Minimal invasive surfactant therapy in preterm infants with respiratory distress syndrome: a single-center experience

BACKGROUND

Minimal invasive surfactant therapy (MIST) includes the tracheal instillation of surfactant via a thin catheter for the treatment of preterm infants with respiratory distress syndrome (RDS). We aimed to evaluate the impact of MIST compared to intubation, surfactant, extubation (INSURE) technique on respiratory outcomes.

METHODS

A prospectively recruited cohort of preterm infants ≤32 weeks with RDS was compared against a historical cohort of infants treated with INSURE. The primary outcome was the need for mechanical ventilation within 72 hours of age and secondary outcomes the overall need and duration of mechanical ventilation, the development of bronchopulmonary dysplasia, common morbidities, and survival.

RESULTS

Thirty-six infants treated with MIST of 29.1±2.2 weeks' gestation and 1219±238 g birthweight compared against 37 infants of 28.8±2.3 weeks' gestation and 1195±336 g birthweight treated with INSURE. A lower proportion of infants treated with MIST required mechanical ventilation within 72 hours of age compared to those treated with INSURE (11% compared 32%, P=0.042). However, no significant differences were noted regarding the overall intubation incidence, bronchopulmonary dysplasia, other morbidities, or survival.

CONCLUSIONS

In spontaneously breathing infants ≤32 weeks with RDS, the MIST technique was associated with a lower need for intubation within 72 hours of age, but otherwise with no significant differences regarding BPD or other neonatal morbidities.

Are neonatal outcomes of triplet pregnancies different from those of singletons according to gestational age?

OBJECTIVES

Multiple pregnancies sustain the high pace of extreme prematurity. Little evidence is available about triplet gestation given the evolution in their management during the last decades. The aim of the study was to compare the neonatal outcomes of triplets with those of matched singletons in a cohort study.

METHODS

An observational retrospective cohort study of triplets and matched singletons born between 2004 and 2017 matched by gestational age was conducted. Additionally, the investigation performed in regard to data from the overall Greek population of interest. The primary outcome was mortality or severe neonatal morbidity based on pregnancy type.

RESULTS

A total of 237 triplets of 24-36 weeks' gestation and 482 matched singletons were included. No differences in the primary outcome between triplets and singletons were found. Rates of severe neonatal morbidities did not differ significantly between triplets and singletons. A threshold of 1000 gr for birthweight and 28 weeks' gestation for gestational age determined survival on triplets [OR: 0.08 (95% CI: 0.02-0.40, p=0.0020) and OR: 0.13 (95% CI: 0.03-0.57, p=0.0020) for gestational age and birthweight respectively]. In Greece stillbirths in triplets was 8 times higher than that of singletons (OR: 8.5, 95% CI: 6.9-10.5). From 3,375 triplets, 94 were stillborn, whereas in singletons, 4,659 out of 1,388,273. In our center 5 times more triplets than the expected average in Greece were delivered with no significant difference in stillbirths' rates.

CONCLUSIONS

No significant differences were identified in mortality or major neonatal morbidities between triplets and matched singletons highlighting the significance of prematurity and birthweight for these outcomes.

G6PD deficiency and Harilaou variant in a newborn: Intrauterine haemolysis and meconium aspiration syndrome

G6PD deficiency is one of the most commonly inherited enzymopathies with a hallmark of an X-linked pattern. G6PD has more than 300 unique variants with different enzyme activity. The G6PD Mediterranean variant is prevalent in Greece and associated with asymptomatic patients who may experience haemolysis under specific circumstances. G6PD Harilaou is a new variant that was first described in Greece in an eight-year-old boy who suffered chronic haemolysis demanding multiple transfusions. We present a new case of the G6PD Harilaou variant in a Greek male neonate who suffered severe intrauterine haemolysis and passed away 39 hours after birth. To our knowledge, it is the second reported G6PD Harilaou case.

Clinical chorioamnionitis and histologic placental inflammation: association with early-neonatal sepsis

OBJECTIVE

Chorioamnionitis and fetal inflammatory response syndrome (FIRS) are significant risk factors for early onset sepsis (EOS). Recently, the use "Intrauterine Inflammation or Infection or both" or triple I has been proposed, classifying cases into an isolated maternal fever, suspected triple I, or confirmed chorioamnionitis. Evidence suggests that the association between suspected chorioamnionitis and confirmed histological chorioamnionitis (HCA) is not consistent, as well as the impact of HCA on the development of EOS.We aimed to evaluate the association between suspected chorioamnionitis and HCA, the impact of HCA on EOS, and the effect of antepartum antibiotic prophylaxis on EOS.

METHODS

We retrospectively reviewed the medical records of all infants admitted to our institution, between 2017 and 2018, with a diagnosis of chorioamnionitis. We recorded the clinical evidence of chorioamnionitis, the histologic report of the placenta, the maternal and neonatal data, the neonatal inflammatory markers including C-reactive protein (CRP), and the incidence of EOS. The impact of antepartum antibiotic prophylaxis on the infants' CRP and EOS was calculated, and the logistic regression model was performed to estimate the association of confirmed HCA with EOS, while controlling for FIRS stage, gestation age, birth weight, maternal fever, foul-smelling amniotic fluid, and prolonged rupture of membranes.

RESULTS

During the study period, a total of 266 infants were identified; 81 (30%) infants had a confirmed HCA (HCA-present cases), and 185 (70%) infants were diagnosed with suspected triple I (HCA-absent cases). Antepartum antibiotics had been commenced in a significantly higher proportion in HCA-present cases (46%) in comparison to 14% of HCA-absent cases (p < .001). HCA-present infants were of significantly lower gestation (31.6 ± 4weeks versus 33.3 ± 4weeks, p = .004), and birth weight (1826 ± 840 g versus 2092 ± 849 g, p = .019), they had a significantly higher rate of clinical symptoms (31% versus 6%, p < .001), and a higher CRP at birth and 24 h (1.4 ± 1.5 mg/dL versus 0.3 ± 0.2 mg/dL, p < .001, and 2.1 ± 2.3 mg/dL versus 0.4 ± 0.6 mg/dL, p < .001, respectively). All HCA-present cases had evidence of FIRS; 43% were stage I, 25% stage II, and 32% were FIRS stage III. A significantly higher proportion of HCA-present infants were diagnosed with EOS (46% as compared to 6%, p < .001). The antepartum antibiotic administration was related to a significantly lower CRP at birth and 24 h only in HCA-present cases, albeit not with any reduction ιn EOS incidence. HCA was significantly associated with EOS (RR 3.18, 95% CI 2.81-5.18, p < .001). After adjusting for perinatal factors, the presence of HCA (OR 7.89, 95% CI 1.19-23.34, p = .032) and an advanced FIRS stage (OR 10.35, 95% CI 4.23-25.32, p < .001) were significantly associated with EOS.

