POS0428 PATHOGENETIC ROLE OF MICROPARTICLES IN RHEUMATOID ARTHRITIS

Background

Microparticles (MPs) are fragments of surface membranes of activated eukaryotic cells. They are characterized by different dimensions (from 0.1 to 1μm) and expression of surface antigens, depending on their origin. MPs are important mediators of cell-to-cell communication as they can be internalized in a dose-dependent manner by macrophages, endothelial cells and other cell types, influencing both functional and phenotypic characteristics of the target cells. Even if MPs formation is enhanced by cell activation or apoptosis, constitutive exocytosis is a continuous ongoing process in vivo for many cells, and MPs originating from different cells can be always found in the plasma. In various autoimmune diseases, it has been found an increased number of MPs derived from activated platelets, leukocytes, vascular endothelium cells and other cell types. In Rheumatoid Arthritis (RA) an excessive production of MPs may predispose to autoimmune manifestations. Moreover, it has been speculated that MPs can stimulate the production, secretion, and transport of inflammatory factors in RA.

Objectives

We investigated the presence on the surface of RA-MPs of antigens derived from post-translationally modified proteins (citrullinated peptides and carbamylated peptides). We assumed that these specific antigens carried on the surface of RA-MPs could participate in RA pathogenetic process.

Methods

We enrolled 20 RA patients naïve for biological therapy fulfilling the 2010 American College of Rheumatology RA criteria and 20 healthy controls (HC), matched for age and sex. For each patient, laboratory and clinical data were recorded and clinical indexes were measured (TJ, SJ, CDAI, VAS pain, CDAI, SDAI, DAS28). A fasting blood sample, obtained from RA patients and HC, was centrifugated in order to obtain platelet-poor plasma (PPP), rich in MPs. Thereafter, MPs in RA patients and HC were measured using nanoparticle tracking analysis. Later on, MPs were incubated with unconjugated anti-citrullinated/carbamylated proteins antibodies and processed by flow cytometry and western blot to evaluate the surface expression of citrullinated/carbamylated antigens.

Results

Nanoparticle tracking analysis revealed a significant increase of number of MPs in RA compared to HC. Moreover, densitometric analysis showed a significative higher expression of citrullinated antigens on MPs’ surface in RA than controls (p < 0.0001), while no substantial difference was found in the expression of carbamylated antigens. The data obtained were confirmed with the western blot which identified the cytoskeletal protein vimentin, the cytoplasmatic glycolytic enzyme alpha-enolase1 and type II collagen as the main citrullinated and carbamylated proteins carried by MPs. Finally, a relevant correlation between the expression of citrullinated and carbamylated antigens and disease activity was found (Figure 1).

Figure 1.

The figure shows: (A) concentration of MPs in RA patients and HC (nanoparticle tracking analysis); (B) expression of citrullinated and carbamylated antigens on MPs’ surface in RA patients (flow cytometry analysis); (C) expression of citrullinated antigens in RA patients and HC and correlation between expression of citrullinated and carbamylated antigens on MPs’ surface in RA patients and DAS28, CDAI, SDAI; (D) cytoskeletal protein vimentin, cytoplasmatic glycolytic enzyme alpha-enolase1 and collagen type II (western blot).

Conclusion

The results of this study confirm an important role of MPs in the pathogenesis of RA not only as markers of disease activity but also as possible inducers of autoimmunity.

Disclosure of Interests

None declared.

Pain perception in NICU: a pilot questionnaire

PURPOSE

Neonatal pain management has made a great step forward over the last several years. Despite the drafting of International guidelines, an under-treatment of neonatal pain is still reported.

MATERIALS AND METHODS

Medical and paramedical personnel working in five Italian NICUs were asked to complete a questionnaire about pain management. The questionnaire was comprised of three sections: (i) brief explanation of the purpose; (ii) demographic information, including age, profession, religious beliefs, and hospital level; (iii) questionnaire about pain management and prevention.

RESULTS

One-hundred and forty caregivers participated in this study. Non-pharmacological analgesia during heel prick or venipuncture was used by 64% and 60% of them, respectively; topical analgesia was performed in 13% of venipunctures; no analgesia was used in 30% of cases for both heel prick and venipuncture. In the case of lumbar puncture, 35% of participants used topical analgesia, 15% non-pharmacological approach, 10% opioids, and 6% intravenous paracetamol. While 65% of participants gave a score of 4 out of 5 about the importance of pain treatment, 39% of them reported that in their department no pain scales were used.

CONCLUSIONS

Pain treatment in these NICUs is still far to be optimal. This nonetheless reflects a worldwide trend, which requires more attention on pain prevention, assessment, and treatment.

Randomized trial of early erythropoietin supplementation after preterm birth: Iron metabolism and outcome

BACKGROUND

Excess of iron and oxidant injury shortly after birth may be associated with neonatal morbidities in preterm infants.

AIMS

The aim was to determine whether administration of erythropoietin without iron supplementation decreases iron load and morbidity.

STUDY DESIGN AND SUBJECTS

In a randomized trial, we administered erythropoietin (EPO 250IU/kg daily during the first 6days of life) or placebo to 39 preterm infants (BW 700-1500g, GA≤30.0weeks).

OUTCOME MEASURES

The iron status, postnatal morbidities and follow-up at the age of two years were investigated.

RESULTS

In all, 21 EPO- and 18 placebo-treated infants were recruited. A requirement of red blood cell transfusions during first 28days was similar between the study groups. EPO treatment decreased total serum iron concentration (p=0.035). EPO supplementation had no significant effect on serum transferrin receptors or reactive non-protein-bound iron. There were no differences in neonatal morbidity or in survival without major neurological abnormality at two years of age.

