Parechovirus infection causing sepsis-like illness in newborns: a NICU approach

Human parechovirus (HpeV) is an important emerging infection in young infants, able to cause sepsis-like disease and meningoencephalitis, especially in newborns. Among the 19 identified genotypes, HPeV1, 3 and 6 are the most common types involved in human infections; HPeV3 is the type mainly responsible for neonatal infections and for infections involving the central nervous system. Signs and symptoms overlap with those of a bacterial infection and patients are usually treated with broad spectrum antibiotics. In the majority of cases lumbar puncture shows absence of pleocytosis, even in the presence of signs of meningitis. In these cases, cerebrospinal fluid cultures are negative for bacteria but, in the absence of diagnosis of viral infection, a full and unnecessary antibiotic cycle is often continued. Moreover, high sensitivity neuroimaging, i.e., magnetic resonance, and follow-up are often missed, thus resulting in substandard care. Availability of a real time PCR assay for HPeV RNA allows rapid and sensitive diagnosis as long as the disease is suspected. In this case study, we present cases of HPeV infections in newborns requiring neonatal intensive care admission, discuss their optimal management, and highlight the most relevant findings in the literature.

Neonatal Lung Sonography: Interobserver Agreement Between Physician Interpreters With Varying Levels of Experience

OBJECTIVES

To assess the reliability of lung sonography in neonates between physician interpreters with different degrees of experience.

METHODS

We retrospectively reviewed lung sonograms from neonates admitted to a neonatal intensive care unit with respiratory distress in the first 24 hours of life. The first scans were selected; only patients with available video clips documenting both hemithoraxes were included. The clips were independently examined by 4 different experienced observers blinded to clinical data. The interpreting physicians made a codified sonographic diagnosis, and the Cohen κ coefficient was used to measure the reliability between a proven experienced main interpreter and expert (κ1), intermediate (κ2), and beginner (κ3) control interpreters. We also calculated the specific agreement on respiratory distress syndrome and transient tachypnea of the neonate.

RESULTS

Four hundred sixty-five clips were taken from 114 neonates examined over a 16-month period. The patients' median gestational age (range) was 34 weeks (25-41 weeks), and the median birth weight (range) was 2085 g (608-4134 g). Eighty-eight percent of examinations were performed within 24 hours after birth. The overall κ coefficients (95% confidence intervals) were κ1 = 0.94 (0.88-1.00); κ2 = 0.72 (0.61-0.83); and κ3 = 0.81 (0.71-0.90). For respiratory distress syndrome, κ1 = 0.94 (0.87-1.00); κ2 = 0.90 (0.81-0.99); and κ3 = 0.87 (0.78-0.97). For transient tachypnea of the neonate, κ1 = 0.95 (0.89-1.00); κ2 = 0.76 (0.64-0.88); and κ3 = 0.81 (0.70-0.91).

CONCLUSIONS

In neonates with early respiratory distress, lung sonography has high interobserver agreement even between interpreters with varying levels of experience.

Lung ultrasound accuracy in respiratory distress syndrome and transient tachypnea of the newborn

BACKGROUND

Lung ultrasound (LUS) is a promising technique for the diagnosis of neonatal respiratory diseases. Preliminary data has shown a good sensitivity and specificity of LUS in the diagnosis of respiratory distress syndrome (RDS) and transient tachypnea of the newborn (TTN).

OBJECTIVE

The aim of this study was to calculate the sensitivity, specificity, and negative (NPV) and positive predictive value (PPV) of LUS for RDS and TTN, using an external reader blinded to the clinical condition.

DESIGN AND METHODS

Neonates with respiratory distress had a LUS within 1 h of admission. Images were uploaded and sent to the external reader, who made the ultrasound diagnosis according to the appearance of the images. The final clinical diagnosis was made according to all the available data, except LUS data. Sensitivity, specificity, PPV, and NPV were calculated considering the final clinical diagnosis as the gold standard.

RESULTS

Fifty-nine neonates were studied (mean gestational age: 33 ± 4 weeks, mean birth weight: 2,145 ± 757 g). Twenty-three infants had a final diagnosis of RDS and 30 of TTN. LUS showed a sensitivity of 95.6% and specificity of 94.4%, with a PPV of 91.6% and a NPV of 97.1% for RDS, and a sensitivity of 93.3% and specificity of 96.5% with a PPV of 96.5% and a NPV of 93.4% for TTN.

CONCLUSIONS

LUS showed high sensitivity and specificity in diagnosing RDS and TTN.