CONCLUSIONS

Amongst infants with suspected chorioamnionitis, the diagnosis is partially supported by histological confirmation, and that is more prominent in pregnancies of a lower gestation. The presence of HCA and an advanced FIRS stage predispose to an increased risk of EOS after adjusting for other perinatal and neonatal factors. The antepartum prophylaxis against intra-amniotic infection was related to a significantly lower CRP in HCA-present cases.

The Intertemporal Role of Respiratory Support in Improving Neonatal Outcomes: A Narrative Review

Defining improvements in healthcare can be challenging due to the need to assess multiple outcomes and measures. In neonates, although progress in respiratory support has been a key factor in improving survival, the same degree of improvement has not been documented in certain outcomes, such as bronchopulmonary dysplasia. By exploring the evolution of neonatal respiratory care over the last 60 years, this review highlights not only the scientific advances that occurred with the application of invasive mechanical ventilation but also the weakness of the existing knowledge. The contributing role of non-invasive ventilation and less-invasive surfactant administration methods as well as of certain pharmacological therapies is also discussed. Moreover, we analyze the cost-benefit of neonatal care-respiratory support and present future challenges and perspectives.

POS1194 THE EFFECT OF SARS-COV-2 ON THE COURSE AND THE TREATMENT OF RHEUMATIC INFLAMMATORY DISEASES. EXPERIENCE FORM THE NORTHWESTERN GREECE

Background:

COVID-19 has been shown to significantly affect the vulnerable population [1,2]. Among them, patients suffering from inflammatory rheumatic diseases, and especially the immunosuppressed [3].

Objectives:

to assess the effect of SARS-CoV-2 on the course and the treatment of rheumatic inflammatory diseases.

Methods:

from February to December 2020, 46 patients with inflammatory rheumatic diseases were included (32 female) that got infected with the SARS-CoV-2. Mean age was 65 years old, 17 were smokers, 12 had arterial hypertension, 8 diabetes mellitus, and 3 hypothyroidism. Most of them had their comorbidities well-controlled and their rheumatic disease was in remission. More specifically, 24 patients had rheumatoid arthritis, 13 psoriatic arthritis, and 9 ankylosing spondylitis. All patients were under treatment with conventional synthetic (cs) and/or biological (b) disease-modifying anti-rheumatic drugs (DMARDs), while 7 of them were also on treatment with glucocorticoids (GC) (<5mg/day). Twenty-eight patients were on tumor necrosis alpha (TNF-α) inhibitors (19 as monotherapy), 4 on anti- interleukin (IL)-6 monotherapy, 3 on Janus Kinase (JAK) inhibitors plus on low dose methotrexate (MTX), and the rest (11 patients) were on a csDMARD with or without GCs.

Results:

positive patients with the SARS-CoV-2, instructed to discontinue their immunosuppressive treatment, except GCs that were adjusted for their disease. Most patients (37 out of 46) had a mild disease course and their symptomatology was nothing more than a simple flu-like syndrome. Furthermore, on 9 of them olfactory dysfunction and gastrointestinal manifestations as well as low grade fever were noted but without the need of a hospital admission. On the other hand, only 5 patients needed hospitalization (2 on MTX monotherapy and 3 on combination therapy) due to dyspnea with low oxygen saturation (hypoxemia) and high fever. From those 5, 3 had a short in-hospital stay, while 2 developed pneumonia and a longer in-hospital stay was required in order to get the appropriate treatment. None of the patients did not require an intensive care unit admission. Finally, in 14 patients that got infected from February to May 2020, viral antibodies had been measured. All patients had high titres of IgG antibodies in their serum for as long as six months after their infection. Of note, none of the infected patients were smokers.

Conclusion:

patients with rheumatic diseases that are in remission using low doses of GCs and DMARDs, have almost the same chances with the general population to have a serious course of their infection with the SARS-Cov-2. In addition, in these patients, the immune response appears to be adequate, both in the production and maintenance of antibodies, which appear to be maintained for at least 6 months after infection.

References:

[1]Patel JA, Nielsen FBH, Badiani AA, Assi S, Unadkat VA, Patel B, et al. Poverty, inequality and COVID-19: the forgotten vulnerable. Public Health. 2020;183:110-111. Doi: 10.1016/j.puhe.2020.05.006.

[2]Poteat T, Millet GA, Nelson LE, Beyrer C. Understanding COVID-19 risks and vulnerabilities among black communities in America: the lethal force of syndemics. Ann Epidemiol. 2020;47:1-3. Doi: 10.1016/j.annepidem.2020.05.004.

[3]Gianfrancesco MA, Hyrich KL, Gossec L, Strangfeld A, Carmona L, Mateus EF, et al. Rheumatic disease and COVID-19: initial data from the COVID-19 Global Rheumatology Alliance provider registries. Lancet Rheumatol. 2020;2(5):e250-e253. Doi: 10.1016/S2665-9913(20)30095-3.

Disclosure of Interests:

None declared.

Changes in Physicians' Perceptions and Practices on Neonatal Pain Management Over the Past 20 Years. A Survey Conducted at Two Time-Points

Intense research for more than three decades expelled the view that neonates do not experience pain. The aim of this survey was to investigate whether the Greek physicians involved in neonatal intensive care have changed their perceptions regarding neonatal pain, adapting their management practices to the knowledge that have emerged in the past 20-years. This study is a survey conducted at two time-points, 20 years apart. Anonymous questionnaires were distributed to 117 and 145 physicians working in neonatal intensive care units (NICUs) all over Greece in years 2000 and 2019, respectively. The response rate was 90.6 and 80.7% in 2000 and 2019, respectively. All respondents, at both time-points, believed that neonates experience pain, which has serious acute and long-term consequences, while the vast majority considered analgesia-sedation (A-S) during painful interventions as obligatory. Utilization of NICU protocols and pain assessment tools remained low although increased significantly between 2000 and 2019. The use of systemic A-S postoperatively was high at both time-points, while its implementation in infants subjected to prolonged pain, specifically mechanical ventilation, increased significantly by 2019. Systemic or local analgesia for acute procedural pain was used by lower proportions of physicians in 2019, except for the tracheal intubation. In contrast, the use of sweet solutions and non-pharmacological measures prior to or during bedside procedures significantly increased over time. Opioid administration significantly increased, while a shift from morphine to fentanyl was observed. International literature and perinatal-neonatal congresses were stated as the main sources of updating physicians' knowledge and improving management practice on neonatal pain prevention and treatment. In conclusion, Greek NICU-physicians' perceptions that neonates can experience pain with potentially serious acute and long-term consequences remained strong over the past 20 years. Although physicians' practices on neonatal pain management improved, they are still suboptimal, while significant differences exist among centers. Continuing education, globally accepted management protocols, and readily applied pain assessment tools would further improve the management of procedural pain and stress in neonates.

