Serum cytokines MCP-1 and GCS-F as potential biomarkers in pediatric inflammatory bowel disease

BACKGROUND

Inflammatory bowel diseases (IBDs) with the subtypes ulcerative colitis (UC) and Crohn disease (CD), are chronic autoimmune inflammatory disorders of the gastrointestinal tract. Cytokines are associated with the development and progression in pediatric IBD. We measured cytokine levels in pediatric IBD patients to assess their potential function as biomarkers in disease assessment.

METHOD

In this prospective cohort study, we enrolled 33 children with IBD. All patients were in stable remission for 3 months on enrollment. Patients who developed a relapse within six months after enrollment were classified as relapsers. Blood sampling was performed at enrolment and for relapsers in relapse and post-relapse. Serum concentrations of 14 cytokines, chemokines and growth factors (IL-1α, IL-1β, IL-6, IL-12p40, IP-10, TNF-α, IFN-γ, IL-10, IL-8, MIP-1α, MCP-1, MCP-3, G-CSF, GM-CSF) were measured simultaneously using multiplex bead-based sandwich immunoassay on Luminex 100 system.

RESULTS

MCP-1 was significantly higher in CD patients compared to UC patients at each disease stage: stable remission (P<0.048), unstable remission (P<0.013), relapse (P<0.026) and post-relapse (P<0.024). G-CSF was significantly increased in UC patients developing a relapse and in post-relapse stage compared to UC patients in remission (P<0.02 and p<0.03, respectively).

CONCLUSION

MCP-1 showed potential as a diagnostic biomarker in CD patients independent of disease activity as it was able to discriminate between subtypes of pediatric IBD. In UC patients, G-CSF was significantly elevated in relapsers indicating its use and role as a potential prognostic biomarker.

Controlled Prospective Study on the Use of Systematic Simulator-Based Training with a Virtual, Moving Fetus for Learning Second-Trimester Scan: FESIM III

OBJECTIVES

To analyze the feasibility of structured ultrasound simulation training (SIM-UT) in teaching second-trimester ultrasound screening using a high-end simulator with a randomly moving fetus.

METHODS

This was a prospective, controlled trial. A trial group of 11 medical students with minimal obstetric ultrasound experience underwent 12 hours of structured SIM-UT in individual hands-on sessions within 6 weeks. Learning progress was assessed with standardized tests. Performance after 2, 4, and 6 weeks of SIM-UT was compared with two reference groups ((A) Ob/Gyn residents and consultants, and (B) highly skilled DEGUM experts). Participants were asked to acquire 23 2nd trimester planes according to ISUOG guidelines in a realistic simulation B-mode with a randomly moving fetus as quickly as possible within a 30-minute time frame. All tests were analyzed regarding the rate of appropriately obtained images and the total time to completion (TTC).

RESULTS

During the study, novices were able to improve their ultrasound skills significantly, reaching the physician level of the reference group (A) after 8 hours of training. After 12 hours of SIM-UT, the trial group performed significantly faster than the physician group (TTC: 621±189 vs. 1036±389 sec., p=0.011). Novices obtained 20 out of 23 2nd trimester standard planes without a significant time difference when compared to experts. TTC of the DEGUM reference group remained significantly faster (p<0.001) though.

CONCLUSION

SIM-UT on a simulator with a virtual, randomly moving fetus is highly effective. Novices can obtain standard plane acquisition skills close to expert level within 12 hours of self-training.

Controlled prospective study on ultrasound simulation training in fetal echocardiography: FESIM II

PURPOSE

To analyze the learning curves of ultrasound novices in fetal echocardiography during structured simulation-based ultrasound training (SIM-UT) including a virtual, randomly moving fetus.

METHODS

11 medical students with minimal (< 10 h) prior obstetric ultrasound experience underwent 12 h of structured fetal echocardiography SIM-UT in individual hands-on sessions during a 6-week training program. Their learning progress was assessed with standardized tests after 2, 4, and 6 weeks of SIM-UT. Participants were asked to obtain 11 fetal echocardiography standard planes (in accordance with ISUOG and AHA guidelines) as quickly as possible. All tests were carried out under real life, examination-like conditions on a healthy, randomly moving fetus. Subsequently, we analyzed the rate of correctly obtained images and the total time to completion (TTC). As reference groups, 10 Ob/Gyn physicians (median of 750 previously performed Ob/Gyn scans) and 10 fetal echocardiography experts (median of 15,000 previously performed Ob/Gyn scans) were examined with the same standardized tests.

RESULTS

The students showed a consistent and steady improvement of their ultrasound performance during the training program. After 2 weeks, they were able to obtain > 95% of the standard planes correctly. After 6 weeks, they were significantly faster than the physician group (p < 0.001) and no longer significantly slower than the expert group (p = 0.944).

CONCLUSION

SIM-UT is highly effective to learn fetal echocardiography. Regarding the acquisition of the AHA/ISUOG fetal echocardiography standard planes, the students were able to reach the same skill level as the expert group within 6 weeks.

Serum vascular endothelial growth factor is a potential biomarker for acute mountain sickness

Background: Acute mountain sickness (AMS) is the most common disease caused by hypobaric hypoxia (HH) in high-altitude (HA) associated with high mortality when progressing to high-altitude pulmonary edema (HAPE) and/or high-altitude cerebral edema (HACE). There is evidence for a role of pro- and anti-inflammatory cytokines in development of AMS, but biological pathways and molecular mechanisms underlying AMS remain elusive. We aimed to measure changes in blood cytokine levels and their possible association with the development of AMS.

