[Reasons for low usage of strep A rapid antigen detection tests for pharyngitis in private medical practice]. / Motifs de la mauvaise utilisation des tests de diagnostic rapide du streptocoque de groupe A en médecine libérale.

UNLABELLED: Rapid group A Streptococcus (GAS) antigen detection tests (RDT) have high diagnostic performance for the management of acute pharyngitis and are recommended before any antibiotic (ATB) prescription in France to reduce ATB use. The rate of general practitioners (GPs) using GAS RDT is low and decreasing. Our aims were to describe the reasons for pediatricians and GPs not using RDT or for prescribing ATB despite of a negative RDT. METHODS: In 2011, a survey was conducted in a random sample of 368 GPs plus all ambulatory pediatricians (n=82) in the Nord-Pas-de-Calais region of France. RESULTS: Response rates were 74% (n=61) for pediatricians and 18% (n=68) for GPs. RDTs for pharyngitis were used by 75% [95% CI: 63-85] of pediatricians and 53% [95% CI: 41-64] of GPs (P<0.001). RDTs were systematically used in children 3years of age and older by only 59% of all physicians using RDTs. An ATB was systematically prescribed in case of positive RDT by 96% of physicians and eventually prescribed in case of negative RDT by 74%. The main reasons for ATB prescription in case of negative RDT were association with otitis media (51%), second visit for the same pharyngitis (45%), and high clinical suspicion of GAS pharyngitis (36%). Forty percent of non-RDT users had used them in the past. The 3 main reasons for not using RDT were the lack of time (57%), high confidence in clinical data to discriminate GAS pharyngitis (48%), and low confidence in RDT (27%). DISCUSSION: This survey highlights the lack of knowledge about low and high discriminant values of clinical data and RDT, respectively, especially the excellent negative predictive value of RDTs, and an erroneous assessment of the low risk of missing GAS pharyngitis compared to the consequences of inappropriate ATB use.

[Systemic adverse effects of topical ocular instillation of atropine in two children]. / Effets systémiques des collyres mydriatiques atropiniques chez deux enfants.

A medication-related cause must be sought when unusual symptoms occur. Topical treatments, including eye drops, whose side effects are more common in exposed children, need to be verified. We report here the cases of two children who developed systemic symptoms after the administration of atropine-based mydriatic eye drops. A 6-month-old boy was admitted to the emergency department with acute urine retention lasting 36h. Investigations identified only eye drop treatment 3h before the onset of symptoms, with 2 drops of homatropine 1 %, as a cause. No other urinary retention was observed during the 1-year follow-up. A 2-year-old boy was admitted to the emergency department for drowsiness, thirst, and dry mouth 30min after the administration of three eye drops of atropine 1 % instead of atropine 0.3 % (error made by the pharmacy). Symptoms disappeared after 6h. Both observations highlight the possible side effects related to mydriatic eye drops. Indeed, because of small penetration of such medications in the eye, a high concentration of the active part of the medication is contained in each drop. In young children, at least 20 to 40 % of the volume of a drop drains into the nasolacrimal duct and thereby into the systemic circulation, without passage through the liver. A close national pharmacologic vigilance follow-up has been set up for atropine-based mydriatic eye drops in young children, who are the most exposed to systemic and potentially severe complications of these medications. We emphasize the appropriate procedure for the use of eye drops in young children to limit systemic passage, with only a 0.3 % maximum atropine concentration in infants, compression of the internal angle of the eye for at least 1min, and at least a 15-mins interval between two eye drop administrations.

[Clostridium difficile reactive arthritis in a 7-year-old child]. / Polyarthrite réactionnelle àClostridium difficile chez un enfant de 7ans.

