Fetal and early neonatal interleukin-6 response

Elevated Interleukin-6 Levels as a Potential Marker of Neonatal Morbidity in Full-term Infants With Polycythemia: A Prospective Study

OBJECTIVE

To research and show that interleukin-6 (IL-6) and c-reactive protein (CRP), which can be used as infection markers, are also higher among newborns with polycythemia. The study took place in the neonatal intensive care unit of Zekai Tahir Burak Maternity Teaching and Research Hospital.

PATIENTS AND METHODS

Infants with a gestational age of >37 weeks were included in the study. Infants with chorioamnionitis, perinatal asphyxia, and positive blood culture were excluded from the study. Blood samples were obtained six hours after the delivery from the peripheral vein of the infants for measurements of central hematocrit, blood culture, IL-6, and CRP. Infants with a venous hematocrit value of >65% were grouped as the "polycythemia group," and the ones with a venous hematocrit value of <65% were designated as the "control group." Observation of significantly higher levels of CRP and IL-6 among newborns admitted to the neonatal intensive care unit due to different causes (such as respiratory distress, hypoglycemia, and feeding intolerance), but significantly higher IL-6 levels in newborns with polycythemia.

RESULTS

Thirty-five newborns (18 infants in the polycythemia group and 17 infants in the control group) were enrolled in the study. The IL-6 values for the polycythemia group were higher than the upper normal limits (mean ± 2SD, 37.6 ± 55 vs 12 ± 5 pg/dL, respectively; P = 0.00). The IL-6 values of the polycythemia group were found to be higher than the IL-6 values of the control group, with a mean ± 2SD of 37.6 ± 55 vs 6.3 ± 3.4 pg/dL, respectively; this was significant ( P = 0.00). Although the CRP values of the polycythemia group were found to be slightly higher than those of the control group (a mean ± 2SD of 3.06 ± 4.07 vs 1.54 ± 2.21 mg/dL, respectively, P > 0.05), this was not significant.

CONCLUSIONS

This study found a significant and robust statistical correlation between IL-6 and v. Hct values ( P = 0.01, rs = 0.641). Contrary to IL-6 levels, however, a meaningful relationship was not found between CRP and v.htc values ( P = 0.286; rs = 0.184).

DEVELOPMENT AND VALIDATION OF A MODEL FOR PREDICTION OF SEPTIC SHOCK IN NEONATES WITH SEPSIS

ABSTRACT

Purpose: This study aimed to develop and validate a model for prediction of septic shock in neonates with sepsis. Materials and methods: This retrospective study included early-onset septic neonates in the Renmin Hospital of Wuhan University between January 2017 and June 2021. The neonates were divided into the training set and the validation set in a ratio of 7:3 and further categorized into septic shock group and none-shock group according to presence or absence of shock symptoms. Results: A total of 406 septic neonates were enrolled, including 217 in septic shock group. Sex (odds ratio [OR] = 0.092, 95% confidence interval [CI]: 0.012 to 0.683, P = 0.020), C-reactive protein at 6 h (OR = 8.475, 95% CI: 3.154 to 22.774, P < 0.001), serum amyloid A at 6 h (OR = 1.179, 95% CI: 1.094 to 1.269, P < 0.01), white blood cells at 6 h (OR = 0.173, 95% CI: 0.092 to 0.326, P < 0.001), platelets at 6 h (OR = 0.985, 95% CI: 0.975 to 0.995, P < 0.001), and Ca 2+ at 6 h (OR = 1.44 × 10 11 , 95% CI: 2.70 × 10 6 to 7.70 × 10 15 , P < 0.001) were identified as independent risk factors for septic shock and were further included in the nomogram. The areas under the receiver operator characteristic curve were 0.873 and 0.920 in training and validation sets, respectively. Conclusions: A predictive model for early diagnosis of septic shock in neonates was developed and initially validated in this study, allowing for timely intervention.

Reliability of IL-6 Alone and in Combination for Diagnosis of Late Onset Sepsis: A Systematic Review

Diagnosis of neonatal sepsis is difficult due to nonspecific signs and symptoms. Interleukin-6 (IL-6) is a promising marker for neonatal sepsis. We aimed to test the accuracy of IL-6 in neonates after 72 h of life in case of late onset sepsis (LOS). We searched for studies regarding IL-6 accuracy for the diagnosis of LOS between 1990 and 2020 using the PubMed database. Following study selection, the reported IL-6 sensitivities and specificities ranged between 68% and 100% and 28% and 100%, with median values of 85.7% and 82% and pooled values of 88% and 78% (respectively) in the 15 studies including 1306 infants. Subgroup analysis revealed a better sensitivity (87% vs. 82%), but not specificity (both 86%), in preterm infants compared to term infants or mixed populations. Early sample collection revealed the highest sensitivity (84%), but had the lowest specificity (86%). To assess quality, we used a STARD checklist adapted for septic neonates and the QUADAS criteria. Limitations of this review include the heterogeneous group of studies on the one side and the small number of studies on the other side that analyzed different combinations of biomarkers. We concluded that IL-6 demonstrated good performance especially in the preterm infant population and the best results were achieved by measurements at the time of LOS suspicion.

B-1 derived anti-Thy-1 B cells in old aged mice develop lymphoma/leukemia with high expression of CD11b and Hamp2 that different from TCL1 transgenic mice

Human old aged unmutated chronic lymphocytic leukemia U-CLL are the TCL1+ZAP70+CD5+ B cells. Since CD5 makes the BCR signaling tolerance, ZAP70 increased in U-CLL not only TCL1+ alone. In mice, TCL1 (TCL1A) is the negative from neonate to old aged, as TC-. VH8-12/Vk21-5 is the anti-thymocyte/Thy-1 autoreactive ATA B cell. When ATA μκTg generation in mice, ATA B cells are the neonate generated CD5+ B cells in B-1, and in the middle age, CD5+ can be down or continuously CD5+, then, old aged CLL/lymphoma generation with increased CD11b in TC-ZAP70-CD5- or TC-ZAP70+CD5+. In this old aged TC-ATA B microarray analysis showed most similar to human CLL and U-CLL, and TC-ZAP70+CD5+ showed certain higher present as U-CLL. Original neonate ATA B cells showed with several genes down or further increase in old aged tumor, and old aged T-bet+CD11c+, CTNNB1hi, HMGBhi, CXCR4hi, DPP4hi and decreased miR181b. These old aged increased genes and down miR181b are similar to human CLL. Also, in old age ATA B cell tumor, high CD38++CD44++, increased Ki67+ AID+, and decreased CD180- miR15Olow are similar to U-CLL. In this old aged ATA B, increased TLR7,9 and Wnt10b. TC+Tg generated with ATAμκTg mice occurred middle age tumor as TC+ZAP70-CD5+ or TC+ZAP70+CD5+, with high NF-kB1, TLR4,6 and Wnt5b,6 without increased CD11b. Since neonatal state to age with TC+Tg continuously, middle age CLL/lymphoma generation is not similar to old aged generated, however, some increased in TC+ZAP70+ are similar to the old age TC- ATA B tumor. Then, TC- ATA B old age tumor showed some difference to human CLL. ATA B cells showed CD11b+CD22++, CD24 down, and hepcidin Hamp2++ with iron down. This mouse V8-12 similar to human V2-5, and V2-5 showed several cancers with macrophages/neutrophils generated hepcidin+ ironlow or some showed hepcidin- iron+ with tumor, and mouse V8-12 with different Vk19-17 generate MZ B cells strongly increased macrophage++ in old aged and generated intestine/colon tumor. Conclusion, neonate generated TC-ATA B1 cells in old aged tumor generation are CD11b+ in the leukemia CLL together with lymphoma cancer with hepcidin-related Hamp2++ in B-1 cell generation to control iron.

Early changes in serum interleukin-6 levels in extremely premature newborns for detecting fetal inflammation

BACKGROUND

Fetal inflammatory response syndrome (FIRS) is defined by elevated levels of inflammatory cytokines circulating in fetal blood, which may result in preterm morbidities. Serum interleukin-6 (IL-6) level has been reported to be a good indicator of FIRS; however, changes in IL-6 levels after birth remain to be elucidated. Herein, we characterized early changes in serum IL-6 levels in extremely premature newborns (EPNs, < 28 wks gestation), and then determined the cut-off values for detecting fetal inflammation at each postnatal epoch.

METHODS

In this single-center study, 49 EPNs were retrospectively studied. Serum IL-6 measurements are routinely performed at delivery, 1-3, 6-12, and 24-36 h of life. Receiver operating characteristic (ROC) curve analyses were performed for detecting the presence of funisitis, the histologic counterpart of FIRS.

RESULTS

Overall, serum IL-6 levels were significantly elevated at 1-3 (298 [31-4719] pg/mL) and 6-12 (29 [2-12,635] pg/mL) hours of life, then returned to at-delivery levels at 24-36 h of life. When comparing serum IL-6 levels at each postnatal epoch, the levels at delivery, 1-3, and 6-12 h of life were significantly higher in the EPNs with funisitis. Serum IL-6 cut-off values at delivery, 1-3, 6-12, and 24-36 h of life for the presence of funisitis were 20, 572, 290, and 13 pg/mL with area under ROCs of 0.75, 0.71, 0.68, and 0.53, respectively.

