Small prenatal diameter of the ascending aorta is associated with increased mortality risk in neonates with congenital diaphragmatic hernia

INTRODUCTION

The aim of this study was to evaluate whether selected prenatal markers obtained from fetal echocardiography can predict postnatal outcome in congenital diaphragmatic hernia (CDH) patients. We also aimed to verify the prognostic value of lung-to-head ratio (LHR).

MATERIAL AND METHODS

The study group included 29 fetuses with CDH. We analyzed potentially prognostic parameters measured using fetal echocardiography and fetal ultrasound. The assessed parameters were compared between the group of patients with CDH who survived to discharge (n = 21) and the subset of patients who died before discharge from hospital (n = 8).

RESULTS

In survivors, mean z-score for ascending aorta (AAo) diameter was 0.23 ±0.98 vs. - 1.82 ±1.04 in patients who died (t-test, p = 0.0015). In survivors, the main pulmonary artery/ascending aorta ratio was 1.22 ±0.17 vs. 1.46 ±0.21 in patients who died (t-test, p = 0.017). In survivors, the LHR was 1.81 ±0.96 vs. 0.95 ±0.6 in patients who died (t-test, p = 0.019). In survivors, the observed to expected LHR was 57 ±30% vs 30 ±18% in patients who died (t-test, p = 0.018).

CONCLUSIONS

Narrowing of the ascending aorta in CDH fetuses is a poor prognostic factor associated with increased mortality in neonates. Our study also confirmed the prognostic value of LHR.

Usefulness of two types of pain monitors in newborns treated in NICU, in the opinion of experts: Results of the survey

Pain experienced in the neonatal period has been shown to have serious short- and long-term consequences. It is also known that painkillers have side effects and should not be abused. The basis of proper pain management is assessment of pain, which in newborns is very difficult due to the lack of verbal communication. In these patients, behavioural scales are used to assess pain, but they have numerous shortcomings. For this reason, many newborns treated in the ICU are at risk of pain, so instrumental methods of detecting and assessing the severity of pain are being sought. During three months, seven Polish NICUs conducted research with the use of NIPE and SCA monitors. After this time, the heads of these departments filled in questionnaires regarding their individual opinions on the usefulness of these devices. All respondents found pain monitors useful in the NICU. The NIPE monitor was rated slightly higher, as its usefulness in assessing the effectiveness of analgosedation and in the management of patients in the postoperative period was better rated. The high acceptance of both devices by legal guardians of newborns is noteworthy. It should be stated that in newborns, any way to improve pain monitoring is valuable. In the opinion of Polish experts, pain monitors are useful in NICU. The NIPE monitor was assessed a little higher and was considered useful in the assessment of analgosedation and in postoperative treatment. Pain monitors can provide valuable support for pain assessment in newborns treated in the NICU.

Newborn Infant Parasympathetic Evaluation Index for the Assessment of Procedural Pain in Nonanesthetized Infants: A Multicenter Pilot Study

OBJECTIVE

The aim of this study is to evaluate the ability of the Newborn Infant Parasympathetic Evaluation (NIPE) index to detect the response to nociceptive stimuli in nonanesthetized infants and to compare these results to simultaneous scoring by behavioral scales.

STUDY DESIGN

Thirty-six nonanesthetized infants admitted to neonatal/pediatric intensive care unit (N/PICUs) were enrolled to the study. Due to faulty records of the data, three patients had to be excluded. To detect pain caused by noxious stimuli, the heart-rate-variability-derived NIPE index and behavioral pain scales designed for measuring procedural pain in nonverbal children were used.

RESULTS

Forty-one painful events were available for analysis. We observed in the whole group a statistically significant decrease in NIPE values at 1, 2, and 3 minutes after a painful stimulus, in comparison to the NIPE value at rest and the statistically significant differences between the minimum NIPE value within 3 minutes after the stimulus in comparison to NIPE value at rest in the whole group, as well as in the subgroups of moderate and severe pain. Receiver operating characteristic (ROC) analysis has shown the strong sensitivity and specificity of the NIPE in detecting the noxious stimuli (ROC AUC: 0.767). We also found that the stronger the sensation of pain was, the more rapidly NIPE reached its lowest value.

DISCUSSION

Our study indicates that the painful procedures are associated with a significant decrease in the NIPE value within 3 minutes after a noxious stimulus. Based on our observation, the minimum value within 3 minutes from the painful procedure seems to be the most distinctive value.

