Servet Ozkiraz

FEBRILE NEUTROPENIA AS THE PRESENTING SIGN OF APPENDICITIS IN AN ADOLESCENT WITH ACUTE MYELOGENOUS LEUKEMIA

The diagnosis and management of a surgical abdomen in patients with acute leukemia is quite difficult because of the complications and treatment of disease itself. A 13-year-old boy with acute myelogenous leukemia developed 2 episodes of febrile neutropenia during induction therapy. The second one was treated with a 5-day course of parenteral antimicrobial therapy, but the patient then presented with right lower quadrant abdominal tenderness, guarding, and rebound tenderness. Abdominal ultrasonography and computed tomography revealed appendicitis. Conservative medical management was unsuccessful, and appendectomy was performed 5 days after appendicitis was diagnosed. The patients clinical manifestations resolved 5 days later. The case illustrates that fever may be the first manifestation of appendicitis in a child with acute myelogenous leukaemia who is neutropenic. Surgery is acceptable as first-line treatment in such cases.

Peripherally inserted central venous catheters in critically ill premature neonates

Purpose To evaluate the safety of peripherally inserted central venous catheters (PICCs) and their complications in critically ill premature neonates. Methods A retrospective collection of data of infants with very low birth weight (VLBW) who underwent PICC placement over a 2-year period. Gestational age, birth weight (BW), sex, site of catheter placement, reason for catheter removal, duration of the catheter use, proven sepsis, type of the reported organism and the rate of complications were collected. The infants were classified into two groups according to BWs: Group 1–-VLBW infants (BW between 1,000 and 1,500 g) and Group 2–-BW <1,000 g (extremely low birth weight, ELBW group). Results During the study period, 90 VLBW infants were admitted to the neonatal intensive care unit. PICCs were attempted in 71 patients. A PICC was successfully inserted into 62 patients (87.3%). Totally, 68 PICCs were inserted into 62 infants. PICCs placed in either the upper or the lower extremity have no differences in complication rates. The median time of catheter insertion was 10 (1-22) days for Group 1 and 16 (1-47) days for Group 2 (p=0.001). The median duration of PICCs was 9 (2-18) and 12.0 (3-30) days, respectively (p=0.012). There were no significant differences between groups for the reasons for removal (p=0.859). Conclusions PICCs are convenient for the administration of long course antibiotics and parenteral nutrition for both VLBW and ELBW infants. The risk of catheter complications did not increase in ELBW infants. Although the technique of insertion is easy and using PICCs has many benefits, serious and fatal complications may occur in premature neonates in critical states.

Comparison of initial evaluation of neonatal heart murmurs by pediatrician and pediatric cardiologist.

The objective of this study was to determine differences between pediatrician and pediatric cardiologists regarding initial assessment of neonatal heart murmur and to evaluate the role of echocardiography in this group of patients. During a 6-month period, all term births in the obstetric unit at Faculty of Medicine, Gazi University, Ankara, Turkey, were initially evaluated clinically by a pediatrician and the most likely clinical diagnosis was recorded. Neonates with a heart murmur were evaluated by the pediatric cardiologist who was unaware of the previous diagnosis. A similar number of neonates without a heart murmurs was also evaluated by a pediatric cardiologist as a control group. Echocardiography was performed in both groups. For pediatrician and pediatric cardiologists, accuracy of the clinical examination demonstrated a sensitivity of 33.3% and 40% in detecting a pathological murmur and a specificity of 95.5% and 98.8%, respectively. No statistically significant differences existed between the two groups. Pediatricians can assess the significance of neonatal heart murmurs as well as pediatric cardiologists.

Persistent pulmonary hypertension in a premature newborn after 16 hours of antenatal indomethacin exposure.

Abstract Premature constriction of the fetal ductus arteriosus has been described with long-term indomethacin therapy, but not in fetuses who have been exposed to the drug for less than 72 hours. The sensitivity of the ductus to extended indomethacin tocolysis increases with advancing gestational age. For this reason, it is recommended that indomethacin not be used beyond 31 weeks of gestation. In the present case the gestational age of the patient was 27 weeks and the period of indomethacin exposure was only 16 hours. Our observations of pulmonary hypertension in this case suggest that administration of indomethacin even hours before delivery can significantly affect the ductus arteriosus and the pulmonary vasculature.

