Mesenteric tissue oxygenation status on the development of necrotizing enterocolitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

[Evaluation of Micafungin Use in Children]

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

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

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

[Results of the use of micafungin in newborns]

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

Turkish Neonatal Society guideline on the management of patent ductus arteriosus in preterm infants

Ductus arteriosus is a physiologic phenomenon in utero and it closes spontaneously in term babies. The closure is problematic in preterm infants due to the intrinsic properties of the preterm ductus arteriosus tissue. Although patent ductus arteriosus has been reported to be associated with many adverse outcomes in this population, treatment has not led to a decrease in outcomes such as bronchopulmonary dysplasia. Treatment modalities also have their own risks and restrictions. The aim of the "Turkish Neonatal Society guidelines for the management of patent ductus arteriosus in preterm babies" is to standardize the diagnosis and treatment of patent ductus arteriosus in preterm infants by combining the current scientific data and the resources of our country.

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

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

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

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

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

AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Sacrococcygeal Teratoma associated with Trisomy 13

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

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

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

Investigation of methicillin resistant Staphylococcus aureus in neonatal intensive care unit

Methicillin resistant Staphylococcus aureus (MRSA) strains lead to severe infections in immunosupressive patients, geriatric population and premature infants. 27 MRSA strains isolated in the Neonatal Intensive Care Unit was considered as an outbreak and it was aimed to investigate the genetic and epidemiologic relation of the MRSA outbreak. MecA gene was investigated in the S. aureus strains and pulsed field gel electrophoresis (PFGE) was used to investigate the genetic relation between outbreak strains. MecA gene was showed in all isolates. PFGE revealed that there were two different strains and most of the isolates (25/27) were owing to same clone. One of the samples were found closely related with the common strain and the other sample was found genetically unrelated. To terminate the outbreak; liquid baby food was gained to the baby food kitchen, no more new patient was imported to the neonatal unit and none of the patients were exported from neonatal unit to other clinics during outbreak, education about infection control precautions was given to all the staff and nursing bottle dishwasher was obtained. To manage and terminate the outbreak, besides the infection control precautions, tests to determine the genetic relation between outbreak strains which are done in the microbiology laboratory are needed. Molecular analysis of outbreak strains will contribute to prove the epidemiologic and evolution of outbreaks.

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULT

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

CONCLUSION

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

Comparison of lipid emulsions on antioxidant capacity in preterm infants receiving parenteral nutrition

BACKGROUND

Although a variety of different lipid emulsions with varying fatty acid contents have been developed, there are some concerns about the administration of these lipid emulsions because of potential adverse effects, including oxidative stress-related morbidity. The aim of the present study was to evaluate and compare the effects of the standard soybean oil-based and olive oil-based i.v. lipid emulsions (ILE) on oxidative stress, determined by total antioxidant capacity (TAC), and to investigate the safety of the use of these two emulsions in terms of biochemical indices.

METHODS

In this prospective study, premature infants were randomly assigned to two groups, each group consisting of 32 patients who received parenteral ILE of either 20% olive oil or 20% soybean oil. They were given ILE for 7 days and then were evaluated with regard to TAC.

RESULTS

No statistically significant difference was observed between the groups in terms of routine biochemical parameters. TAC for both groups on day 7 was significantly lower compared with that on day 0. Although the decrease in TAC within 7 days of ILE administration was greater in the soybean group compared with that in the olive oil group, it was not statistically significant.

CONCLUSIONS

Olive oil-based ILE exhibit similar antioxidant activity and can be used as an alternative to soybean oil-based ILE. TAC significantly decreased in infants following administration of either lipid emulsion, and premature infants tolerated either ILE well, both biochemically and clinically.

Comparison of the efficacy of serum amyloid A, C-reactive protein, and procalcitonin in the diagnosis and follow-up of necrotizing enterocolitis in premature infants

PURPOSE

The aim of this study was to compare the efficacy of serum amyloid A (SAA) with that of C-reactive protein (CRP), and procalcitonin (PCT) in diagnosis and follow-up of necrotizing enterocolitis (NEC) in preterm infants.

METHODS

A total of 152 infants were enrolled into this observational study. The infants were classified into 3 groups: group 1 (58 infants with NEC and sepsis), group 2 (54 infants with only sepsis), and group 3 (40 infants with neither sepsis nor NEC, or control group). The data including whole blood count, CRP, PCT, SAA, and cultures that were obtained at diagnosis (0 hour), at 24 and 48 hours, and at 7 and 10 days were evaluated.

