Communication in NICUs.

In a Neonatal Intensive Care Unit (NICU) counseling should be a shared culture for all the care givers: it should be developed by all the professionals, to face up to parents' needs of information, explanations, facility of decisions, finding of resources, agreement, help, reassurance, attention. The first essential aspect is the training in counseling skills, by periodic courses for all professionals of the department (physicians, nurses, and physiotherapists). In our department, a professional counselor is present, assisting the medical staff in direct counseling. The counselor's intervention allows a better parent orientation in the situation. A more effective sharing of these rules also facilitates the communication among parents and medical staff. Periodic meetings are established among the medical staff, in which the professional counselor discusses difficult situations to share possible communicative strategies. We wanted to have not only a common communicative style, but also common subjects, independent from the characteristics of each of us. Individuals are often faced with different situations. For every setting that we more frequently face in communication (for example the first interview with a parent of a very preterm infant) we have built an 'algorithm' that follows a pattern: (1) information always given; (2) frequent questions from parents; and (3) frequent difficulties in the communication. Counselling is also a tool to face some critical issue, such as the decision to open the department to parents 24 h on 24, or the promotion of mother's milk use in Very Low Birth Weight Infants (VLBWI).

Insulin resistance in pre-school very-low-birth weight pre-term children.

AIMS: To evaluate the metabolic pattern of a group of pre-school small- (SGA) and appropriate-for-gestational age (AGA) pre-term very-low-birthweight (VLBW) (<1500 gr) Italian children and retrospectively verify if the growth rate in the first years of life is associated to the laboratory and anthropometric characteristics of these children. METHODS: 58 (16 SGA, 42 AGA) VLBW children, without major congenital malformations/conditions were enrolled; their anthropometric, clinical and (in 34 of them) laboratory characteristics were evaluated at pre-school age (> 2<6 years of corrected age). RESULTS: Clinical, anthropometric and laboratory characteristics at pre-school age were similar in SGA and AGA. Sixty-nine percent of SGA and 51% of AGA children showed a significant weight centile crossing (CC) at 24 months. Fasting serum glucose, insulin and insulin resistance (evaluated by the Homeostasis Model Assessment -HOMA-IR-) were higher in AGA and SGA with CC. The increment in weight standard deviation scores from birth-to-24 months was significantly associated with pre-school BMI SDS, waist, fasting insulin, and HOMA-IR values, both in unadjusted and adjusted models. In a multiple regression model, after multiple adjustments, this increment is the only significant predictor of pre-school insulin (B = 0.19; 95%CI 0.07-0.31; P = 0.006) and HOMA-IR levels (B = 0.20; 95%CI 0.08-0.32; P = 0.004) both in SGA and AGA children. CONCLUSIONS: The adverse metabolic pattern of pre-school VLBW children seems related to post-natal events (rapid weight growth) independently by their being small- or appropriate-for gestational age.

Postnatal weight increase and growth velocity of very low birthweight infants.

BACKGROUND: Only a few studies have dealt with postnatal growth velocity of very low birthweight (VLBW) infants. OBJECTIVE: To analyse weight growth kinetics of VLBW infants from birth to over 2 years of age. PATIENTS: A total of 262 VLBW infants were selected; inaccurate estimate of gestational age, major congenital anomalies, necrotising enterocolitis, death, and loss to follow up within the first year were the exclusion criteria. METHODS: Body weight was recorded daily up to 28 days or up to discontinuation of parenteral nutrition, weekly up to discharge, then at 1, 3, 6, 9, 12, 18, and 24 months of corrected age. Individual growth profiles were fitted with a seven constant, exponential-logistic function suitable for modelling weight loss and weight recovery, two peaks, and the subsequent slow decrease in growth velocity. RESULTS: After a postnatal weight loss, all infants showed a late neonatal peak of growth velocity between the 7th and 21st weeks; most also experienced an early neonatal peak between the 2nd and 6th week. VLBW infants who were small for gestational age and those with major morbidities grew less than reference VLBW infants who were the appropriate size for gestational age without major morbidities: at 2 years of age, the difference in weight was about 860 g. The more severe growth impairment seen in VLBW infants with major morbidities is almost entirely due to the reduced height of the late neonatal peak of velocity. CONCLUSIONS: The growth model presented here should be a useful tool for evaluating to what extent different pathological conditions or nutritional and medical care protocols affect growth kinetics.

