Urine biomarkers of acute kidney injury and association with brain MRI abnormalities in neonatal hypoxic-ischemic encephalopathy

OBJECTIVE

Determine whether urine biomarkers NGAL (neutrophil gelatinase-associated lipocalin), KIM-1 (kidney injury molecule 1) and IL-18 (interleukin-18) are associated with abnormal MRI findings in neonates with hypoxic-ischemic encephalopathy (HIE) who underwent therapeutic hypothermia (TH).

STUDY DESIGN

Secondary analysis of a multicenter, prospective study of neonates with HIE requiring TH. Urine biomarkers were obtained at 12 and 24 h of life (HOL). Brain MRI was scored per NICHD criteria. Association between biomarkers and MRI stage was determined.

RESULTS

In 57 neonates with HIE, only IL-18 at 24 HOL was significantly increased in neonates with MRI Stage 2B or greater, compared to Stage 2A or less (mean 398.7 vs. 182.9 pg/mL, p = 0.024.) A multivariate model including IL-18 at 24 HOL and 5-min Apgar performed best, with an AUC of 0.84 (SE = 0.07, p = 0.02).

CONCLUSIONS

Elevated urine IL-18 at 24 HOL was associated with more severe brain MRI abnormalities among neonates with HIE.

Major ABO incompatible BMT in children: determining what residual volume of donor red cells can safely be infused following red cell depletion

Major ABO incompatible BM transplantation carries a risk of acute haemolysis. Red cell depletion reduces this risk but not all incompatible RBC (iRBCs) are removed and in children the residual volume can be significant relative to body weight. We sought to determine the volume of iRBCs that can be safely given to children. All patients receiving fresh BM from a donor with a major ABO blood group mismatch between January 2000 and July 2013 at the Hospital for Sick Children, Toronto, were included. Seventy-eight patients were identified. The median volume of iRBCs transfused was 1.6 mL/kg (range 0.1-10.6 mL/kg). Thirty-five patients had minor haemolytic events and five patients had clinically significant adverse events. Two patients, who received 3.66 and 3.9 mL iRBCs/kg, developed renal impairment and in one case hypoxia and hyperbilirubinaemia. One patient had mild hypotension that resolved with i.v. fluid. Two patients developed hypotension secondary to sepsis and unrelated to BM infusion. Although signs of haemolysis occur, with appropriate hydration and monitoring of renal function, clinically significant adverse events related to the infusion of ABO incompatible BM are rare, and, in this study, were only seen in patients receiving >3 mL/kg of iRBCs per kg.

Primary hyperparathyroidism with water clear cell content: the impact of histological diagnosis on clinical management and outcome

Water clear cell hyperplasia (WCCH) and water clear cell adenomas (WCCA) of the parathyroid glands are rare causes of primary hyperparathyroidism. We report in this series one case of WCCH and two cases of WCCA representing 0.3% of patients with primary hyperparathyroidism presenting to our institution. Increased parathyroid cellular water content was responsible for relatively larger parathyroid gland sizes. However, this was not associated with higher biochemical markers or more severe clinical presentations. Histological distinction between WCCH and WCCA is difficult but important since patients with WCCH who have had a parathyroidectomy via a unilateral neck exploration may carry an increased risk of future disease recurrence.

A case of necrotising fasciitis caused by Pseudomonas aeruginosa

Necrotising fasciitis is a rare but severe infection of soft-tissue associated with rapid progression, systemic toxicity and high mortality. Monomicrobial necrotising fasciitis caused by Pseudomonas aeruginosa is exceptionally uncommon with only 12 cases reported in the literature. We describe a fatal case with an atypical presentation in a patient following spinal decompression for a metastasis from prostate cancer.

Nipple discharge: a sign of breast cancer?

INTRODUCTION

Nipple discharge is regarded a sign of breast cancer. Type of discharge and cytology are unreliable for diagnosis. Most malignant cases have a detectable breast mass. The aim of this study was to assess the association between nipple discharge and breast cancer.

PATIENTS AND METHODS

Patients who underwent operation for nipple discharge at a district general hospital (population 460,000) over a 3-year period were included. All had normal clinical, radiological and cytological examination. Operation and histopathology reports were reviewed.

