A regional-based newborn hearing screening program: the Emilia-Romagna model after ten years of legislation

Background

Hearing loss, occurring in 1-3/1,000 newborns in the well-babies population, is one of the most common congenital diseases, and hearing screening at birth still represents the only means for its early detection. Since 2011 the Emilia Romagna Regional Health Agency has recommended Newborn Hearing Screening for all babies at its birth points and for newborns moving to the region. The aims of this study are to analyze the results of this regional-based Newborn Hearing Screening program and to discuss the impact of the legislative endorsement on the organization.

Material and methods

This is an observational retrospective chart study. The recordings of well-babies and babies at Neonatal Intensive Care Units were collected during the period from January 1st 2015 to December 31st 2020. The following data were included: Newborn Hearing Screening coverage, percentage of refer at otoacoustic emissions, prevalence and entity of hearing loss, unilateral/bilateral rate, presence of audiological risk factors.

Results

More than 99% of a total of 198,396 newborns underwent the Newborn Hearing Screening test during the period January 1st 2015 to December 31st 2020, with a coverage ranging between 99.6% and 99.9%. Overall, the percentage of confirmed hearing loss cases was about 17-30 % of refer cases, 745 children received a diagnosis of hearing loss (prevalence 3.7/1,000). Considering profound hearing loss cases, these represent 13% of bilateral hearing loss.

Conclusion

A regional-based Newborn Hearing Screening program is valuable and cost-effective. In our experience, the centralization of the data system and of the data control is crucial in order to implement its efficiency and effectiveness. Healthcare policies, tracking systems and public awareness are decisive for a successful programme implementation.

Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries

Background

Inhaled therapies are key components of asthma and chronic obstructive pulmonary disease (COPD) treatments. Although the use of pressurised metered-dose inhalers (pMDIs) accounts for <0.1% of global greenhouse gas emissions, their contribution to global warming has been debated and efforts are underway to reduce the carbon footprint of pMDIs. Our aim was to establish the extent to which different scenarios led to reductions in greenhouse gas emissions associated with inhaler use, and their clinical implications.

Methods

We conducted a series of scenario analyses using asthma and COPD inhaler usage data from 2019 to model carbon dioxide equivalent (CO₂e) emissions reductions over a 10-year period (2020–2030) in the UK, Italy, France, Germany and Spain: switching propellant-driven pMDIs for propellant-free dry-powder inhalers (DPIs)/soft mist inhalers (SMIs); transitioning to low global warming potential (GWP) propellant (hydrofluoroalkane (HFA)-152a) pMDIs; reducing short-acting β₂-agonist (SABA) use; and inhaler recycling.

Results

Transition to low-GWP pMDIs and forced switching to DPI/SMIs (excluding SABA inhalers) would reduce annual CO₂e emissions by 68%–84% and 64%–71%, respectively, but with different clinical implications. Emission reductions would be greatest (82%–89%) with transition of both maintenance and SABA inhalers to low-GWP propellant. Only minimising SABA inhaler use would reduce CO₂e emissions by 17%–48%. Although significant greenhouse gas emission reductions would be achieved with high rates of end-of-life recycling (81%–87% of the inhalers), transition to a low-GWP propellant would still result in greater reductions.

Conclusions

While the absolute contribution of pMDIs to global warming is very small, substantial reductions in the carbon footprint of pMDIs can be achieved with transition to low-GWP propellant (HFA-152a) inhalers. This approach outperforms the substitution of pMDIs with DPI/SMIs while preserving patient access and choice, which are essential for optimising treatment and outcomes. These findings require confirmation in independent studies.

Environmental impact of inhalers for respiratory diseases: decreasing the carbon footprint while preserving patient-tailored treatment

Patients with asthma and Chronic Obstructive Respiratory Disease (COPD) rely on three main device classes for inhalation therapy: metered-dose inhalers (MDIs), dry powder inhalers (DPIs) and soft-mist inhalers (SMIs). The carbon footprint (CF) of these inhalers differs with MDIs having a higher impact than DPIs and SMIs due to the propellant in MDIs. However, the certified CF of specific MDI products may differ significantly. MDIs still represent an essential option for many patients. Consequently, novel approaches shall be considered to balance environmental goals with patient health and well-being while maintaining a diverse range of choices for patients and physicians.

Travellers' risk behaviors and health problems: Post-travel follow up in two travel medicine centers in Italy

OBJECTIVES

We examined the association between travellers' characteristics, compliance with pre-travel recommendations and health problems.

METHODS

Volunteer travellers were enrolled and data collected using a questionnaire between 30-60 days after returning home. We analyzed the associations through bivariate and multivariate models.

RESULTS

Of the 468 enrolled travelers, 68% consumed raw food and 81% food containing milk and/or eggs. 32% consumed street vendor food and 30% drinks containing ice. 24% used the recommended mechanical prophylaxis measures. 46% got sick during and/or after travel (gastrointestinal symptoms most frequently). Factors predisposing to health problems were female gender, youth/middle age, intermediate travel duration and profession. The American continent and staying in hostels and tents were significantly associated with febrile illness. Street vendor food was significantly associated with skin reactions.

CONCLUSIONS

Adherence to behavioral recommendations remains low. Travellers must be informed of health risks during and after travel.

