Bilateral Neonatal Suppurative Sialadenitis Progressing to Abscess Formation in a Preterm Neonate

Aims We report a case of bilateral neonatal suppurative sialadenitis (NSS) in an extremely low birth weight infant (ELBW). Methods The infant developed bilateral sub-mandibular swelling at 3 weeks of age. NSS with abscess was confirmed with ultrasound. Despite intravenous antibiotic therapy the masses increased in size and developed abscesses. Results Unilaterally the abscess discharged via Wharton's duct necessitating intubation to protect the airway. The abscess remnant was incised and drained. Culture grew a methicillin sensitive staphyloccocus aureus. The NSS resolved following two weeks of antibiotics. Conclusion We wish to highlight the importance of early recognition of this rare condition in preterm neonates.

Mild hypoxic ischaemic encephalopathy and long term neurodevelopmental outcome - A systematic review.

AIMS: Hypoxic ischaemic encephalopathy (HIE) remains a significant cause of long term neurodisability despite therapeutic hypothermia (TH). Infants with mild HIE, representing 50% of those with HIE, are perceived as low risk and are currently not eligible for TH [1]. This review examines the available evidence of outcome in term infants with mild HIE. METHODS: Medline, Embase and Cochrane Clinical Trials databases were searched in March 2017. Studies with well-defined HIE grading at birth and standardised neurodevelopmental assessment at ≥18 months were included. Abnormal outcome was defined as death, cerebral palsy or standardised neurodevelopmental test score more than 1 standard deviation below the mean. RESULT: Twenty studies were included. Abnormal outcome was reported in 86/341 (25%) of infants. There was insufficient evidence to examine the effect of TH on outcome. CONCLUSION: A significant proportion of infants with mild HIE have abnormal outcome at follow up.

Early Cord Metabolite Index and Outcome in Perinatal Asphyxia and Hypoxic-Ischaemic Encephalopathy.

BACKGROUND: A 1H-NMR-derived metabolomic index based on early umbilical cord blood alterations of succinate, glycerol, 3-hydroxybutyrate and O-phosphocholine has shown potential for the prediction of hypoxic-ischaemic encephalopathy (HIE) severity. OBJECTIVE: To evaluate whether this metabolite score can predict 3-year neurodevelopmental outcome in infants with perinatal asphyxia and HIE, compared with current standard biochemical and clinical markers. METHODS: From September 2009 to June 2011, infants at risk of perinatal asphyxia were recruited from a single maternity hospital. Cord blood was drawn and biobanked at delivery. Neonates were monitored for development of encephalopathy both clinically and electrographically. Neurodevelopmental outcome was assessed at 36-42 months using the Bayley Scales of Infant and Toddler Development, ed. III (BSID-III). Death and cerebral palsy were also considered as abnormal end points. RESULTS: Thirty-one infants had both metabolomic analysis and neurodevelopmental outcome at 36-42 months. No child had a severely abnormal BSID-III result. The metabolite index significantly correlated with outcome (ρ2 = 0.30, p < 0.01), which is robust to predict both severe outcome (area under the receiver operating characteristic curve: 0.92, p < 0.01) and intact survival (0.80, p = 0.01). There was no correlation between the index score and performance in the individual BSID-III subscales (cognitive, language, motor). CONCLUSIONS: The metabolite index outperformed other standard biochemical markers at birth for prediction of outcome at 3 years, but was not superior to EEG or the Sarnat score.

The effect of haemolysis on the metabolomic profile of umbilical cord blood.

OBJECTIVES: Metabolomics is defined as the comprehensive study of all low molecular weight biochemicals, (metabolites) present in an organism. Using a systems biology approach, metabolomics in umbilical cord blood (UCB) may offer insight into many perinatal disease processes by uniquely detecting rapid biochemical pathway alterations. In vitro haemolysis is a common technical problem affecting UCB sampling in the delivery room, and can hamper metabolomic analysis. The extent of metabolomic alteration which occurs in haemolysed samples is unknown. DESIGN AND METHODS: Visual haemolysis was designated by the laboratory technician using a standardised haemolysis index colour chart. The metabolomic profile of haemolysed and non-haemolysed UCB serum samples from 69 healthy term infants was compared using both (1)H-NMR and targeted DI and LC-MS/MS approach. RESULTS: We identified 43 metabolites that are significantly altered in visually haemolysed UCB samples, acylcarnitines (n=2), glycerophospholipids (n=23), sphingolipids (n=7), sugars (n=3), amino acids (n=4) and Krebs cycle intermediates (n=4). CONCLUSION: This information will be useful for researchers in the field of neonatal metabolomics to avoid false findings in the presence of haemolysis, to ensure reproducible and credible results.