CONCLUSIONS

A 6-day course of EPO decreased the iron load in preterm infants. There was no change in reactive, non-protein bound iron plasma levels and no influence on the outcomes during early childhood. Whether the neurocognitive effects of early EPO treatment can be detectable later in childhood remained to be verified.

Maternal obesity and perinatal oxidative stress: the strength of the association

Maternal obesity is a chronic inflammatory state, which has been shown to induce increased levels of free fatty acids, reactive oxygen species and inflammatory cells. Recent evidence reveals increased levels of lipid peroxidation products in the plasma of obese women during pregnancy. The aim of this study was to test the hypothesis that maternal overweight or obesity is associated with increased oxidative stress (OS) in offspring. Two hundred and forty-five pregnant women and their newborns were prospectively enrolled. Mothers were divided in two groups: lean control - LC (n=175, Group I); overweight or obese (n=70, Group II) according to BMI ≥ 25 before pregnancy. Cord blood F2-isoprostanes (F2-IsoPs), as reliable markers of OS, were measured in all newborns. Lower 1 minute APGAR score and higher weight at discharge were found in Group II neonates, compared to those of Group I (p less than 0.05). Small for gestational age (SGA) newborns of both groups showed increased levels of F2-IsoPs than appropriate (AGA) or large (LGA) for gestational age (GA) (p less than 0.01). SGA newborns of Group II had higher F2-IsoPs levels compared to SGA of Group I (p less than 0.01), which were significantly correlated to maternal BMI at the end of pregnancy (r=0.451, p less than 0.01). Multivariate regression analysis corrected for confounding factors, showed that maternal overweight or obesity was significantly associated with high F2-IsoPs levels in SGA offspring (p less than 0.01). Maternal overweight or obesity is associated with increased OS in their SGA newborns. Data suggest the need of antioxidant protection for both mothers during pregnancy and infants soon after birth.

A comparative study on oxidative stress role in nasal breathing impairment and obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is a sleep disorder that leads to metabolic abnormalities and increased cardiovascular risk. This study aimed to define the expression and clinical significance of biomarkers involved in oxidative stress in patients with OSAS. A prospective study was designed to compare outcomes of oxidative stress laboratory tests in three groups of subjects. The study involved the recruitment of three groups of subjects, 10 patients with obstructive sleep apnoea syndrome with AHI > 30; 10 patients suffering from snoring at night with AHI < 15; 10 patients with nasal respiratory impairment with AHI < 5. Patients were subjected to skin prick tests for common aero-allergens, nasal endoscopy, active anterior rhinomanometry, fibrolaryngoscopy and polysomnography; and extra-routine diagnostic tests and procedures; analysis of oxidative and antioxidant (plasma thiol groups) biomarkers in blood and urine samples. No statistical differences in age, sex distribution or body mass index were present between the three groups (p > 0.05). There were significant differences in AHI among the three groups of patients (p < 0.05). No statistical significance was found in the Analysis of Variance (ANOVA) test (p > 0.05) between the levels of biomarkers of oxidative stress in the three populations studied. The results of our study show that the nose can play a role in the pathogenesis of OSAS through the production of biomarkers of oxidative stress.

Neonatal oxidative stress depends on oxygen blood pressure in umbilical artery

With advancing gestation, partial pressure of oxygen (pO2) and pH fall significantly. Hypoxia is a main factor inducing free radical generation and thereby oxidative stress (OS). Placental and fetal tissue response when oxygen becomes restricted is complex and partially known. We tested the hypothesis that changes in umbilical artery and vein blood gas concentrations modulate OS occurrence in the newborn. Seventy umbilical artery and vein plasma samples were collected from healthy term newborns immediately after delivery. F2 Isoprostanes (F2-Isop) were measured in all samples as reliable markers of lipid peroxidation. Significantly lower pCO2 and higher pO2 and pH were found in umbilical vein than in artery, as expected. A positive correlation was detected between pH and pO2 only in umbilical artery (p=0.019). F2-Isop levels were no different between artery and vein in cord blood. Significant correlations were found between F2-Isop and pCO2 (p=0.025) as well as between F2-Isop and pH in umbilical vein (p=0.027). F2-Isop correlated with pCO2 (p=0.007) as well as with pO2 values (p=0.005) in umbilical artery blood. Oxidative stress (OS) in newborns depends on oxygen concentrations in umbilical artery. OS biomarkers significantly correlate with pO2 and in umbilical artery but not in umbilical vein. In normoxic conditions fetal-maternal gas exchanges occurring in placenta re-establish normal higher oxygen levels in umbilical vein than artery, with a normal production of free radicals without any deleterious effects.

Resuscitating preterm infants with 100% oxygen is associated with higher oxidative stress than room air

AIM

The starting fraction of inspired oxygen for preterm resuscitation is a matter of debate, and the use of room air in full-term asphyxiated infants reduces oxidative stress. This study compared oxidative stress in preterm infants randomised for resuscitation with either 100% oxygen or room air titrated to internationally recommended levels of preductal oxygen saturations.

METHODS

Blood was collected at birth, two and 12 hours of age from 119 infants <32 weeks of gestation randomised to resuscitation with either 100% oxygen (n = 60) or room air (n = 59). Oxidative stress markers, including advanced oxidative protein products (AOPP) and isoprostanes (IsoP), were measured with high-performance liquid chromatography and mass spectrometry.

RESULTS

Significantly higher levels of AOPP were found at 12 hours in the 100% oxygen group (p < 0.05). Increases between two- and 12-hour AOPP (p = 0.004) and IsoP (p = 0.032) concentrations were significantly higher in the 100% oxygen group.

CONCLUSION

Initial resuscitation with room air versus 100% oxygen was associated with lower protein oxidation at 12 hour and a lower magnitude of increase in AOPP and IsoP levels between two and 12 hours of life. Correlations with clinical outcomes will be vital to optimise the use of oxygen in preterm resuscitation.

