Neurodevelopment of preterm infants with glucose and sodium abnormalities.

BACKGROUND: Blood glucose and serum sodium abnormalities in very low birth weight infants may cause increased morbidity and mortality, but data regarding the long-term outcomes are limited. This study aimed to investigate the association between the peak and nadir blood glucose and serum sodium levels and neurodevelopmental outcomes in very low birth weight infants. METHODS: A single-center retrospective medical record of 284 infants with birth weight<1500 g born between February 1, 2011 and January 31, 2015 was reviewed. We analyzed the correlation between peak and nadir blood glucose and serum sodium levels during hospitalization and Bayley Scales of Infant and Toddler Development, third edition at 6, 12, and 24 months of corrected age. RESULTS: A total of 284 very low birth weight premature infants were eligible, and 223, 208, and 188 patients were assessed at 6, 12, and 24 months of corrected age, respectively. Multiple linear regression analysis with generalized estimating equations showed that the BSID-III cognitive scores were significantly lower in the peak serum sodium group when sodium was ≧150 mmol/L (95% confidence interval -11.681 to -0.822) than when sodium did not exceed 150 mmol/L. CONCLUSION: A peak serum sodium of ≧150 mmol/L is associated with poor cognitive outcomes in very low birth weight infants. Further studies are necessary to determine if this association is causal or an expression of disease severity.

Parenteral nutrition with fish oil-based lipid emulsion reduces the risk of cholestasis in preterm infants.

OBJECTIVE: Preterm infants receive long-term parenteral nutrition (PN) for gastrointestinal immaturity. This study aimed to determine if mixed lipid emulsions containing fish oil decrease the incidence of PN-associated cholestasis by reducing oxidative stress and providing an anti-inflammatory effect. METHODS: This retrospective cohort study enrolled 399 very low birth weight premature infants (gestational age ≤32 weeks) between January 2009 and November 2017 at a single neonatal intensive care unit. Preterm infants received total PN with either mixed lipid emulsion including fish oil (SMOFlipid®, n = 195) or soybean oil-based lipid emulsion (Lipovenoes®, n = 204) for at least 7 days. We compared the outcomes of PN-associated cholestasis, comorbidities, and mortality between the groups. RESULTS: The incidence of PN-associated cholestasis was significantly lower in the SMOFlipid group than in the Lipovenoes group. The duration to full feeding days was significantly shorter in the SMOFlipid group compared with the Lipovenoes group. Relevant complications, such as severe retinopathy of prematurity and bronchopulmonary dysplasia, were also significantly reduced in the SMOFlipid group compared with the Lipovenoes group. CONCLUSION: In premature infants, PN with fish oil-based lipid emulsions is associated with a lower incidence of PN-associated cholestasis compared with soybean oil-based lipid emulsions.

Effects of fish oil-containing lipid emulsions on retinopathy of prematurity in very low birth weight infants.

BACKGROUND: The aim of the study was to assess the impact of different types of parenteral emulsions on retinopathy of prematurity (ROP) in very low birth weight (VLBW, birth body weight < 1500 g) infants by comparing fish oil-containing and soy-based parenteral emulsions. METHODS: Data of preterm infants with body weights below 1500 gm at birth and receiving total parenteral nutrition (TPN) for a minimum of 7 days during the period between January 2009 and November 2017 were analyzed in this retrospective study. We compared clinical outcomes in two epochs using different lipid emulsions: epoch 1 (soybean-based lipid emulsions, January 2009-February 2014) versus epoch 2 (fish oil-containing lipid emulsions, January 2015-November 2017). The primary outcomes measured were the incidence of ROP and the number of ROP cases requiring bevacizumab therapy. RESULTS: A total of 396 infants were enrolled in this study (203 in epoch 1 and 193 in epoch 2). A lower incidence of any stage ROP (24.1 vs. 11.4%, p < 0.001) and lower requirement of bevacizumab therapy (12.8 vs. 5.2%, p = 0.001) were observed in epoch 2. Gestational age, glutamic-pyruvic transaminase, total bilirubin, and alkaline phosphatase levels, and type of lipid emulsion in TPN were associated with higher ROP incidence. Multivariate logistic regression analysis revealed that parenteral nutrition in the form of lipid emulsions containing fish oil was associated with a lower risk of development of ROP [Odds Ratio: 0.178, 95% confidence interval (CI): 0.095-0.330, p < 0.001]. CONCLUSIONS: Compared with soybean-based lipid solutions, the use of fish oil-containing lipid solutions may be associated with a lower incidence of ROP and decreased need for bevacizumab treatment in preterm infants.