Cholera, the Current Status of Cholera Vaccines and Recommendations for Travellers

Cholera is endemic in approximately 50 countries, primarily in Africa and South and Southeast Asia, and in these areas, it remains a disease associated with poverty. In developed nations, cholera is rare, and cases are typically imported from endemic areas by returning travellers. Cholera is readily preventable with the tools available to modern medicine. In developing nations, cholera transmission can be prevented through improved water, sanitation, and hygiene services and the use of oral cholera vaccines (OCVs). For travellers, risk can be mitigated by practicing regular hand hygiene and consuming food and water from safe sources. OCVs should be considered for high-risk travellers likely to be exposed to cholera patients or contaminated water and food. There are currently three World Health Organization pre-qualified OCVs, which are based on killed whole-cell strains of Vibrio cholerae. These established vaccines offer significant protection in adults and children for up to 2 years. A novel live attenuated vaccine that provides rapid-onset protection in adults and children is licensed in the USA and Europe only. Live attenuated OCVs may mimic the natural infection of V. cholerae more closely, generating rapid immune responses without the need for repeat dosing. These potential benefits have prompted the ongoing development of several additional live attenuated vaccines. The objective of this article is to provide a general review of the current landscape of OCVs, including a discussion of their appropriate use in international travellers.

Viral Respiratory Infections in Hematological Patients

Viral infections of the respiratory system represent one of the most important complications in hematological patients in terms of both the severity of the clinical picture and its related impact on the duration of hospitalization, and of mortality. The most implicated viruses are those that commonly cause community-based respiratory diseases: respiratory syncytial virus, Influenza virus and rhinovirus. However, in some cases the clinical picture may be triggered by first infection with or reactivation of pathogens normally not responsible for clinically relevant diseases in immunocompetent subjects. This issue is currently being taken into greater consideration within the scientific community. However, the strong heterogeneity in the epidemiology and clinical expression of these infections and the lack of adequate therapeutic options imply that there is currently no uniform consensus on the best management of these patients. The main purpose of this review is to highlight which viruses are currently most implicated in the onset of these infections, what is their incidence in so heterogeneous and fragile patients and the factors that lead to disease's onset and evolution. Possible or available clinical management options, diagnostic and therapeutic tools, and preventive and prophylaxis measures are also discussed.

Vaccines in older age: moving from current practice to optimal coverage-a multidisciplinary consensus conference

Vaccines are a key strategy to promote healthy aging, but vaccine coverage remains below target levels in at-risk adults and older individuals. We present here the results of a multidisciplinary consensus conference convened to perform a multidimensional assessment of vaccination in geriatric medicine, with a view to developing a well-defined strategy for the promotion of vaccines in older people. We discuss recommended vaccines in older individuals, and describe the wide regional heterogeneity between regions in the Italian context. The main obstacles to implementation of vaccines in practice are reviewed, as well as potential strategies to remove these barriers. Finally, the importance of including vaccines and vaccination in undergraduate and postgraduate medical education is underlined. The information summarized in this document is expected to help develop educational and promotional initiatives to achieve greater uptake of vaccines among older individuals, as a key means to promote healthy aging.

Coronavirus: Update Related to the Current Outbreak of COVID-19

In December 2019, some cases of viral pneumonia were epidemiologically related to a new coronavirus in the province of Hubei, China. Subsequently, there has been an increase in infections attributable to this virus throughout China and worldwide. The World Health Organization (WHO) has officially named the infection coronavirus disease 2019 (COVID-19), and the virus has been classified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This appears to be a virus from Rhinolophus bats, but the intermediate host has not yet been identified. The mechanism of infection of SARS-CoV-2 is not yet known; it appears to have affinity for cells located in the lower airways, where it replicates. The interhuman transmission of coronaviruses mainly occurs through saliva droplets and direct and indirect contact via surfaces. As of March 10, 2020, the number of cases worldwide was 113,702. Along with severe acute respiratory syndrome (SARS) and Middle Eastern respiratory syndrome (MERS), COVID-19 appears to cause a severe clinical picture in humans, ranging from mild malaise to death by sepsis/acute respiratory distress syndrome. The prognosis is worse in elderly patients with comorbidities. To date, there is no specific therapy for COVID-19. Prevention of SARS-CoV-2 infection implies strategies that limit the spread of the virus. WHO and other international and national bodies have developed continuously updated strategic objectives and provisions to contain the spread of the virus and infection.

Co-administration of vaccines: a focus on tetravalent Measles-Mumps-Rubella-Varicella (MMRV) and meningococcal C conjugate vaccines

Simultaneous administration of different vaccines is a strategy to increase the possibility to receive vaccines at appropriate age, safely and effectively, reducing the number of sessions and allowing a more acceptable integration of new vaccines into National Immunization Programs (NIPs). Co-administration can be performed when there are specific indications in the Summary of Product Characteristics (SmPC) of the vaccines; but, in absence of these indications, the practice is possible if there are no specific contraindications nor scientific evidence to discourage simultaneous administration.

The aim of this work is to review the safety and efficacy of co-administration of the tetravalent measles, mumps, rubella, and varicella (MMRV) and the meningococcal C (Men C) conjugate vaccines after 12 months of age.

