Video recording in the delivery room: current status, implications and implementation.

Many factors determine the performance and success of delivery room management of newborn babies. Improving the quality of care in this challenging surrounding has an important impact on patient safety and on perinatal morbidity and mortality. Video recording (VR) offers the advantage to record and store work as done rather than work as recalled. It provides information about adherence to algorithms and guidelines, and technical, cognitive and behavioural skills. VR is feasible for education and training, improves team performance and results of research led to changes of international guidelines. However, studies thus far have not provided data regarding whether delivery room video recording affects long-term team performance or clinical outcomes. Privacy is a concern because data can be stored and individuals can be identified. We describe the current state of clinical practice in high- and low-resource settings, discuss ethical and medical-legal issues and give recommendations for implementation with the aim of improving the quality of care and outcome of vulnerable babies. IMPACT: VR improves performance by health caregivers providing neonatal resuscitation, teaching and research related to delivery room management, both in high as well low resource settings. VR enables information about adherence to guidelines, technical, behavioural and communication skills within the resuscitation team. VR has ethical and medical-legal implications for healthcare, especially recommendations for implementation of VR in routine clinical care in the delivery room. VR will increase the awareness that short- and long-term outcomes of babies depend on the quality of care in the delivery room.

Three-dimensional head shape acquisition in preterm infants - Translating an orthodontic imaging procedure into neonatal care.

BACKGROUND: Head shape and head volume of preterm infants give important information on short- and long-term development. Three-dimensional (3D) assessment of a preterm infant's head would therefore provide more information than currently used two-dimensional methods. AIMS: To evaluate a contactless 3D imaging system to assess head shape and volume in preterm infants. METHODS: A protocol for 3D imaging and reconstruction of an infant's head with a portable stereophotogrammetric camera system was developed. It was validated on a manikin by comparison to an established stationary stereophotogrammetric device. Feasibility for clinical routine and 3D data analysis were assessed in six preterm infants. RESULTS: Ten 3D reconstructions from a manikin were done with ten images each taken from different angles. The accuracy of the 3D reconstruction was measured at the overlapping areas between two images. Comparing the portable to the stationary system, a high concordance was found for the 3D manikin head-reconstructions (mean difference 0.21 ±â€¯0.03 mm). In preterm infants, digital evaluation of the head was proven to be feasible for head circumference (HC), cranial index and asymmetry indices. There was good concordance between manual and digital measurement of the HC (95% CI -0.85 to 0.38 mm). CONCLUSIONS: The portable camera system allowed fast and contactless 3D image capture of a preterm infant's head without any risk or interference with neonatal care. Together with a new software, this technique would allow more precise evaluation of head growth even in very preterm infants and thereby may improve their care and long-term outcome.

Less Oxygen, Later Intubation and Reduced Respiratory Pressures for ELBW Infants from 1997 to 2011.

INTRODUCTION: Evidence concerning delivery room management in extremely low birth weight infants (ELBW) has grown substantially within the last 20 years, leading to several guidelines and recommendations. However, it is unknown in which extent local treatment strategies have changed and if they reflect current recommendations. METHODS: A detailed questionnaire about treatment strategies for ELBW infants was sent to all German neonatal intensive care units (NICUs) treating ELBW infants in 1997. A follow-up survey was conducted in 2011 and sent to all NICUs in Germany, Austria and Switzerland. RESULTS on delivery room management were compared to the first survey. RESULTS: In 1997 and 2011, 63.6 and 66.2% of the approached hospitals responded. In 2011 similar results were observed between university and non-university hospitals as well as NICUs of different size. Differences between Germany, Austria and Switzerland were minimal. Changes over time were a lower initially applied fraction of inspired oxygen (FiO2) and peak inspiratory pressure (PiP) in 2011 compared to 1997. A longer time of apnea was tolerated before tracheal intubation is performed; the time of apnea was less frequently a sole criterion for intubation and surfactant was applied at lower FiO2 in 2011. The time of no thorax excursions and transport of the infant were considered an indication for intubation in 30.2 and 22.5%, and did not change in the observation period. CONCLUSION: Treatment strategies for delivery room management in ELBW infants changed significantly between 1997 and 2011 and largely reflect current recommendations.