Clostridium difficile reactive arthritis is a rare disease; only 5 pediatric cases have been reported in the literature. Its diagnosis is challenging. It manifests as asymmetric aseptic poly- or oligoarthritis, contemporary to infectious colitis, usually after a period of antibiotic therapy. We report a new case in a 7-year-old boy who presented with unusual polyarthritis affecting 12 joints 1 month after antibiotic therapy with amoxicillin-clavulanate. Punctures of both hip joints proved sterile but significantly improved symptoms. Diarrheic stool cultures during hospitalization provided the diagnosis. Antibiotic therapy using metronidazole completely resolved pain and joint swelling within a week. After 1 year of follow-up, there has been no recurrence. We present a review of the literature on this disease and underline the advantages of joint aspiration in this condition with the dual aim of not missing septic arthritis and effectively relieving pain.

[Assessment of primary care physicians' adherence to the national childhood vaccination schedule]. / Évaluation de l'application du calendrier vaccinal de l'enfant en médecine libérale.

OBJECTIVE: To assess the levels of primary care physicians' adherence to the 2010 French vaccination schedule against pertussis, measles-mumps-rubella (MMR), and pneumococcal infections in northern France. METHODS: Two hundred forty-nine primary care physicians were questioned over the phone from February 15th to May 27th 2010. RESULTS: The total response rate was 61% (n=152) : 43 pediatricians and 109 general practitioners (GPs). The conjugated pneumococcal vaccination was routinely proposed by 93% of the physicians (100% of the pediatricians and 90% of the GPs, P=0.02), and the recommended immunization schedule was correctly stated by 98% of the pediatricians and 70% of the GPs, P<0.001. While the pertussis vaccination was proposed by all the physicians, the recommended immunization schedule was correctly followed in only 46% of the cases (there was no significant difference between the 2 groups of physicians). As for the MMR vaccination, 1 physician did not propose it; 27% had correct knowledge about the MMR vaccination schedule (44% of the pediatricians and 20% of the GPs, P<0.01); 39% initiated an early MMR vaccination schedule for children in day care centers. The main source of their information was medical representatives of pharmaceutical companies, medical journals, and to a lesser degree, weekly epidemiological bulletins and continuing medical education meetings. CONCLUSION: The level of physicians' knowledge about the vaccination schedule in children was insufficient in northern France, especially for pertussis and measles. This can decrease vaccination coverage levels as well as its beneficial effects for children.

Effectiveness of multifunction paediatric short-stay units: a French multicentre study.

AIM: To describe the characteristics of the activities of multifunction paediatric 'short-stay units' (SSU) including observation unit (OU), medical assessment and planning unit (MAPU) and holding unit (HU), to evaluate their effectiveness and to explore predictors of inappropriate admissions for OU patients. METHODS: Admissions to nine French paediatric SSUs were analysed. The main outcome measures were SSU length of stay with associated outcome for all patients and appropriate admission rate for OU patients. RESULTS: Of 1084 patients included in the study, 66% were OU patients (n = 718), 21% MAPU patients (n = 225) and 13% HU patients (n = 141). The OU patients constituted the majority of the SSU admissions. The appropriate OU admission rates ranged from 52% to 86%. Head trauma and seizure were the conditions with the highest appropriate OU admission rates (82%). Age <1 year, and need for IV fluids or medications, CT-Scan or MRI and cardiorespiratory monitoring were associated with an increased risk of inappropriate OU admission. Eighteen per cent of the MAPU patients and 5% of the HU patients were discharged home within 24 h. CONCLUSION: By providing extended and easily available facilities for diagnostics and early treatment for a wide range of sick children, the French paediatric SSU is an effective model for 'observation medicine' in emergency department-managed units. The experience and principles may be applicable to similar units in other health care systems.

[Evaluation of imported pediatric malaria management in northern France]. / Évaluation des pratiques dans la prise en charge du paludisme d'importation de l'enfant dans la région Nord--Pas-de-Calais.

