[Suicidal risk prevention in schizophrenia: Importance of family psychoeducation]

OBJECTIVES

Although mortality by suicide in schizophrenia seems to have decreased in some countries over the last 30 years, it remains much higher than in the general population. Studies have shown this risk to impact around 5% of patients, corresponding to a risk almost 2.5 times higher than in the general population. Family psychoeducation in schizophrenia has been demonstrated to lead to symptom reductions and to an improvement of the quality of life, two factors that should contribute to decreasing the suicidal risk. Therefore, if families attend an efficient psychoeducation program, we can expect a decrease in the patient suicidal risk. Attending a family psychoeducation program at the beginning of the disease would also be associated with a stronger preventive effect on suicidal mortality. The objective of this study is to describe the suicide attempt rate of patients who suffer from schizophrenia before and one year after one of their relatives participated to the family psychoeducation program Profamille.

METHOD

We performed a retrospective study on 1209 people who attended the Profamille (V3.2 version) Family Psychoeducation Program. This program has 2 modules: an initial training module of 14 weekly or fortnightly sessions, and a consolidation module of 4 sessions over 2 years. Sessions last 4 hours and follow a precise and structured course. Data were collected from 40 different centers in France, Belgium and Switzerland and were based on participants assessed at the beginning and one year after the first module. Self-assessment from the relatives participating in the program provided the measure of patients' suicide attempts. An assessment at T0 explored the attempts over the 12 months before the beginning of the program while the assessment at T1 analyzed those during the 12 months following the end of the Program. The Chi² test was used to compare the suicide attempt rates for each period, using a significance threshold of 0.05. Since the risk of suicide is greater in the first years of the illness, rates of attempts are also calculated according to the age of disorder. The analysis was carried out with the statistical software R.

RESULTS

The number of participants reporting that their relative had attempted suicide in the previous 12 months decreased from 41 to 21. The annual attempts rate was evaluated at 6.4 % before the Profamille program and decreased to 2.4 % a year after the end of the program (P=0.0003). The reduction of the attempt rate was observed even for patients with schizophrenia for more than 10 years.

CONCLUSION

This study shows the positive impact of Profamille on reducing the rate of suicide attempts in patients with schizophrenia. It has been shown that the risk is highest at the beginning of the disorder. Therefore, based on our results, it would seem appropriate to propose the Profamille program at an early stage.

[Assessment of mental states at risk of psychotic transition: validation of the French version of the CAARMS]

This article aims to present the validation study of the French version of the Comprehensive Assessment of at risk mental states (CAARMS), an interview that seeks to determine whether young adults criteria for at-risk (AR) mental states, or psychosis. We assessed 40 young subjects, 15 were considered as "prodromal" (Prd) and 10 as experiencing a first episode of psychosis (PEP) by our expert clinician at the center - centre d'évaluation des jeunes adultes et adolescents, University Hospital Centre, Paris - and 15 were healthy controls matched for age and sex. When assessed with the CAARMS, 73 % (n=11) of the prodromal subjects reached the criteria for AR mental state, four subjects did not reach the criteria for AR, nor psychosis (P) and 100 % of the PEP reached the criteria for P. The three groups were significantly different on CAARMS total score (P<0.001) and subscores ; Prd subjects had intermediate scores between PEP (P<0.001) and controls (P<0.001) scores, PEP showing the highest scores. Post-hoc analysis showed that Prd significantly differed from Controls on each subscale (P<0.001) and that Prd differed from PEP on the "positive symptoms" subscale (P<0.001), as well as on "behavioural change" (P=0.021), owing to difference on the item "impaired role function". We used the brief psychiatric rating scale 24 items with anchor (BPRS24-EA) in addition to with the CAARMS, the AR group showed intermediate scores between controls and P subjects. Total scores of both scales were correlated (r=0.408 ; P=0.043) and the BPRS24-EA "positive symptoms" score was correlated with CAARMS' scores on the "Positive symptoms" subscale (r=0.456, P=0.022), "emotional disturbance" (r=0.506, P=0.01), and "behavioural change" (r=0.666 P=0.001). We found no correlation between BPRS negative and depression subscales and any of the CAARMS' subscales. When looking at its reliability, reliability coefficients (Cronbach's alpha) showed excellent reliability for "positive symptoms", "emotional disturbance", "behavioural change" and "general psychopathology" (respectively r=0.82, 0.75, 0.78, 0.84, 0.83) and moderate reliability for "cognitive change", "negative symptoms" and "motor/physical change" (respectively r=0.39, 0.59, 0.43). Overall, analysis of the results of construct validity, concurrent validity and reliability of the CAARMS indicates that the French version is valid and reliable. It is now available to develop and implement early detection programs in French speaking countries.

