The assessment of thoracal approaches in the treatment of aortic coarctation.

OBJECTIVES: The optimal choice of surgery in coarctation of the aorta (CoA) remains controversial but it needs to be individualised. However, in most conditions, a surgical approach through thoracotomy maintains adequate exposure to create aortic patency. This study aimed to assess the efficiency and reliability of thoracal approaches in the treatment of CoA by examining the mid- and late-term outcomes, and determining the predictive factors for re-intervention. METHODS: Patients who underwent CoA repair through thoracotomy between September 2015 and February 2023 were included in the study, except for those with complex cardiac diseases. Medical records were retrospectively analysed and peri-operative course, follow-up findings on echocardiogram and physical examinations were obtained. The complication rate, postoperative arch gradient, need for antihypertensive medication use, and freedom from re-intervention were evaluated and then compared in terms of age at surgery. RESULTS: Overall, 98 patients including 50 neonates were reviewed. The most common surgical method was extended end-to-end anastomosis, performed in 53 patients. The median follow-up time was 4.6 years. There was one death in hospital and one late mortality in the cohort. Eight complications were observed in the cohort but all recovered well. Overall, 13 re-interventions, six redo surgeries and seven balloon angioplasties were carried out in 12 patients. Ten of the re-interventions were carried out within the first year of the initial surgery. One- and three-year freedom from re-intervention rates were 89.5 and 86.4%, respectively. However, there was no significant predictive factor for re-intervention. Comparisons according to the age at surgery did not differ, except for intensive care unit stay. The need for hypertensive medication was initially in 14 (14.2%) patients and then reduced to eight (8%) patients. The mean peak residual gradient on postoperative examination was 9 mmHg. CONCLUSION: Thoracotomy provided feasible surgical access that led to satisfactory results with a low complication rate, negligible residual gradient, low incidence of hypertension and excellent rate for freedom from re-intervention in the treatment of CoA.

Social and Medical Characteristics of Neonates Who Were Abandoned in a Tertiary Maternity Hospital in Turkey.

OBJECTIVE: This study aimed to investigate the characteristics of neonates who were aban- doned in a tertiary maternity hospital and to determine the accompanying morbidities. MATERIALS AND METHODS: This hospital-based, retrospective descriptive study was conducted by evaluating the medical records between 2012 and 2019 in a tertiary hospital in Izmir. RESULTS: During the study period, there were 76 women who left their babies in the hospital following delivery. Median age of the mothers was 23 (range 12-44) years. Among them, 31.5% (n = 24) were below 18 years of age. Seventy-three of the pregnancies (96%) were unwanted, 67 of the mothers were unmarried (88.16%), of which 17 revealed a history of rape (22.36%), and 2 of them were victims of incest (2.63%). Thirty-six (47.36%) neonates were female and 36 of them (47.36%) were delivered by cesarean section. The mean gestational age was 37.3 ± 2.2 weeks and the mean birth weight was 2927 ± 572 g. Twenty-one (27.63%) babies were born prematurely and 15 (19.73%) had low birth weight. Four babies (5.26%) had hypoglycemia, 3 (3.94%) had hyponatremia, 5 (6.57%) had hypocalcemia, and 3 (3.94%) had hypomagnesemia. CONCLUSION: Unwanted pregnancies were found to be one of the key reasons for newborn aban- donment and linked to a higher risk of complications for both mother and child. To prevent unintended pregnancy and its negative effects, it is important to ensure that all adolescents have access to high-quality education in a safe and supportive learning environment, school- based health services, and increase access to contraceptive services, including emergency contraception and safe and legal abortion services.

Neonatal Resuscitation Practices in Turkey: A Survey of the Turkish Neonatal Society and the Union of European Neonatal and Perinatal Societies.

