Gastrointestinal effects of caffeine in preterm infants: a systematic review and Bayesian meta-analysis

OBJECTIVE

Caffeine is widely used in preterm infants to prevent or treat apnoea of prematurity. Adverse gastrointestinal effects of caffeine have not been thoroughly researched in preterm infants. With this systematic review and meta-analysis, we aim to summarise the results of trials on the gastrointestinal effects of caffeine in preterm infants.

DESIGN

We searched MEDLINE, Web of Science, Scopus and ClinicalTrials.gov up to 21 April 2023. We included randomised controlled trials assessing caffeine versus placebo in preterm neonates and reporting gastrointestinal side effects. Risk of bias was assessed using the Cochrane Risk of Bias tool. A Bayesian meta-analysis was performed to estimate the pooled OR of gastrointestinal side effects.

RESULTS

Nine trials involving 2746 preterm infants were analysed. Seven trials assessing necrotising enterocolitis and four trials assessing feeding intolerance in our meta-analysis found no differences between caffeine and placebo (OR=1.007 (95% credible interval 0.021, 5.462), I2=97.4%, and OR=1.266 (95% credible interval 0.064, 28.326), I2=84.8%, respectively). Four trials assessed the outcomes spontaneous intestinal perforation, constipation, gastrointestinal disorder (composite outcome: gastro-oesophageal regurgitation or dilated bowel loops), age at oral feeding and cholestasis syndrome and found no differences between groups. One trial assessed the outcomes gastro-oesophageal symptoms and duration of tube feeding and found that caffeine was associated with a reduced burden of gastro-oesophageal reflux symptoms at 2 weeks (p<0.05), but not at term.

CONCLUSIONS

According to this systematic review and meta-analysis, the use of caffeine at usual doses in preterm infants does not seem to be associated with significant gastrointestinal adverse effects.

Use of neonatal lung ultrasound in European neonatal units: a survey by the European Society of Paediatric Research

OBJECTIVE

Regarding the use of lung ultrasound (LU) in neonatal intensive care units (NICUs) across Europe, to assess how widely it is used, for what indications and how its implementation might be improved.

DESIGN AND INTERVENTION

International online survey.

RESULTS

Replies were received from 560 NICUs in 24 countries between January and May 2023. LU uptake varied considerably (20%-98% of NICUs) between countries. In 428 units (76%), LU was used for clinical indications, while 34 units (6%) only used it for research purposes. One-third of units had <2 years of experience, and only 71 units (13%) had >5 years of experience. LU was mainly performed by neonatologists. LU was most frequently used to diagnose respiratory diseases (68%), to evaluate an infant experiencing acute clinical deterioration (53%) and to guide surfactant treatment (39%). The main pathologies diagnosed by LU were pleural effusion, pneumothorax, transient tachypnoea of the newborn and respiratory distress syndrome. The main barriers for implementation were lack of experience with technical aspects and/or image interpretation. Most units indicated that specific courses and an international guideline on neonatal LU could promote uptake of this technique.

CONCLUSIONS

Although LU has been adopted in neonatal care in most European countries, the uptake is highly variable. The main indications are diagnosis of lung disease, evaluation of acute clinical deterioration and guidance of surfactant. Implementation may be improved by developing courses and publishing an international guideline.

Neonatal polycythemia: prevalence, risk factors and predictors of severity

BACKGROUND

Polycythemia is a disorder with several causes and risk factors. The clinical presentation is variable, ranging from asymptomatic newborns to cases with severe physiological changes. The aim of this study was to assess the prevalence, risk factors and predictors of severity of polycythemia in a Portuguese level III Neonatal Intensive Care Unit (NICU).

METHODS

Case-control study of all term newborns with the diagnosis of polycythemia admitted to the NICU of the São João Universitary Hospital Center, Porto, Portugal, from January 1, 1999 to December 31, 2019; and who met one of the following inclusion criteria were eligible for the study: 1) Hct>65% or Hb>22 g/dL; and 2) Hb≥21 g/dL with clinical manifestations of polycythemia.

RESULTS

A total of 53 newborns fulfilled the inclusion criteria and were included in the study, corresponding to a prevalence of 0.57%. Birth outside the hospital was the only risk factor with statistical significance. Of 53 cases, 51 (96.23%) had symptomatic polycythemia. The most frequent symptoms were: hyperbilirubinemia (69.81%), hypoglycemia (52.83%), thrombocytopenia (50.94%), cardiorespiratory (33.96%), and neurological symptoms (33.96%). Of the 53 newborns evaluated, 41 (77.36%) needed treatment. The only risk factors that influenced the hematocrit value were maternal diabetes and fetal growth restriction.

CONCLUSIONS

The best way to improve the prognosis of polycythemia is to identify the risk factors present throughout pregnancy and make an early diagnosis and treatment. Out-of-hospital births should be avoided. The diagnosis should not be excluded, even if hemoglobin and hematocrit are within normal limits.

Impact of advanced maternal age on neonatal morbidity: a systematic review

OBJECTIVE

This systematic review aimed to understand the impact of advanced maternal age (AMA) on the neonatal morbidity, based on the available scientific evidence.

METHODS

A systematic search was conducted on 22 November 2021, using the PubMed and Scopus databases to identify studies that compared the morbidity of neonates delivered to AMA mothers with that of neonates delivered to non-AMA mothers.

RESULTS

Sixteen studies that evaluated the effect of AMA on the neonatal morbidity were included in this review. Nine of these studies found some association between AMA and increased neonatal morbidity (with two of them only reporting an increase in asymptomatic hypoglycemia, and one only reporting an association in twins), six found no association between AMA and neonatal morbidity and one study found a decrease in morbidity in preterm neonates. The studies that found an increase in overall neonatal morbidity with AMA considered older ages for the definition of AMA, particularly ≥40 and ≥45 years.

CONCLUSION

The current evidence seems to support a lack of association between AMA and the neonatal morbidity of the delivered neonates. However, more studies focusing on the neonatal outcomes of AMA pregnancies are needed to better understand this topic.

Subcentimetric Papillary Thyroid Carcinoma: Does the Diagnosis Kind Impact Prognosis?

INTRODUCTION

Subcentimetric papillary thyroid carcinoma (SPTC) (papillary thyroid carcinoma with less than 10 mm in size) usually presents an excellent prognosis, with few aggressive reported cases. Given the globally increased incidence of SPTC, physicians are struggling with the need to identify prognostic factors to stratify SPTC. The aim was to compare clinicopathological variables and prognosis between clinically and incidentally diagnosed SPTC. Materials and methodsː This is a retrospective observational study on patients with SPTC who underwent thyroidectomy between 2002 and 2015. Two groups were considered: G1 (n=60 (61.9%)), clinical diagnosis (Bethesda III-VI cytology in the thyroid tumor/in cervical lymphadenopathies) and G2 (n=37 (38.1%)), incidental diagnosis (thyroidectomy for benign thyroid pathology). The histological material was reviewed, and molecular analysis of the BRAF, RAS, and TERT promoter (TERTp) genes was performed. Resultsː Ninety-seven individuals were included, 60 (61.9%) of which were from G1, with a predominance of female sex (n=83 (85.6%)). Individuals of G1 were younger (53.0±14.2 versus 59.3±13.9 years; p=0.035), were more frequently treated with 131-iodine (39.2% versus 13.4%; p=0.007), had the largest diameter (8 (p25-p75: 7-9) versus 5 (p25-p75: 4-6.5) mm; p<0.001), and higher frequency of minimal extracapsular invasion (45% versus 24.3%; p=0.041). Increased tumor size was the only independent predictor of a clinical diagnosis (p<0.001). Conclusionsː Clinically and incidentally diagnosed SPTC showed excellent medium- to long-term prognosis. A larger SPTC was more likely a driver of clinical detection than a marker of tumor aggressiveness, but caution should be taken as contradictory data persists.