Intravenous fish oil containing lipid emulsion attenuates inflammatory cytokines and the development of bronchopulmonary dysplasia in very premature infants: A double-blind, randomized controlled trial.

BACKGROUND & AIMS: Preterm infants have lower levels of long-chain polyunsaturated fatty acids (LCPUFAs). Supplementing very premature infants with intravenous lipid emulsions that fish oil, which is rich in n-3 LC-PUFAs, may decrease bronchopulmonary dysplasia (BPD) by modulating inflammation and neonatal immune function. METHODS: Sixty very low birth weight (VLBW) premature infants requiring ventilator support were randomized in a double-blind manner to 2 groups and received total parenteral nutrition with fish oil containing LE (intervention group, n = 30) or soybean oil containing LE (control group, n = 30) for 7 days. Blood samples and bronchoalveolar lavage fluid (BALF) were obtained for assay on day 1 and 7 days after LE. The primary outcome was to compare the levels of interleukin (IL)-1ß and IL-6 in serum and BALF. Secondary outcomes were to compare mortality and co-morbidities. RESULTS: The levels of IL-1ß and IL-6 in serum and BALF were significantly lower in the intervention group at day 8 (p < 0.05). The incidence of BPD in the intervention group compared to the control group was 13.3% versus 36.7% (p = 0.04; odds ratio [OR], 0.36; 95% confidence interval [CI], 0.21-0.86). The duration of ventilator support and oxygen use was significantly less in the intervention group than in the control group (p < 0.05). The level of alanine aminotransferase was significantly lower in the intervention group on day 8 (p = 0.031). CONCLUSIONS: In very premature infants, early administration of fish oil containing LE significantly decreased IL-1ß and IL-6 levels in serum and BALF and was associated with shorter duration of ventilator support and less bronchopulmonary dysplasia (BPD). TRIAL REGISTRATION NUMBER: ISRCTN 11427103.

Correlates of Elevated Interleukin-6 and 8-Hydroxy-2'-Deoxyguanosine Levels in Tracheal Aspirates from Very Low Birth Weight Infants Who Develop Bronchopulmonary Dysplasia.

BACKGROUND: Bronchopulmonary dysplasia (BPD) remains the most common complication of very low birth weight (VLBW) preterm infants, and inflammatory regulation plays a role in the development of the BPD. Interleukin-6 (IL-6) has an important role in airway inflammation and therefore can be used as a marker of airway injury. The study aimed to compare the changes between IL-6 and oxidative stress marker with 8-hydroxy-2'-deoxyguanosine (8-OHdG) from serum and tracheal aspiration (TA) in VLBW preterm infants following development of BPD. METHODS: This birth cohort study enrolled 80 VLBW preterm infants, including 26 who developed BPD. All infants completed the study and survived at 36 weeks postmenstrual age. IL-6 and 8-OHdG concentrations from serum and TA on Day 1 and Day 28 after birth were measured using immunoassay. RESULTS: IL-6 and 8-OHdG in serum and TA were higher in the BPD group than in the non-BPD group on the 1st day after birth (p < 0.05). The IL-6 and 8-OHdG levels in TA fluid were persistently increased on the 28th day of life in the BPD group (p < 0.05). The TA IL-6 was positively correlated with 8-OHdG levels on the 1st day (r = 0.64, p < 0.05) and 28th day of life (r = 0.76, p < 0.05). Based on receiver operating characteristic curves as a predictor of BPD development, TA IL-6 (cutoff, 456.8 pg/mg) had 81.5% sensitivity and 77.8% specificity, whereas TA 8-OHdG (cutoff, 4.4 ng/mg) had a sensitivity of 81.5% and a specificity of 64.4%. CONCLUSION: Persistent inflammation with oxidative DNA damage in the respiratory tract may be a crucial mechanism in BPD.

Correlations between pulmonary function and childhood asthma control test results in 5-11-year-old children with asthma.