Newborn infant parasympathetic evaluation for the assessment of analgosedation adequacy in infants treated by mechanical ventilation - a multicenter pilot study

INTRODUCTION

Adequate analgosedation is important in infants treated in pediatric/neonatal intensive care units (P/NICUs), because both too deep and insufficient analgosedation is disadvantageous. To assess the severity of pain, several behavioral and behavioral-physiological scales are used, but their usefulness is limited. It is therefore justified to search for additional methods to assess the adequacy of analgosedation in these patients. The aim of the present study is to evaluate the usefulness of Newborn Infant Parasympathetic Evaluation (NIPE) in the assessment of analgosedation quality in infants requiring mechanical ventilation, who are treated in P/NICUs.

MATERIAL AND METHODS

We performed simultaneously 180 COMFORT-B assessments and heart rate variability measurements using a NIPE monitor in 30 mechanically ventilated infants receiving analgosedation. A generalized linear mixed model with the logit link function was used in order to perform logistic regression analysis to assess the relationship between NIPEi/NIPEm and deep sedation.

RESULTS

The multivariable logistic regression model showed that NIPEi and NIPEm values were higher when analgosedation was deep as compared to when it was moderate or insufficient (OR (95% CI): NIPEm - 1.065 (1.007-1.126), p = 0.03; NIPEi - 1.068 (1.016-1.123), p = 0.01).

CONCLUSIONS

The NIPE indexes are significantly higher in patients whose assessment on the behavioral scale indicates deep analgosedation as compared to those in whom it indicates moderate or insufficient analgosedation. Allowing continuous monitoring, the NIPE device may be a valuable assisting tool in the assessment of analgosedation quality in mechanically ventilated newborns and infants.

Procedural Pain Assessment in Infants Without Analgosedation: Comparison of Newborn Infant Parasympathetic Evaluation and Skin Conductance Activity - A Pilot Study

Objective: New technologies to measure pain responses, such as heart rate variability and skin conductance hold promise in the development of tools that can be reliable and quantifiable of detecting pain. The main objective of this study was to assess the capability of two monitors i.e., Newborn Infant Parasympathetic Evaluation (NIPE) and Skin Conductance Algesimeter for detecting procedural pain in non-anesthetized infants. Materials and Methods: Thirty-three non-anesthetized infants were enrolled to the study. To detect pain caused by heel stick, NIPE, and Skin Conductance monitors and behavioral pain scales were used. Three minutes before and just after heel stick, pain was evaluated by behavioral scales, and simultaneously over the whole period by NIPE and SCA. Results: A statistically significant decrease of NIPE Index and an increase of SCA values were found after the HS procedure. There were no statistically significant differences between the decrease in NIPEi values and the increase in PPS values between subgroups based on pain assessment by behavioral-scale scores. Conclusion: Both NIPE and SCA can be useful for detection of procedural pain and may constitue an additional valuable tool for better handling of pain among patients treated in NICUs. More studies on larger groups of patients are needed.

Skin conductance measurement for the assessment of analgosedation adequacy in infants treated with mechanical ventilation: A multicenter pilot study

BACKGROUND

Patients treated in neonatal/pediatric intensive care units (N/PICUs) are frequently exposed to pain. To assess its severity, several behavioral and behavioral-physiological scales are used, but their usefulness is limited. It is therefore justified to search for additional methods to assess the adequacy of analgesia and sedation in these patients.

OBJECTIVES

To evaluate the usefulness of skin conductance (SC) measurement in the assessment of analgosedation quality in infants requiring mechanical ventilation treated in N/PICUs.

MATERIAL AND METHODS

Thirty infants aged 6-208 days treated in 6 N/PICUs, mechanically ventilated and receiving analgosedation, were included for the study. Simultaneous COMFORT-B assessment and SC measurement using SCA (skin conductance algesimeter) monitor were performed. Due to technical problems, not all of the SC records could be interpreted, and finally 412 simultaneous assessments on the COMFORT-B scale and SC measurements in 29 patients were analyzed.

RESULTS

We found a statistically significant correlation between the COMFORT-B scoring and the SC measurements. Additionally, SC was significantly lower when the behavioral score indicated deep sedation, in comparison to periods when it indicated moderate or insufficient analgosedation.

