Intravenous immunoglobulin in hemolytic disease of the newborn: A moving target in time.

Background: Alloimmune hemolytic disease of the newborn (AIHDN) results in hemolysis, anemia, hyperbilirubinemia with the potential for brain damage. Intravenous immunoglobulin (IVIG) has been investigated as an alternative low-risk procedure for the treatment of AIHDN in addition to traditional treatment methods such as phototherapy and exchange transfusion (ET). Aim: To evaluate the effectiveness of IVIG therapy in decreasing ET needs based on risk factors and clinical outcomes. Materials and Methods: Charts of neonates born >30 weeks of gestation who underwent phototherapy and were administered IVIG therapy due to AIHDN between January 2013 and July 2018 were retrospectively reviewed. Results: Sixty-three neonates were included in our study. Forty-three of them (68.3) % were full-term infants. ABO incompatibility (n = 33, 52.4%) was the major cause of AIHDN (n = 63). Additional risk factors for jaundice were found to coexist in 95.2% (n = 60) of the infants. Fifteen infants (23.8%) required ET, mostly due to Rh incompatibility (n = 11, 73.3%). Mortality was observed in 3.2% (n = 2) of the patients, 1.6% (n = 1) of whom were related to ET. Serum albumin value was found to be negatively correlated with the requirement for ET (r = 0.713, P < 0.001), whereas serum bilirubin albumin ratio was positively correlated (r = 0.489, _P < 0.001). Nine (14.3%) infants needed a simple transfusion during the hospitalization period, whereas five (7.9%) infants had readmission for simple transfusion after discharge. Apnea was the only complication seen in one (1.6%) patient. Conclusion: IVIG treatment should be considered due to its relative benefits when compared to exchange transfusion. In addition to its safety, it is a less complicated treatment modality with low side effect rates. It may be justified for elective use in neonates suffering from AIHDN, who will require ET with a risk of mortality by decreasing the peak of total serum bilirubin levels.

Acute Peritoneal Dialysis in Premature Infants.

OBJECTIVE: This study aimed to investigate the underlying causes and outcomes of less than 1500 g birth weight infants who underwent acute peritoneal dialysis (PD). METHODS: Case records of infants with birthweight less than 1500 g from January 2015 to June 2018 were reviewed. RESULTS: The median (range) birth weight and gestational age of the patients were 720 g (555-1055) and 26 weeks (23-27.5), respectively. Underlying factors for the development of acute kidney injury (AKI) were patent ductus arteriosus (PDA) (15 patients), necrotizing enterocolitis (NEC) (10 patients), sepsis (7 patients), asphyxia (2 patients) and hydrops fetalis (2 patients). Multifunctional 10 F flexible catheter was used for the procedure. Median PD onset time was 7 days (4.5-13.5) and median PD duration was 3 days (1.5-3.5). Overall mortality rate was 81 % (n=17). CONCLUSIONS: Despite high overall mortality, PD is technically feasible in very low birthweight (VLBW) and extremely low birthweight (ELBW) neonates using a multifunctional catheter.

Spectrum of Brevundimonas vesicularis infections in neonatal period: a case series at a tertiary referral center.

OBJECTIVES: To report infections caused by Brevundimonas vesicularis and the treatment regimens administered based on antibiotic studies of this Gram-negative bacterium in the neonatal period. PATIENTS AND METHODS: Eight hospitalized neonates with positive blood cultures for Brevundimonas spp. were studied. Demographic data, clinical and laboratory findings, nutritional regimens, presence of primary disease, and the antibiotic regimens administered during the treatment of these neonates were noted. Antimicrobial susceptibility tests were performed on isolates of the positive cultures. RESULT: Four neonates were preterm, and four were full-term infants. The underlying diseases--with the exception of being a neonate--were congenital heart disease (4 patients), respiratory distress syndrome (2), multiple congenital cerebral anomalies (1), and meconium aspiration syndrome (1). Septicemia was observed in all eight patients, while three also had concurrent meningitis. Multidrug resistance to the antimicrobials, including piperacillin-tazobactam, ceftazidime, and aztreonam, were identified in all eight infants; however, susceptibility to amikacin and imipenem was retained. All study patients responded to the antibiotic treatments and subsequent cultures were sterile. One patient died due to other causes. CONCLUSIONS: We consider that until larger series are available, B. vesicularis should be regarded as virulent. Consequently, in this era of multi-resistant Gram-negative bacteria, serious B. vesicularis infections in neonates should be treated with a broad-spectrum agent, such as third-generation cephalosporin until the results of susceptibility testing are available. Our case reports demonstrate that the susceptibility of this organism to all aminoglycosides and third-generation cephalosporin is not uniform, but that most of the isolates are susceptible to imipenem. More treatment experience and more exact results from antimicrobial susceptibility testing are required to improve on present treatment regimens for invasive B. vesicularis infections.