OBJECTIVE: Optimal care in the delivery room is important to decrease neonatal morbidity and mortality. We aimed to evaluate neonatal resuscitation practices in Turkish centers. MATERIALS AND METHODS: A cross-sectional survey consisted of a 91-item questionnaire focused on delivery room practices in neonatal resuscitation and was sent to 50 Turkish centers. Hospitals with <2500 and those with ≥2500 births/year were compared. RESULTS: In 2018, approximately 240 000 births occurred at participating hospitals with a median of 2630 births/year. Participating hospitals were able to provide nasal continuous-positiveairway-pressure/high-flow nasal cannula, mechanical ventilation, high-frequency oscillatory ventilation, inhaled nitric oxide, and therapeutic hypothermia similarly. Antenatal counseling was routinely performed on parents at 56% of all centers. A resuscitation team was present at 72% of deliveries. Umbilical cord management for both term and preterm infants was similar between centers. The rate of delayed cord clamping was approximately 60% in term and late preterm infants. Thermal management for preterm infants (<32 weeks) was similar. Hospitals had appropriate equipment with similar rates of interventions and management, except conti nuous-positive-airway-pressure and positive-end-expiratory-pressure levels (cmH2O) used in preterm infants (P = .021, and P = .032). Ethical and educational aspects were also similar. CONCLUSIONS: This survey provided information on neonatal resuscitation practices in a sample of hospitals from all regions of Turkey and allowed us to see weaknesses in some fields. Although adherence to the guidelines was high among centers, further implementations are required in the areas of antenatal counseling, cord management, and circulation assessment in the delivery room.

Impact of Maternal Ketogenic Diet on NLRP3 Inflammasome Response in the Offspring Brain.

The effects of maternal diet on the neuroimmune responses of the offspring remain to be elucidated. We investigated the impact of maternal ketogenic diet (KD) on the NLRP3 inflammasome response in the offspring's brain. C57BL/6 female mice were randomly allocated into standard diet (SD) and ketogenic diet (KD) groups for 30 days. After mating, the presence of sperm in the vaginal smear was considered day 0 of pregnancy, and female mice continued their respective diets during pregnancy and the lactation period. Following birth, pups were further allocated into two groups and given either LPS or intraperitoneal saline on postnatal (PN) days 4, 5 and 6; they were sacrificed on PN11 or PN21. Neuronal densities were significantly lower globally in the KD group when compared to the SD group at PN11. Neuronal density in the prefrontal cortex (PFC) and dentate gyrus (DG) regions were also significantly lower in the KD group when compared to the SD group at PN21. Following administration of LPS, the decrease in the neuronal count was more prominent in the SD group when compared to the KD group in the PFC and DG regions at PN11 and PN21. NLRP3 and IL-1ß were higher in the KD group than in the SD group at PN21 in the PFC, CA1 and DG regions, and were significantly lower in the DG region of the KD group especially when compared to the SD group following LPS. Results of our study reveal that maternal KD negatively affects the offspring's brain in the mouse model. The effects of KD exhibited regional variations. On the other hand, in the presence of KD exposure, NLRP3 expression after LPS injection was lower in the DG and CA1 areas but not in the PFC when compared to SD group. Further experimental and clinical studies are warranted to elucidate the molecular mechanisms underlying the impact of antenatal KD exposure and regional discrepancies on the developing brain.

Bilirubin induces microglial NLRP3 inflammasome activation in vitro and in vivo.

Despite current advancements in neonatal care, hyperbilirubinemia resulting in bilirubin-induced neurological dysfunction (BIND) continues to be one of the major reasons of mortality or lifelong disability. Although the exact mechanisms underlying brain injury upon bilirubin exposure remains unelucidated, inflammation is considered to be one of the major contributors to BIND. This study investigates the role of the NLRP3 inflammasome in bilirubin-induced injury using in vitro and in vivo models. We successfully demonstrated that the upregulation of NLRP3 expression is significantly associated with the release of active caspase-1 and IL-1ß in N9 microglial cells exposed to bilirubin. Functional in vitro experiments with NLRP3 siRNA confirms that bilirubin-induced inflammasome activation and cell death are mediated by the NLRP3 inflammasome. Following injection of bilirubin into the cisterna magna of a neonatal mouse, activation of the NLRP3 inflammasome and microglia were determined by double staining with Iba1-NLRP3 and Iba1-Caspase-1. Upon injection of bilirubin into the cisterna magna, neuronal loss was significantly higher in the wild-type mouse compared to Nlrp3-/- and Caspase-1-/- strains. Collectively, these data indicate that NLRP3 inflammasome has a crucial role in microglial activation and bilirubin-induced neuronal damage.

Bilirubin Measurement Through a Smartphone Application in Preterm Infants.

