CSF cytokine levels in preterm infants may reflect systemic inflammation and are independent of gestation.

BACKGROUND: Among preterm infants, high concentrations of inflammatory mediators in cerebrospinal fluid (CSF) are associated with poor outcome. Previous studies have not indicated whether CSF concentrations of inflammatory mediators are associated with important confounders such as gestational age. AIMS: To examine associations between CSF concentrations of inflammatory mediators and gestational age, maternal features suggestive of inflammation, characteristics of the CSF sample or the presence of a systemic inflammatory response. STUDY DESIGN AND SUBJECTS: Aliquots of CSF obtained during routine investigation of potential sepsis among infants born before 35 weeks gestation were assayed for 17 mediators of inflammation using a fluorescent multi-bead analyser. Other information was collected from routine clinical records. RESULTS: 39 infants were assessed. CSF levels of mediators of inflammation were not correlated with gestational age. CSF red blood cell counts were correlated with CSF concentrations of IL-6, GM-CSF and IL-17 (each p<0.003). CSF lactate was correlated with CSF concentrations of IL-1beta, IL-6, GM-CSF, G-CSF, IFN-gamma and MIP-1beta. CSF concentrations of IL-1beta, IL-6, G-CSF, TNF-alpha and IFN-gamma were higher in infants with a raised CRP within 24 h of delivery (each p<0.003). CONCLUSIONS: CSF concentrations of inflammatory mediators most probably reflect inflammatory pathologies and are not influenced by gestational age. They may also, however, reflect contamination with blood or systemic inflammation. CSF concentrations of inflammatory mediators may not provide a specific indicator of CNS inflammation.

Negative exploration for pyloric stenosis--is it preventable?

BACKGROUND: The diagnosis of infantile hypertrophic pyloric stenosis (IHPS), although traditionally clinical, is now increasingly dependent on radiological corroboration. The rate of negative exploration in IHPS has been reported as 4%. The purpose of our study was to look at elements of supportive clinical evidence leading to positive diagnosis, and to review these with respect to misdiagnosed cases undergoing negative exploration. METHODS: All infants undergoing surgical exploration for IHPS between January 2000 and December 2004 were retrospectively analysed with regard to clinical symptoms, examination findings, investigations and operative findings. RESULTS: During the study period, 343 explorations were performed with a presumptive diagnosis of IHPS. Of these, 205 infants (60%) had a positive test feed, 269 (78%) had a positive ultrasound scan and 175 (55%) were alkalotic (pH >or=7.45 and/or base excess >or=2.5). The positive predictive value for an ultrasound (US) diagnosis was 99.1% for canal length >or=14 mm, and 98.7% for muscle thickness >or=4 mm. Four infants (1.1%) underwent a negative surgical exploration; Ultrasound was positive in 3, and negative in 1(who underwent surgery on the basis of a positive upper GI contrast). One US reported as positive had a muscle thickness <4 mm. Two false positive US were performed at peripheral hospitals. One infant had a false positive test feed following a positive ultrasound diagnosis. Two infants had negative test feeds. CONCLUSION: A 1% rate of negative exploration in IHPS compares favourably with other studies. However potential causes of error were identified in all 4 cases. Confident diagnosis comprises a combination of positive test feed and an 'in house US' in an alkalotic infant. UGI contrast study should not be used in isolation to diagnose IHPS. If the test feed is negative, strict diagnostic measurements should be observed on US and the pyloric 'tumour' palpated on table under anaesthetic before exploration.

Pontomedullary disconnection: fetal and neonatal considerations.

The cerebellar and pontocerebellar hypoplasias present a unique challenge when detected in the developing fetus. A diverse aetiology and prognosis make counselling of these families difficult. Advances in fetal imaging allow for more accurate diagnosis and counselling, but postnatal MRI is still required. A case is presented in which cerebellar hypoplasia was detected at 20 weeks gestation. Later fetal imaging provided further information, but a diagnosis of pontomedullary disconnection was not made until the postnatal MRI scan. The clinical findings and possible causes of such pontocerebellar abnormalities are discussed.

Congenital cystic adenomatoid malformation: is there a difference between the antenatally and postnatally diagnosed cases?

