Long-term follow-up of children with haemophilia - low incidence of infections with central venous access devices.

This study reports on 15 years of experience, in a single haemophilia care centre in France, with central venous access devices (VADs) in children with haemophilia. Following the insertion of a central VAD, patients were requested to return to the hospital on a quarterly basis for a multidisciplinary appointment which included clinical examination, chest X-ray, cardiac and major vessels ultrasound and preventive fibrinolysis. The family was urged to return to the Haemophilia Care Centre if complications or problems occurred. The follow-up comprised 50 patients. Data were collected prospectively. The total number of days with a VAD was 86 461 days and the total number of times the VAD was used was 41 192 (approximately every other day). Mean duration of VAD placement was 1269 days (range 113-2794 days). There were 25 complications, of which 9 haematomas and 5 systemic infections. Two VADs, infected with Staphylococcus aureus, had to be replaced. The infection rate was calculated as 0.0578 infections/1000 catheter days. There were no cases of thrombosis. This study concluded that most VAD infections in children can be avoided, even in patients requiring intense, prolonged treatment. The very low infection rate was achieved through the efforts of a multidisciplinary team, combined with extensive training for all individuals involved, adherence to written protocols and specific monitoring measures.

Bacterial aetiology of acute osteoarticular infections in children.

AIM: To study the bacterial aetiology of acute osteoarticular infections in children and to analyse the efficiency of culture methods. METHODS: Bacteriological data of 407 cases of clinically suspected osteoarticular infections affecting 406 children hospitalized in an orthopaedic surgery department between 1999 and 2002 were retrospectively reviewed. RESULTS: Bacterial cultures from clinical specimens were positive in 74 cases (18%): 38 cases of septic arthritis and 36 cases of bone infections (osteitis, osteomyelitis or osteoarthritis). The use of liquid medium bottles to grow bacteria from articular fluids increased the rate of positive cultures compared to the use of standard solid media (p = 0.0001). The most commonly recovered pathogen was Staphylococcus aureus (44%) followed by Kingella kingae (14%), Streptococcus pyogenes (10%) and Streptococcus pneumoniae (10%). K. kingae was most frequently isolated among children under 36 mo of age (p = 0.0003), whereas S. aureus was most frequently isolated among children over 36 mo (p = 0.0015). CONCLUSION: By improving our culture method, we observed a recrudescence of isolation of K. kingae, but S. aureus remains the main pathogen isolated from osteoarticular infections in children. This finding is useful for the adaptation of a probabilistic antibiotic treatment of these infections.

[Successful recanulization of superior venous vessels: a new challenge for interventional pediatric cardiology]. / Reperméabilisation des gros troncs veineux supérieurs: un nouveau défi pour la cardiologie interventionnelle pédiatrique.

UNLABELLED: The use of long-term central venous catheters is a routine in chronic pediatric diseases. Thrombotic complications progressively reduce the central venous capital and hamper the long-term management of these patients. OBSERVATION: We report two cases of obstruction of the central upper venous system and discuss of the techniques used to repermeabilize venous axes before the placement of a new central line. CONCLUSION: The control of the permeability of the central veins should be performed before any withdrawal of central catheters, repermeabilization of the venous axes being simpler when the central catheter is kept in place in the occluded vessel.

Percutaneous replacement of pulmonary valve in a right-ventricle to pulmonary-artery prosthetic conduit with valve dysfunction.

BACKGROUND: Valved conduits from the right ventricle to the pulmonary artery are frequently used in paediatric cardiac surgery. However, stenosis and insufficiency of the conduit usually occur in the follow-up and lead to reoperations. Conduit stenting can delay surgical replacement, but it aggravates pulmonary insufficiency. We developed an innovative system for percutaneous stent implantation combined with valve replacement. METHODS: A 12-year-old boy with stenosis and insufficiency of a prosthetic conduit from the right ventricle to the pulmonary artery underwent percutaneous implantation of a bovine jugular valve in the conduit. FINDINGS: Angiography, haemodynamic assessment, and echocardiography after the procedure showed no insufficiency of the implanted valve, and partial relief of the conduit stenosis. There were no complications after 1 month of follow-up, and the patient is presently in good physical condition. INTERPRETATION: We have shown that percutaneous valve replacement in the pulmonary position is possible. With further technical improvements, this new technique might also be used for valve replacement in other cardiac and non-cardiac positions.