Neonatal outcomes of multiple versus single very preterm infants

BACKGROUND

Neonatal morbidity and mortality differ between very preterm infants that result from single and those that result from a multiple order pregnancy. The aim of our study was to assess and compare the neonatal morbidity and mortality of multiple versus single very preterm infants.

METHODS

Obstetrical and neonatal data on mothers and preterm infants with gestational ages between 24 and 30 weeks, born during 2015 and 2016 at 11 level III perinatal centers after a surveilled pregnancy, were analyzed and compared. Statistical analysis was performed using IBM SPSS® statistics 25 and a p-value < 0.05 was considered statistically significant.

RESULTS

A total of 494 infants delivered from 410 women were enrolled in the study; 320 (64.8%) infants resulted from single gestation and 174 (35.2%) resulted from multiple order gestation (153 double, 21 triple). Multiples were associated with a higher maternal age, a greater use of medically assisted reproduction techniques, higher C-section rates, more frequent full cycle use of antenatal corticosteroids, higher gestational age with adequate birth weight, spent less days on oxygen therapy, presented less prevalence of BPD and cPVL, needed less surgical closure of PDA and had a lower length of stay in NICU. Abruptio placenta, hypertensive disorders of pregnancy and preeclampsia were more frequent in single pregnancies. The multivariate analysis by logistic regression adjusted to gestational age and confounding variables did not show any significant difference on the outcomes of multiples compared to singles.

CONCLUSIONS

The results of our study support the scientific evidence that, with the current practices, the neonatal morbidity and mortality of very premature infants are not different between those resulting from single and multiple gestations.

Prevalence, risk factors and predictors of severity of neonatal thrombocytopenia in neonatal Intensive Care Units: a single center study

BACKGROUND

Thrombocytopenia is a common hematological disorder seen in the neonatal period, especially in newborns admitted to the Neonatal Intensive Care Unit (NICU). The clinical and laboratorial presentation is heterogeneous, with different underlying causes and risk factors. There are still few studies about some possible risk factors and their influence on the newborn's clinical outcome. The aim of this study was to assess the prevalence, risk factors and predictors of severity of thrombocytopenia in a level III NICU.

METHODS

The present analysis was the retrospective study of newborns with thrombocytopenia (platelet count less than 150×109/L) admitted from January 1, 2008, to December 31, 2017. Patients included newborns admitted after the first 72 hours of life and those with thrombocytopenia related to surgical intervention were excluded.

RESULTS

Out of 187 neonates with thrombocytopenia, a total of 134 neonates were included in the study, corresponding to a prevalence of 3.3%. One hundred fourteen (85%) neonates had an early onset presentation (EOT), and 20 (15%) neonates had a late onset presentation (LOT); 68 (50.7%) neonates had severe and 66 (49.3%) had non-severe thrombocytopenia. Sepsis was identified as an independent predictor of LOT. Sepsis by gram-negative bacteria was identified as an independent predictor for severe thrombocytopenia.

CONCLUSIONS

Identification of risk factors, early diagnosis and treatment of the underlying causes are crucial for a better approach of neonatal thrombocytopenia. A strong association between sepsis and sepsis by gram-negative bacteria with LOT and severe thrombocytopenia, respectively, enhances the importance of nosocomial sepsis control in NICU.

A maternal age of 35 years and over may increase the risk for cystic periventricular leukomalacia in very preterm infants

BACKGROUND

Some studies have shown increased risk for neonatal morbidity and mortality with increasing maternal age. The aim of this study was to assess the influence of a maternal age of 35 years, and older, on the neonatal morbidities and mortality of very preterm infants.

METHODS

Obstetrical and neonatal data on mothers and preterm infants with gestational age 24 to 30 weeks, born during 2015 and 2016 after a surveilled pregnancy at 11 Portuguese level III centers were analyzed according to a mother's age <35 years versus ≥35. Statistical analysis was performed using IBM SPSS statistics 23 (IBM, Armonk, NY, USA) and a P value <0.05 was considered significant.

RESULTS

A total of 415 mothers and 499 infants were included; 340 (68.1%) infants were delivered to mothers <35 years old and 159 (31.9%) to mothers ≥35. There were no differences in birthweight, gestational age and gender in both groups of preterm infants. Rupture of membranes over 18 hours and chronic hypertension with superimposed preeclampsia were significantly more frequent in mothers ≥35 years. Cystic periventricular leukomalacia (cPVL) assessed by cranial ultrasound was significantly more prevalent in infants delivered to mothers ≥35 years. The multivariate analysis by logistic regression revealed an association between cPVL and a maternal age ≥35 years (OR=2.34, 95% CI: 1.20-4.54; P=0.012).

CONCLUSIONS

Our study revealed a significant association between a maternal age ≥35 years and echographic cPVL in preterm infants below 30 weeks of gestational age.

Thrombocytopenia requiring platelet transfusions is predictive of retinopathy of prematurity in preterm infants

BACKGROUND

Recent studies suggest that some hematological parameters and ratios provided by blood count collected on the first day of life may be predictors for the development of retinopathy of prematurity (ROP). The aims of this study were to assess whether hematological parameters and ratios in blood count collected on the first day of life are associated with ROP.

METHODS

Retrospective data collection from electronic clinical files of inborn preterm infants with a gestational age of less than 30 weeks delivered from January 2008 to December 2022, in a level III Neonatal Intensive Care Unit (NICU). We collected detailed clinical and demographic data on the mother, pregnancy, mode of delivery, resuscitation, in-hospital neonatal morbidity, pathological examination of the placenta, and hematological parameters and ratios provided by blood count collected on the first day of life. We compared neonates with or without ROP and performed a subgroup analysis on patients with ROP≥2.

RESULTS

We included 140 preterm infants with ophthalmic examination; 81(57.9%) developed ROP. The need for platelet transfusions (OR=5.28; 95% CI: 1.31-21.21; P=0.019) and bronchopulmonary dysplasia (BPD) (OR=5.12; 95% CI: 1.14-22.98; P=0.033) were independent risk factors for ROP. In the multivariate analysis, no associations were found between any of the hematological parameters or ratios studied and ROP.

CONCLUSIONS

In our study, hematological parameters and ratios on the first day of life were not associated with the development of ROP. However, thrombocytopenia that required platelet transfusions was associated with ROP development and severity.

Heart Disease Screening and False Hypoxemia in the Neonate

BACKGROUND

Screening for congenital heart diseases by pulse oximetry is used for the initial assessment of the neonate. Variants of hemoglobin F can compromise light absorbance, inducing erroneous results.

CASE REPORT

Two infants screened for congenital heart disease showed an asymptomatic low peripheral oxygen saturation. Arterial blood gases analysis revealed a normal arterial pressure of oxygen and oxygen saturation. More likely and/or severe causes of hypoxemia were ruled out. This "artifact" with SpO2-SaO2 dissociation, and after exclusion of other common etiologies of hypoxemia, raised the clinical suspicion of hemoglobinopathy. Hemoglobin molecular and genetic studies identified specific mutations in gamma chains from hemoglobin F, named hemoglobin F Sardinia.

CONCLUSION

Hemoglobin F variants may result in low peripheral oxygen saturation readings by pulse oximetry, explaining the discordance in the clinical appearance and low peripheral oxygen saturation readings.

Respiratory and non-respiratory outcomes of bronchopulmonary dysplasia in adolescents: A systematic review

BACKGROUND

There is lack of evidence synthesis on the global consequences of bronchopulmonary dysplasia (BPD) in adolescence.

AIM

Assess the impact of bronchopulmonary dysplasia on respiratory and non-respiratory outcomes in adolescents.

METHODS

A systematic review of studies assessing the outcomes of adolescents aged 10 to 19 years-old with BPD was conducted. We independently screened studies published until 6th March 2023 in PubMed® and Scopus® databases. Data on methodologic design, sample descriptive and findings were extracted from each study. Risk of bias was assessed using quality assessment tools.