CONCLUSIONS

Serum IL-6 levels in EPNs significantly increase early after birth, then decrease to at-delivery levels by 24-36 h of life. Therefore, postnatal age-dependent cut-off values of serum IL-6 might be considered for detecting fetal inflammation with confirmed funisitis.

Correlation between intrapartum CTG findings and interleukin-6 levels in the umbilical cord arterial blood: A prospective cohort study

OBJECTIVE

to investigate the correlation between the intrapartum CardioTocoGraphic (CTG) findings "suggestive of fetal inflammation" ("SOFI") and the interleukin (IL)-6 level in the umbilical arterial blood.

STUDY DESIGN

prospective cohort study conducted at a tertiary maternity unit and including 447 neonates born at term.

METHODS

IL-6 levels were systematically measured at birth from a sample of blood taken from the umbilical artery. The intrapartum CTG traces were retrospectively reviewed by two experts who were blinded to the postnatal umbilical arterial IL-6 values as well as to the neonatal outcomes. The CTG traces were classified into "suggestive of fetal inflammation (SOFI)" and "no evidence of fetal inflammation (NEFI) according to the principles of physiologic interpretation the CTG traces. The CTG was classified as "SOFI" if there was a persistent fetal heart rate (FHR) increase > 10 % compared with the observed baseline FHR observed at the admission or at the onset of labor without any preceding repetitive decelerations. The occurrence of Composite Adverse Outcome (CAO) was defined as Neonatal Intensive Care Unit (NICU) or Special Care Baby Unit (SCBU) admission due to one or more of the following: metabolic acidaemia, Apgar score at 5 min ≤ 7, need of neonatal resuscitation, respiratory distress, tachypnoea/polypnea, jaundice requiring phototherapy, hypotension, body temperature instability, poor perinatal adaptation, suspected or confirmed early neonatal sepsis.

MAIN OUTCOME MEASURES

To compare the umbilical IL-6 values between the cases with intrapartum CTG traces classified as "SOFI" and those classified as "NEFI"; to assess the correlation of umbilical IL-6 values with the neonatal outcome.

RESULTS

43 (9.6 %) CTG traces were categorized as "SOFI"; IL-6 levels were significantly higher in this group compared with the "NEFI" group (82.0[43.4-325.0] pg/ml vs. 14.5[6.8-32.6] pg/mL; p <.001). The mean FHR baseline assessed 1 h before delivery and the total labor length showed an independent and direct association with the IL-6 levels in the umbilical arterial blood (p <.001 and p = 0.005, respectively). CAO occurred in 33(7.4 %) cases; IL-6 yielded a good prediction of the occurrence of the CAO with an AUC of 0.72 (95 % CI 0.61-0.81).

CONCLUSION

Intrapartum CTG findings classified as "SOFI" are associated with higher levels of IL-6 in the umbilical arterial blood.

Arachidonic and docosahexaenoic acid supplementation and brain maturation in preterm infants; a double blind RCT

BACKGROUND

Arachidonic acid (ARA) and docosahexaenoic acid (DHA) are important structural components of neural cellular membranes and possess anti-inflammatory properties. Very preterm infants are deprived of the enhanced placental supply of these fatty acids, but the benefit of postnatal supplementation on brain development is uncertain. The aim of this study was to test the hypothesis that early enteral supplementation with ARA and DHA in preterm infants improves white matter (WM) microstructure assessed by diffusion-weighted MRI at term equivalent age.

METHODS

In this double-blind, randomized controlled trial, infants born before 29 weeks gestational age were allocated to either 100 mg/kg ARA and 50 mg/kg DHA (ARA:DHA group) or medium chain triglycerides (control). Supplements were started on the second day of life and provided until 36 weeks postmenstrual age. The primary outcome was brain maturation assessed by diffusion tensor imaging (DTI) using Tract-Based Spatial Statistics (TBSS) analysis.

RESULTS

We included 120 infants (60 per group) in the trial; mean (range) gestational age was 26+3 (22+6 - 28+6) weeks and postmenstrual age at scan was 41+3 (39+1 - 47+0) weeks. Ninety-two infants underwent MRI imaging, and of these, 90 had successful T1/T2 weighted MR images and 74 had DTI data of acceptable quality. TBSS did not show significant differences in mean or axial diffusivity between the groups, but demonstrated significantly higher fractional anisotropy in several large WM tracts in the ARA:DHA group, including corpus callosum, the anterior and posterior limb of the internal capsula, inferior occipitofrontal fasciculus, uncinate fasciculus, and the inferior longitudinal fasciculus. Radial diffusivity was also significantly lower in several of the same WM tracts in the ARA:DHA group.

CONCLUSION

This study suggests that supplementation with ARA and DHA at doses matching estimated fetal accretion rates improves WM maturation compared to control treatment, but further studies are needed to ascertain any functional benefit.

CLINICAL TRIAL REGISTRATION

www.

CLINICALTRIALS

gov; ID:NCT03555019.

The Placenta and Neonatal Encephalopathy with a Focus on Hypoxic-Ischemic Encephalopathy

Background: Placental examination is important for its diagnostic immediacy to correlate with maternal and/or fetal complications and parturitional difficulties. In a broader context, clinicopathologic studies of the placenta have addressed a range of pathogenetic questions that have led to conclusive and inconclusive results and interpretations. Methods: Recent standardized morphologic criteria and terminology of placental lesions have facilitated the ability to compare findings from studies that have focused on complications and outcomes of pregnancy. This review is an evaluation of recent studies on placental lesions associated with hypoxic-ischemic encephalopathy (HIE). Conclusion: No apparent consensus exists on whether it is fetal inflammation with the release of cytokines or chronic maternal and/or fetal vascular malperfusion is responsible for HIE with a lowering of the threshold for hypoxic ischemia. The counter argument is that HIE occurs solely as an intrapartum event. Additional investigation is necessary.

Antimicrobial Solutions for Endotracheal Tubes in Prevention of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia is one of the most frequently encountered hospital infections and is an essential issue in the healthcare field. It is usually linked to a high mortality rate and prolonged hospitalization time. There is a lack of treatment, so alternative solutions must be continuously sought. The endotracheal tube is an indwelling device that is a significant culprit for ventilator-associated pneumonia because its surface can be colonized by different types of pathogens, which generate a multispecies biofilm. In the paper, we discuss the definition of ventilator-associated pneumonia, the economic burdens, and its outcomes. Then, we present the latest technological solutions for endotracheal tube surfaces, such as active antimicrobial coatings, passive coatings, and combinatorial methods, with examples from the literature. We end our analysis by identifying the gaps existing in the present research and investigating future possibilities that can decrease ventilator-associated pneumonia cases and improve patient comfort during treatment.

Essential Fatty Acid Supplementation and Early Inflammation in Preterm Infants: Secondary Analysis of a Randomized Clinical Trial

INTRODUCTION

Postnatal inflammation is associated with increased mortality and adverse outcomes in preterm infants. The essential fatty acids arachidonic acid (ARA) and docosahexaenoic acid (DHA) are precursors of lipid mediators with a key role in resolving inflammation. Our aim was to investigate the effect of ARA and DHA supplementation on systemic inflammation in very preterm infants and to identify clinical factors associated with early inflammation.

METHODS

Secondary analysis of data from a randomized clinical trial (ImNuT study). Infants with gestational age (GA) less than 29 weeks were randomized to receive a daily enteral supplement with ARA 100 mg/kg and DHA 50 mg/kg (ARA:DHA group) or MCT oil (control group) from the second day of life to 36 weeks postmenstrual age. ARA, DHA, and four proinflammatory cytokines (IL-1β, IL-6, IL-8, and TNF-α) were analyzed in repeated dried blood samples from birth to day 28 and the area under the curve (AUC) for each variable was calculated.

RESULTS

The intention to treat population included 120 infants with mean (SD) GA 26.4 (1.7). The ARA:DHA group had significantly lower IL-6 levels from day 3 to day 28 compared to the control group, mean difference AUC log10 (95% CI): 0.16 (0.03-0.30) pg/mL, p = 0.018. There was no correlation between ARA or DHA blood concentrations and cytokine levels. Having a low gestational age was independently associated with increased levels of all cytokines during the first 4 weeks of life.

CONCLUSIONS

Enhanced supplementation with ARA and DHA may modulate inflammation in very preterm infants.

Serum YKL-40 as a Potential Biomarker for Sepsis in Term Neonates-A Pilot Study

Although YKL-40 is a promising diagnostic biomarker of sepsis in adults, its value in neonatal sepsis is not known. The study objectives included assessing the levels and diagnostic value of serum YKL-40 in term neonates with sepsis and comparing YKL-40 with other commonly used inflammatory biomarkers. In this pilot case-control study, 45 term neonates (30 septic and 15 non-septic, as controls), 4 to 28 days old, were prospectively studied. The International Pediatric Sepsis Consensus Conference criteria were applied to diagnose sepsis. During the acute phase (admission) and remission of sepsis, blood samples were collected from cases (while from controls they were only collected once) for routine laboratory tests, cultures, and the measurement of serum YKL-40 levels via Elisa. In the acute phase of sepsis, YKL-40 levels were significantly elevated in comparison with remission (p = 0.004) and controls (p = 0.003). YKL-40 levels did not differ significantly between patients in remission and controls (p = 0.431). Upon admission, YKL-40 levels correlated positively with white blood count, absolute neutrophil count, and CRP levels. Via ROC analysis, it was shown that YKL-40 levels upon admission were a significant indicator of sepsis (AUC = 0.771; 95% CI 0.632-0.911; p = 0.003). Serum YKL-40 might be considered as an adjuvant biomarker of sepsis in term neonates.