The teacher as observer and experimenter in the modification of disputing and talking-out behaviors

Disputing and talking-out behaviors of individual pupils and entire classroom groups in special education classes and regular classes from white middle-class areas and from all black poverty areas ranging from the first grade to junior high school were studied. The classroom teacher in each case acted as the experimenter and as an observer. Various means of recording behaviors were used and reliability of observation was checked by an outside observer, another teacher, a teacher-aide, a student, or by using a tape recorder. Observation sessions varied from 15 min to an entire school day. After baseline rates were obtained, extinction of inappropriate disputing or talking-out behaviors and reinforcement of appropriate behavior with teacher attention, praise and in some cases a desired classroom activity or a surprise at the end of the week brought a decrease in undesired verbalizations. A reversal of contingencies brought a return to high levels of inappropriate talking with a return to low levels when reinforcement for appropriate talking was reinstated. The experiments demonstrated that teachers in a variety of classroom settings could obtain reliable observational records and carry out experimental manipulations successfully using resources available in most schools.

[Visuospatial context processing in untreated schizophrenic patients and relation to disorganization syndrome]

AIM

Previous studies on schizophrenia have suggested that context-processing disturbances were one of the core cognitive deficits present in schizophrenia. Schizophrenic patients have a failure either of inhibition strategy and maintenance of visuospatial information (25) in condition of contextual interference. In the present study, we explored the performances of untreated schizophrenic patients with 2 tasks exploring detection and long term retention of complex visual features and field dependence-independence tasks were selected. These abilities involve temporary maintenance of visuospatial information and executive functioning of visual working memory system. Several studies have shown that cognitive deficit may depend on schizophrenic symptomatology. However results remain controversial in determining the specific influence of negative and positive symptomatologies as well as clinical disorganization. Our goal was to explore the processing of spatial context and its relation to disorganized syndrome. This study was approved by the local ethic committee.

METHODOLOGY

Thirty-six schizophrenic patients were included according to DSM IV criteria (19 neuroleptic naïve, 17 unmedicated patients during more than 3 months). Thirty-six healthy controls were matched to patients for age, gender and level of education. Absence of axis 1 pathology was attested for controls with SCID-NP. Current symptomatology was evaluated by the Positive and Negative Syndrome Scale (PANSS) (14). Clinical disorganisation was evaluated with the disorganisation score established upon a factorial analysis of PANSS by Lepine and Lançon. Items selected to distinguish the disorganised group were abstraction, disorganization, orientation, and attention.

PROCEDURE

Two tasks of embedded figures were administered individually to patients and controls. The Faverge task (Research of Figures-RF) (10) evaluates the ability to recognize the target from spatial complex geometrical figures. The Group Embedded Figure Task (GEFT - Oltman) assesses the detection and maintenance of visual target and its recognition within a complex figure. Performance between patients and controls were compared with the Student T test. The comparison of two clinical subgroups of disorganized and low disorganized patients and control group was performed with an ANOVA. Tuckey test was used for pairwise comparisons.

RESULTS

We defined two subgroups of patients, disorganized patients (subscore 12, n=17) and low disorganized patients (subscore<12, n=19). Theses 2 subgroups were similar for age and level of education. Concerning the two tasks, there was no significant difference between schizophrenic patients and normal controls. The comparison between subgroups of disorganized and low disorganized patients, for RF task, showed a decrease of correct answers with disorganized patients (p<0.05). For GEFT task, disorganized patients had a decrease of correct answers p<0.01) and more errors (p<0.01) and omissions (p<0.05). The low disorganized patients exhibited for the two tests comparable performance to controls. The disorganized patients had a decrease of right answers (p<0.05) and more errors (p<0.05) than controls for GEFT task and no significant difference for RF. However, with IQ (evaluated with an abstract reasoning test) introduced as covariate, only correct answers for GEFT task remain significant (p<0.05).

DISCUSSION

The weak performance of disorganized schizophrenic patients for two tasks RF and GEFT showed that treatment of visuospatial information was impaired in the first perceptive phase of selection and in the organization of information (RF), especially with the maintenance of visual information in memory (GEFT). By contrast, low disorganized patients demonstrated a correct analytic treatment of elementary processing and visuospatial working memory.

CONCLUSION

The severity of disorganization influences the visuospatial context processing and visuospatial working memory. These results show the heterogeneity of cognitive functioning regarding to schizophrenic symptomatologies. This difficulty could be related to a problem of central executive functioning in the visuospatial component of working memory, possibly mediated by the dysfunction of dorsolateral prefrontal cortex.

[Predictive factors of response to buprenorphine in the substitutive treatment of heroin addicts. Results of a multicenter study of 73 patients]

OBJECTIVE

Buprenorphine has a partial morphine-agonist pharmacological profile. It is proposed as alternative to methadone in opiate drug addicts with greater safety of use and less cost in terms of public health. The aim of this study was to determine the clinical factors of response to this molecule.