RESULTS

Thirty-one studies were included. Adolescents with a history of BPD present with more respiratory symptoms (wheezing, respiratory exacerbations, need for respiratory medication) and twenty-five studies showed a reduction in pulmonary function, with varying impact according to BPD severity and no differences before and after the surfactant era. Spirometry evaluation throughout the years is not consensual, but methacholine and salbutamol response in BPD groups is increased compared to non-BPD groups. Markers of eosinophilic airway inflammation are not increased as in asthma patients. Exercise potential is identical, but data regarding physical capacity and activity are inconsistent. More frequent radiologic abnormalities translate into higher high-resolution computed tomography scores, with linear (72.2 %) and triangular subpleural opacities (58.3 %) as the most common findings. There is a higher risk for special needs in education, but quality of life seems to be equal to non-BPD adolescents.

CONCLUSIONS

BPD negatively impacts both pulmonary and non-pulmonary outcomes in adolescents.

Consequences of early-onset preeclampsia on neonatal morbidity and mortality

Preterm birth is the leading cause of perinatal morbidity and mortality in developed countries. Common reasons for indicated preterm births include pre-eclampsia. The increase in incidences of morbidity and mortality observed in neonates resulting from pregnancies complicated by preeclampsia is also due to alterations in angiogenic and pro-inflammatory factors that directly affect the neonatal health. This review was prepared with the aim of gathering the information available at PubMed/MEDLINE, in the years from 2011 to 2021, on the consequences of neonatal morbidity and mortality of early-onset preeclampsia. There is great controversy in the literature and paucity of studies. Early onset pre-eclampsia has been linked to fetal growth restriction (FGR). Most studies support its association with respiratory distress syndrome (RDS). Most studies point to an association between preeclampsia and bronchopulmonary dysplasia (BPD), with the highest risk in FGR. The association between preeclampsia, patent ductus arteriosus (PDA) and sepsis is not supported by the literature. The association to necrotizing enterocolitis (NEC) is controversial. The risk of spontaneous intestinal perforation (SIP) seems to be increased with preeclampsia. The association between intraventricular hemorrhage (IVH) and preeclampsia is controversial, however, preeclampsia seems to have a protective effect on periventricular leukomalacia (PVL). Most of the evidence points to the non-association between preeclampsia and retinopathy of prematurity (ROP). Hematological changes such as neutropenia, thrombocytopenia and increased nucleated red blood cell counts have been shown to be associated with preeclampsia. The evidence is still quite controversial regarding mortality. The early installation of preeclampsia will have direct consequences on neonatal morbidity. Gestational age at preterm birth is the main risk factor on neonatal morbidity. Obstetricians should aim to prolong the pregnancies complicated by early-onset severe preeclampsia as far as maternal conditions allow. This policy may contribute to improve the neonatal outcomes.

Functional Diversification of Oyster Big Defensins Generates Antimicrobial Specificity and Synergy against Members of the Microbiota

Big defensins are two-domain antimicrobial peptides (AMPs) that have highly diversified in mollusks. Cg-BigDefs are expressed by immune cells in the oyster Crassostrea gigas, and their expression is dampened during the Pacific Oyster Mortality Syndrome (POMS), which evolves toward fatal bacteremia. We evaluated whether Cg-BigDefs contribute to the control of oyster-associated microbial communities. Two Cg-BigDefs that are representative of molecular diversity within the peptide family, namely Cg-BigDef1 and Cg-BigDef5, were characterized by gene cloning and synthesized by solid-phase peptide synthesis and native chemical ligation. Synthetic peptides were tested for antibacterial activity against a collection of culturable bacteria belonging to the oyster microbiota, characterized by 16S sequencing and MALDI Biotyping. We first tested the potential of Cg-BigDefs to control the oyster microbiota by injecting synthetic Cg-BigDef1 into oyster tissues and analyzing microbiota dynamics over 24 h by 16S metabarcoding. Cg-BigDef1 induced a significant shift in oyster microbiota β-diversity after 6 h and 24 h, prompting us to investigate antimicrobial activities in vitro against members of the oyster microbiota. Both Cg-BigDef1 and Cg-BigDef5 were active at a high salt concentration (400 mM NaCl) and showed broad spectra of activity against bacteria associated with C. gigas pathologies. Antimicrobial specificity was observed for both molecules at an intra- and inter-genera level. Remarkably, antimicrobial spectra of Cg-BigDef1 and Cg-BigDef5 were complementary, and peptides acted synergistically. Overall, we found that primary sequence diversification of Cg-BigDefs has generated specificity and synergy and extended the spectrum of activity of this peptide family.

CHYLOUS ASCITES IN THE NEONATE: A NARRATIVE REVIEW

Chylous ascites (CA), also called chyloperitoneum, is a rare form of ascites in the neonate. It results from the leakage of lymph into the peritoneal cavity. There are congenital and acquired forms of CA. CA may occur during fetal life, and the prognosis will depend on its volume, gestational age at the onset, and the association with other anomalies. Lymphangiectasia is the most common congenital cause, and acquired forms are mainly traumatic and/or post-operative. This review aims to gather the most current information on CA and addresses important aspects regarding etiology, pathophysiology, clinic, diagnostic tools, and treatment.

A Unique Shunt For Treatment Of A Postoperative Chylothorax

Postoperative chylothorax can be a serious complication. We report on the case of a neonate who had a postoperative chylothorax immediately after esophageal surgery that did not respond to conservative measures or the first two attempts of surgical management of chylothorax. Lastly, a successful pleuroperitoneal shunt was placed and the patient was discharge at 3-months-old. A pleuroperitoneal shunt is usually the last surgical option but may be a curative measure.

Impact of pharmacological treatment of gestational diabetes on the mode of delivery and birth weight: a nationwide population-based study on a subset of singleton pregnant Portuguese women

AIMS

To access the impact of increasing use of metformin on cesarean section and large for gestational age rates, when compared to insulin.

METHODS

A retrospective observational study was developed using data from the Portuguese National Registry, between 2011 and 2019, of 5038 Portuguese women with single pregnancies and gestational diabetes treated with metformin and/or insulin. Three groups were defined according to the therapeutic regimen adopted: g1-insulin in monotherapy (n = 3027[60.1%]); g2-metformin in monotherapy (n = 1366[27.1%]); g3-metformin and insulin (n = 645[12.8%]). Multivariate analysis was adjusted for statistically significant covariates.

RESULTS

The cesarean section rate in g1 was similar to g2 (g1:36.9% vs. g2:37%, p = 0.982), although g3 was associated with cesarean delivery (g3:43.6% vs. g1:36.9%, p = 0.005; g3:43.6% vs. g1:37.0%, p = 0.002), with no differences reported in the multivariate analysis adjusted for year of delivery and pregestational body mass index. A delivery of a large for gestational age newborn was less frequently observed in g2 than in g1 (g2:4.1% vs. g1:5.4%, p = 0.044) and in g3 (g2:4.1% vs. g3:9.1%, p < 0.001), and in g1, when compared to g3 (g1:5.4% vs. g3:9.1%, p < 0.001). In the multivariate analysis, g2 showed lower odds of delivering a large for gestational age newborn, compared to g1 (β = -0.511, OR = 0.596, CI95% = 0.428-0.832, p < 0.001).

CONCLUSIONS

The use of metformin was not associated with higher cesarean section rates, compared to insulin. Instead, it was suggested a protective role of metformin on large gestational age rates. The concomitant use of dual therapy suggests more complex pregnancies, requiring closer surveillance that mitigate serious perinatal and obstetrical outcomes.

A Preliminary Contribution towards a Risk-Based Model for Flood Management Planning Using BIM: A Case Study of Lisbon

Preparing a city for the impact of global warming is becoming of major importance. Adopting climate-proof policies and strategies in response to climate change has become a fundamental element for city planning. To this end, this research considers a multidisciplinary approach, at the local scale, able to connect urban planning and architecture, as a vital base for considering a coastal cities' ability to control the consequences of climate change, specifically floods. So far, there is a scarcity of research connecting sea ground and land surveys, and this study could become a foundational reference for coastline settlement management using BIM. We found in BIM (Building Information Modeling) a possible tool for managing coastal risk, since it can combine crowdsourced data for geometric and information modeling of the city. The proposed BIM model includes a topography used for 3D thematic maps, a riverbed model, and a waterway model. This model aims to facilitate coordination across separate actors and interests since the urban area model is always updatable and improvable. Focusing on a case study of Lisbon, we developed risk-based 3D maps of the area close to the shoreline of the Tagus River.

