E) resistive loads on diaphragmatic activity were studied in two groups of cats anaesthetized with sodium pentobarbital or ethylcarbamate-chloralose. In intact cats, I or E loading never changed the amplitude of integrated diaphragmatic electric myogram (EMG) measured at 1.0 s (Edi 1.0); only I loading, prolonged the duration of diaphragmatic activity (Tdi). After selective procaine block of non-volume related vagal sensory inputs, I or E loading markedly increased Edi 1.0 and changes in Tdi due to I loading persisted. After bivagotomy, which also suppressed volume related vagal feed back, Edi 1.0 increased during I or E loading but change in Tdi disappeared. Initial spinal section at C8 level only reduced changes in Tdi with inspiratory loading. Bivagotomy plus spinal section abolished all load induced changes in diaphragmatic activity. These results suggest that all vagal information from the lungs participate in the mechanism of load compensation but that spinal sensory pathways play a minor role in this response in anaesthetized cats.

The effects of ischemia, lactic acid and hypertonic sodium chloride on phrenic afferent discharge during spontaneous diaphragmatic contraction.

In 9 sodium pentobarbital anaesthetized cats, 50 single-unit phrenic afferent recordings were determined during spontaneous ventilation, retrograde carotid arterial injection of lactic acid (LA, 0.1 N) and NaCl (5%), and a 2-min occlusion of the superior thoracic aorta. Fifty percent of the units had tonic low-frequency spontaneous discharge; 50% had phasic high-frequency discharge. Tonic fiber activity increased significantly with LA, NaCl and occlusion, while phasic fiber activity decreased in all 3 conditions. These results suggest that the diaphragm contains sensory endings sensitive to ischemia and extracellular metabolic changes.

Effects of airflow resistance variations on resistive load detection in normal subjects.

The sensitivity to airflow resistance variations produced by externally added resistive loads, with modification of background load, was studied in 15 normal subjects, using "Sensory Decision Theory" (SDT), a psychophysical method that gives an index of accuracy, P(A), unaffected by response bias. In six subjects, asked to detect three increasingly added loads (delta R) at different levels of basal resistance (1.6 and 3.6 cmH2O X 1(-1) X s), inspiratory resistive load detection (RLD) improved with background loading, and a highly significant relationship was found between P(A) and peak mouth pressure (Pm). The relationship between P(A) and the change in Pm, i.e. delta Pm, was less significant. These results suggest that, although tension developed by the respiratory muscles reflected by mouth pressure may be an important stimulus to respiratory RLD, other factors must also be considered. In seven subjects, in whom airway resistance was increased at least 50% by inhalation of carbachol, inconsistent variations in P(A) were found. In seven subjects, in whom airflow resistance was decreased by inhalation of heliox, and in six of seven subjects after salbutamol inhalation, RLD was significantly impaired. The results of this study lead us to the conclusion that Weber's law is not verified for weak internal or external background loading.

Phrenic afferents and their role in inspiratory control.

In anesthetized cats, with vagi cut and the spinal cord severed at the C8 level, phrenic motor and/or sensory discharge was recorded. Small afferent phrenic fibers were identified through their activation by lactic acid, hyperosmotic NaCl solution, or phenyl diguanide. They exhibited a spontaneous but irregular low-frequency discharge. Block of their conduction by procaine had no effect on eupneic motor phrenic activity. Large afferent phrenic fibers showed a spontaneous rhythmic discharge, and cold block (6 degrees C) of these fibers significantly prolonged the phrenic discharge time (Tphr) and total breath duration (TT) during eupnea. The stimulation of all afferent phrenic fibers lowered the impulse frequency of phrenic motoneurons (f impulses) and shortened both Tphr and TT. When the stimulation was performed during cold block all of the effects on phrenic output persisted, but changes in timing were less pronounced. Under procaine block, only the effects of phrenic nerve stimulation on Tphr persisted. These results suggest that both large and small afferent phrenic fibers control the inspiratory activity with a prominent role of small fibers on phrenic motoneuron impulse frequency.

