Non-Cystic Fibrosis-Related Meconium Ileus: GUCY2C-Associated Disease Discovered through Rapid Neonatal Whole-Exome Sequencing.

Meconium ileus is caused by cystic fibrosis; however, mutations in the GUCY2C gene also cause this disease. We report non-cystic fibrosis meconium ileus in an infant of non-Middle Eastern origin with compound heterozygous mutations in GUCY2C.

Fertility Treatment Is Associated with Stay in the Neonatal Intensive Care Unit and Respiratory Support in Late Preterm Infants.

Late preterm infants are at risk for short-term morbidities. We report that late preterm singletons conceived with fertility treatment have increased risk for admission to the neonatal intensive care unit and respiratory support compared with spontaneously conceived infants. Fertility treatment may be a risk factor to consider in managing late preterm infants.

Vitamin D and the regulation of placental inflammation.

The vitamin D-activating enzyme 1α-hydroxylase (CYP27B1) and vitamin D receptor (VDR) support anti-inflammatory responses to vitamin D in many tissues. Given the high basal expression of CYP27B1 and VDR in trophoblastic cells from the placenta, we hypothesized that anti-inflammatory effects of vitamin D may be particularly important in this organ. Pregnant wild type (WT) mice i.p. injected with LPS showed elevated expression of mouse Cyp27b1 (4-fold) and VDR (6-fold). Similar results were also obtained after ex vivo treatment of WT placentas with LPS. To assess the functional impact of this, we carried out ex vivo studies using placentas -/- for fetal (trophoblastic) Cyp27b1 or VDR. Vehicle-treated -/- placentas showed increased expression of IFN-γ and decreased expression of IL-10 relative to +/+ placentas. LPS-treated -/- placentas showed increased expression of TLR2, IFN-γ, and IL-6. Array analyses identified other inflammatory factors that are dysregulated in Cyp27b1(-/-) versus Cyp27b1(+/+) placentas after LPS challenge. Data highlighted enhanced expression of IL-4, IL-15, and IL-18, as well as several chemokines and their receptors, in Cyp27b1(-/-) placentas. Similar results for IL-6 expression were observed with placentas -/- for trophoblastic VDR. Finally, ex vivo treatment of WT placentas with the substrate for Cyp27b1, 25-hydroxyvitamin D(3), suppressed LPS-induced expression of IL-6 and the chemokine Ccl11. These data indicate that fetal (trophoblastic) vitamin D plays a pivotal role in controlling placental inflammation. In humans, this may be a key factor in placental responses to infection and associated adverse outcomes of pregnancy.

MyD88 and TRIF mediate the cyclic adenosine monophosphate (cAMP) induced corticotropin releasing hormone (CRH) expression in JEG3 choriocarcinoma cell line.

BACKGROUND: Classically protein kinase A (PKA) and transcription factor activator protein 1 (AP-1) mediate the cyclic AMP (cAMP) induced-corticotrophin releasing hormone (CRH) expression in the placenta. However enteric Gram (-) bacterial cell wall component lipopolysaccharide (LPS) may also induce-CRH expression via Toll like receptor (TLR)4 and its adaptor molecule Myd88. Here we investigated the role of MyD88, TRIF and IRAK2 on cAMP-induced CRH promoter activation in JEG3 cells in the absence of LPS/TLR4 stimulation. METHODS: JEG3 cells were transfected with CRH-luciferase and Beta-galactosidase expression vectors and either empty or dominant-negative (DN)-MyD88, DN-TRIF or DN-IRAK2 vectors using Fugene6 (Roche). cAMP-induced CRH promoter activation was examined by using a luminometer and luciferase assay. Calorimetric Beta-galactosidase assays were performed to correct for transfection efficiency. Luciferase expression vectors of cAMP-downstream molecules, CRE and AP-1, were used to further examine the signaling cascades. RESULTS: cAMP stimulation induced AP-1 and CRE promoter expression and led to dose-dependent CRH promoter activation in JEG3 cells. Inhibition of MyD88 signaling blocked cAMP-induced CRE and CRH promoter activation. Inhibition of TRIF signaling blocked cAMP-induced CRH but not CRE expression, while inhibition of IRAK2 did not have an effect on cAMP-induced CRH expression. CONCLUSION: MyD88 and TRIF exert direct regulatory effect on cAMP-induced CRH promoter activation in JEG3 cells in the absence of infection. MyD88 most likely interacts with molecules upstream of IRAK2 to regulate cAMP-induced CRH expression.