Extracapsular Cervical Hematoma After Thyroid Fine-Needle Aspiration Cytology

Fine-needle aspiration cytology (FNAC) is a safe and well-tolerated procedure with high sensitivity and specificity. Serious complications, such as large hematomas, are very rare and should be promptly identified. We present an unusual case of a 71-year-old woman with a massive cervical hematoma that developed near the thyroid capsule after the FNAC of a nodule. CT showed a hematoma measuring 38 x 34 mm, causing deviation of the laryngotracheal axis. The patient was admitted to the intensive care unit for intubation and surgical drainage. This case illustrates that FNAC, despite being considered a safe procedure with infrequent complications, carries the risk of acute life-threatening events that should be taken into account.

Multiple Bone Fractures in a Patient With Difficult-to-Treat Cushing’s Disease

Osteoporosis at a young age should prompt clinicians to search for secondary causes, namely endogenous Cushing’s syndrome.We report a case of a 33-year-old male with a history of spontaneous fracture of the 12th thoracic vertebra and florid features of Cushing’s syndrome. The physical exam evidenced moon face, facial plethora, muscle atrophy of the upper and lower limbs, and accumulation of abdominal fat. Bone mineral density revealed osteoporosis in the lumbar spine and in the femoral neck. Scintigraphy showed bone fractures in several costal arches, dorsal columns, and sternum. Hypercortisolism was confirmed by blood work. Serum cortisol, adrenocorticotropic hormone and corticotropin (ACTH), and 24-hour urine cortisol values were elevated. Imaging with MRI sellar region was normal and bilateral catheterization of inferior petrosal sinuses was positive. The patient underwent transsphenoidal pituitary surgery (TPS) and a lesion in the right side of the pituitary was identified and resected. Postoperatively, the patient did not meet the remission criteria and we decided to initiate treatment with ketoconazole alongside pituitary radiotherapy. After two years of surgery, the patient presented with recurrent bone fractures, height loss (25 cm), intense fatigue, and difficulty walking without assistance. Due to severe disease, we performed bilateral adrenalectomy, which was essential to control hypercortisolism and improve the patient's quality of life.

Glycaemic control during the COVID-19 pandemic: A catastrophe or a sign of hope for the person with type 1 Diabetes Mellitus?

Introduction

In a person with type 1 diabetes, any change concerning daily routine may lead to changes in glycaemic control. This study aimed to evaluate the impact of work and lockdown on glycaemic control in adults with type 1 diabetes.

Material and methods

A retrospective cohort was stratified into three activity groups (g1-students/telework/laid-off; g2-unemployed/retired; g3-work without lockdown). Continuous and categorical variations (reductions ≥ 0.4%) in glycated haemoglobin were obtained in 2020 (t3:December/2019–March/2020; t4:April/2020–July/2020) and in homologous periods of 2019. Intragroup comparisons between years and intergroups in the same year were made. Regression models were developed to predict the variation of glycated haemoglobin in 2020.

Results

241 participants were included, with a significant reduction between t4 and t3 (vs. t2 and t1) in g1 (p < 0.001) and g2 (p = 0.025) and in 2020 in g1 (vs. g2, p < 0.001; vs. g3, p < 0.001). Only g1 presented superiority in the reduction ≥0.4% in glycated haemoglobin in 2020 (vs. 2019, p < 0.001; vs. g2, p < 0.001; vs. g3, p < 0.001). The insulin regimens were comparable and the development of hypoglycaemia was found to be superimposed between t3 and t4, except for g1, which was higher at t3 (p = 0.029). G1 correlated with continuous reductions (vs. g2, p = 0.001; vs. g3, p < 0.001) and ≥0.4% in glycated haemoglobin in 2020 (vs. g2, OR 3.6, p < 0.001; vs. g3, OR 12.7, p < 0.001), regardless of the age and duration of type 1 diabetes.

Conclusions

A more stable and better glycaemic control was observed in participants who transitioned from face-to-face work to total lockdown.

Insipid diabetes and vaginal ulcers: evidence for the diagnosis of Langerhans cell hypophysitis

Not required for Clinical Vignette.

Large congenital pulmonary airway malformation with mucinous cell clusters - a case report

We report the clinical case of a 38 weeks gestational age neonate, antenatally diagnosed with a left large macrocystic pulmonary malformation conditioning dextrocardia. At birth, he presented with respiratory distress requiring non-invasive ventilation with high-flow nasal cannula (HFNC). A left inferior lobectomy was performed via thoracotomy on day 21 of life. Histological features of the lesion were compatible with congenital pulmonary airway malformation (CPAM) type I with muci- nous cell clusters. No surgical complications were reported and the neonate was discharged six days after surgery. Follow-up two months after surgery was unremarkable.

Cat-Eye Syndrome: A Report of Two Cases and Literature Review

Cat-eye syndrome is a rare genetic disease that involves the proximal long (q) arm of chromosome 22. The classic clinical triad includes coloboma of the iris, ears, and anal malformations. This syndrome was named “cat eye” due to the vertical coloboma of the iris. However, the spectrum of clinical manifestations is variable, and the iris coloboma may be absent in 40-50% of cases. Association with congenital heart disease is also frequent and its diagnosis should raise suspicion of a genetic condition. We describe two cases of male infants affected by the cat-eye syndrome, of which no one presented the classic clinical triad. One of them had unpredictable complications that led to prolonged neonatal intensive care unit stay. Although having distinct phenotypes, the diagnosis in both cases was made through nonobstructive total anomalous pulmonary venous return, anal imperforation, and craniofacial anomalies. Iris coloboma was an important clue only in one of them. Prenatal diagnosis is a challenge, such that a genetic study is essential for a final diagnosis in the absence of the classic triad.

Fluorine-18 Fluorocholine Positron Emission Tomography/Computed Tomography in Primary Hyperparathyroidism: A Case Report and Review of Literature

Positron emission tomography (PET) tracers (Fluorine-18 Fluorocholine [¹⁸F-Fluorocholine] and Carbon-11 Choline [¹¹C-Choline]) have been widely used with promising accuracy in detecting abnormal parathyroids, being crucial for an effective and safe minimally invasive parathyroidectomy. We report a case of a 72-year-old woman with a long-term personal history of osteoporosis and recurrent nephrolithiasis with the need for invasive interventions. Primary hyperparathyroidism was biochemically assumed, although localization of the hyperfunctioning parathyroid had been challenging since cervical ultrasound and technetium-99m sestamibi scintigraphy were negative/equivocal. An ¹⁸F-Fluorocholine positron emission tomography/computed tomography (PET/CT) was performed, having identified a small cervical nodule with increased tracer uptake, compatible with a right parathyroid adenoma. After its removal, the patient went into clinical and biochemical remission. ¹⁸F-Fluorocholine PET/CT allowed an effective and safe parathyroidectomy as conventional imaging modalities were inaccurate in detecting the abnormal parathyroid, in this patient with serious hyperparathyroidism-related complications.

Secukinumab, Pituitary Enlargement and Panhypopituitarism: Are They Related?

Pituitary adenomas are the most common cause of hypopituitarism associated with pituitary enlargement, but other aetiologies have been emerging, namely immune checkpoint inhibitor-induced hypophysitis (ipilimumab, nivolumab and pembrolizumab). Secukinumab is a recently approved human monoclonal antibody used for the treatment of psoriasis, with no know reported cases of hypophysitis. We describe a challenging case of panhypopituitarism in a patient with a pituitary incidentaloma and a temporal relationship between secukinumab initiation and the manifestation of clinical features suggestive of hypopituitarism. In such intricate work-up, the differential diagnoses should be carefully considered, taking into account the therapeutic and prognostic implications.