Biomarkers of cardiovascular disease risk in the neonatal population

The consistently high prevalence of cardiovascular disease (CVD) has urged the need for punctual and effective prevention. Extended research on this specific area has demonstrated the influence of fetal and neonatal periods on the risk of developing CVD in adulthood. Thus, the role of traditional and novel biological markers to the effective screening of CVD among the neonatal population is widely investigated. The objective of the present narrative review is to examine those neonatal biomarkers that may play a role in the development of CVD, to exhibit scientific data that appertain to their association with various perinatal conditions leading to CVD predisposition, and their potential role on prediction and prevention strategies. Multiple biomarkers, traditional and novel, have been mined across the studied literature. Adiposity, insulin resistance, altered lipid profile, inflammation, and endothelial dysfunction seem among the headliners of CVD. Even though various novel molecules have been studied, their clinical utility remains controversial. Therefore, it is quite important for the scientific community to find elements with strong predictive value and practical clinical use.

Serial Measurement of Interleukin-6 Enhances Chance to Exclude Early-Onset Sepsis in Very Preterm Infants

The aim of this retrospective study was to evaluate the reliability of peak interleukin-6 (IL-6) level within 24 hours after delivery as a predictor for early-onset sepsis (EOS) in very preterm neonates. Interleukin-6 was assessed at 2 hours and at 12 to 24 hours after delivery. The highest level was considered a peak value. The definition of EOS was based on positive blood culture and clinical signs of infection or negative blood culture, clinical signs of infection, and C-reactive protein >10 mg/L. Among 445 enrolled infants, 53 developed EOS. A peak IL-6 level of more than 200 ng/L had a sensitivity of 89% and specificity of 77% for the presence of EOS. The negative predictive value was 98%. Receiver operating characteristics curve had area under the curve of 0.92. Peak IL-6 is a reliable marker of systemic inflammatory response and might be useful to exclude EOS within the first 24 hours.

Zinc Supplementation in Preterm Neonates with Late-Onset Sepsis: Is It Beneficial?

OBJECTIVE

Neonatal sepsis (NS) is a serious neonatal disease. The aim of this study was to detect the role of zinc (Zn) supplementation in preterm neonates with late-onset sepsis (LOS).

STUDY DESIGN

A prospective randomized clinical trial study which was done at Tanta University Hospital from August 2016 to March 2018 on 180 preterm neonates with LOS. The studied neonates were divided into two groups: group 1 (90 neonates), which received Zn and antibiotics, and group 2 (90 neonates), which received antibiotics and placebo. In group 1, the neonates received 1.4 mg elemental Zn/kg/d orally for 10 days. Sepsis score, C-reactive protein (CRP), and procalcitonin (PCT) were done for both groups.

RESULTS

As regards sepsis score, it showed that before beginning the treatment, there were 85 and 84 neonates who had high probable sepsis (HPS) in intervention and control groups, respectively, and this revealed nonstatistically significant difference (non-SSD) between both groups (p-value is 0.756) and after 10 days of treatment, there were 1 and 4 neonates who had HPS in intervention and control group, respectively, and this revealed SSD between both groups (p-value is 0.045*). As regards CRP and PCT, the results showed that before beginning the treatment, the mean ± standard deviation (SD) of CRP and PCT were 39.4 ± 10.1 mg/L and 5.2 + 1.8 ng/mL, respectively, in intervention group, while it was 39.6 + 9.9 mg/L and 5.1 + 1.9 ng/mL, respectively, in control group and this revealed non-SSD between both groups (p-value is 0.893 and 0.717, respectively) and after 10 days of treatment, the mean ± SD of CRP and PCT were 5.3 ± 1.8 mg/L and 0.39 ± 0.13 ng/mL, respectively, in intervention group and 6.1 + 2 mg/L and 0.61 + 0.22 ng/mL, respectively, in control group and this revealed SSD between both groups (p-value is 0.008* and 0.044*, respectively).

CONCLUSION

Zn supplementation in preterm neonates with LOS is beneficial in improving the clinical and laboratory finding.

RECOMMENDATION

Zn supplementation for preterm neonates with LOS.

KEY POINTS

· NS is a serious neonatal disease.. · Preterm neonates are more liable to infections.. · Zn supplementation in preterm neonates with LOS is beneficial in improving the condition..

[Clinical features of severe meconium aspiration syndrome (MAS) and early predicting factors for severe MAS in neonates with meconium-stained amniotic fluid]

OBJECTIVES

To study the clinical features of severe meconium aspiration syndrome (MAS) and early predicting factors for the development of severe MAS in neonates with meconium-stained amniotic fluid (MSAF).

METHODS

A total of 295 neonates who were hospitalized due to Ⅲ° MSAF from January 2018 to December 2019 were enrolled as subjects. The neonates were classified to a non-MAS group (n=199), a mild/moderate MAS group (n=77), and a severe MAS group (n=19). A retrospective analysis was performed for general clinical data, blood gas parameters, infection indicators, and perinatal clinical data of the mother. The respiratory support regimens after birth were compared among the three groups. The receiver operating characteristic (ROC) curve and multivariate logistic regression analysis were used to investigate predicting factors for the development of severe MAS in neonates with MSAF.

RESULTS

Among the 295 neonates with MSAF, 32.5% (96/295) experienced MAS, among whom 20% (19/96) had severe MAS. Compared with the mild/moderate MAS group and the non-MAS group, the severe MAS group had a significantly lower 5-minute Apgar score (P<0.05) and a significantly higher blood lactate level in the umbilical artery (P<0.05). Compared with the non-MAS group, the severe MAS group had a significantly higher level of interleukin-6 (IL-6) in peripheral blood at 1 hour after birth (P<0.017). In the severe MAS group, 79% (15/19) of the neonates were born inactive, among whom 13 underwent meconium suctioning, and 100% of the neonates started to receive mechanical ventilation within 24 hours. Peripheral blood IL-6 >39.02 pg/mL and white blood cell count (WBC) >30.345×109/L at 1 hour after birth were early predicting indicators for severe MAS in neonates with MSAF (P<0.05).

CONCLUSIONS

Meconium suctioning cannot completely prevent the onset of severe MAS in neonates with MSAF. The neonates with severe MAS may develop severe respiratory distress and require mechanical ventilation early after birth. Close monitoring of blood lactate in the umbilical artery and peripheral blood IL-6 and WBC at 1 hour after birth may help with early prediction of the development and severity of MAS.

Diagnosis of Neonatal Sepsis: The Role of Inflammatory Markers

This is a narrative review on the role of biomarkers in the diagnosis of neonatal sepsis. We describe the difficulties to obtain standardized definitions in neonatal sepsis and discuss the limitations of published evidence of cut-off values and their sensitivities and specificities. Maternal risk factors influence the results of inflammatory markers as do gestational age, the time of sampling, the use of either cord blood or neonatal peripheral blood, and some non-infectious causes. Current evidence suggests that the use of promising diagnostic markers such as CD11b, CD64, IL-6, IL-8, PCT, and CRP, either alone or in combination, might enable clinicians discontinuing antibiotics confidently within 24-48 h. However, none of the current diagnostic markers is sensitive and specific enough to support the decision of withholding antibiotic treatment without considering clinical findings. It therefore seems to be justified that antibiotics are often initiated in ill term and especially preterm infants. Early markers like IL-6 and later markers like CRP are helpful in the diagnosis of neonatal sepsis considering the clinical aspect of the neonate, the gestational age, maternal risk factors and the time (age of the neonate regarding early-onset sepsis) of blood sampling.

