Gastrointestinal perforations in neonatal period: experience over 10 years.

AIM: This report describes our experience concerning gastrointestinal perforation due to necrotizing enterocolitis during a 10-year period. METHOD: The cases of 27 gastrointestinal perforations, which were treated in our hospital, were retrospectively reviewed. RESULTS: All patients were neonates and infants up to the age of 2 months. The study population consisted of 16 boys (59.3%) and 11 girls (40.7%). Twenty-one neonates (77.8%) were preterm, and the median gestational age was 28 weeks. Twenty-four cases (88.9%) of perforation underwent laparotomy. The overall mortality was 63%. Seventy-six percent of the preterm neonates and only 16.7% of the full-term neonates died. CONCLUSIONS: Gastrointestinal perforation is still connected with a high mortality rate, with necrotizing enterocolitis being the main cause of death. The neonates who did not undergo surgery all died.

Quantitative ultrasound measurements in premature infants at 1 year of age: the effects of antenatal administered corticosteroids.

The aim of this study was to evaluate the effects of antenatally administered glucocorticoids on bone status of preterm infants at 1 year corrected age. The study population consisted of 32 preterm infants with a gestational age of 24-34 weeks. The infants were divided into two groups according to antenatal exposure to corticosteroids. Quantitative ultrasound (QUS) assessment of bone was performed in the study infants at the corrected age of 1 year. Blood levels of carboxy-terminal propeptide of type I procollagen (PICP) and carboxy-terminal telopeptide of type I collagen (ICTP) were measured at birth and at 1 year corrected age. Levels of PICP and ICTP were significantly lower at birth in corticosteroid-exposed neonates (P < 0.05). At corrected age of 12 months ICTP levels remained significantly lower in corticosteroid-exposed infants, but we found no significant difference in levels of the bone-formation marker PICP between corticosteroid-exposed and nonexposed infants. In the majority of participant preterm infants bone speed of sound (SOS) was within age-adjusted normal values of full-term infants. There was no significant difference in bone SOS between exposed and nonexposed infants at corrected age of 12 months. There was no correlation between SOS and levels of bone markers. The results of our study indicate that, despite the suppression of fetal bone turnover at birth in corticosteroid-exposed infants, antenatal glucocorticoid treatment seems to have no long-term impact on bone status of preterm infants assessed by QUS complementary to measurement of bone-turnover markers at 1 year corrected age.

Risk factors for periventricular leukomalacia.

OBJECTIVE: To identify risk factors implicated in the development of periventricular leukomalacia (PVL) and to evaluate the possible association between PVL with neonatal morbidity. DESIGN: Retrospective case control study. SETTING: Medical records of neonates admitted to a University Hospital between January 2000 and December 2005. POPULATION: Sixty-nine neonates with PVL born at gestational ages from 24 to 34 weeks. Forty-three of these had a cystic form of PVL (cPVL), whereas 26 had transient periventricular echodensities (PVE). METHODS: Each case was matched for gestational age and year of birth with one control. The maternal and neonatal medical records were searched. All data was compared between cases with PVL and controls, as well as between cases with cPVL and those with PVE. Stepwise logistic regression analysis was conducted to identify the independent predictors of PVL. RESULTS: Neonates with PVL suffered more frequently from intraventricular hemorrhage (IVH), respiratory distress syndrome type I (RDS I), seizures, sepsis, required more days of both mechanical ventilation and oxygen administration, while the duration of their hospitalization was longer compared to controls. Also, they were born more frequently to mothers who suffered from preterm premature rupture of membranes (PPROM) and clinical chorioamnionitis. We found that male gender, PPROM, preeclampsia, hypocarbia and IVH were independently associated with PVL. CONCLUSIONS: This study revealed that preterm neonates born to mothers with PPROM or preeclampsia, as well as neonates who presented with hypocarbia or suffered from IVH, appeared to be at high risk for the development of PVL.

Invasive non-typhoidal salmonellosis in immunocompetent infants and children.