CONCLUSIONS

Skin conductance measurements are comparable with the COMFORT-B rating in mechanically ventilated infants receiving analgosedation. The SCA monitor may be of value in the assessment of analgosedation quality, and in particular may identify the situation where sedation is deep. Further research is needed regarding the suitability of this device in clinical practice.

Intake of folic acid by Polish women with higher education - a survey research: can we do more?

OBJECTIVES

The objective of the study is to determine efficacy of the Primary Prevention Program of Neural Tube Defects in Polish women with higher education in 5-year interval.

MATERIAL AND METHODS

Survey research was conducted twice (in 2008 and 2013) in 630 female students of universities: 305 female medical students and 325 female non-medical students. The survey was also done among women aged 27- 35 who graduated from medical or non-medical universities and have at least one child. Questions concerned knowledge about prophylaxis and periconceptional folic acid intake. Chi square test was used to assess the significance.

RESULTS

Knowledge concerning prophylaxis was significantly higher in female medical students comparing to non-medical ones, both in 2008 (p < 0,001), and in 2013 (p < 0,001). 92.9% in 2008 and 93.9% in 2013 of medical students knew about the necessity of periconceptional folic acid intake. Awareness of female non-medical students was lower (2008 - 35.3% and 2013 - 41.1%) and did not change in the 5-year long period (p = 0.3). There was no significant difference in preconceptional folic acid intake among mothers with medical and non-medical education (53.3% vs. 45% p = 0.4). However, the highest folic acid intake was among mothers -medical doctors who treat children with neural tube defect.

CONCLUSIONS

Difference between medical and non-medical students shows that better educational programs may improve knowledge about prophylaxis. Aside from knowledge, compliance with recommendations of Primary Prevention Program of Neural Tube Defects is unsatisfactory.

Recommendations “Cardio-Prenatal 2017” From Poland

On 27.10.2017, in the course of the CARDIO-PRENATAL Conference at the Polish Mother’s Memorial Institute and Health Centre in Lodz, we presented, among others, the following problems:

classification of prenatal heart defects, fetal hemodynamic status evaluation in the third trimester, expected neonate’s clinical condition, planned procedures to be conducted just after birth and also planned medical staff to be present in the delivery room. Here are our main recommendations following the meeting and discussion.

Retrospective Analysis of Preterm Neonates with Congenital Heart Defects Delivered by Cesarean Section: Unfavourable Outcomes a Necessity for Fetal Cardiology Education During Obstetrical Training?

Introduction: Congenital heart defects are the most frequent reason for deaths during the neonatal and early infancy periods. The aim of this study was to retrospectively analyze singleton pregnancy outcomes of premature neonates with congenital cardiac defects delivered by Cesarean section. Materials and methods: A retrospective analysis was performed on 10,800 fetuses evaluated in our referral fetal cardiac center between 2010 and 2016. A group of 58 singleton pregnancies was selected with the following criteria: fetal heart defect, Cesarean section (C-section), and gestation of 37 weeks or less. Exclusion criteria included labor outside of our hospital and multiple pregnancy. Results: Isolated heart defects constituted 74,1% (43 cases) of the analysed data set. The majority of newborns were delivered at 36 weeks of gestation (43,1%), with an average of 33,6 weeks. In one case (1,7%), C-section took place at 22nd week. Birth weight of newborns < 2500g constituted 51,7% (30 cases). Neonatal deaths occurred in 60,3% (35 cases). Conclusions: Preterm neonates with congenital heart defect, delivered by C-section in our reference centre, during 2010 to 2016, had generally poor outcomes and high mortality rate. The average hospital stay of surviving neonates was approximately two months. An improvement of knowledge about prenatal cardiology is necessary in obstetrician management with fetuses with congenital heart diseases.

Prenatal Diagnosis of TAPVC on Monday, Delivery of Tuesday and Cardiac Surgery at Wednesday - A Model of Perinatal Care in 3rd Trimester in Case of Fetal/Neonatal Critical Heart Defect in Tertiary Center

Total anomalous pulmonary venous connection (TAPVC) is a congenital heart defect (CHD), in which all pulmonary veins connect to the systemic veins or to the right atrium/coronary sinus instead of the left atrium. We present a case report of fetus with prenatally diagnosed isolated infracardiac type of TAPVC in 38th week of gestation. In fetal echocardiographic examination performed in the Department of Prenatal Cardiology, the fetus presented lack of visible pulmonary veins connection to left atrium, abnormal venous confluence behind left atrium, additional vein leading from abdominal cavity to mediastinum and abnormal smooth Doppler blood flow in pulmonary confluence. The accurate prenatal diagnosis allowed to deliver the neonate at term, in tertiary center one day after diagnosis, and to perform surgical reposition of pulmonary veins the following day. The neonate was referred home in a good condition after 28 days of hospitalization. This case is a good example of the value of the 3rd trimester echocardiography.

