Local interstitial emphysema caused by meconium aspiration: report of one case.

A neonate of meconium aspiration syndrome presented with respiratory distress and bilateral pneumothorax. The image studies, including chest X-ray, chest computed tomography and operation finding all showed cystic changes in the right lung. Therefore congenital cystic lesions of lung was the first impression. However, the pathologic report disclosed meconium aspiration with interstitial emphysema.

Intratracheal oxygen administration during bronchoscopy in newborns: comparison between two different weight groups of infants.

BACKGROUND: The development of ultrathin fiberoptic bronchoscopy (FB) has made the examination of neonatal airways a practical possibility. The aim of this study was to assess the effects of intratracheal oxygen (ITO) administration on blood oxygenation and carbon dioxide (CO2) changes during FB in different body-weight infants. METHODS: Newborns suspected of having airway problems, but in a stable cardiopulmonary condition were studied. An ultrathin (outside diameter, 2.2 mm) fiberoptic bronchoscope that was modified by adding an external tube (internal diameter, 0.3 mm; outside diameter, 0.64 mm) to deliver oxygen was used. For ITO administration, a low oxygen flow rate of 0.1 l/kg/min was delivered directly into the trachea. Oxygenation and CO2 measurements were obtained at five different stages: 1) just before FB (baseline); 2) with the tip of the bronchoscope at the supralarynx; 3) with the tip at the carina without ITO; 4) with the tip at the carina with ITO; and 5) 15 minutes after FB. Forty infants were studied completely and divided into two groups according to their body weight: 1) the light-weight group (< 2,500 g), 21 infants; and 2) the heavy-weight group (> or = 2,500 g), 19 infants. RESULTS: In both groups, arterial blood oxyhemoglobin saturation and oxygen tension decreased significantly (p < 0.05) when the tip of the bronchoscope advanced from the nostril to the supralarynx, and further decreased (p < 0.01) when at the carina level. Small infants had greater decrements of both oxygenation measurements (p < 0.05) than the large infants. After ITO administration, both oxygenation measurements increased significantly (p < 0.001) and returned to baseline following FB. Both end tidal pressure of CO2 (P(ET)CO2) and arterial CO2 tension (PaCO2) significantly increased from the baseline when the FB tip was advanced from the supralarynx to the carina (p < 0.05). During ITO administration, the PaCO2 increased (p < 0.01) but the P(ET)CO2 decreased (p < 0.001). After FB, both CO2 measurements returned to baseline. The pH only decreased during ITO administration. CONCLUSIONS: We conclude that FB causes significant hypoxemia and hypercapnia in newborns, especially in underweight infants. Appropriate ITO can be considered a safe and beneficial technique for maintaining oxygenation during FB. P(ET)CO2 monitoring may mask true blood CO2 retention during ITO administration.

Stability and peptide binding specificity of Btk SH2 domain: molecular basis for X-linked agammaglobulinemia.

X-linked agammaglobulinemia (XLA) is caused by mutations in the Bruton's tyrosine kinase (Btk). The absence of functional Btk leads to failure of B-cell development that incapacitates antibody production in XLA patients leading to recurrent bacterial infections. Btk SH2 domain is essential for phospholipase C-gamma phosphorylation, and mutations in this domain were shown to cause XLA. Recently, the B-cell linker protein (BLNK) was found to interact with the SH2 domain of Btk, and this association is required for the activation of phospholipase C-gamma. However, the molecular basis for the interaction between the Btk SH2 domain and BLNK and the cause of XLA remain unclear. To understand the role of Btk in B-cell development, we have determined the stability and peptide binding affinity of the Btk SH2 domain. Our results indicate that both the structure and stability of Btk SH2 domain closely resemble with other SH2 domains, and it binds with phosphopeptides in the order pYEEI > pYDEP > pYMEM > pYLDL > pYIIP. We expressed the R288Q, R288W, L295P, R307G, R307T, Y334S, Y361C, L369F, and 1370M mutants of the Btk SH2 domain identified from XLA patients and measured their binding affinity with the phosphopeptides. Our studies revealed that mutation of R288 and R307 located in the phosphotyrosine binding site resulted in a more than 200-fold decrease in the peptide binding compared to L295, Y334, Y361, L369, and 1370 mutations in the pY + 3 hydrophobic binding pocket (approximately 3- to 17-folds). Furthermore, mutation of the Tyr residue at the betaD5 position reverses the binding order of Btk SH2 domain to pYIIP > pYLDL > pYDEP > pYMEM > pYEEI. This altered binding behavior of mutant Btk SH2 domain likely leads to XLA.

