Impact of red blood cell transfusions on intestinal barrier function in preterm infants.

OBJECTIVE: To determine the relationships of red blood cell (RBC) transfusion and enteral feeding to changes in intestinal permeability (IP) measured by the relative intestinal uptake of lactulose (La) and rhamnose (Rh) in preterm infants <33 wk gestation. DESIGN/METHODS: Infants 240-326wk gestation received La/Rh solution enterally on study days 1, 8 and 15.Urinary La/Rh ratio was measured by HPLC. Hematocrit preceding transfusion, total RBC transfusion volume, volume/kg, and feeding status during each study interval (birth-d1; d1-d8, and d8-d15) were determined. RESULTS: Of the seventeen (40.5%) subjects who received≥1 transfusion during the study period, 12 (70.6%) infants were <28 wk gestation and 5 (29.4%) infants were≥28 wk gestation, p < 0.0001. Lower pre-transfusion hematocrit was observed in intervals preceding high IP (La/Rh > 0.05) than in intervals preceding low IP (La/Rh≤0.05) measurements (33 vs 35.8, p = 0.1051). RBC transfusions occurred more frequently in intervals preceding high IP than in intervals preceding low IP (26.8%; vs 8.3%, p = 0.0275) with 5-fold higher total RBC volume and volume/kg in intervals preceding any time point with high IP. RBC transfusion during an interval was associated with a three-fold increased risk of high IP (aOR 2.7; 95% C.I 0.564-12.814; p = 0.2143). Exclusive breast milk exposure and post-menstrual age reduced the risk for high IP following RBC transfusion. CONCLUSIONS: Both RBC transfusion number and volume was associated with subsequent high IP measurements in preterm infants <33 weeks gestation and potentially may contribute to impairment of the preterm intestinal barrier.

Post-discharge outcomes of failed car seat tolerance screens: A case-control and follow-up study.

BACKGROUND: Despite widespread implementation, limited data exists relating morbidity or adverse outcomes to Car Seat Tolerance Screen (CSTS) result in preterm and low birth weight (LBW) neonates. The objective of this study was to determine longer term post-discharge outcomes of infants who failed a CSTS. METHODS: We performed a case control study evaluating outcomes of infants born over one year who failed vs. passed an initial CSTS, utilizing both retrospective medical record review and parental survey data 2-3 years after discharge. Subjects were matched one case of failed CSTS to two controls who passed CSTS based on sex, gestational age, and BW. We performed bivariate analysis of clinical and demographic risk factors comparing those who passed vs. failed CSTS. RESULTS: We identified 19 subjects who failed and matched to 37 controls. Cases were significantly more likely to be diagnosed with obstructive sleep apnea (p = 0.027), asthma (p = 0.016), and be treated with albuterol (p = 0.008). We did not find differences in frequency of urgent care visits or hospital admissions between the groups. Although more of the cases were noted to have developmental delays, the difference was not statistically significant. CONCLUSION: This is the first study to evaluate longer term post-discharge outcomes of subjects having undergone CSTS. Subjects who failed CSTS had significantly increased incidence of respiratory diagnoses such as OSA and asthma than matched controls by 2-3 years after discharge. Larger studies are necessary to further evaluate these findings, but this does provide data that CSTS may be useful in identifying at risk neonates.

Excipient exposure in very low birth weight preterm neonates.

OBJECTIVE: The excipients benzyl alcohol, propylene glycol and ethanol are present in medications used in the neonatal intensive care unit. Exposure to high levels can have adverse effects in a neonatal population. The objective was to quantify excipient exposure in very low birth weight (VLBW) neonates and identify risk factors associated with greater exposure. STUDY DESIGN: A retrospective record review of VLBW infants admitted over 1 year. Excipient exposures were calculated and multivariable regression analyses identified risk factors for increasing exposure. RESULTS: In total, 98% of subjects were exposed to at least one excipient. A total of 5 to 9% received doses higher than recommended for adults. Necrotizing enterocolitis, seizure, bronchopulmonary dysplasia and longer stay predicted higher excipient exposure. CONCLUSION: The excipients examined are in medications commonly prescribed for VLBW neonates, and cumulative doses may exceed recommended exposures for adults. Although safety profiles have not been established, judicious use of medication containing these excipients is warranted for this population.

