On the phenotypic overlap between "severe" oto-palato digital type II syndrome and Larsen syndrome. Variable manifestation of a single autosomal dominant gene

We report two familial cases of oto-palato-digital (OPD) Type II syndrome, a father and his son. This family shows that OPDII syndrome is inherited as an autosomal dominant condition. The similarities between the OPDII syndrome and the Larsen syndrome are discussed.

Evaluation of interleukin-6 and soluble receptors of tumor necrosis factor for early diagnosis of neonatal infection

OBJECTIVE

To evaluate plasma levels of interleukin-6 (IL-6) and soluble tumor necrosis factor receptors (sTNF-R) 55 and 75 in neonates as a contribution to the early diagnosis of infection.

STUDY DESIGN

We prospectively measured IL-6 and sTNF-R 55 and sTNF-R 75 plasma levels in 157 newborn infants admitted to our regional neonatal center in a 3-month period and in cord blood of 131 newborn infants delivered in our obstetrics unit. C-reactive protein was sequentially determined after admission. Newborn infants were classified into four groups: group 0, not infected; group 1, possibly infected; group 2a, infected (culture positive), and group 2b, probably infected (culture negative). We looked for the optimal cutoff point of these parameters, using the receiver operating characteristics (ROC) curve.

RESULTS

IL-6 levels were significantly higher in group 2 (n = 11; median level, 250 pg/ml; range, 0 to 81,000), group 2b (n = 25; median level, 750 pg/ml; range, 0 to 180,000), and group 1 (n = 35; median level, 160 pg/ml; range 0 to 10,000), in comparison with group 0 (n = 217; median level, 0 pg/ml; range, 0 to 3400). A cutoff value of 100 pg/ml or greater obtained by the ROC method gives a sensitivity of 83.3% and a specificity of 90.3%. For inborn infants (n = 220) sampled at birth, sensitivity is 100% and specificity 92.3%. This high sensitivity persists until the twelfth hour of life. The sTNF-R 55 levels are significantly higher in group 2a (median, 12.0 ng/ml; range, 3.2 to 24.4). In group 2b (median, 7.0 ng/ml; range, 3.0 to 25.2), and in group 1 (median, 7.0 ng/ml; range, 2.5 to 18.9) than in group 0 (median, 3.9 ng/ml; range, 1.5 to 15.0), and with a cutoff value of 6 ng/ml, sensitivity is 75% and specificity 69%. The sTNF-R 75 levels are significantly higher in group 2a (median, 17.0 ng/ml; range, 7.2 to 48.8). In group 2b (median, 11.2 ng/ ml; range, (2.0 to 31.3), and in group 1 (median, 10.6 ng/ml; range, 2.0 to 33.0); than in group 0 (median, 7.0 ng/ml; range, 1 to 23.0). With a cutoff value of 9 ng/ ml, sensitivity is 80% and specificity 67%. Sensitivity of C-reactive protein is low initially but improves with time. Combining IL-6 with C-reactive protein provides the possibility of identifying the majority of infected infants in the postnatal period.

CONCLUSION

A plasma IL-6 level of 100 pg/ml or greater, obtained before the twelfth hour of life, appears to be an ideal marker for detecting early-onset neonatal infection with a high degree of sensitivity and specificity. After the twelfth hour, the combined determination of IL-6 and C-reactive protein may be equally useful. The sTNF-R levels appear to be less useful in the early diagnosis of infection because of their smaller magnitude of variation.