Method: 15 healthy mountaineers were included into this prospective clinical trial. All participants underwent baseline normoxic testing with venous EDTA blood sampling at the Bangor University in United Kingdom (69 m). The participants started from Beni at an altitude of 869 m and trekked same routes in four groups the Dhaulagiri circuit in the Nepali Himalaya. Trekking a 14-day route, the mountaineers reached the final HA of 5,050 m at the Hidden Valley Base Camp (HVBC). Venous EDTA blood sampling was performed after active ascent to HA the following morning after arrival at 5,050 m (HVBC). A panel of 21 cytokines, chemokines and growth factors were assessed using Luminex system (IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p40, IL-1ra, sIL-2Rα, IFN-γ, TNF-α, MCP-1, MIP-1α, MIP-1β, IP-10, G-CSF, GM-CSF, EGF, FGF-2, VEGF, and TGF-β1).

Results: There was a significant main effect for the gradual ascent from sea-level (SL) to HA on nearly all cytokines. Serum levels for TNF-α, sIL-2Rα, G-CSF, VEGF, EGF, TGF-β1, IL-8, MCP-1, MIP-1β, and IP-10 were significantly increased at HA compared to SL, whereas levels for IFN-γ and MIP-1α were significantly decreased. Serum VEGF was higher in AMS susceptible versus AMS resistant subjects (p &lt; 0.027, main effect of AMS) and increased after ascent to HA in both AMS groups (p &lt; 0.011, main effect of HA). Serum VEGF increased more from SL values in the AMS susceptible group than in the AMS resistant group (p &lt; 0.049, interaction effect).

Conclusion: Cytokine concentrations are significantly altered in HA. Within short interval after ascent, cytokine concentrations in HH normalize to values at SL. VEGF is significantly increased in mountaineers suffering from AMS, indicating its potential role as a biomarker for AMS.

Patterns of volatile organic compounds in excrements of preterm neonates

BACKGROUND

As neonates are susceptible for many diseases, establishing noninvasive diagnostic methods is desirable. We hypothesized that volatile organic compounds (VOCs) could be successfully measured in diaper samples.

METHODS

We performed a feasibility study to investigate whether ambient air-independent headspace measurements of the VOC profiles of diapers from premature infants can be conducted using ion mobility spectrometer coupled with multi-capillary columns (B & S Analytik GmbH).

RESULTS

We analysed 39 diapers filled with stool (n = 10) or urine (n = 20) respectively, using empty diapers as a control (n = 9). A total of 158 different VOCs were identified, and we classified the content of the diapers (urine or stool) according to their VOC profiles with a significance level of p < 0.05.

CONCLUSIONS

We have developed a novel method to study headspace VOC profiles of biosamples using ion mobility spectrometry coupled with multi-capillary columns. Using this method, we have characterized the VOC profiles of stool and urine of preterm neonates. Future studies are warranted to characterize specific VOC profiles in infections and other diseases of the preterm neonate, thus establishing quick and noninvasive diagnostics in the routine care of the highly vulnerable preterm and term neonates.

Is There a Role for Cerebral Ultrasonography in Near-Term/Term Neonates Following Assisted Vaginal Delivery? A Prospective, Single-Center Study

AIM

 To evaluate the role of cerebral ultrasonography studies (CUSS) in detecting intracerebral and cranial pathologies (hemorrhages, ischemia, skull fractures) in near-term and term neonates following assisted vaginal delivery.

PATIENTS AND METHODS

 Prospective single-center study (11/2017-11/2018) at the University Children's Hospital of Saarland, Homburg, Germany including newborns with a gestational age ≥ 36 weeks born by assisted vaginal delivery. In all newborns, a standardized CUSS was performed within the first three days of life prior to discharge.

RESULTS

 200 neonates (43.0 % female, 57.0 % male; gestational age 39.6 ± 1.3 weeks) were included in this study (birth weight 3345.6 ± 450.6 g, body length 51.7 ± 2.5 cm, head circumference 35.0 ± 1.5 cm). 67 (33.5 %) neonates had minor external injuries of the scalp. 5 children showed clinical neurologic abnormalities: 4 (2.0 %) seizures and 1 facial palsy (0.5 %). In 34 (17.0 %) patients, minor incidental intracranial abnormalities unrelated to mode of delivery were detected on CUSS. No intracerebral, cranial pathologies or skull fractures were seen on routine CUSS.

CONCLUSION

 Routine CUSS in newborns after assisted vaginal delivery did not yield clinically relevant results in our cohort. Clinical observation and selective CUSS in symptomatic newborns might be more efficient than routine CUSS.

Genetic Association With Pseudomonas aeruginosa Acquisition in Cystic Fibrosis: Influence of Surfactant Protein D and Mannose-Binding Lectin

