Facteurs pronostiques précoces des myocardites aigües virales de l'enfant

Objectifs. Définir des facteurs pronostiques précoces d évolution favorable à J3 et de guérison pour les myocardites aigües virales de l enfant. Décrire des éléments diagnostiques de myocardiopathie hypokinétique et vérifier si le pronostic diffère entre les formes aigües et fulminantes. Matériels et méthodes. Inclusion rétrospective de 23 patients, sur 10 ans, dans 3 villes : Lyon, Clermont-Ferrand et Grenoble. Résultats. On a compté 14 cas de myocardite aigüe et 9 de myocardite fulminante. Le tableau clinique digestif a été le plus fréquent. Une cardiomégalie était présente dans 74% des cas, une tachycardie sinusale dans 78%. Les troponines et NTProBNP mesurés ont des valeurs médianes respectivement à 0,20 g/L et 29430ng/L. Le taux de survie a été de 87%; quatre patients ont bénéficié de l ECMO avec un taux de survie de 75%. Il n y a pas eu d IRM précoce réalisée, bien qu utile au diagnostic et au pronostic. On ne retrouve pas de différence pour le pronostic favorable des formes fulminantes. Les facteurs pronostiques de guérison ont été: à J0, moins de troubles de repolarisation et acidose métabolique moins importante; à J1, stabilisation ou amélioration des constantes hémodynamiques; à J3, évolution clinique favorable. Les facteurs pronostiques d évolution favorable à J3 ont été: délai diagnostique plus long, acidose métabolique moins importante, critère combiné bicarbonates=0,10 moins fréquent, FEVG plus élevée. Conclusion. Cette étude a montré des critères pronostiques d évolution favorable à J3; les critères pronostiques de guérison à J1 et J3 confirment la nécessité d une prise charge en urgence pour restaurer l hémodynamique du patient dès le diagnostic.Objectives. To assess early predictors for favourable outcome at day 3 and further full recovery for acute viral myocarditis in children. To outline clinical features of hypokinetic cardiomyopathy and check for differences between acute and fulminant myocarditis. Methods. Retrospective inclusion of 23 patients, over a 10 years period, located in 3 cities: Lyon, Clermont-Ferrand and Grenoble. Results. 14 acute myocarditis cases and 9 fulminant myocarditis cases were reported. Digestive clinical signs were the most frequent. Cardiomegaly was detected in 74% of the cases and sinusal tachycardia in 78%. Troponin and NTProBNP were checked for median value at 0,20 g/L and 29430ng/L. Survival rate has been 87%; four patients received ECMO with 75% survival rate. Early MRI was not performed although it is helpful for pertinent diagnosis and prognosis. Positive prognosis for fulminant myocarditis wasn t shown in this study. Recovery predictors conclusion: day 0, less repolarisation troubles and lower rate of metabolic acidosis; day 1, improvement or stabilization in hemodynamic values; day 3, positive outcome issue. Positive outcome predictors at day 3 have been: more time for diagnosis, lower metabolic acidosis, combined criteria bicarbonate=0,10 less frequent, higher FEVG. Conclusion. This study has shown positive outcome predictors at day 3; predictors for a full recovery at day 1 and 3, confirm the need for a quick medical care in order to recover hemodynamic status of patients together with the diagnosis.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Devenir à l âge scolaire des enfants ayant présenté une encéphalopathie anoxo ischémique néonatale