OBJECTIVE: To investigate the extraintestinal manifestations of non-typhoidal Salmonellae (NTS) infection in immunocompetent infants and children. METHOD: The study took place at the University General Hospital at Heraklion, Crete. Over a 10-year period from 1993-2002 we studied 1087 patients, of whom 443 were children less than 14 years old, with a culture-proven diagnosis of NTS infection. Stool and blood cultures were routinely obtained in patients presenting with fever and diarrhea. The cases of invasive infection in otherwise well children, including bacteremia and/or extraintestinal focal infections were further analyzed. RESULTS: Invasive cases were less common in children than adults (4.06% vs. 8.7%; relative risk 0.467; 95% confidence intervals (CI) 0.279-0.784; p=0.0033). Furthermore, invasive cases were much less common in the otherwise well than in immunocompromised children (3.5% vs. 21.4%; relative risk 0.163; 95% CI 0.053-0.500; p=0.0008). The 15 otherwise well children with invasive NTS infection were aged from 3 weeks to 7.5 years, and nine were aged less than 12 months. Among them, 11 presented with bacteremia, and four with focal extraintestinal infections (rectal abscess, deep neck abscess, urinary tract infection, elbow arthritis). Salmonella enterica subsp. enterica serovars Enteritidis and Virchow were the most common invasive serotypes. All invasive strains were susceptible to beta-lactams including ampicillin, and to cotrimoxazole. All patients made a complete recovery with intravenous antibiotics and did not present with relapses or major infections during long-term follow-up. CONCLUSION: Invasive non-typhoidal salmonellosis in immunocompetent children is less frequent than in both immunocompromised children and in adulthood. However, invasive cases may well occur in otherwise healthy children, especially during infancy. In these patients, prompt appropriate treatment leads to favorable outcomes.

Methicillin-resistant Staphylococcus aureus osteomyelitis and septic arthritis in neonates: diagnosis and management.

Acute osteomyelitis (AO) in neonates, although rare, represents a diagnostic and therapeutic challenge. A high index of suspicion is necessary to make an early diagnosis, and the observation of clinical signs is crucial. The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) is an emerging problem in pediatrics. In neonates, MRSA infections can cause a wide spectrum of diseases including bone and joint infections. We report two cases of AO in full-term neonates, with no risk factors, due to MRSA.

Outcome of toxoplasmosis acquired during pregnancy following treatment in both pregnancy and early infancy.

OBJECTIVES: Congenital toxoplasmosis is associated with clinical dilemmas as untreated infants may have a guarded prognosis and as treatment may induce severe side effects. The aim of this study was to investigate the outcome of infants born to mothers with toxoplasmosis acquired during pregnancy, following administration of appropriate regimens both during pregnancy and early infancy. STUDY DESIGN: All 35 infants, born to mothers with toxoplasmosis acquired during pregnancy, and referred to the major Neonatal Department in Crete, Greece, during the 7-year period 1997-2003 were included. All neonates were evaluated soon after birth and on a regular follow-up. RESULTS: Almost all mothers received spiramycin from diagnosis through labor and 2 received pyrimethamine and sulfadiazine. At birth, infants had IgG antibody titers ranging from 1/1,350 to 1/109,350. All infants initially received pyrimethamine, sulfadiazine and folinic acid but in only 4 cases treatment was continued beyond the second month of life. Transient neutropenia was commonly observed. A follow-up period of 1.2-8.2 years did not reveal any remarkable sequelae. CONCLUSIONS: Our findings suggest that effective treatment both during pregnancy and early infancy is safe and may contribute to a good outcome of infants born to mothers with toxoplasmosis acquired during pregnancy.

Serum and urine interleukin-6 and transforming growth factor-beta1 in young infants with pyelonephritis.

BACKGROUND: Cytokines are involved both in the acute response during pyelonephritis and in the progression to renal scarring. The aim of the present study was to assess the pro-inflammatory interleukin-6 (IL-6) and the anti-inflammatory pro-fibrotic transforming growth factor-beta1 (TGF-beta) in very young infants with pyelonephritis. METHODS: Serum and urine concentrations of IL-6 and TGF-beta1 were determined by enzyme immunoassay in infants with acute pyelonephritis before antibiotic treatment and in infants with non-renal fever. IL-6 was studied in 12 infants with pyelonephritis and in eight with non-renal fever (median ages, 2 months for both groups). TGF-beta1 was studied in 11 infants with pyelonephritis and in nine with non-renal fever (median ages, 2 and 4 months, respectively). RESULTS: No significant differences were documented in serum concentrations of IL-6 and TGF-beta1 between patients and controls. Urine IL-6 levels were significantly higher in infants with pyelonephritis than in controls (medians, 147 and 21.4 pg/ml, respectively; P = 0.0106). The urine levels of TGF-beta1 were lower in infants with pyelonephritis than in controls, although not significantly (medians, 6.12 and 11.0 ng/ml, respectively; P = 0.0705). CONCLUSIONS: Our findings confirm the implication of IL-6 but not of TGF-beta1 in the pathogenesis of the early stages of pyelonephritis in young infants. Tauhe role of the pro-fibrotic TGF-beta1 in the development of renal scarring deserves further investigation.