Expression of P21(WAF1/CIP1/SID1) cyclin-dependent kinase inhibitor in hematopoietic progenitor cells

P21(Waf1/Cip1/Sid1) is a critical component of biomolecular pathways leading to the G(1) arrest evoked in response to DNA damage, growth arrest signals and differentiation commitment. It belongs to the Cip/Kip class of cyclin-dependent kinase inhibitors and is at least partly regulated by p53. P21(Waf1/Cip1/Sid1) functional inactivation possibly resulting from mutations of the gene itself or, more likely, from p53 mutations may be critical for either the cell fate following DNA-damaging insults or clonal evolution toward malignancy. In the study presented here we describe a competitive polymerase chain reaction (PCR) strategy whose sensitivity and reproducibility enable us to attain a precise quantitation of p21(Waf1/Cip1/Sid1) expression levels in hematopoietic progenitors, the cell compartment which mostly suffers from the side effects of genotoxic drugs in use for cancer cure. The strategy was set in the M07 factor-dependent hematopoietic progenitor cell line. We confirmed that its p21(waf1/cip1/sid1) constitutive expression level is very low and up-modulated by DNA-damaging agents: ionizing radiations and ultraviolet light. Gene up-modulation resulted in checkpoint activation and, in particular, in a significant G(1) arrest, required for either the repair of damaged DNA sequences or apoptotic cell death. Our competitive PCR strategy was further validated in CD34(+) purified hematopoietic progenitors from healthy donors mobilized into the peripheral blood by granulocyte colony-stimulating factor and intended for allogeneic bone marrow transplantation. The constitutive p21(WAF1/CIP1/SID1) expression levels, measured in three separate harvests, were very low and no significant differences were apparent. Our results support the use of a competitive PCR strategy as a useful tool for clinical purposes, to assess the individual biomolecular response of early hematopoietic progenitors to antiblastic drugs.

Competitive polymerase chain reaction as a method to detect the amplification of bcr-abl gene of chronic myeloid leukemia

BACKGROUND AND OBJECTIVES

The chimeric product of the bcr-abl rearranged gene is critical in the pathogenesis of chronic myeloid leukemia (CML), yet its role in the progression of the disease remains unclear. There is some evidence that increased bcr-abl expression levels, possibly due to gene amplification, precede the clonal evolution of CML hematopoietic progenitors toward a fully transformed phenotype and might be involved in their resistance to interferon-alpha or tyrosine kinase inhibitors.

DESIGN AND METHODS

To quantify the bcr-abl gene both at the genomic and at the transcriptional levels we developed a competitive polymerase chain reaction (PCR) strategy. The competitive PCR technique is based upon the co-amplification of the sample template (target) together with increasing amounts of a DNA fragment (competitor) sharing with the target the primer recognition sites, but differing in size. We constructed a competitor for the quantification of both b2a2 and b3a2 alternative splicing forms of the bcr-abl chimera and established the accuracy and reproducibility of our competitive strategy in a clone of the murine 32DG hematopoietic cell line (32D LG7), which bears a stable integration of a single copy of p210 bcr-abl fusion gene. We utilized this technique to follow, over a period of 200 days, the fusion gene copy numbers and transcription rates in several p210 bcr-abl-transduced 32D cell clones, an experimental condition mimicking the evolution of CML myeloid progenitors in vivo.

RESULTS

Our results are consistent with p210 bcr-abl overexpression but not gene amplification associated with their clonal evolution. Increased p210 bcr-abl transcription rate is associated with the abrogation of radiation-induced apoptotic cell death, suggesting a role for the chimeric gene expression level in cell life expectancy after a genotoxic insult.

INTERPRETATION AND CONCLUSIONS

We conclude that the assessment of gene amplification and expression might serve to improve prognostic classification and follow-up of CML patients.

Design of an adaptive secondary mirror: a global approach

We present the mechanical and actuator design of an adaptive secondary mirror that matches the optical requirements of the active and adaptive corrections. Conceived for the particular implementation for the 6.5-m conversion of the multiple-mirror telescope, with small variations of the input parameters this study is suitable for applications for telescopes of the same class. We found that a three-layer structure, i.e., a thin deformable shell, a thick reference plate, and a third plate that acts as actuator support and heat sink, is able to provide the required mechanical stability and actuator density. We also found that a simple electromagnetic actuator can be used. This actuator, when optimized, will dissipate a typical power of a few tenths of watts.

Wernicke-Korsakoff Encephalopathy Following Biliopancreatic Diversion

Wernicke-Korsakoff disease with sensory-motor neuropathy was diagnosed in three out of a series of 1,663 patients (0.18%), with onset 2, 3 and 5 months after biliopancreatic diversion. Precipitating factors were vomiting, minimal food intake, anorexia, rapid weight loss, and glucose-containing intravenous feeding. Recovery was partial in two and complete in one of the patients. In the early postop, prophylactic thiamine should be given to the patients with excessively limited eating capacity. Larger doses of thiamine should be instituted parenterally either in the case of suspected Wernicke-Korsakoff encephalopathy or before starting feeding for protein malnutrition.