RESULTS

A total of 58 infants had a diagnosis of NEC. Mean CRP (7.4 ± 5.2 mg/dL) and SAA (46.2 ± 41.3 mg/dL) values of infants in group 1 at 0 hour were significantly higher than those in groups 2 and 3. Although the area under the curve of CRP was higher at 0 hour in infants with NEC, there were no significant differences between groups with respect to the areas under the curve of SAA, CRP, and PCT at all measurement times. Levels of SAA decreased earlier than CRP and PCT in the follow-up of NEC (mean SAA levels were 45.8 ± 45.2, 21.9 ± 16.6, 10.1 ± 8.3, and 7.9 ± 5.1 mg/dL at evaluation times, respectively). Levels of CRP and SAA of infants with NEC stages II and III were significantly higher than those with only sepsis and/or NEC stage I.

CONCLUSIONS

Serum amyloid A, CRP, and PCT all are accurate and reliable markers in diagnosis of NEC, in addition to clinical and radiographic findings. Higher CRP and SAA levels might indicate advanced stage of NEC. Serial measurements of SAA, CRP, and PCT, either alone or in combination, can be used safely in the diagnosis and follow-up of NEC.

Human 2009 influenza A (H1N1) virus infection in a premature infant born to an H1N1-infected mother: placental transmission?

Human infection with H1N1 virus reached pandemic status by the spring of 2009. Consequently, the rates of morbidity and mortality related with H1N1 2009 infections have been reported to be higher in pregnant women. H1N1 viremia is rare in the mother, and the risk for transmission of H1N1 2009 influenza from mother to fetus is unknown. To our knowledge, the literature contains only one previous report of a premature infant with H1N1 2009 infection whose mother also had H1N1 2009 infection. Here, we report an H1N1 pandemic influenza 2009-positive female premature infant born at 32 weeks of gestation whose mother had a confirmed H1N1 2009 infection by real-time reverse transcriptase polymerase chain reaction (rRT-PCR). This case suggests that H1N1 2009 virus might be transmitted across the placenta, and therefore, all infants born to an H1N1 2009-positive mother must be evaluated for possible H1N1 2009 infection.

Early left ventricular diastolic dysfunction in premature infants born to preeclamptic mothers

AIM

To evaluate the cardiac function in premature infants born to preeclamptic mothers and its clinical consequences.

METHODS

This was a prospective observational cohort study performed in a tertiary neonatal intensive care unit. Fifty-three premature infants born to preeclamptic mothers comprising the study group were evaluated and compared with 42 premature infants born to normotensive mothers (control group). Relationship between echocardiographic measures and neonatal morbidity were assessed as the main outcome measures.

RESULTS

Left ventricle end-diastolic dimension (LVEDD), peak flow velocities during early diastole (peak E wave), peak flow velocities during atrial contraction (peak A wave), and peak E/A ratio were significantly lower in the study group. Within the study group, these parameters were also significantly lower in infants with respiratory problems. LVEDD was significantly smaller in preeclamptic infants with intrauterine growth retardation (IUGR).

CONCLUSION

Left ventricle diastolic dysfunction (LVDD) was detected in premature infants born to preeclamptic mothers in the first week after delivery. LVDD was associated with higher incidence of respiratory problems, transient tachypnea of the newborn, longer duration of oxygen requirement, and IUGR.

Neonatal outcomes of premature infants born to preeclamptic mothers

OBJECTIVE

Only limited studies with conflicting results are available on neonatal morbidity and mortality in infants born to preeclamptic mothers. The objective of this study was to evaluate neonatal morbidity and mortality in premature infants born to preeclamptic mothers.

METHODS

Premature infants who were admitted to Uludag University, School of Medicine, Neonatal Intensive Care Unit between June 2006 and December 2007 were included in this study. The infants were evaluated according to their demographic characteristics and neonatal morbidities.

RESULTS

Fifty-one infants born to preeclamptic mothers (study group) and 33 gestational age- and gender-matched infants born to normotensive mothers (control group) were included in this study. No statistical difference was found between the two groups in terms of demographic characteristics. However, frequency of neutropenia, duration of mechanical ventilation, and neonatal sepsis rates were found to be significantly higher in the study group compared with those of the control group. Although the rates of other neonatal morbidities such as bronchopulmonary dysplasia, retinopathy of prematurity, intraventricular hemorrhage and necrotising enterocolitis were found to be higher in the study group, the difference was not statistically significant. Mortality rates were also found to be similar in both groups.

