[Benefits of continuous subcutaneous insulin infusion in children with type 1 diabetes mellitus]. / Bénéfices de l'insulinothérapie par pompe chez les enfants diabétiques de type 1.

BACKGROUND: The Diabetes Control and Complications Trial clearly demonstrated the benefits of blood glucose control, especially in children and adolescents, in the prevention of long-term complications of type 1 diabetes (T1D). This can be achieved with intensive insulin treatment with either multiple daily insulin injections (MDI) or continuous subcutaneous insulin infusion (CSII), also known as insulin pump. The aim of this study was to compare glycemic control of T1D children treated with either CSII or MDI. PATIENTS AND METHODS: Thirty-eight T1D children treated with CSII were compared to 38 children treated with MDI, matched for age, gender, and duration of diabetes. Collected data, including daily doses of insulin in IU/kg/d, HbA1c levels, body mass index expressed in standard deviation/age, number of severe hypoglycemia episodes and of admissions related to T1D expressed in events/patient/year, were retrospectively collected every 3 months. RESULTS: There was no difference between the 2 groups at baseline. During the 3 years of follow-up, patients treated with CSII had lower daily doses of insulin (0.78 ± 0.19 vs. 0.87 ± 0.22 IU/kg/d, p<0.05), significantly lower levels of HbA1c (7.5 ± 0.6 vs. 8.0 ± 1.3 %, p<0.05), and a decreased number of admissions related to T1D (0.07 ± 0.14 vs. 0.17 ± 0.22 events/patient/year, p<0.05) than children treated with MDI. In contrast, body mass index and number of severe hypoglycemic episodes did not differ between the two groups. No diabetic ketoacidosis episode was recorded in either group. CONCLUSION: The results from this study suggest that treatment with CSII provided better metabolic control than treatment with MDI, in spite of lower daily doses of insulin and without increasing acute complications, in children with T1D.

Growth and adult height in GH-treated children with nonacquired GH deficiency and idiopathic short stature: the influence of pituitary magnetic resonance imaging findings.

We analyzed the final height of 146 short children with either nonacquired GH deficiency or idiopathic short stature. Our purpose was 1) to assess growth according to the pituitary magnetic resonance imaging findings in the 63 GH-treated children with GH deficiency and 2) to compare the growth of the GH-deficient patients with normal magnetic resonance imaging (n = 48) to that of 32 treated and 51 untreated children with idiopathic short stature (GH peak to provocative tests >10 microg/liter). The mean GH dose was 0.44 IU/kg.wk (0.15 mg/kg.wk), given for a mean duration of 4.6 yr. Among the GH-deficient children, 15 had hypothalamic-pituitary abnormalities (stalk agenesis), all with total GH deficiency (GH peak <5 microg/liter). They were significantly shorter and younger at the time of diagnosis than those with normal magnetic resonance imaging, had better catch-up growth (+2.7 +/- 0.9 vs. +1.3 +/- 0.8 SD score; P < 0.01), and reached greater final height (-1.1 +/- 1.0 vs. -1.7 +/- 1.0 SD score; P < 0.05). Among patients with normal magnetic resonance imaging, there was no difference in catch-up growth and final height between partial and total GH deficiencies. GH-deficient subjects with normal magnetic resonance imaging and treated and untreated patients with idiopathic short stature had comparable auxological characteristics, age at evaluation, and target height. Although they had different catch-up growth (+1.3 +/- 0.8, +0.9 +/- 0.6, and +0.7 +/- 0.9 SD score, respectively; P < 0.01, by ANOVA), these patients reached a similar final height (-1.7 +/- 1.0, -2.1 +/- 0.8, and -2.1 +/- 1.0 SD score, respectively; P = 0.13). Pituitary magnetic resonance imaging findings show the heterogeneity within the group of nonacquired GH deficiency and help to predict the response to GH treatment in these patients. The similarities in growth between the GH-deficient children with normal magnetic resonance imaging and those with idiopathic short stature suggest that the short stature in the former subjects is at least partly due to factors other than GH deficiency.

[Diagnostic value of physical examination and electrocardiogram in the initial evaluation of heart murmurs in children]. / Valeur diagnostique de l'examen clinique et de l'électrocardiogramme dans l'évaluation initiale d'un souffle cardiaque de l'enfant.

OBJECTIVE: To investigate the diagnostic value of the physical examination and electrocardiogram in the evaluation of heart murmur in new patients referred to the pediatric cardiologist. METHOD: From 1 April to 30 September 1998, all consecutive patients referred to the pediatric cardiology clinic for evaluation of heart murmur were included. They were prospectively categorized with no heart disease, possible heart disease or definite heart disease based on history and physical examination. They then underwent electrocardiogram with which the diagnosis was reevaluated by the pediatric cardiologist. Lastly, a doppler-echocardiography was systematically performed. RESULTS: In 120 children aged four days to 14 years (median: ten months), 72 (60%) showed abnormalities on doppler-echocardiography and 48 (40%) no heart disease. After physical examination, 52 patients were categorized with no heart disease: 45 patients had a normal doppler-echocardiography; in three of them, the diagnosis was incorrectly modified to possible heart disease on the basis of the electrocardiogram. In the other seven children, the electrocardiogram was normal and the doppler-echocardiography revealed minor (n = 5) or moderate (n = 2) heart defects. Nineteen patients were suspected of having possible heart disease, no diagnosis was modified after analysis of the electrocardiogram and six had normal doppler-echocardiography; 49 patients were correctly diagnosed as having definite heart disease. The sensibility of the physical examination was 90.3%, the specificity was 93.8%, the positive predictive value 95.6% and the negative predictive value 86.5%. CONCLUSION: The electrocardiogram is of no help in the discrimination between heart disease and no heart disease in children referred to the pediatric cardiologist for a cardiac murmur. The physical examination is able to differentiate children with or without heart disease in most of the cases.

