Effect of high calcium and phosphate concentrations on the physicochemical properties of two lipid emulsions used as total parenteral nutrition for neonates.

Premature infants require protein and energy for their growth and an adequate intake of calcium and phosphorus for their bone formation. However, several factors can affect the stability of intravenous lipid emulsions intended to be administered as neonatal total parenteral nutrition. This study evaluated the effect of additives and various concentrations of both calcium gluconate and glucose-1-phosphate on two intravenous lipid emulsions (Clinoleic 20% and Ivelip 20%) when using Primene 10% as source of amino acids and simulating clinical conditions (24-h storage at 37 degrees C). Two series of experiments for each lipid emulsion were carried out. One used separate ingredients (water, glucose, or amino acids) with various calcium phosphate concentrations; and the second included total parenteral nutrition admixtures with varied amino acid (1%, 2%, or 3.5%) and glucose (8% or 14%) concentrations. Evaluation was performed by visual and microscopic examination and pH, particle size, and zeta potential measurements. Calcium concentrations were determined before and after filtration by atomic absorption spectroscopy. Samples were stored 24 h at 37 degrees C. Investigations of lipid-nutrient admixtures showed a significant decrease of the pH with Primene and a visual instability when mixing with sterile water alone, while total parenteral nutrition admixtures made of Clinoleic 20% or Ivelip 20% were stable regarding pH, particle sizing, and zeta potential after storage conditions. Samples containing only calcium have their zeta potential charge reduced compared to samples containing both calcium and phosphate. Also, the evaluation of calcium phosphate solubility showed a significant decrease of the calcium concentration after filtration of the samples. Our data indicated that total parenteral nutrition admixtures could contribute to protect the lipid emulsion from its physicochemical degradation and that using organic phosphate with calcium gluconate has a less deleterious effect than using calcium alone with total parenteral nutrition. Also, the use of inline filters remains necessary for good protection from hazards of precipitates during the administration of total parenteral nutrition regimens.

Outbreak of Acinetobacter baumannii in a neonatal intensive care unit: antimicrobial susceptibility and genotyping analysis.

PURPOSE: We describe an outbreak of nosocomial respiratory infection caused by multi-drug resistant Acinetobacter baumannii in a neonatal intensive care unit (NICU) in Tunis and our investigation to determine the source. METHODS: Between May 2006 and February 2007, 31 infants hospitalized in the NICU of the Centre of Maternity and Neonatology of La Rabta in Tunis developed A. baumannii pneumonia. A case (infected infant) was defined as any patient hospitalized in the NICU during the outbreak period, with clinical signs of pneumonia and isolation of A. baumannii from tracheal aspirate. Ten rectal swabs and 98 environmental specimens were collected for the epidemiological investigation. Thirty-nine A. baumannii isolates were collected: 31 clinical strains from tracheal aspirates (>10(3) colony-forming units [CFU]/mL), 3 environmental strains from incubators, and 5 from rectal swab. For the genotyping method, we used pulsed-field gel electrophoresis using ApaI restriction endonuclease. RESULTS: Thirty-one neonates developed multiple drug-resistant A. baumannii-associated pneumonia with 10 deaths due to A. baumannii infection, 48.4% had very low birth weight (

Randomized pilot study comparing oral ibuprofen with intravenous ibuprofen in very low birth weight infants with patent ductus arteriosus.

BACKGROUND: We conducted a prospective, randomized, single-masked pilot study with the principal aim of comparing efficacy and tolerance between oral and intravenous ibuprofen in early closure of patent ductus arteriosus in very low birth weight infants. The possibility of ductal closure with only 1 or 2 doses of treatment was a secondary objective. MATERIAL AND METHODS: Sixty-four very low birth weight patients with echocardiographically confirmed patent ductus arteriosus and respiratory distress were studied. The patients were randomly assigned to receive either oral (group O, n=32) or intravenous (group I, n=32) ibuprofen starting on the third day of life. After the first dose of treatment in both groups, echocardiographic evaluation was performed to determine the need for a second or third dose. The rate of ductal closure, adverse effects, complications, and the patient's clinical course were recorded. RESULTS: In each group, 24 (75%) patients were born after 28 weeks' gestation. The rate of ductal closure tended to increase in group O (84.3% vs 62.5%). Closure of the ductus was obtained after 1 or 2 doses of treatment in 19 (70.3%) of 27 patients in group O and 14 (70%) of 20 patients in group I. The adverse effects were increased in group I (31.2% vs 9.3%). There were no significant differences with respect to complications during the stay. Adverse effects were significantly fewer when closure was achieved after an incomplete course of treatment (23.1% vs 76.9%). CONCLUSIONS: In very low birth weight infants, the rate of early ductal closure with oral ibuprofen is at least as good as with the intravenous route. Ductal closure may be obtained with an incomplete course of ibuprofen. Oral ibuprofen is associated with fewer adverse effects. However, a larger sample is needed for more definitive conclusions.