High-frequency oscillatory ventilation in premature infants.

BACKGROUND: Although assisted ventilation has reduced the mortality rate of premature infants, pulmonary disease is still the major cause of morbidity and mortality in very low birth weight infants. We designed this study to evaluate the efficacy and safety of high-frequency oscillatory ventilation (HFOV) in premature infants and to compare the outcome for early intervention with HFOV versus conventional ventilation (CV). METHODS: From January, 1997, to June, 1998, we analyzed premature infants with respiratory failure who required mechanical ventilation and supplemental oxygen to support adequate gas exchange in our neonatal intensive care unit. Patients were eligible if their gestational age was less than 35 weeks or their birth weight was less than 1,751 g. A total of 35 neonates were enrolled in the study. Eighteen infants were treated with HFOV, and 17 infants were treated with CV. They were treated with early intervention of HFOV or CV, within 24 hours-of-age. Patients were excluded if a lethal congenital anomaly, bacteremia, hydrops fetalis, congenital diaphragmatic hernia or intubation only for apnea were noted. Data on demographics, gas exchange and outcome parameters were collected for each patient enrolled in the study. RESULTS: No differences were noted in the demographic features between the study groups. All of the enrolled patients suffered from variable grades of respiratory distress syndrome. A significantly shorter intubation period was found in the HFOV group compared with the CV group (2.8 +/- 1.5 days vs 8.8 +/- 9.4 days; p = 0.013). CONCLUSIONS: HFOV is a safe and effective therapy for premature infants with respiratory failure due to respiratory distress syndrome.

Experiences with high-frequency oscillatory ventilation in premature infants with respiratory distress syndrome.

BACKGROUND: High-frequency oscillatory ventilation (HFOV) has been used in treating premature infants with respiratory distress syndrome who have a low incidence of ventilation-associated lung injury. Herein, we report our initial clinical experience in using HFOV to treat such infants. METHODS: From October 1996 to February 1997, 10 premature infants with severe respiratory distress syndrome treated with HFOV were retrospectively evaluated. Clinical course and laboratory data collected during treatment were analyzed. Parameters evaluated included patient survival rate, incidence of chronic lung disease and morbidity associated with HFOV usage. RESULTS: The mean gestational age was 29 +/- 2 weeks; mean birth weight, 1,182 +/- 342 g; and mean period of HFOV treatment, 3.4 +/- 1.9 days. One patient died of sepsis due to infective pancarditis. Two patients developed moderate chronic lung disease at 30 days post delivery and in one of these patients, the disease persisted at 36 weeks' of age. The overall survival rate was 90%. No patient developed air-leak syndrome during the course of treatment. CONCLUSIONS: Our initial experience demonstrated that using HFOV in treating premature infants with severe respiratory distress syndrome was safe and effective. The incidence of moderate to severe chronic lung disease or air-leak syndrome following HFOV was low.

Pancarditis in an extreme premature newborn following central venous catheterisation: report of one case.

We report a rare complication of pancarditis in an extreme premature neonate with a peripheral inserted central venous catheter which was positioned in the right atrium. She showed a picture of sepsis, pulmonary embolism, and heart failure. This case emphasizes the need for careful monitoring of the neonate with a central venous catheter to eliminate possible sequel. Echocardiography may help in making an early diagnosis of endocarditis in neonates.

Coxsackievirus B1 infection in infants less than 2 months of age.

Most of the neonatal enteroviral infections reported in the literature are associated with Coxsackievirus B2-B5 and echovirus 9 and 11. We report a retrospective Coxsackievirus B1 (CB1) infection in infants less than 2 months of age. Seventeen patients had aseptic meningitis and 8 had systemic sepsis (multi-organ involvement including meningitis, impaired liver function, and abnormality in coagulation). The symptoms and signs were nonspecific and could not be distinguished with bacterial infection on clinical grounds. Virus isolation was mandatory for diagnosis. Impaired liver function and coagulation profiles were noted in patients with systemic sepsis, but not in patients with meningitis only. CSF examination showed some uncommon features of viral meningitis: predominance of polymorphonuclear cells (PMN) was noted in 62.5% of patients and hypoglycorrhachia in 64% of patients. The patients with only meningitis recovered completely without any sequela. One of the eight patients with systemic sepsis died with case fatality rate 12.5%. Physicians should be aware of the possibility of CB1 virus infection in young infants during prevalent seasons. Specimens should be sent for viral culture in patients with meningitis and sepsis to make a definite diagnosis.