Resistin—A Novel Feature in the Diagnosis of Sepsis in Premature Neonates

OBJECTIVE To evaluate the diagnostic potential of resistin in sepsis and to compare results with C-reactive protein (CRP) in infants < 32 weeks of gestation. STUDY DESIGN A total of 64 infants were prospectively included in the study. Blood samples were collected for basal CRP and resistin within the first hour of life. When sepsis was suspected, samples were collected for CRP and resistin before the treatment was started (pretreatment CRP and resistin). On the third day of sepsis, CRP and resistin levels were measured for evaluating the treatment response (follow-up CRP and follow-up resistin). Culture-proven septic patients were divided into groups according to early or late-onset sepsis (EOS and LOS) and gram-negative or gram-positive sepsis (GNS and GPS). RESULTS Pretreatment and follow-up resistin levels were significantly higher than basal resistin levels in both EOS and LOS groups (p < 0.01), with a positive correlation with CRP levels. To predict the GNS and GPS area under curve, values of pretreatment CRP and resistin were 0.714 and 0.984, respectively (p = 0.039). CONCLUSION Resistin had a superior potential to that of CRP in the diagnosis of sepsis in preterm infants. Resistin may be used as an early marker for sepsis in premature infants.

Vestibular evoked myogenic potentials in preterm infants.

The goal of this study was to determine whether there was an association between perinatal risk factors of prematurity and vestibular evoked myogenic potentials (VEMPs). A prospective case-control trial was designed. Fifty preterm newborns (100 ears) with a gestational age <37 weeks were included. The control group consisted of 20 healthy term infants (40 ears). VEMP recordings were performed, and mean latencies of p13 were calculated in all study subjects. Multivariable logistic regression was used to investigate the influence of perinatal variables on abnormal VEMP responses. VEMPs were elicited in all term infants (40 ears). In preterm infants, the responses were normal in 71 ears, delayed in 24 and absent in 5. There was a significant difference between abnormal VEMP rates for preterm and term infants (p < 0.001). Asphyxia (OR = 13.985, p = 0.048) and time of VEMP test (OR = 0.865, p = 0.038) were related to abnormal VEMP responses. There was no association between delayed VEMPs and gestational age, birth weight, hemoglobin and bilirubin levels, phototherapy, intracranial hemorrhage, convulsions, sepsis, ototoxic drugs, transfusion, mechanical ventilation, retinopathy of prematurity, bronchopulmonary dysplasia and respiratory distress syndrome. These results suggest a delay in the maturation of VEMPs in premature infants. Asphyxia was the most important risk factor for abnormal VEMP responses in preterm infants.

Lactate and lactate dehydrogenase in predicting the severity of transient tachypnea of the newborn

Abstract Objective: Low Apgar score is strongly associated with the incidence of transient tachypnea of the newborn (TTN) and other respiratory diseases of the newborn. We aimed to investigate the relationship between hypoxia determinants and the prolonged oxygen and respiratory support requirement even if the Apgar scores were normal. Methods: Retrospective case-controlled study. Infants born after 35 weeks of gestational age with clinical signs, chest X-ray findings and clinical course consistent with TTN were included. Receiver operating characteristic curves were used to assess the predictive values of determinants in predicting the risk for prolonged oxygen requirement and mechanical ventilatory support. Results: We showed a positive correlation between the duration of oxygen with lactate and lactate dehydrogenase (LDH) levels. LDH offered the best predictive value for prolonged oxygen requirement with a positive predictive value (PPV) of 88.9%. The predictive value of lactate exceeds the predictive value of LDH, aspartate aminotransferase, and percentage of normoblasts to predict the requirement of respiratory support with a PPV of 88.5%. Conclusions: Lactate and LDH might be useful for clinicians at first level hospitals for decision making to refer the TTN patient to the secondary or tertiary level neonatal intensive care unit before the clinical situation is worsened.

