Outcomes among preterm infants with patent ductus arteriosus: Relationship with treatment, gestational age, hemodynamic status and timing of treatment

BACKGROUND

There remains controversy regarding the outcomes resulting from treatment versus conservative management of patent ductus arteriosus (PDA) among preterm infants. The effects of extreme prematurity, hemodynamic status of the PDA, and age at treatment remain poorly defined.

STUDY DESIGN

This retrospective case-control study including infants <  1250 gm who were categorized into 3 groups: Group 1: without PDA, Group 2: with untreated PDA, and Group 3: treated PDA. Diagnosis and treatment of PDA extracted from the medical records. Demographics, clinical characteristics, and outcomes compared using chi-square and analysis of variance. Logistic regression used to estimate adjusted odds ratios.

RESULTS

The study included 734 infants, with 141(19%) in Group 1, 329 (45%) in 2, and 264 (36%) in 3. Group 3 had higher incidence of bronchopulmonary dysplasia (BPD) (aOR, 2.9; 95%CI 1.7-4.8). Infant treated for hemodynamically significant PDA (HSPDA) had higher incidence of BPD (aOR, 1.9; 95%CI 1.0-3.8) and retinopathy of prematurity (ROP) (aOR, 3.4; 95%CI 1.6-6.9). There were no differences in outcome associated with treatment among≤26 weeks gestation and the age when treated.

CONCLUSION

Infants with PDA who were treated had higher incidence of BPD. Among those who were treated, those with HSPDA had a higher incidence of BPD and ROP.

A case of posterior shoulder dislocation with ipsilateral humeral shaft fracture

Posterior shoulder dislocations are rare and represent 2–5% of all traumatic shoulder dislocation. A combination of this injury with ipsilateral humeral shaft fracture is extremely rare event. We here report a case of posterior shoulder dislocation with ipsilateral fracture shaft of humerus following road traffic accident. Through this report, we highlight the rarity of the condition and review the available literature on the subject. We also emphasize the importance of complete physical and radiological examination when dealing with such cases to ensure early detection and its subsequent treatment.

The prevalence of vitamin D deficiency and its relationship with disease severity in an urban pediatric critical care unit

OBJECTIVE

To evaluate the prevalence of vitamin D deficiency among patients admitted to a Pediatric Critical Care Unit (PCCU) in an urban children's hospital, and to assess if there is a correlation between vitamin D level and disease severity.

PATIENTS AND METHODS

Patients (216) between the ages of 1-21 years admitted to the PCCU in a children's hospital, excluding those readmitted with a previous vitamin D level, were enrolled. Serum 25-OH vitamin D levels were measured in all patients within 24 h of admission to the PCCU. The severity of patient illness was assessed by the Pediatric Logistic Organ Dysfunction (PELOD) score determined on admission.

RESULTS

Vitamin D deficiency was found in 28% of patients and vitamin D insufficiency was found in 47% of patients. Adolescent age group, female gender, Black race, winter season, and increasing BMI were determined to be risk factors associated with vitamin D deficiency. No significant correlation was found between vitamin D level and PELOD score (p=0.09). There were six deaths (3%), 5 (83%) of which occurred in patients with low vitamin D levels. Total serum calcium levels correlated with vitamin D (p=0.005) and PELOD score (p=0.001). However, ionized calcium levels did not significantly correlate with vitamin D (p=0.62) or PELOD score (p=0.26).

CONCLUSIONS

Vitamin D deficiency is common in children admitted to an urban inner city PCCU, with 75% of patients having abnormal levels. We did not find a significant correlation between disease severity as measured by PELOD score and vitamin D level in a heterogeneous group of critically ill children. Total serum calcium levels significantly correlated with vitamin D and disease severity in this population. There appears to be an association between vitamin D deficiency and mortality.

Prescription habits for preventative medications among pediatric emergency department physicians at an inner-city teaching hospital

INTRODUCTION

As asthma presentation is episodic, patients with acute exacerbations often present in the emergency department (ED) where preventative regimen may not always be addressed. Addressing initiation and modification of controller medications in the setting of an acute exacerbation may facilitate improved asthma control and decrease the frequency of ED visits, particularly so for families who receive most of their asthma management in the ED. However, this aspect has not yet been explored.

METHODS

We reviewed a random sample of 363 charts, 10% of the total number of asthmatic children, aged 2-18, seen from January to December 2007 in the pediatric ED of an urban teaching hospital located in Bronx, NY, USA. We quantified the frequency of modification of the preventative regimen and the influence of seasons on this practice.

RESULTS

Of these 363 children, 42.4% of patients were not previously on a controller medication. Of these, 9.7% were started on a new controller medication, with a significantly higher percent occurring in the summer months. Of those that were previously on a controller medication, 2.87% were started on a new controller medication and 0.95% had their controller medication dose increased. However, the regimen was not adjusted in 14.3% that had been seen four or more times in the preceding 2 years. Of the total 363 children, 78.5% were discharged from the ED on a short course of oral steroids, and this was not part of their preventative regimen. Only four charts had physician-documented asthma severity classification.