Pathophysiology of neonatal transition and meaningful measures for the initial stabilisation of extremely premature neonates.

This report discusses the physiological aspects of neonatal transition from breathing liquid to air. Further, we discuss reasonable medical interventions to actively assist a gentle transition, and focus on team aspects of preparing both the perinatal team and parents for the challenging situation of preterm labour and delivery. Our aim is to critically evaluate current concepts on the physiology of neonatal transition and the current assessment of the newborn infant, to present means to facilitate non-traumatic pulmonary aeration and ways to foster successful teamwork and professional parental guidance in the delivery room. The authors report on their own work and on that of other research groups, as recently published in peer reviewed medical journals. When born, the newborn needs to rapidly clear his/her lungs from fluid to establish breathing. Active fluid transport and passive resorption help to establish the pulmonary functional residual capacity (FRC). Prenatal administration of corticosteroids helps to form and maintain the FRC of the newborn. Many very low gestational age neonates (ELGAN) will breathe at birth but require medical assistance. This is best done by giving distending positive airway pressure at levels of 5 cmH(2)O, or greater. Monitoring of these infants should be by peripheral pulse oximetry. Some ELGANs may require non-invasive ventilation and/or exogenous Surfactant replacement, and even fewer may require intubation and mechanical ventilation. The obstetric and neonatal teams need to coordinate their joined efforts to secure a safe delivery for mother and child. Ways of communication between teams and parents are presented. Many neonatal teams use video recording as a tool to assess and improve their work. We give insights into the use of video as a means to improve teamwork and patient care alike.

The transcriptome of the arbuscular mycorrhizal fungus Glomus intraradices (DAOM 197198) reveals functional tradeoffs in an obligate symbiont.

• The arbuscular mycorrhizal symbiosis is arguably the most ecologically important eukaryotic symbiosis, yet it is poorly understood at the molecular level. To provide novel insights into the molecular basis of symbiosis-associated traits, we report the first genome-wide analysis of the transcriptome from Glomus intraradices DAOM 197198. • We generated a set of 25,906 nonredundant virtual transcripts (NRVTs) transcribed in germinated spores, extraradical mycelium and symbiotic roots using Sanger and 454 sequencing. NRVTs were used to construct an oligoarray for investigating gene expression. • We identified transcripts coding for the meiotic recombination machinery, as well as meiosis-specific proteins, suggesting that the lack of a known sexual cycle in G. intraradices is not a result of major deletions of genes essential for sexual reproduction and meiosis. Induced expression of genes encoding membrane transporters and small secreted proteins in intraradical mycelium, together with the lack of expression of hydrolytic enzymes acting on plant cell wall polysaccharides, are all features of G. intraradices that are shared with ectomycorrhizal symbionts and obligate biotrophic pathogens. • Our results illuminate the genetic basis of symbiosis-related traits of the most ancient lineage of plant biotrophs, advancing future research on these agriculturally and ecologically important symbionts.

Ultrasound for the assessment of bone quality in preterm and term infants.

OBJECTIVE: As 80% of intrauterine bone mineralization takes place during the last trimester of pregnancy, preterm infants should be supplemented postnatally with optimal doses of calcium, phosphate and vitamin D. Calcium and phosphate excretion in the urine may be used to monitor individual mineral requirements, but are sometimes difficult to interpret. The objective of this study was to assess the value of quantitative ultrasound (QUS) for the analysis of bone status in neonates. STUDY DESIGN: All admissions to three independent tertiary neonatal intensive care units were studied. In 172 preterm and term infants with a gestational age between 23 and 42 weeks (mean 33.8±5.0) and a birth weight from 405 to 5130 g (mean 2132±1091 g) bone status was evaluated prospectively by quantitative ultrasound velocity using a standardized protocol. Infants were followed in regular intervals up to their first discharge home. While measurements were conducted in weekly intervals initially (n=55), 2-week intervals were regarded as sufficient thereafter due to limited changes in QUS values within the shorter period. Infants with a birth weight below 1500 g were followed during outpatient visits until up to 17 months of age. RESULT: The intra-individual day-to-day reproducibility was 0.62%. QUS-values from the first week of life correlated significantly with gestational age and birth weight (r=0.5 and r=0.6; P<0.001). Small-for-gestational-age infants showed lower values for QUS than appropriate-for-gestational-age infants allowing for their gestational age. Follow-up measurements correlated positively with age and weight during the week of measurement (r=0.2 and r=0.4; P=0.001). Comparing bone quality at 40 weeks of age in infants born at term versus infants born at 24 to 28 weeks, preterm infants showed significantly lower QUS than term infants (P<.0001).There was a significant correlation of QUS with serum alkaline phosphatase (P=0.003), the supplementation with calcium, phosphate and vitamin D (P< 0.001 each), as well as risk factors for a reduced bone mineralization. No correlation was found between QUS and calcium or phosphate concentration in serum or urine. CONCLUSION: QUS is a highly reproducible, easily applicable and radiation-free technique that can be used to monitor bone quality in individual newborns. Further prospective randomized-trials are necessary to evaluate, if therapeutic interventions based on QUS are able to prevent osteopenia of prematurity.

