Tracheal aspirate gene expression in preterm newborns and development of bronchopulmonary dysplasia.

BACKGROUND: Bronchopulmonary dysplasia (BPD) occurs in association with prenatal conditions predisposing infants to inflammation and remodeling of the premature lungs. Because of the lack of useful biomarkers for BPD, the gene expression of tracheal aspirate fluid (TAF) cells in premature infants was analyzed. METHODS: Of 148 consecutive patients, 26 preterm infants (gestational age <34 weeks) were enrolled, who underwent assisted ventilation at birth for respiratory failure. Patients with congenital disorders were excluded. Half of these infants developed BPD. Interleukin (IL)-10, interferon (IFN)-γ, transforming growth factor (TGF)-ß1, and platelet-derived growth factor (PDGF)-B mRNA of TAF cells were quantified on real-time polymerase chain reaction. RESULTS: IL-10 (P < 0.01) and IFN-γ (P= 0.03) but not TGF-ß1 or PDGF-B mRNA levels at birth were higher in BPD than in non-BPD infants. IL-10 expression differentiated BPD with the highest sensitivity (92%) and specificity (77%). IL-10 levels correlated with TGF-ß1 (P= 0.03) and IFN-γ (P= 0.01), but not with PDGF-B levels. When BPD infants were classified according to comorbidity (group 1, six patients who suffered respiratory distress syndrome [RDS] but not chorioamnionitis [CAM]; group 2, five patients who had CAM but not RDS), PDGF-B levels were higher in group 2 (P= 0.01). High IL-10 expression was selected as a risk factor for BPD in infants who had CAM but not RDS (P= 0.01), although prolonged oxygen therapy was the most sensitive indicator for BPD (P < 0.01) on multivariate analysis. CONCLUSIONS: High IL-10 expression in TAF cells at birth could predict the evolution of BPD, but with less impact than oxygen requirement. PDGF might play a different role in the inflammatory process of premature lungs.

Improvement in the outcome of patients with antenatally diagnosed congenital diaphragmatic hernia using gentle ventilation and circulatory stabilization.

BACKGROUND/OBJECTIVES: No definitive treatment strategy has been established for patients with an antenatal diagnosed congenital diaphragmatic hernia (AD-CDH). From 1997 to 2003 in this department fetal stabilization (FS) was administered using both morphine and diazepam via the placenta just before delivery of the fetus by cesarean section. In contrast, from 2004 to the present, a combination of gentle ventilation (GV) and a delayed operation was selected, which was performed when the patient's circulatory stabilization (CS) was achieved. PATIENTS AND METHODS: This study included 22 patients in the FS group and 16 patients in the GV + CS group, respectively. The outcomes in both groups were compared and the outcome in AD-CDH patients with a patch repaired operation, liver-up or lower lung-to-thorax transverse area ratio (L/T, <0.10) was further investigated in both groups. RESULTS: The overall survival rate (SR) was 93.8% in the GV + CS group and 59.1% in the FS group, respectively (P = 0.04). For the patients with the lower L/T, the SR was 85.7% in GV + CS group and 53.8% in the FS group (P = 0.33). Regarding the patients using a patch and liver-up, the SR in GV + CS group was better than that in the FS group (patch: FS 44.4%, GV +/- CS 87.5%, P = 0.18; liver-up: FS 57.8 and 87.5%, P = 0.30). CONCLUSION: Our strategy of using GV +/- CS might thus be considered to be more effective than that using FS in the treatment of AD-CDH patients.

Head circumference and long-term outcome in small-for-gestational age infants.

OBJECTIVES: To assess risk factors for the growth and development of small-for-gestational age (SGA) infants whose birth weight was less than the 10(th) percentile. PATIENTS AND METHODS: SGA infants who were admitted to the neonatal intensive care unit from 1995 to 1998 were enrolled in the study. Fifty-six SGA infants, having no chromosomal abnormalities, inherited diseases, TORCH infections, major anomaly and/or multiple birth, were divided into 34 asymmetrical and 22 symmetrical SGA infants by >or= or <10(th) percentile head circumference (HC) at birth. The physical growth including HC, and the developmental quotient (DQ) and intelligent quotient (IQ) scores were evaluated up to 6 years of age. RESULTS: Symmetrical SGA infants had lower levels of weight, height and HC, but not of total DQ at 3 years or IQ scores at 6 years of age than asymmetrical SGA infants. The 21 SGA infants who had a HC less than the 10(th) percentile at 1 year of age (non-catch-up group) showed lower total DQ (mean 96 vs. 105) and IQ (82 vs. 102) scores than 34 SGA infants who had not (catch-up group). CONCLUSIONS: These results suggested that psychomotor development of SGA infants depended on the HC at 1 year of age rather than that at birth.