OBJECTIVES: We examined correlations between the two asthma assessment tools, pulmonary function tests, and Childhood Asthma Control Test (C-ACT) scores, in 5-11-year-old children with asthma to determine if the C-ACT scores could predict pulmonary function test results. MATERIALS AND METHODS: A total of 172 children with asthma aged 5-11 years completed C-ACT questionnaires and underwent pulmonary function testing. Correlations between these test results were examined. Patients were also placed into two groups, C-ACT scores ≤19 and >19, to determine if patients with scores >19 had better pulmonary function test results. RESULTS: Weak correlations were found between pulmonary function test results and childhood asthma control test scores in 5-11-year-old children with asthma, with or without the use of an asthma controller. These correlations included: 0.061 for FEV1 [confidence interval (CI): -0.022-0.049] and 0.074 for MMEF (CI: -0.013-0.037). The proportions of children with C-ACT test scores ≤19 group and those with scores >19 group were not significantly different. CONCLUSION: Correlations between C-ACT scores and pulmonary function test results were poor for children aged 5-11 years with asthma. FEV1, FVC, FEF25, FEF50, FEF75, MMEF, and PEFR were not significantly correlated with C-ACT scores.

The accuracy of a glucose-oxidase-based point-of-care glucometer in premature infants.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of a novel commercial glucose-oxidase (GO)-based glucometer in measuring glucose concentrations in arterial blood samples collected from premature infants. PATIENTS AND METHODS: A commercial glucometer, which is a plasma separation GO-based glucometer, was employed to compare the accuracy of the commercial blood glucometer with that of a standard glucose analyser for monitoring blood glucose levels in premature infants. Arterial blood samples were collected and analysed, including samples adjusted for specific glucose (3.6 mmol/L, 8.3 mmol/L and 16.7 mmol/L) and PaO2 levels (range, 40-400 mm Hg). RESULTS: In total, 159 samples were collected. Bland-Altman analysis showed good correlation between the commercial glucometer and standard glucose analyser. Error-grid analysis revealed that all of the results were within zone A (ie, the clinically accurate estimate zone). The biases between the two systems were low at different PaO2 levels and haematocrits. Finally, the influence of different PaO2 levels was within acceptable ranges. CONCLUSIONS: The GO-based glucometer evaluated in this study provides accurate results even when measured at high PaO2 and different haematocrits and is suitable for measuring arterial glucose levels in premature infants.

Nationwide population-based epidemiologic study of childhood and adulthood intussusception in Taiwan.

BACKGROUND: Most studies have evaluated the epidemiology of intussusception only in children. This was the first nationwide population-based study conducted to investigate the epidemiology and associated medical expenses of intussusception for all age groups in Taiwan. METHODS: Cases of intussusception were identified from the annual hospitalization discharge claims of the National Health Insurance Research Database with corresponding International Classification of Diseases, Ninth Revision (ICD-9) code 560.0, from January 2000 to December 2007. RESULTS: In total, 7255 incident cases of intussusception were detected. The majority of cases were children younger than 4 years of age. Significant male predominance was observed in the under-10-, 55-59-, and older-than-80-year age groups. The incidence peaked in the 1-2-year age group, reaching as high as 112.84 and 81.96 per 100,000 person-years for males and females, respectively. The incidence of intussusception was very low in adults. However, the medical expenses, number of coexisting neoplasms and malignancies, and hospitalization days were substantially higher in adults than in children. Although coexisting neoplasms developed in 40.8% of adult patients with intussusception, it occurred in only 0.4% of those younger than 3 years. CONCLUSION: This study is the first to describe detailed age- and sex-specific incidence rates and medical expenses of intussusception for both pediatric and adult groups in Taiwan. There were significant differences between the two groups, with a much higher incidence in young children, but more coexisting neoplasms and malignancies and average medical expenses in adult patients.

Perception of medical care systems and stress responses in preschoolers' caregivers at a pediatric emergency department in Taiwan.

