Two-Year Outcomes After Minimally Invasive Surfactant Therapy in Preterm Infants: Follow-Up of the OPTIMIST-A Randomized Clinical Trial

Importance

The long-term effects of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome remain to be definitively clarified.

Objective

To examine the effect of MIST on death or neurodevelopmental disability (NDD) at 2 years' corrected age.

Design, Setting, and Participants

Follow-up study of a randomized clinical trial with blinding of clinicians and outcome assessors conducted in 33 tertiary-level neonatal intensive care units in 11 countries. The trial included 486 infants with a gestational age of 25 to 28 weeks supported with continuous positive airway pressure (CPAP). Collection of follow-up data at 2 years' corrected age was completed on December 9, 2022.

Interventions

Infants assigned to MIST (n = 242) received exogenous surfactant (200 mg/kg poractant alfa) via a thin catheter; those assigned to the control group (n = 244) received sham treatment.

Main Outcomes and Measures

The key secondary outcome of death or moderate to severe NDD was assessed at 2 years' corrected age. Other secondary outcomes included components of this composite outcome, as well as hospitalizations for respiratory illness and parent-reported wheezing or breathing difficulty in the first 2 years.

Results

Among the 486 infants randomized, 453 had follow-up data available (median gestation, 27.3 weeks; 228 females [50.3%]); data on the key secondary outcome were available in 434 infants. Death or NDD occurred in 78 infants (36.3%) in the MIST group and 79 (36.1%) in the control group (risk difference, 0% [95% CI, -7.6% to 7.7%]; relative risk [RR], 1.0 [95% CI, 0.81-1.24]); components of this outcome did not differ significantly between groups. Secondary respiratory outcomes favored the MIST group. Hospitalization with respiratory illness occurred in 49 infants (25.1%) in the MIST group vs 78 (38.2%) in the control group (RR, 0.66 [95% CI, 0.54-0.81]) and parent-reported wheezing or breathing difficulty in 73 (40.6%) vs 104 (53.6%), respectively (RR, 0.76 [95% CI, 0.63-0.90]).

Conclusions and Relevance

In this follow-up study of a randomized clinical trial of preterm infants with respiratory distress syndrome supported with CPAP, MIST compared with sham treatment did not reduce the incidence of death or NDD by 2 years of age. However, infants who received MIST had lower rates of adverse respiratory outcomes during their first 2 years of life.

Trial Registration

anzctr.org.au Identifier: ACTRN12611000916943.

NRF2 is a potential biomarker for the evaluation of weaning-related oxidative stress in goat kids

Weaning stress is crucial threatening factor in animal breeding. The aim of this study was to investigate the effects of weaning to oxidative stress and stress status of goat kids at the molecular levels. In the study, blood samples were collected at the weaning process (7 days before weaning- Pre-W, Day of weaning- Day-W and 7 days after weaning- Post-W) from 24 healthy Damascus goats. Cortisol, MDA (Malondialdehyde), COX-2 (Cyclooxygenase-2), and NRF2 (Nuclear factor erythroid 2-related factor 2) proteins levels were investigated in plasma, while COX-2 and NRF2 genes expression levels were determined from leukocytes. Compared to Pre-W, COX-2 gene was upregulated almost 2-fold in Day-W. On the other hand, NRF2 gene expression levels were tended to upregulation in Day-W, and it was upregulated approximately 2-fold in Post-W. While MDA levels were gradually increased in the weaning process, the levels of COX-2 and NRF2 proteins showed similar changes with gene expression trends. Positive correlations were also found between cortisol and COX-2 and NRF-2 protein levels in plasma. It was thought that significant outputs gained in terms of MDA levels in plasma of kids at the weaning process. For the first time, determination of COX-2 and NRF2 levels both mRNA and protein levels in the weaning process of goat kids were satisfactorily evaluated in this study. Particularly, NRF2 was found to have the potential to be a fundamental biomarker to assess the oxidative status of weaning kids.

Effect of Minimally Invasive Surfactant Therapy vs Sham Treatment on Death or Bronchopulmonary Dysplasia in Preterm Infants With Respiratory Distress Syndrome: The OPTIMIST-A Randomized Clinical Trial

IMPORTANCE

The benefits of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome are uncertain.