Beta-nerve growth factor levels in newborn cord sera

This study was designed to examine beta-nerve growth factor (NGF) levels in human cord blood by a two-site enzyme immunoassay using MAb 27/21 to mouse NGF and to determine whether beta-NGF levels show developmental changes. Blood was collected at delivery from 61 newborns, 55 neonates appropriate for gestational age (46 term infants and 9 premature infants), 5 neonates small for gestational age, and 1 neonate with congenital hydrocephalus. In addition, samples were collected from 2 microcephalic children (microcephaly vera) aged 15 and 18 mo, 2 control children, and 4 healthy adults. Mean levels of NGF in preterm infants (n = 9; 13.7 +/- 8 pg/mL) were significantly lower than levels in term infants (n = 47; 21.2 +/- 8.8 pg/mL; p = 0.034 by Mann-Whitney U test). There was no correlation between birth weight, length, head circumference, and beta-NGF levels. In microcephalic children, NGF levels were low (8 pg/mL) compared with control infants' values (22 pg/mL). In adults, beta-NGF levels were higher and ranged between 238 and 292 pg/mL. Our study demonstrates that beta-NGF levels can be assessed in human newborn sera using a two-site enzyme immunoassay with MAb 27/21 to mouse beta-NGF, that beta-NGF levels are extremely low in newborns compared with adults, that beta-NGF levels seems to show developmental changes, and that beta-NGF levels may be used to assess NGF utilization under normal and pathologic conditions such as cerebral malformations.

A study of cerebral perfusion using single photon emission computed tomography in neonates with brain lesions

In this study we used a single photon emission computed tomography technique (SPECT) with radiolabelled 99mTcHMPAO to assess cerebral perfusion in newborn infants with documented cerebral lesions and to determine to what extent brain SPECT might be useful in the neonatal period. A total of 15 newborn infants with the following cerebral pathologies were enrolled: severe parietal bilateral periventricular leucomalacia (PVL, n = 6); moderate parietal bilateral PVL (n = 2); intraventricular haemorrhage grade II with unilateral parietal parenchymal extension (IHV + PE, n = 3); cerebral infarction (CI, n = 2) in the zone of middle cerebral artery; and post-haemorrhagic hydrocephalus (n = 2). Follow-up was available in all infants. Alterations in cerebral perfusion were seen in only 12 of 15 infants and at the location of severe PVL, PE and CI. We have noted that the regions of diminished perfusion extended beyond the apparent extent of cerebral pathology delineated by ultrasound or magnetic resonance imaging. Markedly diminished perfusion was seen in 1 infant with hydrocephalus, which recovered following placement of ventriculo-peritoneal shunt. Regarding outcome, SPECT data failed to provide additional information than that of neuroradiological investigations. We conclude that the use of SPECT, under these conditions, to assess alteration of cerebral perfusion in the neonatal period will not provide any additional information than that of neuroradiological investigations.

Cerebral perfusion studies during maturation using single photon emission computed tomography in the neonatal period

In this study, we used single photon emission computed tomography (SPECT) radiolabelled 99mTc HMPAO to assess cerebral perfusion during maturation in the neonatal period. Results of SPECT examinations in 18 newborn infants, in whom gestational age ranged form 30 to 41 weeks, and who were found to be neurologically normal in retrospect, were reviewed. The developmental changes in cerebral perfusion during the neonatal period shown by SPECT parallel findings of other methods on maturational changes of the central nervous system (neuropathological studies, positron emission tomography scan, magnetic resonance imaging). Cerebral perfusion progresses from the central part of the brain to the cerebellum, sensorimotor and then visual cortex. A close relation seems to exist between cerebral perfusion, metabolism and behavior under normal conditions in the neonatal period.

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.

Early treatment of premature infants with recombinant human erythropoietin

OBJECTIVES

The specific objectives of this study were (1) to assess the safety and efficacy of recombinant human erythropoietin (rhEPO) in reducing postnatal hemoglobin decline in premature infants of less than 33 weeks' gestation, and thus reducing the need for transfusion; and (2) to determine the optimal dosage of rhEPO.

MATERIALS AND METHODS

Three groups of premature infants of less than 33 weeks' gestation were treated with rhEPO: group 1 (n = 10) received 300 U/kg per week; group 2 (n = 11), 600 U/kg per week; and group 3 (n = 10), 900 U/kg per week. These three groups were compared to a reference group of 20 infants of the same gestational age and birth weight. Treatment started on the 10th day of life and lasted 6 weeks. All infants were given oral iron and vitamin E supplements.