CONCLUSIONS

The infants born to preeclamptic mothers had significantly higher rates of neutropenia and sepsis. There were no significant difference in terms of other neonatal morbidities and neonatal mortality between the study and the control group.

Early administration of the second surfactant dose in preterm infants with severe respiratory distress syndrome

The aim of this study was to determine whether early administration (2 hours after the first surfactant dose) of the second surfactant dose would be superior to late surfactant treatment (6 hours after the first surfactant dose) in preterm infants with severe respiratory distress syndrome. Between June 2003 and March 2005, 40 newborns born with respiratory distress syndrome in Uludağ University Hospital were investigated in this prospective study. The inclusion criteria for the recruitment of the infants were: age < or = 2 hours, birth weight between 600-2500 g, gestational age between 24-36 weeks, X-ray consistent with respiratory distress syndrome, and need for mechanical ventilation with inspiratory oxygen fraction > or = 0.4 and mean airway pressure > or = 7 cm H2O to obtain arterial pressure of oxygen between 70-80 mmHg. Infants with lethal congenital anomalies or being treated with high-frequency oscillatory ventilation were excluded from the study. Birth weight, gestational age, gender, and Apgar scores were recorded and complications of the surfactant therapy were examined. Twenty boys and 20 girls were enrolled in the study. The first surfactant dose was administered in the first hour of life in all infants. The second surfactant dose was given 2 hours after the first dose in 20 of them and 6 hours after the first dose in the other 20. Infants in both groups (early versus late) were similar with respect to gestational age, birth weight, gender, and the rate of prenatal corticosteroids. There were also no significant differences between the two groups in terms of the response to surfactant therapy and complications. The results of this study show that administration of the second surfactant dose earlier is as effective as late administration, and it may be suggested that the second surfactant dose can be applied earlier in severe respiratory distress syndrome.

Pseudomonas aeruginosa pleural empyema in a preterm infant

Pleural empyema is defined as the pyogenic infection of the pleural space with purulent effusion. Although it is frequently seen in children and therapy protocols have been developed for it, there are only a few reports about pleural empyema in newborn infants. To our knowledge, just one preterm infant has been reported in the literature. In this article, we report an male infant born at 29 weeks of gestation who had pleural empyema on the 53rd day of life. Multidrug-resistant Pseudomonas aeruginosa (P. aeruginosa) was isolated from his pleural fluid culture. We suggest that this is the first preterm infant with P. aeruginosa empyema.

Neonatal myiasis: a case report

Myiasis is a disease caused by fly larvae. Although adult cases have been reported, neonatal myiasis is a rare condition and there are few reports about this subject. In this article, we report a 12-day-old female neonate who was referred to us due to larvae in her eyes and ears. She was infected with Lucilia spp. larvae and was treated with proper antibiotics.

Hyperprostaglandin E syndrome: use of indomethacin and steroid, and death due to necrotizing enterocolitis and sepsis

Hyperprostaglandin E syndrome (HPS) is the antenatal variant of Bartter syndrome and characterized by polyhydramnios and preterm delivery in the antenatal period and salt-wasting, isosthenuric or hyposthenuric polyuria, hypercalciuria and nephrocalcinosis in the postnatal period. We report a one-month-old infant with HPS with a 15-year-old sister with Bartter syndrome. The infant's birth weight was 2750 g and she had severe dehydration on the 2nd day of life. She had hypercalcemia, hyponatremia, hypokalemia, metabolic alkalosis and elevated plasma renin and aldosterone levels. We instituted indomethacin therapy accompanied by steroid therapy for hypercalcemia. However, the patient developed abdominal distention on the 30th day, which was due to diffuse pneumatosis in sigmoid colon revealed by a subsequent surgical intervention. Following surgery, the patient developed fever, electrolyte abnormalities and subsequently sepsis. The patient died due to sepsis 10 days after surgery. We conclude that indomethacin and steroid therapy must be used cautiously in infants with HPS.

Reference values for neonatal thyroid volumes in a moderately iodine-deficient area

BACKGROUND

The reference ranges of thyroid volumes in neonates vary according to the iodine status of a specific region. In different studies, it ranged between 0.47 and 1.62 ml. It has been previously shown that Bursa city was a moderately iodine-deficient area. We therefore aimed at determining normal reference ranges of neonatal thyroid volumes in our moderately iodine-deficient area.

