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Volume 3, No. 2, April, 2002
CLINICAL VALUE OF PLASMA NITRIC OXIDE AND CARBON MONOXIDE IN NEONTAL HYPOXIC-ISCHEMIC ENCEPHALOPATHY.
Hesham E. Abdel-Hady1, Shadia M. El-Sallab1, Ayman M. Hammad1, Ekbal M. Abu-Hashim2, Mohamed K. Matter1
Departments of Pediatrics1 and clinical Pathology2, Mansoura Faculty of Medicine, Mansoura, Egypt.ABSTRACT
Hypoxic-ischemic encephalopathy (HIE) remains one of the most important neurologic complications in the newborn period. Nitric oxide (NO) and carbon monoxide (CO) are endogenous mediators, function as neurotransmitters and have been implicated in many organ dysfunctions. To investigate their role in the pathogenesis of neonatal HIE, we estimated the plasma NO and CO concentrations in 35 term neonates admitted to the NICU of Mansoura University Children’s Hospital with HIE and in 10 healthy controls. Plasma concentrations of NO and CO were significantly higher in infants with HIE compared to controls (72.98 ± 41.74 vs. 28.06 ± 17.40 µmol/L, p<0.001); and (87.17 ± 28.38 vs. 46.58 ± 19.68 nmol/L, p<0.001), respectively. Plasma NO and CO concentrations were higher in those with severe HIE compared to those with mild and moderate HIE (p<0.001). Moreover, plasma NO and CO concentrations were significantly higher in those with adverse short term-outcome compared to those with favorable short-term outcome (p<0.001, p=0.001, respectively). High concentrations of plasma NO (> 46.8 µmol/L) and CO (> 76.5 nmol/L) were associated with adverse short-term outcome. Plasma NO concentrations correlated positively with plasma CO (r=0.60, p <0.001) and negatively with 1 and 5-minutes Apgar scores (r=-0.70, p <0.001; r=-0.68, p <0.001, respectively). In conclusion, NO and CO play important roles in the pathogenesis of neonatal HIE. Plasma NO and CO concentrations have a prognostic value to estimate the severity and short-term outcome in neonatal HIE. The role of early intervention strategies to decrease hypoxic-ischemic brain injury by modulating NO and CO production should be addressed in future trials.
CONGENITAL ANOMALIES: INCIDENCE AND FACTORS AFFECTING IT IN CHILDREN
Meguid NA1, Gamal Ali2, Zaki M3, Khaled Taman2, Temtamy, S3, Awadalla M4, Dardir A1.
Department Of Research On Children With Special Needs, National Research Center, Institute Of Postgraduate Childhood Studies- Medical Department – Ain Shams University, Department Of Human Genetics, National Research Center Pediatrics Department – Ain Shams UniversityABSTRACT
This study included 2600 patients their age ranged from 2 days to 17 years and done in two phases (retrospective and prospective phase). They were referred to the Genetics Clinic, National Research Center, Cairo during the period January 1993 to December 2000. The main aim of our work was to classify cases of congenital anomalies whether they are isolated or multiple, to identify the genetic etiology of cases and to evaluate the genetic components versus environmental components. Also, to construct a special computer program for data collection, registry and search engine and use it to verify syndrome diagnosis and identification.
Patients were subjected to complete history, examination, and genetic investigations as metabolic screening for inborn errors, chromosomal analysis and IQ.
Patients were classified according to system involvement into 20 groups. Our results showed that genetic syndromes were the most frequent group. Genetic etiologic classification of the studied cases showed that the monogenic group of disorders was the most predominant group (53.1% of studied cases) and autosomal recessive pattern of inheritance is the most frequent pattern of inheritance (34.2%). The effect of environment was detected in 3.7% of cases emphasizing a mild impact of environmental effect in the present study.
Rate of consanguinity among the referred patients was 53.6%, and 71% of them were first cousins. Mental retardation represented 44.9% of all referred cases. Chromosomal breaks were the most predominant structural aberrations (26%) and were increased in the genetic syndromes, indicating the use of FISH to detect any cryptic aberrations.
We could conclude that, high incidence and recurrence risk of monogenic defects indicate that there is a need to develop a comprehensive preventive program. This will form the basis of a community based genetic service, which is an integral part of preventive health care.