Several studies demonstrated that MMRV and Men C conjugate vaccines can be administered concomitantly without a negative impact on the safety and immunogenicity of either vaccines, inducing highly immunogenic responses.

Varicella zoster virus vaccines: an update

Varicella zoster virus (VZV) is the etiological agent of varicella, a highly infectious, self-limiting disease with serious complications. The decline in cell-mediated immunity (CMI) that occurs with aging or immunodepression causes a reactivation of the latent VZV as herpes zoster (HZ). Prevention of VZV through varicella vaccination strategies allows to avoid the primary infection in newborns and susceptible subjects. Available monovalent and combined VZV vaccines are effective, safe and generally well tolerated. Universal varicella vaccination has significantly impacted on incidence, complications and deaths related to this disease. Prevention of HZ through vaccination is a priority to avoid the significant burden of its incidence and complications. Currently two HZ vaccines are available. The recombinant zoster vaccine (RZV), approved by the FDA in 2017 and Zoster Vaccine Live (ZVL) licensed in the United States by the FDA in 2006. The advisory committee on immunization practices (ACIP) preferentially recommends RZV. ZVL remains an option for prevention of HZ in immunocompetent adults aged ≥60 years, although the CMI tends to wane a few years after vaccination.

Some facts about the respiratory enzymes of Pseudomonas pseudoalcaligenes KF707 recently renamed as Pseudomonas furukawaii sp. nov., type strain KF707

Kimura and co-workers (Kimura N et al. Int J Syst Evol Microbiol 2018;68:1429-1435) recently proposed renaming the obligate aerobe Pseudomonas pseudoalcaligenes KF707 as Pseudomonas furukawiisp. nov. type strain KF707. Since the first quasi-complete genome sequence of KF707 was reported in 2012 (accession number: PRJNA83639) numerous reports on chemotaxis and function/composition of the respiratory redox chain of KF707 have been published, demonstrating that KF707 contains three cheA genes for aerobic motility, four cytochrome oxidases of c(c)aa3- and cbb3-type and one bd-type quinol oxidase. With this background in mind, it has been quite a surprise to read within Table 1 of the paper by Kimura et al. that strain KF707 is phenotypically characterized as cytochrome oxidase-negative. Further, Table 1 also reports that KF707 is β-galactosidase-positive, an affirmation that is not consistent with results documented in the current literature. In this present 'Letter to the Editor' we show that Kimura et al. have contradicted themselves and provided inaccurate information in respect to the respiratory phenotypic features of P. furukawii. Based on this, an official corrigendum is requested since the publication, as it is, blurs the credibility of the International Journal of Systematic and Evolutionary Microbiology.

Pseudomonas pseudoalcaligenes KF707 grown with biphenyl expresses a cytochrome caa3 oxidase that uses cytochrome c4 as electron donor

Combining peroxidase activity-based heme staining (TMBZ/SDS/PAGE) with mass spectrometry analyses (Nano LC-MS/MS) of protein extracts from wild-type and appropriate mutants, we provide evidence that the polychlorinated biphenyl degrader Pseudomonas pseudoalcaligenes KF707 primarily expresses a caa₃ -type cytochrome c oxidase (caa₃ -Cox) using cytochrome (cyt) c₄ as an electron donor in cells grown with biphenyl versus glucose as the sole carbon source. Homology modeling of KF707 caa₃ -Cox using the three-dimensional structure of that from Thermus thermophilus highlights multiple similarities and differences between the proton channels in subunit I of the aa₃ - and caa₃ -Cox of Paracoccus and Thermus spp., respectively. To our knowledge, this is the first report demonstrating the presence of a caa₃ -Cox using cyt c₄ as an electron donor in a Pseudomonas species.

Biphenyl Modulates the Expression and Function of Respiratory Oxidases in the Polychlorinated-Biphenyls Degrader Pseudomonas pseudoalcaligenes KF707

Pseudomonas pseudoalcaligenes KF707 is a soil bacterium which is known for its capacity to aerobically degrade harmful organic compounds such as polychlorinated biphenyls (PCBs) using biphenyl as co-metabolite. Here we provide the first genetic and functional analysis of the KF707 respiratory terminal oxidases in cells grown with two different carbon sources: glucose and biphenyl. We identified five terminal oxidases in KF707: two c(c)aa₃ type oxidases (Caa₃ and Ccaa₃), two cbb₃ type oxidases (Cbb₃1 and Cbb₃2), and one bd type cyanide-insensitive quinol oxidase (CIO). While the activity and expression of both Cbb₃1 and Cbb₃2 oxidases was prevalent in glucose grown cells as compared to the other oxidases, the activity and expression of the Caa₃ oxidase increased considerably only when biphenyl was used as carbon source in contrast to the Cbb₃2 oxidase which was repressed. Further, the respiratory activity and expression of CIO was up-regulated in a Cbb₃1 deletion strain as compared to W.T. whereas the CIO up-regulation was not present in Cbb₃2 and C(c)aa₃ deletion mutants. These results, together, reveal that both function and expression of cbb₃ and caa₃ type oxidases in KF707 are modulated by biphenyl which is the co-metabolite needed for the activation of the PCBs-degradation pathway.