METHODS

In this cross-sectional study, thyroid volumes of 100 healthy fullterm neonates (51 boys and 49 girls; mean gestational age 38.9+/-1.1 weeks; and mean birth-weight 3370+/-446 g) were measured during the first week of life using thyroid ultrasonography. These data were compared with the gestational age, birth weight, gender, and TSH values of neonates as well as with maternal factors such as gestational diabetes, preeclampsia, smoking, medication use, and heart disease.

RESULTS

All blood samples for TSH were taken during the first 5 days (mean 1.09+/-0.9 days). The mean TSH levels in all male and female neonates were 3.77+/-3.71, 4.57+/-3.61, and 2.93+/-3.66 mIU/l, respectively. This difference was statistically significant (p=0.006). Mean thyroid volumes for all male and female neonates were calculated as 0.82+/-0.18 (range 0.51-2.04), 0.84+/-0.21 (range 0.51-2.04), and 0.80+/-0.14 ml (range 0.58-1.30), respectively. There were no statistically significant differences in thyroid volumes with respect to gestational age, birth weight, gender, TSH values of neonates and maternal factors.

CONCLUSION

Normal thyroid volumes in neonates vary between different regions. Local reference values should be used in thyroid volume assessment. Our results are in concordance with the literature and can be used as reference values for our region.

Increased incidence of congenital hypothyroidism due to iodine deficiency

BACKGROUND

The incidence of congenital hypothyroidism (CH) is expected to be elevated in iodine-deficient areas. In this study, the authors aimed to determine the incidence of transient and permanent CH in a large city which is known to be in the zone of moderate iodine deficiency.

METHODS

Newborn babies in Bursa, Turkey, were screened by measurement of serum thyroid-stimulating hormone (TSH) obtained by heel prick. The babies who had a serum TSH >20 mIU/L were recalled for measurement of T4 and TSH in venous serum.

RESULTS

A total of 11 770 newborns were screened over a period of 9 years. The incidence of CH was found to be 1/840. However, after excluding the transient cases, permanent CH was diagnosed in 1/2354. It was impossible to distinguish transient patients from permanent CH by initial laboratory tests (P > 0.05). The estimated power of the study in determining the incidence of CH in the population was 90% (P < 0.05).

CONCLUSION

The authors conclude that the incidence of CH is very high in their population which warrants a country-wide neonatal screening program. Since transient cases cannot be distinguished and untreated transient hypothyroidism may also cause mental retardation, treatment must be started as early as possible with frequent monitoring to optimize the outcome and identify the transient patients.

Role of procalcitonin and CRP in diagnosis and follow-up of neonatal sepsis

We aimed to investigate the role of procalcitonin in the diagnosis and follow-up of neonatal sepsis, and to compare it with C-reactive protein (CRP) in this context. Between April and October 2002, a total of 67 neonates were randomly recruited into the study and were divided into four groups as: those with highly probable sepsis (group 1), probable sepsis (group 2), possible sepsis (group 3), and no sepsis (group 4; controls). When the initial procalcitonin levels of the groups were compared, the results were statistically significant (p < 0.05) except for the comparison between groups 3 and 4 (p > 0.05). When the initial CRP levels were compared between the groups, the levels measured in groups 1 and 2 were significantly higher than the levels measured in groups 3 and 4 (p < 0.05). In addition, the decreasing levels in procalcitonin were statistically more significant than the decreasing levels in CRP in showing the response to antibiotic treatment (p < 0.01 and p < 0.05, respectively). In conclusion, serum procalcitonin levels seemed to be superior to serum CRP levels in terms of early diagnosis of neonatal sepsis, in detecting the severity of the illness, and in evaluation of the response to antibiotic treatment.

Difficulties in achieving optimal cytoreduction in primary peritoneal carcinoma management

Primary peritoneal carcinoma (PPC) occurs mostly in older women and rarely in women under 50 years of age. The mean age of patients with PPC in our study was 65.5 years. We present the clinical and demographic data, management of cases and the results of six women who underwent exploratory laparotomy between January 2003 and August 2006.