A neonate with intrauterine growth restriction and pseudo-Bartter syndrome due to severe maternal eating disorder: A case report

Maternal diet before and during pregnancy plays an important role for the developing fetus. Any eating disorder in this period can cause transient or/and permanent negative effects on the mother and her offspring.

Epigenetic alterations in Sjögren's syndrome patient saliva

Epigenetic mechanisms have been implicated in the pathogenesis of Sjögren's syndrome (SS). Extensive alterations in DNA methylation have been described in minor salivary gland (MSG) epithelial cells and lymphocytes derived from SS patients compared to sicca controls. In an effort to identify novel potential epigenetic markers that could prove useful in diagnosis and disease monitoring, we explored whether DNA methylation differences can also be detected in saliva from SS patients compared to sicca controls. We performed DNA methylation analysis by methylation-sensitive restriction digestion followed by quantitative real-time polymerase chain reaction of selected genomic loci in saliva samples of 16 SS patients and 10 sicca controls with negative MSG biopsy. We identified reduced DNA methylation of the imprinting control region (ICR) of the H19 locus in SS patient saliva compared to sicca controls. Levels of saliva H19 ICR methylation were negatively correlated with C4 serum complement levels. Consistent with the reduced methylation of the ICR, H19 RNA levels were increased in SS patient peripheral blood mononuclear cells (PBMCs), while no significant change was observed in MSG H19 RNA levels compared to sicca controls. Our findings support that H19 ICR methylation could be a useful molecular epigenetic marker in monitoring patients with SS, highlighting saliva as a valuable biological sample in SS research and clinical practice. The role of H19 in SS pathogenesis remains to be addressed.

The role of thrombospondin-1 in the pathogenesis of antiphospholipid syndrome

OBJECTIVE

Antiphospholipid syndrome (APS) is an acquired thrombophilia characterized by recurrent thrombosis and/or pregnancy morbidity, in the presence of antibodies to β2 glycoprotein-I (β2GPI), prothrombin or Lupus anticoagulant (LA). Anti-β2GPI antibodies recognize complexes of β2GPI dimers with CXCL4 chemokine and activate platelets. Thrombospondin 1 (TSP-1) is secreted by platelets and exhibits prothrombotic and proinflammatory properties. Therefore, we investigated its implication in APS.

METHODS

Plasma from APS patients (n = 100), Systemic Lupus Erythematosus (SLE) (n = 27) and healthy donors (HD) (n = 50) was analyzed for TSP-1, IL-1β, IL-17A and free active TGF-β1 by ELISA. Human Umbilical Vein Endothelial Cells (HUVECs) and HD monocytes were treated with total HD-IgG or anti-β2GPI, β2GPI and CXCL4 and CD4⁺ T-cells were stimulated by monocyte supernatants. TSP-1, IL-1β, IL-17A TGF-β1 levels were quantified by ELISA and Real-Time PCR.

RESULTS

Higher plasma levels of TSP-1 and TGF-β1, which positively correlated each other, were observed in APS but not HDs or SLE patients. Patients with arterial thrombotic events or those undergoing a clinical event had the highest TSP-1 levels. These patients also had detectable IL-1β, IL-17A in their plasma. HD-derived monocytes and HUVECs stimulated with anti-β2GPI-IgG-β2GPI-CXCL4 secreted the highest TSP-1 and IL-1β levels. Supernatants from anti-β2GPI-β2GPI-CXCL4 treated monocytes induced IL-17A expression from CD4⁺ T-cells. Transcript levels followed a similar pattern.

CONCLUSIONS

TSP-1 is probably implicated in the pathogenesis of APS. In vitro cell treatments along with high TSP-1 levels in plasma of APS patients suggest that high TSP-1 levels could mark a prothrombotic state and an underlying inflammatory process.

Customized compared to population-based centiles for detecting term small for gestational age infants in Greece

BACKGROUND

Applying customized centiles may improve the accuracy of detecting small for gestational age (SGA) infants; however, the evidence is inconclusive whether adjusted centiles are more sensitive in identifying infants at increased risk of morbidity. We aimed to examine the validity of customized centiles in a Greek cohort and evaluate their performance compared to population-based centiles in predicting infants at risk of increased morbidity.

METHODS

We prospectively recorded the neonatal and maternal characteristics of singleton, low-risk, term infants over a year. Infants were defined as SGA if their birth weight was under the tenth centile, classified both by population-based centiles and customized centiles, adjusted for maternal and innate factors. We performed a comparative analysis utilizing linear regression analysis and calculating the receiver operating characteristics (ROC) curves.

RESULTS

Overall 657 infants were identified. Population-based centiles detected 42 (6 %) SGA infants, while customized centiles 80 (12 %). Perinatal morbidity was associated with an odds ratio of 1.02 with customized centiles [95 % confidence interval (CI): 1.01-1.04] and with an odds ratio of 1.02 with population-based centiles (95 % CI: 1.02-1.02). In predicting perinatal morbidity, no significant difference was detected between customized centiles [area under the ROC curve 0.773 (95 % CI: 0.699-0.847)] and population-based centiles [area under the ROC curve 0.737 (95 % CI: 0.662-0.813)] (p =0.272).

CONCLUSIONS

Customized centiles provided increased accuracy in comparison to the population-based centiles in detecting SGA term infants. However, customized centiles had no better impact on predicting a poor perinatal outcome. HIPPOKRATIA 2020, 24(3): 133-137.

Evaluation of cerebral oxygenation and perfusion in small for gestational age neonates and neurodevelopmental outcome at 24-36 months of age

Objective To examine cerebral oxygenation and perfusion in small for gestational age (SGA) compared with appropriate for gestational age (AGA) neonates during the first postnatal week, and to investigate any association with neurodevelopmental outcomes at 24-36 months of age. Methods A prospective matched case-control study was conducted evaluating cerebral oxygenation and perfusion, using near-infrared spectroscopy (NIRS), between SGA and AGA neonates, during the first postnatal week. A neurodevelopmental assessment with Bayley-III was performed at 24-36 months of age. Results Forty-eight SGA and 48 AGA neonates of similar gestation (32.8 ± 2.1 vs. 32.5 ± 1.9) were enrolled. On the first postnatal day, the cerebral oxygenation was equal between SGA and AGA neonates (71 ± 7% vs. 72 ± 8%); however, in the subgroup analysis, males had higher oxygenation compared to female SGA neonates (73 ± 7% vs. 69 ± 7%, P = 0.04). Cerebral perfusion was significantly higher in SGA neonates on the first postnatal day (1.4 ± 0.6 vs. 1.1 ± 0.5, P = 0.04), but this difference was diminished on subsequent measurements. There were no significant differences between the SGA and AGA infants regarding the composite cognitive, communication and motor index scores. The length of mechanical ventilation and late-onset sepsis were significant risk factors affecting the cognitive and communication composite index scores, respectively. Conclusion Cerebral oxygenation was equal between SGA and AGA neonates, while cerebral perfusion was transiently increased in SGA neonates during the first postnatal day. There was no significant association of cerebral oxygenation and perfusion with neurodevelopmental outcomes.