Inhaled Pharmacotherapy for Neonates: A Narrative Review

The inhaled route for drug administration in neonates offers several advantages over the systemic routes, since it delivers medications directly to the diseased organ, enabling higher doses locally with less systemic toxicity. Respiratory drugs can be administered in both ventilated and non-ventilated term and preterm infants. This review was carried out using selected literature, with a focus on the most used inhaled pharmacological agents in neonatal care, summarizing, with levels of evidence (LoE), their indications, doses, administration schedules, and main adverse effects. Information is given on several inhaled drugs, namely albuterol, budesonide, ipratropium bromide, sodium cromoglycate, racemic epinephrine, nitric oxide, treprostinil, iloprost, epoprostenol, colistin, rhDNase, hypertonic saline, and calfactant. A summary of the main and most recent published studies on each of these inhaled pharmacological agents is also presented.

Chylothorax in the neonate-A stepwise approach algorithm

BACKGROUND

Chylothorax in neonates results from leakage of lymph from thoracic lymphatic ducts and is mainly congenital or posttraumatic. The clinical course of the effusion is heterogeneous, and consensus on treatment, timing, and modalities of measures has not yet been established. This review aims to present, along with levels of evidence and recommendation grades, all current therapeutic possibilities for the treatment of chylothorax in neonates.

METHODS

An extensive search of publications between 1970 and 2020 was performed in the PubMed, Cochrane Database of Systematic Reviews, and UpToDate databases. A stepwise approach algorithm was proposed for both congenital and traumatic conditions to guide the clinician in a rational and systematic way for approaching the treatment of neonates with chylothorax.

DISCUSSION AND CONCLUSION

The treatment strategy for neonatal chylothorax generally involves supportive care and includes drainage and procedures to reduce chyle flow. A stepwise approach starting with the least invasive method is advocated. Progression in the invasiveness of treatment options is determined by the response to previous treatments. A practical stepwise approach algorithm is proposed for both, congenital and traumatic chylothoraces.

Nephrotoxicity in Neonates

Acute kidney injury (AKI) is classified based on prerenal, intrinsic, and postrenal causes. In the newborn, AKI can occur after an insult during the prenatal, perinatal, or postnatal period. AKI is usually an underrecognized condition and its true incidence is unknown. AKI may result from the administration of a number of different nephrotoxic medications, which are often used concurrently in critically ill neonates, exponentially increasing the risk of renal injury. Drug toxicity may also compromise the formation and development of nephrons, and this is particularly important in preterm infants, who have incomplete nephrogenesis. Little is known about the pharmacokinetics and pharmacodynamics of different medications used in neonates, especially for the most immature infant, and the use of most medications in this population is off label. Strategies to prevent AKI include the avoidance of hypotension, hypovolemia, fluid imbalances, hypoxia, and sepsis as well as judicious use of nephrotoxic medications. Treatment strategies aim to maintain fluids and electrolytic and acid-base homeostasis, along with an adequate nutritional status. Neonates are especially prone to long-term sequelae of AKI and benefit from long-term follow-up. This review summarizes the most relevant aspects of nephrotoxicity in neonates and describes the prevention, treatment, and follow-up of AKI in neonates.

Necrotizing infundibulo-hypophysitis: case-report and literature review

PURPOSE

We describe a rare case of histopathologic-proven necrotizing infundibulo-hypophysitis (NIH).

CLINICAL HISTORY

A 40-year-old female presented with coexistence of central diabetes insipidus and hypopituitarism. Imaging disclosed a thickened infundibulum and a diffusely enlarged pituitary mass with gadolinium rim enhancement pattern. Microsurgical endonasal transsphenoidal resection was performed. The presence of extensive liquefactive necrosis, surrounded by lymphoplasmocytic inflammatory infiltrate, allowed for the diagnosis of NIH. Follow-up cranial imaging 10 months after surgery showed no evidence of reappearance of the lesion. There was no progression to panhypopituitarism.

CONCLUSION

Surgery and histopathological confirmation are the key diagnostic feature in NIH. The current case is the fifth report of NIH and the first one with an indolent course and without progression to panhypopituitarism so far.

The Role of Nutrition in the Prevention and Management of Bronchopulmonary Dysplasia: A Literature Review and Clinical Approach

Bronchopulmonary dysplasia (BPD) remains the most common severe complication of preterm birth, and nutrition plays a crucial role in lung growth and repair. A practical nutritional approach for infants at risk of BPD or with established BPD is provided based on a comprehensive literature review. Ideally, infants with BPD should receive a fluid intake of not more than 135-150 mL/kg/day and an energy intake of 120-150 kcal/kg/day. Providing high energy in low volume remains a challenge and is the main cause of growth restriction in these infants. They need a nutritional strategy that encompasses early aggressive parenteral nutrition and the initiation of concentrated feedings of energy and nutrients. The order of priority is fortified mother's own milk, followed by fortified donor milk and preterm enriched formulas. Functional nutrient supplements with a potential protective role against BPD are revisited, despite the limited evidence of their efficacy. Specialized nutritional strategies may be necessary to overcome difficulties common in BPD infants, such as gastroesophageal reflux and poorly coordinated feeding. Planning nutrition support after discharge requires a multidisciplinary approach to deal with multiple potential problems. Regular monitoring based on anthropometry and biochemical markers is needed to guide the nutritional intervention.

BMI Helps to Calculate the Initial Levothyroxine Dose After Total Thyroidectomy

After total thyroidectomy, an initial dose of levothyroxine is often prescribed based on the patient’s body weight (1.6 mcg / kg / day), regardless of body mass index (BMI). The current literature required that hormone maintenance therapy (THR) in obese patients differs from non-obese patients. Review of the clinical processes of patients with papillary carcinoma followed in the multidisciplinary consultation of Endocrine Pathology at CHVNG / E followed a total thyroidectomy from 2015 to 2017. Patients who achieved euthyroidism with THR were included in the analysis and divided according with BMI. Statistical analysis was performed using SPSS version 25.0. A value of p &lt;0.05 was considered statistically significant. The sample included 82 patients, 90.2% (n = 74) female and 9.8% (n = 8) male, with an average age of 53.02 ± 14.27 years. Of the female gender, 52.4% (n = 43) were in menopause. In the postoperative period, 14 patients (17.1%) had a normal BMI, 46 (50%) were overweight and 22 (32.9%) were obese. The average follow-up time was 75.3 months (32-128). A dose of LT4 required to achieve euthyroidism based on the BMI categories mentioned above was 1.70; 1.54 and 1.49 mcg / kg. Patients with a higher BMI needed a higher dose of LT4 to achieve euthyroidism (p &lt;0.05), but the dose was lower in relation to weight (mcg / kg) (p &lt;0.05). There were no differences related to age and need for L-T4 suplementation (p&gt; 0.05). Our study shows that de calculation of the initial levothyroxine dose should also take into account BMI. Overweight and obese individuals should receive a lower dose than that used in normal weight patients, which goes against what has been described in the literature. The weight-based formula, unlike BMI, does not account for the volume of distribution of L-T4 well. Other methods, which include, for example, ideal body weight instead of actual weight, are being developed to help choose the starting levothyroxine dose.

Nasal CPAP complications in very low birth weight preterm infants

BACKGROUND

Nasal trauma due to nasal CPAP (nCPAP) use is a commonly reported complication in infants under 1500 g of birth weight and 32 weeks of gestation. With the rise of nCPAP as the gold standard for non-invasive respiratory support, preventive measures should be considered.

OBJECTIVE

To assess the prevalence and risk factors of nasal injury in very low birth weight (VLBW) preterm infants with nCPAP.

METHODS

We retrospectively analyzed neonates hospitalized between 2012 and 2017, with less than 1500 g and 32 weeks of gestational age who received more than 12 hours of nCPAP. Demographic, antenatal and clinical data, along with information regarding respiratory support and nCPAP complications, were collected. We used Fischer's classification to grade nasal trauma.