Pretreatment with pancaspase inhibitor (Z-VAD-FMK) delays but does not prevent intraperitoneal heat-killed group B Streptococcus-induced preterm delivery in a pregnant mouse model.

Caspases and apoptosis are thought to play a role in infection-associated preterm-delivery. We have shown that in vitro treatment with pancaspase inhibitor Z-VAD-FMK protects trophoblasts from microbial antigen-induced apoptosis. Objective. To examine whether in vivo administration of Z-VAD-FMK would prevent infection-induced preterm-delivery. Methods. We injected 14.5 day-pregnant-mice with heat-killed group B streptococcus (HK-GBS). Apoptosis within placentas and membranes was assessed by TUNEL staining. Calpain expression and caspase-3 activation were assessed by immunohistochemistry. Preterm-delivery was defined as expulsion of a fetus within 48 hours after injection. Results. Intrauterine (i.u.) or intraperitoneal (i.p.) HK-GBS injection led to preterm-delivery and induced apoptosis in placentas and membranes at 14 hours. The expression of calpain, a caspase-independent inducer of apoptosis, was increased in placenta. Treatment with the specific caspase inhibitor Z-VAD-FMK (i.p.) prior to HK-GBS (i.p.) delayed but did not prevent preterm-delivery. Conclusion. Caspase-dependent apoptosis appears to play a role in the timing but not the occurrence of GBS-induced preterm delivery in the mouse.

Maternal and neonatal outcomes associated with infertility.

Objective: To investigate perinatal outcomes in a cohort of fertile and infertile nulliparous women. Design: Retrospective cohort study. Setting: Academic medical center. Patients: All nulliparous women delivering singletons ≥24-week gestation at our center from 1 January 2012 to 31 December 2012 were included. Women were classified into two groups - fertile and infertile - based on a chart review at the time of delivery. Outcome measure: Perinatal outcomes of interest included mode of delivery, gestational age at delivery, and birth weight. Results: A total of 3293 mother/infant dyads fulfilled the inclusion criteria. Of these, 277 women (8.4%) were classified as infertile. Infertile women were significantly older than fertile women. In bivariate analyses, infertile women were more likely to undergo cesarean delivery (51.8 versus 36.1%, p < .001) and deliver at an earlier gestational age (38.9 ± 2.3 versus 39.4 ± 1.7 weeks, p < .0001). Infertility was no longer significantly associated with cesarean delivery after adjusting for maternal age. Infertility remained associated with an earlier gestational age at delivery after adjusting for maternal age and maternal race (ß coefficient -0.42, 95%CI -0.64, -0.2). There was no difference in infant birth weight. Late preterm deliveries (34-36 completed gestational weeks) accounted for 8.3% of deliveries for infertile women compared to 4.3% for fertile women (p = .032). Conclusions: We conclude that the increased risk of cesarean section associated with infertility is driven by maternal age. Late preterm infants represent a key cohort for further evaluation in the perinatal outcomes of infertile women.

Lipopolysaccharide stimulation of trophoblasts induces corticotropin-releasing hormone expression through MyD88.

OBJECTIVE: We hypothesized that intrauterine infection may lead to placental corticotrophin-releasing hormone (CRH) expression via Toll-like receptor signaling. STUDY DESIGN: To test this hypothesis JEG3 cells were stimulated with lipopolysaccharide (LPS), chlamydial heat shock protein 60, and interleukin (IL)-1. CRH expression was assessed by reverse transcription polymerase chain reaction (RT-PCR). The signaling mechanisms that were involved were examined in transient transfection experiments with beta-galactosidase, CRH-luciferase, cyclic adenosine monophosphate (AMP) response element-luciferase, dominant-negative (DN)-myeloid differentiation primary response gene (MyD88) and DN-toll-IL-1-receptor domain containing adapter inducing interferon (TRIF) vectors. Luciferase activity was determined by luciferase assay. Beta-galactosidase assay was performed to determine transfection efficiency. RESULTS: LPS, chlamydial heat shock protein 60, and IL-1 stimulation led to CRH expression in the JEG3 cells. LPS-induced CRH expression was not due to the autocrine effect of LPS-induced IL-1 because the supernatant from LPS-conditioned JEG3 cells did not induce CRH expression in the naïve cells. DN-MyD88, but not DN-TRIF, blocked the LPS-induced CRH expression. The cAMP response element did not play a role in LPS-induced CRH expression. CONCLUSION: Toll-like receptor signaling 4 may induce placental CRH expression through MyD88.

A New Model for Non-Lipid Compounded Neonatal Parenteral Nutrition Solution Osmolality.