Risk of respiratory syncytial virus in survivors with severe congenital diaphragmatic hernia.

BACKGROUND: During the follow-up period in surviving patients with severe congenital diaphragmatic hernia (CDH), respiratory complications, such as recurrence of CDH or chronic lung disease, have been reported to occur as a late complication. Although some risk factors for deterioration of respiratory condition have been reported in CDH, the risk of respiratory syncytial virus (RSV) in postoperative CDH patients has not as yet been reported upon. METHODS: In 21 survivors with severe CDH, which had been detected antenatally, and whose lung:thoracic ratio was <0.2, the risk of RSV infection in those patients was investigated. RESULTS: Five survivors with severe CDH had RSV infection and three patients needed hospitalization due to bronchiolitis during the follow-up period. In two patients the recurrence of CDH after the infection resulted in the need to perform a re-operation for CDH. All patients often suffered from chronic wheezing requiring medication after the first RSV infection. CONCLUSION: RSV infection is a risk for deterioration of postoperative respiratory condition in severe CDH survivors. Considering the presence of pulmonary hypoplasia in severe CDH, the routine use of monoclonal antibody for RSV (palivizumab) might be effective for patients with severe CDH in the high season of RSV, similar to the patients with chronic lung disease, although further large multicenter studies are needed to clarify this hypothesis.

A new scoring system for computed tomography of the chest for assessing the clinical status of bronchopulmonary dysplasia.

OBJECTIVE: To develop a new scoring system for computed tomography (CT) of the chest for assessing the clinical status of patients with bronchopulmonary dysplasia (BPD) in comparison with a modified Edwards roentgenographic scoring system. STUDY DESIGN: Preterm infants diagnosed with BPD (n = 42) were assessed prospectively by chest CT scan at the time of discharge. Three radiologists classified the CT findings into 1 of 3 categories--hyperexpansion, emphysema, or fibrous/interstitial abnormalities--and developed a new scoring system. We assessed interobserver reproducibility and investigated whether this classification system reflected the severity of BPD in these patients. RESULTS: The CT scores had acceptable reproducibility (coefficient of correlation [cc] = 0.721 to 0.839). The subgroup with a more severe form of BPD had a higher CT score. The CT score correlated with the clinical score at 36 weeks of postmenstrual age (cc = 0.367) and the duration of oxygen therapy (cc = 0.537). Patients who were discharged home on oxygen had higher CT scores than patients who were not. CONCLUSIONS: The new chest CT scoring system may have higher objectivity and accuracy in terms of predischarge assessment of clinical status as well as prediction of the prognosis of patients with BPD.

An echovirus type 18 outbreak in a neonatal intensive care unit.

We describe an outbreak of echovirus type 18 infection involving 20 neonatal intensive care unit (NICU) patients and the results of virological investigations are presented. RT-PCR demonstrated a widespread transmission of the virus in NICU patients during the outbreak. Separation care and additional infection control measures seemed to be effective in preventing further spread of the virus.

Clinical features of selenium deficiency in infants receiving long-term nutritional support.

OBJECTIVE: Selenium deficiency is a known complication in patients requiring long-term nutritional support; however, the clinical features of selenium deficiency in infants have not been completely described. We describe the clinical features of selenium deficiency in infants. METHODS: Six infants with selenium deficiency were studied retrospectively, with a focus on the period of nutritional support, the clinical symptoms, and the chronologic changes in serum selenium concentrations before and after the administration of selenite. RESULTS: The onset of selenium deficiency in five patients occurred at <6 mo of age; selenium deficiency occurred in one patient 14 mo after birth. One patient received parenteral nutrition for 15 mo after birth; the other five patients primarily received an elemental diet for 2-6 mo. In all patients, growth retardation and alopecia with pseudoalbinism were the characteristic symptoms of selenium deficiency. At the time of diagnosis, the serum selenium level in four patients was <2.0 microg/dL and serum selenium levels in two patients were 3.2 and 3.3 microg/dL, respectively. The resolution of hair symptoms corresponded to the level of serum selenium after 1-2 mo and a rapid improvement in growth occurred in all patients after the administration of selenite. CONCLUSION: The early clinical symptoms of selenium deficiency in infants include growth retardation and alopecia with pseudoalbinism, which are reversible if the patients are treated with adequate amounts of selenite. Clinicians who manage infants receiving long-term nutritional support, including an elemental diet, should be aware of the symptoms associated with selenium deficiency.