OBJECTIVE

To examine the effect of selective application of MIST at a low fraction of inspired oxygen threshold on survival without bronchopulmonary dysplasia (BPD).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial including 485 preterm infants with a gestational age of 25 to 28 weeks who were supported with continuous positive airway pressure (CPAP) and required a fraction of inspired oxygen of 0.30 or greater within 6 hours of birth. The trial was conducted at 33 tertiary-level neonatal intensive care units around the world, with blinding of the clinicians and outcome assessors. Enrollment took place between December 16, 2011, and March 26, 2020; follow-up was completed on December 2, 2020.

INTERVENTIONS

Infants were randomized to the MIST group (n = 241) and received exogenous surfactant (200 mg/kg of poractant alfa) via a thin catheter or to the control group (n = 244) and received a sham (control) treatment; CPAP was continued thereafter in both groups unless specified intubation criteria were met.

MAIN OUTCOMES AND MEASURES

The primary outcome was the composite of death or physiological BPD assessed at 36 weeks' postmenstrual age. The components of the primary outcome (death prior to 36 weeks' postmenstrual age and BPD at 36 weeks' postmenstrual age) also were considered separately.

RESULTS

Among the 485 infants randomized (median gestational age, 27.3 weeks; 241 [49.7%] female), all completed follow-up. Death or BPD occurred in 105 infants (43.6%) in the MIST group and 121 (49.6%) in the control group (risk difference [RD], -6.3% [95% CI, -14.2% to 1.6%]; relative risk [RR], 0.87 [95% CI, 0.74 to 1.03]; P = .10). Incidence of death before 36 weeks' postmenstrual age did not differ significantly between groups (24 [10.0%] in MIST vs 19 [7.8%] in control; RD, 2.1% [95% CI, -3.6% to 7.8%]; RR, 1.27 [95% CI, 0.63 to 2.57]; P = .51), but incidence of BPD in survivors to 36 weeks' postmenstrual age was lower in the MIST group (81/217 [37.3%] vs 102/225 [45.3%] in the control group; RD, -7.8% [95% CI, -14.9% to -0.7%]; RR, 0.83 [95% CI, 0.70 to 0.98]; P = .03). Serious adverse events occurred in 10.3% of infants in the MIST group and 11.1% in the control group.

CONCLUSIONS AND RELEVANCE

Among preterm infants with respiratory distress syndrome supported with CPAP, minimally invasive surfactant therapy compared with sham (control) treatment did not significantly reduce the incidence of the composite outcome of death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age. However, given the statistical uncertainty reflected in the 95% CI, a clinically important effect cannot be excluded.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12611000916943.

Mesenteric tissue oxygenation status on the development of necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is an important cause of morbidity and mortality in preterm infants. There is limited data about the role of mesenteric oxygenation status during the first enteral feeding. Therefore, the aim of this study was to determine the mesenteric tissue oxygen saturation values before, during and after the first enteral feeding and to evaluate the effect of these values on the development of NEC in preterm infants.

METHODS

A total of 105 preterm babies with ≤ 32 gestational weeks were included in this prospective study. The continuous monitoring of the mesenteric tissue oxygenation status was performed before, during and 3 hours after the first feeding by near-infrared spectroscopy (NIRS).

RESULTS

The mean gestational week and birth weight of the study group were 28.8±2.1 weeks, and 1215±387 g, respectively. The first enteral feeding was started at 2.4±1.4 days with breast milk in 85% of infants. A total of 12 infants (11.4%) developed NEC (66% stage II, 34% stage III). The mean mesenteric tissue oxygen saturation levels of the infants that developed NEC were significantly lower both before and one hour after feeding (56.1±3.4 vs. 34±8.8, and 47.4±3.3 vs 37.8±10.9, respectively) compared with infants that did not develop NEC.

CONCLUSIONS

Lower mesenteric tissue oxygenation values measured before, and one hour after enteral feeding was associated with NEC development. We suggest that lower mesenteric tissue oxygenation during continuous monitoring of first enteral feeding may be used to predict NEC development during follow-up.

