High positive predictive value of Gram stain on catheter-drawn blood samples for the diagnosis of catheter-related bloodstream infection in intensive care neonates.

Catheter-related bloodstream infections (CRBSIs) remain a leading cause of healthcare-associated infections in preterm infants. Rapid and accurate methods for the diagnosis of CRBSIs are needed in order to implement timely and appropriate treatment. A retrospective study was conducted during a 7-year period (2005-2012) in the neonatal intensive care unit of the University Hospital Erasme to assess the value of Gram stain on catheter-drawn blood samples (CDBS) to predict CRBSIs. Both peripheral samples and CDBS were obtained from neonates with clinically suspected CRBSI. Gram stain, automated culture and quantitative cultures on blood agar plates were performed for each sample. The paired quantitative blood culture was used as the standard to define CRBSI. Out of 397 episodes of suspected CRBSIs, 35 were confirmed by a positive ratio of quantitative culture (>5) or a colony count of CDBS culture >100 colony-forming units (CFU)/mL. All but two of the 30 patients who had a CDBS with a positive Gram stain were confirmed as having a CRBSI. Seven patients who had a CDBS with a negative Gram stain were diagnosed as CRBSI. The sensitivity, specificity, positive predictive value and negative predictive value of Gram stain on CDBS were 80, 99.4, 93.3 and 98.1 %, respectively. Gram staining on CDBS is a viable method for rapidly (<1 h) detecting CRBSI without catheter withdrawal.

Antenatal diagnosis of a sacrococcygeal teratoma.

Although rare, sacrococcygeal teratoma is the most common congenital tumor. We report a case of a precociously diagnosed and rapidly growing cystic lesion. These tumors may be associated with hemodynamic and hemorrhagic complications. Therefore, affected fetuses should be carefully followed during the entire pregnancy by ultrasound and MR imaging in order to evaluate the evolution of the mass, its consequences on the fetal organs and to appreciate the wellbeing of the fetus. Delivery and post natal work up can therefore be optimized.

[Neurodevelopment of extremely low birthweight infants born in Erasmus Hospital between 1992 and 2001]. / Suivi neurodéveloppemental des prématurissimes nés a l'Hôpital Erasme entre 1992 et 2001.

Survival of extremely low birth weight infants has dramatically improved in the last decade of the twentieth century. The objective of our study was to evaluate the neurological evolution of the surviving infants because frequent motor, sensitive and psychological disturbances are related. Prospective, longitudinal study in a population of newborns, nursed in our neonatal intensive care unit and born between 1992 and 2001 with less than 1.000 g and/or less than 28 weeks of gestational age (GA). Neurological assessment of outcome was made using the neurodevelopmental score (O.M.S. 1988) at 6, 9, 12, 18, 24 and 36 months. Neurological follow-up every year and neuropsychological testing at 3, 5 and 8 years. Only children with at least 2 years of follow-up were included. The children were grouped in 3 categories: M (major neurological handicap), m (minor neurological handicap), N (normal neurological outcome). To evaluate the evolution with time, we compared the results from the first period (1992 to 1996) to the second part of this decade (1997 to 2001). Mortality fell from 38% (27/70) in the first period (1992-1996) to 18% (8/44) in the second one (1997-2001) (p = 0.02) including neonates of less than 25 weeks GA. Neurodevelopmental status improved and severe brain lesions decreased (25% with intraventricular haemorrhage III & IV and cystic periventricular leukomalacia versus 6% in the second period) (p = 0.017). Major handicap fell from 26% (9/34) to 16% (5/31) and normal neurological evolution raised from 15% (5/34) to 48% (15/31) (p = 0.013). With the survival of newborns less than 28 weeks, the severe ocular complications increased: 6% (5/79). In conclusion, mortality and quality of life have significantly improved in the past 10 years in our service. Severe brain lesions have decreased under a better multifactorial management. Nevertheless when the gestational age of the surviving babies diminishes, ocular sequelae increase. We still think that prematurity remains a burden for the child, his family and the society.

[The intensive and non-intensive neonatal care department]. / Le Service de Soins Neónatals Intensifs et Non Intensifs.