Identification of a homozygous deletion of the NEU1 gene in a patient with type II sialidosis presenting isolated fetal ascites and central nervous system hypoplasia

BACKGROUND

Mutation of the NEU1 sialidase gene is the etiology of sialidosis, a storage disorder with a plethora of systemic manifestations ranging from ocular abnormalities, bone pathologies, and ataxia (sialidosis type I) to mental decline and infantile death (sialidosis type II). Non-immune hydrops fetalis and isolated ascites are the most severe forms of sialidosis type II that manifests itself prenatally.

CASE REPORT

For the first time, we report congenital sialidosis with homozygous pathogenic deletion of the entire NEU1 gene in a Greek neonate with hydrops fetalis, isolated ascites, central nervous system hypoplasia, and lethal progression. Genetic characterization of the patient showed one previously unreported deletion in the NEU1 gene.

CONCLUSION

Sialidosis type II should be considered in the differential diagnosis of neonatal hydrops fetalis of no immune causality or isolated fetal ascites. Genetic studying of the patient and the family by carrier detection is crucial to prevent missed diagnoses, while genetic counseling for following pregnancies is imperative. HIPPOKRATIA 2019, 23(4): 169-171.

The association of the cerebral oxygenation during neonatal sepsis with the Bayley-III Scale of Infant and Toddler Development index scores at 18-24 months of age

BACKGROUND

Neonatal sepsis has been associated with poor neurodevelopmental outcome, however the evidence regarding the exact mechanism of the inflammation to the developing neonatal brain are inconclusive.

AIMS

To investigate association between cerebral oxygenation during neonatal sepsis and neurodevelopmental outcome.

STUDY DESIGN

Follow-up assessment of a previously described prospective case-control study.

SUBJECTS

A cohort of late preterm (34-37 weeks' gestation) and preterm (<34 weeks' gestation) infants with sepsis and healthy controls, evaluated at 18-24 months of corrected gestational age with Bayley-III Scales for Infant and Toddler Development (BSID-III).

OUTCOME MEASURES

To evaluate the association between cerebral tissue oxygenation index (cTOI) and fractional tissue oxygen extraction (FTOE), measured with near-infrared spectroscopy, during sepsis and the composite cognitive and motor index scores.

RESULTS

Thirty-one infants with blood culture confirmed neonatal sepsis and thirty-five controls were recruited. The cerebral oxygenation was significantly lower in septic neonates, compared to controls (61 ± 7 compared to 72 ± 5; p < 0.001). Infants with sepsis had significantly lower cognitive and motor index scores and higher proportion of suboptimal cognitive (16% compared to 3%, p = 0.045) and motor (16% compared to none, p = 0.008) index score. The low mean cTOI and FTOE noted in septic infants were significantly associated with worse cognitive and motor composite index scores.

CONCLUSIONS

Infants with lower cerebral oxygenation during neonatal sepsis are at increased risk of worse cognitive and motor scores in the neurodevelopmental assessment.

Early caloric deprivation in preterm infants affects Bayley-III scales performance at 18-24 months of corrected age

BACKGROUND

Adequate nutrition is essential for optimal neurodevelopment to preterm infants. Our aim was to evaluate the impact of caloric deprivation on Bayley-III scales performance at 18-24 months of corrected age, in a cohort of preterm infants.

METHODS

We prospectively enrolled infants with gestational age <30 weeks and birth weight <1500 g. Apart from a whole cohort analysis, we performed a subgroup analysis between infants received inadequate calories (<85 Kcal/kg/day) during the first two weeks of age, compared to a standard nutrition group. All infants underwent a Bayley-III assessment at 18-24 months of corrected age.

RESULTS

From the 63 preterm infants analysed, 25% had caloric deprivation compared to 75% with adequate nutrition. Caloric deprived infants were of lower gestational age and birth weight, and received a lower amount of enteral feeding during the first 14 days of age. There were no differences between the two groups regarding the common neonatal co-morbidities. Caloric deprived infants had significantly lower composite index scores at 18-24 months of corrected age. Caloric deprivation, late onset sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia were significant risk factors of neurodevelopmental impairment.

CONCLUSIONS

Several neonatal factors affect the neurodevelopmental outcome of preterm infants, and nutrition may pose an important role.

Evaluation of Cerebral Oxygenation in Neonates with Sepsis with Near-Infrared Spectroscopy

Objective Neonates with sepsis have increased risk of cerebral injury. Our aim was to evaluate cerebral oxygenation in septic neonates using near-infrared spectroscopy. Study Design A prospective study was designed enrolling neonates with sepsis, as defined by the International Consensus Conference of Pediatric Sepsis criteria and matched controls. Three cerebral half-hourly measurements were performed during the first, third, and seventh day of the episode and the values of tissue oxygenation index (TOI) and fractional tissue oxygen extraction (FTOE) were compared between the two groups. Result The study population consisted of 50 septic and 44 control neonates with similar characteristics. No differences on TOI and FTOE were recorded in the first and third day. However, on the seventh day, septic neonates had significantly decreased oxygenation (62.7 ± 7 vs. 71.4 ± 4.4%, p < 0.001) and increased oxygen extraction (0.35 ± 0.07 vs. 0.27 ± 0.05, p < 0.001), irrespectively of the severity of the infection. Conclusion Although septic neonates have normal cerebral oxygenation in the first and third day of the sepsis, they present decreased cerebral oxygenation in the seventh day independently of the infection severity.

Significant reduction of central line-associated bloodstream infection rates in a tertiary neonatal unit

To evaluate the effectiveness of a quality initiative in reducing central line-associated bloodstream infections (CLABSIs) in our neonatal intensive care unit, we designed a prospective study (January 2012-September 2013) estimating CLABSI incidence before and after our implementation. CLABSI rates were significantly decreased after our intervention, from 12 cases per 1,000 central vascular catheter (CVC) days during the preinterventional period to 3.4 cases per 1,000 CVC days during the postinterventional period (P = .004).