Pulmonary toxoplasmosis, a rare but severe manifestation of a common opportunistic infection in late HIV presenters: report of two cases.

Pulmonary toxoplasmosis is rare, particularly in the era of highly active antiretroviral therapy (HAART). Here, we describe two severe cases in patients not known to be HIV-infected. In both patients, early diagnosis and therapy led to a favourable outcome. Pulmonary toxoplasmosis should be considered in the differential diagnosis in potentially HIV-infected patients with respiratory symptoms.

Surfactant without intubation in preterm infants with respiratory distress: first multi-center data.

BACKGROUND: Recently in a report of a single center a method has been described to apply surfactant via a thin endotracheal catheter to very low birth weight infants spontaneously breathing with nasal continuous positive airway pressure. We now analyzed available multicenter data. PATIENTS AND METHODS: In a multicenter study investigating genetic risk factors, clinical and outcome data and data of antenatal and postnatal treatment of infants with a birth weight below 1,500 g were prospectively recorded. The measures of infants treated with the new method of surfactant application were compared to those of infants who received standard care. The analysis was restricted to infants with a gestational age below 31 weeks (n=1,541). RESULTS: 319 infants were treated with the new method and 1,222 with standard care. The need for mechanical ventilation during the first 72 h (29% vs. 53%, p<0.001), the rate of bronchopulmonary dysplasia defined as oxygen at 36 weeks of postmenstrual age (10.9 % vs. 17.5%, p=0.004) and the rate of death or bronchopulmonary dysplasia were significantly lower in the treatment group than in the standard care group. Surfactant, theophyllin, caffeine and doxapram were significantly more often and analgetics, catecholamines and dexamethasone were significantly less frequently used in the treatment group. CONCLUSIONS: A new method of surfactant application was associated with a lower prevalence of mechanical ventilation and better pulmonary outcome. A prospective controlled trial is required to determine whether this approach is superior to standard care.

Molecular evidence of interhuman transmission in an outbreak of Pneumocystis jirovecii pneumonia among renal transplant recipients.

Pneumocystis jirovecii pneumonia (PCP) remains an important cause of morbidity and mortality in immunocompromised individuals. The epidemiology and pathogenesis of this infection are poorly understood, and the exact mode of transmission remains unclear. Recent studies reported clusters of PCP among immunocompromised patients, raising the suspicion of interhuman transmission. An unexpected increase of the incidence of PCP cases in our nephrology outpatient clinic prompted us to conduct a detailed analysis. Genotyping of 7 available specimens obtained from renal transplant recipients was performed using multi-locus DNA sequence typing (MLST). Fragments of 4 variable regions of the P. jirovecii genome (ITS1, 26S, mt26S, beta-tubulin) were sequenced and compared with those of 4 independent control patients. MLST analysis revealed identical sequences of the 4 regions among all 7 renal allograft recipients with available samples, indicating an infection with the same P. jirovecii genotype. We observed that all but 1 of the 19 PCP-infected transplant recipients had at least 1 concomitant visit with another PCP-infected patient within a common waiting area. This study provides evidence that nosocomial transmission among immunocompromised patients may have occurred in our nephrology outpatient clinic. Our findings have epidemiological implications and suggest that prolonged chemoprophylaxis for PCP may be warranted in an era of more intense immunosuppression.