Turkish Neonatal Society Necrotizing Enterocolitis Diagnosis, Treatment and Prevention Guidelines

Necrotizing enterocolitis (NEC) is one of the most common gastrointestinal emergencies in the newborn infant, and the incidence varies between 3% and 15% in neonatal intensive care units (NICU). It has a high risk of mortality and both short- and long-term morbidity which severely impacts the quality of life in the survivors. Lack of specific clinical and laboratory findings makes early diagnosis difficult for the clinician and sometimes results in overtreatment for feeding intolerance which is quite frequent in preterms and can easily be confused with NEC. The fact that there are many definitions and presentations of NEC even complicates the management. This review aims to summarize the guideline of the Turkish Neonatal Society for diagnosis, treatment, and prevention of NEC for the clinician taking care of preterms. Etiopathogenesis and various clinical pictures of NEC, as well as diagnostic methods, are defined. Treatment and prognosis are discussed in detail with reference to current literature and preventive strategies are summarized based on evidence. Finally, the approach to baby presenting with suspected NEC is summarized in an algorithm.

Extremely Preterm Infant Admissions Within the SafeBoosC-III Consortium During the COVID-19 Lockdown

Objective: To evaluate if the number of admitted extremely preterm (EP) infants (born before 28 weeks of gestational age) differed in the neonatal intensive care units (NICUs) of the SafeBoosC-III consortium during the global lockdown when compared to the corresponding time period in 2019. Design: This is a retrospective, observational study. Forty-six out of 79 NICUs (58%) from 17 countries participated. Principal investigators were asked to report the following information: (1) Total number of EP infant admissions to their NICU in the 3 months where the lockdown restrictions were most rigorous during the first phase of the COVID-19 pandemic, (2) Similar EP infant admissions in the corresponding 3 months of 2019, (3) the level of local restrictions during the lockdown period, and (4) the local impact of the COVID-19 lockdown on the everyday life of a pregnant woman. Results: The number of EP infant admissions during the first wave of the COVID-19 pandemic was 428 compared to 457 in the corresponding 3 months in 2019 (-6.6%, 95% CI -18.2 to +7.1%, p = 0.33). There were no statistically significant differences within individual geographic regions and no significant association between the level of lockdown restrictions and difference in the number of EP infant admissions. A post-hoc analysis based on data from the 46 NICUs found a decrease of 10.3%in the total number of NICU admissions (n = 7,499 in 2020 vs. n = 8,362 in 2019). Conclusion: This ad hoc study did not confirm previous reports of a major reduction in the number of extremely pretermbirths during the first phase of the COVID-19 pandemic. Clinical Trial Registration: ClinicalTrial.gov, identifier: NCT04527601 (registered August 26, 2020), https://clinicaltrials.gov/ct2/show/NCT04527601.

Does antenatal magnesium sulphate improve hearing function in premature newborns?

Objective:

Material and Methods:

Results:

Conclusion:

The potential utility of real-time PCR of the 16S-rRNA gene in the diagnosis of neonatal sepsis

İstanbullu K, Köksal N, Çetinkaya M, Özkan H, Yakut T, Karkucak M, Doğan H. The potential utility of real-time PCR of the 16S-rRNA gene in the diagnosis of neonatal sepsis. Turk J Pediatr 2019; 61: 493-499. The purpose of this study was to evaluate the efficacy of real-time polymerase chain reaction (PCR) of the 16S rRNA gene in diagnosis of neonatal sepsis and compare it with conventional blood culture. A total of 150 infants were enrolled in this prospective study. The infants were classified into two groups: sepsis group (n=100) and control group (n=50). Blood samples for complete blood count, C-reactive protein, procalcitonin, serum-amyloid A, blood culture and PCR were obtained before initiating antibiotic treatment. Eight specific probes were used to perform PCR analysis for detection of 8 different microorganisms. The positivity rates of blood culture and PCR were found as 11% and 3%, respectively. The diagnosis of neonatal sepsis by PCR revealed a 16.6 % sensitivity, 97.8 % specificity, 33.3% positive predictive value and 94.8% negative predictive value compared with the blood culture. This study showed a low sensitivity of PCR of the 16S rRNA gene in the diagnosis of neonatal sepsis. This may be associated with the identification of rare microorganisms in the blood culture that were not included to PCR analysis. Implementation of all suspectible microorganisms into PCR assay may increase the sensitivity of 16S rRNA gene PCR in diagnosis of neonatal sepsis.