Factitious disorder in a patient with Arnold-Chiari malformation: A case report

Introduction

The factitious disorder is characterized by simulation or exaggeration by the subject of his/her physical or psychological symptoms to take a sick role. This disorder may be associated with a real disease, used to simulate other symptoms and receive treatment. Our case is represented by a 49-year-old man, affected by Arnold Chiari Malformation Type I (ACM-I), a structural defect in the cerebellum with extension of the cerebellar tonsils into the foramen magnum, without involving the brain stem. The patient had three surgical operations involving the complete resolution of the disease. However, the subject reported a worsening of all symptoms, with the outcome of a severe self-limitation, with admission to a residential care and taken over by the multidisciplinary equipe of the district. Symptoms, which mainly consisted in pain, motor functional impairment, headaches, slurred speech were not evaluated due to the ACM-I. This diagnosis was confirmed when there was the complete resolution of the symptoms in a date pointed by the patient.

Methods

To make an appropriate differential diagnosis, in addition to the neurological examination, the subject had psychiatric interviews and completed an MMPI evaluation.

Results

Neurological examinations revealed no residual outcome of the ACM-I. At MMPI there were not significant peaks. Regarding to the attitude towards this test and its validity, it appears an obvious attempt to lie from the patient, which tries to present himself in a favourable unrealistically way.

Conclusion

This case shows that appropriate diagnosis can help health services in a better management of their resources in such situations.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The Role of cheA Genes in Swarming and Swimming Motility of Pseudomonas pseudoalcaligenes KF707

A genome analysis of Pseudomonas pseudoalcaligenes KF707, a PCBs degrader and metal-resistant soil microorganism, revealed the presence of two novel gene clusters named che2 and che3, which were predicted to be involved in chemotaxis-like pathways, in addition to a che1 gene cluster. We herein report that the histidine kinase coding genes, cheA2 and cheA3, have no role in swimming or chemotaxis in P. pseudoalcaligenes KF707, in contrast to cheA1. However, the cheA1 and cheA2 genes were both necessary for cell swarming, whereas the cheA3 gene product had a negative effect on the optimal swarming phenotype of KF707 cells.

Detection of LIM domain only 2 (LMO2) in normal human tissues and haematopoietic and non-haematopoietic tumours using a newly developed rabbit monoclonal antibody

AIMS

We describe a new rabbit monoclonal antibody, raised against a fixation-resistant epitope of the transcription regulator LIM domain only 2 (LMO2).

METHODS AND RESULTS

Lymphoma cell lines and a large series of normal and neoplastic samples were investigated by Western blot and immunohistochemistry. The antibody detected nuclear positivity for the protein, with the exception of a proportion of classical Hodgkin lymphomas (HLs), peripheral T cell lymphomas (PTCLs) and solid tumours that showed granular cytoplasmic staining. In normal lympho-haematopoietic tissues, LMO2 was expressed at different intensities by CD34(+) blasts, haematopoietic precursors, germinal centre (GC), mantle and splenic marginal zone B cells. While reactive with only scattered elements in the thymus and nine of 237 PTCLs, the antibody stained 31 of 39 T-acute lymphoblastic lymphoma/leukaemias (T-ALLs) and the T-ALL-derived human leukaemic cell line, CCRF-CEM. LMO2 was found in 88% of B-acute lymphoblastic lymphoma/leukaemias (B-ALLs), 5% chronic lymphocytic leukaemias (CLLs) and 14%, 57% and 41% of mantle, follicular and Burkitt lymphomas, respectively. In the setting of diffuse large B cell lymphomas (DLBCLs), LMO2-positivity was related strongly to a GC phenotype. LMO2 was found in 83% primary mediastinal large B cell lymphomas (PMBLs) and 100% nodular lymphocyte predominant Hodgkin lymphomas (NLPHLs), whereas only 10% of classical HLs were stained. Acute and chronic myeloid leukaemias were usually positive.

CONCLUSIONS

The new anti-LMO2 antibody can be applied confidently to routine sections, contributing to the differential diagnosis of several lymphoma subtypes, subtyping of DLBCLs and potential development of innovative therapies.

Use of IGK gene rearrangement analysis for clonality assessment of lymphoid malignancies: a single center experience

Diagnosis of B-non Hodgkin lymphomas (NHLs) is based on clinical, morphological and immunohistochemi-cal features. However, in up to 10-15% of cases, analysis of immunoglobulin heavy (IGH) or light (IGK/IGL) chains genes is required to discriminate between malignant and reactive lymphoid proliferations. In this study, we evaluated the feasibility and efficiency of IGK analysis in the routine diagnostic of B-cell lymphoproliferative disorders (B-LD) when applied to formalin-fixed paraffin-embedded (FFPE) tissues. Clonality patterns were studied in 59 B-LD using the BIOMED-2 protocol for IGK assays, after failure of the IGH assay. PCR products were evaluated by both heterodu-plex and GeneScan analysis. IGK analysis was technically successful in all cases. Overall, it supported the histopa-thological suspicion in 52/59 cases (88%), the sensitivity and specificity being 83% and 80%, respectively. Further, positive and negative predictive values were 95% and 50%, respectively. Interestingly, among various lymphoma subtypes, marginal zone lymphoma and follicular lymphoma most frequently required IGK analysis. In conclusion, IGK study according to the BIOMED-2 protocol resulted feasible and extremely useful in supporting challenging diagnosis of B-LD even if applied on FFPE samples. Accordingly, when NHL is suspected, negative results at IGH analysis should not be considered as conclusive and further investigation of IGK is appropriate.

