Abolfazl Najaf-Zadeh

Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review.

Noninvasive positive pressure ventilation (NPPV) refers to the delivery of mechanical respiratory support without the use of endotracheal intubation (ETI). The present review focused on the effectiveness of NPPV in children > 1 month of age with acute respiratory failure (ARF) due to different conditions. ARF is the most common cause of cardiac arrest in children. Therefore, prompt recognition and treatment of pediatric patients with pending respiratory failure can be lifesaving. Mechanical respiratory support is a critical intervention in many cases of ARF. In recent years, NPPV has been proposed as a valuable alternative to invasive mechanical ventilation (IMV) in this acute setting. Recent physiological studies have demonstrated beneficial effects of NPPV in children with ARF. Several pediatric clinical studies, the majority of which were noncontrolled or case series and of small size, have suggested the effectiveness of NPPV in the treatment of ARF due to acute airway (upper or lower) obstruction or certain primary parenchymal lung disease, and in specific circumstances, such as postoperative or postextubation ARF, immunocompromised patients with ARF, or as a means to facilitate extubation. NPPV was well tolerated with rare major complications and was associated with improved gas exchange, decreased work of breathing, and ETI avoidance in 22-100% of patients. High FiO2 needs or high PaCO2 level on admission or within the first hours after starting NPPV appeared to be the best independent predictive factors for the NPPV failure in children with ARF. However, many important issues, such as the identification of the patient, the right time for NPPV application, and the appropriate setting, are still lacking. Further randomized, controlled trials that address these issues in children with ARF are recommended.

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.

Epidemiology of malpractice lawsuits in paediatrics

A systematic review of malpractice lawsuits involving children identified six articles and 227 cumulative paediatric published cases. The prevalence of medical lawsuits resulting in payment to plaintiff was found to be 50% less frequent than that in adults. The most frequent and severe errors were among infants, including diagnostic errors of meningitis, gastroenteritis and pneumonia. The most implied unit was emergency department (58%). The patients and/or families were compensated in 23– 68% of cases.

Risk of bacterial meningitis in young children with a first seizure in the context of fever: a systematic review and meta-analysis.

Background Of major concern in any febrile child presenting with a seizure is the possibility of bacterial meningitis (BM). We did a systematic review to estimate the risk of BM among various subgroups of young children with a first seizure in the context of fever, and to assess the utility of routine lumbar puncture (LP) in children with an apparent first FS. Methods/Principal Findings MEDLINE, INIST, and the COCHRANE Library databases were searched from inception to December 2011 for published studies, supplemented by manual searches of bibliographies of potentially relevant articles and review articles. Studies reporting the prevalence of BM in young children presenting to emergency care with a first: i) “seizure and fever”, ii) apparent simple FS, and iii) apparent complex FS were included. Fourteen studies met the inclusion criteria. In children with a first “seizure and fever”, the pooled prevalence of BM was 2.6% (95% CI 0.9–5.1); the diagnosis of BM might be suspected from clinical examination in 95% of children >6 months. In children with an apparent simple FS, the average prevalence of BM was 0.2% (range 0 to 1%). The pooled prevalence of BM among children with an apparent complex FS was 0.6% (95% CI 0.2–1.4). The utility of routine LP for diagnosis of CNS infections requiring immediate treatment in children with an apparent first FS was low: the number of patients needed to test to identify one case of such infections was 1109 in children with an apparent first simple FS, and 180 in those with an apparent first complex FS. Conclusion The values provided from this study provide a basis for an evidence-based approach to the management of different subgroups of children presenting to emergency care with a first seizure in the context of fever.

Prevalence and clinical significance of occult fractures in children with radiograph-negative acute ankle injury. A meta-analysis.