[Evaluation of Micafungin Use in Children]

Micafungin is recommended especially in patients with liver and kidney failure and in the presence of other side effects due to antifungals apart from its known priority indications such as invasive candidiasis. The aim of this study was to evaluate the children who have received micafungin treatment. In the study, 125 children who were hospitalized in the pediatric wards and intensive care units of our hospital and had used micafungin between November 2016 and January 2019 were analyzed retrospectively. Clinical data, micafungin indication, blood values on the first and fourth days of the treatment, side effects of the drug and efficacy were evaluated. Sixty percent (75/125) of the patients were male and the mean age of all the patients were 58 ± 67 (0-215, 30) months. Approximately half of the cases (48%) had malignancy and 13% of them were premature. Sixty-two percent (n= 37) of the malignencies were hematological (27 acute lymphocytic leukemia, nine acute myeloid leukemia, one myelodysplastic syndrome) and 38% (n= 23) were oncological (six neuroblastoma, four Hodgkin lymphoma, two Non-Hodgkin's lymphoma, five sarcomas, one hepatoblastoma, five others) malignencies. The major cause of hospitalization was sepsis (53%). The patients had several risk factors like immunosuppressive therapy (n= 68, 54%), neutropenia (n= 61, 49%), central venous catheter (n= 102, 82%), nasogastric tube (n= 63, 50%), endotracheal intubation tube (n= 49, 39%), urinary catheter (n= 14, 11%) and total parenteral nutrition (n= 81, 65%). Thirteen percent (n= 16) of the cases were post-operative patients. Candida species were cultivated in 97 clinical specimens (blood, endotracheal aspirate, sputum, urine, etc.) among 23 (18%) of the patients. Thirteen (10%) of the patients had candidemia and 62% of them were non-albicans strains. In all candidemias, strains were echinocandin susceptible, and blood cultures were negative within four days. When all the patients (n= 125) were evaluated, a significant decrease in C-reactive protein, an increase in sodium, and a decrease in alanine aminotransferase were observed on the fourth day of micafungin treatment (p<0.05). A total of 39 (31%) patients underwent various antifungal treatments for median seven (1-60) days prior to micafungin treatment. Fourteen (36%) of these 39 patients, had elevated liver function tests (LFT), 10 (26%) of them had hypokalemia, and five (13%) of them had elevated renal function tests. Ten (26%) patients had antifungal-induced hypokalemia previously; and potassium levels were normalized after micafungin treatment (p= 0.0001). The patients for which micafungin treatment was chosen due to elevated liver function tests (n= 47, 38%), whether the antifungalinduced or not; alanine aminotransferase and aspartate aminotransferase levels were decreased after micafungin treatment (p= 0.0001 and p= 0.0001, respectively). Nineteen (15%) of the patients have died within the first 30 days of micafungin treatment and one of them had candidemia. No micafungin treatment related significant side effects were observed in any of the patients. Our study showed that micafungin could be a safe and effective option in pediatric cases including newborns with high liver and kidney function tests.

The effectiveness of serum amyloid A for prediction of neonatal cholestasis associated with parenteral nutrition in premature infants

Özkan H, Köksal N, Doğan P, Güney-Varal İ, Bağcı O, Özgür T. The effectiveness of serum amyloid A for prediction of neonatal cholestasis associated with parenteral nutrition in premature infants. Turk J Pediatr 2019; 61: 26-33. Parenteral nutrition (PN) has been widely used in premature infants untill enteral feeding can be tolerated. Cholestasis is an important complication of PN. The objective of this study was to evaluate the role of serial measurements of serum amyloid A (SAA) during PN and compare its` effectiveness with C-reactive protein (CRP) and procalcitonin (PCT). We also aimed to determine the risk factors for PN associated cholestasis (PNAC). Premature infants ( < 34 weeks` gestational age) who were started on PN during hospitalization were included in this prospective study. SAA, CRP and PCT levels were measured on days 0, 3, 7, 14, and 21 of PN in all infants. Infants who had PN for less than 2 weeks, who developed sepsis and/or necrotizing enterocolitis were excluded. A total of 85 infants were included. The mean birth weight was 1226±329 g, and the mean gestational age was 29.4±1.8 weeks. The birth weight of infants who developed cholestasis were significantly lower. Enteral nutrition was started significantly later in infants with cholestasis. CRP and PCT did not correlate with conjugated bilirubin levels at any time point. SAA levels on days 7 and 14 showed a significant correlation with conjugated bilirubin levels. SAA levels on day 7 was found to have the highest sensitivity for prediction of PNAC. Low birth weight, late commencement of enteral feeding, and prolonged PN were the main risk factors for PNAC development. This is the first study that shows the predictive value of SAA for PNAC development. We suggest that SAA may be used as an accurate and useful biomarker for prediction of PNAC in high risk premature infants receiving PN.