Assessment of the accuracy in prenatal diagnosis of congenital malformations. Analysis of 101 questionnaires filled in by parents of neonates hospitalized in the Department of Congenital Malformations Polish Mother's Memorial Research Institute

Introduction:

Prenatal diagnosis is an integral part of modern perinatal care. In the article results of questionnaires pertaining to the prenatal process of diagnosis are presented. Parents whose children were afflicted with congenital malformations of all types responded to enquiry

Materials and methods:

Between March 2014 and March 2015 150 of 355 infants were hospitalized in the Department of Pediatric Intensive Care and Congenital Malformations in Łódź, and 150 had congenital malformations.

Results:

101 parents of 150 children (67,3%) have given the feedback. Anomalies were such as: of the digestive system (37%), CHD (25%), OUN (14 %), genito-urinary (13%), skeletal system (9%) and respiratory system (2%). In 65 children of 101 the defects were detected prenatally. The obstetric US exam was the most frequently pointed out as performed (more than 1200). The biochemical markers and genetic tests in were performed in 34 pregnancies. The high percentage of ability to detect malformation was reported in the group of fetal echo examinations.

Conclusions:

1. Prenatal ultrasound exams were the least effective method of making appropriate prenatal diagnosis of congenital malformation.

2. Fetal echocardiography had a high level of sensitivity and specificity in detecting congenital malformations.

3. Prenatal cardiologists proved to be the most effective in detecting congenital malformations 89,3 % of detected abnormalities.

4. Biochemical exams had a positive result in only one case of Down Syndrome.

[Successful intrauterine therapy in a fetus with a large lung cyst in the third trimester of pregnancy--case report]

Congenital cystic adenomatoid malformation is a rare disorder of the respiratory system which occurs with an incidence of 1/25,000-35,000. Depending on the size of the cysts, CCAM is classified into microcystic and macrocystic. Very large lesions carry a significant risk of causing both, pulmonary hypoplasia due to compression of the lung tissue and fetal hydrops, probably due to impaired cardiac function as a result of mediastinal shift and compression of the vena cava. In this report, we present a case of a fetus with prenatally diagnosed large cyst of the left lung. Despite advanced gestational age, the baby was treated by thoracoamniotic shunting owning to developing impaired cardiac function and polyhydramion. Spectacular effects of the therapy have been achieved.

Difficulties in the hemodynamic assessment of the newborn with prenatally treated congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a malformation with a diverse clinical picture. Its severity can be assessed prenatally using the lung area to head circumference ratio (LHR). LHR lower than 1 as associated with high mortality is an indication for prenatal treatment involving occlusion of fetal trachea. Before such treatment other congenital malformations must be excluded. Assessment of circulatory system in these patients is difficult. Heart is compressed by viscera in the thorax that decreases blood return to the left atrium, and structures of the left heart may be smaller than in healthy fetuses. The echocardiographic picture may be similar to some congenital defects of the left heart. Differentiation between structural and functional cardiac abnormalities is difficult but essential for diagnostic and therapeutic decisions in the most severe type of CDH. The authors present problems with interpretation of hemodynamic disturbances in a neonate with prenatally diagnosed and treated severe CDH.

[Fetal therapy--evaluation of ventriculo-amniotic shunts in the treatment of hydrocephalus]

OBJECTIVE

The aim of the study was to establish optimal diagnostic and therapeutic scheme and to assess the efficacy of intrauterine therapy of hydrocephalus.

MATERIAL AND METHODS

The study was carried out between 1992-2012 on the total of 222 fetuses with hydro- cephalus, using Orbis-Sigma and ACCU-Flow valves (168 cases) and Cook8 shunts, according to a strictly defined diagnostic and therapeutic scheme.