Nonbronchoscopic bronchoalveolar lavage for diagnosing ventilator-associated pneumonia in newborns

The appropriate treatment of ventilator-associated pneumonia (VAP) must be based on accurate diagnosis, which can be done by microbiological examination of the samples obtained from the respiratory tract by nonbronchoscopic bronchoalveolar lavages (NB-BAL). This study was designed to determine the effectiveness of NB-BAL in diagnosing VAP in newborns. Two hundred and seven NB-BAL samples were obtained from 145 intubated neonates for microbiologic and cytologic evaluation of the distal airway. The NB-BAL samples were processed for microscopic quantification of the polymorphonuclear cells (PMN) containing intracellular bacteria (ICB) and quantitative culture (positive threshold, 10(5) cfu/ml). VAP was defined as a new, progressive, or persistent (>24 hrs) infiltrate on the chest radiograph, with two or more of the following criteria: (a) macroscopically purulent tracheal secretions, (b) fever or hypothermia, (c) leukocytosis or leukopenia, and (d) worsening of respiratory status with a Pa O2/F IO2 ratio of <240. Colonization was defined as mechanical ventilation for more than seven days, no signs of infection, and isolation of the same bacteria species in two previously obtained NB-BAL samples. Of the 145 neonates, 40 (27.5%) were infected and 12 (8.3%) were colonized. Forty-four patients (30%) developed VAP according to diagnostic categories based on clinical and radiologic criteria. Forty newborns with VAP (90%) had positive NB-BAL culture. The sensitivity, specificity, and positive and negative predictive values of NB-BAL fluid culture for VAP diagnosis were 90%, 90%, 70%, and 97%, respectively. The percentage of ICB was significantly higher in newborns with VAP. The presence of ICB in 2% or more on Giemsa-stained smears corresponded to a sensitivity of 94%, specificity of 83%, positive predictive value of 94%, and negative predictive value of 83%. The sensitivity and specificity of combination of ICB and NB-BAL quantitative culture in diagnostic samples were 94% and 90%, respectively. The positive and negative predictive values were 71% and 98%. In our study, the presence of leukocytes in the NB-BAL fluid smear of infants with VAP was higher than that of the colonized babies (84%, 26%). This difference was statistically significant (p < 0.0001). The sensitivity and specificity of PMNs in NB-BAL fluid for the diagnosis were 86% and 75%, respectively, and the positive and negative predictive values were 89% and 69%. We conclude that NB-BAL lavage is well tolerated and clinically useful in mechanically ventilated newborns. These results suggest that NB-BAL fluid microscopic examination and cultures can offer a sensitive and specific means to diagnose VAP in newborns and may provide relevant information about the causative pathogens.

Complement 4 levels as early predictors of poor response to surfactant therapy in respiratory distress syndrome

The aim was to determine whether stronger complement activation is an early predictor of poor response to surfactant treatment in infants with severe respiratory distress syndrome (RDS). Thirty-one preterm newborns with severe RDS (initial fraction of inspired oxygen [FiO (2)] > 0.5) and 22 healthy preterm newborns were studied. The study group was divided into two subgroups according to their response to natural surfactant 6 hours after administration: good responders had reduction in FiO (2) > 50% of the presurfactant level, and poor responders had a reduction in FiO (2) < or = 50%. Levels of complement 4 (C4) and C3c were measured in blood samples drawn at admission and 24 hours after birth. The poor responders to surfactant had significantly lower serum C4 levels at admission and in the first day of life than the good responders. The poor responders also had lower C3c levels at birth than the good responders, but higher C3c levels at 24 hours. Receiver-operator curve analysis revealed that, compared with C3c at admission, C4 at admission was a more sensitive and specific predictor of poor response to surfactant treatment in preterm newborns with severe RDS (area under the curve, 0.863; 95% confidence interval, 0.726 to 1; p = 0.001). Significantly decreased serum C4 at admission is a valuable early predictor of poor response prior to surfactant treatment in preterm newborns with severe RDS. C4 level may help investigators determine the mechanisms underlying poor responsiveness to surfactant.

Pregnancy under treatment of imatinib and successful labor in a patient with chronic myelogenous leukemia (CML). Outcome of discontinuation of imatinib therapy after achieving a molecular remission

Because of the teratogenicity data in rats, it is recommended that women treated with imatinib should be aware of the potential teratogenicity of imatinib and effective contraception should be used during imatinib therapy to prevent pregnancy. We describe successful pregnancy and delivery, without any congenital anomaly, in a patient with CML under treatment of imatinib. The fetus had been exposed to imatinib for 8 weeks. The patient remained off treatment during gestation and cytogenetic relapse of CML (5 months after discontinuation of imatinib therapy) developed at seventh month of gestation.