Central venous catheter-related infections in children on long-term home parenteral nutrition: incidence and risk factors.

BACKGROUND AND AIMS: This study aimed to assess the incidence and etiology of central venous catheter (CVC) infections in children on home parenteral nutrition (HPN). METHODS: 207 CVC-years were studied retrospectively in 47 children on HPN, aged 8.1+/-5.0 years. RESULTS: 125 CVC were used (means: 2.6 CVC/patient and 21 months utilization/CVC). Half of the hospitalizations (162) were due to proven CVC-related infections. The mean infection incidence was 2. 1/1000 HPN days. The total population divided in two groups below and above this value: group one including 24 children, incidence < or = 2.1 per 1000 days (mean: 0.83) and group two including 23 children, incidence >2.1 per 1000 days (mean: 4.3). No differences were found between the two groups in terms of underlying disease, presence of ostomies, age at the time of HPN onset, or micro-organisms responsible. The only differences (p<0.05) were the mean duration of HPN (longer in group one) and the delay between HPN onset and the first infection (longer in group one). CONCLUSIONS: This study does not highlight any risk factors for CVC infection. However, early CVC infections after HPN onset appear to predict a bad prognosis.

The analgesic efficacy of an injectable prodrug of acetaminophen in children after orthopaedic surgery.

The analgesic efficacy and safety of propacetamol, an injectable prodrug of acetaminophen, (paracetamol) were studied in 87 children (36 boys, 51 girls; age 6-13; mean age 9.5 years) immediately after limb surgery. Using a double-blind, randomized, parallel group design, the effects of a single IV infusion of 30 mg.kg-1 propacetamol (i.e. 15 mg.kg-1 acetaminophen) were compared with a single injection of placebo (PL). Efficacy was assessed on pain scores rated on a four-point verbal scale, a five-point visual scale (faces) and on a four-point relief verbal scale before administration (T0) and 0.25, 0.5, 1, 2, 3, 4, 5, 6 h after administration. At the end the global efficacy was rated by the physician on a five-point verbal scale. Propacetamol was statistically superior to placebo on all assessment criteria. Seven side-effects were recorded: five in the propacetamol group and two in the placebo group. 30 mg.kg-1 propacetamol provided a significantly greater analgesic effect than placebo in children after orthopaedic surgery.

Nosocomial outbreak of Clostridium difficile diarrhea in a pediatric service.

An outbreak of nosocomial diarrhea that occurred in a pediatric orthopedic service between 1 December 1993 and 15 April 1994 is reported. A total of 37 patients (mean age, 9.6 years; range, 2 months-19.3 years) were involved in the outbreak, including six patients with bacteriologically documented Clostridium difficile infection. A multivariate analysis identified lincomycin treatment for at least three days as the only significant risk factor. Stool samples from four asymptomatic patients were also positive for Clostridium difficile and its cytotoxins. Isolates from all patients belonged to serogroup C, were highly resistant to lincomycin, and exhibited the same restriction pattern by pulsed-field gel electrophoresis. The outbreak ended after treatment with lincomycin was discontinued and hygiene control measures were implemented.

Autologous blood donation for elective surgery in children weighing 8-25 kg.

To determine whether autologous blood donation can be used safely and efficiently in children weighing 8-25 kg, we studied children whose perioperative blood losses were expected to exceed 25% of total blood volume. Blood donations were performed in pediatric units, under the direction of an anesthesiologist and a blood bank physician experienced in paediatric care. Twenty-four children, median age 6 years (1-13), were included. They underwent surgery mainly for digestive or urological disorders, and for orthopedic defects. Forty blood collections were performed of the 46 prescribed. Phlebotomies could not be performed in 1 child because of the mother's apprehension, and in 5 cases because of venous access problems. All phlebotomies were hemodynamically well tolerated. Hemodilution was also performed in 17 children, and cell saver used in 2. Allogeneic blood transfusion was avoided in 21/24 children.

Chronic septic arthritis and osteomyelitis in a prosthetic knee joint due to Clostridium difficile.