RESULTS

A total of 135 infants were evaluated. Mean gestational age was 28 weeks (SD 2) and mean birth weight 1072 g (SD 239). Nasal trauma was reported in 65% of patients and it was of stage I, II and III in 49%, 16% and 1% of patients, respectively. The multivariate logistic regression revealed that the risk of trauma was greater in neonates with a longer duration of nCPAP ventilation (OR = 1.098, 95% CI: 1.055-1.142; p < 0.001) and in patients submitted to oxygen therapy (OR = 3.174, 95% CI: 1.014-9.929, p = 0.004). The median of days after nCPAP administration until the onset of an identifiable lesion was 4.

CONCLUSION

Nasal trauma is a frequent complication in VLBW preterm infants using nCPAP for long periods. Preventive measures in patients who are at greater risk of skin breakdown are of major clinical importance for a better outcome.

Neonatal Atypical Hemolytic Uremic Syndrome in the Eculizumab Era

The atypical hemolytic uremic syndrome (aHUS) in the newborn is a rare disease, with high morbidity. Eculizumab, considered a first-line drug in older children, is not approved in neonates and in children weighing less than 5 kg. We present a 5-day-old female newborn, born at 36 weeks' twin gestation, by emergency cesarean section due to cord prolapse, with birth weight of 2,035 g and Apgar score of 7/7/7, who develops microangiopathic hemolytic anemia, thrombocytopenia, and progressive acute renal failure. In day 5, after diagnosis of aHUS, a daily infusion of fresh frozen plasma begins, with improvement of thrombocytopenia and very slight improvement in renal function. The etiologic study (congenital infection, Shiga toxin, ADAMTS13 activity, directed metabolic study) was normal. C3c was slightly decreased. On day 16 for maintenance of anemia and severe renal failure, she started 300 mg/dose eculizumab. Anemia resolves in 10 weeks and creatinine has normal values after 13 weeks of treatment. The genetic study was normal. In this case, eculizumab is effective in controlling microangiopathy and in the recovery of renal function. Diagnosis of neonatal aHUS can be challenging because of phenotypic heterogeneity and potential overlap with other manifestations that may confound it, such as perinatal asphyxia or sepsis/disseminated intravascular coagulation.

Massive sacrococcygeal teratoma in a preterm infant

In extreme preterm infants, massive congenital sacrococcygeal teratomas with great hemodynamic commitment may be a situation for limitation of care.

Eficácia e adesão a orientações fisioterápicas e psicológicas aplicadas em indivíduos com enxaqueca – Projeto Brasília sem Enxaqueca

IntroduçãoA enxaqueca é uma das doenças mais incapacitantes do mundo e seu tratamento é desafiador. A intervenção interdisciplinar tem se mostrado eficaz, porém sua utilização protocolar ainda é escassa.Material e MétodosOs critérios de inclusão foram indivíduos com diagnóstico de enxaqueca e encaminhados da rede pública. No primeiro atendimento foi oferecido, além das orientações médicas, treinamento em técnicas fisioterápicas e psicológicas com duração de 1 hora cada. Cada técnica oferecida foi avaliada individualmente a cada 2 meses sobre sua adesão e sua eficácia. São elas: 1 exercícios de fisioterapia ensinados e disponibilizados em folder para serem realizados diariamente; 2 exercícios de fisioterapia para o momento de crise; 3 utilização do aplicativo de relaxamento “Acalma”; 4 exercícios de respiração ensinados pela psicologia; 5 meditação (mindfulness)ensinado pela psicologia; 6 relaxamento muscular progressivo ensinado pela psicologia; 7 técnica de visualização ensinado pela psicologia. Os endpoints primários consistiam na contagem dos dias de enxaqueca por mês e o consumo de analgésicos por mês, analisados a cada 2 meses. Os endpoints secundários, motivos desse estudo, foram a porcentagem de técnicas utilizadas ao final dos 6 meses e o seu grau de satisfação elevado (bastante melhora) com as técnicas utilizadas através da escala de Likert (concordo/ discordo) a respeito se determinada técnica trouxe bastante alívio (superior a 75%).ResultadosDos 12 indivíduos, oito completaram o acompanhamento de 6 meses. Quanto a adesão às técnicas oferecidas, 100% dos indivíduos testaram alguma delas. Das 7 técnicas oferecidas, 6 tiveram indivíduos que referiram bastante melhora. Apenas o exercício para o momento da crise não obteve bastante melhora. Todas as técnicas também tiveram indivíduos que não melhoraram e que não fizeram testaram vez. A técnica com melhor resultado foi o aplicativo “Acalma” com 38% de usuários referindo bastante melhora. A técnica menos eficaz foi o exercício para o momento da crise, com 75% discordando que melhoraram bastante. A técnica menos testada foi o relaxamento muscular progressivo, com 50% de indivíduos testando.ConclusõesTécnicas fisioterápicas e psicológicas para enxaqueca apresentam boa adesão e propiciam bastante melhora em alguns indivíduos. Recomenda-se oferecer sempre adicionalmente ao tratamento médico.

Open-care telemedicine in ophthalmology during the COVID-19 pandemic: a pilot study

Objetivo

Reportar una experiencia piloto de atención por telemedicina en la especialidad de oftalmología, en el periodo de confinamiento por la pandemia por COVID-19.

Métodos

Estudio descriptivo. Se describen características demográficas y clínicas de pacientes atendidos en periodo de confinamiento de 10 semanas. Se evalúa la satisfacción de los pacientes y médicos participantes mediante una encuesta en línea.

Resultados

En las primeras 10 semanas, se realizaron 291 atenciones de telemedicina oftalmológica. Los principales motivos de consulta fueron afecciones inflamatorias de la superficie ocular y párpados (79,4%), seguido de requerimientos administrativos (6,5%), afecciones no inflamatorias de la superficie ocular (5,2%), sospecha de estrabismo (3,4%) y síntomas vitreorretinales (3,1%); 22 pacientes (7,5%) fueron derivados a atención presencial inmediata. El nivel de satisfacción con la prestación fue alto, tanto en médicos (100%), como en pacientes (93,4%).

Conclusiones

La atención oftalmológica por telemedicina en periodo de pandemia es un instrumento de utilidad para realizar un filtro de potenciales consultas presenciales, ya sea electivas o de urgencia, y para reducir potencialmente el riesgo de contagio por COVID-19.

Pulmonary pneumatoceles in neonates

Pulmonary pneumatoceles were relatively common in neonates in the pre-surfactant era. In the current era of surfactant, noninvasive and gentle invasive ventilation there is a paucity of data on clinical characteristics and outcomes of pneumatoceles in neonates. The lesion generally resolves spontaneously, but a few cases follow a complicated course with formation of extensive and expanding lesions. To better understand the pathophysiology, clinical significance, natural history, complications, treatment options and prognosis of pulmonary pneumatoceles in neonates, an extensive research was performed on the databases of medical literature. The information collected in this review is important for the clinicians in decision-making, especially in the most difficult cases.

Basic life support training with high schools’ teachers in Bahia, Brazil: an experimental study

Background

Early performing of cardiopulmonary resuscitation is the cornerstone of survival in out-of-hospital cardiac arrest, doubling the odds of survival when correctly performed. The American Heart Association and the European Resuscitation Council advocate for training the entire population in order to enable a quick and effective response to out-of-hospital cardiac arrests, improving its outcomes. In primary healthcare settings the health workers can act as trainers, using the family and territorial approach to deliver basic life support (BLS) basis to general population, assuring that key social actors are skilled enough to aid community when needed. This study aims to compare the knowledge and practice skill of high school teachers before and after a BLS training delivered by health workers and students in a primary healthcare setting.