Normative levels of Interleukin 16 in umbilical cord blood.

OBJECTIVES: The need for early and accurate prediction of outcome in hypoxic-ischaemic encephalopathy (HIE) remains critical. We have previously demonstrated that Interleukin 16 (IL-16) is raised in the umbilical cord blood (UCB) of infants with moderate and severe HIE and has the potential to be developed as a predictive biomarker. Normal reference ranges for IL-16 in UCB have not been previously described. The aim of this study was to determine normative levels of IL-16 in full term neonates using UCB following uncomplicated deliveries and to examine the effect of labour on cord IL-16 values. DESIGN AND METHODS: Full term infants were recruited as part of an ongoing birth cohort study, the Cork BASELINE Birth Cohort Study. All had UCB drawn and bio-banked at -80°C, within 3hours of birth. Samples for this experiment were chosen from this population based cohort study to represent uncomplicated pre-labour caesarean sections and spontaneous vaginal deliveries. Analysis was performed on plasma EDTA, using ELISA Quantikine® (R&D Systems, Europe). RESULTS: Samples were analysed from 48 infants with two modes of delivery; spontaneous vaginal delivery (n=12 male, n=12 female) and elective caesarean section (n=12 male, n=12 female). The range of all samples was normally distributed between 87.0 and 114.6pg/ml. Overall mean (SD) for IL-16 was 102.9 (21.5) pg/ml. Levels were not affected by spontaneous vaginal delivery or gender. CONCLUSION: For the first time we have described the expected range of cord plasma IL-16 levels in healthy term infants following pre-labour and post-labour delivery.

Association of nucleated red blood cells and severity of encephalopathy in normothermic and hypothermic infants.

AIM: To determine whether hypothermia alters the discriminative ability of postnatal nucleated red blood cells (NRBCs) to distinguish between mild and moderate/severely encephalopathic infants. METHODS: A prospective cohort study recruited full-term neonates with hypoxic ischaemic encephalopathy (HIE) from 2003 to 2012 (prehypothermic and hypothermic eras). The NRBC count was analysed in the first 24 h in all infants and compared between normothermic and hypothermic cohorts. The severity of encephalopathy was categorized using both clinical Sarnat score and continuous multichannel EEG. RESULTS: Eighty-six infants with HIE were included: in the normothermic group, 19 were clinically mild, 24 moderate/severe; in the hypothermic group, 22 were mild, 21 moderate/severe encephalopathy. NRBC count discriminated between mild and moderate/severe Sarnat scores in the normothermic group (p = 0.03) but not in the hypothermic group (p = 0.9). This change was due to a decrease in NRBCs among moderately encephalopathic infants in the hypothermic cohort. CONCLUSION: Postnatal NRBCs distinguished between mild and moderate/severe encephalopathy in normothermic infants but not in infants undergoing therapeutic hypothermia. We advise caution when using postnatal blood samples to study diagnostic biomarkers for HIE without first analysing the potential impact of hypothermia upon these markers.

The use of conventional EEG for the assessment of hypoxic ischaemic encephalopathy in the newborn: a review.

Neonatal hypoxic ischaemic encephalopathy continues to be one of the leading causes of morbidity and mortality among neonates around the globe. With the advent of therapeutic hypothermia, the need to accurately classify the severity of injury in the early neonatal period is of great importance. As clinical measures cannot always accurately estimate the severity early enough for treatment to be initiated, clinicians have become more dependent on conventional and amplitude integrated EEG. Despite this, there is currently no single agreed classification scheme for the neonatal EEG in hypoxic ischaemic encephalopathy. In this review we discuss classification schemes of neonatal background EEG, published over the past 35 years, highlighting the urgent need for a universal visual analysis scheme.

Nucleated red blood cells and early EEG: predicting Sarnat stage and two year outcome.