C-reactive protein: a marker of neonatal stress?

AIM

To assess whether blood values of C-reactive protein (CRP) in healthy term newborns, are influenced by stress.

MATERIAL AND METHODS

Since different types of delivery (vaginal delivery [VD], emergency C-section [EMCS] and elective C-section [ELCS]) are notoriously characterized by different levels of stress for the baby, these three groups were used as models of different levels of stress. The mean CRP values of the three groups obtained in the first hours of life were compared.

RESULTS

We retrieved 1012 babies. Median values (3rd-97th ct) were: 0.05 (0.01-0.46), 0.17 (0.02-1.54), 0.30 (0.04-1.77), 0.43 (0.05-1.31), 0.40 (0.04-1.13) at 12, 24, 48, 72 and 96 h, respectively. Mean values in babies born after VD were statistically higher than those born after C-section, and higher CRP values were present in EMCS with respect to ELCS.

CONCLUSION

This study described normal blood CRP values in a wide population of term babies. An influence of the type of delivery on blood CRP is evident, and this may be explained by the different amount of perinatal stress induced by anyone of the three types of delivery we considered.

Antioxidant effects of potassium ascorbate with ribose therapy in a case with Prader Willi Syndrome

Oxidative stress (OS) is involved in several human diseases, including obesity, diabetes, atherosclerosis, carcinogenesis, as well as genetic diseases. We previously found that OS occurs in Down Syndrome as well as in Beckwith-Wiedemann Syndrome (BWS). Here we describe the clinical case of a female patient with Prader Willi Syndrome (PWS), a genomic imprinting disorder, characterized by obesity, atherosclerosis and diabetes mellitus type 2, pathologies in which a continuous and important production of free radicals takes place. We verified the presence of OS by measuring a redox biomarkers profile including total hydroperoxides (TH), non protein-bound iron (NPBI), thiols (SH), advanced oxidation protein products (AOPP) and isoprostanes (IPs). Thus we introduced in therapy an antioxidant agent, namely potassium ascorbate with ribose (PAR), in addition to GH therapy and we monitored the redox biomarkers profile for four years. A progressive decrease in OS biomarkers occurred until their normalization. In the meantime a weight loss was observed together with a steady growth in standards for age and sex.

Use of fetal analgesia during prenatal surgery

OBJECTIVE

Recent progresses in fetal surgery have raised concern on fetal pain, its long-term consequences and the risks of sudden fetal movements induced by pain. In several studies, surgeons have directly administered opioids to the fetus, while others have considered sufficient the maternally administered analgesics. We performed a review of the literature to assess the state of the art.

METHODS

We performed a PubMed search to retrieve the papers that in the last 10 years reported studies of human fetal surgery and that described whether any fetal analgesia was administered.

RESULTS

We retrieved 34 papers. In three papers, the procedure did not hurt the fetus, being performed on fetal annexes, in two papers, it was performed in the first half of pregnancy, when pain perception is unlikely. In 10 of the 29 remaining papers, fetal surgery was performed using direct fetal analgesia, while in 19, analgesia was administered only to the mother. In most cases, fetal direct analgesia was obtained using i.m. opioids, and muscle relaxant. Rare drawbacks on either fetuses or mothers due to fetal analgesia were reported.

CONCLUSION

Fetal direct analgesia is performed only in a minority of cases and no study gives details about fetal reactions to pain. More research is needed to assess or exclude its possible long-term drawbacks, as well as the actual consequences of pain during surgery.

Functional maturation of neocortex: a base of viability

The term "viability" is not simply a synonymous with being "born alive," but is closely related to the capability of having a "meaningful life" and having a reasonable period of survival. The definition of "viability" is generally based on two major criteria: the biological, which takes into consideration the maturity of the foetus, and the epidemiological, which is based on the survival rates reported in literature. The neuromaturation of the cerebral cortex is a dynamic process promoted by the subplate, a transient population of neurons that guides the development of cortical and thalamocortical connections. These connections are for example fundamental for cortical processing of sensory information and mental processes. The first thalamocortical and cortico-cortical connections grows at 23-24 postconceptional weeks, which coincides with the age limit for premature baby survival.

New Pharmacological Approaches in Infants with Hypoxic-Ischemic Encephalopathy

New knowledge of the pathophysiology and evolution of hypoxic-ischemic brain injuries has made feasible interventions to improve clinical outcomes for newborns surviving birth asphyxia. Brain injury following hypoxic-ischemic insult is a complex process evolving over hours to days, which provides a unique window of opportunity for neuroprotective treatment interventions. The specific pathologic processes preceding the onset of irreversible cerebral injury appear to be a combination of several mechanisms that are variable according to the severity and duration of the insult and to biochemical modifications in the brain. Advances in neuroimaging, brain monitoring techniques, and tissue biomarkers have improved the ability to diagnose, monitor, and care for newborn infants with neonatal encephalopathy, as well as to predict their outcome. The role of oxidative stress in newborn morbidity with respect to the higher risk of free radical damage in these babies is growing. However, challenges remain in early identification of infants at risk for neonatal encephalopathy, determination of timing and extent of hypoxic-ischemic brain injury, as well as optimal management and treatment duration. Potential neuroprotective strategies targeting different pathways leading to neuronal cell death in response to hypoxic-ischemic insult have been investigated: hypothermia, erythropoietin, iminobiotin, deferioxamine, magnesium, allopurinol, xenon, melatonin and statins. Hypothermia is currently the only recognized beneficial therapy. However, many infants still develop significant adverse outcomes. It is becoming evident that the association of moderate hypothermia with neuroprotective drugs may enhance the outcome. By virtue of their pleiotropic effects without toxic effects, melatonin and statins may act at different levels of the multiple mechanisms responsible for the progression of the neurodegenerative process and represent promising neuroprotectants, alone or as additional adjunctive therapy, for reducing brain injury and its long-term sequelae in infants. More clinical studies are needed to clarify the role of these potential neuroprotective drugs.