Methods

Teachers of three public high schools in Bahia, Brazil were assessed by a test for theoretical and practical skill in BLS and then trained by a group of primary care workers and students. Training included a 20min lecture and 40min practice session in a simulated scenario. After the training the teachers were assessed with the same test for theoretical and practical skill. A paired-samples T test was used to detect the difference in the mean total score before and after the training, with a significance level of 0.05 (two-sided test) and 95% confidence interval.

Results

The mean total score after the BLS training (8.2 ± 1.5) was significantly higher (p &lt; 0.000) from before training (4.5 ± 1.7).

Conclusions

The high school teachers were unable to deliver proper cardiopulmonary resuscitation before the intervention. Following a BLS training a significant immediate improvement in the knowledge and practical skill was detected. Health workers were able to achieve these results in a primary healthcare setting. Further studies should assess this outcome with larger samples, evaluating the retention of knowledge and skills provided.

Key messages

Basic life support training can be delivered to general population by health workers in primary healthcare settings in order to improve the outcomes to out-of-hospital cardiac arrests. Teachers and health workers can act as key actors in intersetorial health-education initiatives, promoting the health of their communities.

Small for gestational age very preterm infants present a higher risk of developing bronchopulmonary dysplasia

INTRODUCTION

Several studies assessed the influence of a low birth weight on bronchopulmonary dysplasia (BPD), but not all could find a significant association. Our aim was to assess the association between low birth weight and BPD in preterm infants, prospectively recruited at 11 level III Portuguese neonatal centers.

METHODS

Obstetrical and neonatal data on mothers and preterm infants with gestational ages between 24 and 30 weeks, born during 2015 and 2016 after a surveilled pregnancy, were analyzed. Neonates were considered small for gestational age (SGA) when their birthweight was below the 10th centile of Fenton's growth chats and BPD was defined as the dependency for oxygen therapy until 36 weeks of corrected age. Statistical analysis was performed using IBM SPSS® statistics 23 and a p-value <0.05 was considered statistically significant.

RESULTS

Out of 614, a total of 494 preterm infants delivered from 410 women were enrolled in the study; 40 (8.0%) infants with SGA criteria. SGA were more often associated with a single pregnancy, had greater use of antenatal corticosteroids, increased prevalence of gestational hypertensive disorders, C-section, rupture of membranes below 18 hours, rate of intubation in the delivery room, use of surfactant treatment, oxygen therapy, mechanical ventilation need, BPD, cystic periventricular leukomalacia, nosocomial sepsis and pneumonia; had lower prevalence of chorioamnionitis, and lower Apgar scores. The multivariate analysis by logistic regression, adjusted for BPD risk factors revealed a significant association between SGA and BPD: OR = 5.2 [CI: 1.46-18.58]; p = 0.01.

CONCLUSION

The results of this study increase the scientific evidence that SGA is an independent risk factor for BPD.

OP0045 DELINEATION OF A PROINFLAMMATORY CYTOKINE PROFILE TARGETED BY JAK1/2 INHIBITION USING BARICITINIB IN A PHASE 2 SLE TRIAL

Background:

Given the unmet clinical needs in systemic lupus erythematosus (SLE), including poor disease control and drug toxicities, new therapies are needed. In a phase 2, randomized, placebo-controlled, double-blind study (JAHH), once-daily baricitinib (bari) resulted in significant clinical improvement in patients (pts) with active SLE versus PBO. Bari inhibits JAK1 and JAK2 signalling, and in turn may affect STAT1, STAT2, STAT4 pathways. Therefore, bari has the potential to simultaneously impact several pro-inflammatory immune cytokines implicated in the pathogenesis of SLE, including IFN-α, IFN-γ, IL-6, IL-12, and IL-23.

Objectives:

The objectives of the current study were: 1) to examine baseline serum cytokines in the JAHH phase 2 clinical trial for correlations with clinical or immunologic assessments; 2) to determine if changes in serum cytokine levels were associated with bari treatment.

Methods:

Pts enrolled in the JAHH phase 2 trial received daily treatment with PBO, bari 2 mg, or bari 4 mg through week 24. Serum samples were collected at baseline (week [wk] 0), wk 12, and wk 24) from SLE pts (n=270) and 50 sex- and age-matched controls. Samples were analyzed for: IL-2, IL-3, IL-5, IL-6, IL-10, IL-17A, IL-21, IL-12/23p40, IL-12p70, GM-CSF, IFN-α and IFN-γ using ultrasensitive quantitative assays. IFN gene signature, autoantibodies, C3 and C4 were measured as previously described [1].

Results:

At wk 0, serum IL-17A, IL-12/23p40, IL-6, IFN-γ and IFN-α were readily detectable. IL-12/23p40 was detectable in 100% of pts vs. 100% of controls, IFN-γ in 89% of pts vs. 66% of controls, IL-6 in 53% of pts vs. 12% of controls and in IFN-α 41% of pts vs. 2% of controls; detection of serum IL-2, GM-CSF, IL-5, IL-10 and IL-17A was variable (Fig 1). At baseline (wk 0), IL-12/23p40 was positively correlated with SLEDAI and IFN gene signature and negatively correlated with serum C4. IL-6 was positively correlated with joint swelling, joint tenderness, IFN-γ and C3. Serum IFN-α was positively correlated with serum IFN-γ, anti-Sm and anti-RNP, and the IFN gene signature (Fig 2). Treatment with bari 4 mg (Fig 1B) significantly decreased serum IL12/23p40 and IL-6 cytokine levels at wk 12 (p<0.05) but not serum IFN-α or IFN-γ levels (Fig 1B).

Figure 1.

* p = 0.015; ** p = 0.001; Abbreviations: LLOQ, Lower limit of quantification.

Figure 2.

Abbreviations: Anti-dsDNA, Anti-double stranded DNA; Anti-RNP, Anti-ribonucleoprotein; CLASI, Cutaneous lupus erythematosus disease area and severity index; SLEDAI, SLE disease activity index.

Conclusion:

Bari 4 mg treatment was associated with statistically significant decreases of serum IL-12/23p40 and IL-6 at week 12 which continued through week 24. Serum IFN-α or IFN-γ were not reduced with bari treatment. Thus, bari 4 mg simultaneously impacted multiple pro-inflammatory cytokines implicated in the pathogenesis of SLE.

References:

[1]Hoffman RW, et al.Arthritis Rheumatol.2017;69(3):643-654.

Disclosure of Interests:

Thomas Dörner Grant/research support from: Janssen, Novartis, Roche, UCB, Consultant of: Abbvie, Celgene, Eli Lilly, Roche, Janssen, EMD, Speakers bureau: Eli Lilly, Roche, Samsung, Janssen, Yoshiya Tanaka Grant/research support from: Asahi-kasei, Astellas, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Pfizer, and Ono, Consultant of: Abbvie, Astellas, Bristol-Myers Squibb, Eli Lilly, Pfizer, Speakers bureau: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Sanofi, UCB, and Teijin, Michelle A Petri Grant/research support from: GSK, Eli Lilly and Company, Consultant of: Eli Lilly and Company, Josef S. Smolen Grant/research support from: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Consultant of: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Daniel Wallace Consultant of: Amgen, Eli Lilly and Company, EMD Merck Serono, and Pfizer, Brenda Crowe Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Ernst Dow Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Richard E Higgs Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Guilherme Rocha Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Robert Benschop Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Maria Silk Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Stephanie de Bono Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Robert Hoffman Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Damiano Fantini Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company

OP0001 BARICITINIB, TOFACITINIB, UPADACITINIB, FILGOTINIB, AND CYTOKINE SIGNALING IN HUMAN LEUKOCYTE SUBPOPULATIONS: AN UPDATED EX-VIVO COMPARISON

Background:

everal JAKi are now used for the treatment of RA; approved doses include baricitinib (bari) 2- and/or 4-mg QD, tofacitinib (tofa) 5-mg BID, upadacitinib (upa) 15-mg QD. The JAK selectivity these agents is proposed to vary across the class.

Objectives:

In vitro cellular pharmacology of bari to tofa, upa, and filgotinib (filgo) were compared.