Fetal cerebral ventriculomegaly: outcome in 176 cases.

OBJECTIVE: To evaluate the outcome of fetuses affected by different degrees of ventriculomegaly. METHODS: We studied 176 fetuses with ventriculomegaly and evaluated the pregnancy outcome and the neurodevelopmental outcome at age > or = 24 months. The population was divided into three groups according to ventricular width: A (mild ventriculomegaly, 10 to 12 mm); B (moderate, 12.1 to 14.9 mm) and C (severe, > or = 15 mm). RESULTS: Ventriculomegaly was more often an isolated finding in Group A (44/75; 58.7%) than in Group B (10/41; 24.4%) and Group C (24/60; 40%). When the ventriculomegaly was an isolated finding, 97.7% of fetuses with mild, 80% with moderate and 33.3% of those with severe dilatation were alive at > or = 24 months. The neurodevelopmental outcome was normal in 93% of Group A, 75% of Group B and 62.5% of Group C. CONCLUSIONS: Our results suggest that the definition of borderline ventriculomegaly should be limited to ventricular width below 12 mm. Cases with measurements above this value are more often associated with malformations and have a normal neurodevelopmental outcome less frequently.

Use of IgG Avidity test in case definitions of toxoplasmosis in pregnancy.

A survey network for congenital toxoplasmosis (TOXO-NET) was set up in December 1996 in Piedmont (Italy). Participants were asked to classify the infections in pregnant mothers and newborns by the criteria of the European Network on Congenital Toxoplasmosis published by Lebech in 1996. Because the IgG Avidity test is largely employed as a 2nd level test in toxoplasmosis diagnosis and it could be helpful to date infection, the co-ordinators of TOXO-NET suggested including it in the "case definition" of "probable" infection and "unlikely" infection. 117 cases of toxoplasmosis in pregnancy divided into the risk categories under Lebech's criteria were re-examined using the "new" case definitions. 77 out of 117 (65.8%) Toxoplasma gondii infections during pregnancy could be defined with only one serum sample using the IgG Avidity test. The IgG Avidity test proved a useful method to classify the Toxoplasma gondii infections in pregnancy, especially when we had only one serum sample.

Human proteome enhancement: high-recovery method and improved two-dimensional map of colostral fat globule membrane proteins.

The human milk fat globule membrane protein composition is still largely unknown, although it counts for 2-4% of the total milk protein content and contains several important biologically active components. The aim of this work was to create a two-dimensional electrophoresis (2-DE) map of the human milk fat globule membrane proteins, both integral and membrane-associated, and to identify and characterize as many protein components as possible. A new protocol for the solubilization and extraction of the human milk fat globule membrane proteins with a double extraction procedure is presented, and the results compared with the extraction methods reported in the literature. The proteins were separated, in the first dimension, by isoelectric focusing (IEF) in the pH range 3-10 on strips of 13 cm length and, in the second dimension, by Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) on 11.5% T homogeneous gels. A reproducible 2-DE map of integral and membrane-associated proteins was obtained and the first 23 spots, representing the major components, were identified by matrix assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometric analysis and/or by amino acid sequencing.

[Prenatal diagnosis and treatment of congenital toxoplasmosis: a program of regional surveillance]. / Diagnosi prenatale e trattamento della toxoplasmosi congenita: un programma di sorveglianza regionale.