L-carnitine Level in Preterm Infants with RDS
Ghada Farag El-Dorry*, Ashraf Nabil Eissa**, Tarrif Hamza Sallam. *** .Adel ABD El-Rahman **, Salwa Ahmed El - Arabaty*,
Institute Of Postgraduate Childhood Studies *, Pediatric Department Suez Canal University **, And Department Of Clinical Pathology Ain Shams University***.Abstract
Respiratory distress syndrome (RDS) .It occurs primarily in premature infants, due to surfactant deficiency. L-carnitine is a conditionally essential amino acid. Neonates have a limited ability to synthesize it. L-carnitine play an important role in fatty acid oxidation as it is essential for the transfer of long chain fatty acid across the mitochondrial membrane. Administration of L-carnitine stimulates the synthesis of surfactant in the alveoli of experimental animals. Administration of L-carnitine in conjunction with cortiosteroids, to mothers with eminent preterm labor, allows decreasing the required dose of steroid with a concomitant significant reduction of the incidence of RDS. The goal of this work was to study the correlation between L-catrnitine blood level in preterm infants and the development of RDS. Infants in the study were divided into two groups, Group I comprised 55 preterm with RDS, gestational age ranged from 26-36 weeks (mean +/- SD = 32.20 +/- 2.37), 23 cases were females and 32 were males . 20 cases were delivered by caesarian section (CS), and 35 cases by vaginal delivery (VD). Group II included 10 healthy preterm who served as control group, with gestational age from 30-35 weeks (mean +/- SD =33.10 +/- 1.79), 5 were females and 5 were males . 4 were delivered by (CS) while 6 were delivered vaginally .The 2 groups were comparable. Cases with neonatal asphyxia, neonatal sepsis and infants of diabetic mothers were not included in the study. L-carnitine was measured in the two groups by enzymatic UV test. RESULTS: In the RDS group, L-carnitine blood level ranged between 1.2 - 3.9 mg /L, (Mean +/- SD = 2.60 +/- 0.74). In control group: L-carnitine level ranged between 4-5.3 mg /L (mean = 4.44 +/- 0.74). The difference is statistically highly significant (p<0.001). The results showed negative correlation between the blood level of L-carnitine with birth weight and with gestational age in both groups. Sex and mode of delivery had no statistical significant effect on the blood level of L-carnitine. CONCLUSION: Preterm infants with RDS have significantly lower values of blood L-carnitine level than healthy preterm. This may indicate that carnitine has a role in the etiology of surfactant deficiency and therefore the development of RDS in preterm newborns .
ANTIOXIDANT ENZYME SYSTEM STATUS IN NECROTIZING ENTROCOLITIS
K.Taman and * Zeinab Galal
Institute of Postgraduate Childhood Studies (Medical Department) and *Faculty of Medicine (Clinical Pathology Department) - Ain Shams UniversityAbstract
Although the pathogenesis of necrotizing enterocolitis (NEC) remains uncertain, ischemia appears to be an important contributing factor and reperfusion plays a major role in ischemia related injury, and oxygen free radicals produced during reperfusion most likely contribute to the intestinal injury.
This cross sectional controlled study was conducted on 50 preterms with gestational age less than 37 weeks according to modified Dubowitz assessment. They were selected from NICU of Maternity Hospital, Ain Shams University and identified into two groups, patients group (30 preterm with NEC) and control group (20 matched stable preterm). The aim of this work was to define the status of antioxidant enzyme system, (red blood cells (RBCs) superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPX), and serum ceruloplasmin and transferrin) and correlate the results of the system to the severity of NEC.
The results of this work reveal significant lower mean arterial pH and PO2 in NEC group compared to control, with significant higher CRP, decreased platelet count and TLC in NEC group. There was highly significant decrease of mean RBCs SOD, CAT and GPX in NEC group compared to control group (P<0.001) as well as significant lower mean serum level of ceruloplasmin and transferrin (P<0.01 and <0.05 respectively). Our results showed that the more worth the stage of NEC, the more significant decrease of antioxidant enzyme system.
Therefore, we can conclude that preterm with NEC are at greater risk of oxygen free radical mediated injury and the severity of NEC correlated with the decreased level of antioxidant enzyme system. So, it is recommended to use minimum therapeutic concentration of oxygen during resuscitation. Lastly, evaluation of antioxidant therapy in preterm is a point of concern.A STUDY ON REGULATORY PEPTIDES OF THE GUT AND PSYCHOSOCIAL FACTORS IN INFANTILE COLIC
Osman G 1, El Shakankiry H 2, Zaki M 3, and Noman N 4
1,2,4 Children’s Hospital, Ain Shams Faculty of Medicine, Cairo, Egypt 3 Clinical Pathology Dep., Ain Shams Faculty of Medicine, Cairo, EgyptAbstract
The objective of this study was to assess the level of circulating gastrin, gastric inhibitory peptide (GIP), neurotensin (NT) and peptide tyrosin tyrosin (PYY), as markers of intestinal motor activity, as well as the effect of maternal anxiety, socioeconomic status and exposure to smoking as factors in full term breast fed infants presenting with infantile colic.