Neurocutaneous melanosis with transposition of the great arteries and renal agenesis

Neurocutaneous melanosis (NCM) is rare and is characterized by the proliferation of melanocytes in the central nervous system. A 6-day-old infant boy was referred to our department with giant congenital melanocytic nevi and convulsions. On physical examination the patient had a giant black-brown pigmented nevus covering his face, neck, scalp, shoulders, back, chest, and abdomen. Numerous satellite lesions were noted on the face, neck, and upper extremities. In the right bulbar conjunctiva, a brown plaque was present. Magnetic resonance imaging (MRI) showed hyperintense areas in the brain on short repetition time/short echo time sequences, compatible with intraparenchymal melanin deposits. No leptomeningeal abnormality was seen. Further investigation also revealed agenesis of the right kidney and transposition of the great arteries. Transposition of the great arteries, which has never been reported in NCM, may be an incidental finding. We present a case of NCM associated with agenesis of the right kidney and transposition of the great arteries.

Idiopathic thrombocytopenic purpura in pregnancy: a single institutional experience with maternal and neonatal outcomes

We observed 13 pregnant women of 70 females with idiopathic thrombocytopenic purpura (ITP) from January 1992 through September 2002. Thirteen mothers with ITP gave birth to twelve babies and two fetuses died. One of the pregnancies produced twins. Seven of the cases were diagnosed with ITP before pregnancy and six during pregnancy. One of the thirteen pregnancies was complicated by preeclampsia, one by ablatio placentae, and one by intrauterine death. Seven mothers received corticosteroid treatment, four high-dose immunoglobulin therapies, and one underwent splenectomy in the second trimester of gestation. At the time of delivery six mothers had normal platelet counts and seven had low platelet counts. Nine deliveries were by vaginal route and four were by cesarean section. Eleven infants were born with normal platelet counts and one was thrombocytopenic at the time of delivery. No infant showed any clinical signs of hemorrhage and there were no neonatal complications. Two fetuses died; one of them because of ablatio placentae and the other was intrauterine dead. In conclusion, ITP in pregnancy requires the management of two patients, the mother and her baby; hence, the close collaboration of a multidisciplinary group composed of a hematologist, obstetrician, anesthesiologist, and neonatologist is essential.

Risk factors for intraventricular haemorrhage in very low birth weight infants

OBJECTIVE

In a prospective study at Uludag University Hospital, 120 premature infants with birthweights of 1500 g or less were screened for intraventricular hemorrhage (IVH) using cranial ultrasound. With the purpose of studying the incidence of IVH, the associated risk factors for these neonates were considered.

METHODS

We studied all the very low birth weight infants admitted in our neonatal unit. We examined the following variables as risk factors for IVH: sex, birth weight, gestational age, Apgar score, mechanichal ventilation, hypercapnia, use of antenatal steroids, tocolytic drugs, vaginal versus cesarean section delivery, and inborn versus outborn status, vasopressor infusion (any vasoactive drug such as dopamine, dobutamine, or epinephrine) not associated with resuscitation, and surfactant administration.

RESULTS

The incidence of IVH was 15% (18/120), 50% grade I (9/18), 17% grade II (3/18), 11% grade III (2/18), and 22% grade IV (4/18). IVH occurred mainly in the first week of life (78%; 14/18). The significant risk factors for IVH were found to be prematurity, outborn status, low 5 minute Apgar score, vaginal delivery, hypercapnia, mechanical ventilation, hypotension, and use of vasopressors on the day of admission. Significant protective factors against IVH included antenatal steroid therapy, cesarean section, magnesium sulfate tocolysis, increasing gestational age, and increasing birth weight.

CONCLUSION

Our results concur with the notion that a tertiary center is the optimal location for delivery of the high risk neonate. Transportation of infants in utero to a perinatal center specializing in high risk-deliveries results in a decreased incidence of IVH when compared to infants transported postnatally. Aggressive resuscitation, with avoidance of hypercarbia, and rapid restoration of hypovolemia could potentially reduce the incidence of PVH/IVH.

Management of intrabiliary ruptured hydatid disease of the liver

BACKGROUND/AIMS

Intrabiliary rupture of hydatid cyst is an important complication of hydatid disease of the liver. The purpose of this study was to evaluate outcomes of patients with intrabiliary ruptured hydatid disease of the liver.

