Accuracy of prenatal ultrasound screening to identify fetuses infected by cytomegalovirus which will develop severe long-term sequelae.

OBJECTIVES: To compare the ability of detailed routine ultrasound examination, performed without knowledge of maternal serology and fetal status, with that of targeted prenatal imaging performed in prenatal diagnostic units in cases of known fetal infection to identify cytomegalovirus (CMV)-infected fetuses that will develop long-term sequelae. METHODS: All prenatal imaging reports were collected for 255 children with congenital CMV in a registered cohort between 2013 and 2017 (NCT01923636). All women had undergone detailed routine fetal ultrasound examination at 20-24 and 30-34 weeks as part of routine antenatal care. All cases of known fetal CMV infection had also undergone targeted prenatal ultrasound examination. Postnatal structured follow-up for up to 48 months of age involved clinical, audiological and neurological assessment, including Brunet-Lezine scoring. Long-term sequelae (> 12 months) were considered to be mild in cases with isolated unilateral hearing loss and/or vestibular disorders, and severe in cases with bilateral hearing loss and/or neurological sequelae. All imaging reports were analyzed retrospectively with the knowledge of congenital CMV infection, searching for reference to findings that were, or could have been, related to fetal infection. Findings were analyzed in relation to whether the cases were diagnosed with CMV in utero or only postnatally. RESULTS: There were 237 children with complete follow-up data (> 12 months), for a median of 24 (range, 12-48) months. Of these, 30% (71/237) were diagnosed with CMV prenatally and 70% (166/237) were diagnosed within 3 weeks after birth. 72.5% (29/40) of children with long-term sequelae, including 74% (14/19) with severe long-term sequelae, were not identified in the prenatal period. Among those diagnosed prenatally, the sensitivity of prenatal imaging for predicting long-term sequelae and severe long-term sequelae was 91% and 100%, respectively, while, in the group diagnosed only postnatally, non-specific infection-related ultrasound findings had been reported without raising suspicion in 48% of cases with long-term sequelae and 64% of those with severe long-term sequelae. CONCLUSIONS: Routine detailed ultrasound examination in pregnancy is not an appropriate screening tool for congenital CMV infection that leads to long-term sequelae, in contrast with the high performance of targeted prenatal imaging in known cases of fetal infection. The non-specific nature of ultrasound features of CMV and their evolution, and a lack of awareness of caregivers about congenital CMV, are likely explanations. Awareness of the sonologist regarding congenital CMV and knowledge of the maternal serological status in the first trimester seem key to the performance of prenatal ultrasound. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Drug-related problems among older patients: Analysis of 8 years of pharmacist's interventions.

OBJECTIVES: To analyse the most frequent DRP over time and pharmacists' interventions made among older patients aged over 75 years old. DRP between older patients and younger patients aged 18 to 74 years and between older patients treated in geriatric wards or not were also compared. METHODS: A cross-sectional observational study conducted on DRP detected by pharmacists at the university hospital centre of Lyon and prospectively recorded in the Act-IP© database from January 2008 to December 2015. RESULTS: A total of 56,223 DRP were investigated - 19,056 in older patients and 37,167 in younger patients. A supratherapeutic dosage was mainly reported (22.4% in older patients vs. 19.0% in younger patient) and pharmacists made interventions mostly to adjust dosage (27.3% vs. 24.2%). Physicians' acceptance was significantly lower in older patients (57.1% vs. 64.3%). DRP associated to a drug included a supratherapeutic use of acetaminophen (5.2% vs. 3.8%) and hypnotics (4.0% vs. 1.4%), medication in cardiology used without indication (1.4% vs. 0.2%) and underuse of vitamin D (1.2% vs. 0.1%). Supratherapeutic dosages were more significantly detected with a lower overall physicians' acceptance in older patients treated in general wards. CONCLUSIONS: This study highlights the specificity of DRP among older patients and encourages health care professionals to remain especially alert regarding older patients treated in general wards. These findings can contribute to define or adjust training needs and quality indicators to improve the daily practices of health care professionals.