Background: Pseudomonas aeruginosa (PA) infection in cystic fibrosis (CF) is associated with poor prognosis. Surfactant protein-D (SFTPD) and mannose-binding lectin (MBL) play a critical role in innate immunity and response to bacterial infections. We investigated serum levels and genetic variants of SFTPD and MBL in CF patients. Method: Thirty-five Caucasian patients homozygous for ΔF508del were genotyped for functional relevant polymorphisms within MBL2 (promoter-221 Y/X, codons 52, 54, and 57) and SFTPD genes (Met11Thr, Ala160Thr, and Ser270Thr). Serum levels of collectins, clinical characteristics, and PA status were correlated with genetic data. Results: Patients age, gender, and PA status did not affect MBL and SFTPD serum concentrations. MBL concentrations were correlated with MBL haplotypes. Patients with chronic Pseudomonas aeroginosa infection (PAC) and MBL insufficiency had a shorter interval between first PA infection and onset of PAC (0.01 vs. 4.6 years, p < 0.04) as well as a lower median age at transition to PAC (9.8 vs. 16.4 years, p < 0.03) compared to MBL sufficient patients with PAC. SFTPD serum level and FEV1% (Spearman r = -0.41, p < 0.03) showed a negative correlation irrespective of PA infection status. The hazard ratio to PA acquisition was increased in carriers of the SFTPD haplotype 11Thr-160Ala-270Ser compared to carriers of the common 11Met-160Thr-270Ser haplotype [HR 3.0 (95%CI: 1.1-8.6), p < 0.04]. Conclusion: MBL insufficiency leads to a shorter interval between first PA infection and onset of chronic infection. Susceptibility to PA acquisition is associated with SFTPD genetic variants with 11Thr-160Ala-270Ser as risk haplotype for early PA infection. This may be due to presence of threonine associated with oligomeric structure of SFTPD and binding ability to bacteria.

TEACHING MUST GO ON: flexibility and advantages of peer assisted learning during the COVID-19 pandemic for undergraduate medical ultrasound education - perspective from the "sonoBYstudents" ultrasound group

Background: Facing the global COVID-19 pandemic University teaching has been digitalized and German medical faculties took great effort to offer curricular contents online as they agreed that semesters during pandemic should not be suspended. Skill training is an essential part of medical education and cannot be fully digitalized nor should it be omitted. The pandemic demonstrates that skills like ultrasound are essential when treating critical ill patients. Medical faculties use peer assisted learning (PAL) concepts to teach skills, like ultrasound through specially trained student tutors. Aim: Here, we would like to share our experiences and elaborate how ultrasound teaching can be safely performed during the pandemic with an emphasis on adjustment of an existing PAL teaching concept. Method: At the hospital of Saarland University, we implemented a PAL teaching concept for abdominal, including emergency, ultrasound, and echocardiography, called "sonoBYstudents" to teach sonography to undergraduate medical students. Students are generally taught in small groups of 5 people in 90min sessions over a time of 8 weeks with an objective structured clinical exam (OSCE) at the end of the course program. Each semester nearly 50 students are taught in abdominal and emergency ultrasound and 30 students in echocardiography. Over five years, more than 600 students have been taught with at least 30 students being trained as student tutors. Given the pandemic, course size, course interval and total course time and total course time were adapted to the hygienic precautions. Results: 45 and 30 students were taught in abdominal ultrasound and echocardiography respectively achieving their learning goals measured via OSCE at the end of the courses. OSCE results were the same when compared to previous semesters. Conclusion: PAL as a teaching concept lives out of sustained educational strategies like practical and didactical trainings and an ongoing recruitment of new student tutors. Suspending PAL and its skill teaching would require starting from the beginning which is a time and cost consuming process. With sonoBYstudents we were able to demonstrate that an existing PAL concept can, with some effort, be adjusted to changing teaching circumstances. Apart from this ultrasound is a non-omittable part of medical skill training with easily appliable hygienic precautions during teaching sessions.

Neonatal Morbidity and Mortality in Advanced Aged Mothers-Maternal Age Is Not an Independent Risk Factor for Infants Born Very Preterm

Background: As childbearing is postponed in developed countries, maternal age (MA) has increased over decades with an increasing number of pregnancies between age 35-39 and beyond. The aim of the study was to determine the influence of advanced (AMA) and very advanced maternal age (vAMA) on morbidity and mortality of very preterm (VPT) infants. Methods: This was a population-based cohort study including infants from the "Effective Perinatal Intensive Care in Europe" (EPICE) cohort. The EPICE database contains data of 10329 VPT infants of 8,928 mothers, including stillbirths and terminations of pregnancy. Births occurred in 19 regions in 11 European countries. The study included 7,607 live born infants without severe congenital anomalies. The principal exposure variable was MA at delivery. Infants were divided into three groups [reference 18-34 years, AMA 35-39 years and very(v) AMA ≥40 years]. Infant mortality was defined as in-hospital death before discharge home or into long-term pediatric care. The secondary outcome included a composite of mortality and/or any one of the following major neonatal morbidities: (1) moderate-to-severe bronchopulmonary dysplasia; (2) severe brain injury defined as intraventricular hemorrhage and/or cystic periventricular leukomalacia; (3) severe retinopathy of prematurity; and (4) severe necrotizing enterocolitis. Results: There was no significant difference between MA groups regarding the use of surfactant therapy, postnatal corticosteroids, rate of neonatal sepsis or PDA that needed pharmacological or surgical intervention. Infants of AMA/vAMA mothers required significantly less mechanical ventilation during NICU stay than infants born to non-AMA mothers, but there was no significant difference in length of mechanical ventilation and after stratification by gestational age group. Adverse neonatal outcomes in VPT infants born to AMA/vAMA mothers did not differ from infants born to mothers below the age of 35. Maternal age showed no influence on mortality in live-born VPT infants. Conclusion: Although AMA/vAMA mothers encountered greater pregnancy risk, the mortality and morbidity of VPT infants was independent of maternal age.

Novel modified Peyton's approach for knowledge retention on newborn life support training in medical students

AIM

We sought to improve retention of neonatal resuscitation skills by modifying step 3 through additional functional verbalisation in Peyton's four-step approach (P4S).

METHODS

Newborn life support (NLS) training was performed in a simulation-based setting. In contrast to the traditional approach, students taught with the modified approach were requested to explain every step of their performance in Peyton's step 3. A total of 123 students were allocated into both experimental groups. Students were then assessed by megacode on day four (initial assessment) and 6 months (follow-up assessment).