[Which legal consequences for those who provoke pain to infants?]

The advances in perinatal care have led to a significant increase in neonatal survival rate but also to the rise of the number of invasive procedures. Several scientific studies show that newborns are able to feel pain more intensely than adults. Despite this evidence, neonatal pain and the right to an appropriate analgesia are systematically underestimated, ignoring ethical and moral principles of beneficence and non-maleficence. Infants are more susceptible to pain and the prolonged exposure to painful sensations can alter the neural development and the response to pain causing hyperalgesia. Anyone who caused pain without using any analgesic procedure due to negligence or incompetence, should be severely punished. The right to analgesia, fundamental principle, is fully incorporated in the Italian code of Medical deontology (article 3). The doctor who does not use analgesia for newborns' treatment can be indicted by the Italian penal code (art.582 and 583), aggravated by being the victim an infant, who is unable to defend himself. To avoid penal consequences, a careful education and attention are needed: "pediatric analgesia" should become a basic teaching in Universities and in specialization schools; analgesic treatments should be mandatory and annotated in the patient's file even for minor potentially painful procedures.

Exposure to electromagnetic fields from laptop use of "laptop" computers

Portable computers are often used at tight contact with the body and therefore are called "laptop." The authors measured electromagnetic fields (EMFs) laptop computers produce and estimated the induced currents in the body, to assess the safety of laptop computers. The authors evaluated 5 commonly used laptop of different brands. They measured EMF exposure produced and, using validated computerized models, the authors exploited the data of one of the laptop computers (LTCs) to estimate the magnetic flux exposure of the user and of the fetus in the womb, when the laptop is used at close contact with the woman's womb. In the LTCs analyzed, EMF values (range 1.8-6 μT) are within International Commission on Non-Ionizing Radiation (NIR) Protection (ICNIRP) guidelines, but are considerably higher than the values recommended by 2 recent guidelines for computer monitors magnetic field emissions, MPR II (Swedish Board for Technical Accreditation) and TCO (Swedish Confederation of Professional Employees), and those considered risky for tumor development. When close to the body, the laptop induces currents that are within 34.2% to 49.8% ICNIRP recommendations, but not negligible, to the adult's body and to the fetus (in pregnant women). On the contrary, the power supply induces strong intracorporal electric current densities in the fetus and in the adult subject, which are respectively 182-263% and 71-483% higher than ICNIRP 98 basic restriction recommended to prevent adverse health effects. Laptop is paradoxically an improper site for the use of a LTC, which consequently should be renamed to not induce customers towards an improper use.

Increased risk of brain injury in IVF babies

AIM

The aim of this paper was to assess brain injury occurrence among in vitro fertilization (IVF) babies.

METHODS

We examined all babies born in our hospital in the triennium 2004-2006, comparing the presence of brain injuries between IVF babies and the rest of the population.

RESULTS

In IVF group (180 babies), brain injury was present in 4 babies, while in the rest of population (n=3602) it was present in 23 babies (P=0.042, RR: 3.18). IVF babies have a higher risk of being born with a birthweight less than 2 500 grams (P<0.0001; RR: 5.133). When we considered only babies born with a birth weight less than 2 500 grams, the difference of brain injury between the two groups was not significant.

CONCLUSION

In IVF babies, brain injury occurred more frequently than in the rest of population. This is probably due to a higher rate of premature births and low birth weight in IVF population. Anyway, this data should be disclosed to future parents to make an informed decision.

Neonatal pain and oxidative stress

Neonatal analgesia is a recent issue: newborns were supposed to feel no pain until the late "80s; but from that date, many studies were performed to verify the extent of neonates" pain perception, ways to measure and overcome it. Pain can have harmful consequences in babies, due to several causes, and we investigated whether oxidative stress can play a role in this process. Here we resume our findings, that recall to a greater safeguard of babies from unjustified pain.

A case of transient zinc deficiency in a breast-fed preterm infant successfully treated with oral zinc supplementation: review of zinc metabolism and related diseases

A 15-week-old baby girl, born at the 29 week of gestation, presented with a four-week history of demarcated, erythematous, erosive and exudative patches on the perianal, perioral and acral areas. A clinical diagnosis of zinc deficiency was considered. Serum zinc level was decreased (0.5 mg/L; normal 0.70-1.50 mg/L), the mother's serum and milk had normal zinc values. The baby was started an empiric trial of oral zinc supplementation (3 mg zinc gluconate/kg body weight/ day) with complete healing of lesions after two weeks. Treatment was gradually withdrawn at six months of age with no relapse. Transient zinc deficiency due to increased zinc requirements in breast-fed mainly preterm infants is a condition similar to acrodermatitis enteropathica, an autosomal recessive disorder of enteric zinc absorption affecting almost exclusively not breast-fed infants. Early recognition of the disorder and introduction of zinc supplementation rapidly reverses transient zinc deficiency, that probably will become more and more frequent, because of the rising rate of premature infants with breast-feeding only.