Polymorphisms in the Renin-Angiotensin system and outcome of very-low-birthweight infants.

BACKGROUND: The insertion/deletion polymorphism of the angiotensin-converting enzyme (ACE-ins/del) and the angiotensin II type 1 receptor 1166A/C polymorphism (ATR1166A/C) were reported to be associated with several unfavorable outcome parameters in preterm infants like bronchopulmonary dysplasia, persistent ductus arteriosus and impaired insulin sensitivity. OBJECTIVE: To confirm the above-mentioned associations in a large cohort of very-low-birthweight (VLBW) infants. METHOD: Clinical data of VLBW infants were prospectively recorded. The ACE-ins/del polymorphism and the ATR1166A/C polymorphism were determined by polymerase chain reaction in 1,209 and 1,168 infants, respectively. RESULTS: There was no significant association between ACE-ins/del or ATR1166A/C genotype and outcome parameters (death, intraventricular hemorrhage, sepsis, bronchopulmonary dysplasia, ventilation, supplemental oxygen at discharge, postnatal treatment with insulin, surgery for intestinal perforation/necrotizing enterocolitis/retinopathy of prematurity/persistent ductus arteriosus. CONCLUSION: Both known functional polymorphisms of the renin-angiotensin system do not seem to be associated with the outcome of VLBW infants.

Interleukin-6-174-genotype, sepsis and cerebral injury in very low birth weight infants.

We investigated the association between the interleukin 6 (IL-6)-174-genotype and unfavorable outcomes in preterm infants since it has been reported that the IL-6-174GG-genotype is associated with increased susceptibility to sepsis, and the IL-6-174CC-genotype is more common in preterm infants with severe intraventricular hemorrhage (IVH). We studied 1206 preterm infants with a birth weight below 1500 g. In contrast to previously published data, the frequency of IVH grade IV, periventricular leukomalacia, ventricular-peritoneal-shunting or death was not different between infants with different IL-6-genotypes: IL-6-174GG (n = 430) 8%, IL-6-174GC (n = 605) 9% and IL-6-174CC (n = 167) 12% (P = 0.2 for IL-6-174CC vs GG + GC). Furthermore, we were not able to confirm previously reported association between sepsis and the IL-6-174GG-genotype. Blood-culture-proven sepsis occurred in 19% of IL-6-174GG-carriers (n = 157), 26% of IL-6-174GC-carriers (n = 193) and 27% of infants carrying the IL-6-174CC-genotype (n = 67). We were not able to confirm previously reported associations between sepsis, cerebral injury and the IL-6-174-genotype in VLBW-infants.

[Primary HIV-1 infection in Zurich: 2002-2004]. / Die akute HIV-1-Infektion in Zürich: 2002-2004.

Acute HIV-infection mostly presents with unspecifc symptoms. Thus the acute retroviral syndrome is often not readily recognized. Here we present an interim analysis of a prospective study from 62 patients with documented acute HIV infection acquired between January 2002-August 2004 in the greater Zurich area. 61.5% of patients were infected by homosexual contacts, mostly with HIV-1 subtype B, 34% acquired infection by heterosexual contacts, often with non-B-virus subtypes. Transmission occurred in all sexually active age groups (18-72 years). Clinical symptoms presented as follows: fever (77%), pharyngitis (56%), fatigue (52%), gastrointestinal symptoms (45%), rash (39%). On first physician contact, an ARS was only suspected in 27% of the cases. Patients primarily called on their family doctors (37.5%), went to see larger walk in clinics or emergency rooms (37.5%), and 16% were hospitalised. In 16% of patients other sexually transmitted diseases were diagnosed contemporaneously. Drug resistant virus (single class resistance) was transmitted in only one patient.

Mutations in the high-affinity IgE receptor beta-chain are not associated with nonresponder status.