RESULTS

Both groups showed similar scorings in the initial, follow-up assessment and in mean change. On initial megacode, time to start with initial inflation and post-resuscitation care was significantly faster in the control group. All showed a significant loss of performance irrespective of modification in step 3 in the follow-up assessment. Only time until start with post-resuscitation care shows a significant group difference in mean change between initial and follow-up with increasing time in the control and decreasing time span in intervention group.

CONCLUSION

Both methods showed equal levels of knowledge acquisition and long-term decline in NLS performances. Verbalisation in step 3 influenced speed of applied NLS performance.

Plasma levels of osteopontin from birth to adulthood

AIM

Osteopontin (OPN) has been investigated as a biomarker for cancer and nonmalignant diseases during the last decades. Data about OPN as a potential biomarker in childhood diseases are still sparse, and reference values are not available in children. We aimed to establish reference values for children from birth to young adulthood and evaluate whether there are age-, gender-, and weight-specific differences.

METHOD

Umbilical cord blood and blood plasma samples of 117 children were collected in the Children's Hospital of Saarland University in Homburg/Saar. OPN levels were measured by ELISA, and statistical analysis was performed using SPSS software.

RESULTS

Neonates, infants, toddlers, young children, adolescents, and adults were divided into the following six age groups: newborns (birth), infancy and toddlers (0-24 months), early childhood (3-6 years), middle childhood (7-11 years), adolescence (12-18 years), and adults (> 18 years). Highest blood OPN levels were found in the group of 0-1 years of age. OPN blood levels declined significantly with age (Spearman r = -0.874; P < 0.001).

CONCLUSION

Our work is the first prospective and systematic study analyzing OPN cord blood and blood plasma levels in children of all ages. It is the first study yielding reference values for different age groups from birth to young adulthood. Our data give insight on how OPN in umbilical cord blood and OPN in blood plasma are physiologically influenced during childhood development and growth with high OPN levels after birth and a constant age-related decline until the age of 14, when OPN levels reach similar values to those measured in adults.

Long-Term Knowledge Retention after Peer-Assisted Abdominal Ultrasound Teaching: Is PAL a Successful Model for Achieving Knowledge Retention?

BACKGROUND

 Diagnostic ultrasound has a crucial importance in clinical settings, especially in intensive care medicine where bedside ultrasound has become indispensable. Medical students as well as residents therefore have a strong interest in learning this useful skill. Since staff resources are limited, more and more universities are using student tutors in a peer-assisted learning concept (PAL) to teach medical students early in their training. To date, there is very sparse data about knowledge retention after peer-assisted teaching. The aim of this study was to evaluate whether PAL is a suitable method for teaching complex skills like abdominal ultrasound and to evaluate whether students do achieve adequate long-term knowledge retention after peer-assisted teaching.

METHOD

 A total of 40 volunteer 3^rd to 5^th year students were randomly assigned to a basic abdominal ultrasound course in small training groups of 5 persons each. Participants were evaluated using a pre-post-test design by a validated objective structured clinical examination (OSCE) before and immediately after the course. To measure the retention of knowledge, 15 former participants were randomly selected to repeat the OSCE assessment after one year.

RESULTS

 All groups showed a significant improvement in practical skills and knowledge gain after the training with mean values of 13.1 for pre-test compared to 83.5 (maximum 100 points) for post-test (p < 0.001). The overall score achieved after one year was 78.7 and did not significantly differ from the post-test result.

CONCLUSION

 PAL is effective for teaching abdominal ultrasound. Students were able to accomplish a satisfactory level of ultrasound skills. We further demonstrated that PAL can assure long-term knowledge retention.

Bedside Measurement of Volatile Organic Compounds in the Atmosphere of Neonatal Incubators Using Ion Mobility Spectrometry

Background: Early and non-invasive diagnosis of common diseases is of great importance in the care of preterm infants. We hypothesized that volatile organic compounds (VOC) can be successfully measured in the neonatal incubator atmosphere. Methods: This is a feasibility study to investigate whether the discrimination of occupied and unoccupied neonatal incubators is possible by bedside measurement of volatile organic compounds (VOCs) on the neonatal intensive care unit. VOC profiles were measured in the incubator air using ion mobility spectrometry coupled to multi-capillary columns (BreathDiscovery B&S Analytik GmbH, Dortmund, Germany). Results: Seventeen incubators occupied by preterm infants (50 measurements) and nine unoccupied neonatal incubators were sampled, using 37 room air measurements as controls. Three VOC signals that allow the discrimination between occupied and unoccupied incubators were identified. The best discrimination was reached by peak P20 exhibiting a sensitivity, specificity, positive predictive value and negative predictive value of 94.0, 88.9, 97.3, and 72.3%, respectively. Use of a decision tree improved these values to 100.0, 88.9, 98.0, and 100.0%, respectively. Discussion: A bedside method that allows the characterization of VOC profiles in the neonatal incubator atmosphere using ion mobility spectrometry was established. Occupied and unoccupied incubators could be discriminated by characterizing VOC profiles. This technique has the potential to yield results within minutes. Thus, future studies are recommended to test the hypothesis that VOCs within neonatal incubators are useful biomarkers for non-invasive diagnostics in preterm neonates.

Deutschlandweites Vergiftungsspektrum im Kindes- und Jugendalter

Hintergrund Vergiftungen verursachen bei Kindern den Großteil der Notfalleinsätze in Deutschland, die durch präventive Maßnahmen verhindert oder gemildert werden könnten. Daher ist für den Pädiater das Wissen um häufige Intoxikationen essentiell. Die vorliegende Arbeit zeigt allgemeine und epidemiologische Daten zu Vergiftungen sowie einen Überblick über die häufigsten einzelnen Noxen und -kategorien im Kindes- und Jugendalter.