RESULTS

Eighty-six patients underwent operation for nipple discharge. Median age was 54 years (range, 32-84 years). Analysis of nipple discharge revealed red blood cells (RBCs) in 35 patients (40%). At operation, 81 patients underwent radical sub-areola duct excision (Hadfield's procedure) and five microdochectomy. Histopathology reported duct ectasia in 59 patients and benign ductal papilloma in 25. Two patients had occult malignancy - DCIS (1) and LCIS (1). No invasive cancer was found.

CONCLUSIONS

Nipple discharge alone is not usually a sign of breast cancer. Occult malignancy is rare. A period of 'watchful waiting' may prevent patients undergoing unnecessary surgery.

Differential components of sentence comprehension: beyond single word reading and memory

A number of studies have used functional neuroimaging to examine the neural mechanisms of sentence comprehension; however, few fMRI studies have examined activation patterns associated with sentence comprehension after accounting for activation attributable to single-word-level tasks important for sentence comprehension. To investigate the patterns of activation associated with sentence comprehension after controlling for single word reading and maintaining single words in memory, 20 unimpaired adult readers completed a block design paradigm which included sentence comprehension, single word reading, and short-term memory (for words) tasks. Results indicated that, regardless of the aspect of sentence comprehension being controlled for, activation was observed in bilateral temporal lobes (left > right) as well as bilateral occipital lobes and middle frontal gyri. Additional findings showed that bilateral superior parietal lobe activation was greatest for short-term memory for words, while left anterior inferior frontal gyri activation (centered around Brodmann's area 47) was greatest for single word reading. Results suggest that temporal cortex (left > right) is a core region important for sentence comprehension beyond the short-term memory and semantic requirements inherent in processing sentences.

Functional magnetic resonance imaging of human visual cortex during face matching: a comparison with positron emission tomography

Cortical areas associated with the perception of faces were identified using functional magnetic resonance imaging (fMRI). T2*-weighted gradient echo, echo-planar MR images were obtained using a modified 1.5-T GE Signa MRI. In all nine subjects studied, performance of a face-matching task was associated with a region of significantly increased MR signal in the ventral occipitotemporal cortex, extending from the inferior occipital sulcus to the lateral occipitotemporal sulcus and fusiform gyrus. Smaller and more variable signal increases were found in dorsolateral occipitoparietal cortex near the intraparietal sulcus. Signal decreases were found in the angular gyrus and posterior cingulate cortex. Single-subject fMRI analyses revealed discrete areas of activation with well-defined borders. Group analyses of spatially smoothed fMRI data produced results that replicated most aspects of previous studies of face processing using positron emission tomography (PET). These results show that PET and fMRI identify functional areas with similar anatomical locations. In addition, fMRI reveals interindividual variation in the anatomical location of higher-level processing areas with greater anatomical precision.

Experimental infection of dogs with a Zimbabwean strain of Rickettsia conorii

Seroconversion was demonstrated in dogs artificially infected with a Zimbabwean strain of Rickettsia conorii. No haematological or biochemical abnormalities were found and the only clinical signs observed were pain, erythema and oedema at the inoculation site and regional lymphadenopathy. Intermittent rickettsaemia was detected using the centrifugation shell vial technique up to 10 days post inoculation.

A controlled trial of synthetic surfactant in infants weighing 1250 g or more with respiratory distress syndrome. The American Exosurf Neonatal Study Group I, and the Canadian Exosurf Neonatal Study Group

BACKGROUND

Surfactant-replacement therapy is now recognized as a life-saving and safe intervention in small premature infants, but there is little evidence concerning its risks and benefits in larger premature infants.

METHODS

We conducted a placebo-controlled, blinded trial in 1237 infants with respiratory distress who were enrolled at 23 hospitals in the United States and 13 hospitals in Canada. At entry all the infants weighed at least 1250 g, were receiving mechanical ventilation, and had a ratio of arterial to alveolar oxygen tension below 0.22. The initial dose of either the synthetic surfactant (Exosurf, 5 ml per kilogram of body weight) or air (the placebo) was administered less than 24 hours after birth, with a second dose given 12 hours later. A total of 614 infants were assigned to receive surfactant, and 623 to receive placebo.

