I. Pruvost

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.

Streptococcal pharyngitis in children: a meta-analysis of clinical decision rules and their clinical variables

Objective To identify the best clinical decision rules (CDRs) for diagnosing group A streptococcal (GAS) pharyngitis in children. A combination of symptoms could help clinicians exclude GAS infection in children with pharyngitis. Design Systematic review and meta-analysis of original articles involving CDRs in children. The Pubmed, OVID, Institute for Scientific and Technical Information and Cochrane databases from 1975 to 2010 were screened for articles that derived or validated a CDR on a paediatric population: 171 references were identified. Setting Any reference including primary care for children with pharyngitis. Data extraction The methodological quality of the articles selected was analysed according to published quality standards. A meta-analysis was performed to assess the statistical performance of the CDRs and their variables for the diagnosis of GAS pharyngitis. Primary outcome measure The main criterion was a false-negative rate in the whole population not any worse than that of a rapid diagnostic test strategy for all patients (high sensitivity and low negative likelihood ratio). Results 4 derived and 12 validated CDRs for this diagnosis in children. These articles involved 10 523 children (mean age, 7 years; mean prevalence of GAS pharyngitis, 34%). No single variable was sufficient for diagnosis. Among the CDRs, that of Joachim et al had a negative likelihood ratio of 0.3 (95% CI 0.2 to 0.5), resulting in a post-test probability of 13%, which leads to 3.6% false-negative rate among low-risk patients and 10.8% overall, equivalent to rapid diagnostic tests in some studies. Conclusions The rule of Joachim et al could be useful for clinicians who do not use rapid diagnostic tests and should allow avoiding antibiotic treatment for the 35% of children identified by the rule as not having GAS pharyngitis. Owing to its poor specificity, such CDR should be used to focus rapid diagnostic tests to children with high risk of GAS pharyngitis to reduce the antibiotic consumption.

The Value of Body Weight Measurement to Assess Dehydration in Children

Dehydration secondary to gastroenteritis is one of the most common reasons for office visits and hospital admissions. The indicator most commonly used to estimate dehydration status is acute weight loss. Post-illness weight gain is considered as the gold-standard to determine the true level of dehydration and is widely used to estimate weight loss in research. To determine the value of post-illness weight gain as a gold standard for acute dehydration, we conducted a prospective cohort study in which 293 children, aged 1 month to 2 years, with acute diarrhea were followed for 7 days during a 3-year period. The main outcome measures were an accurate pre-illness weight (if available within 8 days before the diarrhea), post-illness weight, and theoretical weight (predicted from the child’s individual growth chart). Post-illness weight was measured for 231 (79%) and both theoretical and post-illness weights were obtained for 111 (39%). Only 62 (21%) had an accurate pre-illness weight. The correlation between post-illness and theoretical weight was excellent (0.978), but bootstrapped linear regression analysis showed that post-illness weight underestimated theoretical weight by 0.48 kg (95% CI: 0.06–0.79, p<0.02). The mean difference in the fluid deficit calculated was 4.0% of body weight (95% CI: 3.2–4.7, p<0.0001). Theoretical weight overestimated accurate pre-illness weight by 0.21 kg (95% CI: 0.08–0.34, p = 0.002). Post-illness weight underestimated pre-illness weight by 0.19 kg (95% CI: 0.03–0.36, p = 0.02). The prevalence of 5% dehydration according to post-illness weight (21%) was significantly lower than the prevalence estimated by either theoretical weight (60%) or clinical assessment (66%, p<0.0001).These data suggest that post-illness weight is of little value as a gold standard to determine the true level of dehydration. The performance of dehydration signs or scales determined by using post-illness weight as a gold standard has to be reconsidered.

Consensus in diagnostic definitions for bone or joint infections in children by a Delphi method with European French-speaking experts.

Aim:  Various diagnostic criteria have been proposed for bone or joint infection. This study used a Delphi process to determine the consensual definitions for arthritis, osteomyelitis and bone or joint infections in general in children.

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.

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

Évaluation des pratiques dans la prise en charge du paludisme d'importation de l'enfant dans la région Nord―Pas-de-Calais

OBJECTIVES The studys 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.

Accidents de la vie courante : prévention active ou passive ?

* Auteur correspondant. e-mail : valerie.hue@chru-lille.fr Les accidents de la vie courante (AcVC) se défi nissent comme les accidents survenant au domicile, dans une aire de sports ou de loisirs, ou à l’école, au cours de la vie privée, à l’exception des accidents de la circulation, du travail, et des agressions. La mortalité par AcVC a diminué de 50 % depuis 1999, mais reste 3 fois plus élevée en France qu’en Suède. De plus la morbidité de ces accidents reste très importante [1]. Les stratégies de prévention peuvent être classées en prévention active et passive. La prévention active suppose une action (par exemple : mettre des cache-prise) ce qui nécessite une éducation. La prévention passive repose souvent sur des mesures législatives qui assurent une protection automatique quel que soit le comportement de la personne (par exemple : airbags à déclenchement automatique) [2].