METHODOLOGY

Two hundred and eleven patients were operated upon for hydatid cyst of the liver between 1990 and 1998 in our hospital. Twenty-four patients with intrabiliary rupture of hepatic hydatid cyst were retrospectively reviewed.

RESULTS

Diagnosis of hydatid cyst was principally made using ultrasonography. We performed partial cystectomy + omentoplasty + transduodenal sphincteroplasty for 18 patients (75%). Daughter cysts and hydatid debris were found in common bile duct in 8 patients (33%). Internal opening of biliary fistula was found in 21 patients (87.5%). Morbidity rate was 12%. One patient died of unrelated causes. The average postoperative hospitalization period for the sphincteroplasty group was 7.6 days.

CONCLUSIONS

Preoperative radiologic examination and laboratory values were not helpful to exclude an intrabiliary rupture of hydatid cysts in our patients. If bile stained cystic fluid is found, it is clear that a communication between hydatid cysts and the biliary tree exist. Transduodenal sphincteroplasty can be preferred in the management of intrabiliary ruptured hydatid disease because of short hospitalization, low morbidity, and ability to decompress intrabiliary pressure.

Meropenem in neonatal severe infections due to multiresistant gram-negative bacteria

Recently, new broad spectrum carbapenem has been investigated on a world-wide scale for the treatment of moderate to severe infections. In the neonatal intensive care units the extensive use of third generation cephalosporins for therapy of neonatal sepsis may lead to rapid emergence of multiresistant gram-negative organisms. We report the use of meropenem in 35 infants with severe infections due to Acinetobacter baumanii and Klebsiella pneumoniae. All gram negative bacteria were resistant to ampicillin, amoxicillin, ticarcilin, cefazoline, cefotaxime, ceftazidime, ceftriaxone and aminoglycosides. Eighty two percent of the cases (29/35) were born prematurely. Assisted ventilation was needed in 85.7% (30/35). All infants deteriorated during their conventional treatment and were changed to meropenem monotherapy. Six percent (2/35) died. The incidence of drug-related adverse events (mostly a slight increase in liver enzymes) was 8.5%. No adverse effects such as diarrhea, vomiting, rash, glossitis, oral or diaper area moniliasis, thrombocytosis, thrombocytopenia, eosinophilia and seizures were observed. At the end of therapy, overall satisfactory clinical and bacterial response was obtained in 33/35 (94.3%) of the newborns treated with meropenem. Clinical and bacterial response rates for meropenem were 100% for sepsis and 87.5% for nosocomial pneumonia. This report suggests that meropenem may be a useful antimicrobial agent in neonatal infections caused by multiresistant gram negative bacilli. Further studies are needed to confirm these results: Meropenem, newborn, sepsis and nosocomial infection.

Evaluation of phagocytic function of macrophages in rats after partial splenectomy

BACKGROUND

Understanding the immunologic properties of the spleen has enabled surgeons to practice splenic conservation surgery. If the upper pole of the spleen can be preserved solely on the upper short gastric vessels, will phagocytic function of macrophages in remnant splenic tissue be affected? The aim of this experimental study was to evaluate the phagocytic function of macrophages in partially resected spleens, with hilar excision preserving the short gastric vessels.

STUDY DESIGN

Forty-eight female Wistar albino rats were divided into four groups. Groups 1 and 2 underwent sham operations and groups 3 and 4 underwent partial splenectomy. One milliliter of sodium chloride 0.9% was injected into the abdomen of the rats in groups 1 and 3 and 1 mL of Streptococcus pneumoniae type III as an antigenic stimulus was injected into the abdomen of the rats in groups 2 and 4, 6 weeks after the first operation. Forty-eight hours later, relaparotomy was performed in all animals. India ink was used to determine the capacity of uptake in the splenic phagocytes. To evaluate the phagocytic function of the splenic tissues, histologic examinations were performed according to a macrophage grading system.

RESULTS

All spleens in all four groups were stained black after injection of India ink. Phagocytic activity of macrophages was reduced in the partially splenectomized groups, compared with intact spleen groups (group 3 versus group 1; p < 0.0001, group 4 versus group 2; p < 0.0001). There was a significant difference between groups 1 and 2 according to phagocytic function of macrophages (p = 0.0121). Also, after Streptococcus pneumoniae type III injection as an antigenic stimulus in group 4, we found that the phagocytic functions of macrophages increased compared with those of the sodium chloride 0.9%-injected group 3 after partial splenectomy (p < 0.0001).