[Premedication before tracheal intubation in French neonatal intensive care units and delivery rooms]. / Sédation-analgésie avant intubation trachéale en réanimation néonatale et en salle de naissance: pratiques en France métropolitaine.

UNLABELLED: Tracheal intubation is a painful procedure commonly used in the neonatal intensive care units and in the delivery rooms. It can be complicated by changes in vital signs. OBJECTIVE: To ascertain the use of sedatives and/or analgesics before tracheal intubation in French neonatal intensive care units and delivery rooms. METHODS: A survey by questionnaire sent to 58 neonatal intensive care units and 58 maternities. RESULTS: We obtained 46 responses (79,3%) from the neonatal intensive care units and 38 (65,5%) from the delivery rooms. In neonatal intensive care units, 74% of the newborns received a sedative and/or an analgesic before being intubated, and 60% of the units had specific written guidelines. Opioïds and benzodiazepines were the main drugs used. In the delivery rooms, sedatives or analgesics were only used in 21% of the centres. CONCLUSION: The use of sedation-analgesia seems to improve in neonatology but is still insufficient in the delivery rooms. The development of specific guidelines and a best learning about the different drugs are necessary.

Validation of mid-infrared spectroscopy for macronutrient analysis of human milk.

OBJECTIVE: Human milk has considerable variation in its composition. Hence, the nutrient profile is only an estimate and can result in under- or over-estimation of the intake of preterm infants. Mid-infrared (MIR) spectroscopy is an evolving technique for analyzing human milk but needs validation before use in clinical practice. STUDY DESIGN: Human milk samples from 35 mothers delivering at 35 weeks to term gestation were analyzed for macronutrients by MIR spectroscopy and by standard laboratory methods using Kjeldahl assay for protein, Mojonnier assay for fat and high-pressure liquid chromatography assay for lactose. RESULTS: MIR analysis of the macronutrients in human milk correlated well with standard laboratory tests with intraclass correlation coefficients of 0.997 for fat, 0.839 for protein and 0.776 for lactose. Agreement between the two methods was excellent for fat, and moderate for protein and lactose (P<0.001). CONCLUSIONS: This methodological paper provides evidence that MIR spectroscopy can be used to analyze macronutrient composition of human milk. Agreement between the methodologies varies by macronutrient.

The unexpected role of bioaerosols in the Oxidative Potential of PM.

Bioaerosols represent up to 15-25% of PM by mass, but there is currently no assessment of their impact on Oxidative Potential (OP), or capacity of particulate matter (PM) to produce damaging oxidative reactions in the human lungs. Here, the OP of selected bioaerosols (bacteria cells vs fungal spores) was assessed through the cell-free DTT assay. Results show that bioaerosols induce Reactive Oxygen Species (ROS) production, varying along the microorganism type, species, and concentration. Fungal spores show up to 10 times more ROS generation than bacterial cells. At the highest concentrations, fungal spores present as much oxidative reactivity as the most redox-active airborne chemicals (Copper, Naphtoquinone). Moreover, bioaerosols substantially influence OP of ambient PM and that of its chemical constituents: in presence of A. fumigatus spores, the OP of Cu/NQ is increased by a factor of 2 to 5, whereas, 104 and 105 S. epidermidis bacterial cells.mL-1 halves the OP of Cu/NQ. Finally, viable and gamma-rays-killed model bioaerosols present similar oxidative reactivity, suggesting a metabolism-independent cellular mechanism. These results reveal the importance of bioaerosols for PM reactivity. PM toxicity can be modified due to bioaerosols contribution or by their ability to modulate the OP of toxic chemicals present in PM.

[Use of thrombelastography to guide posttraumatic hemostatic therapy: More coagulation factor concentrates and less allogenic blood transfusion?] / Intérêt de la thromboélastographie pour guider la correction de la coagulopathie post-traumatique : plus de MDS, moins de PSL ?