Physiopathological effects of the NO donor 3-morpholinosydnonimine on rat cortical synaptosomes

The NO donor 3-Morpholinosydnonimine (SIN-1) releases NO in the presence of molecular oxygen. In this study, we evaluated the effect of SIN-1 on mitochondria of rat cortical synaptosomes. We demonstrated in vitro that the amount of ONOO(-) generated and H(2)O(2) formation directly correlated with SIN-1 concentration. The mean oxygen consumption by synaptosomal mitochondria was approximately 3.8 nmol of O(2) min(-1) mg(-1) protein, which decreased significantly in the presence of SIN-1 1 mM to 2.5 nmol O(2) min(-1) mg(-1). This decrease was not modified by catalase or Trolox, demonstrating that ONOO(-) was responsible for the effect. The same concentration of SIN-1 caused a significant decrease of ATP production by synaptosomal mitochondria and depolarized the mitochondrial membrane. Moreover, ROS production increased progressively and was completely inhibited by pre-incubation of synaptosomes with Trolox. Finally, phosphatidylserine was externalized and, at the same time, intrasynaptosomal lactate dehydrogenase decreased confirming both, the external membrane breakdown after the addition of SIN-1 and the damage to the synaptosomes.

Electromagnetic fields produced by incubators influence heart rate variability in newborns

BACKGROUND

Incubators are largely used to preserve preterm and sick babies from postnatal stressors, but their motors produce high electromagnetic fields (EMFs). Newborns are chronically exposed to these EMFs, but no studies about their effects on the fragile developing neonatal structure exist.

AIM

To verify whether the exposure to incubator motor electric power may alter autonomous nervous system activity in newborns.

MATERIAL AND METHODS

Heart rate variability (HRV) of 43 newborns in incubators was studied. The study group comprised 27 newborns whose HRV was studied throughout three 5-minute periods: with incubator motor on, off, and on again, respectively. Mean HRV values obtained during each period were compared. The control group comprised 16 newborns with constantly unrecordable EMF and exposed to changes in background noise, similar to those provoked by the incubator motor.

RESULTS

Mean (SD) total power and the high-frequency (HF) component of HRV increased significantly (from 87.1 (76.2) ms2 to 183.6 (168.5) ms2) and the mean low-frequency (LF)/HF ratio decreased significantly (from 2.0 (0.5) to 1.5 (0.6)) when the incubator motor was turned off. Basal values (HF = 107.1 (118.1) ms2 and LF/HF = 1.9 (0.6)) were restored when incubators were turned on again. The LF spectral component of HRV showed a statistically significant change only in the second phase of the experiment. Changes in background noise did not provoke any significant change in HRV.

CONCLUSION

EMFs produced by incubators influence newborns' HRV, showing an influence on their autonomous nervous system. More research is needed to assess possible long-term consequences, since premature newborns may be exposed to these high EMFs for months.

Is the ABC pain scale reliable for premature babies?

AIM

We recently developed the ABC scale to assess pain in term newborns. The aim of the present study was to assess the reliability of the scale in preterm babies.

MATERIAL AND METHODS

The scale consists of three cry parameters: (a) pitch of the first cry, (b) rhythmicity of the bout of crying and (c) cry constancy. Changes in these parameters were previously found to distinguish medium and high levels of pain as evaluated by spectral analysis of crying. We enrolled 72 babies to perform the steps usually requested to validate a scale, namely the study of the concurrent validity, specificity and sensibility. Moreover, we assessed the interjudge reliability and the clinical utility and ease of the scale.

RESULTS

A good correlation (r = 0.68; r(2)= 0.45; p < 0.0001) was found between scores obtained with the ABC scale and the premature infant pain profile (PIPP) scale, demonstrating a good concurrent validity. The scale also showed good sensitivity and specificity (we found statistically significant differences between mean values of scores obtained in babies who underwent pain and babies who underwent non-painful stimulus.) Interobserver reliability was good: Cohen's kappa = 0.7.

CONCLUSION

The good correlation between the two scales shows that the ABC scale is also reliable for premature babies.

Is prenatal bonding enhanced by prenatal education courses?

AIM

Prenatal education courses (PEC) are a way of allaying anxiety in pregnancy. PEC consist of a series of five 1-hour lessons in the first and second trimesters of pregnancy. Conducted by nurses or midwives, the course syllabus includes the basics of fetal physiology and development, singing sessions, dance sessions, massage-through-the-womb sessions. Here we investigated whether they can enhance feto-maternal bonding.

METHODS

We studied 77 pregnant women (mean age: 31.5+/-4.1 years), 36 of whom attended PEC. We used the Prenatal Attachment Inventory (PAI), a validated 21-item questionnaire, to score prenatal bonding and compared the scores of the two groups. Three months after delivery, we asked the mothers to fill in another questionnaire to assess infant and maternal well-being.

RESULTS

The PEC group showed a higher PAI score than the control group (65.5+/-6.9 vs. 59.9+/-6.1; P<0.05). Babies born to the PEC group had a higher frequency of unexplained crying.

CONCLUSION

PEC positively influenced prenatal attachment. More studies are needed to assess whether this may be useful for the development of the mother-infant relationship.

Analgesic effect of watching TV during venipuncture

AIMS

To assess the analgesic effect of passive or active distraction during venipuncture in children.

METHODS

We studied 69 children aged 7-12 years undergoing venipuncture. The children were randomly divided into three groups: a control group (C) without any distraction procedure, a group (M) in which mothers performed active distraction, and a TV group (TV) in which passive distraction (a TV cartoon) was used. Both mothers and children scored pain after the procedure.

RESULTS

Main pain levels rated by the children were 23.04 (standard deviation (SD) 24.57), 17.39 (SD 21.36), and 8.91 (SD 8.65) for the C, M, and TV groups, respectively. Main pain levels rated by mothers were 21.30 (SD 19.9), 23.04 (SD 18.39), and 12.17 (SD 12.14) for the C, M, and TV groups, respectively. Scores assigned by mothers and children indicated that procedures performed during TV watching were less painful (p<0.05) than control or procedures performed during active distraction.

