Introduction: The quality of neonatal care is mainly determined by long-term neurodevelopmental outcome. The neurodevelopment of preterm infants is related to postnatal head growth and depends on medical interventions such as nutritional support. Head circumference (HC) is currently used as a two-dimensional measure of head growth. Since head deformities are frequently found in preterm infants, HC may not always adequately reflect head growth. Laser aided head shape digitizers offer semiautomatic acquisition of HC and cranial volume (CrV) and could thus be useful in describing head size more precisely. Aims: 1) To evaluate reproducibility of a 3D digital capture system in newborns. 2) To compare manual and digital HC measurements in a neonatal cohort. 3) To determine correlation of HC and CrV and predictive value of HC. Methods: Within a twelve-month period data of head scans with a laser shape digitizer were analysed. Repeated measures were used for method evaluation. Manually and digitally acquired HC was compared. Regression analysis of HC and CrV was performed. Results: Interobserver reliability was excellent for HC (bias-0.005%, 95% Limits of Agreement (LoA) −0.39–0.39%) and CrV (bias1.5%, 95%LoA-0.8–3.6%). Method comparison data was acquired from 282 infants. It revealed interchangeability of the methods (bias-0.45%; 95%LoA-4.55–3.65%) and no significant systematic or proportional differences. HC and CrV correlated (r2 = 0.859, p<0.001), performance of HC predicting CrV was poor (RSD ±24 ml). Correlation was worse in infants with lower postmenstrual age (r2 = 0.745) compared to older infants (r2 = 0.843). Discussion: The current practice of measuring HC for describing head growth in preterm infants could be misleading since it does not represent a 3D approach. CrV can vary substantially in infants of equal HC. The 3D laser scanner represents a new and promising method to provide reproducible data of CrV and HC. Since it does not provide data on cerebral structures, additional imaging is required.

Thesis (MMed) -- Stellenbosch University, 2010. / ENGLISH ABSTRACT: Introduction: Limited facilities exist at rural hospitals for the management of newborn infants with respiratory distress syndrome (RDS). Furthermore, the secondary and tertiary hospitals are under severe strain to accept all the referrals from rural hospitals. Many of these infants require intubation and ventilation with a resuscitation bag which must be sustained for hours until the transport team arrives. Not only is lung damage inflicted by the prolonged ventilation, but transferring the infant by helicopter and ambulance is expensive. CPAP (continuous positive airway pressure), a non-invasive form of ventilatory support, has been used successfully at regional (Level 2) and tertiary (Level 3) neonatal units, to manage infants with RDS. It is cost-effective for infants with mild to moderate grades of RDS to be managed at the rural hospital instead of being transferred to the regional secondary or tertiary hospital. CPAP was introduced to Ceres Hospital, a rural Level 1 hospital, in February 2008 for the management of infants with RDS. Aim: To determine the impact of CPAP on the management of infants with RDS in a rural level 1 hospital and whether it can reduce the number of referrals to regional hospitals. Study setting: Nursery at Ceres District Hospital, Cape Winelands District, Western Cape. Study design: Prospective cohort analytical study with an historic control group (HCG). Patients and Methods: The study group (SG) comprised all neonates with respiratory distress born between 27/02/2008 and 26/02/2010. The infants were initially resuscitated with a Neopuff® machine in labour-ward and CPAP was commenced for those with RDS. The survival and referral rates of the SG were compared to an historic control group (HCG) of infants born between 1/2/2006 to 31/01/2008 at Ceres Hospital. Results: During the 2 years of the study, 51 neonates received CPAP (34 <1800g, 17>1800g). Twenty (83%) of the SG infants between 1000g and 1800g and 23 (68%) of the infants between 500g and 1800g survived. Those <1800g that failed CPAP, had either a severe grade of RDS which required intubation and ventilation or were <1000g. Seventeen (33%) of the infants that received CPAP, were in the >1800g group. Thirteen (76%) of these infants were successfully treated with CPAP only. The four infants that failed CPAP suffered from congenital abnormalities and would not have benefited from CPAP. There was no statistically significant difference in the survival between the SG and HCG (80%) (p=0.5490) but the number of referrals decreased significantly from 21% in the HCG to 7% in the SG (p=0.0003). No complications related to CPAP treatment, such as pneumothorax, were noted. The nursing and medical staff quickly became proficient and confident in applying CPAP and were committed to the project. Conclusion: CPAP can be safely and successfully practised in infants with mild to moderate RDS in a rural Level 1 hospital. The survival rate stayed the same as the HCG, even though a higher risk infants were treated in the SG. The transfers were significantly reduced from 21% to 7%. This resulted in significant cost savings for the hospital. / AFRIKAANSE OPSOMMING: geen opsomming

Objetivos: avaliar a prevalência de alterações auditivas em recém-nascidos de muito baixo peso na Unidade de Tratamento Intensivo Neonatal do Hospital de Clínicas de Porto Alegre e estudar as variáveis que possam estar relacionadas com as alterações da acui-dade auditiva. Métodos: foi realizado um estudo transversal que incluiu todos os recém-nascidos de muito baixo peso admitidos na Unidade de Tratamento Intensivo Neonatal do Hospital de Clínicas de Porto Alegre no período de 1o de setembro de 2001 a 31 de janeiro de 2002. To-dos os pacientes foram submetidos ao exame de otoemissão acústica evocada por produto de distorção no momento da alta hospitalar. O exame foi repetido em 30 dias quando havia alte-ração no primeiro exame. Quando o paciente apresentava o exame de otoemissão acústica al-terada em duas ocasiões, era realizado o potencial auditivo evocado cerebral, considerado al-terado a partir de 35 dB NA. Resultados: foram estudados 96 recém-nascidos. Seis tiveram tanto o exame de otoemissão acústica quanto o potencial auditivo evocado cerebral alterados. A média da idade gestacional foi de 31,5 ± 2,6 semanas, o peso de nascimento variou de 640 a 1.500 g e 57,3% dos pacientes eram do sexo feminino. A idade gestacional e o índice de Apgar no 5o minuto foram inferiores no grupo otoemissão acústica e potencial auditivo evocado cerebral alterados em relação aos demais grupos, atingindo significância limítrofe. Conclusões: a prevalência de perda auditiva nos recém-nascidos de muito baixo peso da Unidade de Tratamento Intensivo Neonatal do Hospital de Clínicas de Porto Alegre foi de 6,3%, tendo sido observadas associações de significância limítrofe com idade gestacional e índice de Apgar no 5o minuto. / Objectives: to evaluate the prevalence of hearing loss in very low birth weight patients in the Neonatal Intensive Care Unit of the Hospital de Clínicas de Porto Alegre and to study the variables that can be related to hearing loss. Methods: a transversal study was carried through including all very low birth weight neonates admitted in the Neonatal Intensive Care Unit of the Hospital de Clínicas de Porto Alegre during September 1, 2000 to January 31, 2002. All patients were undergone to the distortion evoked otoacoustic emission test in the hospital discharge. When the patient presented alteration in this test, it was repeated in 30 days. However, when the patient who presented pathologic otoacoustic emission on two ocasions was undergone to the auditory evoked brain response. This test was considered abnormal from 35 dB NA. Results: we studied 96 neonates. Six children presented alteration in the distortion evoked otoacoustic emission test as well in the auditory evoked brain response. The children age average was 31.5 ± 2.6 weeks, their birth weight was between 640 g and 1,500 g, and 57.3% of the patients were female. The gestational age and the Apgar score at 5 minutes were inferior in the otoacoustic emission and auditory evoked brain response abnormal group related to the other groups, reaching bordering significance. Conclusions: the hearing loss prevalence of the very low birth weight neonates from the Neonatal Intensive Care Unit of the HCPA was 6.3%, and it was observed bordering significance associations related to gestational age and 5 minutes Apgar score.

