A 10-year experience in paediatric spontaneous cerebral hemorrhage: which children with headache need more than a clinical examination?

INTRODUCTION: When a child is seen in a clinic with a headache, stroke is certainly not the first on the list of differential diagnoses. In western countries, stroke is typically associated with adults and the elderly. Although rare, haemorrhagic strokes are not exceptional in the paediatric population, as their incidence is around 1/100 000/year. Prompt diagnosis is essential, since delayed treatment may lead to disastrous prognosis in these children. MATERIALS AND METHODS: This is a retrospective review of paediatric cases with spontaneous cerebral haemorrhage that presented in two university hospitals in the last ten years. The experience of these primary and tertiary referral centres comprises 22 consecutive cases that are analysed according to aetiology, presenting symptoms, treatment and outcome. RESULTS: 77% of the children diagnosed with haemorrhagic stroke presented with headaches. 41% of them had a sudden onset, while 9% developed headaches over a period of hours to weeks. While 9% presented only with headaches, the majority had either subtle (diplopia, balance problems) or obvious (focal deficits, unilateral weakness and decreased level of consciousness) concomitant neurological signs. 55% had an arteriovenous malformation (AVM), 18% had an aneurysm and 14% had a cavernous malformation. In 14% the aetiology could not be determined. The majority of haemorrhages (82%) were supratentorial, while 18% bled into the posterior fossa. All children underwent an emergency cerebral CT scan followed by specific investigations. The treatment was dependent on the aetiology as well as the mass effect of the haematoma. In 23% an emergent evacuation of the haematoma was performed. Two children (9%) died, and 75% had a favourable clinical outcome. CONCLUSION: Headaches in children are a common problem, and a small minority may reveal an intracranial haemorrhage with poor prognosis if not treated promptly. Although characterisation of headaches is more difficult in a paediatric population, sudden, unusual or intense headaches should lead to imaging work-up. Any neurological finding, even one as subtle as hemianopsia or dysmetria, should alarm the physician and should be followed by emergency imaging investigation. If the cerebral CT reveals a haemorrhage, the child should be referred immediately to a neurosurgical referral centre without further investigation. The outcome is grim for children presenting in coma with fixed, dilated pupils. The long-term result overall for children after spontaneous intracranial haemorrhage is not dismal and depends critically on specialised management

Parents d'enfants hospitalisés dans une unité de soins intensifs: une étude exploratoire de leur vécu.

Le travail présenté ici repose sur une recherche qualitative effectuée par l'Institut universitaire de médecine sociale et préventive de Lausanne (IUMSP), sur l'initiative de l'unité des soins intensifs médico-chirurgicaux de pédiatrie (SIP) du Centre hospitalier universitaire vaudois (CHUV). Cette étude détaille le vécu de parents dont l'enfant a été hospitalisé dans une unité de soins intensifs. Il a paru essentiel aux initiateurs du projet d'imaginer offrir un accompagnement et une aide de type préventif aux personnes concernées par la maladie ou l'accident de leur enfant. Toutefois, avant de procéder à ce dispositif, il convenait de savoir plus précisément: 1. Ce que les parents vivaient durant l'hospitalisation de leur enfant; 2. Quels étaient leurs besoins et leurs attentes (à l'égard de l'unité, à l'égard des soignants) en pareilles circonstances

Toward a Comprehensive Approach to the Collection and Analysis of Pica Substances, with Emphasis on Geophagic Materials

Pica, the craving and subsequent consumption of non-food substances such as earth, charcoal, and raw starch, has been an enigma for more than 2000 years. Currently, there are little available data for testing major hypotheses about pica because of methodological limitations and lack of attention to the problem.In this paper we critically review procedures and guidelines for interviews and sample collection that are appropriate for a wide variety of pica substances. In addition, we outline methodologies for the physical, mineralogical, and chemical characterization of these substances, with particular focus on geophagic soils and clays. Many of these methods are standard procedures in anthropological, soil, or nutritional sciences, but have rarely or never been applied to the study of pica.Physical properties of geophagic materials including color, particle size distribution, consistency and dispersion/flocculation (coagulation) should be assessed by appropriate methods. Quantitative mineralogical analyses by X-ray diffraction should be made on bulk material as well as on separated clay fractions, and the various clay minerals should be characterized by a variety of supplementary tests. Concentrations of minerals should be determined using X-ray fluorescence for non-food substances and inductively coupled plasma-atomic emission spectroscopy for food-like substances. pH, salt content, cation exchange capacity, organic carbon content and labile forms of iron oxide should also be determined. Finally, analyses relating to biological interactions are recommended, including determination of the bioavailability of nutrients and other bioactive components from pica substances, as well as their detoxification capacities and parasitological profiles.This is the first review of appropriate methodologies for the study of human pica. The comprehensive and multi-disciplinary approach to the collection and analysis of pica substances detailed here is a necessary preliminary step to understanding the nutritional enigma of non-food consumption

„En face“-OCT in kleinen pigmentierten choroidalen Tumoren ["En face" OCT in Small Pigmented Choroidal Tumors]

Background "En face" optical coherence tomography (OCT) is an imaging technique with optic sections parallel to the retinal pigment epithelium (RPE). This study aims to define the use of this technique in the evaluation of small pigmented choroidal tumors. Patients and Methods Investigation of 27 small pigmented choroidal tumors with "en face" OCT. Following manual segmentation, the optic sections performed with a spectral domain OCT at 30, 80 and 130 µ under the RPE were selected for morphological and statistical analysis. Results Internal tumor reflectance is variable (hyper-, iso-, or hypo-reflective), with a uniform or a bull's eye appearance. The reflectance becomes progressively lower towards the centre of the tumor. The margins of the pigmented tumors appear similar or less extensive than ophthalmoscopically. Peritumoral vascularization appears distinct from the 80 µ section downwards. Conclusions On "en face" OCT, small pigmented choroidal tumors present with a uniform or bull's eye internal reflectance, and are of variable intensity relative to the surrounding choroid. Their margins can appear more restrained than those on colour fundus photography

Healthcare Students on Placements: a Cyclical Quality Method for Satisfaction Assessments.