AIMS: Hypoxic Ischaemic Encephalopathy (HIE) causes characteristic changes of the electroencephalogram (EEG), and a raised Nucleated Red Blood Cell (NRBC) count compared to controls. We wished to examine whether combining these markers could improve their ability to predict HIE severity in the first 24h. METHODS: Term infants with HIE were recruited. NRBC count and continuous multi-channel EEG were recorded within the first 24h. Neurological assessment was carried out at 24 months. A control population with NRBC counts in the first 24h was recruited. RESULTS: 44 infants with HIE and 43 control infants were recruited. Of the HIE population 39 completed a 2 year follow-up. The median NRBC count differed significantly between the controls and those with HIE (3/100 WBC [range of 0-11] vs 12.3/100 WBC [0-240]) (p<0.001). Within the HIE population the median NRBC count was significantly greater in infants with moderate/severe HIE than mild (16/100 WBC [range of 0-240] vs 8/100 WBC [1-23]) (p=0.016), and among infants with abnormal outcome compared to normal (21.3/100 WBC [1-239.8] vs 8.3/100 WBC [0-50])(p=0.03). The predictive ability of EEG changed with time post-delivery, therefore results are given at both 12 and 24h of age. At both time points the combined marker had a stronger correlation than EEG alone; with HIE severity (12h: r=0.661 vs r=0.622), (24h: r=0.645 vs r=0.598), and with outcome at 2 years (12h: r=0.756 vs r=0.652), (24h: r=0.802 vs r=0.746). CONCLUSION: Combining early EEG and NRBC count to predict HIE severity and neurological outcome, improved the predictive ability of either in isolation.

Quantitative EEG analysis in neonatal hypoxic ischaemic encephalopathy.

OBJECTIVE: To test the hypothesis that quantitative EEG (qEEG) measures are associated with a grading of HIE based on the visual interpretation of neonatal EEG (EEG/HIE). METHODS: Continuous multichannel video-EEG data were recorded for up to 72 h. One-hour EEG segments from each recording were visually analysed and graded by two electroencephalographers (EEGers) blinded to clinical data. Several qEEG measures were calculated for each EEG segment. Kruskal-Wallis testing with post hoc analysis and multiple linear regression were used to assess the hypothesis. RESULTS: Fifty-four full-term infants with HIE were studied. The relative delta power, skewness, kurtosis, amplitude, and discontinuity were significantly different across four EEG/HIE grades (p<0.05). A linear combination of these qEEG measures could predict the EEG/HIE grade assigned by the EEGers with an accuracy of 89%. CONCLUSION: Quantitative analysis of background EEG activity has shown that measures based on the amplitude, frequency content and continuity of the EEG are associated with a visual interpretation of the EEG performed by experienced EEGers. SIGNIFICANCE: Identifying qEEG measures that can separate between EEG/HIE grades is an important first step towards creating a classifier for automated detection of EEG/HIE grades.

Management options for elderly ill patients who present in the weekend.

An informal impression that there was a shortage of facilities for elderly patients who presented, with a routine illness, to a weekend duty doctor was studied by interviewing duty doctors and providers. The duty doctors stated that the major problems were the deficit in support from friends, relatives and neighbours and the lack of remuneration for the duty doctors. The doctors said that the main supports, paradoxically were friends, relatives and neighbours, and the acute medical ward. The recommended facilities included an urgent district nurse and a short-stay, assessment unit. Among providers only the medical ward and the private laboratories were willingly offering more than a minimal service.

General practice: personal view from a deputising service.

This picture of Auckland general practice was developed during 30,000 consultations which the author conducted in after hours deputising services. Most patients are satisfied with their doctor. However, some would value referral when a problem is slow to resolve or during a series of illnesses. Few such patients are advised about increasing their resistance to disease. Some terminal patients have had little discussion about what suffering not to expect, or about possible admission. Many patients do not know their diagnosis. Asthmatics often lack a peak flow meter, supply of understood drugs and a crisis plan. Some asthmatic children lack a correct diagnosis. The management of stress, if addressed, relies on drugs, reassurance and advice and, in the related matter of depression, the doses of drugs are sometimes high enough to cause side effects only.

Senile-presenile dementia: follow-up data on an effective psychotherapy-anticoagulant regimen.

This report contains follow-up data on the effects of an anticoagulant-psychotherapy regimen in presenile and senile dementia. Over a two-year period, 49 such patients who were seriously ill were treated with a Coumadin-psychotherapy regimen; 34 (69 percent) improved (4 of them dramatically) and 15 (31 percent) did not improve or became worse. The underlying pathologic processes are discussed, with the rationale for therapy.