OBJECTIVES: This study was undertaken to understand caregivers' perception of medical care systems and their stress responses throughout their stay with preschoolers at a pediatric emergency department (ED). METHODS: Overall, 201 preschoolers' caregivers in pediatric ED were recruited in this study. They were asked to answer self-made questionnaires regarding the perception of medical care systems and their stress responses immediately before preschoolers' release. RESULTS: The results show that caregivers with a low education or low income level were prone to exhibit greater appreciation for the efficiency of medical care systems and greater degree of anxiety for their lack of treatment and care knowledge than those of caregivers with a high education or high income level. Interestingly, caregivers older than 38 years reported greater emotional responses and physical exhaustion than did younger caregivers. Immigrant caregivers had higher emotional reaction and lower concentration than did Taiwanese caregivers. Paradoxically, caregivers undergoing over 3-time pediatric ED visits for observation expressed stronger stress reactions as compared with caregivers with less observation experiences. Not surprisingly, caregivers reported the highest emotional responses when their preschoolers were diagnosed as having very urgent degree in triage classification. Finally, caregivers' perception of "lack of family support" and "lack of treatment and care knowledge" correlated positively with all aspects of the stress responses. CONCLUSIONS: These results indicate that attention should be paid to the specific psychological weakness and need for the caregivers with certain demographic characteristics by the medical team in pediatric ED.

The dose-dependent immunoregulatory effects of the nitric oxide synthase inhibitor N(G)-nitro-L-arginine methyl ester in rats with sub-acute peritonitis.

BACKGROUND: Chronic inflammation accompanied by arginine deficiency, immune dysfunction, and excess nitric oxide (NO) production is a clinical condition found in patients with peritonitis. A previous study showed that the nonselective NOS inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME) may facilitate the metabolism of the immune nutrient arginine without altering NO homeostasis in rats with sub-acute peritonitis. Here, we investigated the effects of L-NAME on the immunocytic subpopulation distribution and response. MATERIALS AND METHODS: Male Wistar rats with cecal puncture-induced peritonitis were administered parenteral nutrition solutions supplemented with 0 (CPP group), 5 (LNA group), 25 (MNA group) or 50 (HNA group) mg · kg(-1) · day(-1) of L-NAME for 7 days. Parenteral-fed sham-operated rats (TPN group) and orally-fed healthy rats (R group) were included as controls. RESULTS: The TPN group had significantly increased spleen weights and levels of plasma nitrite/nitrate (NOx), circulating white blood cells (WBC), and splenocytic T cells, as well as significantly decreased levels of cytotoxic T- and B-leukocytes and B-splenocytes compared to the R group. The CPP group had significantly decreased levels of plasma NOx and concanavalin (Con) A-stimulated interferon (IFN)-γ and interleukin (IL)-2 production by leukocytes and significantly increased production of Con A-stimulated tumor necrosis factor (TNF)-α and lipopolysaccharide (LPS)-stimulated IFN-γ in the leukocytes. In addition, the LNA and MNA groups had significantly decreased spontaneous IL-6 and Con A-stimulated TNF-α and IFN-γ production by the leukocytes while the HNA group had significantly increased LPS-stimulated TNF-α and Con A-stimulated IFN-γ and IL-2 production by the splenocytes compared to the CPP group. CONCLUSIONS: Low-dose L-NAME infusion may suppress proinflammatory and T-helper-1 (Th1) response in leukocytes, and high-dose infusion may activate the proinflammatory response in splenic macrophages and Th1 response in T-splenocytes in rats with sub-acute peritonitis.

Group B streptococcal infection in Taiwan: maternal colonization and neonatal infection.

BACKGROUND: There is no national data on group B streptococcus (GBS) infection in Taiwan. We investigated incidence of maternal GBS colonization and neonatal GBS infection rate and clinical pictures of neonatal GBS infection to estimate the value of intrapartum chemoprophylactic strategy in Taiwan. METHODS: From January 2004 to June 2005, a prospective study to estimate maternal colonization rate by maternal rectovaginal culture at six hospitals was conducted. Neonatal GBS infection rate based on inborn infants was calculated retrospectively from January 2001 to June 2005; clinical pictures of infants diagnosed with invasive GBS disease were reviewed. RESULTS: Maternal colonization rate of GBS was around 20% at hospital base, incidence of neonatal GBS infection was 1 per 1000 live births of infants born at hospitals. There were 221 infants with GBS infection: in 142, the disease occurred within 7 days of birth (early-onset disease, EOD), and in 79, it developed later (late-onset disease). Infantile EOD was more often seen in mothers with premature rupture of membrane, often accompanied by respiratory failure necessitating ventilator support. Infants with late-onset disease often manifested fever, leukopenia, thrombocytopenia, and meningitis. Fifteen infants died, mostly of EOD type (12 of 15). Risk factors of mortality included rescue at delivery room, leukopenia, thrombocytopenia, sepsis, respiratory distress, persistent hypertension of newborn, respiratory failure needing intensive respiratory support (intermittent mandatory ventilator and high frequency oscillatory ventilator), surfactant use, shock, and congenital heart diseases. CONCLUSIONS: We concluded that universal maternal rectovaginal culture of GBS with intrapartum antibiotic prophylaxis is an urgent call to reduce EOD and mortality because of GBS infection in neonates in Taiwan.