CONCLUSION

TV watching was more effective than active distraction. This was due either to the emotional participation of the mothers in the active procedure or to the distracting power of television.

Early oxidative stress in amniotic fluid of pregnancies with Down syndrome

OBJECTIVE

Some evidence suggests that oxidative stress, due to an imbalance between oxidants and antioxidants, occurs in babies with Down syndrome (DS). This study tests the hypothesis that oxidative stress occurs early in DS pregnancies.

DESIGN AND METHODS

Isoprostanes (IPs), a new marker of free radical-catalyzed lipid peroxidation, were measured in amniotic fluid from pregnancies with normal, growth restricted and DS fetuses, diagnosed by karyotype analysis of amniotic cells cultured.

RESULTS

A nine-fold increase in IP concentrations was found in amniotic fluid of pregnancies with DS fetuses. This increase (595.15; 542.96-631.64 pg/ml, median; 95% CI), was greater than in pregnancies with fetal growth-restricted fetuses (155; 130.57-172.23 pg/ml, median; 95% CI) and normal fetuses (67; 49.82-98.38 pg/ml, median; 95% CI; p<0.0001).

CONCLUSIONS

The study reveals that oxidative stress occurs early in pregnancy and supports the idea of testing whether prenatal antioxidant therapy may prevent or delay the onset of oxidative stress diseases in the DS population.

Neonatal pain analyzer: development and validation

We developed a pain analyzer (ABC analyzer) to perform automatic acoustic analysis of neonatal crying and to provide an objective estimate of neonatal pain. The ABC analyzer uses a validated pain scale (ABC scale) based on three acoustic parameters: pitch frequency, normalized RMS amplitude, and presence of a characteristic frequency- and amplitude-modulated crying feature, defined as "siren cry". Here we assessed the reliability of the analyzer. We enrolled 57 healthy neonates. Each baby was recorded with a video camera during heel prick. Pain intensity was evaluated using a validated scale [Douleur Aigue du Nouveau-Né (DAN) scale] and the analyzer and the two scores were compared. We found a statistically significant concordance between the DAN score and ABC analyzer score (p < 0.0001). The ABC analyser is a novel approach to cry analysis that should now have its properties carefully evaluated in a series of studies, just as is necessary in the development of any other pain measurement tool.

Is an excessive number of prenatal echographies a risk for fetal growth?

AIM

To assess whether a very high number of prenatal ultrasonographies affects birthweight.

POPULATION AND METHODS

We studied 1203 consecutive women who delivered in Siena Hospital. Exclusion criteria were the following: twin pregnancy, maternal smoke or alcohol ingestion in pregnancy, gestational diabetes, placenta or umbilical cord defects, gestational age at birth <37 weeks, and major malformations. We analysed birthweights in relation to the number of ultrasound examinations. 120 women had undergone a minimum number (three or less-base group) and 167 a maximum number (nine or more-intensive group) of fetal US scans. We compared the birthweight of the children born in these two groups and the correlation between number of US scans and birthweight in the whole population.

RESULTS

Mean birthweights of the base and the intensive groups were 3389.5+/-434 g and 3268+/-438 g, respectively (p=0.0206). Nevertheless, the regression study did not show a significant correlation between birthweight and number of US scans. The mean age of the base group was 30.1+/-5.3 years and that of the intensive group was 32.09+/-4.99 years (p=0.0018). Eighteen women of base group underwent amniocenteses vs. 71 in the intensive group (p<0.001). In the base group 57.5% of the mothers had low school level vs. 24.4% in the intensive group (p<0.01).

CONCLUSION

More studies are needed to confirm or exclude any relationship between an intensive use of prenatal ultrasounds and birthweight, and to exclude other effects of ultrasounds on children's health. Moreover, our study shows an excess of prenatal diagnostic procedures, the causes of which should be investigated.

Ante partum bed rest and unexplained infantile crying

AIM

The aim of this study was to assess whether bed rest during pregnancy is a risk factor for infantile colics.

METHODS

In a previous paper a questionnaire was administered to 86 women (43 of whom had stayed in bed during pregnancy for a mean of 3.4+/-1.2 months, and 43 were controls) about the clinical history and the present state of their 11-15 year old babies. In the present paper we traced these women and assessed the presence/absence of unexplained infant crying (UIC, infantile colic), diagnosed by a physician in the first year of life of these children. Forty mothers answered the inquiry, and we compared their answers with 40 control mothers.

RESULTS

Babies born after maternal bed rest during pregnancy had a higher incidence of UIC than the control group (26/40 vs 11/40; P=0.0015). No significant correlation was found between UIC and allergies or between UIC and maternal or artificial breast feeding.

CONCLUSIONS

Our retrospective study shows a possible association between bed rest and UIC: further studies, including other important variables (stress, drugs, smoking) are needed.

Non protein bound iron concentrations in amniotic fluid

OBJECTIVES

To investigate whether amniotic fluid concentrations of non protein bound iron (NPBI) vary with growth in healthy fetuses and also offer a reference curve in the second trimester of pregnancy.

DESIGN AND METHODS

Amniotic fluid concentrations of NPBI were measured by HPLC in 118 women with physiological singleton pregnancies, who underwent amniocentesis for fetal karyotype between weeks 15 and 18 of gestation.

RESULTS

NPBI increased progressively from weeks 14--15 to weeks 15--16, peaking at 17--18 weeks of gestation. NPBI values regressed positively with gestational age (GA). Multiple linear regression analysis between NPBI, as dependent variable, and various fetal parameters, as independent variables, showed a statistically significant regression coefficient with GA, bi-parietal diameter and transverse cerebellar diameter.

CONCLUSIONS

The present data constitutes the first quantification of NPBI concentrations in amniotic fluid under physiological conditions. Correlations with GA and ultrasound fetal biometry suggest that NPBI may play a role in fetal growth.