METHOD

The study was conducted in 73 patients treated for 3 months with adaptable doses. Mean dose was 8.5 mg/d (range: 3 to 16 mg/d). Response to treatment was defined as: still in the study at 3 months and absence of opiates in 75% of urinary samples over the past month.

RESULTS

Forty-eight patients responded and 25 did not. The determinating clinical variables of response were: opiate drug addiction less than 10 years, high score on the Addiction Severity Index (ASI), absence of depression according to the Minnesota Multiphasic Personality Inventory (MMPI) and low rate of disinhibition on Zukerman's sensation seeking scale. Conversely, the dose of buprenorphine within the limits specified in the Marketing Authorisation did not intervene in the response.

CONCLUSION

In view of its partial agonist effect, administration of buprenorphine must be reserved for patients addicted to opiates for less than 10 years, non-depressive and with low disinhibition on Zukerman's scale.

Expression, purification, and characterization of the human receptor activator of NF-kappaB ligand (RANKL) extracellular domain

Receptor activator of NF-kappaB ligand (RANKL) is a type II transmembrane protein found on osteoblasts which functions as a major determinant of osteoclast differentiation and activation. RANKL mediates bone homeostasis through binding to the cognate ligand on osteoclasts, RANK, and a soluble decoy receptor, osteoprotegerin (OPG). We designed a construct encoding the extracellular domain of human RANKL that conformed to reports of native processing. To encourage folding and posttranslational modification of a normally membrane-inserted moiety, we expressed the RANKL truncate as a secreted protein using the signal sequence from OPG in a Trichoplusia ni cell line using a baculovirus expression vector. RANKL was purified by a three-step process including an OPG-Fc affinity column. SDS-PAGE and mass spectral analysis indicated that the protein was >99% pure and glycosylated. Circular dichroism spectra revealed that the protein exhibited structural elements similar to tumor necrosis factor-alpha. By BIAcore analysis, RANKL bound to OPG with an affinity of 6.7 nM. Sedimentation equilibrium analytical ultracentrifugation analyses established that our protein existed as a trimer. We conclude that our expressed human RANKL truncate is folded, is functional, and exhibits self-association consistent with other family members.

[Clinical dimensions and visually guided saccades in schizophrenia]

Eye movement anomalies are more frequent in schizophrenic patients than in healthy subjects. This study deals with visually guided saccadic eye movements in seventeen schizophrenic patients [ten untreated (neuroleptic-naive or free), seven treated patients] and their correlations between symptoms presented by patients and oculomotor performances. There was no significant difference between the patients and the control group in visually guided saccades tasks. However, negative correlations between oculomotor performance and positive or disorganisation symptomatology were found. Thus, although no major oculomotor dysfunction in response to external stimulus was seen in schizophrenic patients, some symptoms were linked to oculomotor performance impairment. Thus psychiatric symptoms might share some common cerebral circuits which those involved in oculomotor tasks.

Impairment of consciously controlled use of memory in schizophrenia

Recent studies of memory in schizophrenia have shown that explicit but not implicit memory performance is impaired. The hypothesis that schizophrenia is associated with a failure of consciously but not unconsciously (automatic) controlled influence of memory on performance was tested using a procedure providing uncontaminated estimates of consciously controlled and automatic memory processes (i.e., the process-dissociation procedure in a stem completion task). Performance of 35 patients with schizophrenia was compared with that of 35 normal participants. Consciously controlled use but not automatic influences of memory was significantly lower in patients with schizophrenia than in controls. Consciously controlled use of memory was negatively and significantly correlated with positive symptoms of schizophrenia. Schizophrenia differentially affects 2 types of memory processes: It impairs consciously controlled use of memory but spares automatic influences. Positive symptoms could reflect the lack of control from higher level conscious processes.

Impairment of consciously controlled use of memory in schizophrenia

Recent studies of memory in schizophrenia have shown that explicit but not implicit memory performance is impaired. The hypothesis that schizophrenia is associated with a failure of consciously but not unconsciously (automatic) controlled influence of memory on performance was tested using a procedure providing uncontaminated estimates of consciously controlled and automatic memory processes (i.e., the process-dissociation procedure in a stem completion task). Performance of 35 patients with schizophrenia was compared with that of 35 normal participants. Consciously controlled use but not automatic influences of memory was significantly lower in patients with schizophrenia than in controls. Consciously controlled use of memory was negatively and significantly correlated with positive symptoms of schizophrenia. Schizophrenia differentially affects 2 types of memory processes: It impairs consciously controlled use of memory but spares automatic influences. Positive symptoms could reflect the lack of control from higher level conscious processes.