OBJECTIVES: The study's objective was to evaluate the adequacy of treatment to recommendations, for the management of pediatric malaria. METHODS: A descriptive, retrospective, multicentre cohort study was conducted over a 7-year period (2000-2006) in 18 pediatric and infectious diseases units in northern France. All children, under 18 years of age, having consulted in one of these hospitals and for whom the diagnosis of malaria has been made by blood smear and/or thick drop examination, were included. RESULTS: One hundred and thirty-three cases of imported malaria were reported. Among the 120 available files, 23 documented severe malaria. Treatment documentation was available for 115 patients. This treatment was initiated orally in 47 cases and intravenously in 68 cases. Intravenous quinine was the first-line treatment in 58% of cases. Halofantrine was the first-line oral treatment. No change was observed along the 6 years. Only 32% of management was in adequacy with recommendations. Five therapeutic failures were recorded. The optimal application of recommendations would have saved 117 days in terms of hospital stay, corresponding to 54,000 €. CONCLUSIONS: The French Infectious Disease Society (SPILF) recommendations were not well observed. This inappropriate management was responsible for treatment failures and increased costs.

[Organization and resource utilization of pediatric emergency care: a French nationwide survey in 2008]. / Organisation et moyens de l'accueil des urgences pédiatriques : enquête nationale française en 2008.

UNLABELLED: Organization and resource utilization of pediatric emergency departments (PEDs) have been poorly evaluated. OBJECTIVES: To assess the access to appropriate pediatric emergency care in France and the degree of preparedness of PEDs and general emergency departments (GEDs) without separate pediatric emergency facilities. METHODS: A closed-response survey was e-mailed and/or posted to 256 hospitals with pediatric wards. RESULTS: A total of 120 useable surveys were returned (93 % of PEDs and 29 % of GEDs). In the PEDs surveyed (n=67, 33 university hospitals [UHs] and 34 non-university hospitals), disease recruitment was medical and surgical with trauma (84 %) or medical only (16 %). The medical directors of the PEDs were pediatricians (99 %). The average number of visits in 2007 was 20,200±10,600 per PED (+13 % within 5 years), and the average number of medical practitioners was 4±3. However, in only 76 % of PEDs was at least one pediatrician present after midnight. Medical staffing of PEDs in UHs did not include a pediatric resident in 30 % and a pediatric attending physician in 63 % of these units. Approximately, 48 % of PEDs had a short-stay observation unit (median, five beds). In GEDs (n=53), children were admitted 24h a day in the GED (41 %) and directly in the pediatric ward during the day and in the GED at night (28 %). Traumas were admitted in 98 % of the GEDs. CONCLUSION: Pediatric coverage 24h a day is still insufficient in PEDs. The training and experience of pediatricians were restricted by the lack of pediatric residency and physician positions in pediatric emergency care. A different access to pediatric emergency care during the day and night was frequent in hospitals without a PED.

Recognising haemorrhagic rash in children with fever: a survey of parents' knowledge.

BACKGROUND: Early recognition and treatment of meningococcal disease improves its outcome. Haemorrhagic rash is one of the most specific signs that parents can learn to recognise. OBJECTIVE: To determine the percentage of parents able to recognise a haemorrhagic rash and perform the tumbler test. METHODS: 123 parents of children consulting for mild injuries were interviewed about the significance and recognition of haemorrhagic rash in febrile children. RESULTS: Although 88% of parents undressed their children when they were febrile, it was never to look specifically for a skin rash. Only 7% (95% CI 3% to 12%) were able to recognise a petechial rash and knew the tumbler test. CONCLUSION: Information campaigns about the significance of haemorrhagic rash and about the tumbler test are needed.

Epidemiology and aetiology of paediatric malpractice claims in France.

OBJECTIVE: To examine paediatric malpractice claims and identify common characteristics likely to result in malpractice in children in France. DESIGN AND MATERIALS: First, the authors did a retrospective and descriptive analysis of all paediatric malpractice claims involving children aged 1 month to 18 years, in which the defendant was coded as paediatrician or general practitioner, reported to the Sou Médical-groupe MASCF insurance company during a 5-year period (2003-2007). Then, a comparison of these results with those from the USA was performed. RESULTS: The average annual incidence of malpractice claims was 0.8/100 paediatricians. 228 malpractice claims were studied and were more frequent (41%) with more severe outcomes in children younger than 2 years of age (52% deaths or major injuries). Meningitis (n=14) and dehydration (n=13) were the leading causes of claims, with highest mortalities (93% and 92%, respectively). The most common alleged misadventures were diagnosis-related error (47%), and medication error (13%). Malignancy was the most common medical condition incorrectly diagnosed (14%). CONCLUSIONS: Paediatric malpractice claims are less frequent in France than in the USA, but they share many similarities with those in the USA. These data would enhance the knowledge of high-risk areas in paediatric care that could be targeted to reduce the risk of medical malpractices and to improve patient safety.