A case of chronic septic arthritis and osteomyelitis in a prosthetic knee joint due to Clostridium difficile is reported. A knee prosthesis was installed in a 16-year-old boy for surgical treatment of an osteosarcoma of the femur. Later, the patient suffered a traumatic closed fracture of his patella, and a sterile fluid was aspirated. One month later, the joint displayed inflammation. Culture of the articular fluid yielded a nontoxigenic Clostridium difficile strain. Despite several attempts using conservative medical treatment with penicillins and ornidazole, Clostridium difficile strains with the same antibiotic susceptibility pattern were repeatedly isolated from the joint over an eight-month period. The foreign material was then ablated, and finally, the patient's leg was amputated one year after Clostridium difficile was first isolated. The possible sources of contamination in our case and other reported cases of extraintestinal infection due to Clostridium difficile are discussed.

Effect of halothane anesthesia on glucose utilization and production in adolescents.

BACKGROUND: It should be possible to avoid variations in plasma glucose concentration during anesthesia by adjusting glucose infusion rate to whole-body glucose uptake. To study this hypothesis, we measured glucose utilization and production, before and during halothane anesthesia. METHODS: After an overnight fast, six adolescents between 12 and 17 yr of age were infused with tracer doses of [6,6-2H2]glucose for 2 h before undergoing anesthesia, and the infusion was continued after induction, until the beginning of surgery. Plasma glucose concentration was monitored throughout, and free fatty acids, lactate, insulin, and glucagon concentrations were measured before and during anesthesia. RESULTS: Despite the use of a glucose-free maintenance solution, plasma glucose concentration increased slightly but significantly 5 min after induction (5.3 +/- 0.4 vs. 4.5 +/- 0.4 mmol.l-1, P < 0.05). This early increase corresponded to a significant increase in endogenous glucose production over basal conditions (4.1 +/- 0.4 vs. 3.6 +/- 0.2 mg.kg-1.min-1, P < 0.05), with no concomitant change in peripheral glucose utilization. Fifteen minutes after induction, both glucose utilization and production rates decreased steadily and were 20% less than basal values by 35 min after induction (2.9 +/- 0.3 vs. 3.6 +/- 0.2 mg.kg-1.min-1, P < 0.05). Similarly, glucose metabolic clearance rate decreased by 25% after 35 min. Despite the increase in blood glucose concentration, anesthesia resulted in a significant decrease in plasma insulin concentration. CONCLUSIONS: These data suggest that halothane anesthesia per se affects glucose metabolism. The decrease in peripheral glucose utilization and metabolic clearance rates and the blunted insulin release question the relevance of glucose infusion in these clinical settings.

[Scoliosis and congenital heart diseases in children. Apropos of 44 cases]. / Scolioses et cardiopathies congénitales chez l'enfant. A propos de 44 cas.

In order to evaluate the difficulties of treatment of associated scoliosis and congenital heart disease (C.H.D.), 44 patients who have been treated between 1970 and 1988 were reviewed. The scoliosis was idiopathic in 30 cases, congenital in 11, neurologic in 3. There were 27 females and 17 males. Twenty one patients had a cyanotic C.H.D. (twelve tetralogies of Fallot). No relation was found between the side of the cardiac approach and the side of the thoracic curves. Three cases of right aortic arch with two left thoracic scolioses were noted. Associated anomalies were encountered in 60 p. 100 of cases. The analysis of old chest X-rays, revealed that the scoliosis was already present an average of 5 years before the first orthopaedic consultation. Eight patients had an orthopaedic treatment; in ten cases surgery was decided but not performed. Twenty six patients were operated. (22 posterior and six anterior procedures). The average angulation was 55 degrees pre-operatively, 30 degrees post-operatively and 40 degrees at a 40 months follow-up. In five cases a pseudarthrosis led to re-intervention. One patient died during a posterior procedure, an other post-operatively. Two patients had a severe complication (one heart arrest; one gaz-embolism) but recovered. The surgical prognosis can be evaluated on an original scale including different cardiac parameters, and the importance of the planned surgical procedure. Under a limited mark, no serious complications occurred. In conclusion, a closed collaboration between pediatricians and the orthopaedic team, should lead to more precocious screening of scoliosis in cardiologic children and before the orthopaedic procedure, to a more precise risk factors evaluation.

[Severe hypertriglyceridemia and acute pancreatitis in pregnancy. A case report]. / Hypertriglycéridémie gravidique majeure et pancréatite aiguë. A propos d'une observation.