Increased inflammatory markers are associated with early periventricular leukomalacia.

The aim of the study was to investigate whether inflammatory markers are associated with the occurrence of periventricular leukomalacia (PVL). Superoxide (O(2) (-)) production of neutrophils and plasma antioxidative superoxide dismutase (SOD) activity in umbilical cord blood were studied. Participants were preterm infants with early PVL (n=6; three males, three females; mean birthweight 1458g [SD 517], range 620-2040g; mean gestational age 29.8wks [SD 2.9], range 27-34wks); and preterm control infants without PVL (n=10; five males, five females; mean birthweight 1838g [SD 664], range 925-2748g; mean gestational age 30.6wks [SD 3.1], range 26-34wks). In addition, pro-inflammatory cytokine levels were measured in the umbilical cord blood. N-formyl-methionyl-leucyl-phenylalanine-induced O(2) (-) production by neutrophils in infants with early PVL was significantly higher than that in the control group. In contrast, there was no significant difference in concentrations of copper/zinc-SOD and SOD activity between groups. Concentrations of interleukin (IL)-1beta and tumour necrosis factor-alpha (but not IL-6, IL-8, or granulocyte-colony stimulating factor) were significantly higher in infants with early PVL than in control infants. The excess O(2) (-) produced by activated neutrophils with increased pro-inflammatory cytokine production could play a role in the molecular cascade leading to white matter damage in PVL.

Prenatal sonographic findings and hematological abnormalities in fetuses with transient abnormal myelopoiesis with Down syndrome.

OBJECTIVES: To determine relevant prenatal findings of transient abnormal myelopoiesis (TAM) that have important prognostic implications. METHODS: The prenatal and postnatal medical records of all cases with confirmed TAM associated with Down syndrome were reviewed retrospectively, with emphasis on prenatal sonographic findings, fetal blood analysis, neonatal outcomes, and causes of death. RESULTS: From January 1992 to December 2005, seven cases were confirmed postnatally as having TAM associated with Down syndrome. Sonography demonstrated hydrops with hepatomegaly in four, and isolated hepatomegaly in two of these seven cases. There were no findings suggestive of cardiac failure in cases of hydrops. Fetal blood analysis revealed elevated liver enzyme levels in six cases and hypoalbuminemia in four cases. Comparison of sonographic findings with fetal blood findings demonstrated an association between hydrops and hypoalbuminemia. Four of the seven cases were fatal. All fatal cases were associated with hydrops and the main cause of death was coagulopathy due to liver failure, which may have resulted from infiltration of the liver by blast cells. CONCLUSIONS: Fetal TAM is associated with hepatomegaly and elevated liver enzyme levels. The prenatal finding with prognostic implications is hydrops, which may result from hypoalbuminemia due to liver failure.

Long-term outcome of infants with twin-to-twin transfusion syndrome.

OBJECTIVE: To clarify the long-term neurodevelopmental outcome of twin-to-twin transfusion syndrome (TTTS) survivors. METHODS: From January 1994 to December 2003, 33 newborns with TTTS who were derived from 18 monochorionic twin gestations were enrolled for the study. The development and growth at 3 or 6 years of age were compared between TTTS survivors and weight-matched singleton controls. RESULTS: The mortality in TTTS (8/33: 24%) was significantly higher than that of the controls (7/80: 9%). Of all 12 TTTS patients who were diagnosed before 25 weeks and born before 28 weeks of gestation, in 10 (83%) it led to neonatal or intrauterine death. The morbidity of cerebral palsy, epilepsy, and mental retardation did not differ between TTTS and control patients. The morbidity and severity of neurological deficits at school age were similar in both groups. No growth parameters at 3 or 6 years of age differed between TTTS and controls. CONCLUSIONS: Morbidity, growth and development of TTTS survivors attained comparable levels of weight-matched controls, despite the higher neonatal mortality. These results suggest that the early management of TTTS is critical for refining the total outcome of the affected twins.

Fetal germinal matrix and intraventricular hemorrhage.

Subependymal germinal matrix with intraventricular hemorrhage (GMIVH) is a common complication associated with delivery in preterm neonates but has rarely been observed in the fetus. Clinical and neuroradiological findings of 5 patients who were diagnosed as having fetal GMIVH with prenatal ultrasonographic examinations (US) and MRI, and postnatal MRI were reviewed retrospectively. During a seemingly uneventful pregnancy, fetal GMIVH occurred at approximately 30-33 weeks of gestation, with the absence of any known factor predisposing to fetal hemorrhage. Routine obstetric US revealed an intraventricular lesion in the enlarged ventricles. Prenatal MRI clearly demonstrated parenchymal change such as intracerebral hematoma adjacent to the subependymal and intraventricular hematoma, and periventricular leukomalacia as well as GMIVH. Although patients without parenchymal destruction (hemosiderin deposit alone) had a favorable neurodevelopmental outcome, encephalomalacia and periventricular leukomalacia contributed to long-term neurodevelopmental deficits. Evaluating parenchymal damage with prenatal MRI can therefore help to predict neurodevelopmental prognosis of the fetus with GMIVH.