RESULTS

Treated infants had significantly higher reticulocyte counts, and the effect was dose dependent (P = .009). Postnatal decline of hemoglobin and hematocrit was lessened in the treated groups; the percent of decrease of hemoglobin and hematocrit was significantly reduced in the treated infants at 35 days of age (P = .0025 and P = .0036, respectively). The need for blood transfusion was also reduced in the rhEPO-treated groups: 19% of treated vs 45% of reference infants received transfusions, and the treated infants received less blood. Serum iron and transferrin saturation percentage dropped significantly during the study and a dose-dependent relationship in treated infants was displayed, suggesting high iron consumption (P = .0008 and P = .006, respectively). No dose effect on hemoglobin level and the need for blood transfusion was found, possibly because of the higher degree of illness severity and iron consumption in groups 2 and 3. No side effects related to rhEPO therapy were observed.

CONCLUSIONS

It is concluded that rhEPO therapy is safe in premature babies when given in the three dosages used in this study; in addition, it enhances erythropoiesis and reduces the need for blood transfusions. rhEPO therapy seems more efficient when given in higher dosages; however, illness severity and iron consumption represent major limiting factors. Controlled, randomized studies are warranted to confirm these data and to determine precise modalities and indications of rhEPO therapy in premature infants.

Oral acyclovir and recurrent genital herpes during late pregnancy

OBJECTIVE

To assess plasma acyclovir levels in pregnant women given oral acyclovir during late gestation and to determine the role and effect of oral acyclovir on asymptomatic shedding of virus in cases of recurrent genital herpes.

METHODS

Five pregnant women with proven genital herpes isolate (herpes simplex virus [HSV] 2) after 37 weeks' gestation were studied. Oral acyclovir was administered every 8 hours at dosages of 300, 400, and 300 mg in two subjects, and 200 mg five times daily in the other three until delivery. Plasma acyclovir peak and trough levels were determined. Viral cultures were obtained from both the mothers and neonates at delivery.

RESULTS

There was no difference in acyclovir plasma levels among the patients. Furthermore, acyclovir levels were comparable to those of nonpregnant adults. The drug failed to suppress asymptomatic shedding of virus and transmission of HSV 2 to the neonate in one of five of the patients.

CONCLUSION

Our study suggests that asymptomatic shedding of virus is not prevented by use of oral acyclovir during late gestation in proven recurrent genital herpes even though plasma acyclovir levels were within the normal range.

Enterovirus infections in neonates. A retrospective study of 21 cases

OBJECTIVES

The aim of this study was to define the major features of enterovirus infections in the neonatal period based on our own experience.

METHODS

Epidemiology, clinical manifestations and laboratory investigations concerning 21 neonates having experienced a Coxsackie B or an Echovirus infection between 1987 and 1991, were retrospectively reviewed. Aetiological diagnosis was made by classical viral isolation and/or by evidencing Coxsackie B-specific IgM antibodies with an immunocapture enzyme immunoassay.

RESULTS

In 13 neonates the infection occurred between June and September. The onset of clinical signs ranged from day 1 to day 25 after birth with two separate periods: before 7 days of age, suggesting a perinatal transmission of the virus, or beyond this date, more likely connected with a postnatal transmission. Clinical manifestations included hyperthermia, gastroenteritis, meningitis, encephalitis, pneumonia and myocarditis, with a diphasic pattern in 6 cases. Most of the neonates improved gradually and developed normally. The Coxsackie B-specific IgM assay was the most rapid method whereas viral isolation, even though it took more time, was the most sensitive technique to establish the aetiological diagnosis in neonates.

CONCLUSIONS

Enterovirus infections in neonates are difficult to diagnose and to differentiate from bacterial infections. A viral-like illness in the environment of the neonate allows the clinician to anticipate the clinical signs and a possibly fatal disease. Identification of the causal virus should be performed by both viral isolation and search for specific IgM antibodies. Treatment and prophylaxis are so far disappointing.