Objetivos: avaliar a prevalência de alterações auditivas em recém-nascidos de muito baixo peso na Unidade de Tratamento Intensivo Neonatal do Hospital de Clínicas de Porto Alegre e estudar as variáveis que possam estar relacionadas com as alterações da acui-dade auditiva. Métodos: foi realizado um estudo transversal que incluiu todos os recém-nascidos de muito baixo peso admitidos na Unidade de Tratamento Intensivo Neonatal do Hospital de Clínicas de Porto Alegre no período de 1o de setembro de 2001 a 31 de janeiro de 2002. To-dos os pacientes foram submetidos ao exame de otoemissão acústica evocada por produto de distorção no momento da alta hospitalar. O exame foi repetido em 30 dias quando havia alte-ração no primeiro exame. Quando o paciente apresentava o exame de otoemissão acústica al-terada em duas ocasiões, era realizado o potencial auditivo evocado cerebral, considerado al-terado a partir de 35 dB NA. Resultados: foram estudados 96 recém-nascidos. Seis tiveram tanto o exame de otoemissão acústica quanto o potencial auditivo evocado cerebral alterados. A média da idade gestacional foi de 31,5 ± 2,6 semanas, o peso de nascimento variou de 640 a 1.500 g e 57,3% dos pacientes eram do sexo feminino. A idade gestacional e o índice de Apgar no 5o minuto foram inferiores no grupo otoemissão acústica e potencial auditivo evocado cerebral alterados em relação aos demais grupos, atingindo significância limítrofe. Conclusões: a prevalência de perda auditiva nos recém-nascidos de muito baixo peso da Unidade de Tratamento Intensivo Neonatal do Hospital de Clínicas de Porto Alegre foi de 6,3%, tendo sido observadas associações de significância limítrofe com idade gestacional e índice de Apgar no 5o minuto. / Objectives: to evaluate the prevalence of hearing loss in very low birth weight patients in the Neonatal Intensive Care Unit of the Hospital de Clínicas de Porto Alegre and to study the variables that can be related to hearing loss. Methods: a transversal study was carried through including all very low birth weight neonates admitted in the Neonatal Intensive Care Unit of the Hospital de Clínicas de Porto Alegre during September 1, 2000 to January 31, 2002. All patients were undergone to the distortion evoked otoacoustic emission test in the hospital discharge. When the patient presented alteration in this test, it was repeated in 30 days. However, when the patient who presented pathologic otoacoustic emission on two ocasions was undergone to the auditory evoked brain response. This test was considered abnormal from 35 dB NA. Results: we studied 96 neonates. Six children presented alteration in the distortion evoked otoacoustic emission test as well in the auditory evoked brain response. The children age average was 31.5 ± 2.6 weeks, their birth weight was between 640 g and 1,500 g, and 57.3% of the patients were female. The gestational age and the Apgar score at 5 minutes were inferior in the otoacoustic emission and auditory evoked brain response abnormal group related to the other groups, reaching bordering significance. Conclusions: the hearing loss prevalence of the very low birth weight neonates from the Neonatal Intensive Care Unit of the HCPA was 6.3%, and it was observed bordering significance associations related to gestational age and 5 minutes Apgar score.

nÃo hà / Neonatos internados em unidade de terapia intensiva neonatal (UTIN) sÃo expostos a uma grande variedade de medicamentos, a maioria sem dados de seguranÃa e eficÃcia. Descrever o perfil de uso de medicamentos em neonatos em UTIN de um hospital pÃblico no Brasil de acordo com dados de registro do medicamento e potencial nocivo destes, foi o objetivo do trabalho. Trata-se de um estudo descritivo retrospectivo sobre uso de medicamentos em UTIN, envolvendo neonatos internados por mais de 24 horas e dados de prescriÃÃo coletados em prontuÃrio eletrÃnico durante o perÃodo de janeiro a junho do ano de 2012. InformaÃÃes sobre os medicamentos, com base nas bulas, foram comparadas com o British National Formulary for Children 2012-2013 e a base de dados Thomson Micromedex. O potencial nocivo de medicamentos e excipientes foi avaliado conforme a literatura. Neonatos foram