Pleural fluid/serum immunoglobulin ratio is a diagnostic marker for congenital chylothorax in utero.

OBJECTIVE: To distinguish congenital chylothorax from other causes of hydrothorax in utero. METHODS: Serum and pleural fluid samples from 8 fetuses with congenital chylothorax and 5 control fetuses with other causes of hydrothorax were tested for total protein, albumin, IgG, IgA, and IgM. RESULTS: Fetuses with congenital chylothorax had higher levels of IgG in pleural fluid, but not the other four proteins, than control fetuses (P<0.05). There were no significant differences in serum proteins among fetuses. When we examined pleural fluid to serum ratios, the IgG ratio in fetuses with congenital chylothorax was significantly higher than that of control fetuses (P<0.05). The IgG ratio in chylothorax was greater than 0.6 regardless of lymphocyte count. CONCLUSION: Pleural fluid/serum IgG ratio may be a diagnostic marker for congenital chylothorax in utero.

Nonimmune hydrops fetalis due to generalized lymphatic dysplasia in an infant with Robertsonian trisomy 21.

We report the first case of generalized lymphatic dysplasia and trisomy 21 presenting with nonimmune hydrops fetalis. This infant showed intractable chylothorax, chylous ascites, and periodic bouts of edema. A karyotype analysis revealed Robertsonian trisomy 21: 46,XY,t(14q21q)(q10;q10) +21. This patient died of multiple organ failure at 400 days of life, despite the management of chylous effusions. The lymphoscintigraphy and histopathological findings led to the final diagnosis of generalized lymphatic dysplasia, which might also contribute to the development of hydrops. Refractory chylothorax in trisomy 21 patients may emphasize the need for intensive scrutiny of lymphatic disorders.

Serum immunoglobulin levels do not affect antibody responses to influenza HA vaccine in preterm infants.

Antibody responses to two doses of influenza hemagglutinin (HA) vaccine were evaluated in 45 previously unimmunized preterm infants aged 6-11 months before the 2003/2004 influenza season. Twenty-three (51.1%), 21 (46.6%) and 2 (4.4%) of the subjects acquired protective (>or=1:40) hemagglutination inhibition (HI) antibody titers after vaccination for A/New Caledonia (H1N1), A/Panama (H3N2) and B/Shandong, respectively. Antibody responses to A (H1N1), A (H3N2) appeared to be comparable to those reported on full-term infants of similar ages vaccinated with the identical vaccine. Serum IgG levels at vaccination had no positive association with antibody responses on univariate or multivariate analysis, indicating that prolonged hypogammaglobulinemia after 6 months of age in preterm infants was not a factor to affect antibody responses to influenza HA vaccine.

Thrombocytosis in preterm infants: a possible involvement of thrombopoietin receptor gene expression.

Transient thrombocytosis is commonly observed in preterm infants after birth, but its physiological mechanism is still unknown. To understand the mechanism of the transient thrombocytosis in preterm infants we firstly evaluated a correlation between platelet counts and thrombopoietin (TPO) levels in preterm infants and next c-mpl mRNA levels on platelets in healthy preterm infants longitudinally during a half-year of life. The mean platelet counts in 45 very low birth weight infants (mean gestational age 27.4+/-1.8 weeks, mean birth weight 1047+/-249 g) was 230+/-71x10(9)/l just after birth and thereafter gradually increased to 579+/-178x10(9)/l by 5 weeks of age. The platelet counts continued this level for about next 8 weeks. Serum TPO levels soon after birth and at 1 month of age were significantly higher than those at the age of 2-6 months. There was a significant negative correlation between platelet counts and serum TPO values. The c-mpl expression levels on platelets at birth and at 1 month of age tended to be lower than those on platelets from adults, and the c-mpl levels gradually increased through 6 months of age, although they were still lower than those of adults. Our results suggest that low expression of TPO receptor on platelets until 1 month after birth cause a decreased TPO clearance and keep a high level of free TPO in blood, thereby promoting platelet production from megakaryocytes or their progenitors in bone marrow, resulting in the subsequent thrombocytosis in preterm infants.

