[Therapeutic advances in neonatology]. / Actualités thérapeutiques en néonatologie.

In this article, we will review major therapeutic advances in neonatology over the past ten years. We will discuss the antenatal administration of magnesium sulfate, the interest of hypothermia in the context of hypoxic ischaemic encephalopathy, the benefits and modalities of placental transfusion, less invasive techniques for ventilation and administration of the surfactant, possibilities to fortify breast milk and the concept of developmental care. These therapeutic advances are sometimes based on new therapeutics, sometimes on new concepts and, sometimes, on new less invasive techniques. They have made it possible to optimize the care of premature babies but also of term newborns.

Dans cet article, nous allons passer en revue les grandes avancées thérapeutiques dans le domaine de la néonatologie au cours des dix dernières années. Nous traiterons de l'administration anténatale du sulfate de magnésium, de l'intérêt de l'hypothermie contrôlée dans le cadre de l'encéphalopathie d'origine hypoxo-ischémique, des bénéfices et modalités de la transfusion placentaire, des techniques moins invasives pour la ventilation et pour l'administration du surfactant, de la fortification du lait maternel et du concept de soins de développement. Ces avancées thérapeutiques reposent tantôt sur des nouveautés thérapeutiques, tantôt sur de nouveaux concepts et, parfois, sur de nouvelles techniques moins invasives. Elles ont permis d'optimiser la prise en charge des prématurés, mais aussi des nouveau-nés à terme.

A not so harmless mass: Kaposiform hemangioendothelioma complicated by a Kasabach-Merritt phenomenon.

A vascular mass localized in the face and the neck was displayed by ultrasonography in a 38-week-old male fetus. At birth, the mass was bulky and purplish. The newborn breathed spontaneously but with severe desaturation. During laryngoscopy, we observed an obstruction of the larynx with a left-shift caused by the hemorrhagic mass. Blood analysis revealed anemia, severe thrombocytopenia, and coagulation disorders. The diagnosis of kaposiform hemangioendothelioma (KHE) complicated by a Kasabach-Merritt phenomenon (KMP) was put forward and treatment with propranolol, corticoids, and vincristine was initiated. Platelets were transfused daily for 8 days but did not resolve the thrombocytopenia. At day 8, we added sirolimus to the treatment and noted a rapid response with the normalization of the platelet count within 1 week and a significant regression of the mass. In this paper, we review the clinical and biological features of hemangioendothelioma associated with KMP and discuss its current and future treatment. Sirolimus seems to be very promising.

[Gonococcal ophthalmia neonatorum: Clinical illustration, prevention, and future prospects]. / Conjonctivite néonatale à Neisseria Gonorrhoeae : illustration clinique, prophylaxie et perspectives d'avenir.

A 6-day-old infant presented with a bilateral suppurative ocular discharge with a conjunctival erythema. Polymerase chain reaction was performed on the pus and showed the presence of Neisseria gonorrhoeae DNA. Therapy with intravenous cefotaxime was initiated and completed with local application of tobramycin. This infection was associated with a small unilateral corneal lesion, with rapid resolution. This case provides the opportunity to focus on newborn suppurative conjunctivitis and its treatment. The different prophylaxes available (silver nitrate, povidone-iodine, local antibiotics, etc.) and their respective advantages and disadvantages are reviewed. There is no clear consensus on the most effective solution. Additionally, universal prophylaxis is challenged in several countries, where it is no longer recommended.

[How I explore and treat a neonatal renal vein thrombosis: a case report]. / Comment j'explore et traite une thrombose veineuse renale néonatale: àpropos d'un cas.

Neonatal renal vein thrombosis is a rare condition. The present case is rather unfrequent and particularly educative since it shows the complete diagnostic triad including hematuria, flank mass and thrombocytopenia. The diagnosis relies on the demonstration, by Doppler ultrasound, of an obstructed renal venous bed. The investigation is completed by a platelet count and the determination of the prothrombin time, of the activated partial thromboplastin time as well as of the concentration of fibrinogen. The screening also includes the search for a possible etiology, such as a deficiency in coagulation proteins, the presence of antiphospholipid antibodies or of a genetic mutation of one of the coagulation factors. Since there exist no evidence based guidelines for the management of the disease, we will discuss the diagnosis and treatment in relation with the published literature.

[Psychiatry today]. / Le secteur psychiatrique aujourd'hui.

A COMMON SITUATION: Primary care physicians often provide care for schizophrenic patients. The main approaches include drug regimens, psychotherapy and psychosocial support. DRUG THERAPY: Neuroleptics should be given in single drug regimens in a continuous protocol for long periods. Side effects, particularly neurological effects, can be countered with antiparkinson medication. The aim is to reach the best possible balance between the therapeutic effect and side effects. PSYCHOTHERAPY: The general practitioner does not necessarily use sophisticated psychotherapeutic protocols but rather relies on a certain number of attitudes aimed at helping the patient accept the medications and control the main pathological mechanisms the schizophrenic state as expressed in the relationship with the health care provider. PSYCHOSOCIAL SUPPORT: A series of assistance measures (allocations for handicapped adults, adapted housing, protection of property) often involve a team of workers who should all take part in the therapeutic strategy.

Neuroleptic-resistant schizophrenic patients treated by clozapine: clinical evolution, plasma and red blood cell clozapine and desmethylclozapine levels.

The aim of this open study was to determine a more rational therapeutic approach for psychotic patients treated with clozapine for several months, using measurement of plasma and red blood cell levels (P, RBC) of clozapine (cloza) and N-desmethylclozapine (descloza), the major metabolite of clozapine, which has been reported to be less active but more toxic (agranulocytosis) than clozapine itself. The RBC concentration may be considered as more representative of the free fraction drug. The study concerned 7 patients suffering from chronic paranoid schizophrenia according to the DSM-IV criteria. All of them were treatment-refractory schizophrenic inpatients (4 men, 3 women, mean age +/- SD: 38.2 +/- 8.4 years; mean duration of illness +/- SD: 14.4 +/- 5.1 years). They had received at least two different neuroleptics, for 6 weeks, before entering the study. Treatment started in our hospitalization unit with clozapine 25 mg up to a maximum of 900 mg/d (mean stabilized daily dose +/- SD: 507 +/- 211 mg and mean daily dose per kg: 6.91 +/- 3.08 mg). Clinical evaluations (Quality of Life Scale: QLS), regular blood monitoring and biological samples were conducted at the same time, weekly for 18 weeks and then monthly (duration of the study: 4 to 38 months; mean +/- SD: 12.9 +/- 11.5 months). Plasma and RBC (after lysis) levels were determined by reversed phase HPLC and UV detection after extraction with hexane. All the patients improved very quickly after the first week of treatment and six were able to leave the hospitalization unit and start outpatient care such as daily hospitalization, returning home or in sheltered accommodation. With the following plasma (P) and RBC levels: mean cloza +/- SD: (P = 294 +/- 146 ng/ml; RBC = 110 +/- 82 ng/ml) and mean descloza +/- SD: (P = 173 +/- 106 ng/ml; RBC = 76 +/- 54 ng/ml); none of the seven patients developed agranulocytosis. The blood levels, ensuring better surveillance, have a predictive value for clinical improvement. A linear pharmacoclinical correlation was only found between RBC cloza concentrations and the evolution of the QLS scores. Clozapine fulfils the criteria for therapeutic drug monitoring, and determination of plasma, and more particularly RBC, cloza and descloza levels may help to find the lowest effective dose with the fewest side effects.