Routine fecal occult blood testing does not predict necrotizing enterocolitis in very low birth weight neonates.

OBJECTIVE: To determine sensitivity, specificity, predictive value of routine fecal occult blood (FOB) testing on the identification of Bell's Stage II or III necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants. METHODS: Retrospective medical record review of VLBW infants from 2012- 2013 evaluating FOB results and clinical and demographic risk factors. We determined predictive values of positive FOB testing within 48 hours of definite NEC diagnosis. We performed logistic regression analyses for predictors of NEC and for predictors of having positive FOB during NICU admission. RESULTS: The incidence of NEC in our cohort of 203 infants was 3.9% (n = 8). None had positive FOB results within 48 hours of diagnosis, and only 12.5% had any positive FOB within 7 days. Sensitivity of positive FOB for predicting definite NEC = 0%, specificity = 34.4%, and positive predictive value = 0%. A majority of VLBWs (67.0%) had > one positive FOB result during their NICU course. On logistic regression, intrauterine growth restricted (IUGR) infants had significantly higher odds of both developing NEC and of having positive FOB. Positive FOB was not a significant predictor of NEC. Those with lower birth gestational ages had higher odds of positive FOB. CONCLUSIONS: Positive FOB testing occurred in a majority of VLBW infants, with higher odds in the more preterm and IUGR. However, the sensitivity, specificity, and predictive value of routine FOB testing for identifying NEC were all very poor. Our data demonstrates that this test offers no advantages in the early diagnosis of NEC.

Growth hormone deficiency after childhood bone marrow transplantation with total body irradiation: interaction with adiposity and age.

OBJECTIVE: Bone marrow transplantation with total body irradiation (BMT/TBI) has adverse effects on growth, growth hormone status and adiposity. We investigated the GH-IGF-I axis in relation to adiposity. DESIGN: Cross-sectional case control study. PATIENTS: BMT/TBI survivors (n = 22) and short stature control participants (n = 19), all GH-naïve or off GH treatment >3 months. MEASUREMENTS: Auxology, DEXA scans and GH-IGF-I axis investigation: (i) 12-h overnight GH profiles; (ii) insulin tolerance test (ITT); and (iii) IGF-I generation test. ANALYSIS: auto-deconvolution of GH profile data and comparison of quantitative parameters using ANOVA. RESULTS: Eighty-two percent of BMT/TBI survivors had growth hormone deficiency (GHD) using ITT. GH profile area-under-the-curve (GH-AUC) was reduced in BMT/TBI survivors vs short stature control participants [geometric mean (range) 209 (21-825) vs 428 (64-1400) mcg/l/12 h, respectively, P = 0·007]. GHD was more marked in those who had additional cranial irradiation (CRT) [ITT peak 1·4 (0·2-3·0) vs TBI only 4·1 (1·1-14·8) mcg/l, P = 0·036]. GHD was more marked at the end of growth in BMT/TBI survivors vs short stature control participants (GH-AUC 551 (64-2474) vs 1369 (192-4197) mcg/l/12 h, respectively, P = 0·011) and more prevalent (9/11 vs 1/9, respectively, P = 0·005). GH profile data were consistent with ITT results in 80% of participants. IGF-I generation tests were normal. BMT/TBI survivors still demonstrated lower GH levels after adjustment for adiposity (fat-adjusted mean difference for GH-AUC 90·9 mcg/l/12 h, P = 0·025). CONCLUSIONS: GHD was more prevalent in BMT/TBI survivors than expected for the CRT dose in TBI, worsened with time and persisted into adulthood. GHD could not be explained by adiposity. There was no evidence of GH neurosecretory dysfunction or resistance after BMT/TBI.

Screening for cardiopulmonary events in neonates: a review of the infant car seat challenge.