Symptomatic patent ductus arteriosus in very low birth weight infants.

BACKGROUND: Premature neonatal survival rates have increased significantly. The diagnosis of patent ductus arteriosus (PDA) has also increased. In this paper, we present our experience of incidence, clinical features and outcome of the treatment of symptomatic PDA in very low birth weight infants. METHODS: From January 1990 to December 1995, 181 premature infants with birth weight less than 1,500 g were admitted to the Neonatal Intensive Care Unit (NICU) of Veterans General Hospital-Taipei. Thirty-seven were diagnosed to have symptomatic PDA. By reviewing hospital records, the clinical features and outcome of treatment of these infants were analyzed retrospectively. RESULTS: The incidence of symptomatic PDA was 20.9% and 21.4% in infants with birth weight less than or equal to 1,000 g, 1,001-1,500 g, respectively. The mean age at diagnosis of infants with symptomatic PDA was significantly less than those without symptoms (3.6 +/- 2.9 days vs 9.6 +/- 17.2 days, p = 0.044, 95% CI = 0.2-11.8). With fluid restriction and diuretic therapy, asymptomatic patients had a higher spontaneous ductal closure rate than symptomatic patients (58.3% vs 10.8%, p < 0.001, 95% CI = 17.9-77.1%). Thirty-two (97.0%) infants with symptomatic PDA responded to indomethacin therapy. However, four infants (12.1%) had recurrence. These four infants and a nonresponder received surgical ligation of the PDA and survived. There were four deaths. The reasons for death were respiratory failure in two, sepsis in one and necrotizing enterocolitis with intestinal perforation in one. CONCLUSIONS: Conservative medical management such as fluid restriction and diuretics are often adequate for asymptomatic PDA. However, since symptomatic PDA tends not to close spontaneously, patients should be treated with indomethacin if ductal shunting compromises cardiopulmonary function.

The relationship between serum and saliva erythropoietin concentrations in adults, full-term and premature infants.

Simultaneous blood and saliva samples were collected for determination of the relationship between serum and saliva erythropoietin (EPO) concentrations in 12 adults (Group I), 15 full-term neonates (Group II), and 11 premature infants (Group III). Saliva was collected with a modified sputum-collecting tube combined with a vacuum suction pump. Serum and saliva EPO concentration was measured by enzyme-linked immunosorbent assay. The relationship between serum and saliva concentrations was explored using (1) regression analysis and (2) serum-to-saliva ratio. Salivary concentrations approximated 15 to 30% of the serum concentrations based on the serum-to-saliva ratios. Significant correlation was observed between serum and salivary concentrations in each group (p < 0.05). The regression analyses produced formulas for predicting serum EPO concentrations from saliva EPO concentrations which seemed to fit the data well. The resulting formula is surprisingly consistent with that derived from Group I. The ratio models seem to fit the data well as regression models. From the results it is concluded that the use of salivary samplings for serum EPO in adults, full term and premature infants may be a possible alternative method to blood samplings.

The effect of povidone-iodine on thyroid function of neonates with different birth sizes.

The aim of this study was to elucidate the role of povidone-iodine (PV-I) on thyroid function of newborns with different birth sizes in a high iodine-intake city. Serial measurements of serum thyroxine (T4) and thyrotropin (TSH) levels were done in 44 newborns locally treated with 10% PV-I for insertion of percutaneous central venous catheters. The results showed that the thyroid function was influenced prominently in very-low-birth weight (VLBW) babies. TSH went significantly higher after application of PV-I for 48 hours in VLBW babies. The smaller the babies were, the lower the T4 at birth and thereafter. In conclusion, PV-I is suggested to be avoided for single application on a wide skin surface in VLBW babies, even in an area with high iodine-intake population.

Percutaneous removal of a nonopaque silastic catheter from the pulmonary artery in two premature infants.