BACKGROUND: Osmotic stress is a physical risk factor for adverse events related to peripheral parenteral nutrition (PN) administration, such as infiltration. We sought to improve prediction of compounded PN osmolality utilizing basic nutrient solutions available to North American neonatal intensive care units. This study tested the hypothesis that calculated osmolarity underestimates osmolality in compounded PN. METHODS: Osmolarity (mOsm/L) was calculated utilizing commercial software. Osmolality (mOsm/kg) was determined by a freezing-point depression micro-osmometer. The relationship between calculated osmolarity and measured osmolality was modeled from linear or polynomial regression analysis using the least squares method. Regression models were based upon calculated osmolarity and included various combinations of PN components. RESULTS: Calculated osmolarity significantly underestimated measured osmolality in all PN samples (n = 363). Based upon the osmolality of PN and the basic nutrient solutions, we determined a polynomial regression that effectively corrects for the osmolal gap (measured osmolality-calculated osmolarity) in the validation set (R2 = 0.99367). The unbiased analysis corrected for the osmolal gap based on individual solute behaviors, as well as the solute-solute interactions in compounded solutions. CONCLUSIONS: Calculated osmolarity (mOsm/L) significantly underestimates the osmolality (mOsm/kg) in compounded PN. We developed a new algorithm to more accurately predict PN osmolality based upon calculated osmolarity from commercial software and composition of neonatal basic nutrient solutions used in North America. We propose that use of this PN algorithm will facilitate future studies to determine whether a causal association exists between PN osmolality and adverse events, and to establish safe thresholds for PN concentration in neonates.

Plasma glucose concentrations in profound neonatal hypoglycemia.

The study goal was to define low thresholds of plasma glucose concentrations that constitute profound hypoglycemia. Population analysis was performed on research publications on neonatal hypoglycemia ascertained by a Medline search. Eligible patients had neurological sequelae associated directly and primarily with hypoglycemia (profound hypoglycemia). Of 89 infants, more than 95% had plasma glucose levels of less than 25 mg/dL that were first detected at more than 10 hours of age. A breakdown of study patients according to those with or without neurological sequelae, who were exposed to a similar degree of hypoglycemia, showed a combined incidence of neurological injury of 21%, with 95% confidence interval from 14% to 27%.

Brain imaging findings in neonatal hypoglycemia: case report and review of 23 cases.

A hypoglycemic infant with secondary occipital brain injury defined by serial computed tomography and magnetic resonance imaging is described. An additional 22 similar cases were previously published in the English language literature. A total of 23 cases (including the present case) were reviewed. Abnormal brain imaging findings are associated with profound hypoglycemia and show involvement of the occipital lobes in 82% of affected newborns. Half of these infants had visual impairment, and their median and range of plasma glucose values, and postnatal age when hypoglycemia was first detected, were 7 mg/dL (range, 2-26 mg/dL) and 48 hours (range, 1-72 hours), respectively.

Neurologic aspects of neonatal hypoglycemia.

Profound neonatal hypoglycemia is one of the leading causes of brain injury. Hypoglycemic encephalopathy is caused by lack of glucose availability to brain cells. Although sharing a similar pathogenesis with hypoxic-ischemic encephalopathy, hypoglycemic brain insult has distinctive metabolic, brain imaging, electroencephalographic and histopathologic findings.

Novel pathway of adipogenesis through cross-talk between adipose tissue macrophages, adipose stem cells and adipocytes: evidence of cell plasticity.