New plasma separation glucose oxidase-based glucometer in monitoring of blood with different PO2 levels.

BACKGROUND: The PalmLab glucometer is a newly designed plasma separation glucose oxidase (GO)-based glucometer. Past studies have shown that the accuracy of GO-based glucometers is compromised when measurements are taken in patients with high PO(2) levels. We performed a two-arm study comparing the fitness of the PalmLab blood glucometer with that of a standard glucose analyzer in monitoring blood glucose levels in pediatric patients, especially when arterial partial pressure of oxygen (PO(2)) was high. METHODS: In the first arm of the study, arterial blood samples from pediatric patients were measured by the PalmLab blood glucometer and the YSI 2302 Plus Glucose/Lactate analyzer. In the second arm of the study, venous blood samples from adult volunteers were spiked with glucose water to prepare three different levels of glucose (65, 150, and 300mg/dL) and then oxygenated to six levels of PO(2) (range, 40-400mmHg). The biases of the PalmLab glucometer were calculated. RESULTS: A total of 162 samples were collected in the first arm of the study. Results of linear regression showed that the coefficient of determination (R(2)) between PalmLab glucometer and standard glucose analyzer was 0.9864. Error grid analysis revealed that all the results were within Zone A (clinically accurate estimate zone). The biases between the two systems were low at different PO(2) levels. In the second arm of the study, the results were also unaffected by changes in PO(2). CONCLUSION: The PalmLab glucometer provides accurate results in samples with high PO(2) and is suitable for measuring arterial glucose levels in pediatric patients.

Dose effects of chronically infused nitric oxide synthase inhibitor N(G)-nitro-L-arginine methyl ester on anabolic response and arginine metabolism in rats with subacute peritonitis.

Nitric oxide synthase (NOS) inhibitors alleviate the adverse effects of nitric oxide (NO) overproduction that occurs during peritonitis, a clinical condition that is accompanied by arginine deficiency. However, the variations in the disease severity and the dosage, route, and period of NOS inhibitor administration are debatable. Therefore, we investigated the dose effects of chronically infused NOS inhibitor, N(G)-nitro-L-arginine methyl ester (L-NAME) on the anabolism, inflammatory responses, and arginine metabolism in parenterally fed rats with cecal puncture-induced subacute peritonitis. Male Wistar rats were divided into 4 groups and were administered total parenteral nutrition solutions with 0, 5 (low dose), 25 (medium dose), or 50 (high dose) mg·kg(-1)·d(-1) of L-NAME for 7 d. Sham-operated rats administered total parenteral nutrition solution and normal healthy rats fed chow diet were also included. Our results showed that parenteral infusion significantly decreased body weight gain and plasma citrulline concentrations. In rats with subacute peritonitis, the parenteral infusion-induced increases in circulating white blood cells and NO were significantly decreased, whereas the decrease in serum albumin levels was significantly increased. Rats with subacute peritonitis that were administered chronic infusion of L-NAME had a significantly reduced nitrogen balance. In addition, rats administered the medium dose of L-NAME had significantly increased plasma arginine, ornithine, glutamate, and proline. In conclusion, chronic infusion of NOS inhibitors may not alter systemic NO homeostasis and inflammatory response but may facilitate the production of arginine-associated amino acids and nitrogen excretion in cases of subacute peritonitis.

Congenital stridor and wheezing as harbingers of the del22q11.2 syndrome presenting cardiovascular malformations of right aortic arch, aberrant left subclavian artery, Kommerell's diverticulum, and left ligamentum arteriosum.