categorizados em grupos de idade gestacional (IG). Os dados foram submetidos à anÃlise descritiva e testes de distribuiÃÃo (ANOVA, Teste U de Mann-Whitney, Kruskal-Wallis, qui-quadrado de Pearson) por IG com o nÃvel de significÃncia de p < 0,05. IncluÃram-se 192 neonatos, a maioria prÃ-termo, com mediana de 33 semanas de IG, totalizando 3.617 neonatos-dia. Registraram-se 3.290 prescriÃÃes, mÃdia 17,1 prescriÃÃes/neonato (DP  17,9) e 8,8 medicamentos/neonato (DP  5,9), maiores em neonatos mais imaturos (p < 0,05). Anti-infecciosos de uso sistÃmico, medicamentos para o sangue e ÃrgÃos formadores do sangue, trato alimentar e metabolismo apresentaram maior utilizaÃÃo, variando conforme a IG. Neonatos apresentaram maior exposiÃÃo a gentamicina seguido por ampicilina, heparina e fitomenadiona. A maioria dos neonatos (99,5%) foi exposta a medicamentos nÃo licenciados (NL) e de uso nÃo padronizado (NP), mais frequentes em neonatos com IG < 28 semanas (p < 0,05). Mais de 70% dos RN estiveram expostos a algum medicamento potencialmente perigoso (MPP), com maior frequÃncia em neonatos com IG < 31 semanas (p < 0,05). Praticamente todos os neonatos estiveram expostos a excipientes nocivos (EN) e potencialmente nocivos, sendo maior o nÃmero de formulaÃÃes prescritas a neonatos mais imaturos. Metilparabeno, propilparabeno e polissorbato 80 foram os EN aos quais os neonatos estiveram mais expostos, principalmente nas formulaÃÃes de domperidona soluÃÃo oral, polivitamÃnicos soluÃÃo oral e fentanila soluÃÃo injetÃvel. Neonatos em UTIN no Brasil, tal como em outras realidades, estÃo expostos a uma variedade de medicamentos NL, NP e com potencial nocivo, uma situaÃÃo preocupante. Alternativas seguras e estudos sÃo necessÃrios sobre esse tema. / Neonates admitted to neonatal intensive care unit (NICU) are exposed to a wide variety of drugs most without data on safety and efficacy. To describe the drug use profile of neonates in NICU of a public hospital in Brazil according to the drugs records and harmful potential of drugs and pharmaceutical excipients. Descriptive and retrospective study of drug use in NICU, with neonate inpatients for over 24 hours and prescription data from electronic medical records over the period from January to June, 2012. Drug information found in the package leaflets were compared with information in the British National Formulary for Children 2012-2013 and in the Thomson Micromedex database. The drug and excipients harmful potential was evaluated according to the literature. Neonates were categorized into groups of gestational age (GA). The data were analyzed using descriptive analysis and Distribution tests tests (ANOVA Mann-Whitney U, Kruskal-Wallis and Pearson's chi-squared) by GA, with a significance level of p <0.05. Were included 192 neonates, most preterm with median 33 weeks of GA and a total of 3.617 neonates-day. Were registered 3,290 prescriptions, average 17.1 prescriptions/neonate (SD  17.9) and 8.8 drugs/neonate (SD  5.9), higher in most immature neonates (p < 0.05). The anti-infectives for systemic use, blood and blood forming organs, alimentary tract and metabolism drugs groups showed increased use among the neonates, varying according to the GA. Neonates had higher exposure to gentamicin followed by ampicillin, heparin and phytomenadione. Most neonates (99.5%) were exposed to unlicensed drugs (UL) and off label use (OL), more frequently those with GA < 28 weeks (p < 0.05). More than 70% of the neonates were exposed to any high-alert medications, with higher frequency among neonates with GA < 31 weeks (p < 0.05). Almost all neonates were exposed to harmful and potentially harmful excipients, being greater the number of formulations prescribed to more immature neonates. Gentamicin (sulfate) injectable Solution 10 mg/mL (1 mL), fentanyl solution injectable 0.05 mg/mL (10 mL) and sodium heparin injectable solution were the containing harmful excipients formulations to which neonates were most exposed. Neonates in Brazilian NICU, as in other settings, are exposed to a variety of OL, UL and potentially harmful drugs and harmful excipients, an alarming situation. Safety alternatives and more studies are needed on this topic.