User involvement in the provision of HIV services: some lessons learned from a user group in an HIV treatment centre in London.

In recent years attention has been focused on the greater participation of health service users in the identification of health service need, service design and delivery and service evaluation. This approach attempts to improve communication between health professionals and the health communities they serve in order to deliver more effective services. The establishment of user groups in HIV services has been one approach by which clinicians have attempted to establish ways that service users could help in the improvement of clinical services. This research article describes the process in the involvement of a user group in an east London HIV service. It describes the challenges that faced both the service users and the clinical staff and it analyses the factors that led to the discontinuation of the user group. The article discusses factors and challenges that must be addressed before meaningful user involvement in HIV services can be established.

3C syndrome with cryptorchidism and posterior embryotoxon.

We report a case of the 3C (cranio-cerebello-cardiac) syndrome, also known as Ritscher-Schinzel syndrome, a rare autosomal recessive disorder characterized by craniofacial, cerebellar, and cardiac anomalies. In addition to features previously reported the child had Wormian bones of the skull, intra-abdominal testes, and posterior embryotoxon that have not previously been reported as part of the 3C syndrome.

Incidence of toxoplasmosis in 5532 pregnant women in Crete, Greece: management of 185 cases at risk.

OBJECTIVES: To study the incidence of toxoplasmosis in pregnant women in Crete and to test a designed protocol for handling those at risk of delivering congenitally infected infants. STUDY DESIGN: Pregnant women were screened serologically over a period of 5 years. Cases with suspected acute toxoplasmosis were treated, peripheral blood (PB), and amniotic fluid (AF) tested by polymerase chain reaction (PCR) and culture, and fetuses monitored by ultrasonography. The absence of congenital infection in infants was confirmed by serology and clinical evaluation. RESULTS: Of the 5532 pregnant women followed, 70.57% remained seronegative, 29.45% were seropositive, and there was direct evidence of seroconversion in six cases. Acute toxoplasmosis was suspected in 185 cases, maternal parasitemia was detected in five cases and positive amniotic fluid in one case. Congenital infection was excluded in all infants followed, based on the absence of ultrasound findings in utero, lack of clinical symptoms at birth, negative Western blotting (WB) at birth and 3 months later, and descending serology for a year. CONCLUSION: Overall, 29.45% of the pregnant women followed were seropositive, 3.3% with suspected acute toxoplasmosis, and in 0.02% cases there was evidence of maternofetal transmission. The protocol tested allowed differentiation between acute and latent toxoplasmosis, safe management of the cases at risk and assisted in avoidance of unwarranted pregnancy terminations.

Feeding difficulties in a neonate with primary cricopharyngeal achalasia treated by cricopharyngeal myotomy.

Primary cricopharyngeal achalasia resulting from failure of relaxation of the cricopharyngeus muscle is a rare but significant cause of dysphagia in newborns. Symptoms may be nonspecific. Although surgical management with cricopharyngeal myotomy has been employed successfully for the treatment of this disorder, swallowing difficulties may persist postoperatively, probably due to association with other esophageal abnormalities. Alternative methods of feeding may be required to ensure adequate nutrient intake. We report the case of a full-term, 2-day-old neonate with this rare clinical condition, treated by myotomy, in whom swallowing difficulties persisted for several weeks after surgery. Satisfactory nutrition was maintained postoperatively with the support of a nasogastric feeding tube until improvement in feeding intolerance. Complete symptomatic relief was attained at the age of 5 months.

Peritoneal fluid concentrations of ß-chemokines in endometriosis.