Spatial orientation of the alpha and betac receptor chain binding sites on monomeric human interleukin-5 constructs

Interleukin-5 (IL-5), a disulfide-linked homodimer, can be induced to fold as a biological active monomer by extending the loop between its third and fourth helices (Dickason, R. R., and Huston, D. P. (1996) Nature 379, 652-655). We have designed eight monomeric IL-5 proteins to optimize biological activity and stability of the monomer. This was achieved by (i) inserting the joining loop at three different positions, (ii) by introducing an additional intramolecular disulfide bridge onto these backbones, and (iii) by creating circular permutations to fix the position of the carboxyl-terminal helix relative to the three other helices. The proteins dimerize with Kd values ranging from 20 to 200 microM and are therefore monomeric at the picomolar concentrations where they are biologically active. Introduction of a second disulfide confers increased stability, but this increased rigidity results in lower activity of the protein. Contrary to wild type IL-5, mutation of the betac contact residue on the first helix, Glu12, to Lys, into the circularly permutated constructs, did not abolish TF-1 proliferative and eosinophil activation activities. These results indicate that activation of the IL-5 receptor complex is not mediated solely by Glu12 on the first helix, and alternative mechanisms are discussed.

Agouti regulation of intracellular calcium: role of melanocortin receptors

Several dominant mutations at the murine agouti locus cause a syndrome of marked obesity and insulin resistance. We have recently reported that intracellular free Ca2+ concentration ([Ca2+]i) is elevated in viable yellow mice. Because [Ca2+]i has a key role in the pathogenesis of insulin resistance, obesity, and hypertension, the role of the purified agouti gene product in regulating [Ca2+]i was evaluated in a number of cell types. Purified murine agouti induced slow, sustained increases in [Ca2+]i in A7r5 vascular smooth muscle cells and 3T3-L1 adipocytes in a dose-dependent fashion. In L6 skeletal myocytes, agouti stimulated an increase in [Ca2+]i with an apparent concentration eliciting 50% of the maximal response (EC50) of 62 nM. This response was substantially inhibited by Ca2+ entry blockade with nitrendipine. To determine whether melanocortin receptors play a role in agouti regulation of [Ca2+]i, we examined the effect of melanocortin peptides and agouti in cells stably transfected with human melanocortin receptors. Human embryonic kidney cells (HEK-293 cells) transfected with either the human melanocortin 1 receptor (MC1R) or melanocortin 3 receptor responded to human agouti with slow, sustained increases in [Ca2+]i, whereas nontransfected HEK-293 cells with no melanocortin receptors did not respond to agouti. Dose-response curves in the MC1R line showed that agouti had an EC50 of 18 nM, which is comparable to that for agouti antagonism of (125)I-Nle,D-Phe-alpha-melanocyte-stimulating hormone binding in the same cell line. This direct effect of agouti on stimulating increases in [Ca2+]i suggests a potential mechanism for agouti-induced insulin resistance.

Structural features and biochemical properties of TNF-alpha converting enzyme (TACE)

Tumor necrosis factor-alpha is a potent cytokine, secreted primarily by activated monocytes and macrophages, that possesses a broad range of immunomodulating properties. Involvement of this cytokine has been validated in disease states such as arthritis and Crohn's disease and implicated in diverse neuroimmunological pathologies such as multiple sclerosis, Alzheimers and stroke. TNF-alpha is initially synthesized as a 26 kDa precursor molecule that is subsequently processed to the mature form by cleavage of the Ala76 Val77 bond. The 17 kDa carboxy-terminal protein is then secreted to function in a paracrine manner. The enzyme that processes precursor TNF-alpha has previously been identified as a microsomal metalloprotease called TNF-alpha converting enzyme (TACE). We have now purified and partially cloned the enzyme. TACE represents a novel target for therapeutic intervention in a variety of inflammatory and neuroimmunological diseases.

Efficacy and safety of pravastatin in the treatment of patients with type I or type II diabetes mellitus and hypercholesterolemia

PURPOSE

Patients with type I and type II diabetes mellitus have an increased risk of coronary heart disease. In many diabetics, hypercholesterolemia is present and further exacerbates this risk. We investigated the efficacy and safety of pravastatin in the treatment of patients with type I or type II diabetes mellitus and hypercholesterolemia.

PATIENTS AND METHODS

In this 24-week, multi-center, double-blind, placebo-controlled study, 94 patients (45 men, 49 women), 18 to 70 years of age, with type I or type II diabetes mellitus and hypercholesterolemia (fasting plasma low-density lipoprotein cholesterol [LDL-C] levels > 150 mg/dL and above the 75th percentile for the US population by age and gender) were randomized to receive pravastatin 20 mg hs or matching placebo. Two patients were randomized to treatment with drug for every 1 randomized to placebo. The dose could be doubled after 10 weeks, and cholestyramine or colestipol could be added after 18 weeks, as needed, to attempt to lower the LDL-C levels to below the 50th percentile for the US population.