Cold-induced bronchospasm in normal and sensitized rabbits.

In anesthetized, paralyzed and artificially ventilated rabbits, changes in lung resistance induced by cooling the inspired air were studied under dry air conditions. Airway response to cold was measured in normal animals and in rabbits sensitized to bovine serum albumin. The magnitude of cold-induced bronchospasm was significantly greater in sensitized than in normal rabbits but the time course for recovery of control lung resistance during rewarming was the same in both groups and lasted longer than 4 min. Inhalation of a nebulized aerosol of sodium cromoglycate (SCG) markedly reduced cold-induced bronchospasm and shortened the recovery period, which then lasted only 20 to 30 sec. Vagotomy abolished the airway response to cold air in all cases and this was observed whether the vagus nerves were cut before or after SCG inhalation. SCG or vagotomy exerted the same effect on the response to cold air in normal or sensitized rabbits. Sensitized animals showed an hyperresponsiveness to histamine as well as to cold air. These results suggest that cold-induced bronchospasm results from a vagally mediated reflex whose effects are only enhanced and prolonged by a local release of humoral factors, linked to the reflex path. The increased response to cold air in the sensitized rabbits seems to correspond to non-specific hyperresponsiveness of bronchial smooth muscle rather than to an increased local release of inflammatory mediators.

Role of vagal and spinal sensory pathways on eupneic diaphragmatic activity.

The interactions between vagal and spinal afferents in the control of eupneic diaphragmatic activity were studied in two groups of cats anesthetized either with pentobarbital sodium (SPB) or with ethyl carbamate-alpha-chloralose (ECC), which enhanced spinal reflexes. Under both conditions of anesthesia two experimental protocols were performed: 1) bilateral cervical vagotomy followed by spinal section at C8 level or 2) spinal section followed by vagotomy. Changes in integrated diaphragmatic activity (Edi) were studied during eupneic ventilation and tracheal occlusion at end expiration. Vagotomy always significantly increased the amplitude of Edi during eupnea (SPB + 30%; ECC + 15%) and prolonged its duration (Tdi) (SPB + 110%; ECC + 75%) but did not modify the overall shape of the Edi vs. time relationship. Spinal section induced reverse changes in the amplitude of Edi, whether vagal afferents were present or suppressed and modified the shape of the Edi wave, but did not significantly modify Tdi. These results indicate that both vagal and spinal afferents may participate in the control of eupneic inspiration but exert different and interdependent influences on the recruitment and firing time of phrenic motoneurons. In addition, Tdi measured during tracheal occlusion (Todi) was markedly prolonged under ECC anesthesia. In this situation spinal section reduced Todi, which became close to the values obtained in intact or spinal cats under SPB anesthesia. Thus the response to tracheal occlusion at end expiration cannot be interpreted as resulting from the sole suppression of volume related vagal information.

Pulmonary function and electromyographic study of respiratory muscles in myotonic dystrophy.

Ten adult myotonic dystrophy patients underwent measurements of lung function, maximal dynamic and static ventilatory efforts, and respiratory muscle electromyography (EMG). EMG studies were performed during spontaneous breathing or when subjects breathed through high inspiratory or expiratory resistive loads. Present results show that (1) a moderate restriction of lung volumes with hypoxemia plus normocapnia is often observed; (2) patients sustain dynamic ventilatory efforts more easily than static work; and (3) abnormalities in respiratory muscle EMG exist with spontaneous expiratory and inspiratory intercostal activities during quiet breathing and changes in muscular response to resistive loads. Inspiratory loading evokes contraction of expiratory muscles, with a marked decrease in inspiratory activities. Expiratory resistive loads prolong the diaphragmatic contraction throughout the expiratory time, and in some patients, relaxation of the diaphragm does not occur during the loaded run. These EMG data suggest that the reciprocal inhibition among respiratory neurons is enhanced in myotonic dystrophy and that myotonia also occurs in the diaphragm when loads oppose its relaxation.

