[Effect of magnesium sulphate on mortality and neurologic morbidity of the very-preterm newborn (of less than 33 weeks) with two-year neurological outcome: results of the prospective PREMAG trial]. / Effet du sulfate de magnésium sur la mortalité et la morbidité neurologique chez le prématuré de moins de 33 semaines, avec recul à deux ans: résultats de l'essai prospectif multicentrique contre placebo PREMAG.

OBJECTIVE: To evaluate whether magnesium sulphate (MgSO(4)) given to women at risk of very-preterm birth would be neuroprotective in preterm newborns. PATIENTS AND METHODS: In 18 French centres, women with fetuses of gestational age less than 33 weeks whose birth was expected within 24 hours were randomised from 1993 to 2003 with follow-up of infants until two years of age after discharge. They received a single injection of 0.1 mg/l de MgSO(4) (4g) or isotonic 0.9% saline over 30 minutes. This study is registered as an International Standard Randomised Controlled Trial, number 00120588. Analyses were based on intention to treat. RESULTS: Data from 688 infants were analysed of which 606 were followed up and 10 were lost to follow-up. Comparing infants who received MgSO(4) or placebo, respectively, has shown a decrease of all primary endpoints (total mortality, severe white matter injury and their combined outcome) and of all secondary endpoints (motor dysfunction, cerebral palsy, cognitive dysfunction and their combined outcomes at two years of age) in the MgSO(4) group. The decrease was nearly significant or significant for gross motor dysfunction (OR: 0.65 [0.41-1.02]) and combined criteria: death and cerebral palsy (OR: 0.65 [0.42-1.03]); death and gross motor dysfunction (OR: 0.62 [0.41-0.93]); death, cerebral palsy and cognitive dysfunction (OR: 0.68 [0.47-1.00]). No major maternal adverse effects were observed in the MgSO(4) group. DISCUSSION AND CONCLUSION: Given its beneficial effects and safety, the use of prenatal low-dose MgSO(4) for preventing neurodisabilities of very-preterm infants should be discussed either as a stand-alone treatment or as part of a combination treatment, at least in the context of clinical trials.

[Pneumopericardium with favorable outcome in a ventilated premature infant]. / Pneumopéricarde d'évolution favorable chez un prématuré ventilé.

UNLABELLED: Pneumopericardium is a rare and severe complication of artificial ventilation in neonates. CASE REPORT: A preterm neonate born after 29 weeks of gestation was placed under ventilatory support for bronchopulmonary dysplasia. At 63 days of life, just after a severe bronchospasm which required bag ventilation with high pressures, she collapsed and required immediate cardiopulmonary resuscitation with epinephrine infusion. The diagnosis of pneumopericardium was deduced from the chest X-ray obtained in emergency, on which there was also a right pneumothorax. Cardiac recovery with return of spontaneous circulation was only obtained after evacuation of the pneumopericardium with a 23-gauge needle via the sub-xiphoid route. The pneumothorax was drained and the long-term evolution was favorable. CONCLUSION: In the case of cardiopulmonary compromise, the early diagnosis of pneumopericardium should lead to the immediate evacuation of the pneumopericardium in order to improve the prognosis.

[A cause of acute encephalitis: primary infection due to Epstein-Barr virus]. / Une cause d'encéphalite aiguë: la primo-infection à virus d'Epstein-Barr.

UNLABELLED: The neurologic complications of Epstein-Barr virus (EBV) primary infection are frequently overlooked, yet EBV is responsible for some cases of acute encephalitis. We report on a case of an infant with acute brain-stem encephalitis during EBV primary infection. OBSERVATION: A 22-month-old boy was admitted to the hospital for acute neurological symptoms. Initially, he presented ataxia and dysphagia. During the first days, his neurological status worsened with loss of consciousness requiring ventilatory support. A progressive improvement appeared after a 1 week course. One month later, a moderate ataxia was still noted, but 3 months later, the clinical examination was normal. The neuroradiological explorations revealed damage of the white matter, with high T2-weighed signal on the first brain magnetic resonance imaging. One month later, the control magnetic resonance imaging was normal. The diagnosis of EBV encephalitis was based upon the exclusion of other possible causes and positive serology for EBV, consistent with acute primary infection. CONCLUSION: EBV infection should be looked for during the etiologic work-up of an acute encephalitis. The different cases reported in the literature show a favorable initial outcome, but neurological relapse and sequelae are possible. No specific treatment is effective.

[Use of the intraosseous route in a premature infant]. / Utilisation de la voie intraosseuse chez un prématuré.

BACKGROUND: The intraosseous route (IOR) is a rehabilitated vascular access in emergency situations. Its indications and duration are defined, although the age limit at which it is usable is not clearly established. CASE REPORT: A 34-week-old preterm neonate, without infection, receiving gastric gavage, developed, at 8 days of life, a severe septic shock requiring ventilatory support and emergency volume expansion via a subclavian catheter. During the chest X-ray to check its position, the catheter was unfortunately pulled out. The child presented an acute desaturation with bradycardia, requiring bag ventilation and endotracheal epinephrine. The umbilical vein being unusable, an intraosseous access (20 G, distal hole, Cook) was performed at the upper tibial level to continue resuscitation and left in place for 14 hours to infuse antibiotics, inotropic support, blood products and colloids. Blood cultures grew Klebsiella pneumoniae. After a severe initial phase, course was favorable with normal examination at 3 years without complication of the IOR. DISCUSSION: To our knowledge, it is the youngest child in whom IOR was performed. For neonates and especially preterms, the site of puncture is just below the tibial superior tuberosity, otherwise there is a risk of fracture of the diaphysis. This risk justifies the control of the IOR by X-ray. The place of the IOR among emergency vascular accesses in neonates, seems to us to be reserved to situations when umbilical vein is unusable. CONCLUSION: Although no study compared IOR to superior longitudinal sinus access, we suggest to reserve the sinus access only when IOR has failed, because of its potential cerebral complications.