Effects of delayed umbilical cord clamping on peripheral blood hematopoietic stem cells in premature neonates

Abstract Aim: To investigate the effects of delayed cord clamping (DCC) on peripheral hematopoietic progenitor cells (HPCs) and hematological parameters in premature infants (<32 weeks) during the neonatal period. Methods: This was a prospective, randomized, and controlled, single-center study. Prior to delivery, 21 infants were randomly assigned to immediate cord clamping (ICC) at 5–10 s and 21 infants to DCC at 30–45 s. One milliliter blood sample was taken in the first 30 min of life. HPCs were measured by three-color flow cytometry using monoclonal antibodies. Results: There were no significant differences between groups in either maternal or neonatal demographics. All HPC counts were higher in the ICC group, but the difference was not significant. CD34+ cell counts were 45.3±36.6/μL in the ICC and 33.2±26.6/μL in the DCC group (P=0.33); multi-potent progenitor cell counts were 43.2±35/μL in the ICC and 31.1±26.6/μL in the DCC group (P=0.28); and hematopoietic stem cell counts were 2.1±2.1/μL in the ICC and 2.1±3.1/μL in the DCC group (P=0.66). Conclusion: Contrary to our expectation, all HPC counts were lower in the DCC group.

The role of plasminogen activator inhibitor-1 and angiotensin-converting enzyme gene polymorphisms in bronchopulmonary dysplasia.

BACKGROUND Bronchopulmonary dysplasia (BPD) is a multifactorial disease of preterm infants that is characterized by airway injury, inflammation, and parencymal remodeling. Activation of the coagulation cascade leads to intraalveolar fibrin deposition in many inflammatory pulmonary disorders. Increased fibrin formation or decreased fibrinolysis may cause extravascular fibrin deposition. Extravascular fibrin deposits in septae and alveoli due to the altered fibrin turnover are the pathological hallmarks of BPD, which strongly indicate the importance of the imbalance in the competing activities of coagulation and fibrinolysis. OBJECTIVE We investigated the predictive value of variations in plasminogen activator inhibitor-1 (PAI-1) and angiotensin-converting enzyme (ACE) genes as molecular determinants for BPD in neonates. METHODS The study group comprised 98 preterm infants with BPD and a control group including 94 preterm infants without BPD. Restriction fragment size analyses were performed by visualizing digested polymerase chain reaction products for ACE and PAI-1 genotypes. RESULTS No significant associations were found between ACE, PAI-1 gene polymorphisms, and BPD phenotype in our population. CONCLUSIONS The two gene polymorphisms (PAI-1 and ACE) had no role in the development of BPD in our study. Further studies with other genes are required for the identification of molecular predisposing factors for BPD that may help in the development of new treatments.

Serum prohepcidin levels and iron parameters in term small-for gestational age newborns

Abstract Aim. To understand the effect of prenatal chronic hypoxia on prohepcidin levels in term newborns. Method. We determined prohepcidin (Pro-Hep) levels in both term appropriate-for-gestational age (AGA) and term small-for-gestational-age (SGA) infants. Uteroplacental insufficiency had exposed all SGA infants to chronic hypoxia. Serum samples were collected from nine full-term SGA infants. Samples were analyzed for complete blood count, serum iron and ferritin concentrations, iron-binding capacity, and prohepcidin levels. Results. The mean serum Pro-Hep level was 156.4 ± 46.7 ng/ml for SGA infants and 482 ± 371.9 ng/ml for 16 healthy term AGA infants (historical controls); this difference was statistically significant. Statistical analyses revealed significant between-group differences for hemoglobin, hematocrit, mean corpuscular volume, red blood cell distribution width, and serum ferritin and Pro-Hep levels. Conclusion. This study showed that compared with AGA infants, Pro-Hep levels were lower in term SGA infants, suggesting that prenatal chronic hypoxia decreases Pro-Hep synthesis.