[Results of the use of micafungin in newborns]

Invasive candidiasis is a common and serious infection in premature newborns. Preventing and treating fungal infections is very important to improve the prognosis of premature infants. Fluconazole and amphotericin B are used as the first choice in the treatment of invasive fungal infections of the newborns. In some cases, fluconazole and amphotericin B cannot be used due to nephrotoxicity, hepatotoxicity or resistant strains. Micafungin, which is among recently developed echinocandins, is the drug of choice in these cases. The use of micafungin in newborns is new and there is a limited experience about the effect of high dose usage in the central nervous system. The aim of this study was to evaluate the electronic files of patients who used micafungin for the treatment of culture-proven or possible invasive fungal infection during their hospital stay in the neonatal intensive care unit during a 24-month period (2016-2017) in the third-level intensive care unit. A total of 15 patients (10 premature and 5 term babies) were included in the study. The mean birth weight of the patients was 1732 ± 999 g and the mean gestational age was 32.2 ± 5.8 weeks. All patients had long-term intensive care and increased risk of invasive candidiasis infection. Central venous catheterization and multiple antibiotics usage were the most common risk factors in these patients. The other risk factors included intubation, total parenteral nutritional use and surgical procedure application. Candida species were isolated from the cultures of four patients. Candida species isolated from patients were Candida albicans, Candida glabrata, Candida catenulata, Candida parapsilosis. The mean time for onset of micafungin was 29.9 ± 16.6 days. Mean duration of micafungin therapy was 22.4 ± 11.2 days. Eight patients received amphotericin B, three patients received fluconazole therapy and four patients did not receive any antifungal therapy before the onset of micafungin. None of these patients had an abnormal kidney or liver function tests due to micafungin use. As a conclusion, high dose (10 mg/kg/day) micafungin is a safe and effective treatment choice both in the treatment of neonatal culture proven or probable invasive candida infections that were caused by refractory Candida strains, and in the case of nephrotoxicity and hepatotoxicity.

Aluminum exposure in premature babies related to total parenteral nutrition and treatments

Aşut E, Köksal N, Dorum BA, Özkan H. Aluminum exposure in premature babies related to total parenteral nutrition and treatments. Turk J Pediatr 2018; 60: 385-391. This study aimed to measure aluminum contamination of parenteral nutrition (PN) solutions and aluminum contents of parenteral products given to newborn infants for nutrition or treatment. In this study, the aluminum content of the first products used to prepare PN solutions for premature neonates, of the final parenteral products prepared therefrom, and of the parenteral drugs frequently used in newborn units was measured using the inductively coupled plasma mass spectrometry. The aluminum contamination of all parenteral nutritional products evaluated, except for one, was detected to be over the recommended doses. Of all the first products analyzed within the scope of the study, trace-element preparation, preparation containing fat-soluble vitamins, 20% dextrose solution, calcium gluconate ampoule and sodium phosphate ampoule indicated high aluminum contamination. The total aluminum content of the prepared final products was identified to be at least 40% higher than the total aluminum content of the ingredients added to the compound. Accordingly, the minimum amount of aluminum content was measured as 233 μg/kg/day in nutrition solutions prepared for a baby weighing 1,000 g. Contamination was detected in 9 of the 18 drugs evaluated. This study indicated that the rate of aluminum exposure of the premature babies receiving parental nutrition is still much higher than the safe doses recommended as 5 µg/kg/day by the FDA. Products with lower aluminum content should be preferred in the care of premature infants.