The study was conducted on 64 full term breast-fed infants, 3-12 weeks old, presenting with infantile colic. Twenty-six healthy infants of matched age were included as a control group. Each enrolled infant was subjected to full history taking, through questionnaire form regarding age, sex, birth order, maternal age, feeding history, description and signs of colic, exposure of the infant to passive smoking, family history of colic or allergy, family socioeconomic status, thorough clinical examination with special emphasis on anthropometric measurements, and psychological assessment of the mother using the State-trait Anxiety Inventory, as well as laboratory estimation of fasting serum gastrin and fasting plasma GIP, NT and PYY levels of colicky infants and control group.
Significant difference was found between colicky infants and the control group as regards the levels of PYY and NT. Moreover, the pattern of gastrointestinal peptides studied in the different age groups of colicky and age matched control infants was different, there was an inverse relation between the level of GIP and age of the colicky infants. Also PYY level had a tendency to decline with age in colicky infants, while a mild surge was observed in healthy infants aging >6-9weeks. As for NT and gastrin hormones levels, there was insignificant fluctuation among different age groups of colicky infants. A significant increase in the incidence of anxiety state among mothers of infants with colic was found especially at the age group > 6-9 weeks. An association between infantile colic, order of birth and passive smoking was also found whereas no association was found between infantile colic and socioeconomic status.
In view of this study, we could conclude that immaturity of gut regulatory peptides resulting in gut motility disturbance may play an important role in the pathogenesis of infantile colic. Reactional anxiety of mothers may further alter the mother-infant interaction.
Further elaboration of the phase and type of dysfunction of gastrointestinal motility in infants with colic, through manometric study of gut motility in these infants is recommended in order to help in the future development of a specific management for this world wide problem.SERUM CORTISOL LEVEL IN PREMATURE NEONATES : IS IT A PROGNOSTIC MARKER OF RESPIRATORY DISTRESS SYNDROME ?
Nagwa A. El-Shafie; Mohammed M. Gaafar; Abdel Razek M. Elshiekh;
Refaat A. Sadek* and Ayman A. El-Badry
Pediatric and Microbiology* Departments, Faculty of Medicine, Zagazig UniversityABSTRACT
Objective : To evaluate serum cortisol level in premature neonates and its relation to occurrence, severity and prognosis of respiratory distress syndrome (RDS). Study design : This study was carried out on 90 premature neonates. Thirty out of them had RDS (RDS group), 30 had respiratory distress due to causes other than RDS (NRDS group) and 30 were apparently healthy (control group). Premature neonates of mothers who had received antenatal corticosteroids were ruled out. All premature neonates were subjected to full clinical history, thorough clinical examination, routine investigations and estimation of morning serum cortisol level within the first 6 hours of life as well as on the 3rd day of life.
Results : Serum cortisol level during the first 6 hours of life was significantly lower in RDS group (Mean + SD 4.3 + 1.9 µg/dl) than NRDS (Mean + SD 8.7 + 3.6 µg/dl) and control group (Mean + SD 9.5 + 2.8 µg/dl) P<0.001. Within RDS group, serum cortisol level showed a significant increase on 3rd day of life (being 7.7 + 2.04 µg/dl during 3rd day versus 4.3 + 1.9 µg/dl during 1st day P<0.001). This was not the case among the other 2 groups. Also among RDS group, serum cortisol levels were significantly more lower in male prematures than females (P<0.05), twin than single (P<0.01), prematures with body weight <1.5 kg than with those with body weight >1.5 kg (P<0.01) and preterm newborns delivered by C.S than those delivered by normal vaginal delivery (P<0.006). Also it was found that there were significant lower cortisol levels, in neonates with severe RDS than those with mild RDS as well as significant lower levels in those who died than survived neonates (Mean + SD 2.23 + 0.8 µg/dl versus 5.65 + 0.92 µg/dl respectively, P<0.001).
Conclusion : Serum cortisol level during the first 6 hours of life of premature neonates may be used not only as a predictor but also as a prognostic marker of RDS. We recommend further studies to re-evaluate the use of postnatal corticosteroids with special interest to inhaled steroids.
