[Mortality and morbidity in extremely premature newborns]. / Mortalità e morbilità nel pretermine di età gestazionale estrema.

The progress of perinatal medicine greatly reduced neonatal mortality and prognosys of the lowest gestational age (G.A.) newborns is improving continuously. The survival of the newborns with G.A. < 32 weeks doubled from the years 1973-1978 to 1995-99 in the our neonatal intensive therapy (TIN), whereas the incidence of the most serious pathologies of prematurity, which increases with the decreasing of G.A., has not changed in the years. In the surfactant era, Respiratory Distress Syndrome is not the first cause of death and Intra Ventricular Hemorrage and Retinopaty Of Prematurity occur now in the lower stage of severity in comparison with the past. Cortison profilaxys antepartum, delivery with caesarian section and agressive intensive neonatal therapy seem to be the reason of these results.

[Congenital cardiopathy in a data-based population]. / Le cardiopatie congenite in una popolazione data-based.

Altogether 429.139 consecutive births were surveyed during the eighteen years study period by the Emilia-Romagna Registry. Among these, 2147 newborns with congenital heart defects (CHD) (prevalence 5 per 1000) were detected within the first week of life. There were 1607 isolated CHDs and 540 cases had other associated defects. During the study period an increase in prevalence/rate of CHDs was observed (from 3.1 per 1000 in 1980 to over 7 per 1000 in 1998), particularly isolated CHDs increased from 2.2 to 6 per 1000, while the prevalence rate of CHDs cases with other associated anomalies was constant ranging from 1 to 2 per 1000. The increase of isolated CHDs was due to the increased number of "minor" lesions such as ventricular (VSD) and atrial septal defect. The apparent increase in birth prevalence of CHD mainly results from improved diagnosis due to widespread use of color-doppler ecocardiography. As in other studies, a significant shift in the sex-ratio has been documented: a male predominance in transposition of great arteries, left hypoplastic heart and aortic stenosis (male/female ratio 2.2, 2.3, 4.5 respectively) were found; while VSD had a slight female excess (male/female ratio 0.96). The study confirmed that the majority of the affected parents were mothers. The recurrence risk of a cardiac defect in first degree relatives was 2.3%, while the recurrence risk of isolated conotruncal defects was 3.9%. Out of 47 cases with isolated conotruncal defects 4 had microdeletion of chromosome 22q11.2 and concerning the first degree relatives in one case the father had the deletion without CHD.

[Vertical transmission of the hepatitis C virus]. / La trasmissione verticale del virus dell'epatite C.

The incidence of hepatitis C in childhood is approximately 0.4%. The mode of transmission can be parenteral, sexual, occupational and also vertical. The latter has an incidence that varies widely and it increases in the case of human immuno-deficiency virus (HIV) coinfection and high titers of HCV in the mother. The vertical transmission is not influenced by breast feeding, however, data are discrepant with regard to child delivery (cesarean section vs vaginal delivery). Ninety-seven babies born from mothers with hepatitis C from 1996 to 1999, were evaluated prospectively in the Day Hospital of the Pediatric Department of Parma. The protocol of observation established a blood sampling for titers of antibodies anti-HCV and HCV-RNA at the 3rd trimester of pregnancy and subsequent clinical and biochemical controls at 3-6-9-12-15 and 18 months. Thirty (31.2%) out of the 96 mothers evaluated were positive for antibodies anti-HCV and 66 (68.8%) were positive for antibodies anti-HCV and HCV-RNA. Five (5.15%) out of the 97 babies evaluated were infected by HCV. Of these 4 were delivered vaginally and 1 by cesarean section. Of the 3 babies born to mothers with HIV coinfection, none was infected by HIV, but 1 was infected by HCV. Vertical transmission is increased by HCV viral load or HIV coinfection in the mother. The vaginal delivery and breastfeeding do not represent an additional risk factor.