Reliability of Interleukin-6 Alone and in Combination for Diagnosis of Early Onset Neonatal Sepsis: Systematic Review

Neonatal sepsis is a major cause of morbidity and mortality in both preterm and term infants. Early-onset neonatal sepsis (EONS) presents within the first 72 h of life. Diagnosis is difficult as signs and symptoms are non-specific, and inflammatory markers are widely used to confirm or rule out neonatal sepsis. Interleukin-6 (IL-6) is part of the fetal inflammatory response syndrome (FIRS) and therefore an interesting early marker for neonatal sepsis. The main objective for this review was to assess the diagnostic potential of IL-6, alone and in combination, for diagnosis of early neonatal sepsis (EONS) in term and preterm infants, in cord and peripheral blood, and in dependence of timing of sample collection. IL-6 diagnostic accuracy studies for diagnosing EONS published between 1990 and 2020 were retrieved using the PubMed database. We included 31 out of 204 articles evaluating the potential of IL-6 for the diagnosis of EONS in a study population of newborns with culture-proven and/or clinically suspected sepsis. We excluded articles dealing with neonatal bacterial infections other than sepsis and biomarkers other than inflammatory markers, those written in languages other than English or German, studies that did not distinguish between EONS and late-onset sepsis, and animal and in vitro studies. Full-text articles were checked for other relevant studies according to the PRISMA criteria. We identified 31 studies on IL-6 diagnostic accuracy for EONS diagnosis between 1990 and 2020 including a total of 3,276 infants. Sensitivity and specificity were reported, and subgroup analysis was performed. A STARD checklist adapted for neonates with neonatal sepsis was used for quality assessment. The range of IL-6 sensitivity and specificity in neonatal samples was 42.1-100% and 43-100%; the median values were 83 and 83.3%, respectively. IL-6 accuracy was better in preterm infants than in mixed-study populations. Early sample collection at the time of sepsis suspicion had the highest sensitivity when compared to other time points. Cord blood IL-6 had higher diagnostic value compared to peripheral blood. The biomarker combination of IL-6 and CRP was found to be highly sensitive, but poorly specific. Limitations of this review include use of only one database and inclusion of a heterogeneous group of studies and a small number of studies looking at biomarker combinations; a strength of this review is its focus on early-onset sepsis, since type of sepsis was identified as a significant source of heterogeneity in IL-6 diagnostic accuracy studies. We concluded that IL-6 has a good performance as an early diagnostic marker of EONS within a study population of preterm infants, with best results for cord blood IL-6 using cutoff values above 30 pg/ml.

Biomarkers for the Diagnosis of Neonatal Sepsis

Neonatal sepsis is a major cause of morbidity and mortality in neonates and is challenging to diagnose. Infants manifest nonspecific clinical signs in response to sepsis; these signs may be caused by noninfectious conditions. Time to antibiotics affects neonatal sepsis outcome, so clinicians need to identify and treat neonates with sepsis expeditiously. Clinicians use serum biomarkers to measure inflammation and infection and assess the infant's risk of sepsis. However, current biomarkers lack sufficient sensitivity or specificity to be consider useful diagnostic tools. Continued research to identify novel biomarkers as well as novel ways of measuring them is sorely needed.

Creating and validating a DNA methylation-based proxy for interleukin-6

Background

Studies evaluating the relationship between chronic inflammation and cognitive functioning have produced heterogeneous results. A potential reason for this is the variability of inflammatory mediators which could lead to misclassifications of individuals’ persisting levels of inflammation. DNA methylation (DNAm) has shown utility in indexing environmental exposures and could be leveraged to provide proxy signatures of chronic inflammation.

Method

We conducted an elastic net regression of interleukin-6 (IL-6) in a cohort of 875 older adults (Lothian Birth Cohort 1936; mean age: 70 years) to develop a DNAm-based predictor. The predictor was tested in an independent cohort (Generation Scotland; N = 7028 [417 with measured IL-6], mean age: 51 years).

Results

A weighted score from 35 CpG sites optimally predicted IL-6 in the independent test set (Generation Scotland; R² = 4.4%, p = 2.1 × 10⁻⁵). In the independent test cohort, both measured IL-6 and the DNAm proxy increased with age (serum IL-6: n = 417, β = 0.02, SE = 0.004, p = 1.3 × 10⁻⁷; DNAm IL-6 score: N = 7028, β = 0.02, SE = 0.0009, p < 2 × 10⁻¹⁶). Serum IL-6 did not associate with cognitive ability (n = 417, β = −0.06, SE = 0.05, p = .19); however, an inverse association was identified between the DNAm score and cognitive functioning (N = 7028, β = −0.16, SE = 0.02, p_FDR < 2 × 10⁻¹⁶).

Conclusions

These results suggest methylation-based predictors can be used as proxies for inflammatory markers, potentially allowing for further insight into the relationship between inflammation and pertinent health outcomes.

MicroRNAs miR-4535 and miR-1915-5p in amniotic fluid as predictive biomarkers for chorioamnionitis

Background:

This study was performed to investigate the clinical significance of miR-4535 and miR-1915-5p in severe chorioamnionitis.

Materials & methods:

Amniotic fluid samples from 37 patients with severe chorioamnionitis were subjected to miRNA array analysis and ddPCR™. Diagnostic values were assessed using the receiver operating characteristic curve. The patients were separated into three groups according to Blanc’s criteria.

Results:

The expression of miR-4535 and miR-1915-5p was significantly correlated with the copy number of 16S rDNA, had extremely high diagnostic accuracy for severe chorioamnionitis, and was linked to maternal and fetal inflammation.

Conclusion:

miR-4535 and miR-1915-5p serve as promising biomarkers for the diagnosis of severe chorioamnionitis.

Chorioamnionitis and fetal inflammatory response syndrome, which is linked to chorioamnionitis, are considered serious diseases in perinatal care. In this study, miR-4535 and miR-1915-5p are recognized as promising biomarkers for the diagnosis of chorioamnionitis before delivery. In particular, the increased expression of miR-4535 in amniotic fluid is expected to be regarded as a positive indicator for fetal inflammatory response syndrome, and the elevated expression of miR-4535 in serum is also considered to predictively diagnose intrauterine infection in pregnancy. Our results highlight that further studies should explore the underlying clinical significance of miR-4535 and miR-1915-5p.

Procalcitonin in Preterm Neonates: A Different Threshold and Prolonged Interpretation

Objectives: To evaluate the positive threshold of PCT for neonates of <32 weeks of gestation for the diagnosis of early-onset sepsis and to determine if the level of PCT collected within 6 h of life could be used. Design: Retrospective and bicentric study from May 2016 to April 2018. Setting: Two groups were established, neonates evaluated for PCT at birth (CordPCT) and within 6 h of life (delPCT). Patients: Two hundred and sixty neonates of <32 weeks of gestation born in Nice and South Paris (Bicêtre) University Hospitals, had been evaluated for PCT level. Main Outcomes Measures: The value of the PCT positive threshold was determined for the total population and each groups thanks ROC curves. Results: The threshold level of PCT for the total population was 0.98 ng/mL. The threshold value of cordPCT group was 1.00 vs. 0.98 ng/mL for delPCT group. The area under the Receiver Operating Characteristics curve for PCT sampled in delPCT group was significantly higher than in cordPCT group (0.94 compared to 0.75). Conclusions: The threshold level of PCT was higher in this cohort of neonates of <32 weeks of gestation compared to the value generally described for term neonates. The secondary sampling PCT level seems to be usable in screening algorithm for early-onset neonatal sepsis.

Relevance of Biomarkers Currently in Use or Research for Practical Diagnosis Approach of Neonatal Early-Onset Sepsis

Neonatal early-onset sepsis (EOS) is defined as an invasive infection that occurs in the first 72 h of life. The incidence of EOS varies from 0.5–2% live births in developed countries, up to 9.8% live births in low resource settings, generating a high mortality rate, especially in extremely low birth weight neonates. Clinical signs are nonspecific, leading to a late diagnosis and high mortality. Currently, there are several markers used for sepsis evaluation, such as hematological indices, acute phase reactants, cytokines, which by themselves do not show acceptable sensitivity and specificity for the diagnosis of EOS in neonates. Newer and more selective markers have surfaced recently, such as presepsin and endocan, but they are currently only in the experimental research stages. This comprehensive review article is based on the role of biomarkers currently in use or in the research phase from a basic, translational, and clinical viewpoint that helps us to improve the quality of neonatal early-onset sepsis diagnosis and management.

Expression of interleukin-6 (IL-6), signal transducer and activator of transcription-3 (STAT-3) and telomerase in choriocarcinomas

Abstract

Blastocyst implantation and neoplastic invasion have some common properties related to tissue invasion, mediated by various cytokines.

Aim

To compare the expression of IL-6, STAT-3 and telomerase in material of abortions in the first trimester of pregnancy, at term placentas and in choriocarcinomas.

Methods

Immunohistochemical reactions were performed on formalin fixed and included in paraffin samples from 3 groups: abortions, normal at term placentas and choriocarcinomas. Western Blot and Real-Time PCR assays were performed on fresh material from BeWo cell line and in primary culture cells of normal placenta.

Results

Immunohistochemical reactions: IL-6 expression was moderate in the first trimester abortion samples and high in at term placentas and choriocarcinomas. STAT-3 was strongly positive in all groups. Telomerase expression was absent in normal at term placentas but was increased in BeWo cells.

Conclusion

IL-6 and STAT-3 are present in the invasion process of the normal placental development and they are maintained during the malignant transformation to choriocarcinoma. The intense telomerase expression observed in BeWo cells was strongly associated with the malignant phenotype, confirming it as a good marker for cell transformation and tumor progression.

The value of interleukin-6 (IL-6) within 6 hours after birth in the prompt diagnosis of early-onset neonatal sepsis

BACKGROUND

To investigate the value of interleukin-6 (IL-6) for neonates within 6 hours after birth in the prompt diagnosis of early-onset neonatal sepsis (EONS).

