Biomedical subjects
Publications and source records attributed to J Laugier.
The fulminant forms of congenital myotonic dystrophy, which rapidly lead to death, are difficult to diagnose. The case described illustrates the roles of persistent pulmonary hypertension in such a fatal form.
The main contribution of EEG during intensive care in infants with hypoxic-ischemic encephalopathy is i) to help determine whether infants with subtle clinical manifestations present with epileptic seizures, ii) to determine whether paralyzed or heavily sedated infants present with convulsive phenomena, iii) to assess the therapeutical response to anticonvulsants, 4) to contribute, in combination with ultrasound scanning, to diagnostic evaluation of the severity of lesions, and to provide valuable prognostic informations via the analysis of the background activity, as normal EEG is highly predictive of normal outcome, whereas various abnormal EEG features are constantly associated with subsequent major neurological abnormalities or death. These EEG features are readily available from a very early stage and may both precede and be prognostically more sensitive than information obtained from ultrasound. Recording of neonatal electroencephalogram requires awareness of the normal development of electroencephalographic features in the newborn, skilled technicians, and experienced readers of EEG tracings.
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Changes in mice haemopoietic cellular populations and in the radiosensitivity of CFU-C and BFUe progenitors cells were determined in vivo for mixed field radiations composed of a gamma-ray component and a neutron component. Five Dgamma/Dtotal ratios (gamma-rays over total dose ratios, quoted as tau in this report) were obtained (tau = 0.95, 0.83, 0.67, 0.33 and 0.09). Myelogram changes were enlarged with the increase of the neutron component. Radiosensitivity of the two progenitor cell lineages were increased with lower tau values (excess of neutrons). The radiosensitivity of haemopoietic progenitor cells exposed in vivo varies with the ratio of the high- and low-LET components in the mixture. The D0 value varied from 3.3 +/- 0.22 to 0.85 +/- 0.04 Gy with the decrease of tau for CFU-C and from 2.08 +/- 0.22 to 0.64 +/- 0.07 Gy for BFUe. The obtained relative biologic efficiency (RBE) varied from 1.2 +/- 0.08 to 4.7 +/- 0.24 for CFU-C and from 1.1 +/- 0.1 to 3.6 +/- 0.16 for the BFUe. The relation between RBE and tau could be somewhat non-linear for CFU-C and seems to be close to linear for BFUe. The higher is the neutron component, the higher is the radiosensitivity. These results indicate that variations of the quality of the mixed field in the haemopoietic local territory are of great importance in terms of radiation damage and cell killing as well as in terms of the ability to restore the haemopoietic system.
The basic physiological variable in hypoxic-ischaemic brain injury is cerebral oxygen delivery. When oxygen delivery becomes insufficient to meet the cellular demands for oxygen, a sequence of biochemical events will be triggered leading to cell death. High levels of CBF following severe birth asphyxia is now well documented by Doppler ultrasound which has been shown to be a useful prognostic indicator following birth asphyxia. Near infrared spectroscopy (NIRS) is of great potential value since it may be used at the bed-sid and allows to measure the cerebral blood volume and the concentrations of cytochrome aa3. Magnetic resonance spectroscopy (MRS) allows noninvasive assessment of cerebral metabolism in asphyxiated neonates. 31P MRS has demonstrated that birth asphyxia leads to delayed impairment of cerebral energy metabolism and is predictive of later neurodevelopmental outcome. 1H MRS has shown lactate accumulation and a later decline in N-acetyl aspartate concentration.
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This paper has reviewed the techniques used for recording evoked potentials in the premature infant and the early developmental changes. The maturational changes in the evoked potentials, including morphological changes, and the very rapid latency changes within the first months of life, provide an invaluable means for assessing and monitoring development within the central nervous system. The maturational changes are such that normative values are requisite, and the norms must take into account both the infant's gestational age at birth as well as the postnatal age. These norms can then be used to aid in the assessment of gestational age, and whether there has or has not been normal maturational development, either in utero or during the postnatal preterm period. Evoked potentials are of increasing value clinically in preterm neonates, primarily because of the difficulty in obtaining reliable neurological evaluation of these infants. Median nerve SEPs may provide reliable information in preterm infants at risk of PVL, and when recorded in the second week of life, predict cerebral palsy. PTN SEPs seem to be even more reliable indicators of outcome, but the difficulty in obtaining them in preterm infants needs to be taken into consideration. Further study is needed in some areas, such as in apnoeic preterm babies clearly to establish the role that evoked potentials (in this case BAEPs) may have in understanding both the aetiology and the clinical course of this dysfunction. In other conditions, such as delayed intrauterine growth, that may lead to neurological sequelae, evoked potentials can provide objective CNS assessment. Evoked potentials may also prove useful in the monitoring of treatment modalities for preterm infants. The evoked potentials are a valuable adjunct in the assessment of preterm neonates and, as their value is recognised, we expect their use to increase.