Neutrophil CD45+RA and CD45+RO isoforms expression: a sensitive early diagnostic marker for early onset neonatal sepsis
Sahar M. Hassanein, Wael Abbas*, Eman A Omar**, Dalia Swefi**
Departments of Pediatrics, Neonatal Intensive Care Unit*, Clinical Pathology**, Ain Shams University, Cairo, EgyptAbstract
Background: Diagnosis of perinatal infection in the newborn is difficult; there may be few clinical signs and current tests are slow or non-specific. Early confirmation of sepsis is mandated to give appropriate treatment or to discontinue antibiotics if infection is excluded. This stimulated us to study the changed expression of T-lymphocyte surface activation markers CD45+RA and CD45+RO, as a rapid laboratory test for detection of infection in neonates of different gestational age, comparing them to healthy newborns and adults.
Design/ Methods: A prospective controlled study was conducted on 51 neonates; (31 neonates with suspected sepsis and 20 healthy neonates. Their gestational age ranged between (32 – 40 weeks), with a mean of (36 + 4.2 weeks). They were chosen from the newborn unit of Maternity Hospital, Ain Shams University. They were compared also to 20 healthy adults. All were subjected to full history taking and thorough clinical examination, Complete blood count, C-reactive protein, Blood and CSF cultures, and Flow cytomertic T-lymphocyte surface activation markers (CD45+RA and CD45+RO) assessment.
Results: Out of the 31 neonates with suspected sepsis, in 21 neonates sepsis was confirmed by blood culture, and 10 sepsis was excluded by negative cultures(they had other diseases as respiratory distress syndrome, maternal fever, and premature rupture of membranes. Healthy neonates have statistically significant lower % expression of CD45+RO (mean + SD= 15.2 + 5.8 %, 95% confidence interval (CI) of 11.49% and 18.9%), compared to healthy adults (mean 51.9 + 14.6%, 95% CI 38.4%, 65.4%), t=7.8, p<0.0001. CD45+RA/RO ratio was significantly higher in healthy neonates (mean 4.7 + 3.6, 95%, CI 2.44%, 7.03%), t= 2.3, p<0.05. Neonates with confirmed sepsis have significantly higher CD45+RA % expression (mean 83.3 + 12.4, 95% CI 77.7%, 89.3%), compared to healthy neonates (mean 58.3 + 20, 95% CI 45.49, 71.1%, t=4.43, p<0.0001. Also, higher than neonates with no infection (mean 53.2 + 26.9, 95% confidence interval 33.9%, 72.5%, t=4.3, p<0.0001. There is no difference in CD45+RA and RO % expression between neonates with no infection, and healthy neonates. Septic full term neonates (n=9) have statistically significant higher CRP (17.5 + 29.5 mg%), TLC (15.2 + 6.9 x 109/L), basophils (35 + 59 x 109/L), and % expression of CD45+RO (25.8 + 15.4 %), compared to septic preterm neonates CRP (9 + 16.2 mg%, f=3.3, p <0.05), TLC (9.1 + 6 x 109/L, t=2.59, p< 0.01), basophils (25.5 + 117 x 109/L, f= 3.86, p <0.05), and CD45+RO (13.94 + 11.15 %, t=2.36, p<0.05). Septic full term neonates have statistically significant lower mean eosinophils (10 + 40 X 109/L), compared to septic preterm neonates eosinophils (110 + 140 x 109/L, F= 28.7, P <0.001). Neonates with confirmed sepsis have statistically significant lower CRP (10.69 +16.5 mg%), compared to neonates with no infection (18 +35.7 mg%), f=4.48, p < 0.05. Neonates with confirmed sepsis have significantly higher eosinophils (60.48 + 134 x 109/ L), and % expression of CD45+RA (83.3 + 12.45%), compared to neonates with no infection eosinophils (18 + 23 X 109/ L, f=14.4, p< 0.001), and % expression of CD45+RA (53.28 + 26.9%, t=4.1, p< 0.001). Non-survivor septic neonates have statistically significant lower % expression of CD45+RO (15.4 + 14.6%), compared to survivors of neonatal sepsis % expression of CD45+RO (23.69 + 16.9%, t=2.73, p < 0.01). Non-survivor septic neonates have statistically significant higher mean CRP (19.69 +30.5 mg%), band cells (30.5 + 105 x 109/ L, eosinophils (63.3 + 134 x 109/ L), % expression of CD45+RA (86.5 + 14.45%), compared to neonates survived from neonatal sepsis CRP (8.7+17.3 mg%, f=4.48, p < 0.05), band cells (0 x 109/ L, f= 2.81, p <0.001), eosinophils (12.6 + 35x 109/ L, f=18.3, p< 0.001), % expression of CD45+RA (66.49 + 23.8 %, t=2.8, p< 0.01). Sensitivity of % expression of CD45+RA (90.4%), specificity (80%), positive predictive value (90.4%), and negative predictive value (80%) for confirmation of sepsis in neonates with suspected sepsis. % expression of CD45+RO carries sensitivity of (66.6%), specificity (80%), positive predictive value (87.4%), and negative predictive value (53.3%) for confirmation of sepsis. At a cutoff values of 72% for CD45RA, and 19% for CD45RO.