CONCLUSIONS

We found that the preventative regimen was modified in only 0.9-2% of all asthmatic children seen in an urban ED whereas 78.5% were started on systemic steroids. Asthma severity was evaluated in a very small number of patients. Because modification of preventative regimen requires appropriate asthma severity classification, the inclusion of asthma severity classification as part of routine ED evaluation may encourage physicians to address controller medications in persistent asthmatics.

Comparison of asthma knowledge, management, and psychological burden among parents of asthmatic children from rural and urban neighborhoods in India

INTRODUCTION

Asthma prevalence is increasing in developing countries such as India. Little is known on parental knowledge of asthma severity, management and psychosocial impact, particularly among rural dwellers. Further, it is not known whether the female asthmatic child is particularly vulnerable.

OBJECTIVE

To evaluate parental asthma knowledge and psychological impact of having an asthmatic child.

METHODS

134 consecutive caregivers were surveyed at the visit for their child's asthma exacerbation at an urban hospital in Kanpur, India between 3/2007-3/2008.

RESULTS

The child's age range was 5.7A +/- 2.7 years. 76% were urban city dwellers with significantly higher number having a college degree. 23% children had moderate to severe persistent asthma; however, only 42% were on inhaled steroids. Parental severity perception was comparable to National Heart, Lung and Blood Institute (NHLBI) classification. While 67% identified bronchoconstriction occurred with asthma, only 8.9% recognized that inflammation played a role. There was no difference in the perceived stress by area of residence with 89% reported not or only sometimes feeling stressed with having an asthmatic child. Similarly, the concern among those with a female asthmatic child did not differ with 73% of caregivers believing that asthma would not affect their daughter's future.

CONCLUSION

In an urban Indian hospital, 23% of asthmatic children had moderate to severe persistent asthma but only 9% were on controllers. Their parents were well educated, able to identify asthma severity appropriately and denied being stressed with having asthmatic children, irrespective of the gender of the child. However, their understanding of asthma pathophysiology was sub-optimal. Increased disease knowledge may lead to greater medication adherence among asthmatic children in India.

Primitive neuroectodermal tumour of the prostate gland: ultrasound and MRI findings

We report a rare case of primitive neuroectodermal tumour (PNET) of the prostate occurring in a 26-year-old man with a mass replacing the prostate gland in the absence of any lesion involving the bone and soft tissues. To our knowledge, there is no radiological literature that has described the imaging findings in a case of PNET of the prostate. Imaging findings in cases of PNET of the kidney are described in the literature. On ultrasound, the mass appeared multilobulated and multinodular with intratumoural heterogeneity. No brightly reflective echoes with posterior acoustic shadowing to suggest calcification were noted. MRI revealed a heterogeneous lobulated mass with irregular septae within. The mass showed low signal intensity on T(1) weighted images and appeared heterogeneous on T(2) weighted images. Haemorrhage and necrosis were also seen in the tumour.

T-helper type 2 polarization among asthmatics during and following pregnancy

BACKGROUND

Asthma is the most common medical condition during pregnancy. While increased production of T helper cytokines has been reported to occur in both asthma and pregnancy, the effect of T-helper type 2 (Th2) polarization on asthma symptoms during pregnancy has not been well-characterized.

OBJECTIVE

We hypothesized that systemic Th2 cytokine and chemokine polarization occurs among asthmatics to a greater extent during their pregnancy, and is associated with more severe asthma and increased Th2 polarization in the newborn.

METHODS

Fifty-six pregnant asthmatics were recruited from prenatal clinics affiliated with New York Presbyterian Hospital. Systemic production of interleukin-4, interferon-gamma, eotaxin and IP10 were measured by intracytoplasmic staining or ELISA at recruitment, peripartum and post-partum, and in the cord blood. The frequency of asthma symptoms was measured by questionnaires and compared with Th biomarkers.

RESULTS

The chemokine ratio (IP10/eotaxin) declined over the course of pregnancy (from 3.3 +/- 1.3 to 1.4 +/- 0.2, P = 0.016), but IP10 and eotaxin increased post-partum. The decrease in the chemokine ratio was associated with more frequent asthma symptoms. A non-significant trend towards decreased interferon-gamma and increased interleukin-4 production was detected. Cord blood eotaxin levels correlated with maternal levels (r = 0.35, P = 0.03). Other peripartum biomarkers were not associated with Th2 polarization nor with subsequent respiratory symptoms in the newborn.

CONCLUSION

IP10/eotaxin declined over the course of pregnancy and was associated with worse asthma symptoms. Alterations of Th1/Th2 chemokine balance during pregnancy may identify women prone to more severe asthma during pregnancy.

Host-bacterial interactions in the initiation of inflammation

The respiratory epithelium provides both a physical and an immunological barrier to inhaled pathogens. In the normal host, innate defences prevent bacteria from activating inflammation by providing efficient muco-ciliary clearance and antimicrobial activity. Bacteria that persist in the airway lumen, as in cystic fibrosis, activate both the professional immune cells in the respiratory mucosa as well as the more abundant airway epithelial cells. As most of the bacteria become entrapped in airway mucin, shed bacterial products such as pili, flagella, peptidoglycan and lipopolysaccharide from lysed bacteria are likely to be the stimuli most important in activating epithelial signalling. The airway cells respond briskly to bacterial components through several signalling systems which activate epithelial expression of pro-inflammatory cytokines and chemokines. These signals recruit neutrophils to the airways where they eliminate the contaminating bacteria causing inflammation and the ensuing clinical signs of infection.