Objetivos: avaliar a prevalência de alterações auditivas em recém-nascidos de muito baixo peso na Unidade de Tratamento Intensivo Neonatal do Hospital de Clínicas de Porto Alegre e estudar as variáveis que possam estar relacionadas com as alterações da acui-dade auditiva. Métodos: foi realizado um estudo transversal que incluiu todos os recém-nascidos de muito baixo peso admitidos na Unidade de Tratamento Intensivo Neonatal do Hospital de Clínicas de Porto Alegre no período de 1o de setembro de 2001 a 31 de janeiro de 2002. To-dos os pacientes foram submetidos ao exame de otoemissão acústica evocada por produto de distorção no momento da alta hospitalar. O exame foi repetido em 30 dias quando havia alte-ração no primeiro exame. Quando o paciente apresentava o exame de otoemissão acústica al-terada em duas ocasiões, era realizado o potencial auditivo evocado cerebral, considerado al-terado a partir de 35 dB NA. Resultados: foram estudados 96 recém-nascidos. Seis tiveram tanto o exame de otoemissão acústica quanto o potencial auditivo evocado cerebral alterados. A média da idade gestacional foi de 31,5 ± 2,6 semanas, o peso de nascimento variou de 640 a 1.500 g e 57,3% dos pacientes eram do sexo feminino. A idade gestacional e o índice de Apgar no 5o minuto foram inferiores no grupo otoemissão acústica e potencial auditivo evocado cerebral alterados em relação aos demais grupos, atingindo significância limítrofe. Conclusões: a prevalência de perda auditiva nos recém-nascidos de muito baixo peso da Unidade de Tratamento Intensivo Neonatal do Hospital de Clínicas de Porto Alegre foi de 6,3%, tendo sido observadas associações de significância limítrofe com idade gestacional e índice de Apgar no 5o minuto. / Objectives: to evaluate the prevalence of hearing loss in very low birth weight patients in the Neonatal Intensive Care Unit of the Hospital de Clínicas de Porto Alegre and to study the variables that can be related to hearing loss. Methods: a transversal study was carried through including all very low birth weight neonates admitted in the Neonatal Intensive Care Unit of the Hospital de Clínicas de Porto Alegre during September 1, 2000 to January 31, 2002. All patients were undergone to the distortion evoked otoacoustic emission test in the hospital discharge. When the patient presented alteration in this test, it was repeated in 30 days. However, when the patient who presented pathologic otoacoustic emission on two ocasions was undergone to the auditory evoked brain response. This test was considered abnormal from 35 dB NA. Results: we studied 96 neonates. Six children presented alteration in the distortion evoked otoacoustic emission test as well in the auditory evoked brain response. The children age average was 31.5 ± 2.6 weeks, their birth weight was between 640 g and 1,500 g, and 57.3% of the patients were female. The gestational age and the Apgar score at 5 minutes were inferior in the otoacoustic emission and auditory evoked brain response abnormal group related to the other groups, reaching bordering significance. Conclusions: the hearing loss prevalence of the very low birth weight neonates from the Neonatal Intensive Care Unit of the HCPA was 6.3%, and it was observed bordering significance associations related to gestational age and 5 minutes Apgar score.

The preterm delivery (<37 weeks gestation) rates are generally 5-9% in Europe, 12-13% in the US, and each year about 13 millions preterm infants are born worldwide (MacDorman and Mathews, 2009; Slattery and Morrison, 2002). The early exposure to the extra-uterine environment increases the risks of perinatal brain injury, involving more often the white matter. The white matter injury is characterized by a potential subsequent occurrence of cognitive problems, of developmental delay and of major motor deficits (e.g. cerebral palsy). <p>The most widely used imaging technique for studying neonatal brain is cranial ultrasound that can be performed at bedside and detects major brain abnormalities (hemorrhage, infarctions, cysts, dilatation of the lateral ventricles). However, it has a poor sensitivity for non-cystic or diffuse white matter abnormalities (WMA), the most common form of white matter injury in preterm infants. In comparison to ultrasound, MR (magnetic resonance) imaging has been reported to be superior in detecting WMA and is considered as an essential modality for imaging the neonatal brain. The standard sequences (e.g. T1-, T2-weighted imaging) are routinely performed for assessing not only brain anatomy, but also for evaluating brain lesions. Nevertheless, ¡§conventional MR imaging¡¨ has been criticized because it is limited in qualitative assessment and it does not provide information on the