To be born very prematurely in 2002 is very different of to be born very prematurely in 1978: the progress of the fetal and perinatal care have, amongst others, decrease the mortality of the neonates with a birthweight below < 1,000 g from 61% to 12%. The technological progresses in artificial ventilation have led to a significant decrease in chronic lung disease down to 5% or less, and of cerebral complications (intraventricular hemorrhages, grade 3 and 4 and/or periventricular leucomalacia) down to 11% or less. The progress in surgery and anesthesiology have allowed us to operate the extremely low birthweight infants in the neonatal unit when needed. This has been possible thanks to a multidisciplinary team approach: many specialists working together from conception to birth and from birth to home try to offer the best to these sometimes very small human beings.

[Twins: interpretation of height-weight curves at birth]. / Jumeaux: interprétation des courbes staturo-pondérales à la naissance.

Weight, head circumference and body length curves were established with the data at birth of 770 twins born alive in our hospital. Those curves were compared with the Gairdner-Pearson curves realized on a population of singleton newborns. The twin weight curve shows the expected fall down from 32 weeks of gestation. More than 50% of twins would have been qualified as small for dates on the Gairdner standard for singletons. The head circumference and the body length curves show few differences, except a late fall down, significant from 39 weeks. So the normal twin shows usually an "asymmetrical" hypotrophy if compared with a general newborn population standard. The general weight standards do not allow to assess the normality of a twin and to suspect other reasons of fetal growth restriction that could also be present. These considerations plead for the use of specific twin charts. Yet the evaluation of twins on the general standards has still a place to estimate the immediate and at long-term adverse outcomes of fetal growth restriction. The evaluation of twin measurements would not be completed without the assessment of the weight discordancy inside the twin couple, as a risk factor of morbidity and mortality.

[Definition of asphyxia neonatorum and incidence of neurologic and systemic complications in the full-term newborn]. / Définition de l'asphyxie à la naissance et incidence des complications neurologiques et systémiques chez le nouveau-né à terme.

PATIENTS AND METHODS: In a prospective multicentric study, 152 of 10,065 live term births had birth asphyxia, defined by the association of three indicators (fetal distress, depression at birth and metabolic acidosis). RESULTS: The incidence of birth asphyxia was 1.5% of live term births when birth asphyxia was defined by the presence of at least two indicators, and 1% of live term births when birth asphyxia was defined by the association of metabolic acidosis and another indicator. Neurological complications were observed in 66 cases (43%). The incidence of post-asphyxial encephalopathy (PAE) was 5.9/1000 of live term births (mild PAE: 3/1000; moderate PAE: 2.7/1000; severe PAE: 0.2/1000). Systemic complications were observed in 87 patients (57%). Renal injury and coagulopathy were associated with moderate or severe PAE. Respiratory complications (39%), infections (17%) and gastro-intestinal intolerance (15%) often complicated the course. Severe complications were never seen in the absence of significant metabolic acidosis at 30 minutes of life. CONCLUSION: Our study has many implications concerning the diagnosis of birth asphyxia and its complications. A terminology based on clinical observation and arterial pH evaluation is proposed in order to clarify the situation.

Anterior fontanelle pressure recording with the Rotterdam transducer: variation of normal parameters with age.

Using a reliable non-invasive technique for ICP monitoring, we realized 93 continuous anterior fontanelle pressure (AFP) recordings in 86 healthy infants aged from 29 to 85 post-conceptional (PC) weeks. For each recording, we calculated the mean and extremes values of AFP, cerebral pulse amplitude, and pressure waves rate and amplitude. We observed the occurrence of plateau-waves of relatively low amplitude and duration in most infants aged of more than 49 PC weeks. We postulate that PW represents a physiological phenomenon which is amplified under pathological conditions. All AFP parameters are correlated to PC age and vary during early infancy according to an ascending sigmoidal relation (this variation may be explained by a connection between several cranio-cerebral characteristics of the young infant). We conclude that the interpretation of AFP recordings must take into account [1] PC age rather than postnatal age, [2] variation of AFP parameters with age, and [3] occurrence of physiological plateau-waves.

[The focus in neonatology]. / Le point en néonatologie.