Severe hepatitis with prolonged cholestasis and bile duct injury due the long-term use of ornidazole.

Nitroimidazole derivatives are commonly used in the treatment of protozoal and anaerobic infections, and reports of their hepatotoxicity are rare. We report a case of severe hepatitis due to the long-term (8 weeks) use of ornidazole. A 27-year-old woman presented for evaluation of elevated serum transaminase and total bilirubin levels. Liver biopsy revealed portal inflammation, hepatocellular and canalicular cholestasis, porto-portal and portocentral bridging fibrosis, and a tendency to form nodules. No aetiological factors associated with chronic liver disease were identified. The abdominal ultrasonographic findings were compatible with chronic liver disease. We therefore made the diagnosis of severe hepatitis resulting from the long-term use of ornidazole. We conclude that nitroimidazole derivatives may lead to serious liver damage, especially in female patients.

The effects of Gingko biloba, vitamin E and melatonin on bacterial translocation in thioacetamide-induced fulminant hepatic failure in rats.

BACKGROUND AND STUDY AIMS: Bacterial translocation (BT) has been implicated in the development of infectious complications in many serious clinical conditions such as fulminant hepatic failure (FHF). We aimed to investigate the effects of Gingko biloba (GB), vitamin E (Vit E) and melatonin on intestinal oxidative damage and BT in thioacetamide (TAA)-induced FHF in rats. MATERIALS AND METHODS: A total of 42 rats were divided into five groups. Group 1 (n = 8) was the control group. Group 2 (n = 10) was the TAA group, in which rats received 350 mg/kg TAA daily by the intraperitoneal (ip) route for 3 days. Oral 100 mg/kg GB per day was administered to group 3 (n = 8), oral 200 mg/kg Vit E per day to group 4 (n = 8) and ip 3 mg/kg melatonin per day to group 5 (n = 8) 48 h prior to the first TAA injection and was continued for 5 consecutive days. RESULTS: When compared with the control group, serious hepatic and intestinal oxidative damage, increased Escherichia coli counts in ileal aspirates and high BT frequencies were observed in the TAA group (all p < 0.0001). Only GB treatment attenuated hepatic oxidative damage (p < 0.0001). There was no difference in intestinal oxidative damage, E. coli counts in ileal aspirates and BT frequency between TAA and the other antioxidant treatment groups (p > 0.05). CONCLUSION: Our results suggest that intestinal oxidative damage plays a major role in the development of BT by disrupting the barrier function of intestinal mucosa.

Effect of fish oil, olive oil, and vitamin E on liver pathology, cell proliferation, and antioxidant defense system in rats subjected to partial hepatectomy.

The high capacity of liver regeneration after partial hepatectomy (PH) is well known. This study investigated the role of the antioxidant defense system in regeneration among Wistar-albino male rats subjected to 70% partial hepatectomy after a pretreatment period of 2 weeks with eicosapentanoic acid (EPA) rich fish oil (FO), first pressed virgin olive oil (OO), or vitamin E. The control group of 10 rats underwent PH only. On postoperative day 3, all rats were humanely killed. Liver sections of animals treated with FO or vitamin E showed significant increases in regeneration within both liver parenchyma and cut surface compared with the control group (P < .05). Liver sections of OO displayed an insignificant increase in liver regeneration (P > .05), with less increase in parenchyma than of the cut surface. The enhancement of the liver parenchymal regeneration in the FO group was significantly greater than that of the vitamin E group. Concerning liver function tests (LFT), there was no significant difference among the groups. When the treatment groups were compared to the control group glutathione (GSH) levels were increased and content of malondialdehyde (MDA), nitric oxide (NO), and superoxide dismutase (SOD) were decreased. Based on these results, we concluded that after 70% PH in rats, the liver parenchyma and cut surface regeneration were greatest with FO and least with OO treatment. Both FO and vitamin E served to improve the antioxidant defense system more than OO treatment.

The effects of methylene blue on lung injury in septic rats.