A modified snare was made from a 0.016' guidewire and a 0.1-mm fishing string to remove a nonopaque Silastic catheter via a femoral vein approach in 2 premature infants at the 44th and 120th day of life, respectively. A foldover guidewire loop snare had failed in 1 infant before this technique was successfully applied.

High-frequency oscillatory ventilation--a new management for respiratory distress syndrome and intractable respiratory failure.

High-frequency oscillatory ventilation (HFOV) has been proved to decrease the incidence of volutrauma and improve oxygenation and ventilation in severe pulmonary diseases by many investigators with animal studies and clinical reports, particularly in prematurities with severe respiratory distress syndrome. Patients with intractable respiratory failure or air-leak syndrome may be rescued by HFOV. During HFOV small volume, less than dead space, is delivered at high frequencies. Both inspiration and expiration are active. Oxygenation is mainly maintained by mean airway pressure to achieve optimal lung volume. Carbon dioxide elimination is mainly controlled by delivered volume. Mean airway pressure, fraction of inspiratory oxygen and amplitude are the only three items that need frequent adjustments after initial settings. The first two items determine the oxygenation and the last one determines ventilation. Careful monitoring of conditions the patients, discontinuous learning and cooperation of all coworkers are important to use the new therapy. Further studies with long-term follow-up are important to assess its appropriate role in different treatment methods and different degrees of respiratory diseases.

Neonatal thyroid function is unaffected by single treatment with different preparations of povidone-iodine on a wide skin surface.

Povidone-iodine (PV-I) are commonly used for disinfection in hospitals. Previous investigators had proved that iodine can be absorbed from the skin. In an attempt to determine the effect of single treatment of various PV-I preparations on thyroid function in fullterm newborns, serial measurements of serum thyroxine (T4) and Thyroid stimulating hormone (TSH) were done in 48 neonates treated with one dose antiseptics (tincture PV-I, aqueous PV-I, tincture PV-I followed with 75% alcohol and no treatment in control group). The results revealed no significant change of thyroid function in any study group. In conclusion, PV-I with different preparations, aqueous or tincture, did not significantly influence neonatal thyroid function if they were used to a fullterm neonate only once and even to a wide skin surface.

Stomach rupture associated with physical struggle in a child.

A 5-year-old girl with spontaneous rupture of the stomach was treated successfully with excision of the ischemic edges of the perforation with primary repair. In this case, vigorous resistance against medical measurement resulted in rupture of the stomach, which was already distended with a large amount of fluid and air. The child survived following immediate surgical intervention and intensive postoperative care.

Complications of intra-cardial placement of silastic central venous catheter in pediatric patients.

UNLABELLED: A three-year prospective study was undertaken to determine the incidence and early complications from intra-cardiac placement of percutaneous central venous catheter (CVC). CVC was inserted by using "Catheter-through-needle" technique, and the insertion length was measured by body surface landmark. CVC course and tip location were routinely checked by roentgenography. Echocardiography was performed in case of arrhythmia. After analysis of 784 CVCs, 104 (13.3%) were proved to be intra-cardial, as located by either roentgenography or echocardiography. However, catheters passed via the upper trunk (14.5%) were significantly (p < 0.05) more intra-cardially located than those via the lower trunk (4.8%). Catheters which passed via the right upper trunk veins (basilic, cephalic, or external jugular veins) were also more intra-cardially located than those via their left veins counterparts, but the finding was not statistically significant (p > 0.05). The mean body weight (3.1 +/- 2.4 kg) in the intra-cardial placement group was significantly (p < 0.05) less than that in the non-intracardial placement group (7.9 +/- 4.5 kg). In intra-cardial placement patients, 32 cases (30.8%) had episode(s) of cardiac arrhythmia including 31 premature ventricular depolarization and 1 supra-ventricular tachycardia. All cases showed the presence of intra-ventricular catheter. All arrhythmias ceased abruptly after the catheters were pulled from the hearts. No other early complications were observed. CONCLUSIONS: the incidence of the intracardiac placement of CVC is high, especially in small infants or when the insertion via the upper trunk. Short term intra-cardiac catheter placement has a benign clinical course except that the intraventricular catheter may cause arrhythmia. However, this kind of arrhythmia can be resolved spontaneously by withdrawing the catheter.

Hemolytic disease of the newborn due to anti-Di(a): report of one case.