The effect of early administration of combined multi-strain and multi-species probiotics on gastrointestinal morbidities and mortality in preterm infants: A randomized controlled trial in a tertiary care unit

Güney-Varal İ, Köksal N, Özkan H, Bağcı O, Doğan P. The effect of early administration of combined multi-strain and multi-species probiotics on gastrointestinal morbidities and mortality in preterm infants: A randomized controlled trial in a tertiary care unit. Turk J Pediatr 2017; 59: 13-19. Necrotizing enterocolitis (NEC) is a gastrointestinal emergency of the neonatal period. The aim of this study was to demonstrate the use of multistrain and multispecies probiotic on gastrointestinal morbidities and mortality. The study was organized as a randomized controlled, prospective study in premature infants (≤32 week and ≤1500 gram). The ready commercial preparations which contain multi-combined probiotics of Lactobacillus rhamnosus (4.1x10⁸ cfu) + Lactobacillus casei (8.2x10⁸ cfu) + Lactobacillus plantorum (4.1x10⁸ cfu) + Bifidobacterium animalis (4.1x10⁸ cfu) together with 383 mg of fructooligosaccharides and 100 mg of galactooligosaccharides as the prebiotic content, was administered enterally to the probiotic group (n=70); control group constituted of 40 preterms. Primary outcomes of the present study were ≥ Stage 2 NEC and the mortality. Secondary outcomes were culture-proven sepsis and days to reach full enteral feeding. All cases of NEC were seen in group 2 as 3.6% (n=4) of all infants. The mortality was found to be 1.4% (n=1) in Group 1 and 22.5% (n=9) in Group 2. The incidence of NEC and the mortality rate were found to be significantly lower in Group 1 (p=0.016, p=0.001, respectively). In Group 1, the NEC-related mortality rate and sepsis-related mortality rate were significantly lower than that of the control group (p=0.046, p=0.023). In this study, we showed that using probiotic strains in combined multistrain and multispecies forms at higher doses and for prolonged duration had positive effects on gastrointestinal complications, sepsis and mortality in premature infants.

The role of serial measurements of serum insulin-like growth factor 1 levels in the development of retinopathy of prematurity

AIM

To determine the role of serum insulin-like growth factor-1 levels in the development of retinopathy of prematurity, which is a major cause of childhood blindness worldwide.

MATERIAL AND METHODS

We prospectively studied newborn infants born at a postmenstrual age of <32 weeks and birth weights <1 500 gr, between January 1st, 2015, and December 31st, 2015. A total of 40 infants were enrolled in the study. The retinal examination time was determined in accordance with the American Academy of Pediatrics recommendations for retinopathy of prematurity screening and follow-up. Retinopathy of prematurity was classified according to the international classification of retinopathy of prematurity. Serum Insulin like growth factor 1 levels were measured serially in blood samples on the 1st, 3rd, 7th, 21st, and 28th day.

RESULTS

Among the 40 infants, 11 (27.5%) constituted the retinopathy of prematurity group and 29 comprised the non-retinopathy of prematurity group. In the retinopathy of prematurity group, the mean gestational age and birth weight was significantly lower. The demographic features of the study cohort were similar. The duration of mechanical ventilation was significantly greater in the retinopathy of prematurity group compared with the non-retinopathy of prematurity group (p=0.036). In terms of neonatal morbidities such as respiratory distress syndrome, intraventricular hemorrhage, bronchopulmonary dysplasia, patent ductus arteriosus, and necrotizing enterocolitis, no differences were detected between the groups. The mean serum insulin-like growth factor-1 levels in retinopathy of prematurity group were significantly lower than those in the non-retinopathy of prematurity group at each time point (1st, 3rd, 7th, 21st, and 28th day of postnatal life) (p=0.001).

CONCLUSIONS

This study demonstrated the low serum insulin-like growth factor-1 levels was associated with retinopathy of prematurity development.

Sacrococcygeal Teratoma associated with Trisomy 13

Sacrococcygeal teratoma (SCT) is rarely associated with syndromes. We report a female newborn with a prenatal diagnosis of small sacrococcygeal teratoma and postnatally diagnosed as having trisomy 13. The sacrococcygeal teratoma was excised. It was reported as mature teratoma. The child succumbed to sepsis postoperatively.