Accurate neurosonographic prediction of brain injury in the surviving fetus after the death of a monochorionic cotwin

OBJECTIVE

To assess the feasibility of the prenatal diagnosis using fetal neurosonography of brain injuries in the surviving fetus after the demise of a monochorionic cotwin.

METHODS

This was a retrospective observational study in the period 1990-2004 of monochorionic twin pregnancies with a single fetal demise. A detailed sonographic evaluation of the intracranial anatomy of the surviving twin had been performed whenever possible using a multiplanar approach and from 1999, fetal magnetic resonance imaging was offered as well. Postnatal follow-up was obtained in all cases.

RESULTS

In six of nine cases, abnormal neurosonographic findings were identified including intracranial hemorrhage, brain atrophy, porencephaly and periventricular echogenicities evolving into polymicrogyria. Prenatal diagnosis of brain lesions was confirmed postnatally and all affected infants who survived had severe neurological sequelae. Two fetuses had normal cerebral structures both on the prenatal neurosonogram and on postnatal imaging and were following normal developmental milestones, one at 1 and the other at 5 years of age. In one case the neurosonographic examination was suboptimal and the infant was found at birth to have a porencephalic cyst. Fetal magnetic resonance imaging was performed in two cases and confirmed the ultrasound diagnosis.

CONCLUSIONS

Prenatal neurosonography is a valuable tool for the prediction of neurological outcome in fetuses surviving after the intrauterine death of a monochorionic cotwin. Although our experience is limited, we suggest that magnetic resonance imaging should also be offered.

Prophylactic nasal continuous positive airways pressure in newborns of 28-31 weeks gestation: multicentre randomised controlled clinical trial

BACKGROUND

The role of nasal continuous positive airways pressure (nCPAP) in the management of respiratory distress syndrome in preterm infants is not completely defined.

OBJECTIVE

To evaluate the benefits and risks of prophylactic nCPAP in infants of 28-31 weeks gestation.

DESIGN

Multicentre randomised controlled clinical trial.

SETTING

Seventeen Italian neonatal intensive care units.

PATIENTS

A total of 230 newborns of 28-31 weeks gestation, not intubated in the delivery room and without major malformations, were randomly assigned to prophylactic or rescue nCPAP.

INTERVENTIONS

Prophylactic nCPAP was started within 30 minutes of birth, irrespective of oxygen requirement and clinical status. Rescue nCPAP was started when Fio2 requirement was > 0.4, for more than 30 minutes, to maintain transcutaneous oxygen saturation between 93% and 96%. Exogenous surfactant was given when Fio2 requirement was > 0.4 in nCPAP in the presence of radiological signs of respiratory distress syndrome.

MAIN OUTCOME MEASURES

Primary end point: need for exogenous surfactant. Secondary end points: need for mechanical ventilation and incidence of air leaks.

RESULTS

Surfactant was needed by 22.6% in the prophylaxis group and 21.7% in the rescue group. Mechanical ventilation was required by 12.2% in both the prophylaxis and rescue group. The incidence of air leaks was 2.6% in both groups. More than 80% of both groups had received prenatal steroids.

CONCLUSIONS

In newborns of 28-31 weeks gestation, there is no greater benefit in giving prophylactic nCPAP than in starting nCPAP when the oxygen requirement increases to a Fio2 > 0.4.

Sonographic demonstration of brain injury in fetuses with severe red blood cell alloimmunization undergoing intrauterine transfusions

OBJECTIVE

To assess sonographically brain anatomy in fetuses with severe anemia due to red blood cell alloimmunization undergoing intrauterine intravascular transfusions.

METHODS

Multiplanar neurosonography was performed in seven consecutive hydropic fetuses undergoing intrauterine transfusions (mean gestational age 22 +/- 2.5 weeks; mean hemoglobin concentration at the first transfusion 2.3 +/- 1.0 g/dL).

RESULTS

Abnormal cerebral findings were identified in four out of seven fetuses. An intracerebellar hemorrhage developed in two fetuses after the first transfusion and one fetus that had severe brain edema before the first transfusion was later found to have cystic periventricular leukomalacia. In one fetus unilateral ventriculomegaly was noted after the first transfusion. Two fetuses were terminated. The remaining pregnancies had an uneventful course, the infants were delivered between 34 and 36 gestational weeks and were alive and well at the time of writing. Prenatal diagnosis of brain injury was always confirmed except for the case with ventriculomegaly that underwent spontaneous intrauterine resolution.

CONCLUSIONS

Fetuses with extreme anemia due to red blood cell alloimmunization can be salvaged by intrauterine transfusion. In some of these cases brain injury may occur prenatally, and the risk seems to be particularly high when the hemoglobin concentration at the time of the first transfusion is <or= 2 g/dL. We suggest that in these pregnancies detailed fetal neuroimaging by either multiplanar sonography and/or magnetic resonance imaging is indicated.