Risk factors of the failure of surfactant treatment by transient intubation during nasal continuous positive airway pressure in preterm infants.

We sought to identify risk factors and neonatal outcomes associated with the failure of the INSURE method ( INtubation- SURfactant- Extubation) during nasal continuous positive airway pressure for preterm infants with respiratory distress syndrome. We used a retrospective analysis of the prenatal histories, clinical courses, and laboratory data of all inborn infants with gestational age 27 to 34 weeks and respiratory distress syndrome treated with INSURE method. Infants were categorized into two groups: INSURE failure group and INSURE success group. One hundred nine infants were eligible to the study. INSURE failure was registered in 35 infants (32.1%). After control for confounding variables, INSURE failure was significantly associated with arterial partial pressure of carbon dioxide (adjusted odds ratio [OR] = 1.82; 95% confidence interval [CI] = 1.76 to 90.56), mean arterial-to-alveolar oxygen tension ratio (adjusted OR = 1.13; 95% CI = 1.06 to 85.34) and severe radiological grade (adjusted OR = 1.31; 95% CI = 1.15 to 70.16). Positive predictive values of these variables were 70, 75, and 55%, respectively. Patent ductus arteriosus and mortality rates were significantly higher in INSURE failure group. Arterial partial pressure of carbon dioxide, arterial-to-alveolar oxygen tension ratio, and severe radiological grade are predictors of the failure of INSURE method in preterm infants with respiratory distress syndrome. However, a prospective randomized controlled trial is needed to determine whether or not infants at risk for INSURE failure are better off being treated with mechanical ventilation.

Effect of the intravenous lipid emulsions on the availability of calcium when using organic phosphate in TPN admixtures.

PURPOSE: The addition of high amounts of calcium remains a pharmaceutical concern due to its precipitation with phosphate in total parenteral nutrient (TPN) admixtures, compromising also the stability of the lipid emulsion. MATERIALS AND METHODS: Calcium-phosphate solubility was compared when using binary PN solutions versus all-in-one TPN (admixtures with lipid emulsions) in three formulas using organic calcium gluconate and glucose-1-phosphate. RESULTS: It was found that variation of Ca-P solubility exists between formulation with or without lipid emulsions. Concentrations of Ca decreased after filtrations of all admixtures (from 5% to 30%) and it was more significant in binary solutions. Precipitation has been observed by microscopy at high concentrations of both organic Ca-P after critical conditions of storage (24 h at 37 degrees C plus one day at ambient temperature) for admixtures containing 1% amino acids and 8% glucose with or without lipids compared to admixtures containing 2% or 3.5% amino acids and 14% glucose. CONCLUSIONS: These data demonstrated that availability of Ca using organic glucose-1-phosphate increased when lipids were present in TPN admixtures, without alteration of the lipid emulsion. Thus, high amounts of Ca (up to 30 mmol/l) and phosphates (up to 40 mmol/l) might be provided safely in parenteral nutrition admixtures.

The Tunisian population history through the Crigler-Najjar type I syndrome.

Crigler-Najjar syndrome type I (CN-I) is a rare and severe metabolic disorder. A recurrent mutation - c.1070A>G in exon 3 - was identified in the Tunisian population, suggesting a founder effect. In 2004, the detection of this mutation in two Kuwaiti Bedouin families has called the Tunisian founder effect in question again. To determine the origin of this mutation, 21 Tunisian and 2 Kuwaiti Bedouin CN-I patients were screened using nine genetic markers. Haplotype analysis confirmed the founder effect hypothesis and dated the appearance of this mutation some 32 generations ago in the Tunisian population. Using the same genetic analysis, the ancestor haplotype was identified in these two families. This result genetically confirms the blending of the Bedouin nomads within today's Tunisian population. After population migration from east to west, this mutation was introduced into the Tunisian population, and then perpetuated, probably because of marriages in isolated communities.

Oral ibuprofen in early curative closure of patent ductus arteriosus in very premature infants.