OBJECTIVE: To examine whether the levels of MCP-1, RANTES and MCP-3 in the peritoneal fluid correlate with endometriosis. STUDY DESIGN: Patients with endometriosis were compared with controls. SETTING: Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA. SUBJECTS: This study involved 95 women of reproductive age who were undergoing laparoscopy for evaluation of infertility or for pelvic pain. They were divided into an endometriosis group (n=54) and a control group (n=41). INTERVENTIONS: Peritoneal fluid samples were obtained and ß-chemokines (MCP-1, RANTES and MCP-3) were measured using ELISA. STATISTICAL ANALYSIS: Mean and median values were used to present values. Due to the non-normality of chemokines, a log transformation was applied. Differences were examined using independent samples t-test. One-way ANOVA and Tukey HSD multiple comparison post hoc tests were applied. A significance level at 0.05 was set. RESULTS: The levels of MCP-1 are higher (p for log values=0.024) in the control group (mean=687.6, SD=467.7 pg/ml) than those of the endometriosis group (mean=570.4, SD=633.1 pg/ml). The same is true for the median values of MCP-1 (control median=568.5, endometriosis median=384.7 pg/ml). MCP-3 and RANTES do not differ significantly (MCP-3 p=0.787, RANTES p=0.153). The levels of MCP-1 in patients with stage II endometriosis are significantly lower in comparison with stage III (p=0.048) and stage IV (p=0.033) endometriosis. CONCLUSIONS: A decrease in the concentrations of MCP-1 in stage I endometriosis has been observed, which is even larger in stage II, in contrast to stage III and stage IV endometriosis, which exhibit concentrations similar to the controls.

Levels of bone collagen markers in preterm infants: relation to antenatal glucocorticoid treatment.

Although the beneficial effects of antenatally administered glucocorticoids are well documented, data on the potential of adverse consequences are limited. The objective of this study was to determine the effects of antenatally administered glucocorticoids on biochemical markers of bone metabolism of 55 preterm infants with a gestational age of 24-34 weeks who were enrolled in the study. Neonates were divided into two groups according to antenatal exposure to corticosteroids. There were no significant differences between the groups in clinical characteristics and anthropometric variables. We studied blood levels of osteocalcin (OC), carboxy-terminal propeptide of type I procollagen (PICP), and carboxy-terminal telopeptide of type I collagen (ICTP) at the time of delivery, on postnatal day 10, and at 2 and 4 months of life. Comparing the groups, we found statistically significant reduction in PICP levels at birth in corticosteroid-exposed neonates (P < 0.05). The levels of bone markers increased progressively on the first days of life. There were no significant differences between groups in bone markers at 10 days or at 2 and 4 months of life. We found no significant difference for bone markers between groups of infants exposed to single or repeated maternal corticosteroid treatments. In summary, antenatal glucocorticoid treatments are suggested to have a negative impact on fetal bone formation as reflected by low PICP levels at birth. However, this negative effect on bone markers seems to be a temporary effect that subsides on the first days of life and afterward.

Urine interleukin-8 as a marker of vesicoureteral reflux in infants.