BACKROUND: Aim of the present study is to evaluate the feasibility and reliability of an smartphone application for monitore of bilirubin levels in preterm infants. METHODS: Preterm infants hospitalized in the neonatal intensive care unit with gestational age of<35 weeks were included. Exclusion criteria were parental reluctance and requirement of phototherapy in the last 12 hours. Measurements were obtained through a smartphone application (BiliScan) along with simultaneous transcutaneous device (Dräger JM 105) and venous blood biochemistry. RESULTS: Mean gestational age was 30.8±2.4 weeks and birth weight was 1622±566 g. Measurements were obtained at a median of 4 (1-21) days of life. Twenty-five infants (19.4%) had ABO and/or Rh incompatibility and 39 infants (30.2%) required phototherapy. None of the cases required exchange transfusion. Mean total serum bilirubin (TSB) level was 8.16±2.60 mg/dL, mean transcutaneous bilirubin (TcB) level was 8.60±2.70 mg/dL, and the mean bilirubin level measured by BiliScan was 7.26±2.68 mg/dL. For TSB and TcB measurements, the intraclass correlation coefficient (ICC) was found to be 0.915 (95% confidence interval 0.835-0.951; p<0.001) and a strong positive correlation was found between these two measurements. When TSB and BiliScan measurements were compared, ICC was found to be significant as 0.512 (95% confidence interval 0.353-0.638; p<0.001), with a moderate correlation. CONCLUSIONS: In this study, we evaluated the feasibility and reliability of a smartphone application for monitoring bilirubin levels in preterm infants. Although BiliScan measurements reported to display high correlation in term infants, a moderate correlation was found in the preterm infants. It is an emerging low-cost, non-invasive alternative for neonatal jaundice monitoring, however, results should be interpreted with caution in preterm infants.

In vitro effects of H2O2 on neural stem cell differentiation.

The development of the CNS is a complex and well-regulated process, where stem cells differentiate into committed cells depending on the stimuli from the microenvironment. Alterations of oxygen levels were stated to be significant in terms of brain development and neurogenesis during embryonic development, as well as the adult neurogenesis. As a product of oxygen processing, hydrogen peroxide (H2O2) has been established as a key regulator, acting as a secondary messenger, of signal transduction and cellular biological functions. H2O2 is involved in survival, proliferation, and differentiation of neural stem cells into committed cells of the CNS. Effects of different concentrations of exogenous H2O2 on neuronal differentiation and the molecular pathways involved are yet to be clearly understood. Here, we investigated the concentration-dependent effects of H2O2 on differentiation of neural stem cells using CGR8 embryonic mouse stem cell line. We have demonstrated that treated doses of H2O2 suppress neural differentiation; additionally, our study suggests that relatively high doses of exogenous H2O2 suppress the differentiation process of neural stem cells through AKT and p38 pathways.

Oxygen exposure in early life activates NLRP3 inflammasome in mouse brain.

Despite widely known detrimental effects on the developing brain, supplemental oxygen is still irreplaceable in the management of newborn infants with respiratory distress. Identifying downstream mechanisms underlying oxygen toxicity is a key step for development of new neuroprotective strategies. Main purpose of this study is to investigate whether NLRP3 inflammasome activation has a role in the pathogenesis of hyperoxia-induced preterm brain injury. C57BL6 pups were randomly divided into either a hyperoxia group (exposed to 90 % oxygen from birth until postnatal day 7) or control group (maintained in room air; 21 % O2). At postnatal day 7, all animals were sacrificed. Immunohistochemical examination revealed that hyperoxic exposure for seven days resulted in a global increase in NLRP3 and IL-1ß immunopositive cells in neonatal mouse brain (p ≤ 0.001). There was a significant rise in Caspase-1 positive cell count in prefrontal and parietal area in the hyperoxia group when compared with controls (p ≤ 0.001). Western blot analysis of brain tissues showed elevated NLRP3, IL-1ß and Caspase-1 protein levels in the hyperoxia group when compared with controls (p ≤ 0.001). To the best of our knowledge, this is the first study that investigates an association between hyperoxia and establishment of NLRP3 inflammasome in preterm brain.

Intranasal surfactant protein D as neuroprotective rescue in a neonatal rat model of periventricular leukomalacia.

BACKGROUND: Periventricular leukomalacia (PVL) is the leading cause of neurocognitive deficits in children with prematurity. We previously hypothesized that surfactant protein D (SPD) with its ability to bind toll-like receptors may have a possible ameliorating effect in PVL. METHODS: Three groups were defined as: LPS-administered and postnatal intranasal saline administered group, LPS-administered and postnatal intranasal SPD-treated group, and control group. Twenty-eight offspring rats were reared with their dams until their sacrifice for histological evaluation on day 7. RESULTS: A significant loss of brain weight occurred in the LPS group compared with controls. The postnatal intranasal SPD treatment significantly reduced the number of TUNEL-positive cells in the periventricular white matter as compared with the LPS-treated group. Compared with the control group, LPS injection in the rat brain significantly reduced the MBP-positive staining. Postnatal SPD treatment greatly prevented LPS-stimulated loss of MBP staining. CONCLUSIONS: Present study demonstrated a neuroprotective effect of SPD in a rat model of PVL. Our results offer future implications towards increasing our understanding about multifactorial mechanisms underlying periventricular leukomalacia and developing plausible therapeutic strategies in order to prevent neurocognitive deficits in preterm infants.