Recurrent giant cell fibroblastoma: Malignancy predisposition in Kabuki syndrome revisited

Kabuki syndrome is a genetic condition characterized by distinctive facial phenotype, mental retardation, and internal organ malformations. Mutations of the epigenetic genes KMT2D and KDM6A cause dysregulation of certain developmental genes and account for the multiple congenital anomalies of the syndrome. Eight cases of malignancies have been reported in young patients with Kabuki syndrome although a causative association to the syndrome has not been established. We report a case of a 12-year-old girl with Kabuki syndrome who developed a tumor on the right side of her neck. A relapsing tumor 19 months after initial excision, proved to be giant cell fibroblastoma. Τhis is the first report of giant cell fibroblastoma -a rare tumor of childhood- in a patient with Kabuki syndrome.

Investigating the role of Natural Killer T-cells in Gram negative infections of patients with type 2 diabetes mellitus

BACKGROUND

Invariant Natural Killer T (iNKT) cells belong to innate immunity and combine T-cell receptor specificity with Natural Killer surface markers. They can produce cytokines immediately after stimulation and direct immunity to either Th1 or Th2 cytokine production. iNKT cells participate in a variety of immune responses, such as microbial infections, autoimmunity, and cancer. Type 2 Diabetes Mellitus (T2DM) has been associated with activated innate immunity and certain cytokine profile during microbial infections. This study aimed to evaluate whether iNKT cells have a role in the immune response of T2DM patients during infections with gram-negative bacteria.

METHOD

The T2DM group consisted of patients (n =11) who had a diagnosis of T2DM for at least six months and febrile illness for three days, while the control group consisted of patients (n =11) who had not T2DM, but were febrile for three days. All patients were infected by gram-negative bacteria. Physical examination was performed, and peripheral blood was drawn on days three and six of febrile illness. Flow cytometry was utilized for iNKT cell identification with monoclonal antibodies Phycoerythrin (PE) - Cyanin (CY) 5 anti-Human CD3, Fluorescein isothiocyanate (FITC) anti-Human CD4, PE anti-human invariant NKT T-Cell Receptor. For intracellular staining, we used Alexa Fluor anti-Human interferon-γ (IFN-γ) and Allophycocyanin (APC) anti-human interleukin-4 (IL-4). The variables processed were: CD3+IL-4+iNKT+ , CD4+IL-4+iNKT+, CD3+IFNγ+iNKT+, CD4+IFNγ+iΝΚΤ+, CD3+iNKT+, CD4+iNKT+ ,CD3+IL4+, CD4+IL-4+, CD3+IFNγ+, CD4+IFNγ+ on days three and six of febrile illness (CD3+, CD4+: T lymphocyte surface markers, iNKT+: invariant Natural Killer T- Cell Receptor, IL4+: interleukin 4, IFNγ+: interferon γ).

RESULTS

Comparisons between T2DM patients and controls revealed no statistically significant difference in any of the study's variable. Regarding within T2DM patients comparisons CD4+IL4+iNKT+, CD3+IL4+iNKT+, CD4+IFN+iNKT+, CD3+IFN+iNKT+, and CD3+iNKT+  decreased, whereas CD3+IL4+ was increased at day six compared to day three. Within control group CD4+IL4+iNKT+, CD3+IL4+iNKT+, and CD3+iNKT+ were decreased, whereas CD4+IFN+, CD3+IFN+ were increased at day six compared to day three.

CONCLUSION

The absence of statistical difference between T2DM patients and controls implies that the role of iNKT cells is virtually the same in both groups of patients during the course of gram-negative infections and that there is no numerical variance of this cell population between the two groups. Despite the small sample size, we notice that all iNKT parameters (both IL4/IFNγ) are suppressed in the T2DM group during the later phase, but only those concerning IL4+iNKT+ in the control group, suggesting that IFNγ production remains elevated in the controls. A compensatory anti-inflammatory type-response could provide an explanation for the prevalence of IL4 production during the later phase of infection in T2DM and the sustained production of IFNγ in controls. Hippokratia 2015; 19 (3): 231-234.

Correlation of brain ultrasonography scans to the neuromotor outcome of very-low-birth-weight infants during the first year of life

To evaluate the consistency of the Hammersmith Infant Neurological Examination scores of very-low-birth-weight infants at 6 and 12 months of age and its correlation to cranial ultrasonography findings, we designed a prospective study between January 2005 and January 2008, in the tertiary Neonatal Unit of Aristotle University of Thessaloniki, Greece. All infants enrolled had a cranial ultrasonography performed at term. Preterm infants born at <32 weeks gestation with a birth weight <1500 g were eligible for the study. One hundred seventy-four infants were finally enrolled; out of those, 46 (26%) had an optimal score at 6 and 76 (44%) at 12 months of age. Mean global scores were 61 and 69 at 6 and 12 months, respectively. The Hammersmith Infant Neurological Examination score significantly increased between 6 and 12 months, equally in all ultrasonography groups. The presence of cystic periventricular leukomalacia was associated to lower scores and neurologic impairment.

Glutathion-S-Transferase P1 polymorphisms association with broncopulmonary dysplasia in preterm infants

BACKGROUND

Oxidative stress, characterized by the excretion of pre-oxidative and anti-oxidative proteases, has a key role in the pathogenesis of bronchopulmonary dysplasia (BPD). One of the many host anti-oxidant enzymes is glutathione-S-transferase P1 (GSTP1), with three polymorphic alleles having been identified: homozygous ile, heterozygous ile/val and homozygous val isomorph. The aim of this study was to examine the genetic predisposition to BPD in the GSTP1 polymorphisms.

METHODS

A prospective case-control study was carried out in the 2nd Neonatal Intensive Care Unit of Aristotle University in Thessaloniki, Greece during 2008. The genetic polymorphisms of GSTP1 in 28 preterms <32 weeks gestational age (GA) with BPD compared to 74 controls (33 preterms without BPD and 41 healthy terms) were examined.

RESULTS

The homozygous ile isomorph was predominant in all groups (preterms with BPD: 82%, preterms without BPD: 70%, healthy terms: 78%), followed by the heterozygous ile/val (14%, 18% and 20% respectively) and the homozygous val isomorph (4%, 12% and 2% respectively). The homozygous ile isomorph was also identified in the majority of preterms with mild (80%), moderate (100%) and severe (73%) BPD. The GSTP1 genetic distribution did not differ between the groups and GSTP1 polymorphisms were not associated with the severity of BPD.

CONCLUSIONS

This study could not confirm an association between GSTP1 polymorphisms and the development of BPD or the severity of the disease.

Assessment of lung ventilation in infants with respiratory distress syndrome using electrical impedance tomography

AIM

The aim of the present study was to determine immediate changes of global and regional lung function after exogenous surfactant administration in mechanically ventilated infants with respiratory distress syndrome (RDS) using electrical impedance tomography (EIT) measurements.