During the last years, neonatology has greatly improved. In the last decade, mortality and morbidity have decreased: mortality from respiratory failure of prematurity has decreased from 22% to 12%, mortality of the very low birthweight infants under 1000 g fell from 56% to 35% and mortalities related to asphyxia have diminished from 21% to 12% and to malformations from 33% to 28%. Prematurity is now the first cause of neonatal mortality. During this period, the number of babies under 1000 g has increased 4-fold and the number of multiple births increased more than 2-fold from 3% to 7% of the live births of our hospital. Attitudes towards the premature infant have changed, especially towards the extremely small (called the micropremies). The number of disabled children has increased in parallel with the better survival of the very immature newborns who till recently were not resuscitated.

Selective feticide by embolization in twin-twin transfusion syndrome. A report of two cases.

BACKGROUND: The early development of complications in twin-twin transfusion syndrome is a poor prognostic sign. For this reason, new techniques for intrauterine therapy are being developed: invasive options, such as selective feticide of one of the twins, have been reported. CASES: Two cases of twin-twin transfusion syndrome in the late second trimester were treated by selective feticide using vascular embolization to the more severely damaged fetus. In one case the embolized fetus was a hydropic recipient with a normal cotwin; in the other, the donor fetus was affected by bilateral hydrocephalus. These fetuses underwent ultrasound-guided embolization using a bolus of histoacryl injected into the umbilical vein and fetal heart. Both patients went on to deliver healthy singletons in the third trimester. CONCLUSION: In twin-twin transfusion syndrome of early onset, embolization may help one of the twins survive. This technique is neither time-consuming nor expensive and does not require a general anesthetic.

A fatal case of Mycoplasma hominis meningoencephalitis in a full-term newborn.

We report the case of a 20-day-old full-term baby, born to a mother who had had an uncomplicated pregnancy and delivery, who died 13 days after the onset of meningitis. Mycoplasma hominis was the sole agent repeatedly recovered from cerebrospinal fluid and from postmortem brain tissue.

Sonographic prediction of chronic lung disease in the premature undergoing mechanical ventilation.

The aims of the study are to investigate the possible role of ultrasound (US) of the chest in predicting the development of chronic lung disease (CLD) in patients with hyaline membrane disease (HMD) and to determine the optimal age for the sonographic examination. One hundred and five consecutive prematures undergoing mechanical ventilation were prospectively studied by US of the chest. The US examinations were performed at birth and at least once a week until discharge from the neonatal unit. The sonographic patterns observed behind the diaphragm and their evolutions were recorded and correlated with the clinical and radiological data at day 28, which corresponds to the currently accepted limit for determining the presence of CLD. CLD is currently defined as oxygen dependency on day 28 with radiographic abnormalities. A diffuse retrodiaphragmatic hyperechogenicity was observed in all the patients with HMD. The hyperechogenicity resolved completely in patients with an uncomplicated clinical evolution. In contrast, in patients with CLD the hyperechogenicity resolved only partially, resulting in less diffuse and less extensive hyperechogenicity. Day 18 was the earliest day where the persistence of the abnormal retrodiaphragmatic hyperechogenicity was observed in 100% of the patients presenting CLD at day 28. At that time, 95.2% of the patients without abnormal hyperechogenicity showed uncomplicated evolution and no CLD. US can be a useful diagnostic tool to determine the occurrence of CLD and to predict as early as day 18 the prematures at risk for the disease.

Anterior fontanelle pressure monitoring for the evaluation of asymptomatic infants with increased head growth rate.

We studied non-invasive intracranial pressure monitoring in 20 asymptomatic infants with increased head growth rate. Both basal anterior fontanelle pressure (AFP) traces and occurrence of pressure waves were analysed and compared with normal range values previously established. Eight recordings were classified as pathological; cerebral imaging showed subdural collections or ventricular dilatation in all cases. Five out of these eight infants further developed neurological deficits and/or increase of the ventricular size, and required neurosurgical procedures. Twelve infants had normal AFP traces; six of these had normal cerebral imaging and six showed enlargement of subarachnoid spaces with normal ventricles. All of these 12 patients normalised their head growth rate and remained asymptomatic. This observation suggests that AFP monitoring may be helpful in asymptomatic infants with increased head growth rate to identify a progressive intracranial process and the potential need for a neurosurgical procedure.