[Risk of materno-fetal transmission of the HIV infection with antiretroviral therapy and cesarean section: experience of the Parma group]. / Rischio di trasmissione materno-fetale dell'infezione da HIV mediante terapia antiretrovirale e taglio cesareo: esperienza del gruppo di Parma.

Vertical transmission of HIV is by far the most important way of infection in pediatric patients. Transmission rate of infection varies between 15-40% in the absence of antiretroviral prophylaxis. Only 2% of infected pregnant women who underwent caesarean section and zidovudine treatment transmitted the infection to their newborns. From January 1995 to September 2000 twenty seropositive pregnant women and their twenty newborns were followed at the Azienda Ospedaliera of Parma. Nine women (45%) were treated with only zidovudine according to the ACTG 076 protocol; eight women (40%) continued the treatment they were assuming before pregnancy with the eventual addition of zidovudine. 3 women (15%) were not treated because HIV infection was only detected after delivery. 15 women underwent caesarean section, in 13 cases in association to antiretroviral prophylaxis: in the remaining 2 cases no intrapartum treatment was started due to the urgency of delivery. The rate of vertical transmission among the 20 women was 5% (1/20), significantly less then that observed (20.5%) among 31 pregnant HIV women followed in Parma from January 1987 to December 1994 and not treated with antiretroviral prophylaxis and/or cesarean section (Magnani G. Personal data). The only infected baby was born by vaginal delivery. No transmission was observed in the group of pregnant women who underwent the combination of antiretroviral prophylaxis and cesarean section.

[Early discharge and breast-feeding]. / Dimissione precoce e allattamento al seno.

Early discharge is often correlated with negative events such as feeding problems leading to hypernatremic dehydration and malnutrition and non initiation or premature cessation of breastfeeding. In the reality of Parma we have valued the impact of early discharge on breastfeeding, analyzing a cohort of 267 dyads, 134 of which were in the "late discharge" group and 133 in the "early discharge" group. Our study showed, according to the most recent literature, that early postpartum discharge did not negatively affect the start and length of breastfeeding: early discharge indeed, if associated with suppression of "hospital routines" and with home-based postpartum follow-up visits, is a determining factor for the success of breastfeeding.

Use of surfactant for prophylaxis versus rescue treatment of respiratory distress syndrome: experience from an Italian-Bulgarian trial.

OBJECTIVE: To show if surfactant applied in different social-sanitary realities as prophylaxis of respiratory distress syndrome (RDS) is equally useful and able to reduce mortality and incidence of 3-4 radiological grade RDS. METHODS AND PATIENTS: Two neonatal intensive care units (NICU) in Italy, one NICU in Bulgaria and one NICU in Romania were involved in a randomized controlled clinical trial of prophylaxis vs rescue treatment of RDS. Babies with gestational age 26-30 wks were randomized before birth to prophylaxis in the delivery-room with 200 mg/kg of porcine surfactant (prophylaxis) or to routine assistance (control). Subsequently the babies developing RDS requiring mechanical ventilation and fraction of inspired oxygen (FiO2) > or = 0.4 to maintain PaO2 about 50 mmHg were allowed to be treated rescue with 200 mg/kg of the same surfactant. To reach end-points of reducing mortality by 40% and incidence of radiological grade 3-4 RDS a total number of 174 patients were required. RESULTS: Due to logistic, practical and social-political problems the study was interrupted after enrollment of 93 babies (61 in Italy and 32 in Bulgaria). The Romanian centre did not start the study because it was impossible in the scheduled times to equip it for mechanical ventilation of the newborn infants. Analysis done on an intention to treat basis did not show significant reductions of mortality and 3-4 radiological grade RDS, even if there was a trend towards a reduction in the babies given prophylaxis. A significantly lower number of babies given prophylaxis required a subsequent rescue treatment compared to controls (p < 0.001). There was no difference in other complications such as intraventricular haemorrhage, air-leak syndromes and infections between prophylaxis and control infants. As regards pulmonary gas exchange, the PaO2/FiO2 ratio was significantly improved in the babies given prophylaxis for the first 12 hours of life vs the controls. CONCLUSION: Even if the study was terminated before term, the analysis of the data shows that prophylaxis with surfactant is equally effective in different social-clinical conditions to improve pulmonary gas-exchange, especially in the first critical hours of life of premature babies.