The infant car seat challenge (ICSC), or period of observation in a car safety seat before discharge to monitor for episodes of apnea, bradycardia and desaturation, is one of the most common tests performed on preterm neonates in the United States. However, the utility of the ICSC to identify infants at risk for adverse cardiopulmonary events in the car seat remains unclear. Minimal evidence exists to guide clinicians in performance of this test including appropriate inclusion criteria and failure criteria. In this article, the origins of the ICSC are discussed as well as potential etiologies of desaturations and bradycardia in the car seat position. Current literature on implementation, inclusion and failure criteria, incidence of failure and data on the meaning of a 'passed' vs 'failed' ICSC are discussed. Emphasis is made on minimizing time in car seats and seated devices given concern over the risk of desaturations.

Test-retest reliability of the infant car-seat challenge.

OBJECTIVE: To evaluate how a single infant car-seat challenge (ICSC) predicts subsequent respiratory physiology in premature infants. STUDY DESIGN: Prospective observational study of infants born at <37 weeks gestational age. Subjects underwent three ICSCs and we evaluated clinical characteristics, pass rate, and predictive value of a single ICSC pass. RESULT: Completed three ICSCs on 60 subjects. Seven failed initial ICSC (11.7%). Those who failed had lower birth weights. Of the 53 that initially passed, 47 passed two subsequent tests (89%). Those who passed an initial test and failed a subsequent test had lower weights at each ICSC. CONCLUSION: Our results indicate that passing an ICSC is highly predictive of passing subsequent ICSCs. Lower weights at birth and at the time of ICSC were associated with increased risk of failure. We recommend including low birth weight as an inclusion criterion for ICSCs.

Effects of rapid antigen degradation and VEE glycoprotein specificity on immune responses induced by a VEE replicon vaccine.

Genetic vaccines are engineered to produce immunogens de novo in the cells of the host for stimulation of a protective immune response. In some of these systems, antigens engineered for rapid degradation have produced an enhanced cellular immune response by more efficient entry into pathways for processing and presentation of MHC class I peptides. VEE replicon particles (VRP), single cycle vaccine vectors derived from Venezuelan equine encephalitis virus (VEE), are examined here for the effect of an increased rate of immunogen degradation on VRP vaccine efficacy. VRP expressing the matrix capsid (MA/CA) portion of SIV Gag were altered to promote rapid degradation of MA/CA by various linkages to co-translated ubiquitin or by destabilizing mutations and were used to immunize BALB/c mice for quantitation of anti-MA/CA cellular and humoral immune responses. Rapid degradation by the N-end rule correlated with a dampened immune response relative to unmodified MA/CA when the VRP carried a glycoprotein spike from an attenuated strain of VEE. In contrast, statistically equivalent numbers of IFNgamma(+)T-cells resulted when VRP expressing unstable MA/CA were packaged with the wild-type VEE glycoproteins. These results suggest that the cell types targeted in vivo by VRP carrying mutant or wild type glycoprotein spikes are functionally different, and are consistent with previous findings suggesting that wild-type VEE glycoproteins preferentially target professional antigen presenting cells that use peptides generated from the degraded antigen for direct presentation on MHC.

Future vaccines against emerging encephalitides.

The vaccine strategies available for control of emerging encephalitides range in a continuum from traditional approaches to those utilizing new technologies. In this report, we explore the use of live attenuated vaccines where the attenuating mutations have been selected in a rational way to improve attenuation without sacrificing effectiveness. A strategy for paired lethal and resuscitating mutations is presented that will greatly reduce the possibility of reversion to virulence. Finally, we describe an example of a vaccine vector system that could be rapidly adapted for use against these virus diseases as they emerge.

Immunopathogenesis and immune modulation of Venezuelan equine encephalitis virus-induced disease in the mouse.