Outcome of antenatally diagnosed intracranial hemorrhage: case series and review of the literature

OBJECTIVES

Prenatal diagnosis of intracranial hemorrhage (ICH) has been widely reported. Hemorrhages may occur either within the cerebral ventricles, subdural space or infratentorial fossa. The aim of this study was to determine the sonographic criteria for the diagnosis of fetal ICH, the role of in utero magnetic resonance imaging (MRI) and the outcome of this condition.

METHODS

The archives of our ultrasound laboratory and the literature were searched for all cases of antenatally diagnosed ICH. A grading system was used to classify the intraventricular lesions as suggested in postnatal sonographic studies.

RESULTS

Adding our series of 16 fetuses to the 93 cases identified in the literature, a group of 109 fetal ICHs was obtained: 89 were intracerebral (79 intraventricular and 10 infratentorial) and 20 were subdural hemorrhages. Intraventricular lesions were mostly classified as severe (32 each for Grades III and IV). In 27 cases antenatal MRI was performed additionally to ultrasound and confirmed the sonographic findings. Of the entire group, 65 infants (59%) were reported to be alive 1 month after birth (51 intraventricular hemorrhages, three infratentorial hemorrhages, 11 subdural hematomas). At 12 months, of the 48 infants whose follow-up was available, 25 or 52% were judged neurologically normal (17/36 or 47% among the intraventricular hemorrhages, 6/9 or 66% among the hematomas, and 2/3 or 66% among the infratentorial hemorrhages).

CONCLUSIONS

Fetal ICH may be accurately identified and categorized by antenatal sonography. The outcome is usually poor, especially for those fetuses affected by higher-grade intraventricular hemorrhages.

Infants of immigrant parents in Italy. A national multicentre case control study

BACKGROUND

The aim of this study was to evaluate health state of newborns of immigrated parents from developing countries.

METHODS

Hospital records of 69,605 infants born during 1996/1997 in Italy were reviewed comparing, in a case-control study, each infant of immigrated parents to two infants born immediately before and after to Italian parents.

RESULTS

Of the 69,605 newborns 3906 (5.6%) were born to immigrated parents. This prevalence prolongs the increasing trend observed during the last 10 years of infants born to immigrated parents and reduces the fall of the birth rate linked to the few infants born to Italian parents. It was influenced by geographical factors, being higher in Northern-Central Italy (7%) than in Southern and Insular Italy (2.8%), as consequence of more elevated incomes in these Italian regions. The origin countries of immigrated parents were mainly Northern Africa (31.7%), Eastern Europe (18%) and Sub Saharan Africa (11.6%). Infants of immigrated parents showed higher incidences of prematurity, low birth weight, asphyxia and neonatal mortality rate than newborns with Italian parents. These higher incidences appeared related to some risk factors such as higher parity, short gestational age, some maternal infections, maternal drug dependence, maternal age less than 18 years, low familiar income, inadequate obstetric cares, difficulty to accessing the public health services.

CONCLUSIONS

The health problems of infants with immigrated parents are mainly related to social disadvantage and can be overcome improving the social state, the lifestyles and the obstetric cares of the immigrated women, so as monitoring their risk pregnancies.

The clinical significance of fetal isolated cerebral borderline ventriculomegaly: report of 31 cases and review of the literature

OBJECTIVE

To assess the clinical significance of fetal isolated borderline cerebral lateral ventriculomegaly defined as a width of the atrium of the lateral cerebral ventricles of 10-15 mm in the absence of other sonographically demonstrable malformations.

DESIGN

Retrospective study of the outcome of fetuses with a sonographic diagnosis of isolated borderline cerebral lateral ventriculomegaly and review of the English-language literature.

RESULTS

Of 31 fetuses, two had chromosomal aberrations (trisomy 21 and trisomy 13) and three had neurological complications (one infant developed shunt-dependent hydrocephalus, one lissencephaly and one cerebral hemorrhage and periventricular leukomalacia). The literature search revealed eight independent studies. Including the present series, 234 cases were available for analysis. An abnormal outcome was documented in 22.8% of cases. Perinatal death occurred in 3.7%. Chromosomal aberrations, mostly trisomy 21, were present in 3.8%, malformations undetected at a second-trimester sonogram in 8.6% and neurological sequelae, mostly a mild to moderate delay in cognitive and/or motor development, were present in 11.5%. The risk of an abnormal neurological outcome was increased in females versus males (22.6% versus 4.6%, relative risk 4.892; 95% confidence interval 1.356-17.656), when the atrial width was 12 mm or more (13.9% versus 3.8%, relative risk 3.6, 95% confidence interval 1.035-12.846) and when the diagnosis was made in the second trimester versus later in gestation.

CONCLUSIONS

In most cases, isolated borderline cerebral lateral ventriculomegaly has no consequence. However, this finding carries an increased risk of cerebral maldevelopment, delayed neurological development and, possibly, chromosomal aberrations. The optimal management of these cases remains uncertain.