RESULTS

In the first stage of the study (between 1992-2001), a total of 168 fetuses with prenatally diagnosed hydrocephalus received intrauterine therapy In 91.6% of the cases the therapy resulted in a decreased size of cerebral ventricles. The valve dislocated in 23 cases (13.6%). Preterm delivery occurred in 44% of the affected neonates. Severe mental impairment occurred in 17.76%, average in 36.8%, and slight in 32.9% of the infants. Normal mental development at the age of 3 was observed in 12.5% of the children. A total of 11.2% of chldren did not require further neurosurgical treatment. In the second stage of the study (between 2006-2012) after therapy the size of the right lateral cerebral ventricle decreased by 54.76% (average of27.54 mm to 12.46 mm) and the left lateral cerebral ventricle decreased by 53.12% (average of 26.41 mm to 12.38 mm) (p=0.0018). The maximum and minimum width of the cerebral cortex increased by 23.06% and 27% (average of 9.04 mm to 11.75 mm vs. 3.65 mm to 5 mm), respectively Early complications were observed in 22% of the cases: PROM (6), intrauterine fetal death (4), intrauterine infection (1), and premature detachment of the placenta (1). Average gestational age at delivery was 34 weeks, and 24% of the patients delivered at term.

CONCLUSIONS

Implantation of ventriculoamniotic shunts proved to be an effective form of therapy resulting in normalization of intracranial pressure. In both stages of therapy reduction of ventricular size in patients with hydrocephalus and good neurological outcome (45.4% in I stage, 60% in II stage) were observed. In the second stage of therapy the size of lateral brain ventricles after fetal therapy was significantly lower (54%). A total of 18% of the neonates did not require neurosurgical treatment.

Benign but fatal. A case of a newborn with congenital osteochondroma

Osteochondroma is one of the most frequent benign bone tumors in children. Its incidence is hard to determine because this tumor usually is asymptomatic. These tumors may present as solitary, nonhereditary lesions or as hereditary multiple osteochondromas that are inherited in an autosomal dominant manner. Although osteochondromas are usually asymptomatic, significant symptoms may occur because of complications such as bone fracture, bone deformation, or joint problems. The tumor may also mechanically compress nerves or vessels. Osteochondromas growing inwardly may cause injury to internal organs. The authors present a preterm (34 weeks of corrected gestational age) neonate in whom osteochondroma, although histologically benign, caused death because of its size and location. Prenatal ultrasound imaging performed during the third trimester of pregnancy showed bilateral hydrothorax and hydroperitoneum as well as heterogeneous parenchymal area on the right side of the thorax. After birth, the neonate's condition was extremely severe. Although intensive and multidirectional treatment was applied, the condition of the infant continued to deteriorate and he died 26 h after birth. The autopsy confirmed presence of the tumor - osteochondroma - that caused total mediastinal shift with significant hypoplasia of both lungs and with signs of significant compression of the superior and inferior vena cava.

[Treatment of twin to twin transfusion syndrome - comparison of two therapeutic methods - amnioreduction and lasertherapy]

BACKGROUND

Twin to twin transfusion syndrome occurs in 15% of monochorionic twin pregnancies. Untreated, TTTS has been reported to have a mortality of nearly 100%. Two main therapies include serial amnioreduction and fetoscopic laser coagulation for the vascular anastomoses.

OBJECTIVES

The aim of the project was to investigate the optimal diagnostic and therapeutic procedure in pregnancies complicated by TTTS. Additionally the study was supposed to compare non-invasive and invasive methods of treatment and to show antenatal and postnatal follow - up to 4 months of age.

METHODS

42 pregnant women with twin-to-twin transfusion syndrome were assigned to laser therapy using diode laser and 33 pregnant women underwent only several amnioreductions. Selected parameters characterizing the pregnancy were compared in both groups.

RESULTS

In the amnioreduction group, the perinatal survival rate seven days after the delivery was 31.8%. The survival rate of at least one twin was 39.4%. As compared to the amnioreduction group, in the laser group the survival rate of at least one twin was observed in 31 cases (31/42) and it was equal to 74%. Neurological complications in the amninoreduction group were observed in 19% (4/21) of cases, in the laser group and in 5% (2/40) of neonates at 4 months of age.

CONCLUSIONS

Currently the preferred and only method that addresses the cause of the disease is the endoscopic laser coagulation of anastomoses. Comparison of the two treatments shows better outcomes with higher survival rates and minor neurological defects in cases treated with laser coagulation.