extent of specific white matter pathways injuries. <p>Currently, diffusion tensor imaging (DTI) enables more detailed exploration of white matter microstructure. Furthermore, DTI is now the best in vivo technique capable of delineating white matter pathways and quantifying microstructural changes not visible on conventional MR imaging. Diffusion tensor tractography allows the reconstruction of the principal white matter fibers. Moreover, it also provides diffusion indices like fractional anisotropy (FA), mean diffusivity (MD), longitudinal diffusivity (£f//), transverse diffusivity (£f¢r) that help assess the changes in fiber tracts, even before myelination becomes histologically evident. <p>Structural MR imaging studies performed in neonates are scarce. A number of essential questions are still under debate, concerning the normal white matter structure, as well as premature brain injury. First, left language lateralization and right handedness are complex phenomena incompletely understood and the question rises whether structural lateralization already exist in healthy preterm neonates at term-equivalent age. Second, it is of interest to know whether gender-related structural differences exist in healthy preterm neonates. Finally, in the assessment of preterm brain injury, the relationship between WMA on conventional imaging and altered diffusion indices in fiber tracts is still unclear. Therefore, the aims of the thesis were to investigate the brain structure in a population of preterm neonates at term-equivalent age by DTI and probabilistic tractography.<p>The first part of this thesis (Study I and Study II) was devoted to the study of white matter structural characteristics in healthy preterm neonates. Previous studies have shown that structural asymmetries in language and motor related fibers are present in adults and in infants (Dubois et al. 2009; Westerhausen et al. 2007). Our hypothesis was that these structural asymmetries are already present in preterm neonates at term-equivalent age. In Study I, DTI and probabilistic tractography were performed and we found volume and microstructural asymmetries in the language related parieto-temporal superior longitudinal fasciculi (SLF), in the motor related corticospinal tract (CST) and in the motor part of the superior thalamic radiation (STR) as well. In Study II, we found that compared to boys, girls have larger relative tract volumes and an advanced maturation in language and motor related fiber tracts. <p>The second part of this thesis (Study III) investigated whether WMA on conventional MR imaging are related to abnormalities within the fiber tract microstructures. WMA were classified as normal, mild, moderate and severe according to Woodward¡¦s classification (Woodward et al. 2006). Woodward and colleagues studied a large population (167 infants) of preterm infants at term equivalent age with MRI. They demonstrated that WMA were important predictors of neurological outcomes by comparing their results with the neurological outcomes of those infants at corrected age of two. We found that compared to neonates with no abnormalities, infants with mild abnormalities have significantly higher ƒÜ¢r in the right CST, the left anterior thalamic radiation (ATR), the left sensory STR and bilateral motor STR. Those findings might be related to injuries of premyelinating oligodendrocytes resulting in subsequent failure of both development and ensheathment of axons. Considering that those fiber tracts connect important cortical zones, microstructural changes in those fiber tracts might be responsible for the later neurodevelopment deficits in motor and cognitive functions. <p>We concluded that structural asymmetries and gender differences in motor and language related fibers are present in healthy preterm neonates at term-equivalent age well before the development of speech and hand preference. Structural asymmetries and gender differences have to be considered in neonatal white matter assessment. Finally, altered DTI indices are associated with WMA on conventional MR imaging in preterm neonates. Our results suggest that disrupted premyelination is the major correlate with WMA rather than axonal pathology. Non-invasive DTI and tractography constitute an additional tool for the assessment of white matter injuries, as it could provide more adequate diagnostic information on brain microstructure in preterm neonates at term-equivalent age. / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