METHODS

The clinical and laboratory data of 129 neonates in the neonatal intensive care unit (NICU) of our center from March 31, 2017, to February 29, 2020, were retrospectively analyzed. These patients were divided into two groups on their disease conditions: the EONS group (n=66) and the healthy control group (n=63). All enrolled patients were born in our hospital's Obstetrics Department and were admitted to the NICU within 2 hours after birth. The first session of the blood test was conducted within 4-6 hours after birth for the measurements of IL-6, C-reactive protein (CRP1), serum amyloid A1 (SAA1), and serum immunoglobulin M (IgM). The second session of the blood test was performed 12-24 hours after birth for procalcitonin (PCT), CRP2, and SAA2. All the tests were completed in our clinical laboratory. The non-parametric test (Mann-Whitney U test) was used to compare all parameters between these two groups. The receiver operating characteristic (ROC) curves were drawn to compare the diagnostic sensitivities and specificities. The pairwise comparisons of the ROC curves were on the MedCalc18.2.1 software. A P value of <0.05 was considered statistically significant.

RESULTS

Gender, birth weight, and gestational age were matched between the EONS group and the control group (all P>0.05). The differences of IL-6, CRP2, PCT, and SAA2 were statistically significant between these two groups (all P<0.05), while there was no significant difference in CRP1, SAA1, and IgM (all P>0.05). The area under the ROC curve (AUC) is 1 (95% CI: 0.918-1.000), 1 (95% CI: 0.918-1.000), 1 (95% CI: 0.918-1.000), and 0.977 (95% CI: 0.878-0.999), respectively, for IL-6, CRP2, PCT, and SAA2. Pairwise comparisons among four biomarkers showed the diagnostic specificity and sensitivity of IL-6 were not significantly different from those of CRP2, PCT, and SAA2 (all P>0.05).

CONCLUSIONS

IL-6 is a quick and independent diagnostic biomarker for EONS, and its sensitivity and specificity are inferior to the conventional inflammation markers, including CRP, PCT, and SAA.

Clinical values of common biomarkers for efficacy monitoring of antibiotics in early-onset neonatal sepsis

BACKGROUND

To investigate the clinical values of the common biomarkers including blood routine (B-Rt), C-reactive protein (CRP), serum amyloid A (SAA) and procalcitonin (PCT) for efficacy monitoring of antibiotics in early-onset neonatal sepsis (EONS).

METHODS

The clinical and laboratory data of 78 neonates with confirmed EONS in the neonatal intensive care unit (NICU) of our center from July 1, 2019 to June 30, 2020 were retrospectively analyzed. All the subjects were treated with cefotiam (50 mg/kg q12h) and augmentin (30 mg/kg q12h) within 12 hours after birth. Blood samples were collected 0-12 hours after birth for blood culture, measurements of B-Rt, CRP and SAA. Subsequently, blood sampling was performed at intervals of 12-24, 24-48, 48-96, and 96-144 hours for measurements of B-Rt, CRP, SAA and PCT. Statistical analyses were performed in the SPSS 20.0 software package. P value of <0.05 was considered statistically significant.

RESULTS

WBC count showed no significant change among different intervals (12-24, 24-48, 48-96, and 96-144 hours); in contrast, NEU%, CRP, SAA and PCT significantly differed across all intervals. SAA had sensitivities of 75.86%, 93.1%, 44.83%, and 3.45%, respectively; specificities of 100% across all intervals; and AUCs of 0.879 (P<0.0001), 0.966 (P<0.0001), 0.724 (P<0.0001), and 0.500, respectively (P=1). PCT had sensitivities of 100%, 100%, 79.31%, and 51.72%, respectively; specificities of 100% across all intervals; and AUCs of 1 (P<0.0001), 1 (P<0.0001), 0.793 (P<0.0001), and 0.517 (P>0.8551), respectively.

CONCLUSIONS

WBC count, NEU% and CRP showed no clinical significance for any intervals for efficacy monitoring of antibiotic treatment. SAA and PCT had similar monitoring values at 12-24 and 24-48 hours. SAA is thus more valuable than PCT for efficacy monitoring of antibiotics at the 48-96 and even at the 96-144 hours intervals in EONS.

H. Smith L, Puttonen H, Fyhr IM, Sävman K, Nilsson AK, Klevebro S. Docosahexaenoic Acid and Arachidonic Acid Levels Are Associated with Early Systemic Inflammation in Extremely Preterm Infants

Fetal and early postnatal inflammation have been associated with increased morbidity in extremely preterm infants. This study aimed to demonstrate if postpartum levels of docosahexaenoic acid (DHA) and arachidonic acid (AA) were associated with early inflammation. In a cohort of 90 extremely preterm infants, DHA and AA in cord blood, on the first postnatal day and on postnatal day 7 were examined in relation to early systemic inflammation, defined as elevated C-reactive protein (CRP) and/or interleukin-6 (IL-6) within 72 h from birth, with or without positive blood culture. Median serum level of DHA was 0.5 mol% (95% CI (confidence interval) 0.2–0.9, P = 0.006) lower than the first postnatal day in infants with early systemic inflammation, compared to infants without signs of inflammation, whereas levels of AA were not statistically different between infants with and without signs of inflammation. In cord blood, lower serum levels of both DHA (correlation coefficient −0.40; P = 0.010) and AA (correlation coefficient −0.54; p < 0.001) correlated with higher levels of IL-6. Levels of DHA or AA did not differ between infants with and without histological signs of chorioamnionitis or fetal inflammation. In conclusion, serum levels of DHA at birth were associated with the inflammatory response during the early postnatal period in extremely preterm infants.

Antibiotics, Inflammation, and Preterm Labor: A Missed Conclusion

Regarding the risk of antibiotic therapy during pregnancy, any medication given to the mother should be according to the indications due to the risk of possible side effects. Antibiotics are one of the most important groups of these medications to be considered. Along with direct antibiotic-induced side effects, indirect pathways also affect the fetus through the maternal changes. According to the data, different cytokines including interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-α (TNF-α) are involved in both term and preterm parturition. These cytokines could trigger expression of different substances such as prostaglandins (PGs), their receptors, and PGs synthetizing molecules with already proven roles in parturition. Moreover, IL-1, IL-6, and TNF-α knocked-out mice have delayed parturition and lower levels of PGs compared to the wild types. The earlier-mentioned cytokines are able to induce matrix metalloproteinases and are also involved in parturition. Certain antibiotics have been shown capable of inducing inflammation cascade directly. Both in-vivo and in-vitro studies in human have also demonstrated this inflammation as elevated levels of inflammatory cytokines especially IL-1, IL-6, and TNF-α. This increase has been observed both in the presence and the absence of lipopolysaccharide (LPS). Moreover, antibiotics can induce endotoxemia in healthy cases which finally leads to the pro-inflammatory cytokine release. Regarding the role of mentioned pro-inflammatory cytokines in both term and preterm parturition, it seems that non-indicated use of antibiotics during pregnancy may increase the risk of preterm labor.

Oropharyngeal Colostrum Positively Modulates the Inflammatory Response in Preterm Neonates

During the first days of life, premature infants have physiological difficulties swallowing, thereby missing out on the benefits of breastfeeding. The aim of this study is to assess the effects of oropharyngeal mother’s milk administration in the inflammatory signaling of extremely premature infants. Neonates (n = 100) (<32 week’s gestation and/or <1500 g) were divided into two groups: mother’s milk group (n = 48), receiving 0.2 mL of oropharyngeal mother’s milk every 4 h for the first 15 days of life, and a control group (n = 52), not receiving oropharyngeal mother’s milk. Serum concentrations of interleukin (IL) IL-6, IL-8, IL-10, IL-1ra, tumor necrosis factor alpha (TNF-α), and interferón gamma (IFN-γ) were assessed at 1, 3, 15, and 30 days of postnatal life. Maternal and neonatal outcomes were collected. The rate of common neonatal morbidities in both groups was similar. The mother’s milk group achieved full enteral feeding earlier, and showed a decrease in Il-6 on days 15 and 30, in IL-8 on day 30, and in TNF-α and INF-γ on day 15, as well as an increase in IL-1ra on days 3 and 15 and in IL-10 on day 30. Oropharyngeal mother’s milk administration for 15 days decreases the pro-inflammatory state of preterm neonates and provides full enteral nutrition earlier, which could have a positive influence on the development of the immune system and inflammatory response, thereby positively influencing other developmental outcomes.

Interleukin-6 elevation in healthy neonates

OBJECTIVE

This study aimed to identify peripartum and neonatal factors associated with elevated Interleukin-6 levels in the cord blood of neonates without clinical signs of an infection.

STUDY DESIGN

We conducted a prospective single-center study with healthy term and preterm neonates between March and November 2017. We investigated correlations between 21 peripartum factors and neonatal IL-6 concentrations.

RESULTS

Four hundred and seventy-one infants (GA: 32.9-42.3 weeks) were included. The risk for elevated neonatal IL-6 levels was 3.1 to 4.5-fold increased in the presence of either peripartum maternal temperature >37.5 °C (p = 0.012), duration of labor >12 h (p < 0.001), vaginal delivery (p < 0.001), or neonatal neutrophils >8 × 10⁹ cells/L (p < 0.001).

CONCLUSION

The results indicate that a considerable number of neonates with elevated IL-6 levels can sufficiently cope with an exposition to substantial perinatal stress or intrauterine inflammation and do not require postnatal antibiotic treatment.