RESULTS

Significant reductions in LDL-C (-27.6%), total cholesterol (-22.1%), very-low-density lipoprotein cholesterol (-22.6%), and triglycerides (-12.8%) (P < or = 0.001 versus placebo for all reductions), and significant increases in high-density lipoprotein cholesterol (4.4%) (P < or = 0.05 versus placebo) were noted in the pravastatin treatment group (average dose 29.5 mg) at 16 weeks. The beneficial lipid-lowering effects of pravastatin were maintained throughout the 24 weeks of the study. Pravastatin was well tolerated, and the frequency of side effects was similar in the pravastatin and placebo groups. No clinically significant changes in the control of diabetes, as assessed by fasting blood glucose levels and glycosylated hemoglobin measurements, were seen during this study.

CONCLUSION

The results of this study demonstrate that pravastatin is well tolerated and effective in lowering total cholesterol and LDL-C in patients with type I or type II diabetes mellitus and hypercholesterolemia.

Agouti protein is an antagonist of the melanocyte-stimulating-hormone receptor

The genetic loci agouti and extension control the relative amounts of eumelanin (brown-black) and phaeomelanin (yellow-red) pigments in mammals: extension encodes the receptor for melanocyte-stimulating hormone (MSH) and agouti encodes a novel 131-amino-acid protein containing a signal sequence. Agouti, which is produced in the hair follicle, acts on follicular melanocytes to inhibit alpha-MSH-induced eumelanin production, resulting in the subterminal band of phaeomelanin often visible in mammalian fur. Here we use partially purified agouti protein to demonstrate that agouti is a high-affinity antagonist of the MSH receptor and blocks alpha-MSH stimulation of adenylyl cyclase, the effector through which alpha-MSH induces eumelanin synthesis. Agouti was also found to be an antagonist of the melanocortin-4 receptor, a related MSH-binding receptor. Consequently, the obesity caused by ectopic expression of agouti in the lethal yellow (Ay) mouse may be due to the inhibition of melanocortin receptor(s) outside the hair follicle.

The chemokines IL-8, monocyte chemoattractant protein-1, and I-309 are monomers at physiologically relevant concentrations

The chemokines are a family of immune mediators involved in a wide range of inflammatory processes, most importantly as chemoattractants of monocytes, neutrophils, lymphocytes, and fibroblasts to sites of inflammation. Nuclear magnetic resonance and x-ray crystallographic studies have shown that IL-8 and macrophage-inflammatory protein-1 beta (MIP-1 beta) form noncovalent dimers and that platelet factor-4 (PF-4) forms noncovalent dimers and tetramers, leading to the assumption that, as a family, the chemokines would form multimeric structures. In this study, we analyze the association states of the chemokines IL-8, monocyte chemoattractant protein-1 (MCP-1), and I-309, by using a combination of size exclusion HPLC, sedimentation equilibrium ultracentrifugation, and chemical cross-linking. We find that the association states of MCP-1 and IL-8 are characterized by an equilibrium between monomers and dimers: although dimers predominate at concentrations above 100 microM, these chemokines are almost exclusively monomeric at the nanomolar concentrations at which they display maximal chemotactic activity. I-309, by contrast, remains a monomer at all concentrations tested. I-309 contains two additional cysteine residues (C26 and C68) that are not found in any other members of the chemokine family. We used cyanogen bromide and trypsin digestion strategies to demonstrate that these two residues are linked in a unique intramolecular disulfide bond. Furthermore, by using site-directed mutagenesis, we show that the integrity of this bond is crucial for protein secretion.

The chemokines IL-8, monocyte chemoattractant protein-1, and I-309 are monomers at physiologically relevant concentrations

The chemokines are a family of immune mediators involved in a wide range of inflammatory processes, most importantly as chemoattractants of monocytes, neutrophils, lymphocytes, and fibroblasts to sites of inflammation. Nuclear magnetic resonance and x-ray crystallographic studies have shown that IL-8 and macrophage-inflammatory protein-1 beta (MIP-1 beta) form noncovalent dimers and that platelet factor-4 (PF-4) forms noncovalent dimers and tetramers, leading to the assumption that, as a family, the chemokines would form multimeric structures. In this study, we analyze the association states of the chemokines IL-8, monocyte chemoattractant protein-1 (MCP-1), and I-309, by using a combination of size exclusion HPLC, sedimentation equilibrium ultracentrifugation, and chemical cross-linking. We find that the association states of MCP-1 and IL-8 are characterized by an equilibrium between monomers and dimers: although dimers predominate at concentrations above 100 microM, these chemokines are almost exclusively monomeric at the nanomolar concentrations at which they display maximal chemotactic activity. I-309, by contrast, remains a monomer at all concentrations tested. I-309 contains two additional cysteine residues (C26 and C68) that are not found in any other members of the chemokine family. We used cyanogen bromide and trypsin digestion strategies to demonstrate that these two residues are linked in a unique intramolecular disulfide bond. Furthermore, by using site-directed mutagenesis, we show that the integrity of this bond is crucial for protein secretion.