La toxine de pertussis (PTX) est une A-B protéine considérée comme l’un des principaux facteurs de virulence de Bordetella pertussis, l’agent bactérien responsable de la coqueluche. Aujourd’hui, cette maladie représente encore un réel danger pour les nouveaux-nés et les<p>nourrissons non ou partiellement immunisés. Actuellement, la coqueluche provoque encore la<p>mort d’environ 350.000 individus par an. La toxicité de la PTX est liée à l’activité<p>enzymatique de sa sous-unité A capable d’inhiber les voies de signalisation associées aux<p>protéines Gi. La partie B, quant à elle, permet l’entrée de cette sous-unité A dans le<p>cytoplasme des cellules cibles en se liant spécifiquement à son ou ses récepteurs<p>membranaires toujours inconnus de nos jours.<p><p>Des études réalisées chez la souris et chez l’homme ont montré que les vaccins anticoquelucheux combinés à différents antigènes vaccinaux étaient capables de moduler<p>leurs réponses humorales spécifiques. Par ailleurs, la PTX est couramment qualifiée d’agent<p>immunostimulant. En effet, des modèles murins de vaccination permirent d’identifier des<p>propriétés adjuvantes de la PTX coadministrée avec des antigènes non relevants.<p><p>Le travail développé dans ce manuscrit étudie les effets de la PTX sur 2 types cellulaires<p>primordiaux sollicités lors d’une vaccination :la cellule dendritique (DC) et le lymphocyte T<p>CD4+ naïf.<p><p>Les DC sont les seules cellules présentatrices d’antigènes aptes à initier une réponse immune<p>primaire. Dans un premier temps, nous avons montré que la PTX était capable d’activer des<p>DC générées in vitro à partir de monocytes. En effet, elles acquièrent un phénotype mature<p>caractérisé par une augmentation de l’expression membranaire des molécules costimulatrices<p>et du CMH de classe II, démontrant un effet direct et spécifique de la PTX sur les DC<p>myéloïdes. Parallèlement, ces DC produisent du TNF-a, de l’IL-12p40 et de l’IL-12p70 et<p>activent NF-kappaB, un facteur de transcription essentiel au processus de maturation. Nous<p>avons obtenu des résultats similaires avec une toxine génétiquement modifiée qui est<p>enzymatiquement inactive. A partir de sang total incubé avec la PTX, nous avons par ailleurs<p>observé que les DC circulantes du nouveau-né étaient déficientes dans leur maturation et leur<p>sécrétion d’IL-12p70 comparées aux DC de l’adulte.<p><p>D’autre part, il a été décrit précédemment que la PTX exerçait des effets mitogènes sur les<p>lymphocytes T humains et murins. Cependant, le rôle qu’elle joue sur la population des<p>lymphocytes T CD4 naïfs reste peu connu. A l’issue de notre second travail, nous pouvons<p>dès lors affirmer que la PTX est également capable d’activer des lymphocytes T<p>CD4+CD45RA+ naïfs isolés à partir des cellules mononuclées du sang périphérique, et ce<p>indépendamment de son activité enzymatique. En effet, ces lymphocytes T CD4+ naïfs stimulés par la PTX prolifèrent, synthétisent des quantités non négligeables d'ARN messagers<p>codant pour l’IL-2 et le TNF-a, augmentent l’expression membranaire des molécules CD40L,<p>CD69 et CD25 et expriment la protéine Foxp3. Cette activation s’accompagne de la translocation nucléaire de NF-kappaB et NFAT. Parallèlement à l’adulte, la PTX active les lymphocytes T CD4 néonataux. Néanmoins, ceux-ci prolifèrent moins bien et expriment plus faiblement le CD40L à leur surface.<p><p>Enfin, la PTX induit la sécrétion de taux importants d’IFN-g par des T CD4+CD45RA+ naïfs<p>adultes mis en présence de DC autologues.<p><p>Nous terminerons en proposant l’hypothèse suivante :La PTX pourrait exercer ses propriétés<p>adjuvantes par l’intermédiaire de différents mécanismes comprenant notamment la maturation<p>des DC d’origine myéloïde et l’activation des lymphocytes T CD4+CD45RA+ naïfs. Ces 2 populations cellulaires sont en effet les principaux protagonistes impliqués dans la réponse<p>immune primaire. / Doctorat en sciences pharmaceutiques / info:eu-repo/semantics/nonPublished

L'augmentation de la survie des grands prématurés fait de la réduction des séquelles dans cette population un enjeu majeur. Alors qu'il influence leur devenir, le support nutritionnel des grands prématurés échoue souvent à prévenir le déficit protéino-énergétique, les carences nutritionnelles, et les ralentissements de croissance, aggravant leur pronostic. Nos recherches investiguaient plusieurs axes des stratégies nutritionnelles actuelles, leurs limites ainsi que les perspectives d'améliorations : I) parentérales, II) entérales, III) préventions des complications, IV) évaluation de la croissance. Il s'agissait d'un ensemble d'études cliniques, qui révélaient : I) Des variations significatives d'apports parentéraux à l'intérieur des centres, ainsi qu'une sous-utilisation des lipides, participant au déficit protéino-énergétique précoce. Un impact des lipides sur la croissance, le développement cérébral, voire l'incidence de complications était suggéré. II) Des avantages de l'utilisation