Background and purpose — Plain radiographs may fail to reveal an ankle fracture in children because of developmental and anatomical characteristics. In this systematic review and meta- analysis, we estimated the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture, and assessed the diagnostic accuracy of ultrasound (US) in the detection of occult fractures. Methods — We searched the literature and included studies reporting the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture. Proportion meta-analysis was performed to calculate the pooled prevalence of occult fractures. For each individual study exploring the US diagnostic accuracy, we calculated US operating characteristics. Results — 9 studies (involving 187 patients) using magnetic resonance imaging (MRI) (n = 5) or late radiographs (n = 4) as reference standard were included, 2 of which also assessed the diagnostic accuracy of US. Out of the 187 children, 41 were found to have an occult fracture. The pooled prevalence of occult fractures was 24% (95% CI: 18–31). The operating characteristics for detection of occult ankle fractures by US ranged in positive likelihood ratio (LR) from 9 to 20, and in negative LR from 0.04 to 0.08. Interpretation — A substantial proportion of fractures may be overlooked on plain radiographs in children with acute ankle injuries and clinical suspicion of fracture. US appears to be a promising method for detection of ankle fractures in such children when plain radiographs are negative.

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.

Les décès par déshydratation aiguë du jeune enfant : les leçons de l’analyse d’une base de données de société d’assurances

Une revue générale récente de la littérature nous a montré que les seules études publiées des plaintes médicolégales en pédiatrie étaient nord-américaines [1]. Cela nous a conduit à proposer une étude en collaboration avec le Groupe Sou médical–Mutuelle d’assurances du corps de santé français (MACSF) qui assure en responsabilité civile professionnelle environ 66 % des pédiatres libéraux, 49 % de l’ensemble des pédiatres et 60 % des généralistes français. Nous avons ainsi pu analyser les 228 déclarations de plaintes à l’encontre de pédiatres ou de médecins généralistes assurés du groupe Sou médical MACSF (GAMM), concernant des enfants âgés de 1 mois à 18 ans, et intervenues entre janvier 2003 et décembre 2007. Dans 41 % des cas, il s’agissait de nourrissons âgés de 1 à 24 mois. Les erreurs diagnostiques étaient les causes alléguées de plaintes les plus fréquentes (47 %), suivies par les accidents ou les erreurs liées aux médicaments (19 %). Les déshydratations représentaient la seconde affection en cause après les méningites avec 13 cas (soit 6,6 % des plaintes pour lesquelles une affection pouvait être identifiée), dont 12 décès (92 %) et 1 enfant n’ayant pas présenté de séquelle. L’âge moyen était de 15 12 mois : 4 enfants dans le 1er semestre de vie, 3 dans le 2nd semestre, 2 dans la 2e année de vie et 4 dans la 3e année. Le sex-ratio était de 0,86. Trois enfants étaient décédés au cours de leur hospitalisation, et ce en dehors d’un contexte de simple choc hypovolémique : un présentait une hyperplasie des surrénales et 2 présentaient un tableau de défaillance multiviscérale évoquant une éventuelle maladie métabolique (non démontrée). Les 9 autres étaient décédés à domicile (n = 7) ou à leur arrivée aux urgences (n = 2) du fait d’un choc hypovolémique sur déshydratation majeure et ne présentaient aucune affection sous-jacente. Sept des 9 enfants avaient eu au moins une consultation préalable (3 par un médecin généraliste, 1 par un pédiatre, et 3 aux urgences), dans un délai moyen de 20 11 h (extrêmes : 9 à 34 h) par rapport à l’heure du décès. Quatre

Educating Asthmatic Children in European Ambulatory Pediatrics: Facts and Insights.