A complete vascular ring composed of right aortic arch, aberrant left subclavian artery with Kommerell's diverticulum, and left ligamentum arteriosum was diagnosed by barium esophagography, echocardiography, angiography, and multidetector computed tomography of chest in an 18-day-old male neonate who presented with remarkable inspiratory stridor, expiratory wheezing, postprandial vomiting, and dysphagia since birth, and survived surgical division of the left ligamentum arteriosum, resection of the Kommerell's diverticulum, and reimplanation of the left subclavian artery to the left common carotid artery. Cytogenetic analysis and fluorescence in situ hybridization study of his blood revealed chromosome 22q11.2 deletion, with a karyotype of 46,XY.ish del(22)(q11.2 q11.2). A constellation of right aortic arch, aberrant left subclavian artery with Kommerell's diverticulum, and left ligamentum arteriosum in neonates may cause refractory stridor, wheezing, vomiting, and dysphagia, which can serve as harbingers of the del22q11.2 syndrome.

Changing clinical presentations and survival pattern in trisomy 18.

BACKGROUND: The clinical presentations and survival patterns of infants with trisomy 18 have changed with increasing utilization of prenatal ultrasound and amniocentesis, and improvements in neonatal intensive care. METHODS: We obtained data on duration of survival, male to female ratio, and clinical details for patients with trisomy 18, and calculated the prevalence rate. RESULTS: We studied 31 consecutive trisomy 18 infants. The estimated prevalence was 1/4, 144. Eleven (35%) were premature infants, and 20 (65%) were full term. Mean birth weight was 1896 g. Median life expectancy was 12 days; 11 days for males and 14 days for females (p = 0.87). The short-term survival rates of 1 week, 4 weeks, and 6 months were 58%, 32%, and 10%, respectively. The long-term survival rates of 1 year, 2 years, and 3 years were 6%, 6%, and 3%, respectively. Families signed do-not-resuscitate consent forms for five male (50%) and 19 female infants (90%) (p = 0.043). CONCLUSION: All trisomy 18 infants in this study were preterm or full-term deliveries. Mean birth weight was lower than previously reported, and a high percentage of families signed do-not-resuscitate consent forms. Females did not survive longer than males, due to more females not being resuscitated. Most infants died in the first few weeks of life, but 3-6% of infants lived for 21 year. The possibility of long-term survival should be considered when counseling parents regarding trisomy 18.

Outcomes in neonates with pulmonary atresia and intact ventricular septum underwent pulmonary valvulotomy and valvuloplasty using a flexible 2-French radiofrequency catheter.

PURPOSE: Outcomes in 6 neonates with pulmonary atresia and intact ventricular septum (PAIVS) undergoing radiofrequency pulmonary valvulotomy and valvuloplasty (RPVV) were reported to identify the factors favorable for RPVV as the treatment of choice. MATERIALS AND METHODS: From May 2000 to January 2008, 6 patients with PAIVS were included in this retrospective study. They were aged 1 day to 90 days old. Study modalities included review of recordings of presentations and profiles of chest radiography, electrocardiography, echocardiography, and cardiac catheterization with angiography. Hemodynamic profiles from the echocardiography and the cardiac catheterization were analyzed. RESULTS: Echocardiography showed severe tricuspid regurgitation, membranous atresia of the pulmonary valve, intact ventricular septum, patent ductus arteriosus, and hypoplastic right ventricle in 6 patients. The pulmonary valve annulus were 4.2 to 6.9 mm in diameters, and those of the tricuspid valve were 7.1 to 10.1 mm. Elevated serum level of cardiac enzymes were found in 1 patient with ventriculocoronary communication (VCC). At cardiac catheterization, the ratio of systolic pressure of the right ventricle to that of the left ventricle ranged from 1.43 to 2.33 before RPVV, and from 0.54 to 1.15 after RPVV (p=0.027). The pressure gradients ranged from 76 to 136 mmHg before RPVV, and from 15 to 39 mmHg after RPVV (p=0.028). The echocardiographic gradients ranged from 16 to 32 mmHg within 24 hours after RPVV, and from 15 to 50 mmHg at the follow-ups. CONCLUSION: RPVV can be a treatment of choice for neonates with PAIVS, if there is patent infundibulum, no right-ventricular dependent coronary circulation, and adequate tricuspid valve and pulmonary valve.

Late-onset Enterobacter cloacae sepsis in very-low-birth-weight neonates: experience in a medical center.