de lait maternel frais dans la 1ère semaine de vie sur la poursuite de l'allaitement des nouveau-nés hospitalisés, ainsi que des variations importantes de sa composition. Une augmentation des taux d'allaitement sur les périodes d'études révélait un effet bénéfique de la recherche, même « observationnelle », sur l'allaitement. III) Une augmentation du risque d'hyperglycémie en cas de diminution de la phosphatémie. IV) Des répercussions modérées de la restriction de croissance intra-utérine sur le neuro-développement des prématurés, malgré des réserves auxologiques. Ces travaux permettaient donc d'identifier plusieurs barrières, et d'envisager différentes stratégies d'amélioration du soutien nutritionnel. Ils soulignent la complexité et l'importance des liens entre nutrition, croissance et développement neurologique des enfants à risques. Des efforts supplémentaires sont nécessaires pour optimiser les connaissances, les recommandations et les pratiques dans ce domaine / Facing to increasing survival of very preterm neonates, reducing sequelae in this population became a major public issue. Nutritional support of preterm neonates has a durable impact on their future. However, it often fails to prevent the protein-energetic imbalance, nutritional deficiencies, and post-natal growth restriction, which act as aggravating factors. Our researches evaluated different axes of current nutritional strategies, limitations and possible improvements: I) parenteral, II) enteral, III) prevention of complications, IV) growth assessment. Most relevant findings of these clinical studies were: I) Significant variations of parenteral intakes in the centres, as well as inadequate use of lipids, involved in early energetic-protein deficit. Impact of lipids on growth, brain development, and even the incidence of complications were suggested. II) Advantages in using fresh raw mother's own milk in the early days to enhance breastfeeding in hospitalized neonates, as well as important changes in mother's milk composition. An increase in breastfeeding rates over the periods of studies showed a beneficial effect of the research, although "observational", on breastfeeding. III) An increased risk of hyperglycemia in case of low phosphatemia. IV) A moderate impact of being small for gestational age on neuro-development in a preterm cohort, and related auxologic limitations. This work allowed to recognize some barriers of the nutritional support, and to consider different improvement strategies. It emphasizes the close and important links between nutrition, growth and neurological development of vulnerable infants. Further efforts are needed to optimize knowledge, recommendations and practices in this area

Introduction: The quality of neonatal care is mainly determined by long-term neurodevelopmental outcome. The neurodevelopment of preterm infants is related to postnatal head growth and depends on medical interventions such as nutritional support. Head circumference (HC) is currently used as a two-dimensional measure of head growth. Since head deformities are frequently found in preterm infants, HC may not always adequately reflect head growth. Laser aided head shape digitizers offer semiautomatic acquisition of HC and cranial volume (CrV) and could thus be useful in describing head size more precisely. Aims: 1) To evaluate reproducibility of a 3D digital capture system in newborns. 2) To compare manual and digital HC measurements in a neonatal cohort. 3) To determine correlation of HC and CrV and predictive value of HC. Methods: Within a twelve-month period data of head scans with a laser shape digitizer were analysed. Repeated measures were used for method evaluation. Manually and digitally acquired HC was compared. Regression analysis of HC and CrV was performed. Results: Interobserver reliability was excellent for HC (bias-0.005%, 95% Limits of Agreement (LoA) −0.39–0.39%) and CrV (bias1.5%, 95%LoA-0.8–3.6%). Method comparison data was acquired from 282 infants. It revealed interchangeability of the methods (bias-0.45%; 95%LoA-4.55–3.65%) and no significant systematic or proportional differences. HC and CrV correlated (r2 = 0.859, p<0.001), performance of HC predicting CrV was poor (RSD ±24 ml). Correlation was worse in infants with lower postmenstrual age (r2 = 0.745) compared to older infants (r2 = 0.843). Discussion: The current practice of measuring HC for describing head growth in preterm infants could be misleading since it does not represent a 3D approach. CrV can vary substantially in infants of equal HC. The 3D laser scanner represents a new and promising method to provide reproducible data of CrV and HC. Since it does not provide data on cerebral structures, additional imaging is required.