MATERIALS AND METHODS

A prospective study was conducted in a Neonatal Intensive Care Unit at a university hospital. Seventeen preterm infants (<12 hours old) suffering from RDS were included in this study. Interventions taken were low-pressure recruitment maneuver, surfactant administration and minimal adjustments in ventilator settings. Repeated EIT measurements (401 in total) were performed before and after (15 min - 30 min) surfactant administration. Global lung function changes were assessed with two markers, namely absolute resistivity (AbsR) and normalized impedance change (ΔZ); redistribution of regional lung ventilation was assessed as well. Airway pressure and arterial blood gases were recorded.

RESULTS

Surfactant administration resulted in a statistically significant increase of both the AbsR and ΔZ markers. Moreover, there was a ventilation shift towards dorsal - dependent lung areas with less asymmetry in the right-to-left air distribution.

CONCLUSIONS

Surfactant administration in the recruited lung with RDS modifies regional ventilation, as assessed by EIT, contributing to a more homogeneous air distribution. Furthermore, significant changes in EIT markers reflect improvement of global lung function after surfactant administration.

Is there a necessity for multiple doses of surfactant for respiratory distress syndrome of premature infants?

Both prophylactic and early surfactant (SF) replacement therapy reduce pulmonary complications and mortality in ventilated infants with respiratory distress syndrome (RDS). The effectiveness of one or more doses and the impact on morbidity and mortality of premature neonates with RDS need to be further clarified. The objective of this study was to investigate the necessity of repeated surfactant replacement therapy in premature infants ≤32 weeks of gestational age and the possibility of an underlying pathology. This study included 126 premature neonates of 24-32 weeks of gestation. We used 200 mg/kg per dose of porcine surfactant (Curosurf®) as primary treatment and 100 mg/kg in cases that required retreatment. The subjects were classified into two groups: the first group (Group 1) received a single dose of surfactant (n=98) and the second group (Group 2) included infants who required more than one dose (n=28). The 1st dose was administered in the first 20 minutes after birth while the second was given six hours later. In four cases, a 3rd dose was required, that was provided 12 hours after birth. Recorded data included: clinical and radiological classification of RDS, extubation time, oxygenation estimation indexes (OI: oxygenation index, A-aDO2: alveolar-arterial oxygen difference, a/APO2: arterial-alveolar ratio of partial oxygen pressure), requirement and duration of oxygen administration, total duration of mechanical ventilation, and survival rate. Patient Group 1 did not present any radiological findings of RDS of grade 3 or 4 six hours after SF administration, whereas such findings were recorded in three neonates of Group 2. Therefore, we assumed that failure of a single-dosing treatment indicates a more severe RDS and might reflect an underlying pathology. The impact of maternal chorioamnionitis in the neonates that necessitated further replacement therapy was statistically significant (p=0.045); moreover, infection markers were positive in the majority of the patient population of the second group. Twenty-two neonates (22%) of the first group needed intubation in the delivery room compared to 16 (57%) of the second group (p=0.0001). In conclusion, premature infants treated with a single dose of surfactant can usually be successfully extubated. Requirement of retreatment could be attributed to other pathogenetic mechanisms. A positive history of maternal chorioamnionitis was the commonest reason.

Identification of a mutation in the MTM1 gene, associated with X-linked myotubular myopathy, in a Greek family

X-linked myotubular myopathy (XLMTM) is a rare congenital myopathy, usually characterized by severe hypotonia and respiratory insufficiency at birth, in affected, male infants. The disease is causally associated with mutations in the MTM1 gene, coding for phosphatase myotubularin. We report a severe case of XLMTM with a novel mutation, at a donor splicing site (c.1467+1G) previously associated with severe phenotype. The mutation was also identified in the patient's mother, providing an opportunity for sound genetic counseling.

Glycemia and cardiovascular risk: challenging evidence based medicine

Optimal glycemic control is well known to reduce effectively the risk of micro vascular complications both in type 1 and type 2 diabetes mellitus. However the role of glycemic control in decreasing the risk of myocardial infarction and ischemic stroke, the leading causes of death in patients with diabetes, has been so far controversial. In this review, based on data recently reported from large interventional studies, we discuss the possible causal relationship between glycemia and cardiovascular outcomes in type 1 and type 2 diabetes. Strict glycemic control right from the diagnosis of the disease may be effective in reducing long term incidence of cardiovascular (CV) disease in both T1 and T2 diabetics. Nevertheless such a strategy could be potentially harmful for T2 diabetics with long duration of sub optimal glycemic control and already established CV complications. Treatment targets in these patients should be individualized taking into account other aspects of glycemic control and diabetes complications such as hypoglycemia and autonomic neuropathy.

Early versus delayed minimal enteral feeding and risk for necrotizing enterocolitis in preterm growth-restricted infants with abnormal antenatal Doppler results

We studied the effect of early (< or = 5 days) versus delayed (> or = 6 days) initiation of minimal enteral feeding (MEF) on the incidence of necrotizing enterocolitis (NEC) and feeding intolerance in preterm infants with intrauterine growth restriction (IUGR) and abnormal antenatal Doppler results. We performed a randomized, nonblinded pilot trial of infants receiving early or delayed MEF in addition to parenteral feeding within 48 hours of life. Demographic data, maternal preeclampsia, antenatal steroid exposure, Doppler studies, as well as cases of NEC and feeding intolerance were all recorded. Of the 84 infants enrolled, 81 completed the study: 40 received early (median age: 2 days, range: 1 to 5 days) and 41 delayed (median age: 7 days, range: 6 to 14 days) MEF. The incidence of NEC and feeding intolerance was not significantly different between groups (p = 0.353 and p = 0.533, respectively). Birth weight was an independent risk factor for NEC in both groups. Early MEF of preterm infants with IUGR and abnormal antenatal Doppler results may not have a significant effect on the incidence of NEC or feeding intolerance. Furthermore, birth weight seems to be an independent risk factor for the development of NEC, irrespectively of the timing of MEF introduction.

Neurological outcome in preterm small for gestational age infants compared to appropriate for gestational age preterm at the age of 18 months: a prospective study

The aim of this study was to investigate the neurological outcome of premature small for gestational age infants at the corrected age of 18 months by the Hammersmith Infant Neurological Examination. A prospective trial was conducted comparing 41 preterm infants being small for gestational age with 41 appropriate for gestational age infants. Birth weight was significantly lower in small for gestational age infants compared with appropriate for gestational age infants (1724.6 +/- 433 versus 1221 +/- 328 g). There were no significant differences regarding the median gestational age and Apgar scores. Median global scores differ significantly between both groups: 75 (47-78) versus 76 (72-78) for the small for gestational age and appropriate for gestational age infants, respectively. Both groups had optimal scores. In conclusion, although the small for gestational age group scored lower in the Hammersmith Infant Neurological Examination, median global score in both groups was within optimal range.