Antibiotics sensitivity of Candida clinical and food-borne isolates

Candida is a yeast species recognized as the most frequent etiological agent of systemic and invasive thrush in humans. Invasions can affect all tissues, organs and systems of human in various stages of development. In the last 10 years Candida infections have increased 15 times. The purpose of our study was to determine the sensitivity of four antibiotics belonging to three different groups of antifungal agents against clinical and food-borne Candida strains. Our studies showed that of all tested strains, 7% was resistant to nystatin, 32% to fluconazole, 23% to voriconazole, and no strains grew in the presence of caspofungin. Despite the differences in biochemical profiles of clinical and food-borne isolates of Candida, a group of strains showing resistance to antibiotics include both types of isolates. At the same time circulating of antibiotic-resistant strains outside the hospital environment and the yeast infection via food is possible.

[Ebstein's malformation in the fetus with cardiomegaly. To treat or to observe?--a case report]

Ebstein's malformation is a rare congenital cardiac defect characterized by an abnormal formation and/or displacement of the leaflets of the tricuspid valve. Prognosis for a neonate is poor in case of cardiomegaly due to coexistence of lung hypoplasia. This paper presents a case of a fetus with Ebstein's malformation with massive cardiomegaly (HA/CA = 0.62) in a 27-year-old patient in her first pregnancy. The cardiac defect was diagnosed in the 22nd week of pregnancy. Due to the fact that the patient decided to continue her pregnancy, and taking into consideration single reports of transplacental Digoxin therapy an attempt to apply Digoxin therapy was made. The mother and the fetus were monitored in two centers, in Rzeszów and in Łódź. In the course of a 12-week transplacental therapy, 8 fetal echocardiography examinations were performed and the following parameters improved: HA/CA (0.62-0.5), CVPS (5/10-7/10) SF RA (0%-11%), SF RV (18%-28%). There was also a conversion of the oxygen test from negative to positive, which seems to document that prevention of the lung hypoplasia was achieved. The neonate died on the 8th day of postnatal life before a cardiac surgery attempt.

[Fetal echocardiography in 83 fetuses with omphalocele from Dept. for Diagnoses and Prevention of Fetal Malformations, Research Institute Polish Mother's Memorial Hospital, and Medical University of Lodz, (1999-2006)]

MATERIAL AND METHODS

It was a retrospective analysis of fetal echocardiography results (analysis of congenital heart defect (CHD) and functional abnormalities in normal heart anatomy) in 83 fetuses diagnosed and treated in the same institution.

RESULTS

In our group of fetuses, the most common structural defect, in addition to omphalocele, proved to be CHD. In the group of omphalocele, normal heart anatomy and functional abnormalities (tricuspid regurgitation, myocardial hypertrophy, arrhythmias), the hospital stay was longer comparing to the group of omphalocele, normal heart anatomy and normal heart study (t-test p = 0.005). CHD was a bad prognostic factor and most fetuses/newborns did not survive (Chi-square 0.0005, Fisher test 0.000032). In the group of omphalocele and normal heart anatomy based on fetal echocardiography, the survival rate was 70%. The omphalocele and CHD survivors (n=3) had been only those who did not require a cardiac surgery in first month of postnatal life.

CONCLUSION

Echocardiography exam of fetus with omphalocele and CHD and functional abnormalities has diagnostic and prognostic value.

[Diaphragmatic hernia in reference hospital ICZMP--diagnostic problems and outcome]

OBJECTIVES

The aim of the study was to analyze US/ECHO examinations in fetuses with diaphragmatic hernia (DH) diagnosed and treated in our institution from 1994-2006, and their follow-up.

MATERIAL AND METHODS

Retrospective analysis of the data base from Department for Diagnoses & Prevention of Fetal Malformations, Research Institute of the Polish Mother's Memorial Hospital: 14,481 fetal echo/ultrasound examinations in 10,077 fetuses have been analyzed to retrieve 115 fetuses with DH.

RESULTS

The mean gestational age at the targeted US/ECHO examination was 30 wks. There were 8 terminations of pregnancies (at mean 21 wks), 6 intrauterine demises, 60 neonatal deaths after delivery (in 1-3rd day of postnatal life), 8 deaths after surgery, 19 neonates were discharged home and in 14 cases the follow-up could not be monitored. The most common anomalies accompanying DH have been central nervous system anomalies (20%), polyhydramnion (16%) and cong heart defects (10%). In this subgroup, there was 100% mortality. Isolated DH has been diagnosed in every third case. In this subgroup, 27 neonates had undergone surgery and the survival rate was 70%, however since 2004 there was not a single death on record.