The aim of this study was to assess the role of European ambulatory pediatricians in caring for asthmatic children, especially in terms of their therapeutic education. We developed a survey that was observational, declarative, retrospective and anonymous in nature. 436 ambulatory pediatricians in Belgium, France, Germany, Italy, Luxembourg and Slovenia were asked to participate in the survey providing information on three children over 6 years old suffering from persistent asthma, who had been followed for at least 6 months. We considered the pediatricians’ profile, and their role in the therapeutic education of children. 277 pediatricians (64%) responded: 81% were primary care pediatricians; 46% participated in networks; 4% had specific training in Therapeutic Patient Education; 69% followed more than 5 asthmatic children per month, and over long periods (7 ± 4 years). The profiles of 684 children were assessed. Answers diverged concerning the provision of a Personalized Action Plan (60–88%), training the child to measure and interpret his Peak Expiratory Flow (31–99%), and the prescription of pulmonary function tests during the follow-up programme of consultations (62–97%). Answers converged on pediatricians’ perception of their role in teaching children about their condition and its treatment (99%), about inhalation techniques (96%), and in improving the children’s ability to take preventive measures when faced with risk situations (97%). This study highlights the role of European pediatricians in caring for asthmatic children, and their lack of training in Therapeutic Patient Education. Programmes and tools are required in order to train ambulatory pediatricians in Therapeutic Patient Education, and such resources should be integrated into primary health care, and harmonized at the European level.

Incidence des déclarations de plaintes envers les pédiatres

[1] Najaf-Zadeh A, Dubos F, Aurel M, et al. Epidemiology of malpractice lawsuits in paediatrics. Acta Paediatr 2008;97:1486–91. [2] Martinot A, Pruvost I, Aurel M, et al. Prise en charge des diarrhées aiguës en France : quels progrès ? Arch Pediatr 2007;14:S181–5. [3] Pruvost I, Dubos F, Aurel M, et al. Valeur des données anamnestiques, cliniques et biologiques pour le diagnostic de déshydratation par diarrhée aiguë chez l’enfant de moins de 5 ans. Presse Med 2008;37:600–9. [4] Chevallier B, editor. Pédiatrie par téléphone, aide à l’orientation. Paris : Groupe de pédiatrie générale; 2004. [5] Schmitt BD, editor. Pediatric telephone advice. Philadelphia: Lippincott-Raven; 1999.

[Deaths in children with acute dehydration: learning from a nationwide medical insurance company database].

Une revue générale récente de la littérature nous a montré que les seules études publiées des plaintes médicolégales en pédiatrie étaient nord-américaines [1]. Cela nous a conduit à proposer une étude en collaboration avec le Groupe Sou médical–Mutuelle d’assurances du corps de santé français (MACSF) qui assure en responsabilité civile professionnelle environ 66 % des pédiatres libéraux, 49 % de l’ensemble des pédiatres et 60 % des généralistes français. Nous avons ainsi pu analyser les 228 déclarations de plaintes à l’encontre de pédiatres ou de médecins généralistes assurés du groupe Sou médical MACSF (GAMM), concernant des enfants âgés de 1 mois à 18 ans, et intervenues entre janvier 2003 et décembre 2007. Dans 41 % des cas, il s’agissait de nourrissons âgés de 1 à 24 mois. Les erreurs diagnostiques étaient les causes alléguées de plaintes les plus fréquentes (47 %), suivies par les accidents ou les erreurs liées aux médicaments (19 %). Les déshydratations représentaient la seconde affection en cause après les méningites avec 13 cas (soit 6,6 % des plaintes pour lesquelles une affection pouvait être identifiée), dont 12 décès (92 %) et 1 enfant n’ayant pas présenté de séquelle. L’âge moyen était de 15 12 mois : 4 enfants dans le 1er semestre de vie, 3 dans le 2nd semestre, 2 dans la 2e année de vie et 4 dans la 3e année. Le sex-ratio était de 0,86. Trois enfants étaient décédés au cours de leur hospitalisation, et ce en dehors d’un contexte de simple choc hypovolémique : un présentait une hyperplasie des surrénales et 2 présentaient un tableau de défaillance multiviscérale évoquant une éventuelle maladie métabolique (non démontrée). Les 9 autres étaient décédés à domicile (n = 7) ou à leur arrivée aux urgences (n = 2) du fait d’un choc hypovolémique sur déshydratation majeure et ne présentaient aucune affection sous-jacente. Sept des 9 enfants avaient eu au moins une consultation préalable (3 par un médecin généraliste, 1 par un pédiatre, et 3 aux urgences), dans un délai moyen de 20 11 h (extrêmes : 9 à 34 h) par rapport à l’heure du décès. Quatre