Intravenous indomethacin and intravenous ibuprofen are widely used for the treatment of patent ductus arteriosus (PDA) in premature infants. Intravenous indomethacin may lead to renal impairment, enterocolitis, and intraventricular hemorrhage. Intravenous ibuprofen was shown to be as effective and to cause fewer side effects. If ibuprofen is effective intravenously, it will probably be effective orally, too. This study was conducted to test oral ibuprofen in early curative closure of PDA in very premature infants hoping for a better tolerance and the same efficacy as intravenous ibuprofen. Forty very premature infants (mean gestational age: 29.4 +/- 1 to 2 weeks [range: 26 to 31.5 weeks]; mean weight: 1237.2 +/- 198 g [range: 650-1770 g]) with PDA and respiratory distress were studied prospectively. They received, while between 48 and 96 hours old, oral ibuprofen at a dose of 10 mg/kg, followed, if needed, at 24-hour intervals by one or two additional doses of 5 mg/kg each. Color Doppler echography of the heart, brain, and abdomen were performed before treatment and after each dose administration. Ductal closure, early outcome (1 week after treatment), and late outcome were recorded. Thirty-eight patients (95%) achieved pharmacological closure. Two patients did not respond to the treatment: One required surgical ligation of the ductus, and the other patient received and well tolerated ductal shunting. Twenty-four patients were treated with one dose of oral ibuprofen, 10 were treated with two doses, and 6 were treated with three doses. Early outcome showed no case of renal impairment, no significant differences in serum creatinine levels, nine cases (22.5%) of intraventricular hemorrhage, three cases (7.5%) of necrotizing enterocolitis, and two cases (5%) of gastrointestinal bleeding. Late outcome showed 15 cases (37.5%) of nosocomial sepsis, 3 cases (7.5%) of chronic lung disease, 2 cases (5%) of periventricular leukomalacia, and 17 cases of death. In this study, oral ibuprofen was effective and well tolerated for early curative closure of PDA in very premature infants. Nevertheless, larger randomized comparative studies with pharmacokinetics measures are warranted.

[Antenatal corticotherapy: ten years after the first conference of consensus]. / Corticotherapie antenatale: dix ans apres la premiere conference de consensus.

Beneficial effects of antenatal corticotherapy on neonates are now well established. However, after the first conference of consensus, three controversial issues were left unresolved = use of dexamethasone or betamethasone, ideal number of curses to be given, and appropriateness of corticotherapy in case of prmature of the membranes. A literature review suggests that betamethasone is preferred to dexamethasone, that prscription of a single course is more advisable than multiple courses, and that antenatal corticotherapy is finally not contraindication in case of premature rupture of membranes.

Clinical and anatomic features of acardiac twins.

OBJECTIVE: To report 6 cases of acardiac twins, and to investigate prognostic factors that would lead to survival of the normal twin. SUBJECTS AND METHODS: During a 9-year period from 1993 to 2001, 6 cases of acardiac twins out of 109,000 deliveries at the Maternity Center, Tunis, Tunisia were studied. Detailed inspection, X-rays, ultrasound and autopsies were performed. RESULTS: Prenatal diagnosis was made in only 1 case at 33 weeks of gestation. Rudimentary cardiac tissue was observed in 2 of the 6 perfused twins, and the cephalic pole was less developed than other parts of the body. Severe agenesis or hypoplasia of the thoracoabdominal organs was commonly observed. Many limb malformations were observed, with arms the most affected. One of the pump twins was stillborn, 3 died between days 1 and 3 from respiratory distress, and 2 developed cardiac failure after birth and were treated with diuretics and digoxin, which led to a favorable outcome in only 1. The ratio of the weight of the acardiac to pump twin (TWR) ranged from 50 to 142%. CONCLUSION: The findings of this study indicate that acardia can be diagnosed by means of ultrasound in front of a monochorial twin pregnancy when one of the fetuses is deformed and has no cardiac activity. Heart failure and polyhydramnios, as well as a TWR greater than 50% are prognostic factors for the pump twin.

[Retrocervical cystic hygroma: about 35 cases]. / Hygroma kystique du cou: à propos de 35 cas.

Retrocervical cystic hygroma is a congenital defect associated to chromosomic anomalies. We report a retrospective study about 35 cystic hygroma autopsies colliged in C.M.N.T in 10 years. Antenatal sonography has a sensibility 94.5%. Genetic abnormalities dominated by trisomie 13 Turner syndrome dad found in 11.5%. Medical abortion has done in 48.5%. A multidisciplinary management autorized to understand etiopathogeny of this defect.

Prenatal diagnosis of Crigler-Najjar syndrome type I by single-strand conformation polymorphism (SSCP).

Crigler-Najjar syndrome type I (CN-I) is a rare and severe inherited disorder of bilirubin metabolism, caused by the total deficiency of bilirubin-UDP-glucuronosyltransferase (UGT) activity. Enzymatic diagnosis cannot be performed in chorionic villi or amniocytes as UGT is not active in these tissues. The cloning of the UGT1 gene and the identification of disease-causing mutations have led to the possibility of performing DNA-based diagnosis. Here we report DNA-based prenatal diagnosis of CN-I in two Tunisian families in whom CN-I patients were diagnosed. As we had previously shown that CN-I was, in Tunisia, associated with homozygosity for the Q357R mutation within the UGT1 gene, we were able to detect this mutation in both families and to show that it was easily recognized by single-strand conformation polymorphism (SSCP) analysis. In both cases, SSCP analysis of fetal DNA showed that the fetus was heterozygous for the Q357R mutation. In one family, the pregnancy was carried to term and a healthy baby was born, whereas, in the other family, the pregnancy is still continuing. Thus the prenatal diagnosis of CN-I is possible, provided disease-causing mutations have been identified. SSCP analysis of DNA prepared either from amniocytes or from chorionic villi is a simple, reliable and fast method for prenatal diagnosis.