L objectif : décrire le devenir neurologique moteur et cognitif à l âge scolaire, d enfants ayant présenté une encéphalopathie anoxo ischémique (EAI) à la naissance à terme et mettre en évidence des facteurs pronostiques néonatals prédictifs de séquelles ou au contraire annonciateurs d une évolution favorable. Patients et méthode : nous avons procédé à l évaluation clinique et neuropsychologique à 6 ans d enfants ayant présenté une EAI néonatale. Le fonctionnement intellectuel global a été évalué par les échelles de la WPSSI III. Les fonctions attentionnelles, exécutives, visuo-spatiales, praxiques et sensori-motrices ont été analysées par certaines épreuves de la NEPSY et du KABC-2. Résultats : 38 nouveau-nés ont été inclus dans l étude. 5 enfants étaient décédés en période néonatale (13%). Parmi les 33 survivants, 67% ont été suivis par un médecin néonatologue jusqu à 18/24 mois mais seulement 30% jusqu à l âge préscolaire de 4/5 ans. Nous retrouvons pour l échantillon total 39,5% d évolution défavorable et 60,5% d évolution favorable. Avec 100% d évolution favorable chez les EAI de grade I, 100% d évolution défavorable chez les EAI de grade III et 43% d évolution défavorable parmi les EAI de grade II. Les paramètres périnatals significativement (p<0,05) associés à une évolution défavorable étaient une acidose métabolique sévère mesurée dans la première heure de vie, une arrivée en réanimation néonatale supérieure à la sixième heure de vie, un examen neurologique anormal à sept jours de vie, un EEG (tracé de fond) anormal à sept jours de vie et une IRM cérébrale anormale. Conclusion : Les résultats de notre étude sont comparables aux données de la littérature. Les stades I et III d EAI sont à eux seuls des facteurs pronostiques puissants. Les autres facteurs pronostiques néonatals mis en évidence dans notre étude ont certes une valeur prédictive plus faible mais ils trouvent tout leur intérêt dans les EAI de grade II au pronostic incertain. Un suivi rapproché, multidisciplinaire et prolongé jusqu à l âge scolaire, avec un bilan neuropsychologique vers 4/5 ans s avère indispensable pour tout patient ayant présenté une EAI néonatale.Purpose: to describe the neurological and cognitive outcomes at school age of term infants with post asphyxia neonatal encephalopathy and to investigate neonatal prognostic factors : predictive factors of disabilities or predictive factors of favorable outcome. Patients and methods: we conducted a clinical and neuropsychological assessment at 6 years of age on children who had had a hypoxic ischemic neonatal encephalopathy (NE). We used the WPPSI III for assessing their general intelligence (IQ). The other cognitive functions (attentional, executive and visuospatial functions, memory, praxis, sensorimotor function, language) were measured by certain tests of the NEPSY and the KABC-2. Results: 38 newborns were included in our study. 5 children died during neonatal hospitalization. Among the survivors, 67% were followed up by a neonatologist until 18/24 months and only 30% until the preschool age (4/5 years). In our study, we found 39,5 % with adverse outcomes and 60,5% with favorable outcomes. The proportion of infants with adverse outcomes was nil in stage I (mild NE), 47 % in stage II (moderate NE), and 100 % in stage III (severe NE) according to the SARNAT and SARNAT grading. The perinatal characteristics significantly (p<0,05) associated with an adverse outcome were: -a severe metabolic acidosis measured in the first hour of life, -an entrance in a neonatal intensive care after the sixth hour of life, -an abnormal neurological examination at the end of the first week of life an abnormal EEG at the end of the first week of life, -an abnormal cerebral MRI. Concluded: Our results are comparable to data from the literature. The stages I and III according to the SARNAT and SARNAT grading are strong prognostic factors. The other prognostic factors have a lower predictive value but are very important for the stage II which has an uncertain prognosis. All the children with post asphyxia neonatal encephalopathy must receive a long acting follow up until school age with a neuropsychological assessment when they are 4/5 years.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Calibration of Respiratory Inductance Plethysmograph in Preterm Infants With Different Respiratory Conditions