BACKGROUND: Basophils of some individuals do not release histamine upon activation of their high-affinity immunoglobulin E (IgE) receptor (Fc(epsilon)RI), but do so if this receptor is circumvented for cell activation. This so-called nonresponder phenomenon is clinically relevant, because in various studies atopy was less frequent or absent in nonresponder individuals. So far, it is unknown if this phenomenon is acquired during adulthood or exists from birth on. METHODS: Histamine release was determined from isolated leucocytes stimulated with anti-IgE or calciumionophor. Also, random primed cDNA was synthesized and the open reading frame (ORF) of the Fc(epsilon)RI beta-subunit amplified and sequenced. RESULTS: In the first part of our study, we examined the role of atopic status, type of atopy, and age in a random population of 95 children of whom we found 22% to be nonresponder. None of these parameters correlated with the nonresponder status. Except for food allergy, no specific type of atopy correlated with histamine release. The mechanism underlying the nonresponder phenomenon is assumed to occur early in the signalling cascade. We hypothesized that mutations in the Fc(epsilon)RI beta-chain may be associated with the nonresponder status, and in the second part of our study sequenced the beta-subunit in 20 responders and 20 nonresponders. Two conservative and two nonconservative heterozygous one base mutations (Thr179Thr, Asp216Asp, Ile147Leu and Glu237Gly) were found in two nonresponders and one responder. Three of these mutations have not been described so far. CONCLUSION: The nonresponder phenomenon is present from birth on and genetically determined. In our population, it was not associated with age or the presence of atopy, and appeared not to be caused by mutations in the Fc(epsilon)RI beta-chain.

Elevated MIA levels in the serum of pregnant women and of children.

Recent studies have shown that the protein MIA (melanoma inhibitory activity) is a potent serum marker for malignant melanoma. MIA is expressed in chondrocytes at high levels, and might potentially be elevated during periods of growth in childhood. Therefore, we evaluated MIA serum levels in pregnant women and in growing children. We found that no significant enhancement of MIA serum levels was apparent until 38 weeks of pregnancy. Starting at 38 weeks, a significant increase was noted. The study further revealed that children and teenagers also have increased MIA serum levels. However, from the age of 17 years MIA serum levels are not different from those in healthy adults. In summary, MIA can be used as a serum marker for melanoma in adults starting at the age of 17 years. In pregnant women (> 38th week), children, and teenagers MIA should not be used in serum diagnostics for malignant melanoma until larger studies have been performed to generate cut-off levels for each group.

Impact of TNFalpha, LTalpha, Fc gammaRII and complement receptor on HIV-1 trapping in lymphoid tissue from HIV-infected patients.

OBJECTIVES: To investigate HIV trapping mechanisms in patients with acute infection and in asymptomatic individuals prior to and during antiretroviral therapy. To determine the role of complement receptor (CR), Fc gamma receptor II (Fc gammaRII), tumour necrosis factor alpha (TNFalpha), and lymphotoxin alpha (LTalpha) expression in HIV trapping efficiency. METHODS: Lymphoid tissues from three acutely HIV-infected patients and six asymptomatic, chronically HIV-infected patients collected prior to and during antiretroviral therapy were compared with lymphoid tissues from six HIV-seronegative subjects. HIV, TNFalpha and LTalpha RNA expression was detected and quantified by fluorescence in situ hybridization. CR, Fc gammaRII and HIV p24 antigen were detected and quantified by fluorescence immunohistochemistry. RESULTS: The amount of trapped HIV did not differ significantly between patients with acute HIV infection and asymptomatic individuals, and was independent of the presence of CR or Fc gammaRII expression. However, in patients with acute infection, the amount of trapped virus was correlated inversely with the number of HIV-infected cells (P = 0.0092) and with the size of the light zone (P = 0.037). In these patients, the number of TNFalpha-expressing cells was correlated inversely with the amount of trapped virus (P = 0.014) and positively correlated with the size of the light zone in germinal centers (P = 0.041). No correlations were observed between TNFalpha or LTalpha expression and Fc gammaRII or CR expression. CONCLUSION: This report provides the first evidence that in humans TNFalpha is involved in the development of lymphoid follicles, HIV trapping, and, consequently, in early host immune responses. A model is proposed for early events in patients during acute HIV infection.

The broad bean nodulin VfENOD18 is a member of a novel family of plant proteins with homologies to the bacterial MJ0577 superfamily.