Nicotine analysis in neonates' hair for measuring gestational exposure to tobacco

Hair samples were collected at time of delivery from 40 neonates whose mothers were known to be smokers during the prenatal period. Hair was decontaminated in dichloromethane, homogenized in NaOH, and nicotine was extracted in diethyl ether. After separation on a BP-5 capillary column, nicotine was identified and quantified by GC/MS using selected ion monitoring. In all cases, nicotine was found in the neonatal hair and in the hair of the corresponding mother. The ranges of nicotine levels were 0.15 to 11.80 ng/mg, and 0.37 to 63.50 ng/mg, for the neonates, and their mothers, respectively. It was possible to establish a significant correlation between both concentrations, and the correlation coefficient was 0.83. These findings suggest the possibility of monitoring the transfer of maternal nicotine through the placenta by measuring nicotine concentration in neonatal hair.

[Medical treatment of chylous effusions in newborn infants. Apropos of 3 cases]

BACKGROUND

Chylous effusions are the most frequent cause of non immunologic hydrops fetalis. They can be recognized antenatally by ultrasonography. Their evacuation is sometimes necessary and medical treatment often effective.

CASE REPORTS

Case n. 1: fetal ascites was detected by ultrasonography at the 30th week of gestation. Paracentesis was performed at 36 weeks, followed 3 days later by spontaneous delivery. The newborn was fed milk formula. A second paracentesis showed a milky fluid, rich in cholesterol, triglycerides and chylomicrons. The child was fed formula rich in medium-chain triglycerides and the chylous ascites disappeared completely within 2 weeks. Case n. 2: a diagnosis of bilateral hydrothorax and hydramnios was made at the 27th week of gestation. An in utero evacuation of the hydrothorax performed at the 30th week was ineffective and a pleuro-amniotic drainage was performed 2 weeks later. The baby was born at the 35th week, and presented a moderate respiratory distress due to the hydrothorax and ascites. Aspiration of the thoracic fluid confirmed its chylous origin. The chylous effusions completely disappeared when the child was fed a high medium chain triglycerides diet. A lymphedema of legs appeared at the age of 1 month. Case n. 3: ascites, hydramnios, hydrothorax and peripheral edema were found at the 21st week of a third pregnancy (the 2 first pregnancies were complicated by lethal hydrops fetalis). Bilateral hydrothorax and peripheral edema were found again after birth at the 37th week. Diuresis and albumin-infusion led to recovery, but chylothorax and chylous ascites reaccumulated after introduction of milk formula, despite repeated evacuations and feeding medium-chain triglycerides formula. The thoracic fluid remains chylous at the age of 9 months.

CONCLUSIONS

In utero, and sometimes post-natal, evacuation of fluid present in the thoracic and peritoneal cavities can be necessary, depending of the functional tolerance. Medical management including feeding a low fat and/or high medium-chain triglycerides diet, and sometimes temporary total parental nutrition, is necessary, together with salt restriction, diuresis and albumin infusion as required. Most cases recover spontaneously or as a result of therapy within a few weeks.

Modified peptidoglycan precursors produced by glycopeptide-resistant enterococci

Cytoplasmic precursors of the peptidoglycan biosynthetic pathway were purified from vancomycin-treated, glycopeptide-sensitive and -resistant strains of Enterococcus faecium. Resistance was due to production of a modified precursor, UDP-MurNAc-L-Ala-D-Glu-L-Lys-D-Ala-D-lactate, where lactate was identified on the basis of mass of the precursor and on its ability to act as a substrate for D-lactate dehydrogenase after release from the precursor. The presence of the D-lactate residue instead of D-alanine in the terminal position would hinder formation of a vancomycin-precursor complex, without preventing incorporation of the precursor into mature peptidoglycan.