We report the case of a 32-year old woman who developed major hypertriglyceridaemia complicated by acute pancreatitis at 35 weeks of pregnancy. Caesarean section was performed within 24 hours of admission. After delivery, hypocaloric parenteral feeding without lipid emulsion was initiated. The outcome was favourable, and the patient could resume oral feeding after 5 weeks. The incidence of pancreatitis during pregnancy is 1 in 1,000 to 3,000 pregnancies. In the identification of the metabolic abnormality in our patient the differential diagnosis was between type III and type IV hyperlipaemia, according to Fredrickson's classification.

[Surgery of juvenile chronic arthritis]. / La chirurgie de l'arthrite chronique juvénile.

A number of surgical procedures can be proposed in juvenile chronic arthritis (JCA). These are particularly useful in two circumstances: 1), during the early stages of the disease, as local treatment for hyperplasic synovium (intra-articular injection or synovectomy) in order to avoid further articular destruction; 2) in the late stages of the disease with the aim of restoring function to as near normal as possible (osteotomy, arthrodesis, arthroplasty, tendon repair). However, in all circumstances, such surgery must be decided upon by a team consisting of paediatrician and orthopaedic surgeon. Procedures are often multiple and require careful preparation including psychological support, nutritional, medical and orthopaedic care. And should be followed by intensive and specific physiotherapy. When these conditions are fulfilled, the operative procedures may restore nearly normal joint function in severe forms of JCA, thus allowing children and adolescents to maintain good physical, intellectual and psychological development through independent mobility.

[Thromboembolic complications in pediatric orthopedics. Multicentric collection of 33 case reports]. / Complications thromboemboliques en orthopédie pédiatrique. Recueil "multi-centrique" de 33 observations.

We report 33 cases of venous thrombosis of the limb, in children aged 15 years or less (average age is 10 years old): 22 acute thrombophlebitis have been treated, 11 children shown post-phlebitic disease. The thrombus was found, most of the time, in the iliac and/or femoral vein. Acute complications were seen in 30% of our cases, and 25% treated children reviewed, had post-phlebitic sequelae. Congenital disease of hemostasis (deficiency of antithrombin III, protein C or S) must be detect before anticoagulant start, because such deficiency influence the treatment and the prognosis. There is non indication for preventive treatment, because of the rarity of spontaneous thrombophlebitis by children. Nevertheless, we can draw an "high risk" population: antecedent of phlebitis, antecedent of congenital disease of hemostasis, antecedent of thrombophlebitis by parents below 40 years old, thrombogenic disease (homocystinuria), vertebral arthrodesis.

Ethylene chlorohydrin determination in ethylene oxide sterilized polyvinyl chloride tubing.

A convenient rapid gas-chromatographic method is described for the quantitative determination of ethylene chlorohydrin. The method reported herein extracts the ethylene chlorohydrin with water. The method is simple and offers advantages since no elaborate and expensive gas extraction apparatus is required. The ethylene chlorohydrin levels in five different sterilized polyvinyl chloride samples were found to vary between 5 and 25 ppm. The effect of resterilization with ethylene oxide was investigated and was found to produce less ethylene chlorohydrin.

[Surgical treatment of scoliosis of 100 degrees and greater in children and adolescents (neurological and myopathic scoliosis excluded). Apropos of a series of 66 cases]. / Traitement chirurgical des scolioses de 100 degr'es et plus chez l'enfant et l'adolescent (à l'exclusion des scolioses neurologiques et myopathiques). A propos d'une série de 66 cas.

In a retrospective study the authors had compared the results obtained in two series of identical scoliosis. All were examined after a two year minimal follow-up. Group A. There were 31 children operated on between 1966 and 1972. The average initial curve measured 111 degrees, and the average follow-up was eight years. In this group there was no preoperative preparation, and a Harrington rod was accompanied by cancellous grafting. The average correction was 34 degrees. Four paraplegias were seen, three of which recovered. Group B. There were 45 children operated on between 1973 and 1980. The average initial curve was 170 degrees and the average follow-up was 4.5 years. In this group, there was pre-operative use of a Halo cast routinely. In 14 children, Harrington rodding was supplemented by anterior fusion to correct associated kyphosis. The posterior Harrington rodding was completed by tibial grafting. The average correction was 47 degrees, without any neurological complications. It was noted that after one year, pulmonary function was not impaired to a greater extent after an anterior fusion than after a purely posterior fusion. Two-thirds of the cases gained considerable cosmetic benefit.