OBJECTIVE: Vesicoureteral reflux (VUR) is a common finding in children presenting with urinary tract infection (UTI) and prenatally diagnosed urinary tract dilatation and in relatives of index patients. Children with VUR are at risk for ongoing renal damage with subsequent infections. Detecting VUR and renal scarring currently depends on imaging modalities with associated problems of radiation, invasiveness, and expense. Noninvasive methods would greatly facilitate diagnosis and would also help in identifying relatives of index cases who should be screened. Interleukin-8 (IL-8) is produced by epithelial cells of the renal tract in response to inflammatory stimuli and has been shown to increase during acute UTI. The objective of this study was to assess the urine levels of IL-8 as a noninvasive marker of VUR in infants in the absence of a recent UTI episode. METHODS: We evaluated urine concentrations of IL-8 in 59 infants aged 1 month to 2 years. All infants were free of UTI for a minimum of 3 weeks before IL-8 evaluation. Infants were divided into 3 groups: group A, subjects with proven VUR (24 infants aged 0.15-1.95 years, median 0.43); group B, subjects with a history of UTI but negative investigation for VUR (14 infants aged 0.32-1.95 years, median 0.57); and group C, subjects without any history of acute or chronic condition that might impair renal function (21 infants aged 0.08-1.92 years, median 0.33). IL-8 concentrations were determined by a commercially available quantitative enzyme-linked immunosorbent assay. To avoid dilution effects, urinary levels of IL-8 were expressed as the ratio of cytokine-to-urinary creatinine. RESULTS: Results were presented as medians and ranges. The Kruskal-Wallis test, the Mann-Whitney rank sum U test, and the Spearman rank order correlation test were performed for the univariate analysis. Two-tailed P values were calculated and the conventional level of significance P < .05 was applied in all cases. Infants in groups A and B had been free of UTI for a period of 3 to 52 weeks (median, 5.0 weeks) and 3 to 78 weeks (median, 4.5 weeks), respectively, before IL-8 determination. No significant difference was noted in the length of the UTI-free period between groups A and B (P = .469). Urine creatinine concentrations did not differ among groups A, B, and C (medians 1.15, 2.25, and 1.15 micromol/mL, respectively; P = .080). The median urine IL-8/creatinine concentrations (pg/micromol) were 40.5 (range, 2.04-3874) in group A, 1.91 (range, 0.001-386) in group B, and 2.47 (range, 0.002-55.6) in group C. Urine IL-8/creatinine concentrations were significantly higher in group A than both in group B (P = .0003) and in group C (P < .0001). No significant difference was observed between groups B and C (P = .749). In group A, no significant correlation was shown between IL-8/creatinine concentrations and the presence of renal parenchymal damage (P = .506), reflux grade (P = .770), or time from UTI (P = .155). A receiver-operator characteristic curve was constructed by plotting the sensitivity versus the specificity for different cutoff concentrations of IL-8/creatinine. With a cutoff concentration of urinary IL-8/creatinine at 5 pg/micromol, the sensitivity of this marker in diagnosing VUR was 88%, the specificity 69%, the positive prognostic value 66%, and the negative prognostic value 89%. In higher cutoff concentrations, specificity of the marker increased but sensitivity rapidly decreased. CONCLUSIONS: We present evidence that urine IL-8 concentrations remain elevated in infants with VUR even in the absence of UTI and that a cutoff of 5 pg/micromol IL-8/creatinine is of high sensitivity and adequate specificity for diagnosing VUR. Elevated urine IL-8 levels in VUR and renal scarring have already been reported; however, the present study is, to our knowledge, the first to confirm significant differences between infants with VUR and infants with a history of UTI alone and healthy controls, and to suggest a reliable cutoff concentration for diagnosing VUR. Our findings additionally suggest that inflammatory process in VUR is ongoing even after UTI has resolved, pointing against the currently held belief that sterile reflux cannot harm kidneys. The chronic inflammatory cell infiltrate associated with reflux nephropathy rather than VUR itself might offer an explanation for the secretion of IL-8, which may well be independent of reflux grade. Using urine IL-8 for diagnosing VUR is not free of limitations, because IL-8 may be elevated as a result of urinary tract manipulation or undetected UTI. In addition, this study focused on infants and not in older children with longstanding VUR. Increased urine IL-8 concentrations after UTI has resolved is a promising noninvasive marker for an initial screening for VUR in infancy with high sensitivity and adequate specificity.

Interleukin-6 in preterm premature rupture of membranes as an indicator of neonatal outcome.

BACKGROUND: The aim of this study was to investigate whether the levels of interleukin-6 (IL-6) can be used as markers of adverse outcome in preterm neonates born after preterm premature rupture of membranes (PPROM). METHODS: This study involved 109 preterm neonates and their mothers. The PPROM group consisted of 58 neonates who were born after PPROM, and the control group consisted of 51 neonates. IL-6 levels were measured in umbilical cord blood, maternal blood sampled during delivery and in neonatal blood taken on the fourth day of life. RESULTS: In the PPROM group, IL-6 concentrations in maternal blood, cord blood, and neonatal blood were significantly higher in neonates with sepsis, compared with those without sepsis (P < 0.001). Choosing 108.5 pg/ml as a cut-off concentration of IL-6 in umbilical cord blood for neonatal sepsis resulted in sensitivity 95%, specificity 100%, positive predictive value 100%, and negative predictive value 97.4%. Concerning IL-6 in maternal blood, a cut-off concentration of 81 pg/ml showed sensitivity 90%, specificity 97.4%, positive predictive value 94.7%, and negative predictive value 94.9%. Eighteen of 20 neonates with early sepsis and seven of nine neonates, who died in the PPROM group, were born of mothers with IL-6 levels above the cut-off concentration in their blood during delivery. CONCLUSIONS: IL-6 in umbilical cord blood was the most significant variable for predicting early onset sepsis in preterm neonates. IL-6 in maternal blood was indicative of intrauterine environmental threats and might be used to identify pregnancies where intervention would be appropriate.