Sonographic demonstration of nuchal cord and abnormal umbilical artery waveform heralding fetal distress

Ultrasound examination of a 30-week fetus, appropriate for gestational age, revealed a nuchal cord and absence of end-diastolic velocities in the Doppler waveforms of the umbilical artery. Cardiotocography suggested impending fetal distress, clinically confirmed following expedient abdominal delivery. We suggest that Doppler velocimetry of the umbilical vessels may be useful in the assessment of viable fetuses with a sonographic diagnosis of a nuchal cord. Conversely, a nuchal cord should be considered as part of the differential diagnosis of abnormal Doppler velocimetry of the umbilical vessels.

Antigen retrieval techniques in immunohistochemistry: comparison of different methods

Routine sections of normal and pathological samples fixed in 10 per cent buffered formalin or B5, including EDTA-decalcified bone-marrow biopsies, were tested with 61 antibodies following heating in three different fluids: 0.01 M citrate buffer (pH 6.0), 0.1 M Tris-HCl (pH 8.0), and 1 mM EDTA-NaOH solution (pH 8.0). The sections underwent either three cycles of microwave treatment (5 min each) or pressure cooking for 1-2 min. The alkaline phosphatase/anti-alkaline phosphatase (APAAP) technique was used as the standard detection method; with 16 antibodies a slightly modified streptavidin-biotin complex (SABC)-immunoperoxidase technique was applied in parallel. The results obtained were compared with those observed without any antigen retrieval (AR), or following section digestion with 0.05 per cent protease XIV at 37 degrees C for 5 min. Chess-board titration tests showed that all antibodies but one profited by AR. Protease XIV digestion represented the gold standard for five antibodies, while 55 produced optimal results following the application of heat-based AR. By comparison with the other fluids, EDTA appeared to be superior in terms of both staining intensity and the number of marked cells. These results were independent of tissue processing, immunohistochemical approach, and heating device. Pressure cooking was found to be more convenient on practical grounds, as it allowed the simultaneous handling of a large number of slides and a time saving of 1 min 30 s, representing the proper time for the treatment.

Differential diagnosis and outcome of fetal intracranial hypoechoic lesions: report of 21 cases

Our objective was to evaluate the diagnostic and prognostic value of sonography hypoechoic lesions. A retrospective study revealed revealed a total of 21 cases diagnosed over a period of 10 years. Most of the diagnosis were made in the third trimester. The presence fluid-filled lesions within the brain matter always predicted porencephaly and a poor outcome. In most of these cases (nine out of ten), the lesions were seen to communicate with the cavity of the lateral ventricles. Among the 11 cases of hypoechoic lesions that were external to the brain matter, Doppler ultrasound was always able to distinguish between arachnoid cysts (seven cases) and vein of Galen aneurysms (four cases). Arachnoid cysts were associated with a good outcome in four out of the five pregnancies that delivered at term. Three of the four cases of vein of Galen aneurysm were associated with distortion of the cerebral architecture and/or hydrops: one pregnancy was terminated and two resulted in early postnatal death. One pregnancy with vein of Galen aneurysm and normal cerebral structures, without signs of hydrops, had a good outcome. It is concluded that current antenatal ultrasound has the capability of accurate differentiation between different clinical entities resulting in fetal intracranial hypoechoic lesions, and that the sonographic findings have practical clinical implications.

Cerebrospinal fluid shunt infections in infants

Infection remains a major cause of morbidity and mortality following CSF shunt procedures. In this study 191 shunt procedures carried out from January 1981 to December 1992 in a series of 81 infants (less than 6 months old) were retrospectively analyzed for possible risk factors. The overall surgical infection rate was 7.8%, with 15 infections occurring in 14 patients (17.2%). No significant difference in the rate of infections was found in relation to sex, birth weight, gestational age, and type of shunt procedure (primary insertion/revision). The occurrence of other infections during the period of shunt surgery did not influence the infection risk either. Intraventricular hemorrhage and central nervous system infections as causes of the hydrocephalus were found to correlate with septic risk. Young age (less than 6 months) seems to represent the main risk factor, and this is related both to the immunologic deficiency and to the particular features of residential bacterial flora in this age group.

Intraventricular fused fornices: a specific sign of fetal lobar holoprosencephaly

Lobar holoprosencephaly can be recognized in utero with sonography. However, a specific diagnosis is difficult and thus far has relied upon a qualitative evaluation of the morphology of the cerebral ventricles. In infants with this condition, magnetic resonance imaging demonstrates at times an abnormal appearance of the fornices, which are rudimentary and fused in to a single fascicle running within the third ventricle. In a 30-weeks' fetus affected by lobar holoprosencephaly, this finding could be well demonstrated by sonography and was confirmed after birth by both transfontanellar ultrasound and magnetic resonance imaging. It is proposed that the antenatal demonstration of an echogenic linear structure running within the third ventricle is a specific sign of lobar holoprosencephaly, and can assist this difficult diagnosis.