Areas of increased echogenicity in the fetal abdomen: diagnosis and significance.

Areas of increased echogenicity in the fetal abdomen are defined as abnormally bright areas with an echogenicity similar to that of surrounding bones. Such areas are encountered in various normal and abnormal processes. When increased echogenicity is discovered in the fetal abdomen, a careful search should be made for a potential cause. The causes to be considered depend on the location of the areas of increased echogenicity, which can be classified as intestinal, peritoneal, hepatic, retroperitoneal, and parietal. In each case, vascular, ischemic, infectious, tumoral, metabolic, and chromosomal abnormalities should be included in the differential diagnosis before considering the finding a normal variant. Therefore, in utero detection of fetal abdominal areas of increased echogenicity requires a complete sonographic survey of the fetus and placenta along with close sonographic follow-up, evaluation of familial factors, and testing for possible associated cystic fibrosis, infection, or a chromosomal anomaly. The prognosis depends more on the underlying disease than on the extent of the increased echogenicity.

Management of the growth-restricted fetus: the role of noninvasive tests and fetal blood sampling.

OBJECTIVE: To assess the accuracy of two noninvasive tests, the nonstress test (NST) and Doppler velocimetry of the umbilical artery, in predicting fetal acidemia or hypoxia demonstrated by funipuncture, and to determine any association between acidemia or hypoxia and perinatal outcome. METHODS: The study included 112 consecutive growth-restricted fetuses diagnosed by ultrasonography between 26-39 weeks' gestation. For Doppler sonograms, the absence of end-diastolic flow was considered pathologic. Acidemia and hypoxia were defined as a pH and an oxygen pressure (PO2) below the fifth percentile at the given gestational age. The fetuses were classified according to the results obtained by the different tests (Doppler velocimetry, NST, cord blood gases). RESULTS: Fetuses with one or both noninvasive tests abnormal (group A, N = 32) had a significantly lower mean gestational age at sampling than those fetuses with both noninvasive tests normal (group B, N = 80). Mean pH and PO2 values for groups A and B were significantly different. Obstetric and perinatal data were collected, and a statistically significant difference was demonstrated between those with a pH and/or PO2 below the fifth percentile and those with a pH and PO2 above the fifth percentile for all indices except birth weight below the tenth percentile. CONCLUSION: Fetal growth restriction is a benign condition in physically normal fetuses if both noninvasive tests and pH and PO2 measured by funipuncture are normal in the absence of maternal pathology. One single fetal blood analysis for pH and PO2 helped separate groups having different obstetric and neonatal outcomes.

Hyperechoic thickened ependyma: sonographic demonstration and significance in neonates.

In the neonate, hyperechoic thickening of the ependyma is believed to be related to ventriculitis. Yet, in our experience, this sign is much more often observed in association with subacute intraventricular hemorrhage (IVH), without infection. Sixty premature neonates were prospectively studied. The observations of transfontanellar sonograms (intracranial hemorrhage, ependymal echogenicity, and ventriculomegaly) were correlated with the results of MRI, lumbar punctures and clinical work-up. Intracranial hemorrhage was detected in 28 patients, and hyperechoic thickening of the ependyma was observed in 21 of them, all of whom had IVH. In 9 of these 21 patients IVH was diagnosed retrospectively thanks to the visualization of the hyperechoic ependyma. In all but one, this sign persisted for at least 2 months after disappearance of other signs of IVH. MRI demonstrated the presence of hemosiderin and ferritin in ependymal or subependymal location only in patients with hyperechoic ependyma. One of our patients had in utero diagnosis of IVH owing to the visualization of the same hyperechoic aspect of the ependyma. Nine of the neonates with hyperechoic ependyma developed ventriculomegaly, and three underwent surgery. Hyperechoic thickening of the ependyma in prematures often results from a subacute IVH. It is related to hemoglobin catabolites which can be detected by MRI. It does not require immediate potentially harmful diagnostic punctures. The presence of this hyperechoic rim allows a retrospective diagnosis of IVH and indicates a clinical and sonographic follow-up in newborns at risk for secondary hydrocephalus.