[Acute intravascular hemolysis after complete occlusion of a patent ductus arteriosus by detachable coils]. / Hémolyse intravasculaire aiguë après occlusion complète d'un canal artériel par coils détachables.

A case of acute intravascular haemolysis after complete occlusion of a patent ductus arteriosus by detachable coils in a 10 months old child is reported. The child had a patent ductus arteriosus, a small secundum atrial defect, mild valvular pulmonary stenosis, and stenosis of branches of the pulmonary artery not diagnosed before closure of the ductus. Haemolysis developed several hours after complete occlusion of the ductus by two detachable coils. The mechanism of the haemolysis was thought to be the presence of metallic spirals in the left pulmonary artery, just beyond stenosis situated at the origin of this artery. Simple balloon dilatation of the left pulmonary artery stenosis resulted in the complete regression of haemolysis.

[Prevalence and distribution of congenital heart diseases in Indre-et-Loire. Evaluation of prenatal diagnosis (1991-1994)]. / Prévalence et répartition des cardiopathies congénitales en Indre-et-Loire. Evaluation du diagnostic anténatal (1991-1994).

UNLABELLED: Congenital heart diseases are the most frequent malformation at birth. New technologies have improved diagnosis procedures (echocardiography and Doppler). The aim of our study was to evaluate the prevalence of congenital heart diseases, their different types, and the detection rate of antenatal diagnosis. METHODS: A retrospective study was performed for all infants with congenital heart disease (CHD), born between January 1st 1991 and December 31st 1994, and for all fetuses which died after disruption of pregnancy, in Indre-et-Loire (a French country). In all cases, CHD diagnosis was confirmed with echocardiography and Doppler. RESULTS: CHD prevalence in newborns was 9.8% and 10.4% for the total population including dead fetal material. A high proportion of septal defects (64.8%) was observed with muscular, isolated and small forms (< 3 mm) in 70.2% of cases. The prevalence of great vessels transposition (0.15%), left ventricular hypoplasia (0.11%), and atrioventricular septal defect (0.11%), were lower than in previous studies. The performance of antenatal diagnosis was estimated at 40.5% for the four years; the prevalence of detectable CHD was only 1.4/1000. The atrioventricular septal defect was the most frequently detected. CONCLUSION: Relative high prevalence of congenital heart disease in this French county is due to the high level of small septal defects. Prevalence of detectable CHD remains low, which explains in part the difficulties of improving the antenatal diagnosis.

[Evolution of ventricular septal defects. Relation to echocardiographic anatomy]. / Evolution des communications interventriculaires membraneuses. Relation avec l'anatomie échocardiographique.

The aim of this study was to analyse the outcome of membranous ventricular septal defects (VSD) with respect to the echocardiographic data obtained during the first year of life. This retrospective series included patients born between January 1st 1986 and December 31st 1995, in the Indre et Loire department, with membranous ventricular septal defects alone or associated with minor abnormalities. The initial echocardiography, an echocardiography performed 2 to 6 months later, one a year later and the final echocardiography were compared. Three groups of VSD were constituted according to their diameter: group I (< or = 3 mm), group II (3-6 mm), and group III (> 6 mm). Depending on the outcome, the patients were classified as spontaneous closure (group A), surgical closure (group B) or persistent VSD (group C). The population comprised 84 children. There were 6 spontaneous deaths, three of which were unexplained, and 7 children were lost to follow-up. After the initial echocardiography, the VSD were classified as group I (38%), group II (26.2%) and group III (35.7%). After the second echocardiogram, 24 VSD changed group (31.5%), by increase (N = 10) or decrease (N = 14) in diameter. Aneurysms of the membranous septum were observed during the first two echocardiographies in 31.2% and 79.3% of VSDs of group I, 31.8% and 70% of VSDs of group II and 6.6% and 3.3% of VSDs of group III (p < 0.01). The average follow-up was 3.1 years (range 1 month-10 years). In group A (N = 22), the mean age of closure of the VSD was 26 months (3 months-7 years). In group B (N = 28), surgery was undertaken at an average age of 10 months (range 3 months-5 years). In group C (N = 21), the VSDs were classified as group I (N = 19) or group II (N = 2) at the last echocardiography. The frequency of aneurysms of the membranous septum in groups A, B and C were respectively 100%, 7.1% and 66.6% (p < 0.01). At the second echocardiographic examination, a significant relationship (p < 0.001) was observed between the diameter of the VSDs and their outcome. The VSDs of group A were associated with aneurysms of the membranous septum more often than those of group C (p < 0.005). The authors conclude that surgery is required in about one third of membranous VSD. At medium term, the others either close spontaneously or become smaller in comparable numbers. The outcome is directly related to the diameter of the VSD and the development of an aneurysm of the membranous septum. During the first 6 months, the dimensions of membranous VSDs change in about 30% of cases with an increase in frequency of aneurysms of the membranous septum.