The course of Venezuelan equine encephalitis (VEE) disease in immunodeficient and immunologically normal mice was compared to define the role of the immune system in this disease process. Immunocompetent mice infected with VEE exhibited a biphasic illness characterized by an early self-limiting lymphoid phase and a fatal CNS phase. The lymphoid phase of the illness was characterized by extensive viral replication within spleen, thymus, Peyer's patches, and lymph nodes, was accompanied by a high-titered serum viremia, and resolved with the production of VEE-specific IgM class antibody at 72 h postinfection (p.i.). Immunocompetent animals survived an average of 6.8 +/- 1.2 days before succumbing to fulminant encephalitis. In contrast, SCID mice infected with VEE showed a persistent replication of virus throughout all organs tested beginning at 24 h p.i. VEE-infected SCID mice exhibited a severe spongiform encephalopathy with 100% mortality and an average survival time of 8.9 +/- 0.9 days. These studies indicated that the characteristic organ tropism of VEE in the mouse is due in large part to an early anti-viral state, the establishment of which is dependent upon the presence of an intact immune system. Finally, the CNS pathology in a VEE-infected mouse had a significant immunologic component. However, in contrast to other neurovirulent alphaviruses, VEE was directly cytopathic for the cells of the CNS, even in the absence of an immune response.

Role of alpha/beta interferon in Venezuelan equine encephalitis virus pathogenesis: effect of an attenuating mutation in the 5' untranslated region.

Venezuelan equine encephalitis virus (VEE) is an important equine and human pathogen of the Americas. In the adult mouse model, cDNA-derived, virulent V3000 inoculated subcutaneously (s.c.) causes high-titer peripheral replication followed by neuroinvasion and lethal encephalitis. A single change (G to A) at nucleotide 3 (nt 3) of the 5' untranslated region (UTR) of the V3000 genome resulted in a virus (V3043) that was avirulent in mice. The mechanism of attenuation by the V3043 mutation was studied in vivo and in vitro. Kinetic studies of virus spread in adult mice following s.c. inoculation showed that V3043 replication was reduced in peripheral organs compared to that of V3000, titers in serum also were lower, and V3043 was cleared more rapidly from the periphery than V3000. Because clearance of V3043 from serum began 1 to 2 days prior to clearance of V3000, we examined the involvement of alpha/beta interferon (IFN-alpha/beta) activity in VEE pathogenesis. In IFN-alpha/betaR(-/-) mice, the course of the wild-type disease was extremely rapid, with all animals dying within 48 h (average survival time of 30 h compared to 7.7 days in the wild-type mice). The mutant V3043 was as virulent as the wild type (100% mortality, average survival time of 30 h). Virus titers in serum, peripheral organs, and the brain were similar in V3000- and V3043-infected IFN-alpha/betaR(-/-) mice at all time points up until the death of the animals. Consistent with the in vivo data, the mutant virus exhibited reduced growth in vitro in several cell types except in cells that lacked a functional IFN-alpha/beta pathway. In cells derived from IFN-alpha/betaR(-/-) mice, the mutant virus showed no growth disadvantage compared to the wild-type virus, suggesting that IFN-alpha/beta plays a major role in the attenuation of V3043 compared to V3000. There were no differences in the induction of IFN-alpha/beta between V3000 and V3043, but the mutant virus was more sensitive than V3000 to the antiviral actions of IFN-alpha/beta in two separate in vitro assays, suggesting that the increased sensitivity to IFN-alpha/beta plays a major role in the in vivo attenuation of V3043.

Hearing preservation in acoustic neuroma surgery.

This article reviews the Montreal experience of hearing preservation in acoustic neuroma surgery. The medical records since 1995 of 36 patients who underwent acoustic neuroma extirpation with the intent to preserve hearing were examined. Intraoperative monitoring was conducted using auditory brainstem response measurement with electrocochleography via a transtympanic electrode. The role of intraoperative monitoring in guiding surgical technique and its correlation with postoperative hearing outcome are discussed. A review of the literature regarding hearing preservation in acoustic neuroma surgery is included.

Influenza virus (A/HK/156/97) hemagglutinin expressed by an alphavirus replicon system protects chickens against lethal infection with Hong Kong-origin H5N1 viruses.

Venezuelan equine encephalitis virus replicon particles (VRP) containing the gene expressing hemagglutinin (HA) from the human Hong Kong Influenza A isolate (A/HK/156/97) were evaluated as vaccines in chicken embryos and young chicks. Expressed HA was readily detected in bird-tissue staining with anti-H5 HA antibody and in chicken cells infected with the replicon preparations following immunoprecipitation with monoclonal antibody. Birds challenged with a dose of the lethal parent virus were protected to different extents depending on the age of the bird. In ovo and 1-day-old inoculated animals that received no boost with the VRP were partially protected; birds 2 weeks of age were completely protected with a single dose of VRP.