CONCLUSIONS

Late gestational age of US/ECHO examinations in our tertiary center suggests that DH has been relatively difficult to detect during ultrasound screening. DH and the other structural malformations have been a lethal disease in our series in 100%. Isolated DH was much less frequent and was present in every third case (29%), and in this group the survival rate was 70%, regardless of the way of the delivery (CS or Vaginal).

[Effective transplacental therapy in fetal cardiomegaly to prevent lung hypoplasia--case report]

In our referral center, 14,481 fetal echocardiography examinations were performed in 10,077 fetuses, in years 1994-2006. Fifty four fetuses presented cardiomegaly HA/CA > 0.6. There was one single survivor whose medical history is presented. Fetal cardiomegaly was detected by obstetrical ultrasound screening. In tertiary center HA/CA was evaluated as the following: 0.5 at 32 wks and 0.65 at 36 wks. In addition to cardiomegaly, pulmonary stenosis/atresia, dysplastic tricuspid valve with massive regurgitation were diagnosed. Digoxin was administered transplacentally for 33 days and, additionally, 30 min. oxygen was provided by mask for pregnant woman, 3 times per day. Spontaneous labour took place at 38 wks, with 3100 birth weight and 9 Apgar score. The newborn baby had only temporary tachypnoe, had a planned postdelivery therapy including prostin and cardiacsurgery and was discharged home at the age of 4 weeks in a good clinical condition. This is the first case in our institution of such massive cardiomegaly who did survived the neonatal period. The possible beneficial effects of transplacental digoxin and oxygen therapy are discussed, as well as fetal echocardiography monitoring using HA/CA and pulmonary venous Doppler flow.

[Usefulness of Doppler ultrasound imaging in monitoring of hypoxic-ischemic encephalopathy in preterm infants]

Cerebral blood flow disregulation could be one of the main causes of hypoxic-ischaemic encephalopathy (HIE). It is difficult to differentiate between sonographic appearance of immature periventricular white matter of premature neonate and changes of HIE type. Therefore the diagnostic and prognostic value of doppler ultrasound resistance index (RI) examination in anterior cerebral arteries of premature infants with early sonographic signs of periventricular white matter hyperechogenicity was the aim of the study. The study group consisted of 23 premature infants: birth weight 1550 +/- 570 g, gestational age 24-32 weeks, Apgar score 2-7 points, of which 19 were ventilated. Doppler ultrasound imaging was performed twice: during the first 24 hours of life and 3 weeks later. As not all infants survived to the time of control examination, the final study group consisted of 17 subjects. Doppler examination of premature infants having finally sonographic signs of HIE (n = 12) revealed that RI value in this group of infants was increased during initial as well as the next examination. In the group of premature infants having finally normal sonographic scan (n = 5), doppler examinations showed that RI value stayed in normal limits or was slightly decreased all the time. We conclude that doppler imaging of premature infants could be important diagnostic and prognostic tool in differentiating between the ultrasonographic view of immature periventricular white matter and real HIE. Doppler imaging is useful in identification of patients having increased risk of HIE and supplements routine transfontanellar ultrasound in estimation of HIE progression.

Leukocytes and endothelium interaction as rate limiting step in the inflammatory response and a key factor in the ischemia-reperfusion injury

Leukocyte-endothelium interactions play a key role in regulation of the inflammatory response, leukocytes migration and ischaemia-reperfusion injury. These adhesive reactions controlling the circulation of leukocytes, are key parts of immune surveillance arising from extravasation of neutrophils, and migration into tissue to eliminate invading microorganism. They also play important role in the generation of ischaemic-reperfusion injury of different organs including brain. Plasma levels of soluble adhesion molecules may be a diagnostic marker of the systemic endothelial injury. It is likely that the next few years bring new therapies to control leukocyte-endothelial interaction by directly inhibiting the adhesion molecules or by modulating their expression.