Involvement of pp60c-src with two major signaling pathways in human breast cancer

The phosphotyrosine residues of receptor tyrosine kinases serve as unique binding sites for proteins involved in intracellular signaling, which contain SRC homology 2 (SH2) domains. Since overexpression or activation of the pp60c-src kinase has been reported in a number of human tumors, including primary human breast carcinomas, we examined the interactions of the SH2 and SH3 domains of human SRC with target proteins in human carcinoma cell lines. Glutathione S-transferase fusion proteins containing either the SH2, SH3, or the entire SH3/SH2 region of human SRC were used to affinity purify tyrosine-phosphorylated proteins from human breast carcinoma cell lines. We show here that in human breast carcinoma cell lines, the SRC SH2 domain binds to activated epidermal growth factor receptor (EGFR) and p185HER2/neu. SRC SH2 binding to EGFR was also observed in a nontumorigenic cell line after hormone stimulation. Endogenous pp60c-src was found to tightly associate with tyrosine-phosphorylated EGFR. Association of the SRC SH2 with the EGFR was blocked by tyrosyl phosphopeptides containing the sequences surrounding tyrosine-530, the regulatory site in the SRC C terminus, or sequences surrounding the major sites of autophosphorylation in the EGFR. These results raise the possibility that association of pp60c-src with these receptor tyrosine kinases is an integral part of the signaling events mediated by these receptors and may contribute to malignant transformation.

Specific developmental profiles of lysosomal and brush border enzymuria in the human

Various enzymatic urinary activities have been proposed to assess renal proximal tubule damage in children, including neonates. Nevertheless comprehensive knowledge on the developmental aspects of physiological enzymuria is limited, particularly with regard to lysosomal and brush border enzymuria. Urinary activities of two lysosomal enzymes, N-acetyl-beta-D-glucosaminidase (NAG) and beta-galactosidase (GAL), and of two brush border enzymes, alanine aminopeptidase (AAG) and gamma-glutamyltransferase (GGT) were comparatively investigated in normal prematures (n = 28), term neonates (n = 52), infants aged less than 2 years (n = 19) and children (n = 33), and compared to urinary excretion of beta 2-microglobulin (B2M). Enzymatic activities were assayed using either spectrophotometrical (NAG, AAP, GGT) fluorimetrical (GAL) or radioimmunological (B2M) methods, and were related to urinary creatinine excretion. Developmental profiles of both the studied lysosomal enzymes and of B2M were similarly characterized with significantly decreasing values from prematures (NAG 9.29 +/- 1.44, GAL 2.26 +/- 0.26 IU/mmol creatinine, indicated as mean +/- SEM) to term neonates (6,94 +/- 0.58 and 1.76 +/- 0.15 IU/mmol creatinine, respectively) and older infants and children. Lysosomal enzymatic urinary activities correlated linearly with a coefficient of r = 0.75, (p < 0.05), while correlations between each lysosomal enzymatic activity and B2M urinary excretion were weaker.(ABSTRACT TRUNCATED AT 250 WORDS)

[Complications due to insufficient preventive measures in a neonatal intensive care unit]

In 100 records collected from a neonatal intensive care unit, 19 cases of insufficient prevention were noted. In some of them, several tactical faults affected the same infant. In 9 cases pre- or perinatal surveillance was lacking; there were 9 cases of inappropriate transfer and 11 cases of iatrogenic complications. Three mothers refused all examinations. In all other cases, both medical and paramedical staffs did not utilize the means at their disposal to satisfaction. We conclude that for a better effective use of intensive care it seems rational to convince the perinatology actors to exploit under good conditions the existing possibilities of prevention rather than demanding a reinforcement of the present statutory structures.

Contribution of MRI in supracardiac total anomalous pulmonary venous drainage

A case of supracardiac total anomalous pulmonary venous drainage (TAPVD) in an infant aged 2 1/2 months is presented. Diagnosis was established non invasively by magnetic resonance image (MRI). Not only did MRI precisely depict the anomalous venous pathway but it moreover securely excluded pulmonary venous obstruction.

[Biological indicators of bacterial infection in newborn infants]

Biological markers of neonatal bacterial infection are useful if they bring early indications and if they are sensitive and specific. There are two kinds of tests: hematological signs and acute phase proteins. The most specific hematological signs are, in chronological order: leuconeutropenia--myelemia--neutrophilic polynucleosis. Gestational and post-natal ages have to be taken in consideration for correct interpretation of white cell count and differential. Several acute phase proteins increase in infected newborns: fibrinogen, C reactive protein, orosomucoïd. If determined quantitatively, C reactive protein is a sensitive, specific and early marker allowing, in addition, to follow the reaction to treatment: the return to normal range of CRP and later of orosomucoïd attest for recovery. These biological tests have to be sequentially determined during the first days in order to obtain a maximal information.