Expression of the two major envelope proteins of equine arteritis virus as a heterodimer is necessary for induction of neutralizing antibodies in mice immunized with recombinant Venezuelan equine encephalitis virus replicon particles.

RNA replicon particles derived from a vaccine strain of Venezuelan equine encephalitis virus (VEE) were used as a vector for expression of the major envelope proteins (G(L) and M) of equine arteritis virus (EAV), both individually and in heterodimer form (G(L)/M). Open reading frame 5 (ORF5) encodes the G(L) protein, which expresses the known neutralizing determinants of EAV (U. B. R. Balasuriya, J. F. Patton, P. V. Rossitto, P. J. Timoney, W. H. McCollum, and N. J. MacLachlan, Virology 232:114-128, 1997). ORF5 and ORF6 (which encodes the M protein) of EAV were cloned into two different VEE replicon vectors that contained either one or two 26S subgenomic mRNA promoters. These replicon RNAs were packaged into VEE replicon particles by VEE capsid protein and glycoproteins supplied in trans in cells that were coelectroporated with replicon and helper RNAs. The immunogenicity of individual replicon particle preparations (pVR21-G(L), pVR21-M, and pVR100-G(L)/M) in BALB/c mice was determined. All mice developed antibodies against the recombinant proteins with which they were immunized, but only the mice inoculated with replicon particles expressing the G(L)/M heterodimer developed antibodies that neutralize EAV. The data further confirmed that authentic posttranslational modification and conformational maturation of the recombinant G(L) protein occur only in the presence of the M protein and that this interaction is necessary for induction of neutralizing antibodies.

A single-site mutant and revertants arising in vivo define early steps in the pathogenesis of Venezuelan equine encephalitis virus.

The early stages of Venezuelan equine encephalitis virus (VEE) pathogenesis in the mouse model have been examined using a genetic approach. Disease progression of a molecularly cloned single-site mutant was compared with that of the parental virus to determine the step in the VEE pathogenetic sequence at which the mutant was blocked. Assuming that such a block constitutes a genetic screen, isolates from different tissues thought to be distal to the block in the VEE pathogenetic sequence were analyzed to determine the pathogenetic step at which revertants of the mutant were selected. Directed mutation and analysis of reversion in vivo provide two powerful genetic tools for the dissection of the wild-type VEE pathogenetic sequence. Virus from the parental virulent clone, V3000, first replicated in the draining lymph node after subcutaneous inoculation in the left rear footpad. Movement of a cloned avirulent mutant, V3010 (E2 76 Glu to Lys), to the draining lymph node was impaired, replication in the node was delayed, and spread beyond the draining lymph node was sporadic. Serum, contralateral lymph node, spleen, and brain isolates from V3010 inoculated animals were invariably revertant with respect to sequence at E2 76 and/or virulence in mice. Revertants isolated from serum and contralateral lymph node retained the V3010 E2 Lys 76 mutation but also contained a second-site mutation, Glu to Lys at E2 116. Modification of the V3010 clone by addition of the second-site mutation at E2 116 produced a virus that bypassed the V3010 block at the draining lymph node but that did not possess full wild-type capacity for replication in the central nervous system or for induction of mortality. A control construct containing only the E2 116 reverting mutation on the V3000 background was identical to V3000 in terms of early pathogenetic steps and virulence. Therefore, analysis of mutant replication and reversion in vivo suggested (1) that the earliest steps in VEE pathogenesis are transit to the draining lymph node and replication at that site, (2) that the mutation in V3010 impairs transit to the draining lymph node and blocks dissemination to other tissues, and (3) that reversion can overcome the block without restoring full virulence.

Vaccination of macaques against pathogenic simian immunodeficiency virus with Venezuelan equine encephalitis virus replicon particles.