Ventilatory effects of domperidone, a new dopamine antagonist, in anaesthetized rabbits.

The ventilatory effects of domperidone (DP), a dopamine antagonist that does not cross the blood-brain barrier, were studied on rabbits anaesthetized with pentobarbitone. DP induced hyperventilation (+20%), which was not dose-dependent, without any marked change in arterial blood gases. This effect was abolished by previous transection of both carotid sinus nerves. On an average, steady state hypoxia (PaO2 approximately 45 mmHg for 5 min) doubled ventilation before, and increased itself threefold after DP (0.10 mg kg-1 i.v.). Prazosin (PZ, 0.1 mg kg-1 i.v.), an alpha 1-adrenoceptor antagonist, induced hyperventilation (+16%) but decreased systemic arterial blood pressure. PZ did not modify the ventilatory response to steady state hypoxia. In short, DP has a slight stimulating effect on resting ventilation and potentiates the ventilatory response to steady state hypoxia. This last effect would not depend on additional alpha 1-adrenoceptor antagonism of DP, as PZ does not change the ventilatory response to hypoxia.

Inspiratory and expiratory resistive load detection in normal and asthmatic subjects. A sensory decision theory analysis.

The ability to detect added external inspiratory and expiratory resistive loads was studied in normal and asthmatic subjects using sensory decision theory as a psychophysical method. Performances P(A)/delta R [where P(A) represents the index of sensitivity and delta R the additional resistor] were similar in normal and asthmatic subjects, but when sensitivity was expressed in relation to airway resistance [P(A)/delta R/Raw], asthmatics showed higher inspiratory and expiratory performances than normal subjects. After bronchodilation the relative sensitivity in the asthmatic group was impaired and approached that of normal subjects. Comparing inspiratory and expiratory load detection, normal subjects showed a higher sensitivity for expiratory than for inspiratory loads. In contrast, there was no difference in the asthmatic group. The response bias remained the same across conditions. If one accepts the assumption that the variability of sensitivity presented by asthmatic and normal subjects might be related to the variable state of their pulmonary function, our results can be interpreted as demonstrating a relationship between sensitivity and pulmonary distension or airway obstruction. These results are in agreement with the hypothesis that the site of perception for respiratory load detection is the chest wall.

[Influence of chronic smoking on leukocytes]. / Influence du tabagisme chronic sur les leucocytes.

The authors showed a significant increase in total leukocyte count (2p less than 0.001), neutrophil concentration (2p less than 0.001) and lymphocyte concentration (2p less than 0.01) in 21 chronic smokers compared to 22 non-smokers. However, only the total leukocyte count and the neutrophil count proved to be correlated to carboxyhemoglobin saturation. Slightly different hypotheses are proposed to explain the increase in leukocyte count: the carbon monoxide and/or the carboxyhemoglobin acts directly on peripheral blood leukocytes or indirectly, via the adrenalin secretion. The average leukocyte count in smokers corresponds to the upper borderline in nonsmokers; therefore, it seems pertinent to take into consideration the number of cigarettes smoked per day when assessing a smoker's leukocytosis.

[Equipment of a water spirometer with a view to automation of spirometry]. / Equipement d'un spiromètre à eau en vue de l'automatisation de la spirométrie.

This work describes the complete automatisation of spirometry, the basic examination when assessing respiratory function. The movements of a water spirometer bell, transformed into electrical signals, are transmitted to a micro-computer, equipped with a digital analogue interface and then analysed. A few seconds after the performance of the examination the complete results are automatically edited in absolute values and as a percentage of predicted values (CECA). They are compared to previous calculations in the same spirometer, using the usual technique. The correlations obtained between the two series of results (145 examinations) show the reliability of the automated technique both for calculating volumes as for the maximal expired flows. In conclusion, while conserving the standard information in spirometry, the automatisation of this exam allows a considerable saving of time.