Fetal Inflammatory Response Syndrome and Cerebral Oxygenation During Immediate Postnatal Transition in Preterm Neonates

Introduction: Fetal inflammatory response syndrome (FIRS), defined as elevated umbilical cord blood interleukin-6 (IL-6) values > 11 pg/ml, is associated with an increased risk of neonatal morbidity and mortality. The primary aim of the present study was to evaluate a potential influence of FIRS on cerebral oxygen saturation (crSO2) and fractional tissue oxygen extraction (cFTOE) during immediate postnatal transition in preterm neonates. The secondary aim was to analyze the potential influence of FIRS on cerebral injury and mortality. Methods: Secondary outcome parameters of prospective observational studies were analyzed. Preterm neonates with measured IL-6 values from umbilical cord blood and cerebral near-infrared spectroscopy (NIRS) measurements during immediate transition after birth were included. Preterm neonates with FIRS (FIRS group) were matched 1:1 for gestational age (± 1 week) to preterm neonates without FIRS (non-FIRS group). crSO2, cFTOE, arterial oxygen saturation (SpO2), heart rate (HR), and fraction of inspired oxygen (FiO2) were compared between both groups. In addition, cerebral injury and mortality were compared between both groups. Results: A total of 46 preterm neonates were included. Twenty-three neonates in the FIRS group [median gestational age 32.1 (IQR 30.3-33.0) weeks; median IL-6 19.7 (IQR 12.2-37.0) pg/ml] were compared to 23 neonates in the non-FIRS group [gestational age: 32.0 (30.4-33.1) weeks; IL-6: 5.4 (3.0-6.7) pg/ml]. cFTOE showed significantly lower values within the first 4 min and a trend toward lower values in minute 5 after birth in the FIRS group. There were no significant differences in crSO2 within the first 15 min after birth between the two groups. SpO2 was significantly lower in minutes 5 and 6 and HR was significantly lower in minutes 2 and 4 after birth in the FIRS group compared to the non-FIRS group. Survival without cerebral injury was similar in both groups. Conclusion: In preterm neonates with FIRS the crSO2 was similar despite significantly lower cFTOE values during the first minutes after birth. This observation may be a result of compromised oxygen consumption and delivery in the first minutes after birth in neonates with FIRS.

The fetal inflammation response syndrome and adverse neonatal outcomes: a meta-analysis

Background: The clinical performance of fetal inflammatory response syndrome (FIRS) is often atypical. The aim of this meta-analysis is to investigate whether FIRS is associated with adverse neonatal outcomes.Methods: PubMed, Embase, and Cochrane Library were used in this study. The adverse neonatal outcomes data including neonatal early-onset sepsis (EOS), bronchopulmonary dysplasia (BPD), periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH), respiratory distress syndrome (RDS), and neonatal death were collected to make analysis.Results: A total of 10 articles (1116 patients) were included in this study. Compared to the non-FIRS group, the FIRS group was associated with higher incidence of adverse neonatal outcomes, such as EOS (RR = 3.10, 95% CI: 1.26, 7.65; p=.014), BPD (RR = 5.93, 95% CI = 4.35, 8,08; p < .001), IVH (RR = 4.89, 95% CI = 2.96, 8.08; p < .001), PVL (RR = 3.32, 95% CI: 1.73, 6.40; p < .001), RDS (2.35, 95% CI = 1.67, 3.31; p < .001), and the neonatal death (RR = 7.04, 95% CI: 3.34, 14.85; p < .001).Conclusions: The FIRS is associated with higher incidence of adverse neonatal outcomes, and is a risk factor of severe neonatal morbidity or death.

Prenatal infection with Mycoplasma pulmonis in rats exaggerates the angiotensin II pressor response in adult offspring

Exposure to different stressors in utero is linked to adult diseases such as obesity and hypertension. In this study, the impact of prenatal infection (PNI) on adult body weight and cardiovascular function was evaluated using a naturally occurring rodent pathogen, Mycoplasma pulmonis (MP). Pregnant Sprague-Dawley rats were infected with MP on gestational day 14 and gave birth naturally. Adult PNI offspring weighed more than controls, but resting mean arterial pressure (MAP) was unchanged. Subcutaneous injection of angiotensin II (10 μg/kg) elicited a rise in MAP that was greater in both male and female PNI offspring compared with controls (P < 0.03). The accompanying reflex bradycardia was similar to the controls, suggesting that PNI induced baroreflex dysfunction. Subcutaneous nicotine administration, a potent cardiorespiratory stimulus, also elicited a transient rise in MAP that was generally greater in the PNI group, but the change in MAP from baseline was only significant in the PNI females compared with controls (P < 0.03). Elevated body weight and cardiovascular reactivity in the PNI offspring was associated with an increase in the ratio of hypothalamic corticotrophin-releasing hormone receptors type 1 to type 2 gene expression in both sexes compared with controls. These findings support previous studies demonstrating that PNI induces alterations in cardiovascular function and body weight. Yet, unlike previous studies utilizing other models of PNI (e.g., endotoxin), MP PNI did not induce resting hypertension. Thus, our study provides a foundation for future studies evaluating the cardiovascular risks of offspring exposed to microbial challenges in utero.

Necrotizing enterocolitis: It's not all in the gut

Necrotizing enterocolitis is the leading cause of death due to gastrointestinal disease in preterm neonates, affecting 5–12% of neonates born at a very-low birth weight. Necrotizing enterocolitis can present with a slow and insidious onset, with some neonates displaying early symptoms such as feeding intolerance. Treatment during the early stages includes bowel rest and careful use of antibiotics, but surgery is required if pneumoperitoneum and intestinal perforation occur. Mortality rates among neonates requiring surgery are estimated to be 20–30%, mandating the development of non-invasive and reliable biomarkers to predict necrotizing enterocolitis before the onset of clinical signs. Such biomarkers would allow at-risk neonates to receive maximal preventative therapies such as careful nutritional consideration, probiotics, and increased skin-to-skin care.

Impact statement

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease; its high mortality rate mandates the development of non-invasive biomarkers to predict NEC before its onset. This review summarizes the pathogenesis, prevention, unresolved issues, and long-term outcomes of NEC.

Inflammatory markers in systemic lupus erythematosus

While systemic lupus erythematosus (SLE) is an autoantibody and immune complex disease by nature, most of its organ manifestations are in fact inflammatory. SLE activity scores thus heavily rely on assessing inflammation in the various organs. This focus on clinical items demonstrates that routine laboratory markers of inflammation are still limited in their impact. The erythrocyte sedimentation rate (ESR) is used, but represents a rather crude overall measure. Anemia and diminished serum albumin play a role in estimating inflammatory activity, but both are reflecting more than one mechanism, and the association with inflammation is complex. C-reactive protein (CRP) is a better marker for infections than for SLE activity, where there is only a limited association, and procalcitonin (PCT) is also mainly used for detecting severe bacterial infection. Of the cytokines directly induced by immune complexes, type I interferons, interleukin-18 (IL-18) and tumor necrosis factor (TNF) are correlated with inflammatory disease activity. Still, precise and timely measurement is an issue, which is why they are not currently used for routine purposes. While somewhat more robust in the assays, IL-18 binding protein (IL-18BP) and soluble TNF-receptor 2 (TNF-R2), which are related to the respective cytokines, have not yet made it into clinical routine. The same is true for several chemokines that are increased with activity and relatively easy to measure, but still experimental parameters. In the urine, proteinuria leads and is essential for assessing kidney involvement, but may also result from damage. Similar to the situation in serum and plasma, several cytokines and chemokines perform reasonably well in scientific studies, but are not routine parameters. Cellular elements in the urine are more difficult to assess in the routine laboratory, where sufficient routine is not always available. Therefore, the analysis of urinary T cells may have potential for better monitoring renal inflammation.

Ghrelin ameliorates the phenotype of newborn rats induced with mild necrotizing enterocolitis

BACKGROUND

We have shown previously that an attenuated rodent model of mild necrotizing enterocolitis (NEC) increases intestinal histopathological severity grade, prevents typical developmental increases in the high-frequency spectrum of heart rate variability (HF-HRV), alters the nitrergic myenteric phenotype, and increases IL-6 and IL-1β when combined with anterior subdiaphragmatic vagotomy. The aims of the present study were to test the hypotheses that in mild NEC-induced pups, administration of the orexigenic hormone ghrelin (a) reduces the histopathological score, (b) increases the HF-HRV power, (c) improves the altered myenteric phenotype, and (d) subdiaphragmatic vagotomy prevents the effects of ghrelin.

METHODS

Newborn Sprague Dawley rats were subjected to seven days of brief periods of cold stress and hypoxia to induce mild NEC with or without anterior subdiaphragmatic vagotomy. HRV was measured at postnatal days one, five, and ten; intraperitoneal ghrelin (0.05 mg kg^-1 ) was administered postnatal days five through ten b.i.d. Pups were sacrificed at day 12, and whole brains, gastrointestinal tissues, and blood were collected for immunohistochemical, corticosterone, and cytokine analysis.