Vaccine vectors derived from Venezuelan equine encephalitis virus (VEE) that expressed simian immunodeficiency virus (SIV) immunogens were tested in rhesus macaques as part of the effort to design a safe and effective vaccine for human immunodeficiency virus. Immunization with VEE replicon particles induced both humoral and cellular immune responses. Four of four vaccinated animals were protected against disease for at least 16 months following intravenous challenge with a pathogenic SIV swarm, while two of four controls required euthanasia at 10 and 11 weeks. Vaccination reduced the mean peak viral load 100-fold. The plasma viral load was reduced to below the limit of detection (1,500 genome copies/ml) in one vaccinated animal between 6 and 16 weeks postchallenge and in another from week 6 through the last sampling time (40 weeks postchallenge). The extent of reduction in challenge virus replication was directly correlated with the strength of the immune response induced by the vectors, which suggests that vaccination was effective.

Intratympanic cholesteatoma.

Cholesteatomas occurring behind an intact TM are relatively unusual, and intratympanic keratomas are even less common. This article presents the case of a Baffin Zone Inuit gentleman with an intratympanic cholesteatoma confined to the membranous portion of his TM. Although it is generally accepted that many native populations, including the Inuit, demonstrate an elevated preponderance of aural disease, cholesteatoma formation, particularly within the TM, in an individual from this area of the high Arctic is extremely rare.

Venezuelan equine encephalitis virus vectors expressing HIV-1 proteins: vector design strategies for improved vaccine efficacy.

A live virus vaccine vector has been constructed from a molecularly cloned attenuated strain of Venezuelan equine encephalitis virus (VEE). High levels of foreign protein expression are regulated by an additional copy of the 26 S viral subgenomic RNA promoter. The position of this additional promoter and foreign gene in the VEE genome was predicted to have a major influence on expression level of the heterologous protein. Two sites in the genome were tested to determine the optimal site for expression of the matrix/capsid (MA/CA) coding region of human immunodeficiency virus (HIV-1). One vector contained the additional promoter and the MA/CA genes immediately downstream of the VEE E1 gene at the 3' end of the genome. In the second vector, the additional promoter was introduced immediately upstream from the authentic 26 S subgenomic promoter. Significantly higher levels of MA/CA were expressed from the downstream vector compared to the upstream vector. However, the stability of expression for both vectors was similar following passage in baby hamster kidney cells (BHK) cells. In BALB/c mice, the two vectors elicited similar levels of cellular immune responses to MA/CA as determined by bulk cytotoxic T-lymphocyte assays and precursor frequency analysis, but the humoral response induced by the downstream vector was significantly stronger. At 11 months post boosting with the downstream vector, serum antibody levels against HIV MA/CA were undiminished, and MA/CA specific CTLp were detectable in all mice tested. These findings suggest that VEE vectors can be optimized to elicit strong, balanced and long-lived immune responses to foreign viral proteins.

The development of a novel intraperitoneal tumor-seeding prophylactic.

BACKGROUND: Peritoneal tumor dissemination and implantation is a complication of both open and laparoscopic oncologic surgery. This study evaluates the efficacy of paclitaxel-loaded poly(L-lactic acid) microspheres as prophylaxis against intraabdominal tumor seeding. METHODS: 2 x 10(6) 9L glioblastoma cells were introduced into the abdominal cavity of Wistar rats. Fifteen minutes later, the peritoneal cavity was washed with the experimental solutions, and 2 weeks later the presence of tumor implantation was determined. After defining the optimum dose of paclitaxel PLA microspheres in a dose-ranging study, the microsphere formulation was then compared with conventional paclitaxel in four experimental groups (n = 5) as follows: 100 mg of 30% paclitaxel-loaded microspheres; 100 mg PLA microspheres; paclitaxel 4.1 mg; and controls receiving no intraabdominal therapy. RESULTS: Although carcinomatosis developed in all control animals, none in the paclitaxel-loaded microsphere group had biopsy proven cancer. The conventional paclitaxel group (3) showed significant toxicity; only 1 animal survived and had positive histology. CONCLUSIONS: In this animal model of peritoneal carcinomatosis, the paclitaxel-loaded microsphere formulation was more effective than conventional paclitaxel in preventing tumor seeding.