Peroneal nerve palsy: a complication of umbilical artery catheterization in the full-term newborn of a mother with diabetes.

Umbilical artery catheters are an essential aid in the treatment of newborn infants who have cardiopulmonary disease. However, it is well-known that umbilical artery catheterization is associated with complications. The most frequent visible problem in an umbilical line is blanching or cyanosis of part or all of a distal extremity or the buttock area resulting from either vasospasm or a thrombotic or embolic incidence. Ischemic necrosis of the gluteal region is a rare complication of umbilical artery catheterization. We report the case of a full-term infant of an insulin-dependent diabetic mother with poor blood glucose control who developed a left peroneal nerve palsy after ischemic necrosis of the gluteal region after umbilical artery catheterization. The infant was born weighing 5050 g. The mother of the infant had preexisting diabetes mellitus that was treated with insulin from the age of 14 years. The metabolic control of the mother had been unstable both before and during the pregnancy. The neonate developed respiratory distress syndrome soon after birth and was immediately transferred to the neonatal intensive care unit. Mechanical ventilation via endotracheal tube was quickly considered necessary after rapid pulmonary deterioration. Her blood glucose levels were 13 mg/dL. A 3.5-gauge umbilical catheter was inserted into the left umbilical artery for blood sampling without difficulty when the infant required 100% oxygen to maintain satisfactory arterial oxygen pressure. Femoral pulses and circulation in the lower limbs were normal immediately before and after catheterization. A radiograph, which was taken immediately, showed the tip of the catheter to be at a level between the fourth and fifth sacral vertebrae. The catheter was removed immediately. Circulation and femoral pulses were normal and no blanching of the skin was observed. Another catheter was repositioned and the tip was confirmed radiologically to be in the thoracic aorta between the sixth and seventh thoracic vertebrae. The catheter was continuously flushed with heparinized solution. Three days after umbilical arterial catheterization, bruising was observed over the left gluteal region. The catheter was immediately removed despite its correct position. Over the next few days, the bruised skin and underlying tissues became necrotic. The area affected was 3 x 4 cm in diameter, with central necrosis surrounded by a rim of dark, red skin, which, in turn, was sharply demarcated from normal skin by a narrow, pale zone. Surgical excision of the gluteal necrosis was performed, but a deep ulcer 3 cm in diameter was left. The gluteal ulcer required 1 month to heal completely with extensive scar tissue formation. Throughout this period, the infant showed active movements in all of her limbs. At 4 weeks of age deterioration of all movement below the left knee with a dropping foot was observed. Severe peroneal nerve palsy was confirmed through nerve conduction studies, and there was electromyographic evidence of degeneration of the muscles supplied by the peroneal branch of the sciatic nerve. A Doppler study, which was also conducted, revealed no vascular damage. Treatment with physiotherapy and night-splinting of the left ankle was instituted. Repeated examination and nerve conduction tests at 3 months showed slow improvement with the left peroneal nerve remaining nonexcitable. At the time of this writing, the infant is 6 months old, and muscular strength below the left knee is still weak and atrophic changes in the form of muscle-wasting are already present. The rest of her motor development is normal. In our case, gangrene of the buttocks and sciatic nerve palsy followed displacement of the tip of the catheter into the inferior gluteal artery, a main branch of the internal iliac artery supplying the gluteus maximus, the overlying skin, and the sciatic nerve. The gangrenous changes were probably caused by vascular occlusion resulting from catheter-induced vasospasm of the inferior gluteal artery. Sciatic nerve palsy associated with umbilical artery catheterization has been postulated to be caused by vascular occlusion of the inferior gluteal artery. Infants of diabetic mothers may exhibit changes in coagulation factors and be at increased risk of thrombotic complications in utero and postnatally. In addition, maternal diabetes mellitus is associated with an increased incidence of congenital abnormalities, the incidence of which is 3 to 5 times higher than that among nondiabetic mothers. Although no particular or specific abnormalities have been associated with maternal disabilities, abnormalities of the cardiovascular system, including the development of umbilical vessels, frequently occur. This complication of umbilical artery catheterization has not been widely reported. We describe the first case that refers to gluteal gangrene and peroneal nerve palsy after umbilical artery catheterization of a newborn infant of a diabetic mother with poor blood glucose control. It should be noted that there were no contributing factors except that of the displacement of the catheter into the inferior gluteal artery. We speculate that the displacement of the tip of the catheter, with no difficulty in the present case, was associated with the maldevelopment of normal branching patterns of arteries after exposure of the fetus to hyperglycemia. In conclusion, umbilical artery catheterization is possibly associated with vascular occlusion, particularly in infants of diabetic mothers. Frequent inspection after the procedure has been performed is of the utmost importance especially in these neonates who often suffer from cardiopulmonary disease and require catheterization of their umbilical artery.