Viscoelastic technics are used for 10 years and include the ROTEM® and the TEG®. These devices that exploit the viscoelastic properties of the clotting blood, allow a rapid and global analysis of the haemostatic process taking into account all the process interfering with haemostasis such as inflammation. It has been shown that the use of these technics in clinical situations such as trauma, postpartum haemorrhage, gastrointestinal bleeding or cardiac surgery may reduce the need for blood product, the cost and perhaps may improve the outcome of the patients. Thanks to a rapid identification of the underlying coagulation deficit, these technics facilitate decision-making during acute care and help to guide the treatment, particularly with coagulation factor's concentrate.

Delayed surgery in pericardial teratoma with neonatal hydrops.

Timing of neonatal surgery in cases of pericardial teratoma with hydrops is not standardised. We report two cases of hydropic premature newborns with pericardial teratoma in which surgery was delayed until respiratory and haemodynamic stabilisation. Mature teratoma was removed on day 3. The newborns were weaned from the ventilator on postoperative day 5 and 10, respectively. Both infants were doing well at 18 months, suggesting delayed surgery may be feasible and effective.

Long-term pulmonary functional outcome of bronchopulmonary dysplasia and premature birth.

Pulmonary function and exercise tolerance were evaluated in late childhood in two groups of prematurely born children: one group with bronchopulmonary dysplasia (BPD) [n = 15; gestational age at birth (GA): 29.6 +/- 2.8 weeks; birth weight (BW): 1,367 +/- 548 g; age at test: 7.9 +/- 0.6 years], and a second group without significant neonatal lung disease [pre-term (PT)] (n = 9; GA: 30.3 +/- 1.7 weeks; BW: 1,440 +/- 376 g; age at test: 7.8 +/- 0.22 years). The results were compared with a control group of children of similar ages and heights, born at term [term born (TB)]. We observed that total lung resistance (RL) was significantly higher in BPD (11 +/- 3 cmH2O/L/s), and in PT (9 +/- 2) than in TB [5 +/- 1; (P < 0.001 and P < 0.05, respectively)]. In BPD RL was higher than in PT (P < 0.05). Dynamic lung compliance (CLdyn) was decreased in BPD (43 +/- 11 mL/cmH2O) and in PT (56 +/- 17) compared with TB (76 +/- 20) (P < 0.001 and P < 0.05), and also in BPD compared with PT (P < 0.05). Forced expiratory volume in 1 second (FEV1) and FEV1/forced vital capacity (FVC) were lower in BPD (1.07 +/- 0.15 L and 72 +/- 7%) than in PT (1.29 +/- 0.23 L, and 80 +/- 7%) (P < 0.05). Exercise tests were performed in six boys with BPD. The ratio between minute ventilation at maximal workload (VEmax) and the predicted value of maximal voluntary ventilation (MVV) was elevated in the six BPD boys tested, compared with five boys of Group 2 and five TB boys (87 +/- 15% vs. 62 +/- 14% and 65 +/- 13%) (P < 0.05). We conclude that: 1) prematurity and BPD is followed by long-term airway obstruction and a mild degree of exercise intolerance and; 2) premature birth without BPD may be followed by a milder degree of airway obstruction in childhood than in infants who developed BPD during the neonatal period.

[Deafness in the neonatal period: basis for screening]. / La surdité en période néonatale: les bases du dépistage.

Deafness must be recognized in infancy in order to reduce auditory disability to a minimum. To achieve this, it is important to implement screening programmes as soon after birth as possible. In the United States, the Joint Committee on Infant Hearing recommended in 1982 that identification of hearing loss should be screened in the neonatal period. This early detection is now considered critical for optimal rehabilitative outcome. This paper presents the "state of art" neonatal screening principles and procedures. In France, neonatal screening programs for auditory dysfunction are not consistent with these principles. Evoked otoacoustic emissions represent an important advance in screening for hearing loss in normal neonates and babies from neonatal intensive care units. This method records very low intensity sound energy released by the cochlea in response to a brief sound stimulation. These otoacoustic emissions show promise as a rapid, cost-effective means of quickly discharging all babies with normal peripherical auditory systems.