Morphology, histology and phylogeny of Henneguya sinova sp. nov. (Myxobolidae: Myxozoa) infecting gills of Parablennius tentacularis in the Black Sea, Turkey

Myxosporeans of the genus Henneguya have a global distribution and infect organs and tissues of both marine and freshwater fishes. Here we describe the morphological, histological and molecular characteristics of Henneguya sinova sp. nov. parasitizing the gill arches of tentacled blenny Parablennius tentacularis (Perciformes: Blenniidae) collected from the coast of Sinop on the Black Sea in Turkey. Several oval whitish plasmodia of different sizes in the gill arches of fish were found. The mature spores were rounded oval in frontal view, with a mean (range) total length 57.5 (51.5-68.0) µm; the spore body was 11.7 (11.3-12.0) µm in length by 7.6 (7.3-8.3) µm in width and 6.7 (6.6-6.8) µm in thickness. The caudal appendages, measuring 46.0 (40.0-55.0) µm in length, were very thin at the tapered end. The prevalence of infection by H. sinova sp. nov. was 35.5%. Phylogenetic analysis of nuclear small subunit ribosomal DNA (SSU rDNA) clearly suggested H. sinova as a new species which is clustered within the marine Henneguya lineage. Pairwise nucleotide similarities and DNA distance values of SSU rDNA between H. sinova sp. nov. and other related Henneguya species also supported this suggestion.

Population structure of rice varieties used in Turkish rice breeding programs determined using simple-sequence repeat and inter-primer binding site-retrotransposon data

Effective breeding programs based on genetic diversity are needed to broaden the genetic basis of rice (Oryza sativa L.) in Turkey. In this study, 81 commercial varieties from seven countries were studied in order to estimate the genomic relationships among them using nine inter-primer binding site (iPBS)-retrotransposon and 17 simple-sequence repeat (SSR) markers. A total of 59 alleles for the SSR markers and 96 bands for the iPBS-retrotransposon markers were detected, with an average of 3.47 and 10.6 per locus, respectively. Each of the varieties could be unequivocally identified by the SSR and iPBS-retrotransposon profiles. The iPBS-retrotransposon- and SSR-based clustering were identical and closely mirrored each other, with a significantly high correlation (r = 0.73). A neighbor-joining cluster based on the combined SSR and iPBS-retrotransposon data divided the rice varieties into three clusters. The population structure was determined using the STRUCTURE software, and three populations (K = 3) were identified among the varieties studied, showing that the diversity harbored by Turkish rice varieties is low. The results indicate that iPBS-retrotransposon markers are a very powerful technique to determine the genetic diversity of rice varieties.

Investigation of vancomycin resistant Enterococcus faecium outbreak in neonatal intensive care unit

Enterococci are one of the major agents of community-acquired and nosocomial infections. In this study we aimed to analyze the clonal relation of the vancomycin-resistant Enterococci outbreak seen at the Neonate Intensive Care Unit (NICU) of Uludag University Hospital. Vancomycin resistance gene was investigated in the Enterococcus faecium strains and pulsed field gel electrophoresis (PFGE) was used to investigate the genetic relation between outbreak strains. Enterococci grown in all patient samples were identified as Enterococcus faecium by BD Phoenix 100 (Becton Dickinson, USA). We found vanA resistance gene in all of the swab samples by Xpert VanA/B test on Cepheid (Cepheid, USA). PFGE band patterns revealed two different strains, of which the majority of them (22/24) had the same clonal origin. The common clonal origin was also isolated from rectal probes. Perianal swab culture positivity was evaluated as colonization but culture growth in two blood cultures, two urine cultures and one wound culture was evaluated as infection and treated with linezolid. All of the patients survived the outbreak. Besides the infection control precautions determining the genetic relation between outbreak strains which can be done in the microbiology laboratory is necessary to control an outbreak. PFGE is a reliable method in the microbiologic analysis of outbreaks. Molecular microbiologic analysis of outbreak strains will contribute to prove the epidemiologic and evolution of outbreaks.