Rebound in the incidence of pneumococcal meningitis in northern France: effect of serotype replacement.

AIM: To determine whether the recent emergence of nonvaccine pneumococcal serotypes has affected the incidence of pneumococcal meningitis in children a few years after the introduction of the heptavalent pneumococcal conjugate vaccine. METHODS: We conducted a multicentre retrospective cohort study from 2005 to 2008 in all hospitals with paediatric units in northern France. It included all patients < 18 years of age who were admitted for laboratory-confirmed pneumococcal meningitis during the study period. Data were collected from medical files and laboratory records at each hospital and compared with the regional hospital discharge codes. We assessed global and age-specific incidence rates of pneumococcal meningitis from 2005 through 2008, compared them with those from the prevaccine era (2000-2002) and evaluated pneumococcal serotypes. RESULTS: In all, 41 cases were found during the study period. The incidence rate of pneumococcal meningitis varied from 0.8/100,000 children < 18 years in 2005 to 1.8/100,000 children in 2008 (2.2-fold increase, p = 0.06); and from 1.8 to 11.9/100,000 children < 2 years (6.5-fold increase, p = 0.004). This increase was caused by nonvaccine pneumococcal serotypes. CONCLUSION: The incidence of pneumococcal meningitis in infants has rebounded in northern France during the pneumococcal conjugate vaccine programme, with the emergence of nonvaccine pneumococcal serotypes.

[Improvement in the management of acute diarrhoea in France?]. / Prise en charge des diarrhées aiguës en France: quels progrés?

The management of acute diarrhoea in France improved during the last ten years, with a large increase of oral rehydration solution (ORS) prescription in infants. Severity assessment is too often based on an uncertain evaluation of weight loss instead of a clinical determination. Telephone triage is not accurate without use of protocols and decision-making guidelines. Laboratory tests are rare in ambulatory management but still too frequent in hospital management of children with oral rehydration. ORS prescription of general practitioners regularly increased: 16% in 1988, 29% in 1996, 39% in 2001; and 71% in 2005 (after their reimbursement). The quality of oral rehydration advice remains insufficient. Intravenous rehydration on admission remains still too frequent. Drugs prescriptions include 2 or 3 drugs, with a decrease of loperamide and antibiotics, and an increase of racecadotril (81%). Lactose-free milk prescriptions in infants dropped from 46% in 1996 to 16% in 2005. Isolation and disinfection procedures are insufficient. Rotavirus nosocomial infections incidence is high: 1,6 to 6,3/1000 children less than 5 years of age, contributing to high direct costs.

[Severity assessment of acute diarrhoea]. / Critères de gravité d'une diarrhée aiguë

Clinician should recognize any life-threatening causes of diarrhoea, such as intussusceptions, surgical abdomen, and haemolytic uraemic syndrome. The following clinical features should alert: abdominal pain with tenderness, with or without guarding, pallor, jaundice, oligo-anuria, bloody diarrhoea, systemically unwell out of proportion to the level of dehydration, shock. The risk of dehydration is related to age (highest in young infants<6 months), and frequency of watery stools (>8/day) and vomiting (>2/day before 1 year and >4/day after 1 year), but these historical points have a moderate sensitivity. The severity of dehydration is rarely estimated with accuracy in terms of weight loss (third sector with full colon, absence of accurate baseline pre-dehydration weight). Combinations of examination signs perform markedly better than any individual sign in predicting dehydration (poor rate agreement, clinically unhelpful likelihood ratio). The presence of at least three signs better correlate with dehydration. Laboratory tests are not helpful. New studies are mandatory to validate severity scoring systems.