Last years, il became obvious that the colonization pattern described in 1976-1978 was no more valid: early colonization by Enterobacteriaceae at the 2-3 rd day of life in all newborns, with constant presence of antibioresistant strainseven in non treated newborns. To establish the new pattern of colonization, the same quantitative method of dilution and culture on selective media was used daily from day 1 to day 7 (5 days only for M). The number of Enterobacteriaceae, enterococci and staphylococci was determined in the stools of 10 newborns in the Maternity unit (= M) (term 40 weeks +/- 1, birth weight 3,356 g +/- 383), 10 in the Premature nursery (= P) (term 34.9 weeks +/- 1, birth weight 2,457 g +/- 676), and 14 in the Neonatal intensive care unit (= R) (term 35.2 weeks +/- 3.8, birth weight 2,457 g +/- 763). The results establish that colonization by Enterobacteriaceae is no more constant at D3. It could be demonstrated only in 8/10 M, 1/10 P, and 6/14 R (statistically different - p < 0.01 - between M and P). At D5, 9/10 M, 5/10 P, 10/14 R, and at D7, 6/10 P and 10/14 R were colonized. Resistant Enterobacteriaceae (Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae) could be found in only 3/10 M, 4/10 P and 6/14 R. Enterococci could be found in 1 newborn M, 2 P and 7 newborns R. Staphylococci appeared earlier: all newborns M, P and R were colonized at D2, 4 and 5 respectively. These bacteria were coagulase negative, associated with Staphylococcus aureus in 3 P. Our hypothesis is that late colonization with Enterobacteriaceae and enterococci is due to the improvement of hygiene procedures and due to the decontaminating effect of antibiotics in other treated newborns (Enterobacteriaceae by 3 rd generation cephalosporin and enterococci by pharyngeal vancomycin).
We report 18 premature infants (gestational age: 31.1 weeks +/- 2.6 [mean +/- SD] (range: 28-36]) with necrotizing enterocolitis (NEC) who developed total parenteral nutrition (TPN) associated cholestasis. Liver function tests were performed at the start of TPN (D1) and repeated once a week. Considering the date of cholestasis onset (direct bilirubin > 30 mumol/l and/or serum bile salts > 10 mumol/l), the patients can be divided in two groups. The first group consisted of 9 patients who had cholestasis at D1. In these patients shock and/or hypoxia occurred prior to D1 and were the only risk factors of cholestasis identified before D1. The second group consisted of 9 patients who developed cholestasis after D1 and in whom the cause of cholestasis was multifactorial (sepsis, lack of enteral feeding, shock and/or hypoxia). These results suggest that shock and/or hypoxia can be responsible for early cholestasis in premature infants. We conclude that shock and hypoxia should be considered when discussing TPN-associated cholestasis.
Because diphtheria, tetanus, pertussis and poliomyelitis vaccine is routinely given during the period of highest incidence of sudden infant death syndrome (SIDS), we carried out a retrospective case-control study to assess whether such vaccination increased the risk of SIDS. The vaccination status of 118 SIDS and 332 control children, matched for sex, date of birth and age of the victims at death, was compared: the victims of SIDS were not significantly more often vaccinated than control children, the odds ratio was estimated at 1.9 with a 95% confidence interval from 0.9 to 3.9. There was a statistical difference between vaccination status of SIDS cases and controls aged less than three months. Nine percent of SIDS cases under 3 months had been vaccinated whereas the matched controls had not. In our study DTCP vaccination was not a risk factor for SIDS; although more of the SIDS infants less than 3 months of age had been vaccinated. This result however, concerns only one subgroup of the population studied and needs to be confirmed with another study of only SIDS infants less than 3 months of age, because DTCP vaccination was not a risk factor for SIDS when considering the total sample of the study.
OBJECTIVE: Based on the information acquired in the first two parts of this study and the data in the literature, to propose ethic codifications for solving moral dilemmas concerning fetal medicine. METHODS: Identification of situations where the object of the conflict is ethics: general methodology propositions for making individual decisions. RESULTS: In all cases a rigorous method is required, based on three main elements: a complete and well documented medical file; the opinion of the couple after appropriate participative communication; case by case collegial discussion. CONCLUSION: The methodology proposed underscores the roles played by health carers: obtain a medical file as complete as possible with prime emphasis on the infant; establish active communication with the parents giving greater value to their free examination of the situation; collegial discussion in order to be pertinent social partners.