Methoden Retrospektiv wurden Vergiftungsfälle bei Kindern und Jugendlichen aus 6 deutschen Giftnotrufzentralen (2012–2016 und 2002–2016) ausgewertet. Kategorielle Daten sind als Mittelwerte±Standardabweichung, häufigste Noxen nach Punkten angegeben.

Ergebnisse Die Anruferzahl insbesondere der Laien nahm ab 2002 deutlich zu. Zwei Drittel der Fälle traten bei Klein- und Vorschulkindern auf, häufiger bei Jungen (50%) als bei Mädchen (44%), bei Jugendlichen überwiegen weibliche Patienten (>60%). Im Alter<14 Jahre sind Intoxikationen auf Unfälle in Haushalt, Kindertagespflege oder Schulen zurückzuführen (>95%), bei Jugendlichen treten suizidale Intoxikationen und Abusus (13%) in den Vordergrund. 90% der Fälle verlaufen asymptomatisch oder leicht, wobei der Anteil der klinisch symptomatischen Fälle mit dem Alter zunimmt (Jugendliche 13% vs. Säuglinge 1%). Vergiftungen mit Medikamenten stellen bei Jugendlichen die häufigste Gruppe dar, bei Kindern tensidhaltige Reinigungsmittel und Kosmetika, Sanitärreinigungsmittel, Tabak, Knicklicht und Entkalker in Lösung.

Diskussion und Schlussfolgerung Stetig steigende Anruferzahlen von Fachpersonal und Laien veranschaulichen die Bedeutung der Giftnotrufzentralen. Obwohl Vergiftungen bei Kindern und Jugendlichen meist asymptomatisch oder mit leichten Symptomen verlaufen, darf die Relevanz präventiver Maßnahmen v. a. bei Kindern<7 Jahren nicht unterschätzt werden.

Vitamin A Supplementation by Endotracheal Application of a Nano-encapsulated Preparation Is Feasible in Ventilated Preterm Lambs

BACKGROUND

Vitamin A (VA) is crucial for lung growth and development. In premature infants, inadequate VA levels are associated with an increased risk of bronchopulmonary dysplasia (BPD). Intramuscular VA supplementation has been shown to decrease the incidence of BPD, but is not widely used in the clinical setting due to concerns about feasibility and pain. We studied VA kinetics, distribution, and the induction of early genetic expression of retinoid homeostatic genes in the lung after endotracheal and intravenous application in a preterm lamb model.

METHODS

Lambs were delivered prematurely after 85% of gestation, intubated, and ventilated for 3 hours. The animals were randomized to receive no VA ("control"), a bolus of VA intravenously ("i.v."), or VA endotracheally directly after administration of surfactant ("e.t.").

RESULTS

Animals treated with VA endotracheally directly after administration of surfactant showed significant increases of VA in serum and lung compared to controls. Animals treated with a bolus of VA intravenously showed significant increases of VA in serum, lung, and liver; however, peak serum concentrations and mRNA levels of homeostatic genes raised concerns about toxicity in this group.

CONCLUSIONS

Endotracheal VA supplementation in preterm lambs is feasible and might offer advantages in comparison to i.v. Further studies are warranted to explore biological effects in the context of BPD.

Are Cytokines Useful Biomarkers to Determine Disease Severity in Neonates with Congenital Diaphragmatic Hernia?

Background This study investigates plasma cytokine levels in neonates with the more common left-sided congenital diaphragmatic hernia (CDH) and correlates them with severity of disease indicated by position of the liver. An intrathoracic part of liver is associated with higher need for extracorporeal membrane oxygenation (ECMO) and higher risk for chronic lung disease (CLD). Methods A total of 28 newborns with CDH were subdivided by their liver position in partially intrathoracic (n = 16) and only abdominal (n = 12) position. Only liver-up patients went on ECMO (n = 9) and developed severe/moderate CLD (n = 5). Controls consisted of 19 healthy matched-term neonates. Laboratory samples were extracted from umbilical cord blood and during the neonatal period. Results In umbilical cord blood, CDH patients showed decreased IL-8 values while MIP-1a (macrophage inflammatory protein-1) values were increased. Concerning the severity of CDH, we measured significantly higher levels of TGFb2 in CDH patients with liver-up than in liver-down cases and controls (p < 0.006). During the neonatal period, the concentration of IL-10 and vascular endothelial growth factor (VEGF) showed significant deviations in the liver-up group with need for ECMO (p < 0.009). Conclusion In neonates with CDH, plasma cytokine levels are already altered in utero. TGFb2 may work as an early predictor for severity of disease. VEGF and IL-10 could serve as potential biomarkers predicting the course of disease in CDH.

Influence of prenatal hypoxia and postnatal hyperoxia on morphologic lung maturation in mice

Background

Oxygen supply as a lifesaving intervention is frequently used to treat preterm infants suffering additionally from possible prenatal or perinatal pathogen features. The impact of oxygen and/or physical lung injury may influence the morphological lung development, leading to a chronic postnatal lung disease called bronchopulmonary dysplasia (BPD). At present different experimental BPD models are used. However, there are no systematic comparative studies regarding different influences of oxygen on morphological lung maturation.

Objective

We investigated the influence of prenatal hypoxia and/or postnatal hyperoxia on morphological lung maturation based on stereological parameters, to find out which model best reflects morphological changes in lung development comparable with alterations found in BPD.