INTRODUCTION: Previous studies highlight a complex relationship between lineage and phenotype for adipose tissue macrophages (ATMs), adipose stem cells (ASCs), and adipocytes, suggesting a high degree of plasticity of these cells. In the present study, using a novel co-culture system, we further characterized the interaction between ATMs, ASCs and adipocytes. RESEARCH DESIGN AND METHODS: Human adipocytes and the stromal vascular fraction containing ATMs and ASCs were isolated from human adipose tissue and co-cultured for 24 hours. FACS was used to characterize ATMs and ASCs before and after co-culture. Preadipocytes generated after co-culture were characterized by immunostaining for DLK (preadipocytes), CD14 and CD68 (ATMs), CD34 (ASCs), and Nile Red staining for lipid drops. qRT-PCR was used to quantify adipogenic markers such as C/EBPα and PPARγ. A novel fluorescent nanobead lineage tracing method was utilized before co-culture where fluorescent nanobeads were internalized by CD68 (+) ATMs. RESULTS: Co-culture of adipocytes with ATMs and ASCs increased the formation of new preadipocytes, thereby increasing lipid accumulation and C/EBPα and PPARγ gene expression. Preadipocytes originating after co-culture were positive for markers of preadipocytes, ATMs and ASCs. Moreover, fluorescent nanobeads were internalized by ATMs before co-culture and the new preadipocytes formed after co-culture also contained fluorescent nanobeads, suggesting that new preadipocytes originated in part from ATMs. The formation of CD34(+)/CD68(+)/DLK (+) cell spheres supported the interaction of ATMs, ASCs and preadipocytes. CONCLUSIONS: Cross-talk between adipocytes, ATMs and ASCs promotes preadipocyte formation. The regulation of this novel adipogenic pathway involves differentiation of ATMs to preadipocytes. The presence of CD34(+)/CD68(+)/DLK(+) cells grouped in spheres suggest that paracrine interactions between these cell types plays an important role in the generation and proliferation of new preadipocytes. This phenomenon may reflect the in vivo plasticity of adipose tissue in which ATMs play an additional role during inflammation and other disease states. Understanding this novel pathway could influence adipogenesis, leading to new treatments for obesity, inflammation, and type 2 diabetes.

Decreased neonatal jaundice readmission rate after implementing hyperbilirubinemia guidelines and universal screening for bilirubin.

Readmission rate for neonatal jaundice approximate 10 per 1000 live births. After applying hyperbilirubinemia guidelines and universal screening for bilirubin in term and near-term newborns, the readmission rate declined significantly from 24 to 3.7 per 1000 live births. Decreased readmission rate for neonatal jaundice may reduce kernicterus rate and health care costs. Further studies are necessary to explore these potential benefits.

A computer simulation of progesterone and Cox2 inhibitor treatment for preterm labor.

BACKGROUND: Sufficient information from in vitro and in vivo studies has become available to permit computer modeling of the processes that occur in the myometrium during labor. This development allows the in silico investigation of pathological mechanisms and the trialing of potential treatments. METHODS/RESULTS: Based on the human literature, we developed a computer model of the immune-endocrine environment of the myometrial cell. The interactions between molecules are represented by differential equations. The model is designed to simulate the estrogen and progesterone receptor changes during pregnancy and particularly the changes in the progesterone receptor (PR) isoforms A and B that are thought to mediate functional progesterone withdrawal in the human at labor. Parturition is represented by an increase in the PRA to PRB ratio to levels seen in women in labor. Infection is shown by inducing inflammation in the system by increasing phospho-IkB kinase concentration (IKK) levels; which lead to increased NF-kappaB activation, causing an increase in the PRA/PRB ratio. We examined the effects of progesterone or cyclo-oxygenase 2 (Cox2) inhibitor treatments on the PRA/PRB ratio in silico. The model predicted that high doses of progesterone and Cox2 inhibition would be effective in preventing an NF-kappaB-induced PRA/PRB ratio increase to the levels found during labor. CONCLUSIONS: Our data illustrate the use of dynamic biological computer simulations to test the effectiveness of therapeutic interventions. This may allow the early rejection of ineffective therapies prior to expensive field trials.

A videolaryngoscopy technique for the intubation of the newborn: preliminary report.

OBJECTIVE: We describe videolaryngoscopy equipment and technique for endotracheal intubation and airway evaluation in the delivery room (DR) and NICU for endotracheal intubation and airway evaluation. We report our first experience of 47 patients. METHODS: Forty-seven infants who weighed 530 to 6795 g and required endotracheal intubation or airway evaluation were considered for intubation or assessment by using the modified Kaplan-Berci videolaryngoscope. We report quality-improvement data after initial introduction of newly approved technology. RESULTS: We report results of 48 intubations in 42 patients and videolaryngoscopic inspection without intubation in 5 patients. Five intubation attempts were successful after failed attempts by experienced intubators; 6 attempts by residents were completed with video guidance rather than requiring an additional attempt. Only 3 intubations required more than 2 attempts. Enlarged panoramic view and recording assisted in correct diagnosis of vocal cord paralysis. The features and main advantages are discussed in detail. No complications or difficulties resulting from the technology occurred. CONCLUSIONS: This new technique and technology show promise to improve airway management, evaluation, and teaching. Future research to validate improved intubation success in difficult airways and in teaching situations is warranted.

Group B streptococcus induces trophoblast death.