[Indications of magnetic resonance imaging in congenital cardiopathies in neonatal period. Apropos of 54 cases]

Between February 1988 and July 1989, the authors used magnetic resonance imaging (MRI) to study 54 newborn infants aged between 2 and 35 days and suspected of congenital heart disease. All children also underwent echocardiography and 7 angiography during the neonatal period (13% of children studied). MRI was well tolerated and there were no adverse events. MRI proved to be complementary to echocardiography in several lesions affecting the great vessels of the base and the left atrial region. Agreement between angiography and MRI results was very good, with MRI being more useful in one case. MRI enables full and non-invasive postoperative follow-up. In conclusion, despite the great heterogenicity of the cardiac malformations studied and which requires a degree of caution, the authors feel that MRI is a second line investigation after echocardiography. It may limit the indications of angiography. Its own indications are the retrocardiac region, the main arteriovenous vessels of the base and postoperative follow-up in congenital heart disease. The development of techniques such as angio RM will further modify data in the future.

[Magnetic resonance imaging in the diagnosis of retrotracheal pulmonary artery]

The authors report the case of a 3-month-old infant with a history of interventricular septal defect with pulmonary arterial hypertension. This child had pulmonary symptomatology (dyspnea, recurrent bronchitis, acute attacks of asphyxia) which it was possible to link to a retrotracheal left pulmonary artery by magnetic resonance imaging (MRI). Classical investigations (upper GI barium series and chest X-ray) were suggestive of a bronchogenic cyst type abnormal pulmonary structure. Angiography confirmed the MRI diagnosis. In this case the infant also had tracheal lesions (lower tracheal hypoplasia) which required further evaluation by fibroscopy and bronchography. Thus MRI shows itself to be a useful investigation in the study of basic vascular abnormalities.

Neonatal echovirus encephalitis with white matter necrosis

The authors report a case of neonatal echovirus encephalitis associated with white matter necrosis. The pattern of illness in the neonatal period was diphasic, marked by hyperthermia and the occurrence of seizures. Echovirus was recovered from the cerebrospinal fluid. Cerebral magnetic resonance imaging (MRI) performed at one month of age showed right periventricular white matter necrosis. The infant exhibited mild left hemiparesis. Cerebral MRI at 6 months of age showed a delay in myelination in the right hemisphere. Echovirus encephalitis in the neonate can cause brain damage.

Magnetic resonance imaging in congenital heart disease of newborns: preliminary results in 23 patients

Until now little attention has been paid to the potential of MR imaging in congenital heart disease of the newborn. ECG-gated MRI was therefore performed at 0.5 tesla in 23 newborns (mean age 7.5 days) with suspected congenital heart disease. Two newborns were controlled after surgery (switch, Blalock-Taussig procedure). All had undergone prior evaluation by two-dimensional Doppler echocardiography (2-D DE). MR imaging was of a satisfying quality in all but one newborn. The aim of this study was to assess complementary information provided by MRI in comparison to 2-D DE. Pre-operatively MRI missed some abnormalities shown by 2-D DE: one coartaction, one ductus arteriosus and one pulmonary atresia. MRI demonstrated lesions that echocardiography had either failed to visualize or found inconclusive, including double aortic arch (one patient), muscular ventricular septum defect (two patients) and severe ductus arteriosus (one patient). In one of the two patients with a ventricular septum defect, angiography was avoided and in the other patient it merely confirmed the MRI results. Post-operatively, MRI demonstrated information complementary to that obtained from to 2-D DE: (1) clearly visualizing the reinsertion of the coronary arteries in the 'switched' transposition of the great vessels, (2) appreciating the diameter and patency of the palliative shunt in the Blalock-Taussig procedure.

Ultrasound as a tool in the diagnosis and management of exit-site infections in patients undergoing continuous ambulatory peritoneal dialysis

Ultrasonographic examination of the subcutaneous course and exit site of the Tenckhoff catheter in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) was performed to evaluate catheter-related infections. Real-time ultrasound studies were performed in 24 patients with initial exit-site infections; clinically suspected tunnel infections were excluded from analysis. A peri-catheter sonolucent fluid collection, considered a positive study, was demonstrated in 13 ultrasound examinations and tended to be organism-specific; eight of 12 Staphylococcus aureus exit-site infections and three of four gram-negative exit-site infections had positive studies. Only two of seven Staphylococcus epidermidis exit-site infections were initially positive on ultrasound examination. Nine of 13 patients with positive ultrasound studies ultimately lost their catheters to infection despite weeks of parenteral antibiotic therapy and local incision and drainage. There were 11 negative ultrasound studies. Only one of these patients' catheters was lost because of infection. In some episodes of CAPD-associated exit-site infections, especially those caused by S aureus and gram-negative organisms, ultrasound examination of the catheter course may be useful to diagnose unsuspected tunnel infections, direct early therapy, and confirm resolution or persistence of the infections.