Conclusion: While, % expression of CD45+RA is sensitive and specific for early diagnosis of sepsis in the neonates with suspected sepsis, at admission before the result of blood culture. % expression of CD45+RO is only specific for early diagnosis of sepsis but it is not sensitive, it is good if high but could not be used to exclude sepsis. Presence of high % expression of CD45+RA together with low CD45+RO, in neonates with confirmed sepsis carries a poor outcome .
TWO-STAGE ONE VOLUME EXCHANGE TRANSFUSION VERSUS THE TRADITIONAL EXCHANGE TRANSFUSION IN THE MANAGEMENT OF NEONATAL HYPERBILIRUBINEMIA
Wael Abbas*, Nayera Ismail** and Sahar Hassanein***.
* Neonatal ICU, Maternity Hospital, Ain Shams University.** Institute of Postgraduate Childhood Studies.
*** Pediatric Department, Ain Shams UniversityAbstract
Objective: Evaluation of a new clinical trial of two-stage (each stage one volume) exchange transfusion aiming to decrease the rebound of serum bilirubin level with subsequent reduction of the need for repeated exchange transfusions.
Patients and Methods: The present study was carried out in the Neonatal Intensive Care Unit, Ain Shams Maternity Hospital from April, 2000 to March, 2002. The study included 104 neonates with hyperbilirubinemia needing exchange transfusion. They were divided randomly into two equal groups, each group comprised 52 neonates. Exchange transfusion by the suggested method was performed for the neonates of study group I and the traditional exchange transfusion was performed to the neonates of study group II .
Results: The present study revealed a very highly statistically significant lower rebound serum bilirubin level in the study group I compared to the study group II (15.7?1.1 mg/dL & 17.3?1.7 mg/dL respectively) P<0.001. Also the percentage of neonates needing repeated exchange transfusions was significantly lower in group I compared to group II (13.5% & 32.7% respectively) P<0.05. No significant difference was found between the two groups as regards the morbidity (11.5% & 9.6% respectively) and the mortality (1.9% for both groups)
Conclusion: So we can conclude that this new method of two-stage exchange transfusion proved to be more effective than the traditional method in reducing rebound serum bilirubin level and in decreasing the need for repeated exchange transfusions.Rapid detection of neonatal sepsis using polymerase chain reaction
Suzan Samir. Hanaa Fahmi. Emad Ismail. Tarek Mansour.
Pediatric , Clinical pathology , Biochemistry departments - Suez Canal University.
Abstract
Background and aim : Clinical diagnosis of sepsis in newborn infants is not easy and there is no laboratory test with 100 % specificity and sensitivity, with the exception of blood culture. The results of which are not available for at least 48 - 72 h. . Polymeras chain reaction has been used to diagnose different bacterial , viral and protozoal infections , and the possibility of amplifying the DNA region common to all bacteria could represent an optimal method for diagnosis of sepsis. This study was designed , to compare the utility of a 16S r RNA PCR assay to that of the blood culture for detecting early bactermia in blood obtained from neonates suspected of having bacterial sepsis.
Subject and methods : Twenty neonates at risk for early-onset sepsis under went complete blood picture, C. reactive protein, blood culture, and 16S r RNA PCR. Ten normal neonates as control group.
Results : There were statistically significant differences between the two groups regarding to total WBCs, neutrophilic count and CRP. The correlation analysis between PCR and blood culture revealed high level of agreement between the two methodologies. The posilivity rates for blood specimens analyzed by culture and PCR were 4 (20 %) and 5 (25 %) positive specimens from a total 20 tested, respectively.
Conclusions : Rapid detection of neonatal sepsis is feasible using 16S rRNA PCR ussay. This test had an accurate result in ruling out the diagnosis of bacterial sepsis in the uninfected neonates admitted to NICU in short time (few hours) .
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