In the Diego blood group, the frequency of the Di(a + b +) or Di(a + b -) phenotype among Chinese in Taiwan is estimated to be 3.2%. Here we report a case of severe hemolytic disease caused by anti-Di(a). The baby's total bilirubin elevated to 23 mg/dl at the age of 72 hours. A blood exchange transfusion and phototherapy were performed. We suggest to include Diego positive cell panels in testing antibody specificities that are likely to be encountered in this population.

Direct tracheobronchial suction for massive post-extubation atelectasis in premature infants.

UNLABELLED: A prospective four-year study was done in a neonatal intensive care unit (NICU) to evaluate a technique, called direct tracheobronchial suction (DTBS), for rapidly removal of obstructive secretions from the tracheobronchial tree in newborn infants with massive post-extubation atelectasis (PEA). Selected cases who met the following criteria were enrolled: 1) developing new massive atelectasis within 48 hours after extubation; 2) no response to vigorous chest physiotherapy(CPT) and continuous deterioration; and 3) no air-bronchogram in the atelectatic lung field. DTBS was carried on at bedside by direct insertion a 6.5 Fr suction catheter into tracheobronchial tree and suctioning. Clinical and laboratory assessments were made in each case prior to and at two hours after DTBS for comparison. A total of 145 (19.7%, 145/736)) PEA occurred in a consecutive 736 postextubated newborn infants. Thirty-one atelectasis (4.2%, 31/736) that developed in 18 infants were managed with DTBS. There was a significant higher incidence of PEA developed, as well as a higher ratio of PEA been treated by DTBS, in the group of body weight < 1,500 g than the group of > or = 1,500 g. All except one infants weighed less than 1,500 g, with a mean of 1,043 +/- 269 g. Sixteen infants had been intubated for more than seven days with a mean of 14.1 +/- 5.0 days. Nine infants required more than one session of DTBS. DTBS was quite effective in immediate removal of retained secretions and improvement of pulmonary condition. By clinical assessment, respiratory distress improved with increased audible air entry on the affected lung, decreased chest retractions, and a significant fall in respiratory rate and heart rate. Arterial blood gases analysis showed significant improvement of pH, partial pressure of carbon dioxide and oxygenation ratio. By chest radiograph, DTBS resulted partial or nearly complete resolution of the atelectasis in all cases. DTBS procedures were well tolerated by all infants without significant sequelae. CONCLUSION: This study suggests that DTBS is a simple and effective therapeutic modality to rapidly correct the massive PEA which resist to vigorous CPT in small infants.

The application of a modified mini-flexible-fiberoptic endoscopy in pediatric practice.

BACKGROUND: The application of bronchoscopy in infants and small children is still restricted in most institutions because of their limited airways. The purpose of this study was to evaluate the usefulness of a modified mini (2.1 mm OD) flexible fiberoptic endoscope (FFE) in diagnosis and therapy of suspected pediatric airway problems. METHODS: A prospective two-year study was carried out in a tertiary care neonatal/pediatric intensive care unit and general ward in a children medical center of a university-affiliated hospital. The employed mini-FFE (Machida ENT-30 F III, Tokyo, Japan) was modified with the addition of an external silastic catheter (0.5 mm inward diameter, 0.9 mm outward diameter) for suctioning, oxygen delivery, and medications during study. RESULTS: Totally, 247 laryngoscopies and 212 bronchoscopies were performed in 207 patients without significant morbidity or any associated mortality. The age of patients ranged from 1 day to 10 years. About one-fifth of the procedures (larngoscopy 21.5%, 53/247; bronchoscopy 19.8%, 42/212) were performed in patients under the age of one month. Patient's body weight ranged from 650 g to 40 kg. About fifty-five percent of the procedures (laryngoscopy 55.1% 136/247; bronchoscopy 55.2%, 117/212) were performed in patients weighing less than 5 kg. The most common path of either laryngoscopy (94.3%, 233/247) or bronchoscopy (94.8%, 201/212) was through the nasal route. In 102 patients who had been demonstrated to have upper airway problems, 16 patients (15.7%) also proved to ahve significant lesion(s) below the glottis. CONCLUSIONS: This modified FFE is a safe and a valuable instrument that can serve as an important aid in the diagnosis and therapy as well as a guide for surgical intervention of respiratory tract disorders in small infants and children.