Significance of hypocarbia in the development of periventricular leukomalacia in preterm infants.

BACKGROUND: Despite rapid advances in the management of preterm infants, periventricular leukomalacia (PVL) remains a considerable problem in neonatal intensive care. The aim of this study was to determine whether hypocarbia is associated with the development of PVL in mechanically ventilated, preterm infants and to emphasize the importance of avoiding this disturbance. METHODS: The authors evaluated 52 mechanically ventilated infants with a gestational age of <34 weeks, who exhibited hypocarbia in the first three postnatal days (lowest carbon dioxide tension being <25 mmHg). These infants were then compared with 52 infants in a control group not exhibiting hypocarbia, matched for birthweight and gestational age. A diagnosis of PVL was made on the basis of the results of cranial ultrasonography. Confounding factors potentially associated with the development of PVL were controlled in logistic regression analyses. RESULTS: Of the 52 mechanically ventilated preterm infants with hypocarbia, 10 (19.2%) developed cystic PVL, and six (11.5%) developed periventricular echodensity. Of the 52 infants in the control group only two (3.8%) developed cystic PVL, and one (1.9%) infant developed periventricular echodensity. The authors observed no significant differences in other prenatal and perinatal risk factors between the two groups. CONCLUSION: Hypocarbia in mechanically ventilated preterm infants during the first days of life is suggested as being an independent predictor of PVL, predisposing these infants to subsequent neurodevelopmental delay.

Comparative randomized study: administration of natural and synthetic surfactant to premature newborns with respiratory distress syndrome.

BACKGROUND: The respiratory distress syndrome (RDS) in premature newborns has been etiologically correlated to immature lungs and specifically with surfactant deficiency. Exogenous administration of surfactant is nowadays considered to be the treatment of choice. In this paper we attempt a comparison of clinical results from the administration of natural Alveofact and synthetic Exosurf surfactants in premature newborns with respiratory distress syndrome. METHODS: The study subjects were 92 premature newborns who had been hospitalized in the Department of Neonatology, of the University of Crete. A total of 42 subjects received synthetic surfactant and 50 subjects received natural surfactant. The surfactant was administered in one to three doses, depending on respiratory support requirements. RESULTS: The time of administration was a little longer for the natural surfactant group. The duration of mechanical ventilatory support, requiring oxygen, the duration of hospitalization and the percentage of increase of arterial alveolar partial pressure oxygen ratio (a/APO2) were slightly higher for the synthetic surfactant group. The mortality rate during the neonatal period (28th day) was higher for the synthetic surfactant group than for the natural surfactant group (38.1 vs 24%). A similar tendency was noticed also as regards to complications, e.g. pneumothorax (11.2 vs 5.2%; relative risk (RR) 0.27) intraventricular hemorrhage (34.6 vs 21.1%; RR 0.61), septicemia (11.5 vs 5.2%; RR 0.46) and bronchopulmonary dysplasia (12.5 vs 2.8%; RR 0.22). CONCLUSION: The use of natural surfactant seems to offer more advantages in comparison with its synthetic counterpart.