Nucleated red blood cell count in term and preterm newborns: reference values at birth

The prognostic value of nucleated red blood cell count at birth in relation to neonatal outcome has been established. However, reference values were needed to usefully interpret this variable. The normal range of reference values for absolute nucleated red blood cell count in 695 preterm and term newborns is reported.

Reduction of exposure of newborns and caregivers to very high electromagnetic fields produced by incubators

The aims of this paper is to measure whether ferromagnetic panels sufficiently reduce the high electromagnetic fields (EMF) to which newborns are exposed in incubators and to which caregivers are exposed when working near the incubators. We measured EMF at mattress level in three neonatal incubators with and without ferromagnetic panels between the electric motor and the mattress. We then measured the EMF at the level of the maximum emission point for caregivers, i.e., near the display panel. The ferromagnetic panels were (a) 5 mm thick iron, (b), (c), (d) respectively, one, two, and three sheets of 0.3 mm thick mu-metal. The weight of iron sheet was 4 g/cm2, and mu-metal 0.2 g/cm2. The use of the ferromagnetic panels significantly reduced the EMF. No significant difference in attenuation was recorded using one, two, or, three sheets of mu-metal, or a single sheet of iron. One, two, and three sheets of mu-metal reduced EMFs by 77%, 82%, and 84.3%, respectively; the reduction with iron was 80%. EMF values measured in incubators were higher than those to which the general population is exposed. The use of ferromagnetic panels significantly reduces the level of EMFs to which neonates and caregivers are exposed.

Effect of blood transfusions on oxidative stress in preterm infants

OBJECTIVE

To confirm the increase in non-transferrin bound iron (NTBI) after packed red cell (PRC) transfusion and to evaluate the association with increased oxidative stress in preterm infants.

METHOD

Twenty healthy preterm infants (gestational age 28.2 (2.2) weeks; birth weight 1047 (230) g), who required blood transfusion for anaemia of prematurity were prospectively studied. Serum concentrations of NTBI, total hydroperoxides (TH), and protein SH groups, and plasma total radical trapping antioxidant capability (TAC) were measured within three hours before and after PRC transfusion. The infants were transfused with 38.6 (23) ml PRCs over 5.8 (1.0) hours, at a mean age of 43.3 (25.1) days.

RESULTS

After PRC transfusion, haemoglobin concentration increased from 9.2 (1.1) to 14.6 (1.5) g/l. Mean plasma NTBI concentration after transfusion was significantly higher (0.43 (0.45) v 2.03 (1.31) micromol/l; p = 0.001), while plasma concentrations of TH (212.3 (42.2) v 214.7 (66.3) Carr units/l) and protein SH groups (317.5 (38.8) v 353.8 (57.4) micromol/), and TAC (256.3 (36.1) v 267.1 (42.4) micromol HClO/ml) remained unchanged.

CONCLUSION

For three hours after PRC transfusion, plasma NTBI is significantly increased in preterm infants, but this is not associated with significant changes in oxidative stress.

Feasibility of quantitative ultrasound measurements on the humerus of newborn infants for the assessment of the skeletal status

Quantitative ultrasound (QUS), although widely used in adults has, so far, been scarcely employed in newborn infants and children. This study aimed to evaluate the feasibility of the use of QUS in newborn children and the factors influencing QUS parameters. In 140 consecutive healthy full-term newborn babies (76 male and 64 female; gestational age: 39.5 +/- 1.5 weeks) QUS parameters were assessed within 3 days of the child's birth at the distal diaphysis of the humerus by use of Bone Profiler, after an appropriate modification of caliper and software. In all subjects we evaluated the amplitude-dependent speed of sound (AD-SoS) (meters per second), the characterizing graphic trace parameters [signal dynamic (SDy), fast wave amplitude (FWA) and bone transmission time (BTT)], SoS (meters per second), that is, the speed of sound calculated on the first peak, and hBTT, that is, the interval time between the first peak of the ultrasound and when this reaches the speed of 1,570 m/s, which is the velocity of ultrasound in the soft tissue. This latter parameter allows one to measure bone tissue independently of soft tissue. QUS measurements were also performed at the phalanges on all mothers (age range 24-38 years), who also completed a self-report questionnaire on their obstetric history, smoking and dietary habits and family history of osteoporosis. In 73 mothers and their children QUS was repeated after 12 months. All QUS parameters were slightly higher in male than in female newborn infants but the difference was not significant. BTT and hBTT of neonates showed a significant relationship with birth weight (r = 0.20; P < 0.05 and r = 0.37; P < 0.01, respectively) and with cranial circumference (r = 0.22; P < 0.05 and r = 0.36; P < 0.01, respectively). In newborn infants none of the QUS parameters was significantly influenced by maternal QUS or by maternal smoking and calcium intake. In a model of multiple regression analysis the cranial circumference was the only parameter entered into the model, explaining approximately 15% of hBTT value. At month 12 AD-SoS and SoS were slightly lower than at birth (-11% and -0.1%, respectively), whereas both BTT and hBTT showed a significant (P < 0001) increase. The present study demonstrated the feasibility of the use of QUS, as assessed by a new measurement approach at the humerus, in the evaluation of skeletal status in neonates. BTT and, above all, hBTT, appears to be the best parameter for both evaluation of skeletal status at birth and monitoring of bone growth in the first year of life.