KEY RESULTS

Ghrelin treatment reduced the intestinal histopathological score, increased the HF-HRV power, improved the altered intestinal myenteric phenotype, and subdiaphragmatic vagotomy prevented the effects of ghrelin. There were no differences in serum cytokines or corticosterone between groups.

CONCLUSIONS AND INFERENCES

Our data suggest that ghrelin administration is able to recover the mild NEC-induced changes to the histology, HF-HRV, and myenteric phenotype in a vagally dependent manner.

Antimicrobial polymer modifications to reduce microbial bioburden on endotracheal tubes and ventilator associated pneumonia

Hospital associated infections (HAIs), infections acquired by patients during care in a hospital, remain a prevalent issue in the healthcare field. These infections often occur with the use of indwelling medical devices, such as endotracheal tubes (ETTs), that can result in ventilator-associated pneumonia (VAP). When examining the various routes of infection, VAP is associated with the highest incidence, rate of morbidity, and economic burden. Although ETTs are essential for the survival of patients requiring mechanical ventilation, their use comes with complications. The presence of an ETT in the airway impairs physiological host defense mechanisms for clearance of pathogens and provides a platform for oropharynx microorganism transport to the sterile tracheobronchial network. Antibiotics are administered to treat lower respiratory infections; however, they are not always effective and consequently can result in increased antibiotic resistance. Prophylactic approaches by altering the surface of ETTs to prevent the establishment and growth of bacteria have exhibited promising results. In addition, passive surface modifications that prevent bacterial establishment and growth, or active coatings that possess a bactericidal effect have also proven effective. In this review we aim to highlight the importance of preventing biofilm establishment on indwelling medical devices, focusing on ETTs. We will investigate successful antimicrobial modifications to ETTs and the future avenues that will ultimately decrease HAIs and improve patient care. STATEMENT OF SIGNIFICANCE: Infections that occur with indwelling medicals devices remain a constant concern in the medical field and can result in hospital-acquired infections. Specifically, ventilator associated pneumonia (VAP) occurs with the use of an endotracheal tube (ETT). Infections often require use of antibiotics and can result in patient mortality. Our review includes a summary of the recent collective work of antimicrobial ETT modifications and potential avenues for further investigations in an effort to reduce VAP associated with ETTs. Polymer modifications with antibacterial nature have been developed and tested; however, a focus on ETTs is lacking and clinical availability of new antimicrobial ETT devices is limited. Our collective work shows the successful and prospective applications to the surfaces of ETTs that can support researchers and physicians to create safer medical devices.

Associations between maternal plasma measurements of inflammatory markers and urinary levels of phenols and parabens during pregnancy: A repeated measures study

BACKGROUND

Maternal immune system regulation is critical for maintenance of a healthy pregnancy and fetal development. Exposure to phenols and parabens is widespread, and may be linked to systemic inflammation and alteration of circulating immunological biomarkers.

OBJECTIVE

We sought to characterize associations between repeated measures of individual urinary phenols, parabens and plasma inflammatory markers across pregnancy.

METHODS

In the LIFECODES prospective birth cohort, we conducted a nested preterm birth case-control study, including 130 cases and 352 controls. In urine samples collected from each participant at up to four study visits during pregnancy, we measured concentrations of six phenols and four parabens, as well as five plasma inflammatory markers. We used multivariable linear mixed models to analyze repeated measures of exposures on inflammatory markers. We created and applied inverse probability weights to account for the sampling approach.

RESULTS

We observed bidirectional associations between select phenols and parabens and inflammatory markers. An interquartile range increase in triclosan (55.2 ng/mL) was associated with a 12.5% (95% CI: 3.67, 22.0) increase in C-reactive protein, a 7.95% (95% CI: 1.95, 14.3) increase in interleukin 10, and a 7.93% (95% CI: 3.82, 12,2) increase in tumor necrosis factor-α. Additionally, an interquartile range increase in 2,5-dichlorophenol (11.0 ng/mL) was associated with a 10% increase in C-reactive protein (95% CI: 1.92, 18.7). Conversely, an interquartile range increase in ethyl paraben (10.4 ng/mL) was associated with a 7.7% decrease in interleukin‑1β (95% CI: -14.1, -0.86).

CONCLUSIONS

Our findings can be organized into two thematic frameworks, one where concentrations of urinary phenols and parabens during pregnancy reflected a pro-inflammatory relationship with immunological biomarkers, and the other contrary theme - an anti-inflammatory relationship. These findings have implications for fetal development and reproductive outcomes, and emphasize the need for further research on immunological mechanisms of phenol and paraben action during pregnancy.

Inflammatory and Immune Proteins in Umbilical Cord Blood: Association with Hearing Screening Test Failure in Preterm Neonates

Objective

We aimed to determine whether elevated levels of various inflammatory and immune proteins in umbilical cord blood are associated with an increased risk of newborn hearing screening (NHS) test failure in preterm neonates.

Methods

This retrospective cohort study included 127 premature singleton infants who were born at ≤33.6 weeks. Umbilical cord plasma at birth was assayed for interleukin (IL)-6, complement C3a and C5a, matrix metalloproteinase (MMP)-9, macrophage colony-stimulating factor (M-CSF), and endostatin levels using ELISA kits. Neonatal blood C-reactive protein (CRP) levels were measured within 2 hours of birth. The primary outcome measure was a uni- or bilateral refer result on an NHS test. Univariate and multivariate analyses were applied.

Results

Fifteen (11.8%) infants failed the NHS test. In the univariate analyses, high IL-6 and low C3a levels in umbilical cord plasma, funisitis, and an elevated CRP level (>5 mg/L) in the immediate postnatal period were significantly associated with NHS test failure. However, the levels of umbilical cord plasma MMP-9, C5a, M-CSF, and endostatin were not significantly different between infants who passed and those who failed the NHS test. Multiple logistic regression analyses indicated that elevated umbilical cord plasma C3a levels were independently associated with a reduced risk of NHS test failure, whereas elevated levels of umbilical cord plasma IL-6 and high CRP levels in the immediate postnatal period were significantly associated with NHS test failure.

Conclusions

Our data demonstrated that in preterm neonates, a systemic fetal inflammatory response reflected by umbilical cord plasma IL-6 and immediate postnatal CRP levels may contribute to the risk for NHS test failure, whereas the changes in complement activation fragments initiated in utero may have protective effect of hearing screen failure.

Plasma proteome changes in cord blood samples from preterm infants

OBJECTIVE

In the presented study, we aimed to systematically analyze plasma proteomes in cord blood samples from preterm infants stratified by their gestational age to identify proteins and related malfunctioning pathways at birth, possibly contributing to the complications observed among preterm infants.

STUDY DESIGN

Preterm newborns were enrolled of three subgroups with different gestation age: newborns born ≤26 (group 1), between 27 and 28 (group 2) and between 29 and 30 (group 3) weeks of gestation, respectively, and compared to the control group of healthy, full-term newborns in respect to their plasma proteome composition.

RESULT

Preterm delivery is associated with multiple protein abundance changes in plasma related to a plethora of processes, including inflammation and immunomodulation, coagulation, and complement activation as some key features.

CONCLUSION

Plasma proteome analysis revealed numerous gestation-age-dependent protein abundance differences between term and preterm infants, which highlight key dysregulated pathways and potential new protein treatment targets.

Preclinical testing of a broad-spectrum antimicrobial endotracheal tube coated with an innate immune synthetic mimic

Background

Endotracheal tubes provide an abiotic surface on which bacteria and fungi form biofilms, and the release of endotoxins and planktonic organisms can cause damaging inflammation and infections.

Objectives

Ceragenins are small molecule mimics of antimicrobial peptides with broad-spectrum antibacterial and antifungal activity, and a ceragenin may be used to provide antimicrobial protection to the abiotic surface of an endotracheal tube.

Methods

A hydrogel film, containing CSA-131, was generated on endotracheal tubes. Elution of CSA-131 was quantified in drip-flow and static systems, antifungal and antibacterial activity was measured with repeated inoculation in growth media, biofilm formation was observed through electron microscopy, safety was determined by intubation of pigs with coated and uncoated endotracheal tubes.

Results

Optimized coatings containing CSA-131 provided controlled elution of CSA-131, with concentrations released of less than 1 μg/mL. The eluting ceragenin prevented fungal and bacterial colonization of coated endotracheal tubes for extended periods, while uncoated tubes were colonized by bacteria and fungi. Coated tubes were well tolerated in intubated pigs.

Conclusions

Thin films containing CSA-131 provide protection against microbial colonization of endotracheal tubes. This protection prevents fungal and bacterial biofilm formation on the tubes and reduces endotoxin associated with tubes. This coating is well suited for decreasing the adverse effects of intubation associated with infection and inflammation.

The role of the maternal and fetal inflammatory response in retinopathy of prematurity

PROBLEM

There is a paucity of research on the contribution of placental inflammation to severe retinopathy of prematurity (ROP).

METHOD OF STUDY

A retrospective cohort study (n = 1217) was conducted of infants screened for ROP (2006-2016). The outcomes of the study were severe ROP (type 1 or type 2 ROP) and low grade ROP. We categorized the placental pathology as the presence of (i) maternal plus fetal inflammatory response, (ii) maternal inflammatory response only, (iii) fetal inflammatory response only and, (iv) no evidence of a maternal or fetal inflammatory response. The data were analyzed using univariate and multivariate logistic regression analyses (P < .05).