CONCLUSIONS

Phagocytic function of macrophages in rats decreased after partial splenectomy. Nevertheless, the remnant spleens in rats could be stimulated when challenged with an antigenic stimulus.

Hemodynamic stability is the most important factor in nonoperative management of blunt splenic trauma

Since January 1998, non-operative management of blunt splenic trauma has become the preferred method for the selected paediatric and adult patients in our clinic. Of the 26 patients who were admitted to our clinic because of blunt splenic trauma between January 1998 and May 2000, 20 were elected for non-operative management according to our protocol which was primarily based on hemodynamic status regardless of the age and grading of the injury. Diagnostic computed tomography (CT) was obtained in the patients with non-operative management. Non-operative management rate was 76.9% for patients with blunt splenic trauma (83.3% and 71.4% for the paediatric and adult patients, respectively). All of these cases were managed conservatively without any complication and no mortality was observed. Six patients required emergent surgical exploration based on preoperative evaluation. In all of these 6 cases, associated injuries were present. No significant differences were found with regard to the age of operative and non-operative management groups (p = 0.421). The mean operative splenic injury grade was 3 in the patients who underwent surgery, and the mean injury grade based on CT scan was 2.6 in the patients who were managed conservatively (p = 0.572). The mean duration of hospitalisation in the patients with operative and non-operative management groups were 7.6 and 8.6 days, respectively (p = 0.572). The mean unit of blood transfusion in the patients with operative and non-operative management groups were 1.1 and 0.6, respectively (p = 0.453). Our data revealed that hemodynamic stability is the most important factor which could effect the selection of patients for non-operative management outcome regardless of the patient age and computed tomography scan grading of the injury.

Complete remission of the liver metastases of anorectal malignant melanoma with regional chemotherapy: a case report

The prognosis of anorectal malignant melanoma is very poor. We present a 48-year-old male patient with anorectal malignant melanoma and multiple liver metastases who underwent abdominoperineal resection. A port system was implanted to the gastroduodenal artery for regional chemotherapy for liver metastases. Histopathological findings of tumor were 5 cm diameter and 2 cm depth, invading to the external sphincter. Both regional chemotherapy and immunotherapy were initiated 4 weeks postoperatively. The immunochemotherapy regimen included cisplatin (via port system) 50 mg/m2 once in 2 weeks, x 8 cycles, alpha-interferon 5 x 10(6) U subcutaneously on days 1-7 in 4 weeks, x 8 cycles, interleukin-2 9 x 10(6) U subcutaneously on days 5-9 in 4 weeks, x 8 cycles. Computed tomography scan was taken after the 2nd and 4th cycles of chemotherapy and the tumor had not responded to chemotherapy. Dacarbazine 200 mg/m2 intravenously on days 1-5 in a month, x 4 cycles, was added to the previous immunochemotherapy regimen. Computed tomography and magnetic resonance imaging scans were taken on the 10th and 12th months after operation, respectively, no evidence of metastases in the liver was noted. No case of complete remission of liver metastases of anorectal malignant melanoma with regional intraarterial chemotherapy and systemic immunochemotherapy has been previously reported in the literature.

Diagnosis of tuberculosis: PPD or BCG test

In recent years, several articles have been published about BCG tests in the diagnosis of tuberculosis, particularly in children. The test is reportedly more sensitive and more specific than tuberculin test (PPD). We evaluated the results of simultaneous application of PPD and BCG test in order to assess its efficacy in adults and adolescents with tuberculosis (tbc). We applied BCG test and PPD concurrently in 35 healthy controls and 41 tuberculosis cases presented to Research Hospital, Inönü University and Malatya Tuberculosis Dispensary with clinical and radiological findings. The subjects also had sputum examined for presence of acid-fast bacilli (AFB) by direct microscopy, culture on Lowenstein Jensen medium and by polymerase chain reaction (PCR). We conclude that BCG test is more sensitive and more specific than PPD in diagnosis of tuberculosis in adults and adolescents.

Transient hepatitis B surface antigenemia after neonatal hepatitis B immunization

Following immunization with hepatitis B vaccine, 39 infants were followed prospectively for hepatitis B surface antigen (HBsAg). A total of 69.2% of the infants tested positive for antigenemia at least once. Antigenemia was identified most often at 2-3 days (43.5%) and 5-6 days (43.5%) after immunization. The longest documented duration of antigenemia was 21 days. In all cases the antigenemia was transient and cleared by 28th day post-vaccination.