PURPOSE: We aimed to investigate the effects of methylene blue (MB) on NO production, myeloperoxidase (MPO) activity, antioxidant status and lipid peroxidation in lung injury during different stages of sepsis in rats. MATERIAL AND METHODS: Rats were randomly divided into 4 groups (n = 20): group C, sham operated; group CMB, sham operated and receiving MB (25 mg/kg, i.p.); group S, sepsis; group SMB, sepsis and receiving MB (25 mg/kg, i.p.). Sepsis was induced by cecal ligation and puncture (CLP). The MB dose was administered after CLP. Each group was subdivided into two subgroups (n = 10) which were sacrificed at 9 or 18 h after the surgical procedure. The levels of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-PX) and MPO activity, total nitrite/nitrate and malondialdehyde (MDA) in the lung tissue were measured. Lung injury was graded from 1 (injury to 25% of the field) to 4 (diffuse injury) by the pathologist. RESULTS: In group SMB, while SOD and CAT increased in both early and late sepsis periods, GSH-PX increased significantly only in the early sepsis period when compared with group S. Increase in lung MPO activity after CLP-induced sepsis was prevented by MB administration. MB significantly decreased to nitrite/nitrate and MDA levels both in early and late sepsis periods when compared with group S (p < 0.05). Group S showed a marked increase in neutrophil infiltration into the interstitial space and thickening of the alveolar septa, whereas the alveolar damage score was lower in the SMB group (p < 0.05). CONCLUSION: MB reduced the MPO activity and lipid peroxidation by both decreasing oxidative stress and NO overproduction in the lungs, which resulted in the attenuation of lung injury after CLP-induced sepsis in rats.

Polyurethane stent obstruction as a cause of recurrent epiphora. Case report.

SUMMARY: A Song's nasolacrimal duct stent was placed in a patient with epiphora due to primary nasolacrimal duct obstruction and the stent was kept for 32 months. Mitomycin C 0.02% eye drops four times a day were prescribed for four weeks following polyurethane stent placement procedure. No epiphora-related complaints occurred for thirty months after then the epiphora started. Nasolacrimal stent was removed from nasal cavity endoscopially and the tissues within the extruded stent were examined histopathologically. The patient's complaints were relieved following stent removal. Dacryocystogram revealed normal passage and a filling defect within the lacrimal sac. Macroscopic evaluation of the stent revealed a firm mass in the stent mushroom, causing complete obstruction. Pathological examination of the mass revealed chronic inflammation, increased connective tissue and vascular proliferation. Nasolacrimal polyurethane stents can be removed easily by nasal approach. Nasolacrimal passage may be left open temporarily after stent removal. The use of Mitomycin C drop is a novel approach in nasolacrimal stent placement cases. However, when the long-term results of endoscopic and external dacryocystorhinostomy are considered, further research is needed on the biocompatibility of stent material.

Maxillary brown tumor and uremic leontiasis ossea in a patient with chronic renal insufficiency.

Findings of renal osteodystrophy in cranial bones are not uncommon and include osteomalacia, osteosclerosis, erosion of the cortical bone, brown tumors and resorption of the lamina dura. However, massive thickening of the cranial vault and facial bones, called uremic leontiasis ossea, have been reported very rare. In the present article, we describe the case of an uncooperative female patient with a brown tumor, involving the left maxillary sinus and massive thickening of the cranial vault and facial bones, secondary to severe secondary hyperparathyroidism during 8 years of regular hemodialysis treatment.

Uterine metastasis from infiltrating ductal carcinoma of breast in a patient receiving tamoxifen.

The established relationship between tamoxifen and the development of endometrial cancer causes differential diagnostic problems between metastatic and primary uterine neoplasms. A 45-year-old woman underwent modified radical mastectomy because of left-breast cancer. She presented with abnormal vaginal bleeding 6 years later, while still on tamoxifen therapy. The endometrial curettage revealed undifferentiated adenocarcinoma. She underwent total abdominal hysterectomy, bilateral salphingoopherectomy as well as pelvic and periaortic lymphadenectomy. Microscopic examination revealed neoplastic cells which formed sheets and duct-like structures in the endometrium. The pattern was not that of a primary endometrial tumour and an immunohistochemical staining was performed using human breast gross cystic disease fluid protein-15 (GCDFP-15) which was found out to be positive in the tumour cells. A diagnosis of metastatic ductal carcinoma of the breast in the uterus was rendered. Uterine metastasis should be kept in mind in patients with a history of breast cancer who are on tamoxifen therapy.