Leukemoid reaction in extremely low-birth-weight infants

The objective of this paper was to determine the incidence of leukemoid reaction and to evaluate its relationship with maternal and neonatal factors in extremely low-birth-weight (ELBW) infants. The design a case-controlled retrospective study of all live-born ELBW infants (<1000 g) over a period of 2 years, from July 1994 to June 1996. A total of 60 preterm infants were born during the study period, and are included in this report. The infants who demonstrated leukemoid reaction formed the study group, while the remainder formed the control group. Leukemoid reaction was defined as a white blood cell (WBC) count > or = 50,000/mm3. The relationship between maternal and neonatal variables and WBC counts was studied. Nine of the 60 infants studied demonstrated counts >50,000/mm3, with an incidence of 15%. There was no significant association demonstrated between maternal or neonatal variables and leukemoid reaction. Patients with leukemoid reaction had a better overall survival. Leukemoid reaction in ELBW infants is a rare and recently documented phenomenon. In our study the incidence was 15%. Although many factors have been postulated as a cause of this phenomenon, we could not demonstrate any relationship between these factors and high WBC counts, including sepsis and the use of antenatal steroids, the two most likely variables. It was interesting to note that the infants who were able to mount a leukemoid response had a better chance of survival than those who did not.

Pseudohypoparathyroidism-Albright hereditary osteodystrophy

A 13 year old girl with short stature, and retarded mental growth with coarse facies and deranged thyroid function test was initially suspected as a case of hypothyroidism and was started on thyroxine. Lack of response to treatment and on further investigations it was diagnosed as a case of pseudohypoparathyroidism. High index of suspicion and careful evaluation is important to diagnose such an entity.

Uncoupling of oxidative phosphorylation does not induce thermotolerance in cultured Chinese hamster cells

Two uncouplers of oxidative phosphorylation, 2,4-dinitrophenol (DNP) and carbonyl cyanide m-chlorophenylhydrazone (CCCP), were tested for their ability to modify the survival of cultured Chinese hamster ovary (CHO) and Chinese hamster V79 cells treated with hyperthermia. The uncouplers were used under conditions that inhibit oxidative ATP synthesis, as judged from measurements of cellular ATP levels. Incubation of CHO cells in glucose-free Hanks' balanced salt solution (HBSS) containing 1 mM DNP for 1 h at 37 degrees C followed by reincubation at 37 degrees C in complete growth medium for 3 or 16 h, showed no substantial changes in the 45 degrees C heat survival curve as compared to heated cells not exposed to DNP. Thus, DNP treatment of CHO cells did not induce thermotolerance. Carbonyl cyanide m-chlorophenylhydrazone (CCCP), tested under similar experimental conditions, did alter cellular heat resistance. The major change in the 45 degrees C survival curve of CHO cells pretreated with CCCP was an increase in the width of the shoulder: the Dq value increased from 14 min to 24 min, for the control and CCCP-treated cells respectively. The D0 value did not change appreciably. In contrast, heat-induced thermotolerance (10 min, 45 degrees C + 16 h, 37 degrees C) was characterized primarily by an increase in the D0 parameter from 4 min (unheated cells) to 17 min. Similar results were observed with CCCP-treated V79 cells. The data demonstrate that heat resistance induced by 1.2 microM CCCP was manifest as an increased cellular capacity to accumulate and/or repair hyperthermia damage, rather than an induction of thermotolerance, and that this effect probably was not related to the action of CCCP as an uncoupler of oxidative phosphorylation.

Development of thermotolerance in CHO cells: modification by procaine

We have tested the reported ability of procaine to inhibit the induction and the development of thermotolerance in Chinese hamster ovary cells. Thermotolerance was induced either by hyperthermia alone (10 min, 45 degrees C) or by combining hyperthermia and procaine (5 min, 45 degrees C + 10 mM procaine) with heating times adjusted to yield similar cell survival after the conditioning treatments. Both the kinetics of thermotolerance development in fresh medium without procaine and the magnitude of thermotolerance 6 h after heat conditioning were similar for the two treatment groups. Development of thermotolerance in the presence of procaine was tested by adding the drug at 5 or 10 mM to culture medium between, but not during two fractionated heat treatments. Thermotolerance development was observed even in the presence of 10 mM procaine, but only if cell survival was corrected for the 37 degrees C-procaine toxicity. Complete survival curves of cells incubated for 6 h at 37 degrees C in 7.5 mM procaine between heat conditioning and test heating showed a D0 that was only 35 per cent lower than that of thermotolerant controls. The data are consistent with the reported sensitization to heat killing by procaine, but show that thermotolerance induction and development were only minimally perturbed by procaine.