Toxo-net is a regional program of survey on congenital toxoplasmosis which has two aims: 1) to estimate the incidence of gestational and congenital toxoplasmosis in our Region (Piemonte); 2) to assess the compliance to our diagnostic, therapeutic and follow-up protocols which are thoroughly described. Thirty-two obstetrical, neonatal and laboratory units of Piemonte Region have been involved. During 18 months (January 1997-June 1998) 365 pregnant women were studied because of suspected seroconversion: in 129 patients infection was confirmed. Amniocentesis for prenatal diagnosis was carried on 11 patients; two fetuses were affected. 35% of the mothers were untreated or inadequately treated. Hydrocephaly was observed in two fetuses. Neonatal follow-up at 12 months is available for 68 of the 129 infected mothers. Four babies (5.8%) were infected, three of them being symptomatic; their mothers had not been treated. It is concluded that the implementation of a screening program for toxoplasmosis during pregnancy seems to be beneficial. However an effort to improve the surveillance system and the education of the gynecologists, general practitioners and of the patients is needed, and economic evaluations are warranted.

[CRIB score: mortality, morbidity, and long-term neurologic development]. / CRIB score: mortalità, morbilità e sviluppo neurologico a distanza.

The purpose of this study is to assess the possibility of predicting mortality, major pathology and long-term neurodevelopmental impairment in very low birth weight VLBW infant using Clinical Risk Index for Babies (CRIB). We studied a cohort of 251 VLBW infants, whose CRIB could be calculated, born from 1995 to 1998 in our Unit. We analyzed the mortality before discharge, the incidence of chronic lung disease (CLD) and of retinopathy of prematurity (ROP), the length of stay before discharge and the neurodevelopmental impairment at one and two years of corrected age using the Griffiths developmental scales (impairment was defined by a general quotient of 85 or below). The CRIB score was divided into three risk groups: 0-5, 6-10 and > 10. Mortality rate raises with the CRIB's increase (respectively 5.6% in the first group, 32.4% in the second and 93.8% in the third group); besides the incidence of severe ROP and of CLD, calculated in infants survived > 28 days, is higher (18.4% and 40.7% respectively) in the second group than in the first (1.9% and 7.4% respectively). In the end, the incidence of neurodevelopment impairment at one and two years of corrected age is respectively 6.8% and 6.0% for children with CRIB 0-5 and 29.4% and 21.4% for children with CRIB 6-10. CRIB score is strongly associated with mortality and there is an increasing risk for severe ROP, CLD and neurodevelopment impairment from class 0-5 to class 6-10; no statement can be made for these diseases in class > 10 because there is only one survivor in this class.

Congenital toxoplasmosis: 10-year follow up.

A long-term follow up was begun in 1982 on offspring of mothers who acquired toxoplasmosis during gestation. The 114 newborns were subdivided into 3 groups: (1) 26 born to mothers with certain infection; (2) 51 born to mothers with probable infection, and (3) 37 born to mothers with doubtful infection. There were five infections in the first group (19.2%), three in the second (5.8%) and none in the third. For purposes of data elaboration we considered only the 77 offspring of mothers with certain or probable infection. Of these, 2 infected cases out of 52 (3.8%) were born to mothers with infection in the first trimester of pregnancy, 4 out of 21 (19%) in the second trimester, and two out of four in the third. There were a total of 8 congenital infections (10.4%). Specific IgM antibodies were revealed in five out of eight infected children (62.5%). Infection was symptomatic in two children (2.6% of newborns at risk, 25% of infected cases), both born to mothers with infection in the second trimester. In the other six cases diagnosis was reached by evaluating trends in antibody levels: the percentage of infected newborns was higher in the group of maternal infections untreated (50%) or improperly treated (15.4%), compared to those receiving adequate treatment (6.9%). We suggest considering as infected children presenting specific IgM antibodies and/or antibody titres which do not become negative, even when symptoms are absent. Therapy with spiramycin should be started in all newborns at risk, while the use of sulphamides and pyrimethamine is justified only after the presence of infection is confirmed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Congenital infections caused by TORCH agents]. / Le infezioni congenite da agenti TORCH.

The frequency of transplacental infections varies depending on the pathogen responsible. Of the TORCH infections this paper studies the epidemiology, pathogenesis, clinics, therapy and prophylaxis of infections caused by Rubella, Varicella-Zoster, Cytomegalo and Herpes Simplex Viruses and by Toxoplasma Gondii, Treponema Pallidum.