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The acute effects of surfactant instillation rate on the cerebral and cardiovascular haemodynamics were studied in a randomised trial of 27 preterm neonates with respiratory distress syndrome (RDS). Cerebral blood flow velocity (CBFV), mean arterial blood pressure (MABP), blood gases and electroencephalogram (EEG) were continuously recorded before, during, and for at least 10 minutes after the administration of surfactant. The measurements were repeated one, three, and six hours later. Left ventricular output (LVO) and ductal patency were assessed 10 minutes before and then one, three, and six hours after surfactant administration. Surfactant (Exosurf) was instilled rapidly over five minutes in 13 infants and slowly over 15 minutes in 14 infants. The rapid group showed a significant but transient increase (mean 38%) in CBFV, a rise strongly related to an increase in carbon dioxide tension. No significant change in CBFV was observed in the slow group. There were no significant changes in EEG, MABP, LVO, or ductal shunting in either group. The findings suggest that rapid instillation of Exosurf leads to an increase in CBFV and partial carbon dioxide pressure (PCO2) and requires a close monitoring of blood gases to maintain adequate ventilation. Furthermore, the findings should alert clinicians to the need for slow infusion of Exosurf.
Twenty-five infants with suspected or confirmed coagulase negative staphylococcal infection were studied. Continuous administration of vancomycin was used because it is usual with infusions prepared daily for catheterized patients, and because continuous infusions are well tolerated and achieve better penetration in tissues and CSF. Vancomycin acts as a time-dependent antibiotic. The aim was to obtain a level of 20-25 mg/l. in serum. Fifteen newborns term 27-35 weeks (m = 30.3) aged 7-30 days (m = 16.1) received 10 to 45 mg/kg/day of vancomycin and were monitored for 2 to 12 days. The sample for assay was taken in a peripheral vein, and the results were the same during the infusion or 15 minutes after its end. The daily dose of vancomycin necessary varied from 25 to 40 mg/kg for newborns with serum creatinine < 70 mmol/l and 10 to 30 mg/kg with serum creatinine > or = 90 mmol/l. Except for a newborn with multiorgan failure, serum creatinine rapidly decreased. Four newborns term 38-40 weeks (m = 39.5) aged 2-12 days (m = 8.3) received 20 to 45 mg/kg/day of vancomycin and were monitored for 2 to 12 days. The daily dose necessary varied from 30 to 40 mg/kg/day with important individual variations, and 20 mg/kg/day in a newborn with a high level of creatinine. In 6 infants aged 2-22 months receiving 22-45 mg/kg/day of vancomycin, a mean daily dosage of 40-45 mg/kg was adequate, with important individual variations.(ABSTRACT TRUNCATED AT 250 WORDS)
OBJECTIVE: To evaluate the regional programme designed to train personnel for resuscitation of the neonate in the delivery room and organized in the district of Centre, France in 1990. STUDY: Transversal study. SITE: The different maternities of the district. POPULATION: 31 maternities, 156 persons in charge of neonates in the delivery room including medical personnel (doctors, mid-wives) and paramedics, with or without any special training in 1990. METHOD: A single evaluator visited each maternity and met the personnel involved. The modalities of the evaluation were not given in advance and included a census of the personnel who had participated in the training programme and changes in material. The success of the training programme was evaluated on a theoretical and practical basis for the personnel and on the number of severe meconium aspirations observed. RESULTS: The training programme had reached 53% of the personnel involved. It had a wide impact both in terms of changed material and in neonatal resuscitation rates compared with untrained personnel. The number of severe meconium aspirations fell from 3 in 1989 to 0 in 1990.
We studied the inhibition of angiotensin converting enzyme (ACE) in eight infants with congestive heart failure (CHF) poorly controlled with digoxin and diuretics, treated orally with 0.25 mg kg-1 enalapril maleate once a day. Baseline ACE activities were compared between these infants and control children without CHF or ACE inhibitor. Except for one infant who vomited, inhibition of ACE activity was 75.5 +/- 12.2%, 75.5 +/- 10.5% and 51.7 +/- 12.2%, at 4, 12 and 24 h after drug intake respectively. There was no correlation between postnatal age and inhibition of ACE activity. In infants with CHF, mean baseline ACE activity was significantly higher than in control infants (36.4 +/- 7.2 mu ml-1 vs 26.9 +/- 6.9 mu ml-1, P < 0.05). These results were very similar to those seen in adults.