Group B streptococcus (GBS) is one of the leading causes of neonatal infection; however the molecular mechanisms involved are not clearly known. Here we used high and low hemolytic GBS isolates and mutant GBS that lacks beta-hemolysin expression and showed that GBS infection or exposure to GBS hemolysin extract induces primary human trophoblast, placental fibroblast and JEG3 trophoblast cell line death, and that GBS-induced trophoblast death was beta-hemolysin dependent. The fibroblasts and trophoblasts provide an innate immune barrier between fetal and maternal circulation in the placenta. These data suggest that GBS may disrupt this barrier to invade fetal circulation.

Population meta-analysis of low plasma glucose thresholds in full-term normal newborns.

There is extreme variation in the definition of low plasma glucose levels in newborn infants in the first postnatal days, ranging from < 30 to < or = 60 mg/dL. The goal of the present study was to define low thresholds (< or = 5th percentile) of plasma glucose concentrations in full-term normal newborns during the first 72 hours of life. Population meta-analysis was performed on published studies of neonatal hypoglycemia ascertained by MedLine search. One-way analysis of variance was computed across the studies for each of the following four postnatal time periods: 1 to 2 (physiological nadir), 3 to 23, 24 to 47, and 48 to 72 hours. The estimated < or = 5th percentiles of neonatal hypoglycemia during 1 to 2, 3 to 23, 24 to 47, and 48 to 72 hours after birth were < or = 28, < or = 40, < or = 41, and < or = 48 mg/dL, respectively. Based on this statistical definition, we recommend that low thresholds of plasma glucose levels of 28, 40, and 48 mg/dL be adopted in full-term normal newborns at 1 to 2, 3 to 47, and 48 to 72 hours of life, respectively.

Chlamydia heat shock protein 60 induces trophoblast apoptosis through TLR4.

Intrauterine infection affects placental development and function, and subsequently may lead to complications such as preterm delivery, intrauterine growth retardation, and preeclampsia; however, the molecular mechanisms are not clearly known. TLRs mediate innate immune responses in placenta, and recently, TLR2-induced trophoblast apoptosis has been suggested to play a role in infection-induced preterm delivery. Chlamydia trachomatis is the etiological agent of the most prevalent sexually transmitted bacterial infection in the United States. In this study, we show that in vitro chlamydial heat shock protein 60 induces apoptosis in primary human trophoblasts, placental fibroblasts, and the JEG3 trophoblast cell line, and that TLR4 mediates this event. We observed a host cell type-dependent apoptotic response. In primary placental fibroblasts, chlamydial heat shock protein 60-induced apoptosis was caspase dependent, whereas in JEG3 trophoblast cell lines it was caspase independent. These data suggest that TLR4 stimulation induces apoptosis in placenta, and this could provide a novel mechanism of pathogenesis for poor fertility and pregnancy outcome in women with persistent chlamydia infection.

Hemodynamic changes in anemic premature infants: are we allowing the hematocrits to fall too low?

OBJECTIVE: Currently, many nurseries allow hematocrits to fall to <21% in apparently "stable" premature infants before considering a blood transfusion. We evaluated clinical changes and hemodynamic changes by echocardiogram in "stable" anemic premature infants before, during, and after transfusion. METHODS: "Stable" premature infants (< or =32 weeks' gestation) who were to receive transfusions (2 aliquots of 10 mL/kg packed red blood cells, 12 hours apart) were eligible for prospective enrollment. Cardiac function by echocardiography and vital signs were measured 4 times: 1 to 3 hours before and 2 to 4 hours after the initial aliquot and 4 to 7 hours and 27 to 34 hours after the second aliquot. Infants were grouped prospectively according to pretransfusion hematocrit ranges for analysis: < or =21% (low), 22% to 26% (mid), and > or =27% (high). RESULTS: Thirty-two infants were enrolled. No differences were observed between the groups in sex, birth weight, postconceptional age, or postnatal weight at enrollment. Before transfusion, low- and mid-range groups had higher left ventricular end systolic and diastolic diameters, in comparison with high range. Low range had increased stroke volume in comparison with the high-range group. These changes persisted after transfusion. Mean diastolic blood pressure rose and peak velocity in the aorta fell in the low-range group after transfusion. Pretransfusion hematocrit was correlated with but poorly predictive of echocardiographic measurements. Infants with inappropriate weight gain had increased ventricular end diastolic diameters, consistent with congestive heart failure. CONCLUSIONS: Apparently "stable" anemic premature infants may be in a clinically unrecognized high cardiac output state, and some echocardiographic measurements do not improve within 48 hours after transfusion. The benefits of transfusion practices guided by measures of cardiac function should be evaluated.