Ratio of neutrophil/lymphocyte and platelet/lymphocyte in patient with ankylosing spondylitis that are treating with anti-TNF

Ankylosing spondylitis (AS) is a type of chronic inflammatory arthritis resulting in ankylosis of the spine and inflammation in the tendons. After NSAIDs, the use of anti-TNF medications has provided a significant contribution to the treatment of patients with AS. The present study was a retrospective, controlled and multicenter study. A total of 105 patients followed in the outpatient clinics of the Department of Physical Therapy in Abant Izzet Baysal University and Harran University and 50 healthy controls were included in the study. The patients had been receiving anti-TNF therapy at least for 6 months. Hemogram results of the patient and control groups examined retrospectively. There was no significant difference between the groups in terms of N/L ratio; however, the P/L ratio was significantly different between the two groups. The present study found a significantly different P/L ratio in patients with AS when compared to the control group. However, the N/L ratio was not significantly different between the groups. The P/L ratio can be used as a marker to monitor disease progression and indicate subclinical inflammation in patients with AS.

Very Low Birth Weight Infant Necessitating Nissen Fundoplication for Weaning off the Mechanical Ventilator

Gastro-esophageal reflux (GER) is one of the common problems of neonatal intensive care units. Although this condition does not always need to be treated, it occasionally causes clinically serious consequences. Initial management is medical; however, in some cases surgery might be required. A premature neonate with birth weight of 1370 grams was managed in our ICU. The patient was mechanical ventilator dependent due to GER. The patient needed Nissen fundoplication for successfully weaning off the ventilator.

A new scoring system for evaluation of multiple organ dysfunction syndrome in premature infants

BACKGROUND

The Neonatal Multiple Organ Dysfunction (NEO-MOD) scoring system is used to predict mortality in infants with multiple organ dysfunction syndrome (MODS). The NEOMOD scoring system was extended to include involvement of the microvascular system. This modified scoring system was developed to enable more accurate and earlier diagnosis of MODS in premature infants.

OBJECTIVE

To evaluate the modified NEOMOD scoring system in preterm infants with MODS and compare its effectiveness with the NEOMOD scoring system.

METHODS

This prospective study was performed in a tertiary neonatal intensive care unit. A total of 198 premature infants were enrolled. Infants were evaluated for development of MODS by using the modified NEOMOD scoring system until discharge or death according to clinical and laboratory findings. Infants who had organ dysfunction in 2 or more organ systems had MODS diagnosed.

RESULTS

In the 160 infants (80.8%) with MODS, the gastrointestinal system, respiratory system, and hematologic system were involved most often. The gastrointestinal system, respiratory system, and acid-base metabolism were involved initially in 99.4%, 86.3%, and 26.3% of infants, respectively. The mean modified NEOMOD score for the infants who died in the first 28 days after birth was significantly higher than the mean score for infants who survived. The number of systems involved was also higher in infants who died.

CONCLUSIONS

The modified NEOMOD scoring system is a safe and accurate tool for determining both mortality rate and dysfunction of multiple organ systems affecting mortality in pre-term infants.

Serum mannose-binding lectin (MBL) gene polymorphism and low MBL levels are associated with neonatal sepsis and pneumonia

OBJECTIVE

The aim of this study was to determine the serum mannose-binding lectin (MBL) levels and the frequency of MBL gene polymorphisms in infants with neonatal sepsis.

STUDY DESIGN

Between January 2008 and January 2010, a total of 93 infants were included in this study and 53 of them had neonatal sepsis diagnosis as study group and 40 infants who had no sepsis according to clinical and laboratory findings as control group.

RESULT

Serum MBL levels were found to be low in 17 of 93 infants. Eleven of them were in the sepsis group and six of them were in the control group. Serum MBL levels were significantly lower in infants with sepsis compared with the control group. Frequencies of genotype AB and BB were also significantly higher in the study group compared with the control group. Most importantly, presence of B allele of MBL exon 1 gene was found to be associated with an increased risk for neonatal sepsis. Additionally, in the study group, the mean serum MBL levels were found to be significantly lower in the premature infants compared with the term infants. Pneumonia, bronchopulmonary dysplasia (BPD) and intraventricular hemorrhage (IVH) were significantly higher in infants with MBL deficiency compared with infants with normal MBL levels.

CONCLUSION

Low MBL levels and presence of B allele of MBL exon 1 gene were found to be important risk factors for development of both neonatal sepsis and pneumonia, especially in premature infants. Low MBL levels and MBL gene polymorphisms might also be associated with inflammation-related neonatal morbidities such as BPD and IVH.