RESULTS

In this cohort, the number of infants with the maternal plus fetal inflammatory response, the maternal inflammatory response only, the fetal inflammatory response only, and no maternal or fetal inflammatory response was 305 (25%), 82 (7%), 8 (1%), and 822 (67%), respectively. Adjusted for covariates, the maternal plus fetal inflammatory response was a significant risk factor for severe ROP (AOR = 2.6, 95% CI 1.1-5.9, P = .03). None of the categories of placental inflammation were significantly associated with low grade ROP.

CONCLUSION

Placental pathology distinguished by the maternal plus fetal inflammatory response was a significant risk factor for severe ROP. Our study supports a link between intrauterine inflammatory events and the subsequent development of severe ROP.

Periodontal disease and intra-amniotic complications in women with preterm prelabor rupture of membranes

OBJECTIVE

Periodontal disease is frequently suggested as a possible causal factor for preterm delivery. The link between periodontal disease and preterm delivery is a possible translocation of periopathogenic bacteria to the placenta and amniotic fluid as well as a systemic response to this chronic inflammatory disease. However, there is a lack of information on whether there is an association between clinical periodontal status in women with preterm prelabor rupture of membranes (PPROM) and the presence of microbial invasion of the amniotic cavity (MIAC) and intra-amniotic inflammation (IAI). Therefore, the main aim of this study was to evaluate the incidence and severity of periodontal disease in women with PPROM. The secondary aim was to characterize an association between periodontal status and the presence of intra-amniotic PPROM complications (MIAC and/or IAI).

MATERIALS AND METHODS

Seventy-eight women with PPROM at gestational ages between 24 + 0 and 36 + 6 weeks were included in this study. The samples of amniotic fluid were obtained at admission via transabdominal amniocentesis, and amniotic fluid interleukin (IL)-6 concentrations were determined using a point-of-care test. All women had a full-mouth recording to determine the periodontal and oral hygiene status. Probing pocket depth and clinical attachment loss were measured at four sites on each fully erupted tooth.

RESULTS

In total, 45% (35/78) of women with PPROM had periodontal disease. Mild, moderate, and severe periodontal disease was present in 19% (15/78), 19% (15/78), and 6% (5/78) of women, respectively. The presence of MIAC and IAI was found in 28% (22/78) and 26% (20/78) of women, respectively. Periopathogenic bacteria (2 × Streptococcus intermedius and 1 × Fusobacterium nucleatum) was found in the amniotic fluid of 4% (3/78) of women. There were no differences in periodontal status between women with MIAC and/or IAI and women without these intra-amniotic complications.

CONCLUSIONS

The presence of MIAC and IAI was not related to the periodontal status of women with PPROM.

Urinary Levels of IL-1β and GDNF in Preterm Neonates as Potential Biomarkers of Motor Development: A Prospective Study

Objectives. To evaluate the association between inflammatory biomarkers, neurotrophic factors, birth conditions, and the presence of motor development abnormalities in preterm neonates. Methods. Plasma and urinary levels of cytokines (IL-1β, IL-6, IL-10, TNF, and IL-12p70), chemokines (CXCL8/IL-8, CCL2/MCP-1, CCL5/RANTES, CXCL10/IP-10, and CXCL9/MIG), and neurotrophic factors (BDNF and GDNF) were evaluated in 40 preterm neonates born between 28 and 32 incomplete weeks of gestation, at four distinct time points: at birth (umbilical cord blood) (T0), at 48 (T1), at 72 hours (T2), and at 3 weeks after birth (T3). Biomarkers levels were compared between different time points and then associated with Test of Infant Motor Performance (TIMP) percentiles. Results. Maternal age, plasma, and urinary concentrations of inflammatory molecules and neurotrophic factors were significantly different between groups with normal versus lower than expected motor development. Higher levels of GDNF were found in the group with lower than expected motor development, while IL-1β and CXCL8/IL-8 values were higher in the group with typical motor development. Conclusion. Measurements of cytokines and neurotrophic factors in spot urine may be useful in the follow-up of motor development in preterm neonates.

Epstein-Barr virus-induced gene 3 (EBI3) can mediate IL-6 trans-signaling

Epstein-Barr virus-induced gene 3 (EBI3) is a subunit of the composite cytokines IL-27 and IL-35. Both have beneficial functions or effects in models of infectious and autoimmune diseases. This suggests that administration of EBI3 could be therapeutically useful by binding free p28 and p35 to generate IL-27 and IL-35. IL-27- and IL-35-independent functions of EBI3 could compromise its therapeutic uses. We therefore assessed the effects of EBI3 on cytokine receptor-expressing cells. We observed that EBI3 activates STAT3 and induces the proliferation of the IL-6-dependent B9 mouse plasmacytoma cell line. Analyses using blocking mAbs and Ba/F3 transfectants expressing gp130 indicate that EBI3 activity was linked to its capacity to mediate IL-6 trans-signaling, albeit less efficiently than soluble IL-6Rα. In line with this interpretation, co-immunoprecipitation and SPR experiments indicated that EBI3 binds IL-6. An important pro-inflammatory function of IL-6 trans-signaling is to activate blood vessel endothelial cells. We observed that EBI3 in combination with IL-6 could induce the expression of chemokines by human venal endothelial cells. Our results indicate that EBI3 can promote pro-inflammatory IL-6 functions by mediating trans-signaling. These unexpected observations suggest that use of EBI3 as a therapeutic biologic for autoimmune diseases will likely require co-administration of soluble gp130 to prevent the side effects associated with IL-6 trans-signaling. Together with previous studies that demonstrated activation of IL-6R by p28 (IL-30), new findings further suggest a complex interrelation between IL-27 and IL-6.

Biomarkers for the diagnosis of neonatal sepsis and necrotizing enterocolitis: Clinical practice guidelines

Sepsis and necrotizing enterocolitis are major contributors to morbidity and mortality in neonates, especially in those born preterm. While therapeutic interventions are available for both (for e.g. antibiotics), a major dilemma is early diagnosis so that these interventions can be done in a timely manner. As clinical evaluation alone is unreliable in identifying infants in the early stages of neonatal sepsis or necrotizing enterocolitis, there is a need to find specific biomarkers associated with these conditions to improve diagnostic capabilities. Optimal use of biomarkers in the identification and management of affected neonates requires an understanding of the properties of each marker within the timeline of the inflammatory response. We propose that early- and mid-phase markers such as neutrophil CD64 and procalcitonin should be combined with the late-phase biomarker C-reactive protein for maximal diagnostic benefit. Appropriately powered trials evaluating the serial measurements of these markers in decisions related to antibiotic stewardship in the neonatal population are indicated, in addition to more studies investigating other potentially useful biomarkers.

Improved survival after induction of sepsis by cecal slurry in PD-1 knockout murine neonates

BACKGROUND

Sepsis and the ensuing immune dysfunction continue to be major contributors to neonatal morbidity and mortality. Neonatal sepsis also is associated with profound immune dysfunction. We have recently identified a role for a family of coinhibitory molecules that are altered in murine sepsis and in critically ill adult patients, which may be a target for development of novel therapies. There is, however, a paucity of data pertaining to the role of coinhibitory checkpoint proteins in the control and modulation of neonatal sepsis.

METHODS

The cecal slurry model consists of harvesting the cecal content of an adult, wild-type, male mouse and combining it with 5% dextrose to create a cecal slurry with a concentration of 80 mg/mL (LD₇₀ at 7 days). Neonatal mice (5-7 days of age) underwent intraperitoneal injection of the cecal slurry or 0.9% saline for the sham procedure. Wild-type (C57BL/6) or PD-1^-/- mice were used; a 7-day survival study was undertaken. Cytometric bead array was used for cytokine expression. Blood and peritoneal fluid was cultured for bacterial burden. Flow cytometry was used to assess the peritoneal cavity cell populations.

RESULTS

There was no mortality after the sham procedure in either wild-type or PD-1^-/- pups. PD-1 markedly affected sepsis survival with significantly improved survival in the PD-1^-/- pups (40% vs 80%; P < .01). This survival improvement was not associated with any difference in bacterial clearance. The bacterial burden was equivalent between wild-type and PD-1^-/- pups at 24 hours after cecal slurry. However, PD-1^-/- pups did display an increased circulating cytokine response to the cecal slurry compared with wild type, with increased expression of IL-6, IL-10, and TNF-α levels. Within the peritoneal cavity, sepsis induced an influx of neutrophils, a finding that was increased in PD-1^-/- pups. Although the T-cell response was unaffected by PD-1, it was noted that cecal slurry induced a loss of peritoneal B cells in WT, while the peritoneal B-cell population was preserved in PD-1^-/- pups.

CONCLUSION

Our data suggest that the checkpoint protein, PD-1, plays an important role in controlling the immune response to sepsis in the neonate, ultimately affecting sepsis-related mortality in this neonatal murine model of sepsis. Akin to adult studies, these data further emphasize the potential therapeutic target for PD-1 across a spectrum of septic patients.