Perfluorocarbons attenuate oxidative lung damage

The aim of this study was to investigate the effect of tidal liquid ventilation (TLV) compared to conventional mechanical ventilation (CMV) on oxidative lung damage in the setting of acute respiratory distress syndrome (ARDS). After repeated lung lavages, 10 minipigs were treated with CMV or TLV for 4 hr before the animals were sacrificed. Samples for blood gas analysis and bronchial aspirate samples were withdrawn before the induction of lung injury, and at 10 min, 2 hr, and 4 hr after the beginning of ventilatory support. To assess lung oxidative damage, total hydroperoxide (TH) and advanced oxidation protein product (AOPP) concentrations were measured in bronchial aspirate samples. After 2 and 4 hr of ventilatory support, partial oxygen tension (PaO(2)) and base excess (BE) were significantly higher in the TLV group than in the CMV group, while PaCO(2) was slightly higher, but with no statistical significance. In the CMV group, the AOPP level was significantly higher at 4 hr than at baseline. TH and AOPP bronchial aspirate concentrations were higher in the CMV group than in the TLV group at 2 and 4 hr of ventilation. We conclude that animals treated with TLV showed lower oxidative lung damage compared to animals treated with CMV.

Encephalocraniocutaneous lipomatosis (Haberland syndrome) with bilateral cutaneous and visceral involvement

Encephalocraniocutaneous lipomatosis, or Haberland syndrome, is a rare congenital neurocutaneous disease. It is characterized clinically by unilateral lipomatous hamartomata of the scalp, eyelid, and outer globe of the eye, ipsilateral porencephalic cysts with cortical atrophy, cranial asymmetry, marked developmental delay and mental retardation. This syndrome should be distinguished from other mosaic neurocutaneous phenotypes such as as Delleman syndrome, Schimmelpenning syndrome, Goltz syndrome, Goldenhar syndrome and Proteus syndrome. Here we report a case of Haberland syndrome with bilateral involvement which underscores the extreme heterogeneity of clinical presentation of this and related syndromes.

Oxidant injury in neonatal erythrocytes during the perinatal period

It has been known for many decades that oxidative stress leads to oxidation of hemoglobin and damage to the erythrocyte membrane. More recently, the factors involved in denaturating of membrane proteins and lipid peroxidation have been investigated in detail, as well as the mechanism of reactive oxygen species formation in red cells. Oxidative stress depletes adenosine triphosphate (ATP) and adenine nucleotides, whereas adenosine monophosphate (AMP) deaminase seems to depress energy metabolism by blocking the salvage pathway of purine nucleotides. Depletion of ATP and activation of AMP deaminase are related to calcium ion concentrations. Denaturating of membrane proteins generally precedes lipid peroxidation and consequent phagocytosis due to caspase activation. Extensive investigations demonstrated the key role of oxidative stress and iron release in a reactive form causing membrane protein damage via the Fenton reaction and hydroxyl radical production. In the absence of efficient protection by antioxidant factors and other molecules such as flavonoids, oxidative stress is responsible for the release of iron in reactive form, predisposing red cells to hemolysis through the formation of senescence antigen. Other well-known sources of oxidative stress in red cells are free radical production outside the red cell by activated phagocytes, endothelial metabolism, hyperoxia, ischemia-reperfusion and the arachidonic acid cascade.

CONCLUSION

The recent insight into the mechanism of oxidative injury of red cells and evidence of relationships between erythrocyte oxidative stress and hypoxia suggest that increased hemolysis is induced by severe hypoxia and acidosis in the fetus as well as the newborn.

New biomarkers of fetal-neonatal hypoxic stress

The complex pathophysiological mechanisms underlying perinatal hypoxia make it difficult to define early markers of severe hypoxia-ischemia encephalopathy. However, as progress in the development of neuroprotective therapeutic measures continues, the early identification of neonates at risk of severe hypoxic-ischemic encephalopathy is an important goal for appropriate decision making. Although the timing of perinatal hypoxic brain damage may vary and is sometimes unknown, high levels of non-protein-bound iron and high nucleated red blood cell counts in cord blood indicate an antepartum origin of neurological impairment, because they can occur only as a consequence of a pre-existing asphyxic event.

CONCLUSION

The combined assessment of nucleated red blood cells and non-protein-bound iron at birth seems extremely useful for the early identification of newborns at high risk of brain damage. Activin A also seems to be a reliable marker of perinatal hypoxia. Prospective long-term follow-up studies are needed to verify their predictive role.

Alone no more: pain in premature children

It is only recently that newborns have been recognised to feel pain. To avoid the drawbacks of common analgesics, alternative analgesic methods (e.g. sucking and/or oral sugar) have been proposed. We showed that these methods are of little effect without the relaxing, distracting, comforting presence of a person at the cribside who talks to and massages the baby. This is a further demonstration that newborns, including premature babies, look for a reassuring presence when experiencing pain. This is surprising as premature babies are relatively unreactive, often completely isolated in an incubator and considered incapable of social behavior. To the attentive observer, however, they reveal an unsuspected emotional world. Not only do they feel pain, but they are also capable of suffering, distress, anxiety and fear. This needs to be considered in neonatal analgesic treatment, even for extremely premature children. It is mandatory for caregivers to be a reassuring presence during painful procedures: premature babies are exacting patients. They not only feel pain, they even suffer; they request not only drugs, but a human presence nearby.

[Free radicals and brain damage in newborns with hypoxic-ischemic lesion]

Free radicals (FR) are highly reactive chemical molecules containing one or more unpaired electrons. Oxygen-derived free radicals, collectively termed reactive oxygen species (ROS), are normally produced in living organisms. When over produced, they are major mediators of cell and tissue injury. There is a critical balance between free radical generation and antioxidant defenses. Oxidative stress in vivo is a degenerative process due to the over production and propagation of FR reactions. FR reactions lead to oxidation of lipids, proteins, polysaccharides and to DNA damage. Newborns and particularly preterm infants are very susceptible to FR oxidative damage. In these subjects, there is evidence of an imbalance between antioxidant and oxidant-generating systems enhancing oxidant injury.