[Tracheal compression by an aberrant brachiocephalic trunk: diagnosis by magnetic resonance]

In a full-term infant who underwent surgery for type III esophageal atresia, attempts to remove the tracheal tube postoperatively failed. Bronchoscopy disclosed external compression of the trachea in the chest. Selection of the investigations most likely to provide the etiologic diagnosis was discussed. Because of the patient's poor general condition, MRI of the mediastinal area was performed first and showed an abnormal origin of the brachiocephalic trunk which was the cause of tracheal compression. No attempt at corrective surgery was made and the patient was successfully extubated at four months of age.

Periventricular haemorrhagic infarction associated with subependymal germinal matrix haemorrhage in the premature newborn. Report of two cases

Two cases of unilateral subependymal germinal matrix haemorrhage associated with homolateral periventricular haemorrhagic infarction (PVHI) are reported in two premature newborns. This association is rather rare. Indeed, PVHI occurs generally with large intraventricular haemorrhage. Diagnosis is made by brain imaging (ultrasound, MRI) scans and single photon emission computed tomography. PVHI is probably caused by obstruction of periventricular venous drainage by large intraventricular haemorrhage leading to a haemorrhagic venous infarction. From our cases, we conclude that extraventricular haemorrhage leading to a large subependymal haematoma can result in obstruction of periventricular venous drainage, subsequent PVHI and abnormal neuromotor development.

[Unilateral cerebellar atrophy in 2 newborn infants. Value of MRI]

The authors report 2 cases of unilateral cerebellar atrophia presenting in the neonatal period with facial peripheral palsy and iso-immune thrombocytopenia respectively. The recognition of cerebellar atrophia has been made by MRI. Unilateral cerebellar atrophia be due to ischemia. MRI seems to be a useful tool in the recognition of cerebellar malformations in the neonatal period.

Lipase/amylase ratio. A new index that distinguishes acute episodes of alcoholic from nonalcoholic acute pancreatitis

Because of observations that patients with acute episodes of alcoholic pancreatitis had high serum lipase levels whereas patients with gall stone pancreatitis had high serum amylase levels, a prospective study was undertaken to determine whether the ratio of serum lipase to serum amylase, a newly computed ratio, would discriminate between acute episodes of alcoholic and nonalcoholic pancreatitis. In phase one, 30 consecutive patients with acute pancreatitis were entered into the study and divided into groups A and B. Patients with renal failure were excluded from the study. Group A consisted of 20 patients in whom the etiology of pancreatitis was alcohol. Group B consisted of 10 patients whose pancreatitis was nonalcoholic in etiology (predominantly gallstones). Serum lipase values in group A ranged 492 to 25,706 U/L (median, 3433 U/L) and in group B from 711 to 31,153 U/L (median, 1260 U/L). These differences were not significant statistically. Serum amylase values in group A ranged from 104 to 2985 U/L (median, 331 U/L) and in group B from 423 to 13,000 (median, 1187 U/L). Although these figures were statistically different (P less than 0.005), there was a considerable degree of overlap in the values between the two groups. The lipase/amylase ratio calculated from the blood sample obtained at presentation appeared to be a promising discriminatory index. The lipase/amylase ratio was calculated by using the amylase and lipase levels expressed as multiples of the upper limit of normal in each case. The lipase/amylase ratios in the alcoholic group ranged from 2.2 to 14.8, whereas the lipase/amylase ratio in nonalcoholic pancreatitis ranged from 0.31 to 1.93. These differences were statistically significant (P less than 0.005). A lipase/amylase ratio of greater than 2 was indicative of an alcoholic etiology, and a ratio of less than 2 suggested that the pancreatitis was nonalcoholic in nature. In phase two, this lipase/amylase ratio of 2 was applied prospectively to an unselected population of 21 consecutive patients with acute pancreatitis. Thirteen patients had a lipase/amylase ratio of greater than 2; in 11 of them, the etiology of the pancreatitis was alcohol. Eight patients had a lipase/amylase ratio of less than 2; of them, only 1 patient had an alcoholic etiology for the pancreatitis. These differences were statistically significant (P less than 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)