Sonography of fetal agenesis of the corpus callosum: a survey of 35 cases

Agenesis of the corpus callosum was identified by ultrasound examination in 35 fetuses between 19 and 37 weeks' gestation. The ultrasound findings included absence of the corpus callosum and cavum septum pellucidum (hypoplasia in one case of partial agenesis of the corpus callosum), a typical 'teardrop' configuration of the lateral ventricles, distension of the interhemispheric fissure, upward displacement of the third ventricle, radiate arrangement of the medial cerebral gyri, and abnormal branching of the anterior cerebral artery. Associated anomalies were identified in 20 fetuses, including heterogeneous malformations and chromosomal aberrations (mosaic-trisomy 8 in three, trisomy 18 in two and partial duplication 8p in one). Five cases of agenesis of the corpus callosum were identified in a population of pregnant patients prospectively investigated because of genetic risk for agenesis of the corpus callosum or related syndromes. In this group, no diagnostic errors were made. Long-term neurological follow-up (6 months to 11 years) was available in 11 infants with antenatal diagnosis of isolated agenesis of the corpus callosum. Normal intellectual development was present in nine, and a low intellect (developmental quotient between 70 and 85) was found in two. It is concluded that fetal agencies of the corpus callosum is associated with elusive sonographic findings that can, however, be accurately identified by targeted examinations. In routine sonograms, an increased atrial width and/or failure to visualize the cavum septum pellucidum should arise the suspicion of fetal agencies of the corpus callosum. Given the high frequency of associated anomalies, prenatal diagnosis of agencies of the corpus callosum dictates the need for a careful survey of fetal anatomy and karyotyping. The prognosis is isolated agencies of the corpus callosum remains uncertain, although it is expected that a normal or boarderline intellectual development will occur in many cases.

Prenatal diagnosis of lobar holoprosencephaly

Lobar holoprosencephaly was identified with sonography in 12 fetuses between 21 and 35 weeks' gestation. A confident diagnosis was made in each case by a mid-coronal view of the brain demonstrating absence of the cavum septum pellucidum with fusion and squaring of the frontal horns. The only associated anomaly was Dandy-Walker malformation that occurred in three cases. All fetuses had mild to severe ventriculomegaly. Five pregnancies were terminated; there was one spontaneous abortion and six fetuses were delivered at term. A ventriculo-peritoneal shunt was implanted in four. Follow-up was available for five and revealed severe mental retardation in each case. Lobar holoprosencephaly is amenable to prenatal ultrasound diagnosis, although a differentiation with other cerebral malformations may be difficult at times. The outcome of affected infants remains uncertain, but neurological impairment occurs frequently.

Sonography of unilateral megalencephaly in the fetus and newborn infant

A 27-year-old primigravida women was referred for ultrasound studies at 32 weeks' gestation because of the suspicion of fetal ventriculomegaly. Sonographic examination of the fetal brain found a marked shift of the midline, with enlarged left hemisphere and ipsilateral occipital horn, and abnormal convolutions. A 3500 gm male infant was delivered by cesarean section at 39 weeks' gestation because of worsening macrocrania after which the diagnosis of unilateral megalencephaly was confirmed by computed tomography.

Sonographic findings in septo-optic dysplasia in the fetus and newborn infant

A 28-year-old primigravida woman was referred for ultrasound studies at 27 weeks' gestation. Sonographic examination found enlarged cerebral ventricles, communicating lateral ventricles, bilateral cleft lip and palate. A 2500 gm male infant was delivered at 36 weeks' gestation, after which the diagnosis of septo-optic dysplasia was made.

Sonographic diagnosis of agenesis of the corpus callosum in the fetus and newborn infant

The sonographic findings in nine cases of agenesis of the corpus callosum examined before and after birth are reported. Agenesis of the corpus callosum was suspected in utero due to a typical configuration of the lateral ventricles, which included enlargement of the atria and occipital horns and marked separation of the bodies. In three cases pregnancy was terminated because of severe associated anomalies. In the remaining six cases postnatal ultrasound examination allowed a certain diagnosis by demonstrating the abnormal configuration of the lateral ventricles, varying degrees of enlargement, and upward displacement of the third ventricle and absence of the corpus callosum.

Ultrasonographic appearance of the mega cisterna magna in the newborn

The mega cisterna magna is a congenital developmental malformation which in the majority of instances is symptomless and does not require further study or surgical treatment. However, differential diagnosis with other cerebellar diseases is often necessary especially in newborn infants. Ultrasonographic recognition of the mega cisterna magna in a newborn infant is reported. The reported case demonstrates the usefulness of the ultrasonographic technique in the study of the posterior cranial fossa abnormalities of newborn infants.

Evaluation of cerebral blood flow changes by transfontanelle Doppler ultrasound in infantile hydrocephalus

Doppler ultrasound investigation of cerebral blood flow velocity was performed in hydrocephalic infants through the anterior fontanelle. Systolic (S) and end-diastolic (D) frequency values recorded on the anterior cerebral artery were used to define the pulsatility index (PI) calculated from the equation PI=S-D/S. Comparison between systolic, end-diastolic and pulsatility index values of 50 normal infants and 10 hydrocephalic infants showed a statistically significant difference (P less than 0.05) for systolic and pulsatility index values. However, no significant difference was found for end-diastolic values. The authors believe that the phenomenon could be explained as an increase of the cerebrovascular compliance which counteracts the increase of the perivascular pressure in an attempt to maintain a normal cerebral blood flow. Therefore, the transfontanelle Doppler ultrasound technique may provide a useful and early tool in diagnosing cerebral blood-flow changes in hydrocephalic infants.