The Lausanne University Hospital (CHUV, Switzerland) is a university hospital with more than 11,000 employees who perform clinical, research and teaching roles. It was ranked in March 2019 among the ten best hospitals in the world according to the magazine Newsweek. The education scheme of the CHUV includes the practical training of more than 1700 young people, in particular from the University of Applied Sciences and Arts of Western Switzerland (HES-SO). This research and development, carried out in collaboration with the University of Teacher Education of State of Vaud (UTE Vaud), has enabled the creation and implementation of a cyclical method for evaluating the satisfaction of HES-SO healthcare students at CHUV. The method created and tested-the Cycle of Construction and Quality Control for Satisfaction Evaluations (CCQCSE)-comprises nine stages: Issues, Analysis, Design, Items, Information, Collection, Processing, Feedback and Adjustment. It was designed with the help of a multidisciplinary team of healthcare professionals (CHUV) and experts in education sciences (UTE Vaud) as part of a master's thesis (Kaeser 2018) directed by our research team. A 4-month pilot phase allowed more than 250 placement students' satisfaction levels to be collected with respect to ten aspects of the practical training scheme, and provided diagnostic feedback. Identifying strengths and areas for improvement has significantly helped with the development of a quality policy for student training at the institution. CCQCSE is now considered as a robust method in line with the quality measures already in place at CHUV. In particular, it encouraged those responsible for the practical training to reflect on their mentoring practices. Beyond the context of CHUV and the mentoring of healthcare students on placements, the CCQCSE model could be transferred to other sectors in which training placements are offered, opening up new avenues of collaborative research

Prise en charge du choc septique chez l'enfant. [Management of pediatric septic shock]

Septic shock is a frequent admission cause in intensive care unit. In spite of the important progresses in the understanding of his physiopathology, mortality due to septic shock is about 20%. Recently, it has been demonstrated that an early goal-directed therapy permitted to improve the patient prognosis. With a good hemodynamic management and early antibiotherapy, mortality could be reduced

Cardiorespiratory arrest and vitamin D deficiency rickets: A case report

Vitamin D deficiency rickets became a rare disease in industrialized countries due to vitamin D supplementation in infants and nutritional guidelines. Symptoms of hypocalcemia due to vitamin D deficiency rickets may be life threatening. We report a case of a 16 months old infant who initially presented with stridor that was misdiagnosed as viral laryngitis. He presented, two weeks later, a cardiorespiratory arrest related to a laryngospasm secondary to severe hypocalcemia (ionized calcium level: 0.42 mmol/l,total calcium level: 1.15 mmol/). He was successfully resuscitated and vitamin D deficiency rickets was diagnosed. The medical history revealed that the infant was exclusively breast fed without vitamin D supplementation till the age of 10 months and also deprived from other milk products intentionally by the parents due to cultural habits. The laboratory investigations showed an elevated alkaline phosphatase level at 577 U/l, a normal phosphatemia level at 2 mmol/l, a decreased 25 (OH) cholecalciferol at 5.7 mcg/l,a normal calciuria level at 0.35 mol/mol of creatinine and an increased parathyroid hormone level at 325 ng/l. Cardiocirculatory arrest secondary to vitamin D deficiency rickets is very rare. The aim of this presentation is to highlight the symptoms of vitamin D deficiency rickets and to raise pediatricians' awareness to the necessity of including the diagnosis of hypocalcemia in case of stridor especially if the nutritional history or ethnic origin of the infant predispose to vitamin D deficiency. Vitamin D supplementation is important for some ethnic minority population, whom are faced with the risk of developing this diseas

Prospective study of the barriers to nutritional support in a paediatric intensive care unit : P16

Introduction and aim: Children hospitalised in a paediatric intensive care unit (PICU) are mainly fed by nutritional support (NS) which may often be interrupted. The aims of the study were to verify the relationship between prescribed (PEI) and actual energy intake (AEI) and to identify the reasons for NS interruption. Methods: Prospective study in a PICU. PEI and AEI from day 1 to 15, type of NS (enteral, parenteral, mixed), position of the feeding tube, interruptions in NS and reasons for these were noted. Inter - ruptions were classified in categories of barriers and their frequency and duration were analysed. Results: Fifteen children (24 ± 25.2 months) were studied for 84 days. The NS was exclusively enteral (69%) or mixed (31%). PEI were significantly higher than AEI (54.7 ± 32.9 vs 49.2 ± 33.6 kcal/kg, p = 0.0011). AEI represented 93% of the PEI. Ninety-eight interruptions were noted and lasted 189 h, i.e. 9.4% of the evaluated time. The most frequent barriers were nursing procedures, respiratory physiotherapy and unavailability of intravenous access. The longest were caused by the necessity to stop NS for surgery or diagnostic studies, to treat burns or to carry out medical procedures. Conclusion: AEI in PICU were inferior by 7% to PEI, considerably lower than in adult studies. Making these results available to medical staff for greater anticipation and compensation could reduce NS interruptions. Starving protocols should be reconsidered