Clinical applications of creatine supplementation on paediatrics

Creatine plays a central role in energy metabolism and is synthesized in the liver, kidney and pancreas. In healthy patients, it is transported via the blood stream to the muscles, heart and brain with high and fluctuating energy demands by the molecule creatine transporter. Creatine, although naturally synthesized in the human body, can be ingested in the form of supplements and is commonly used by athletes. The purpose of this review was to assess the clinical applications of creatine supplementation on paediatrics. Creatine metabolism disorders have so far been described at the level of two synthetic steps, guanidinoacetate N-methyltransferase (GAMT) and arginine: glycine amidinotransferase (AGAT), and at the level of the creatine transporter 1(CrT1). GAMT and AGAT deficiency respond positively to substitutive treatment with creatine monohydrate whereas in CrT1 defect, it is not able to replenish creatine in the brain with oral creatine supplementation. There are also data concerning the short and long-term therapeutic benefit of creatine supplementation in children and adults with gyrate atrophy (a result of the inborn error of metabolism with ornithine delta- aminotransferase activity), muscular dystrophy (facioscapulohumeral dystrophy, Becker dystrophy, Duchenne dystrophy and sarcoglycan deficient limb girdle muscular dystrophy), McArdle's disease, Huntington's disease and mitochondria-related diseases. Hypoxia and energy related brain pathologies (brain trauma, cerebral ischemia, prematurity) might benefit from Cr supplementation. This review covers also the basics of creatine metabolism and proposed mechanisms of action.

Continuous subcutaneous insulin infusion versus multiple daily injections

BACKGROUND AND AIM

Continuous Subcutaneous Insulin Infusion (CSII) and Multiple Daily insulin Injections (MDI) are both strategies aiming to achieve a tight glycemic and metabolic control. However, the choice between them remains controversial. The aim of the present study was to compare the efficacy of MDI (three or more injections daily) with CSII on glycemic control in patients with Type 1 Diabetes Mellitus and assess satisfaction from treatment in the CSII group.

MATERIAL AND METHODS

Seventeen patients with Type 1 Diabetes Mellitus on CSII (previously on MDI) and 17 patients on MDI, matched for age, gender, BMI and duration of diabetes, were retrospectively studied. Glucosylated Hemoglobin A1c (HbA1c), frequency of hypoglycaemias (assessed as self reported episodes), BMI and total units of insulin per day were evaluated at baseline and after 6 months in both groups. CSII group completed a questionnaire concerning motive for treatment selection, advantages, deficiencies and inconvenience at the end of the study. Satisfaction from treatment was assessed with a scale from 0 to10.

RESULTS

CSII group had more hypoglycaemic episodes at baseline than MDI group (16.2+/-2.8 vs 2.8+/-1.3, p<0,001). HbA1c (8.4+/-0.5 before vs 7.3+/-0.4 after, p<0.05) and total hypoglycaemic episodes per month (16.2+/-2.8 before vs 8.7+/-2.3 after, p<0.05) significantly decreased in CSII group 6 months after baseline. On the contrary, total hypoglycaemic episodes per month were increased in MDI group (2.8+/-1.3 before vs 10.8 +/-2,6 after, p<0.05) in order to maintain HbA1c levels. No significant differences were observed in BMI in both groups. Total insulin demands were reduced in the CSII group (49.4+/-3.3 before vs 39.0+/-4.6 after, p<0.05) and remained unchanged in MDI group. None of the patients discontinued CSII therapy, while overall satisfaction rate in this group was high. The main motive for CSII selection was frequent hypoglycaemic episodes and glucose fluctuations (10/17). The majority of patients expressed their wish for incorporating glucose trend indicator and/or continuous glucose measurement into pump and reducing pump size (15/17). Most commonly stated advantage was improved flexibility, followed by greater freedom and decreased sense of physical restrictions (10/17). Inconvenience mainly derived from alarm malfunction and catheter or needle occlusion and was reported from a minority of patients (4/17).

CONCLUSION

CSII group reported more hypoglycaemias than MDI group at baseline but 6 months later had significantly less hypoglycaemic events, while on the contrary, MDI group 6 months after baseline had more frequent and more severe hypoglycaemias. Although baseline hypoglycaemias are not equal between the two groups, we can assume that CSII group achieved less hypoglycaemic events along with significant reduction in HbA1c while utilising less insulin units.

Haemostatic profile of full-term, healthy, small for gestational age neonates

BACKGROUND

Small for Gestational Age (SGA) neonates often appear with haemostatic alterations, principally due to hepatic dysfunction that results from chronic intrauterine hypoxia. Polycythaemia and thrombocytopenia are common findings in this neonatal population.

STUDY DESIGN

We performed a comparison of coagulation, natural inhibitors and fibrinolysis between SGA and Appropriate for Gestational Age (AGA) infants born full term [gestational age (G.A.) >37 weeks]. Study population consisted of 188 healthy newborns, 90 of whom were SGA (62 females and 28 males), while the rest were the control group (44 females and 54 males). Blood samples were obtained within 30 minutes following birth and before the administration of vitamin K. Investigation included: PT, INR, APTT, fibrinogen, coagulation factors II, V, VII, VIII, IX, X, XI, XII, vWillebrand factor, protein C and free protein S, antithrombin (AT), APCR, tPA and PAI-1. The independent t-test was used to compare the differences between the values of haemostatic parameters.

RESULTS

Statistical analysis revealed a significant prolongation in PT, INR, elevated levels of tPA (p<0.015, 0.01 and 0.002 respectively) and a decrease in the values of XII and free protein S (p<0.045 and 0.007 respectively) in SGA full term neonates. The two groups had similar demographic characteristics (except birth weight), without significant differences in the values of other haemostatic parameters.

CONCLUSIONS

Despite of statistically significant differences in PT, INR, values of tPA, XII and free protein S, levels of haemostatic factors range within laboratory references for healthy full term newborns. These findings were not accompanied with clinical manifestations of altered haemostasis.

Influence of smoking during pregnancy on haemostasis in healthy full term neonates

BACKGROUND

Clinical and experimental researches have linked smoking to disturbances of coagulation and fibrinolysis. Several potential mechanisms are incriminated involving inflammation, fibrinogen synthesis and clotting factors. Based on the fact that the majority of tobacco components cross the placental barrier, the objective of our current study is to investigate the influence of smoking during pregnancy on neonatal haemostasis.