OBJECTIVE: The objective of this study was to review the early clinical profiles and outcomes of very-low-birth-weight (VLBW) neonates with late-onset sepsis caused by Enterobacter cloacae. METHODS: We reviewed the medical records of VLBW neonates whose blood and/or cerebral spinal fluid yielded E. cloacae after 3 days of hospitalization in our neonatal intensive care unit. RESULTS: From January 1997 to December 2006, a total of 29 episodes of E. cloacae infection occurred in 28 VLBW neonates. The onset of E. cloacae infection ranged from 4 to 70 days (27.4 +/- 9.6) days after birth. The most common symptoms and signs of sepsis were desaturation (58.6%), tachycardia (58.6%), apnea (55.2%), unstable body temperature (48.3%), and decreased activity (44.8%). The infected neonates had an average of four kinds of symptoms in each sepsis episode. The most common laboratory findings in VLBW neonates with E. cloacae sepsis were thrombocytopenia (65.5%), C-reactive protein > or = 1 mg/dL (55.2%), band-form neutrophils > or = 5% (41.4%), and leucopoenia (20.7%). Empirical intravenous antibiotic therapy comprising piperacillin (or piperacillin and tazobactam) and gentamicin (or amikacin) was successful in the early treatment of 24 episodes of E. cloacae sepsis in 25 patients. Three neonates (10.7%) died due to E. cloacae sepsis. Four neonates (14.3%) developed E. cloacae meningitis, and two of them developed brain abscesses. CONCLUSIONS: E. cloacae infection in VLBW neonates usually presents with nonspecific symptoms and signs. Early recognition of sepsis and empirical combination of piperacillin (or piperacillin and tazobactam) and gentamicin (or amikacin) may be useful for treatment of sepsis caused by this highly virulent pathogen.

Early or late surgical ligation of medical refractory patent ductus arteriosus in premature infants.

Optimal time to surgical ligation of patent ductus arteriosus (PDA) in very-low-birth-weight (< 1500 g) premature infants remains an area of controversy. We compared the outcomes of early or late ligation of medical refractory PDA in very-low-birth-weight premature infants. Fifty-six infants underwent surgical closure of PDA after failure of or having contraindications to medical treatment. Thirteen infants were in the early ligation (< or = 14 days) and 43 in the late ligation (> 14 days) groups. Basic clinical features, major morbidity of prematurity and mortality were compared. Clinical features and major outcomes were similar. The early ligation group had earlier onset of symptomatic PDA (5.7 +/- 1.6 days vs. 8.1 +/- 3.6 days, p = 0.024), and fewer days of total parenteral nutrition (TPN) (39.6 +/- 13.9 days vs. 60.4 +/- 31.4 days, p = 0.025) and ventilator use (11.1 +/- 6.7 days vs. 18.6 +/- 10.5 days, p = 0.019). Early ligation of medical refractory PDA in very-low-birth-weight premature infants improves enteral feeding tolerance and reduces TPN and ventilator use, but long-term benefits need further investigation.

Heat-shock response protects peripheral blood mononuclear cells (PBMCs) from hydrogen peroxide-induced mitochondrial disturbance.

The present study was designed to investigate ex vivo the protective mechanisms of heat-shock response against H(2)O(2)-induced oxidative stress in peripheral blood mononuclear cells (PBMCs) of rats. Twenty-four hours later, heat-shock treatment was executed in vivo; rat PBMCs were collected and treated with H(2)O(2). The accumulation of reactive oxygen species and the mitochondrial membrane potential were evaluated by intracellular fluorescent dHE and JC-1 dye staining, respectively, and expression of HSP72 and cytochrome c was detected by Western blot analysis. Cellular apoptosis was assayed by TUNEL staining and double staining of Annexin V and PI. The results showed that H(2)O(2)-induced oxidative stress leads to intracellular superoxide accumulation and collapse of the mitochondrial membrane potential in rat PBMCs. Moreover, cellular apoptosis was detected after H(2)O(2) treatment, and the release of mitochondrial cytochrome c from mitochondria to cytosol was significantly enhanced. Heat-shock pretreatment decreases the accumulation of intracellular superoxide in PBMCs during H(2)O(2)-induced oxidative stress. Moreover, heat-shock treatment prevents the collapse of the mitochondrial membrane potential and cytochrome c release from mitochondria during H(2)O(2)-induced oxidative stress. In conclusion, mitochondria are critical organelles of the protective effects of heat-shock treatment. Cellular apoptosis during H(2)O(2)-induced oxidative stress is decreased by heat-shock treatment through a decrease in superoxide induction and preservation of the mitochondrial membrane potential.