[Palliative percutaneous pulmonary valvuloplasty in neonatal forms of tetralogy of Fallot]

Percutaneous pulmonary valvuloplasty was performed successfully in two neonates with cyanotic tetralogy of Fallot. It seems that balloon valvotomy may represent a palliative therapeutic alternative of choice in the neonatal period.

Neonatal renal dysfunction and intrauterine exposure to prostaglandin synthesis inhibitors

Three cases of renal dysfunction at birth were observed in premature babies exposed in utero to prostaglandin synthetase inhibitors (PSI) and corticosteroids. Transient water and sodium retention with uraemia occurred in one patient, and severe acute renal failure with marked hyperkalaemia in twins. These findings may be due to impairment of prostaglandin (PG)-mediated renal adaptation to stress conditions after transplacental passage of PSI. Corticosteroids may also have affected PG synthesis inhibition.

[Diagnosis of double aortic arch in the neonatal period. Contribution of magnetic resonance imaging. Apropos of a case]

The authors report a case of double aortic arch in the newborn (age: 1 month) explored with magnetic resonance imaging. MRI offers a non invasive and non ionizing examination very well-tolerated by the patient if a correct methodology is used (total acquisition time 40 mn). The quality of the images is sufficient for diagnosis and presurgical evaluation: the diameter, the permeability and the relationship with the surrounding organs of the respective aortic arches were well demonstrated with this technique. The contributions of MRI with respect to 2-D echocardiography and angiography as well as the future possible totally non invasive evaluation of this cardiac anomaly is discussed.

[Meningomyocarditis caused by Coxsackie virus B4 in perinatology. Value of anti-Coxsackie virus B IgM]

The authors report a case of meningocarditis in a neonate caused by a Coxsackie virus B4. Outcome was favorable. Diagnosis was possible by detecting Coxsackie B4 specific IgM using an ELISA test with the sera of the infant and his mother. This assay allows rapid diagnosis and prevention of maternal and neonatal enterovirus infection.

Pharmacokinetics of teicoplanin in children

A single dose of 6 mg/kg teicoplanin was infused over 10 min in six children of mean age 7 years, and a single dose of 6 mg/kg was infused over 20 min in four neonates of mean age 8.5 days. Serum sampling was performed at 0 and 10 min and at 1, 4, 12 and 24 h and thereafter 24-hourly, up to ten days. Urine was collected for each 24 h throughout the study in children. Teicoplanin was assayed by high performance liquid chromatography. Tolerability of teicoplanin was excellent both in children and in neonates. For all the patients the serum concentrations of teicoplanin followed an open two-compartment model. Mean Cmax was 48.6 +/- 16.7 mg/l (10 min) in children, and 19.6 +/- 1.05 mg/l (20 min) in neonates, and mean t1/2 beta was 20.5 +/- 5.5 h and 30.3 +/- 6.3 h, respectively. On the basis of the results dosage recommendations for children and neonates are made.

[The transfer of newborn infants. Experience of a department of neonatology]

The results of 6 years of neonatal transport to the neonatology unit of the Hautepierre hospital (January, 1980 to December, 1985) are reported. During that period 1866 neonates were transferred from maternities of Strasbourg and its region to the neonatology unit, representing 23.77% of total admissions. The 350 premature babies born before or at 32 weeks of pregnancy amount to 55% of babies born at the same gestational age. Mortality in that group (46.52%) was associated mainly with hyaline membrane disease and intraventricular haemorrhage. Neonatal infections and congenital malformations were seen in children born after 32 weeks. To improve the quality of transport and reduce morbidity and mortality, the biological and haemodynamic parameters of the neonates should be stabilized prior to their transfer, and all the necessary precautions (i.e. ventilation, oxygenation, temperature, glycaemia, asepsis) should be observed at every stage of their journey. In high-risk pregnancies, "transfer in utero" to a neonatal intensive care unit undoubtedly is the best solution.

[Persistent hyperbilirubinemia after intrauterine intraperitoneal transfusions in 4 newborn infants. Role of intraperitoneal red cells present at birth]

Four neonates who had undergone intra-uterine peritoneal blood transfusions for Rhesus disease and hydrops fetalis presented, during the first days of life, with intractable hyperbilirubinemia in spite of multiple exchange transfusions. The hyperbilirubinemia was due to delayed absorption and hemolysis of peritoneal red cells. This unusual complication can be successfully managed with peritoneal lavage which should be performed when the antenatal history is contributive for low absorption of transfused blood.