Evaluation of reactive oxygen metabolites with micromethod in neonates: determination of standards of normality in full-term babies.

We have evaluated the value of reactive oxygen metabolites (ROMs) in 98 full-term neonates at 72 +/- 6 hours of life with a new colorimetric simple and rapid method (d-ROMs Test, Diacron s.r.l.) to establish the normal values for infants. The mean value of ROMs we have obtained in the total of the population was 127.9 +/- 39.2 U.Carr. We have then considered subgroups of infants on the basis of vaginal delivery vs cesarean section, and asphyxia vs non asphyxia during the delivery. We have found no difference within these groups and between the subgroups and the total population for the value of ROMs. We have preferred to consider as reference value for normality that of babies without intrapartum asphyxia, independently of the mode of delivery. This value is 125.2 +/- 27.6 U.Carr. The value of normality for full-term infants is lower than that reported for adults (between 250-300 U.Carr). This can be interpreted as a particular response of full-term baby to oxidative stress.

[Vertebral hydatidosis with extra- and intra-rachidian hydatid ossifluent pseudoabscess]. / Hidatidosis vertebral con pseudoabsceso osifluente hidatídico extra e intrarraquídeo.

A clinical case of a 35-year-old male with antecedents of frequent dog contacts suffering a progressive spastic paraparesis and pains of the low dorsal column is presented. Radiographies of the spinal column showed absence + of D6 right pedicle and a mass in the vicinities. A dorsal spinal column computed axial tomography revealed a retropleural mass close to D6-D7 invading the epidural space and compressing the spinal cord. An indirect hemagglutination test for hydatidosis resulted positive. Laminectomy of D5-D6-D7 and extraction of hydatic vesicles from the epidural space were performed. The patient had an excellent evolution, but four months later symptomatology reappeared with paraplegia. A new laminectomy of D8-D9, also with extraction of hydatic vesicles were carried out. As paraplegia persisted, another laminectomy of D3-D4 and D5 with extraction of additional hydatic elements was executed. Fifteen days later thoracotomy permitted to extirpate an osifluent hydatic abscess. Finally, 18 months after the onset of the illness, laminectomy of D1-D2 with extirpation of hydatic vesicles were performed. The patient was submitted to physiotherapy and rehabilitation. At present he needs a wheel chair. The characteristics of vertebral hydatidosis are commented and the frequent erroneous concepts on the parasitology and clinics of the disease are stressed.

[The Walker-Warburg syndrome. A new case]. / Le syndrome de Walker-Warburg. Une nouvelle observation.

Walker-Warburg syndrome is a fatal cerebro-ocular malformation. It appears to be of autosomal recessive inheritance, but materno-fetal infection cannot be excluded as a possible etiology. Antenatal diagnosis consists in screening for fetal hydrocephalus. The authors report one personal case of this syndrome and a review of 34 previous observations in the literature.

[Intra uterine devices: a study about 103 cases (author's transl)]. / Etude critique de 103 observations utilisant des dispositifs intra-uterins au ciuvre.

PIP: 83 patients users of Copper 200 were observed for a total of 760 months, together with 20 users of Gravigard, for 280 months. Age of users was between 19-43. Failure rate was 1.57% for the Copper 200, and 4.28% for Gravigard; continuity rate was 93.7% with Copper 200, and 91.44% with Gravigard. A few patients complained of pain and/or menorrahgia. Such results indicate that both IUDs were well tolerated; still, the utmost importance of a careful selection of patients and type of device must be stressed. (Summary in ENG).^ieng