Methods

Pregnant mice were exposed to normoxia, the offspring to normoxia (No/No) or to hyperoxia (No/Hyper). Furthermore, pregnant mice were exposed to hypoxia and the offspring to normoxia (Hypo/No) or to hyperoxia (Hypo/Hyper). Stereological investigations were performed on all pups at 14 days after birth.

Results

Compared to controls (No/No) 1) the lung volume was significantly reduced in the No/Hyper and Hypo/Hyper groups, 2) the volume weighted mean volume of the parenchymal airspaces was significantly higher in the Hypo/Hyper group, 3) the total air space volume was significantly lower in the No/Hyper and Hypo/Hyper groups, 4) the total septal surface showed significantly lower values in the No/Hyper and Hypo/Hyper groups, 5) the wall thickness of septa showed the highest values in the Hypo/Hyper group without reaching significance, 6) the volume density and the volume weighted mean volume of lamellar bodies in alveolar epithelial cells type II (AEII) were significantly lower in the Hypo/Hyper group.

Conclusion

Prenatal hypoxia and postnatal hyperoxia differentially influence the maturation of lung parenchyma. In 14 day old mice a significant retardation of morphological lung development leading to BPD-like alterations indicated by different parameters was only seen after hypoxia and hyperoxia.

Levels of cytokines in umbilical cord blood in small for gestational age preterm infants

INTRODUCTION

Being born small for gestational age (SGA) can be a reference to intrauterine growth retardation (IUGR) and is associated with increased neonatal morbidity and mortality. In pregnancies complicated by IUGR placental insufficiency is thought to be one of the leading underlying pathogenetic mechanisms. As cytokines appear to be implicated in implantation and -placental development, imbalances in cytokine levels may contribute to pregnancy disorders i. e., IUGR.

OBJECTIVE

Cord blood cytokine profiles were analyzed in order to characterize differences in cytokine profiles between SGA and appropriate for gestational age (AGA) preterm infants.

METHODS

Cytokine concentrations were measured in venous cord blood of preterm infants delivered by caesarean section without previous labour activity and without signs of maternal or fetal infection.

RESULTS

93 preterm infants were enrolled, 29 SGA preterm infants (GA 31.0 (24.6-36.7) weeks; BW 1080 (315-2010) grams) and 63 AGA preterm infants (GA 33.3 (26.0-36.9) weeks; BW 1790 (760-3570) grams). In both groups multiple cytokines could be detected. Significant differences in cytokine levels between the groups were found for G-CSF, IL-12p40 and IL-8, while levels of IL-1a, IL-6, IL-10, IP-10, MCP-1, MCP-3, MIP-1a and TNF-a were not different.

CONCLUSIONS

Alteration of cytokine levels in SGA preterm infants may be involved in the pathogenesis of reduced intrauterine growth as well as in the higher morbidity in these infants. Further studies are needed to get more comprehension of the complex function of cytokines in pregnancies complicated by IUGR.

Sexual dimorphism of neonatal lung development

BACKGROUND

Gender differences in overall neonatal survival and in short term pulmonary outcome have been reported. Furthermore gender differences in childhood chronic lung disorders have been described all in favor of females.

METHODS

A typical survey on published data regarding gender differences in lung development has been carried out.

RESULTS

1. Structural aspects of lung development: Lung development is regulated by a number of genes, being differently active in the terminal saccular and alveolar period. Gender differences have been described among others for regulation of vascular-endothelial and platelet derived growth factors (VEGF) and platelet-derived growth factor (PDGF), which are active during early lung development with a permissive effect of estrogens mediated by estrogen receptor beta (ER-β). 2. Functional aspects of lung development: Functional components of lung development mainly include surfactant synthesis. Regulation of surfactant protein synthesis was shown to be positively regulated by estrogens, thus favoring lung maturation in females. 3. Lung development and pregnancy complications: Inflammatory alterations induced by LPS lead to larger lung volumes under experimental conditions in females, whereas pulmonary prognosis after impaired intrauterine growth is not affected as clearly by gender.

CONCLUSION

Epidemiological findings indicating an impaired male prognosis in neonatal lung disorders which can at least in part be explained by above described experimental findings. Increased estrogen concentrations in females acting via ER-β may be a key for understanding these findings.

Levels of cytokines in umbilical cord blood in relation to spontaneous term labor

OBJECTIVE

Inflammatory mechanisms are thought to play an important role in the process of labor, both in preterm and spontaneous term delivery. We aimed to determine whether normal spontaneous vaginal delivery (SVD) at term was associated with an inflammatory activation compared with elective cesarean section (ECS) without previous onset of labor.

METHODS

Cytokine concentrations were measured in venous cord blood obtained from 60 term newborns (ECS, n=35; SVD, n=25) born to mothers with clinically uneventful pregnancy and without signs of infection.

RESULTS

Both study groups showed no differences in birth weight, umbilical artery pH, Apgar at 5 min, and gender distribution. Infants delivered by ECS had lower gestational age: mean, 38.5 weeks (range, 37.0-39.6 weeks) vs. mean, 39.8 weeks (range, 37.9-42.4 weeks) (P<0.001). Concentrations of interleukin (IL)-1α, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p40, IL-12p70, IL-17, IL-1 receptor antagonist, soluble IL-2 receptor α, granulocyte-macrophage colony-stimulating factor, interferon (IFN)-α2, IFN-γ, tumor necrosis factor (TNF)-α, TNF-β, and interferon inducible protein 10 were not different between ECS and SVD. Newborns after SVD displayed increased levels of transforming growth factor β1 (TGF-β1): mean, 8580 pg/mL (95% CI, 5554-11,606) vs. mean, 4864 pg/mL (95% CI, 2471-7257) (P<0.0012).