STUDY DESIGN

The study was based on a comparative evaluation of coagulation and fibronolysis between healthy full term infants of women who smoked during pregnancy and a control group. Subjects consisted of 39 newborns of smoking and 43 newborns of nonsmoking mothers. Blood samples were obtained shortly after birth and before the administration of vitamin K. Investigation included: PT, INR, aPTT, fibrinogen, coagulation factors II, V, VII, VIII, IX, X, XI, XII, vWillebrand (vWF), protein C and S, APCr, anti-thrombin (AT), t-PA and PAI-1. The independent t- test was used to compare the differences between the values of coagulation and fibrinolytic parameters at the p<0.05 level.

RESULTS

We discovered a statistically significant decrease in factor II and protein S levels and an elevation in t-PA and factor VIII concentrations in newborns of smoking mothers, without clinical manifestations of altered haemostasis. There were no significant differentiations in other coagulation or fibrinolytic parameters.

CONCLUSION

The alteration in factor II, protein S, t-PA and factor VIII in neonates exposed in utero to tobacco smoke is not accompanied by loss in the balance between coagulation and fibrinolytic pathways.

A female infant with Silver Russell Syndrome, mesocardia and enlargement of the clitoris

Silver Russell Syndrome (SRS) is a rare condition (1/3000 - 1/100,000 newborns). We present a female infant with SRS, cardiac malposition and asymmetric enlargement of the clitoris. She is the first child of Greek nonconsanguinous parents, born at 38 weeks gestation, following in vitro fertilisation (IVF). The patient had intrauterine growth retardation, body asymmetry, enlarged clitoris, hemihypertrophy of external genitalia and features characteristic of SRS. Electrocardiography and chest X-rays revealed a median position of the heart. The infant fulfilled the criteria proposed by Price et al for SRS. Genetic analysis did not reveal mUPD of chromosome 7. This is the first report of a patient with SRS presenting ìmesocardiaî and asymmetric enlargement of the clitoris. Our case constitutes another paradigm of SRS following IVF, which possibly supports the hypothesis that IVF may be associated with higher prevalence of SRS than natural fertilisation.

HDAC3: taking the SMRT-N-CoRrect road to repression

Known histone deacetylases (HDACs) are divided into different classes, and HDAC3 belongs to Class I. Through forming multiprotein complexes with the corepressors SMRT and N-CoR, HDAC3 regulates the transcription of a plethora of genes. A growing list of nonhistone substrates extends the role of HDAC3 beyond transcriptional repression. Here, we review data on the composition, regulation and mechanism of action of the SMRT/N-CoR-HDAC3 complexes and provide several examples of nontranscriptional functions, to illustrate the wide variety of physiological processes affected by this deacetylase. Furthermore, we discuss the implication of HDAC3 in cancer, focusing on leukemia. We conclude with some thoughts about the potential therapeutic efficacies of HDAC3 activity modulation.

Is the use of rFVIIa safe and effective in bleeding neonates? A retrospective series of 8 cases

BACKGROUND

Recombinant activated factor VII (rFVIIa), originally developed for the treatment of life-threatening bleeding in hemophilic patients with inhibitors to factors VIII or IX, has been increasingly used to control hemorrhage unresponsive to conventional treatment, in the absence of a defined coagulopathy or thrombocytopathy. To date, clinical experience of rFVIIa administration in neonates, especially preterms, is rather limited, because of the lack of controlled studies and based solely on some published case reports and 1 prospective pilot study. The objective of this study was to retrospectively evaluate the clinical outcome of newborns treated with recombinant activated factor VII for intractable bleeding or severe coagulation disturbances, resistant to conventional hemostatic therapy.

METHODS

The medical records of 8 neonates treated with rFVIIa (100 micro g/kg) were retrospectively reviewed for the course of hemorrhage and the hemostatic interventions performed before and up to 24 hours after the administration rFVIIa. Coagulation parameters of 3 different time-points were assessed and compared: before administration of any blood product (time-point 1), before administration of the first dose of rFVIIa (time-point 2), and 4 hours after the administration of the last dose of rFVIIa (time-point 3). The safety and tolerability profile of rFVIIa in bleeding neonates was also evaluated.

RESULTS

Six preterm and 2 term patients were included in the study. Seven patients presented with refractory bleeding and 1 was diagnosed with severe coagulopathy unresponsive to the conventional treatment. Prompt hemostasis was achieved in half of the patients with their coagulation profile being restored within 4 hours after the administration of the first dose of rFVIIa. Improvement in prothrombin time, activated partial thromboplastin time, and fibrinogen after rFVIIa administration was statistically significant, as compared with that observed after conventional treatment. No major safety issues were observed during the study. All 8 patients survived and had their hemorrhage or coagulopathy controlled within 4 hours after transfusion of the last dose of rFVIIa.

CONCLUSIONS

In this study, the hemostatic agent rFVIIa was well-tolerated and behaved in a safe and efficacious manner in all infants treated for life-threatening bleeding and coagulation disorders. Future prospective controlled trials are needed to determine the efficacy, safety, tolerability, and possibly the optimal dose and timing of rFVIIa administration.

Loss of FEV1 in cystic fibrosis: correlation with HRCT features

The purpose of this study was to determine which high-resolution computed tomography (HRCT) features in patients with cystic fibrosis are most strongly associated with functional impairment as expressed by forced expiratory volume in one second (FEV1). Forty-seven patients with cystic fibrosis underwent chest HRCT and had pulmonary function tests. The HRCT examinations were evaluated for 11 features scored using a modification of Bhalla system and FEV1 was recorded as percentage of the predicted value. Univariate and multivariate correlations between HRCT scores and FEV1 were performed. The most common HRCT feature was bronchiectasis (98%) followed by atelectasis-consolidation (81%), bronchial wall thickening (77%), tree-in-bud sign (74%), mucous plugging (72%) and mosaic perfusion pattern (47%). On univariate analysis the following features correlated strongly with FEV1: bronchial wall thickening ( p<0.0000001), tree-in-bud sign ( p<0.0000001), mucous plugging ( p<0.0000001), atelectasis-consolidation (p<0.0000001), thickening of interlobular septa ( p<0.0002), severity ( p<0.0002) and extent of bronchiectasis ( p<0.0002). On multivariate analysis bronchial wall thickening and atelectasis-consolidation were the strongest independent determinants of the FEV1. We found a regression equation between FEV1 and the two HRCT features: FEV1=constant variable+a multiplied by bronchial wall thickening+b multiplied by atelectasis-consolidation (a and b=regression coefficients, R(2)=0.48). The major morphological determinants of functional abnormality in cystic fibrosis, as expressed by the loss of FEV1, are bronchial wall thickening and atelectasis-consolidation.