BACKGROUND: The majority of congenital cystic adenomatoid malformation (CCAM) lesions are diagnosed antenatally. A few cases however may not be recognised antenatally and present in infancy or later childhood with chest symptoms, including chest infection. OBJECTIVE: To review the clinical and radiological spectrum of CCAM, comparing the antenatally with the postnatally diagnosed cases. MATERIALS AND METHODS: Fifteen cases of antenatally and/or postnatally diagnosed and histopathologically proven CCAM were retrospectively identified over a period of 4 years. Clinical notes, chest radiograph and chest CT were reviewed in all cases. RESULTS: Nine patients were diagnosed antenatally and six postnatally. All antenatally diagnosed patients were asymptomatic at birth, six remained asymptomatic until they had elective surgery and the remaining three developed symptoms before the age of 2 years. In the postnatally diagnosed group, one patient was symptomatic at birth and one patient presented at 16 years; the remaining four presented before the age of 2 years. Depending on the type of lesion, we recognised five radiographic patterns of CCAM. CCAM lesions were classified as CT Stocker type I in seven cases, type II in seven cases and type III in one case. CONCLUSIONS: No significant difference was found between the two groups. Recognition of these lesions antenatally would benefit patients by avoiding delay in making the diagnosis, which can lead to serious complications. CT was successful in accurately diagnosing and grading CCAM lesions.

Isochromosome 20p associated with multiple congenital abnormalities.

A second case of tetrasomy 20p due to an additional isochromosome 20p is reported. This resulted in a spontaneous intrauterine death with multiple congenital abnormalities. In keeping with the previous report, the foetus had poor ossification resulting in multiple long bone fractures.

Atypical chronic lung disease in preterm infants.

An atypical pattern of chronic lung disease (CLD) has been described in preterm infants and a potential association with intrauterine inflammation has been proposed. We aimed to describe patterns of CLD, to determine the incidence of atypical CLD, and to compare the distribution of various perinatal factors in infants with classic and atypical CLD. Information about demographics, respiratory status and various perinatal variables was collected for all neonatal admissions <1250 g. CLD was defined as oxygen dependency at 28 days of age. Ninety (51%) survivors at 28 days of age developed CLD; of these 37 (41%) were classified as atypical CLD. Factors significantly and independently associated with development of atypical CLD included being inborn, receiving natural surfactant, fewer days of mechanical ventilation within the first 28 days of life and higher birthweight. Chorioamnionitis, postnatal infection and symptomatic PDA were not found to be significantly associated with atypical CLD. Atypical CLD is a common pattern of prolonged oxygen dependency in preterm survivors and is a feature of larger, more mature babies. Our findings do not support the hypothesis that exposure to intrauterine inflammation is an important aetiological factor in the development of atypical CLD.

Patients' perceptions of "uncertainty" in nurse practitioner consultations.

The aim of this qualitative study was to explore patients' perceptions of consulting with a nurse practitioner in situations of clinical uncertainty. Uncertainty in this context is defined as one where there is no obvious diagnosis, treatment or where the outcome of the consultation is not definite. Three general practice sites were recruited to participate. 43 patients who consulted with one of three nurse practitioners were interviewed using a semistructured schedule. The nurse practitioners identified uncertainty in 30 of these consultations; only two patients expressed any awareness of uncertainty with the consultation. The results showed that patients appear to accept that there will be a level of uncertainty in some consultations. Recognition of uncertainty within the consultation does not appear to have a negative effect on patients' perception of the nurse practitioner as they feel that the nurse will refer to a doctor if necessary.

Left pulmonary artery sling presenting as unilateral echogenic lung on 20-week detailed antenatal ultrasound examination.

BACKGROUND: We report the first case of left pulmonary artery sling (LPAS) presenting as unilateral echogenic lung at a routine 20-week antenatal US examination. The infant had minimal symptoms at delivery, but developed an oxygen requirement and respiratory distress from day 10 of postnatal life. Antenatal US and antenatal MRI indicated an intrathoracic anomaly, so permitting definitive investigations in the neonatal period using CT, MRI and helical-CT-acquired virtual bronchoscopy. The infant successfully underwent corrective surgery. REASON TO REPORT: Antenatal ultrasound detected an anomaly permitting definitive diagnostic investigations to be performed shortly after birth. Investigations were completed before significant signs and symptoms developed. WHAT WAS UNIQUE: This is the first report of antenatally detected unilateral echogenic lung leading to the diagnosis of pulmonary artery sling. RAMIFICATIONS OF THIS REPORT: This report provides further evidence that improvements in antenatal ultrasound and MRI permit earlier diagnosis and improve patient management.

Neonatal brain abscess--potential pitfalls of CT scanning.

CASE REPORT. A 6-day-old preterm infant collapsed on the neonatal unit and was found to have enterobacter meningitis. Cranial ultrasounds had been normal in the first few days of life, but an ultrasound on day 9 of life showed a well-defined lesion, which was thought to be an abscess in view of his underlying illness. This finding could not be confirmed on CT scanning, which showed oedematous frontal lobes with a lack of grey-white differentiation. OUTCOME. The correct diagnosis and treatment were delayed until a follow-up CT scan showed more typical features of an abscess 4 days later.