CONCLUSIONS

Our findings suggest that, in healthy, term neonates, the exposition to normal spontaneous delivery and labor is not associated with systemic activation of different inflammatory mediators compared with ECS except for TGF-β1. Further studies are needed to evaluate the immunomodulatory role of labor-associated TGF-β1 increase in fetal cord blood.

[Respiratory disorders in preterm and term neonates: an update on diagnostics and therapy]

Respiratory disorders remain a major problem in postnatal adaptation. In term neonates, an increased incidence of the risk for transient tachypnoea of the neonate has been observed during the past decade, most likely secondary to an increased usage of primary Caesarean section. The disorder is mainly caused by a delayed resorption of foetal lung fluid. Further disorders in term neonates include meconium aspiration syndrome and congenital diaphragmatic hernia leading to impaired gas exchange and pulmonary hypertension. In preterm neonates, respiratory distress syndrome is the main disorder leading to severe acute and long-term impaired gas exchange. Prenatal administration of glucocorticoids and postnatal surfactant therapy remains an established principle in perinatal care for very preterm neonates. The most relevant long-term sequelae, bronchopulmonary dysplasia, is currently being observed in about 15% of preterms with less than 32 weeks of gestation and is associated with severe pulmonary and extrapulmonary consequences. Due to the overall improvement in perinatal care, respiratory disorders still remain a major problem in pulmonary adaptation. However, mortality secondary to neonatal lung failure has been decreased substantially by the improvements in the whole field of perinatal medicine.

Impact of labor on outcomes in transient tachypnea of the newborn: population-based study

OBJECTIVE

Our aim was to assess the effect of labor on the risk and course of transient tachypnea of the newborn (TTN) in term neonates from a contemporary, population-based cohort.

METHODS

We analyzed perinatal characteristics of term singleton newborns (gestational age [GA] of > or =37 completed weeks) who were born between January 2001 and December 2005 in the federal states of Hesse and Saarland (Germany). TTN was diagnosed on the basis of International Classification of Diseases, 10th Revision codes.

RESULTS

Of a total of 275 459 births, 239 971 fulfilled the inclusion criteria of GA of > or =37 completed weeks and singleton live birth. Among those, 13 346 term infants were admitted for neonatal care and 1423 were diagnosed as having TTN. The overall incidence of TTN was 5.9 cases per 1000 singleton live births in our study cohort. Elective cesarean section, low GA, male gender, and low birth weight were associated with TTN. The duration of oxygen supplementation for newborns with TTN was associated inversely with the duration of labor (r = -0.151; P = .028).

CONCLUSIONS

Our study indicates that TTN is strongly related to elective cesarean section and low GA. Furthermore, the absence of exposure to labor contractions is associated with increased risk and severe course of TTN at term, with longer duration of oxygen supplementation.

In utero tobacco exposure: the effects of heavy and very heavy smoking on the rate of SGA infants in the Federal State of Saarland, Germany

OBJECTIVE

To assess the effects of heavy and very heavy smoking on the rate of small for gestational age (SGA) infants, and to assess socio-economic and regional differences in smoking patterns in pregnant women in Germany.

STUDY DESIGN

The Neonatal and Perinatal database of the federal state of Saarland, Germany was used to perform a population-based analysis of preterm (>32 weeks of gestation) and term (>36 weeks of gestation) newborns in 2004-2006. The rate of SGA babies dependent on the amount of tobacco exposure among self-identified smokers and non-smokers were assessed, and distinct maternal risk factors for smoking were evaluated. Our data were compared with the German National Perinatal database.

RESULTS

14,593 paired data sets (peripartum/perinatal) were included in this study. The overall rate of smoking during pregnancy was 11.8% with a high percentage of pregnant women smoking 11-20 cigarettes/day (heavy smoker; 4.0%), and >20 cigarettes/day (very heavy smoker; 0.6%). Self-identified heavy tobacco use significantly increased the risk for SGA infants (p<0.01) in women without uteroplacental insufficiency. Risk factors for smoking included ethnicity (German/Caucasian), socio-economic parameters (single vs. non-single households, status of employment) and age. Smoking pattern and the rate of SGA babies in our cohort differed substantially from the national average.

CONCLUSIONS

Although the overall rate of smoking appears comparable to previously published data, heavy and very heavy smoking was high in our cohort. Heavy smoking was disproportionately associated with SGA. Preventative measures and strategies should take into consideration socio-economic risk factors as well as regional differences, and should be targeted at distinct subgroups that are especially prone to smoking during pregnancy.

Transient tachypnea of the newborn (TTN): a role for polymorphisms in the beta-adrenergic receptor (ADRB) encoding genes?

AIM

Transient tachypnea of the newborn (TTN) is a common cause of early respiratory distress in the neonatal period of term infants. Delayed resorption of foetal lung fluid after birth is considered as the main pathophysiological factor. As resorption of foetal lung fluid is a catecholamine dependent process, we aimed at investigating, whether beta1- and beta2-adrenoreceptor (ADRB1, ADRB2) polymorphisms, known to alter catecholamine activity, are operative in TTN.

METHODS

DNA was collected for genotyping from 73 term newborns suffering from TTN and 55 healthy controls from a Caucasian cohort.