[Congenital hyperammonemia in neonates treated with hemodiafiltration]

Inborn defects of urea cycle often results in life-threatening hyperammonemia in neonates. The initial therapy of this disease comprises administration of benzoate sodium, arginine, lactulose, neomycin, and restrictive alimentation based on carbohydrates. Renal replacement therapy for ammonia removal should be considered for the most severe cases. We present a case report of two neonates with very rare inborn urea cycle disorders--deficiency of argininosuccinate lyase and carbamyl-phosphate synthetase, treated with spontaneous arterio-venous haemodiafiltration.

Can magnesium sulfate reduce the risk of cerebral injury after perinatal asphyxia?

Hypoxia-ischemia produces brain damage by processes that continue for many hours after reoxygenation/reperfusion. This provides a window of opportunity for therapy aimed at preventing further loss of brain cells. Sulfate magnesium can prevent posthypoxic brain injury by blocking glutamate receptors within the calcium (Ca++) ion channel. We used sulfate magnesium in nine newborn infant after perinatal hypoxia. We investigated the brain damage, by ultrasound examination, on third day, in first, second and third week, and third, sixth month of life. We have estimated the neurological development in the first week of life and third and twelfth month of life. We did not find deviations in ultrasound examination. We did not observe convulsions. We did not observe any side effect of this therapy. The examination at 1 of year of life in all of children was correct.

[Analysis of perinatal death at the Institute of the Health Center of the Polish mother in 1995, 1996 and 1997. The reason for making changes in the accountability for perinatal death]

Perinatal death's causes of fetuses and newborns from single and twin pregnancies delivered at the PMMHI from 1995-1997 were discussed. Data from the Pathology Department were analysed and compared to information regarding prenatal US + ECHO diagnoses coming from the Department for Diagnoses of Congenital Malformations at the PMMHI. The most frequent cause of death of fetuses and newborns from single pregnancies were congenital malformations (42%). In twins there prevailed such typical for multiple pregnancies' death causes as TTTS (27%), intrauterine demise of one of the twins (17%). Premature labor occupies the second most frequent cause of death both in single and multiple pregnancies. Most of perinatal deaths may be predicted prenatally by means of ultrasound and fetal echocardiography.

Monitoring of rat islet allografts with dithizone after induction of donor specific transplant tolerance by intrathymic administration of soluble alloantigens

Transplantation of whole pancreas or pancreatic islets remains a promising approach to treatment of diabetes mellitus. Since there is no efficient method presently known for in vivo detection of pancreatic islet rejection, we have utilized dithizone [DTZ] to monitor the survival of transplanted islet allografts following the induction of tolerance by a new strategy of deliberate introduction of donor antigens into the adult thymus. In this study, we examined the morphology of islet allografts in vivo and in vitro following pretreatment with intrathymic (IT) inoculation of 2 mg soluble Ag obtained from 3M KCl extracts of resting T-cells with or without ALS immunosuppression in the WF-to-Lewis combination. Fresh isolated rat islets stained pink 3-5 minutes following exposure to medium containing 0.12 mM DTZ solution in DMSO. Intravenous (i.v.) injection of DTZ solution into unmodified recipients of islet allografts that had rejected their grafts showed massive degranulation of islets which did not stain pink with DTZ. This was confirmed by microscopic finding of fibrosis and lymphocytic infiltration. In contrast, i.v. injection of DTZ solution into long-term recipients of islet allografts at 50, 100, and 150 days after transplantation showed viable islet cells which stained crimson red with DTZ and the findings were confirmed with microscopic sections. This study demonstrates that DTZ is an effective means of in vivo and in vitro identification of transplanted pancreatic islets and suggests that this strategy may have potential clinical application in the diagnosis of the pancreatic islet rejection.

Antibiotics sensitivity of Candida clinical and food-borne isolates

Candida is a yeast species recognized as the most frequent etiological agent of systemic and invasive thrush in humans. Invasions can affect all tissues, organs and systems of human in various stages of development. In the last 10 years Candida infections have increased 15 times. The purpose of our study was to determine the sensitivity of four antibiotics belonging to three different groups of antifungal agents against clinical and food-borne Candida strains. Our studies showed that of all tested strains, 7% was resistant to nystatin, 32% to fluconazole, 23% to voriconazole, and no strains grew in the presence of caspofungin. Despite the differences in biochemical profiles of clinical and food-borne isolates of Candida, a group of strains showing resistance to antibiotics include both types of isolates. At the same time circulating of antibiotic-resistant strains outside the hospital environment and the yeast infection via food is possible.