Anatomopathological study of dementia syndrome linked with an abnormal cerebrospinal fluid flow. Report of literature and personal observations

The authors have analysed the data of the literature to identify the cases of normotensive hydrocephalus that underwent surgery and then died after the operation; some of these patients died over varying periods of time after the operation and the death was due to accidents. It seems that the anatomopathological lesions are less important in cases that benefited from the operation compared with cases that did not present perceptable clinical variations. The authors report the anatomopathological data of four personal cases which, from the clinical point of view, presented the dementia symptom associated in varying degrees to other neurological symptoms such as disturbances of the gait and of the sphincters functions (Adams' triad). All four subjects presented dilatation of the cerebral ventricles without cortical atrophy. From the histological point of view, there was: exfoliation of the ependyma, subependymal gliosis, demyelination of the white periventricular matter and spongiosis; there were no lesions of the meninges, of the cerebral cortex, no vascular alterations, except for those due to age, or stenosis of the aqueduct. The cause of the ventricular dilatation that was responsible for the clinical symptoms was not clear from the histological examination; the value and the significance of the histopathological data obtained and from the data available from the review of the literature are discussed and they point out the fact that many of the lesions encountered seem to be the consequence rather than the cause of the hydrocephalus.(ABSTRACT TRUNCATED AT 250 WORDS)

Scinticisternography in presenile and senile degenerative disease

86 patients suffering from various senile and presenile degenerative diseases were studied using scinticisternography with In111-DTPA. Flow reversal and delayed clearance were observed in 62 of these patients. These alterations, possibly related to the cerebrospinal fluid dynamics, show the aspecificity of the SC picture. The SC picture does not seem to be correlated to the clinical signs.

Thyrotoxic encephalopathy and recurrent seizures

Epilepsy is a rare but possible manifestation of thyrotoxicosis. The patient reported here developed recurrent, generalized and focal seizures, as presenting symptoms of a thyrotoxic encephalopathy. Intercritic EEG records showed triphasic waves. Seizures and signs of encephalopathy disappeared and the EEG reverted to normal only after treatment of the thyroid hyperfunction. It is concluded that thyroid function should be evaluated in cases of otherwise unexplained encephalopathy with untreatable seizures and triphasic waves.

Spinal cord softenings of identifiable cause: anatomical and clinical features

To complete our bibliographic review of spinal cord softenings, we now discuss the clinical and pathological findings in the cases of known or probable cause. Comparison of the diagnostic groups yields some differences in respect of sex, age and mode of onset, survival and extent of the anatomical lesion. Further differences, especially in age at onset, clinical pattern and lesion site, emerge from a comparison of these cases of known or probable cause with those whose cause is not apparent.

Recurrent vascular myelopathy. Report of a case with autopsy

A case of ischemic myelopathy which was marked by two clinical episodes, separated by a 4-month interval and affecting the same level of the spinal cord, is reported. A wide-ranging search through the literature shows that the recurrent type of ischemic vascular myelopathy is very rare.

Some little-known aspects of spinal cord softening

311 cases of spinal cord softening, were selected for review. The following points emerged from this study: 1) spinal cord softening is a rare occurrence; 2) while formerly syphilis was the most frequent cause, recently reports of cases secondary to aortic disease or to embolism with diffuse signs of arteriosclerosis and circulatory failure pointing to a different pathogenesis have become more frequent; 3) the site of softening rarely corresponds to the vascular spinal territories as defined by the anatomists, from which it may be argued that often several arterial territories may be involved simultaneously or, alternatively, that the arterial territories are not so rigidly defined as anatomical research has led us to suppose; 4) the few cases of multiple vascular lesions show that, as happens in the brain, the cord may be damaged contemporaneously or successively in several areas.

Electrophysiological analysis of motor control in patients with vascular hemichorea

An EMG analysis of motor control was performed in 4 patients with unilateral choreic movements of sudden onset, 3 of whom presented CT scan evidence of lacunar infarcts involving the contralateral striatum. The choreic dyskinesias were correlated with EMG bursts of variable duration occurring with a random order of activation. Ballistic elbow flexion movements were performed with a normal triphasic EMG pattern, but both size and duration of the first agonist burst were increased on the affected side. Abnormalities of cerebral somatosensory evoked responses were observed in 3 patients on stimulation of the side with choreic movements.

Long-term prognosis of patients with lacunar syndromes

A follow-up study of 107 patients with lacunar syndromes has been performed using the analysis of the survival curves and the recurrence curves for new focal cerebrovascular acute episodes. At the end of the 7th year of follow-up, the survival rate of lacunar patients was 479 per 1000, lower than the survival rate of the normal population matched for sex and age (755 per 1000). A more severe prognosis was observed in subjects over 65 years of age, in patients with pseudobulbar syndrome, hypertension and higher degree of disability. The average recurrence rate for new cerebrovascular episodes was 4.74 per 100 patient-years, much lower than that in survivors from cerebral infarction.