Methods:

PBMCs from 6 healthy donors were incubated with the JAKis over a 7- to 8-point concentration range. Following cytokine stimulation, levels of pSTAT were measured and IC50 calculated in gated leukocyte subpopulations. Therapeutic dose relevance was assessed using calculated mean concentration-time (CT) profiles over 24 hours for bari 2- and 4-mg QD; tofa 5- and 10-mg BID; upa 15- and 30-mg QD; filgo 100- and 200-mg QD. Average daily % inhibition of pSTAT (%SI) was calculated for each JAKi, cytokine, and cell type; filgo %SI integrated parent drug + metabolite.

Results:

The cytokines did not signal in all cell types (Figure 1). When signaling was detected, IC50 and %SI for a particular JAKi were generally similar across cell types, with dose-dependent inhibition (Figures 1 & 2). Based on IC50s, upa was most and filgo/metabolite least potent across JAK2/2 or JAK2/TYK2-dependent (IL-3, GM-CSF, G-CSF), JAK1/3-dependent (IL-2, 4, 15, 21), and JAK1/2/TYK2 dependent (IL-6 & 10, IFN-α & γ) signaling pathways.

Figure 1.

IC50 values (nM) for baricitinib, tofacitinib, upadacitinib, filgotinib (parent and metabolite) in cytokine-stimulated human PBMC preparations. *p<0.01, **p<0.001, ***p<0.0001 vs. bari.

Incorporating CT profiles, no agent potently or continuously inhibited an individual cytokine signaling pathway throughout the dosing interval. Comparing bari 4-mg to tofa 5-mg BID, upa 15-mg QD, and filgo 100-mg QD, %SI of JAK2/2 or JAK2/TYK2-dependent cytokines was highest with bari 4-mg and upa. Inhibition of JAK1/2/TYK2 cytokines was highest with bari 4-mg. Inhibition of JAK2/2 or JAK2/TYK2, and of JAK1/3-dependent cytokines was lowest for filgo 100-mg QD. For bari 2-mg QD vs. these other JAKi doses, %SI of JAK2/2 or JAK2/TYK2 was highest with upa followed by bari 2-mg. The highest inhibitors of the JAK1/2/TYK2-dependent cytokines varied by cytokine / cell type though consistently included upa. Inhibition of JAK1/3 was highest for upa and tofa. Across comparisons, filgo 100-mg QD showed the least %SI of JAK2/2 or JAK2/TYK2-dependent, and of JAK1/3-dependent cytokines. Filgo reached the highest levels of %SI among agents only for 200-mg QD vs. lower doses of the other JAKi (for selected JAK1/2/TYK2-dependent cytokines).

Conclusion:

JAKis display different in vitro pharmacologic profiles which, coupled to their in vivo pharmacokinetics, suggest they modulate distinct cytokine pathways to differing degrees and durations over 24 hours. Ex vivo whole cell assays seem distinct from cell free kinase inhibition assays in determining the overall cytokine modulatory potential of members of the JAKi class.

References:

[1]McInnes IB, et al. Arthritis Res Ther. 2019 Aug 2;21(1):183

Figure 2.

Baricitinib, tofacitinib, upadacitinib, filgotinib: calculated average percent daily STAT inhibition for selected cytokines. -p<0.01, --p<0.001, ---p<0.0001 significantly lower compared to bari (vs. 2-mg if left of vertical line “|”, vs. 4-mg if right of vertical line “|”). +p<0.01, ++p<0.001, +++p<0.0001 significantly higher compared to bari (vs. 2-mg if left of vertical line “|”, vs. 4-mg if right of vertical line “|”).

Disclosure of Interests:

Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Guilherme Rocha Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Richard E Higgs Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Daniel Dairaghi Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Thomas Wehrman Shareholder of: An insignificant amount in AbbVie as part of a larger portfolio, Consultant of: Primity Bio Inc. works with many pharmaceutical and biotech companies and provides CRO services., Evan Wang Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Zhang Xin Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Jorge Ross Terres Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Terence Rooney Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB

Functional Insights From the Evolutionary Diversification of Big Defensins

Big defensins are antimicrobial polypeptides believed to be the ancestors of β-defensins, the most evolutionary conserved family of host defense peptides (HDPs) in vertebrates. Nevertheless, big defensins underwent several independent gene loss events during animal evolution, being only retained in a limited number of phylogenetically distant invertebrates. Here, we explore the evolutionary history of this fascinating HDP family and investigate its patchy distribution in extant metazoans. We highlight the presence of big defensins in various classes of lophotrochozoans, as well as in a few arthropods and basal chordates (amphioxus), mostly adapted to life in marine environments. Bivalve mollusks often display an expanded repertoire of big defensin sequences, which appear to be the product of independent lineage-specific gene tandem duplications, followed by a rapid molecular diversification of newly acquired gene copies. This ongoing evolutionary process could underpin the simultaneous presence of canonical big defensins and non-canonical (β-defensin-like) sequences in some species. The big defensin genes of mussels and oysters, two species target of in-depth studies, are subjected to gene presence/absence variation (PAV), i.e., they can be present or absent in the genomes of different individuals. Moreover, big defensins follow different patterns of gene expression within a given species and respond differently to microbial challenges, suggesting functional divergence. Consistently, current structural data show that big defensin sequence diversity affects the 3D structure and biophysical properties of these polypeptides. We discuss here the role of the N-terminal hydrophobic domain, lost during evolution toward β-defensins, in the big defensin stability to high salt concentrations and its mechanism of action. Finally, we discuss the potential of big defensins as markers for animal health and for the nature-based design of novel therapeutics active at high salt concentrations.

Renal Dysplasia and Progressive Renal Failure in a Newborn with Interstitial Chromosome 4 Deletion 4q25-28.3: A New Phenotype?

The deletion of the long arm of chromosome 4 is rare, presenting with a variable phenotype depending on the chromosomic area affected. A term newborn with prenatal diagnosis of anhydramnios, dysplastic cystic kidneys, and cardiomegaly was born with generalized subcutaneous edema, several dysmorphic features, and progressive renal failure requiring dialysis. The infant continued to deteriorate and died at 52 days of age. Autopsy confirmed bilateral renal dysplasia with cysts. Array-comparative genomic hybridization (CGH) identified a large deletion on 4q25-q28.3, which is not yet described in association with renal disease. The clinical progression could be expected due to the severity of the perinatal clinical presentation.

Very preterm infant outcomes according to timing of birth

INTRODUCTION

Extremely preterm infants are a population of high risk for morbidity and mortality. NICU's staffing is often lower during nights, weekends and holidays than weekdays, and this fact may contribute to higher morbidities and mortality. Our aim was to analyze the neonatal morbidity and mortality of very preterm infants delivered at our center and admitted to the NICU during the night period, weekends and holidays compared to that registered on weekday admissions.

METHODS

A retrospective study was conducted at our level III NICU, including data on mother, pregnancy, delivery, and neonatal outcomes of preterm infants with a gestational age below 30 weeks, admitted between January 1st 2005 and December 31st 2017. Statistical analysis was performed using IBM SPSS® Statistics 23.

RESULTS

220 infants were included in the study; median gestational age 27 weeks (min = 23; max = 29); median birth weight of 922 g (min = 360; max1555); 95 (43.2%) infants were delivered during weekdays and 125 (56.8%) were delivered during weeknights, weekends and holidays. There were no differences on mother's age, pregnancy complications, Apgar scores, birth weights, gestational ages and gender between the two groups. C-sections (p = 0.006), and small for gestational age infants (p = 0.010) were more prevalent in week day births. Chorioamnionitis with chorionic vasculitis (p = 0.028) and cystic periventricular leukomalacia (p = 0.032) were more prevalent in those delivered during the night period, weekends and holidays. In the multivariate analysis, cystic periventricular leukomalacia was not associated to a deliver during weeknights, weekends and holidays (OR = 0.580; 95% CI: 0.19-1.71, p = 0.324).

CONCLUSION

We did not find any increased morbidity and mortality associated with a birth during nights, weekends and holidays compared to that registered on weekday admissions.