CD25+CD4+ T cells in human cord blood: an immunoregulatory subset with naive phenotype and specific expression of forkhead box p3 (Foxp3) gene.

OBJECTIVE: To address the role of cord blood (CB) CD25+CD4+ T cells, the gene expressions and function of this subset were analyzed. MATERIALS AND METHODS: CD25+CD4+ T cells fractionated from CB of term and preterm infants were subjected to flow cytometry, quantitative polymerase chain reaction analysis for cytokines, costimulatory molecules, and transcription factors, and functional assays. RESULTS: Human preterm CB contained a high proportion of CD25+CD4+ T cells that declined with gestational age to the level of adult peripheral blood (PB). CD25+ or CD25-CD4+ T cells in CB had a higher frequency of CD45RA+ and CD38+ cells than in PB. CB CD25+CD4+ T cells less frequently expressed CD45RO, CD71, and HLA-DR than PB CD25+CD4+ T cells, despite similar expressions on CB and PB CD25-CD4+ T cells. No expression of IL-10, transforming growth factor-beta, interleukin-4, and interferon-gamma mRNA differed between CB CD25+CD4+ and CD25-CD4+ T cells, in contrast to the high interleukin-10 expression in PB CD25+CD4+ T cells. CTLA-4 was more transcribed in CB and PB CD25+CD4+ T cells than in the counterpart CD25-CD4+ T cells. CD28 or ICOS was similarly expressed in CB and PB T cells. CB CD25+CD4+ T cells effectively suppressed the proliferation of CB CD25-CD4+ T cells in a dose-dependent manner. Human CB and PB CD25+CD4+ T cells preferentially transcribed Foxp3, which governs the regulatory function of this subset in mice. CONCLUSIONS: These results suggest that CB contains CD25+CD4+ regulatory T cells as a functionally mature population with naive phenotype. This subset may naturally arise and decline in fetus to play a potential immunoregulatory role in intrauterine life.

Characteristic expression of aryl hydrocarbon receptor repressor gene in human tissues: organ-specific distribution and variable induction patterns in mononuclear cells.

To investigate the expression of aryl hydrocarbon receptor repressor (AhRR) and related molecules in various tissues and the effects of aromatic hydrocarbons (AHs) on their expression, we developed a reliable technique of quantification of human AhRR as well as aryl hydrocarbon receptor (AhR), AhR nuclear translocator (ARNT) and cytochrome P450 1A1 (CYP1A1) mRNA by real-time TaqMan PCR method. First, we examined the expression of these genes in human adult or fetal tissues. The levels of AhRR expression were extremely high in testis, very high in lung, ovary, spleen and pancreas from adults, whereas those were low in those from fetuses. On the other hand, CYP1A1 expression was extremely high in lung, and AhR and ARNT were ubiquitously expressed in almost all tissues. Second, we compared the expression levels of these genes in mononuclear cells (MNCs) from various sources. Comparison of the basal expression levels of these genes in MNCs demonstrated that MNCs from umbilical cord blood showed higher AhRR or CYP1A1 expression than those from adults. The induction of AhRR or CYP1A1 expression by 3-methylcholanthrene (3-MC) was observed in MNCs from adults but not from umbilical cord blood. Consequently, there existed characteristic differences in the basal levels of AhRR and CYP1A1 expression in MNCs, as well as in their inducibility by 3-MC among MNCs from various types of human bloods. These results will provide basic information for a possible application of AhRR and CYP1A1 measurements to evaluate AH exposure in vivo.

[Symmetrical hemispheric porencephalic cysts due to twin embolization syndrome: a case report].

Twin embolization syndrome (TES) is a complication of monozygotic twining following in utero demise of the co-twin. Passage of thromboplastic materials into the circulation of the surviving fetus results in ischemic structural defects of various systemic organs including the central nervous system (CNS). In our case of monozygotic twining prenatal sonography at the 18th week of gestation revealed intracranial abnormality and demise of the co-twin. Postnatal MRI demonstrates localized cerebral parenchymal defects (porencephalic cysts) in the bilateral hemispheres, which probably were the sequelae to the occlusion of the peripheral branches of the bilateral middle cerebral arteries. She developed physio-mental retardation and subsequently West syndrome. At the 6th months, right porencephalic cyst-peritoneal shunt was performed for progressive enlargement of the head. While the enlargement of the head was well controlled, no changes in her epileptic symptoms were noted. The development of generalized epilepsy in our case may indicate that the involvement of the CNS with TES in our case is not restricted to the porencephalic cysts and their surrounding areas.