Full-length transcript sequences were isolated from broad bean root nodules, which encode a novel nodulin designated VfENOD18. The corresponding transcripts were detected in early and in late stages of nodule development and were localized exclusively in the nitrogen-fixing zone III. The VfENOD18 sequence is not only homologous to a number of ESTs from various mono- and dicotyledonous plants, but also to the ATP-binding protein MJ0577 from Methanococcus jannaschii and to a range of bacterial proteins that belong to the MJ0577 superfamily. Hence, VfENOD18 is a member of a ubiquitous family of plant proteins that might function as ATP-binding proteins or ATPases. On the genomic level, VfENOD18 genes can be divided into two groups on the basis of differences in their 5' UTRs. One group lacks the 5' UTR region including the ATG initiation codon, whereas the second group contained the complete 5' UTR region. Further upstream of this VfENOD18 gene, a retrotransposon sequence was identified. The -14/-964 VfENOD18 promoter fragment was devoid of complete organ-specific elements known from other nodulin gene promoters. Nevertheless, this region was able to mediate full promoter activity in the central region of transgenic Vicia hirsuta root nodules.

CSF interleukin-6 in neonatal Citrobacter ventriculitis after meningitis.

An infant with neonatal severe Citrobacter koseri (formerly Citrobacter diversus) meningoencephalitis developed necrosis with multicystic regression of both hemispheres. The ventriculitis persisted over months in spite of antibiotic therapy. The treatment succeeded with cefotaxime in a high dose (300 mg/kg/day) without surgical intervention. The infant had been previously treated with cefotaxime (200 mg/kg/day) over 5 weeks. High levels of CSF interleukin-6 (IL-6) permitted to attribute persisting CSF pleocytosis in spite of sterile CSF cultures to chronic infection and not to reminiscence of brain necrosis. This report reveals two main points. On the one hand, the importance of therapy monitoring with IL-6 in CSF for the consequent treatment of Citrobacter meningitis and on the other hand, high-dose cefotaxime (300 mg/kg/day) treatment of Citrobacter ventriculitis, which succeeded without surgical intervention.

Treatment-induced decline of human immunodeficiency virus-1 p24 and HIV-1 RNA in lymphoid tissue of patients with early human immunodeficiency virus-1 infection.

We report detailed quantitative analysis of human immunodeficiency virus-1 (HIV-1) p24 and HIV-1 RNA in tonsil biopsies from 13 patients with early, asymptomatic HIV infection before and during combination antiretroviral therapy. Using fluorescent microscopy in conjunction with reverse transcriptase-polymerase chain reaction of frozen tissue sections, we show that plasma and tissue viral loads decreased by approximately 3 logs during the 1-year treatment period, with good correlation between the HIV-1 p24 and HIV-1 RNA response in tissue. The decrease of tissue viral load was delayed compared to plasma viral load, possibly explained by the observation that the amount of follicular dendritic cell-associated virus correlated best with the area under the curve of plasma HIV-1 RNA throughout the last 12 weeks. Before and during treatment, the relative proportions of HIV-1 on follicular dendritic cells and within mononuclear cells remained constant, suggesting similar decay characteristics in these two lymphoid tissue compartments. However, viral p24 or RNA remained almost always detectable in tissue despite full suppression of HIV-1 RNA in plasma, and increased even after short-term rebounds in plasma viral load. Thus, full and sustained suppression of viral replication was required to efficiently decrease viral load in lymphoid tissue, but complete abolition of residual viral replication was not achieved.

Genomic organization and expression properties of the VfENOD5 gene from broad bean (Vicia faba L.).

A full-length cDNA encoding the broad bean (Vicia faba L.) early nodulin VfENOD5 was isolated from a nodule cDNA library. In addition to the ENOD5 homologues from other legumes the derived VfENOD5 amino acid sequence also displayed homologies to the phytocyanin-related nodulins GmENOD55-2, MtENOD16, and MtENOD20. A close inspection of the ENOD5 proteins from broad bean, pea and vetch indicated that all these nodulins possess a putative C-terminal GPI-anchor signal sequence. This novel finding supports the hypothesis that ENOD5 is an arabinogalactan protein. Tissue print hybridizations revealed that the broad bean ENOD5 gene was not only expressed in the central tissues of root nodules. In contrast to other legumes hybridizing transcripts were also be detected in a narrow zone within the peripheral nodule tissues. Sequence analysis of a genomic clone indicated the presence of a single intron interrupting the VfENOD5 coding region at a position precisely corresponding to the MtENOD16 and MtENOD20 introns.