[Comparative study of nebulized sambutol against placebo in the acute phase of bronchiolitis in 33 infants aged 1 to 6 months]. / Etude comparative des nébulisations de salbutamol contre placebo à la phase aiguë d'une bronchiolite chez 33 nourrissons de 1 à 6 mois.

BACKGROUND: The therapeutic role of bronchodilators in bronchiolitis remains controversial. The aim of this study is to evaluate the safety and the clinical response to nebulized salbutamol in infants with mild acute bronchiolitis. PATIENTS AND METHODS: Thirty-three infants, aged 1 month to 5 months and 22 days (mean: 92.4 days) were included in the study. Patients received either nebulized salbutamol (0.15 mg/kg per dose: 16 infants) or a placebo (normal saline aerosol: 17 infants), delivered by an oxygen propellent, three times at intervals of 1 hour, as part of a double-blind randomized trial. Effect of treatment was evaluated by measuring respiratory and heart rate, clinical scores based on the degree of retraction and wheezing, and oxygen saturation. Clinical assessment was repeated 30 minutes after each nebulization. A nasopharyngeal swab was obtained for detection of respiratory syncytial virus (VRS) antigens by immunofluorescence assay in all patients. RESULTS: Patients in the salbutamol group exhibited significantly greater improvement in respiratory rate (P = 0.01), accessory muscle score (P < 0.001) and wheezing score (P < 0.001). There was no significant difference in oxygen saturation between both groups. Infants treated with salbutamol exhibited a non-significant increase in heart rate after the three sprays; no other adverse effects were noted. VRS was identified in 78% of the children tested. CONCLUSIONS: Salbutamol is safe and effective in relieving the respiratory distress of young infants with acute bronchiolitis. Our study confirms previous observations that infants younger than six months of age respond as well as older children when given three doses of nebulized salbutamol. Responders could not be differentiated from non responders by personal or family histories of atopy and VRS isolation. A longitudinal study could establish a correlation between response to bronchodilator therapy and later development of asthma.

[Relationships between air conditioning, airborne microorganisms and health]. / Etude des relations entre climatisation, micro-organismes aéroportés et santé.

Concurrently with the increase of air-conditioning, potentially severe or frequent new diseases have emerged, giving rise to social and economical consequences. The first part of this work is a state of the art review of the relationships between air-conditioning, airborne microorganisms and health, through a technical, metrological and medical approach. The second part presents four studies performed in this field. Two of them deal with the relationship between airborne microorganisms and technical features of air-conditioning. Measurements performed on actual sites demonstrated the benefit of using high efficiency filters and low risk components in air-conditioning systems. The third study was aimed to look for a relationship between airborne microorganisms and sick building syndrome symptoms. Statistical analyses of individual data revealed significant associations between airborne bacteria or fungi and symptoms. These results may be the first step in determining a dose-response relationship, in order to define threshold limit values in this field. In the fourth study, the contribution of particle counting in assessing exposure to airborne microorganisms was explored by monitoring simultaneous variations of microbial and particle concentrations. The results showed that associating particle counting may allow to detect microbial variations instantaneously, and therefore improve the assessment of exposure to airborne microorganisms.

Adrenal enzyme impairment in neonates and adolescents treated with ritonavir and protease inhibitors for HIV exposure or infection.