Summary. Respiratory inductance plethysmography (RIP) is a method for respiratory measurements particularly attractive in infants because it is noninvasive and it does not interfere with the airway. RIP calibration remains controversial in neonates, and is particularly difficult in infants with thoraco-abdominal asynchrony or with ventilatory assist. The objective of this study was to evaluate a new RIP calibration method in preterm infants either without respiratory disease, with thoraco-abdominal asynchrony, or with ventilatory support. This method is based on (i) a specifically adapted RIP jacket, (ii) the least squares method to estimate the volume/motion ribcage and abdominal coefficients, and (iii) an individualized filtering method that takes into account individual breathing pattern. The reference flow was recorded with a pneumotachograph. The accuracy of flow reconstruction using the new method was compared to the accuracy of three other calibration methods, with arbitrary fixed RIP coefficients or with coefficients determined according to qualitative diagnostic calibration method principle. Fifteen preterm neonates have been studied; gestational age was (mean AE SD) 31.7 AE 0.8 weeks; birth weight was 1,470 AE 250 g. The respiratory flow determined with the new method had a goodness of fit at least equivalent to the other three methods in the entire group. Moreover, in unfavorable conditions-breathing asynchrony or ventilatory assist-the quality of fit was significantly higher than with the three other methods (P &lt; 0.05, repeated measures ANOVA). Accuracy of tidal volume measurements was at least equivalent to the other methods, and the breath-by-breath differences with reference volumes were lower, although not significantly, than with the other methods. The goodness of fit of the reconstructed RIP flow with this new method-even in unfavorable respiratory conditionsprovides a prerequisite for the study of flow pattern during the neonatal period

Is sequential cranial ultrasound reliable for detection of white matter injury in very preterm infants?

Cranial ultrasound (cUS) may not be reliable for detection of diffuse white matter (WM) injury. Our aim was to assess in very preterm infants the reliability of a classification system for WM injury on sequential cUS throughout the neonatal period, using magnetic resonance imaging (MRI) as reference standard. In 110 very preterm infants (gestational age < 32 weeks), serial cUS during admission (median 8, range 4-22) and again around term equivalent age (TEA) and a single MRI around TEA were performed. cUS during admission were assessed for presence of WM changes, and contemporaneous cUS and MRI around TEA additionally for abnormality of lateral ventricles. Sequential cUS (from birth up to TEA) and MRI were classified as normal/mildly abnormal, moderately abnormal, or severely abnormal, based on a combination of findings of the WM and lateral ventricles. Predictive values of the cUS classification were calculated. Sequential cUS were classified as normal/mildly abnormal, moderately abnormal, and severely abnormal in, respectively, 22%, 65%, and 13% of infants and MRI in, respectively, 30%, 52%, and 18%. The positive predictive value of the cUS classification for the MRI classification was high for severely abnormal WM (0.79) but lower for normal/mildly abnormal (0.67) and moderately abnormal (0.64) WM. Sequential cUS during the neonatal period detects severely abnormal WM in very preterm infants but is less reliable for mildly and moderately abnormal WM. MRI around TEA seems needed to reliably detect WM injury in very preterm infants.Epidemiology in Pediatrics and Child Healt

Animal Models of Periventricular Leukomalacia

Periventricular leukomalacia, specifically characterized as white matter injury, in neonates is strongly associated with the damage of pre-myelinating oligodendrocytes. Clinical data suggest that hypoxia-ischemia during delivery and intrauterine or neonatal infection-inflammation are important factors in the etiology of periventricular leukomalacia including cerebral palsy, a serious case exhibiting neurobehavioral deficits of periventricular leukomalacia. In order to explore the pathophysiological mechanisms of white matter injury and to better understand how infectious agents may affect the vulnerability of the immature brain to injury, novel animal models have been developed using hypoperfusion, microbes or bacterial products (lipopolysaccharide) and excitotoxins. Such efforts have developed rat models that produce predominantly white matter lesions by adopting combined hypoxia-ischemia technique on postnatal days 1-7, in which unilateral or bilateral carotid arteries of animals are occluded (ischemia) followed by 1-2 hour exposure to 6-8% oxygen environment (hypoxia). Furthermore, low doses of lipopolysaccharide that by themselves have no adverse-effects in 7-day-old rats, dramatically increase brain injury to hypoxic-ischemic challenge, implying that inflammation sensitizes the immature central nervous system. Therefore, among numerous models of periventricular leukomalacia, combination of hypoxia-ischemia-lipopolysaccharide might be one of the most-acceptable rodent models to induce extensive white matter injury and ensuing neurobehavioral deficits for the evaluation of candidate therapeutics