RESULTS

TTN infants were more likely to be male (70% vs. 49%; p < 0.05), had a lower mean birthweight (3120 +/- 450 vs. 3396 +/- 504 g; p < 0.001) and gestational age (GA) (38.4 +/- 1.2 vs. 39.4 +/- 1.3 weeks; p < 0.001) and were more often delivered by caesarean section (CS) (71% vs. 26%; p < 0.001). The beta1Ser49Gly polymorphism differed significantly between cases and controls. Multivariate analysis provided beta1Gly49 homozygotes with higher risk for TTN (OR 18.5; 95%CI 1.5-229; p = 0.023) than beta1Ser49 allele carrier. Further analysis showed significant association of T-47C, A46G, C79G and C491T (TACC) haplotype in ADRB2 gene with TTN (p = 0.048).

CONCLUSION

We conclude that beta1Gly49 homozygosity and TACC haplotype of ADRB2 gene, both loss-of-function genetic variations, may predispose to TTN.

Is transient tachypnoea of the newborn associated with polymorphisms in the epithelial sodium channel encoding gene? Investigation of the second transmembrane spanning domain of the alpha subunit

AIM

We hypothesized that polymorphisms in the region encoding for the second transmembrane spanning domain of the epithelial sodium channel may be one factor in the pathogenesis of transient tachypnoea of the newborn. We thus searched for polymorphisms in this region in neonates with transient tachypnoea of the newborn. We also investigated samples from preterm neonates with respiratory distress syndrome, as dysfunction of the epithelial sodium channel might also increase the risk for developing respiratory distress syndrome and influence its course.

METHODS

We used denaturing gradient gel electrophoresis to detect sequence variants in exon 12 and 13 of the epithelial sodium channel. Forty-three neonates with transient tachypnoea of the newborn (gestational age [mean +/- SD]: 38.3 +/- 1.2 completed weeks; birthweight: 3088 +/- 426 g), 57 neonates with RDS (gestational age: 29.6 +/- 3.5 completed weeks; birthweight: 1272 +/- 638 g), and 50 healthy controls were enrolled prospectively.

RESULTS

We did not detect any polymorphism. Neither did confirmative sequencing of this region in 16 neonates with transient tachypnoea of the newborn reveal any polymorphism.

CONCLUSION

We conclude that reasons other than polymorphisms in the second transmembrane spanning domain cause transient tachypnoea of the newborn.

Synthetic and natural surfactant differentially modulate inflammation after meconium aspiration

OBJECTIVE

Meconium aspiration syndrome remains a relevant cause of neonatal respiratory failure and is associated with severe pulmonary changes including surfactant inactivation and pronounced inflammatory changes. The present study investigated the effect of two different surfactant preparations-recombinant surfactant protein C surfactant (rSP-C Surf) and natural bovine surfactant-on pulmonary gas exchange and inflammatory response.

DESIGN AND SUBJECTS

Twenty-three newborn piglets were intubated, mechanically ventilated, received 5 ml/kg 20% sterile meconium for induction of lung injury, and were randomized thereafter for controls ( n=7), rSP-C Surf ( n=8), or natural surfactant ( n=8). Surfactants were given as an intratracheal bolus (75 mg/kg) and animals were further ventilated.

MEASUREMENTS AND RESULTS

Lung function variables, arterial blood gas samples and lung tissues were obtained. Histological evaluation was performed in right lung tissue using an established score. Cytokine mRNA expression (left lung tissue) was quantified using TaqMan real-time PCR (DeltaDeltaCT method, normalized to controls). In addition to significant improvement in gas exchange and lung function, histological evaluation showed significantly lower sum scores in the rSP-C Surf group than in controls). Cytokine mRNA expression of IL-1beta in whole lung tissue was significantly lower after administration of rSP-C Surf than in natural surfactant and controls whereas IL-10 mRNA expression was significantly induced in both surfactant groups.

CONCLUSIONS

Surfactant administration improved both gas exchange and pulmonary inflammatory cytokine transcription. Mechanisms underlying the differential inflammatory response in both surfactant preparations need to be further addressed.

Transient Tachypnea of the Newborn (TTN): A Role for Polymorphisms of Surfactant Protein B (SP-B) Encoding Gene?

BACKGROUND

Transient tachypnea of the newborn (TTN) is usually a benign self-limiting respiratory disorder in the immediate neonatal period. The lipophilic surfactant-associated protein B (SP-B) was demonstrated to be the most relevant structural component of the surfactant system for immediate postnatal pulmonary adaptation. We hypothesized genetic variations of surfactant protein B (heterozygous 121 ins 2 mutation er intron 4 polymorphisms) to be related to TTN.

PATIENTS AND METHOD

We screened genomic DNA of 83 healthy term neonates (gestational age: 39 (37 - 41) completed weeks [median and range]; birth weight: 3325 +/- 541 grams [mean +/- SD]) and 75 infants presenting with TTN (gestational age: 38 (37 - 41) completed wecks [median and range]; birth weight: 3091 +/- 435 grams [mean +/- SD]) by means of PCR-amplification, fragment length and sequence analysis. TTN was diagnosed an the basis of the clinical signs with respiratory rate > 60 breaths/minute, fraction of inspired oxygen > 0.21, and characteristic radiographic findings within less than 24 hours after birth. Newborns with any infection, pulmonary or cardiac congenital malformations, postnatal asphyxia and infants born to diabetic mothers were excluded.

RESULTS

In TTN-group the frequency of male infants (68.4 % versus 44.6 %, p < 0.05) and caeserian section were significantly higher (68.4 % versus 30.1 %, p < 0.05). We did not find any statistical difference in frequency of intron 4 variations between controls and TTN-group (8.4 % versus 10.7 %). None of the infants were heterozygous for the 121ins2 SP-B mutation.

CONCLUSIONS

WC conclude polymorphisms of intron 4 and heterozygous 121 ins 2 mutation not to associated with TTN.