BACKGROUND: Human deficiency virus (HIV) protease inhibitors (PIs) are widely used drugs whose effects are pharmacologically enhanced by ritonavir, a potent cytochrome P450 inhibitor. We reported previously that prophylactic postnatal ritonavir-PI therapy in HIV-exposed neonates was associated with increases in plasma 17-hydroxyprogesterone (17-OHP) and dehydroepiandrosterone sulfate (DHEA-S). AIMS: To further investigate adrenal function in neonates and adolescents given ritonavir-PI. METHODS: Adrenal function was assessed prospectively in 3 HIV-exposed neonates given short-term prophylactic treatment and 3 HIV-infected adolescents given long-term treatment. Plasma cortisol, 17-OHP, 17-OH-pregnenolone, DHEA-S, and androstenedione were measured before and after ACTH administration. RESULTS: None of the patients had clinical signs of adrenal dysfunction. The only neonate exposed to ritonavir-PI in utero had up to 3-fold increases in plasma 17-OHP. Increases in 17-OH-pregnenolone of up to 3.1-fold were noted in 4 of the 6 patients, and all 6 patients had elevations in DHEA-S (up to 20.4-fold increase) and/or DHEA (up to 4.7-fold) and/or androstenedione (up to 5.2-fold). All these parameters improved after treatment completion. CONCLUSION: Neonates and adolescents given ritonavir-PI exhibit a similar adrenal dysfunction profile consistent with an impact on multiple adrenal enzymes. These abnormalities require evaluation, given the potentially long exposure times.

[Palliative care in the neonatal period. Part one: general considerations]. / Réflexions et propositions autour des soins palliatifs en période néonatale : 1(re) partie considérations générales.

In France, the law dated 22 April 2005 required that all practitioners offer palliative care to patients as an alternative to unreasonable obstinacy. The practical development of palliative care during the neonatal period is not easy, even though obstetricians and neonatologists have always been aware of the ethical necessity of comfort in the dying newborn. The decision leading to palliative care begins with the recognition of patent or potential unreasonable obstinacy, followed by withdrawing treatment and technical support, and finally a palliative care plan is drawn up with the medical team and the parents.

[Implementing palliative care for newborns in various care settings. Part 3 of "Palliative care in the neonatal period"]. / La mise en oeuvre pratique des soins palliatifs dans les différents lieux de soins : 3(e) partie des réflexions et propositions autour des soins palliatifs en période néonatale.

Palliative care in newborns may take place in the delivery room and then continued either in maternity wards or in the neonatal unit. For babies developing a chronic condition, going home may be advantageous. The population concerned includes babies born with a severe intractable congenital malformation and certain extremely preterm newborn babies at the limits of viability. Care procedures as well as withholding and withdrawing treatments are reviewed.

[Retrospective diagnosis of congenital CMV infection in DBS from Guthrie cards: French experience]. / Le diagnostic rétrospectif de l'infection congénitale à cytomégalovirus sur le sang séché des cartes de Guthrie: l'expérience en France.

Systematic screening for cytomegalovirus congenital infection is not performed in France. For children with hearing loss or other neurological CMV compatible symptoms, retrospective diagnosis is possible by PCR detection of CMV DNA in dried blood spot of neonatal Guthrie cards. We report here the results obtained with this technique in the French national reference laboratory for cytomegalovirus.

[Disclosure by neurologic signs of right subclavian aneurysm. Post-traumatic aneurysm?]. / Révélation par des signes neurologiques d'un anévrysme de la sous-clavière droite.

BACKGROUND: Aneurysms of the subclavian artery are rare in childhood and may be due to traumatic, infectious or congenital causes. CASE REPORT: A 15 year-old boy presented with a sudden left visual disturbance plus decreased muscle strength and paresthesias of the left arm; these manifestations disappeared within 15 minutes. His neurological examination on admission was normal. The right arm radial pulse was weak and the blood pressures of the right and left arms were significantly different. Doppler showed a right subclavian artery aneurysm containing several clots, that was confirmed by angiography. There were no signs of inflammation or indication of autoimmune disease. This aneurysm might have been caused by trauma as the patient had had a violent cervical traumatism after a diving accident 2 years earlier. The aneurysm was surgically removed and the right vertebral artery arising from it was reimplanted. Histological examination of the aneurysm gave no evidence of etiology. The post-surgical MRI showed no brain abnormaly. CONCLUSIONS: This aneurysm is probably of post-traumatic origin. The cerebral disturbance could be due to embolism or transient ischemia; the latter is more compatible with the normal NMR.