Multiple Scrotal Ulcers in an Infant Due to a Traditional Child Care Practice: Salting.

Application of salt to the newborn's skin is a common traditional child care custom in Turkey. We present an infant with multiple ulcerating scrotal lesions due to prolonged salt exposure in the diaper area. Scrotal ulcers associated with salting have not been described previously.

Early signs that predict later haemodynamically significant patent ductus arteriosus.

OBJECTIVE: Our aim was to determine the optimal cut-off values, sensitivity, specificity, and diagnostic power of 12 echocardiographic parameters on the second day of life to predict subsequent ductal patency. METHODS: We evaluated preterm infants, born at ⩽32 weeks of gestation, starting on their second day of life, and they were evaluated every other day until ductal closure or until there were clinical signs of re-opening. We measured transductal diameter; pulmonary arterial diastolic flow; retrograde aortic diastolic flow; pulsatility index of the left pulmonary artery and descending aorta; left atrium and ventricle/aortic root ratio; left ventricular output; left ventricular flow velocity time integral; mitral early/late diastolic flow; and superior caval vein diameter and flow as well as performed receiver operating curve analysis. RESULTS: Transductal diameter (>1.5 mm); pulmonary arterial diastolic flow (>25.6 cm/second); presence of retrograde aortic diastolic flow; ductal diameter by body weight (>1.07 mm/kg); left pulmonary arterial pulsatility index (⩽0.71); and left ventricle to aortic root ratio (>2.2) displayed high sensitivity and specificity (p0.9). Parameters with moderate sensitivity and specificity were as follows: left atrial to aortic root ratio; left ventricular output; left ventricular flow velocity time integral; and mitral early/late diastolic flow ratio (p0.05) had low diagnostic value. CONCLUSION: Left pulmonary arterial pulsatility index, left ventricle/aortic root ratio, and ductal diameter by body weight are useful adjuncts offering a broader outlook for predicting ductal patency.

Platelets and platelet-derived growth factor in closure of the ductus arteriosus.

The crucial role of platelets in the permanent closure of the ductus arteriosus has recently been elucidated in an animal model; however, clinical studies investigating the impact of platelet count on ductal patency have conflicting results. Our aim is to compare platelet count, indices and serum platelet-derived growth factor levels in preterms with and without ductal patency. Preterms with a gestational age of 27-30 weeks followed up during a twelve-month period in the neonatal intensive care unit of Adnan Menderes University Hospital were enrolled. Infants underwent echocardiographic evaluation starting on the second day and subsequently assessed every other day until ductal closure was achieved, or upon clinical signs of reopening. Platelet-derived growth factor was measured on the second and fifth days of life. Eleven very low birth weight infants who subsequently required medical treatment for patent ductus arteriosus were compared with twenty-three infants with closed ductus. Although platelet count and indices were similar, median serum plateletderived growth factor levels on day 5 were significantly lower among babies who subsequently required medical treatment for ductal patency (874.6 vs 1099.6 pg/ml). The current study points out a possible association between serum platelet-derived growth factor levels and ductal closure. Our results suggest that platelet-derived growth factor may play a role in ductal closure independent from platelet count and might be used as an adjunct surrogate for prediction of future need for treatment for hemodynamically significant patent ductus arteriosus in preterm infants.

A milk pump as a source for spreading Acinetobacter baumannii in a neonatal intensive care unit.

Acinetobacter baumannii is a Gram-negative coccobacillus that has emerged as a troublesome pathogen causing institutional outbreaks. Environmental contamination is a distinctive characteristic of this microorganism, which brings a further difficulty in infection control. During A. baumannii outbreaks in intensive care units, a common contaminated object can be found as a reservoir. Finding out this source by epidemiological investigations is of particular importance in order to develop effective interventions. We describe an outbreak of A. baumannii and the results of epidemiological investigations in a neonatal intensive care unit. The outbreak strain was isolated from the outer surface of a breastmilk pump. We have successfully controlled the outbreak by careful reviewing of our milk collection process.