RESULTS

Fewer infants in the surfactant group than in the placebo group died before 28 days of age or survived at 28 days with bronchopulmonary dysplasia (7 percent vs. 12 percent, P = 0.002). In the first 28 days of life, there were fewer deaths due to respiratory distress syndrome in the surfactant group (1 percent vs. 3 percent, P = 0.043), lower overall neonatal mortality (4 percent vs. 7 percent, P = 0.04), and a lower incidence of bronchopulmonary dysplasia (3 percent vs. 6 percent, P = 0.008). There was also a significantly lower incidence of pulmonary air leaks, intraventricular hemorrhage, patent ductus arteriosus, seizures, hypotension, and pulmonary hypertension in the surfactant group. The infants treated with surfactant were weaned from oxygen and mechanical ventilation significantly sooner than those given placebo, and they less often required high-frequency ventilation or extracorporeal membrane oxygenation. The primary side effect observed more frequently among the infants who received surfactant treatment was pulmonary hemorrhage (six infants vs. one infant, P = 0.055).

CONCLUSIONS

In infants weighing at least 1250 g at birth who have respiratory distress syndrome, treatment with two doses of synthetic surfactant improves survival and reduces perinatal morbidity.

Mortality and morbidity of prostatectomy. How far does preselection and pre-operative care influence the result?

Mortality and morbidity rates of prostatectomy have been progressively reduced over the past years, but with increasing ageing of the population, a limit is reached when medical complicating factors ensue, beyond which operative intervention carries an unacceptable risk. Results of surgery have little meaning if patients who are not fit or too old are excluded and not shown. It is with the above objectives in view that a prospective study is reported where all patients who presented or were admitted with prostatic symptoms over 1 year were recorded. There were 246 patients. Age, presentation and ASA (American Society of Anesthesiologists) status, post-operative problems and stay were noted. Joint assessment with a senior anaesthetist was performed in all higher-risk patients. 132 patients were operated on, 91% by transurethral resection of the prostate. 66% were ASA 2 and 3. Age itself bore no relation to length of post-operative stay but ASA status did. There was no mortality. However, 12 (9%) ASA 4 cases were excluded from surgery. It is concluded that with careful assessment, patients who are old and medically compromised can undergo prostatectomy safely, but one has to identify accurately those unsuitable for surgery and offer alternative treatment.

Temporal changes in plasma and liver lipids and in the hepatic activities of acetyl-coenzyme a carboxylase and fatty acid synthetase after oestrogen treatment of the male chicken (Gallus domesticus)

1. Male chickens (Gallus domesticus) were treated with a single intramuscular injection of oestradiol-17 beta, then changes in the liver and plasma levels of triacylglycerol, phospholipid, nonesterified fatty acids and in the hepatic activities of acetyl-CoA carboxylase and fatty acid synthetase were measured at various times after injection. 2. The results suggest that the initial phase (less than 20 hr) of oestrogen-induced hyperlipidaemia occurs in the absence of changes in the hepatic activities of the major enzymes of fatty acid biosynthesis, but a subsequent increase in these enzyme activities may contribute to the later phase (greater than 20 hr) of oestrogen-induced lipogenesis in avian liver.

Early effects of oestrogen treatment on lipogenesis de novo and on biosynthesis of triacylglycerol from fatty acids in male chick liver

1. Early changes (0-44 hr) in liver and plasma lipid levels and in the rate of hepatic lipogenesis were measured in male chicks after a single intramuscular injection of oestradiol-17 beta. 2. Chick liver slices were employed to measure the rate of lipogenesis de novo using 3H2O and the rate of triacylglycerol synthesis from [9, 10-3H] palmitate at various times after injection. 3. The results suggest that oestrogen-induced lipogenesis occurs initially by a rapid and coordinated stimulation of the total hepatic capacity for lipogenesis de novo and for triacyglycerol synthesis from fatty acids. 4. The results are discussed in relation to oestrogen-induced changes in hepatic lipogenic enzymes.

Ultrasound screening of premature infants: longitudinal follow-up of intracranial hemorrhage

Ninety-four infants weighing less than 2 kg were screened for intracranial abnormalities on the third and seventh days after birth using high-resolution real-time ultrasound. An overall abnormality rate of 37% was documented, with intracranial hemorrhage making up 83% of the abnormalities. Infants with abnormalities were then followed up for one to 12 months. Reversion to a normal ultrasound appearance was unlikely on follow-up in patients with lateral ventricular dilatation on the day-seven scan, whether or not dilatation was accompanied by intracranial hemorrhage. The ultrasound appearance became normal in 93% of the infants with intracranial hemorrhage but without dilated ventricles on their day-seven scan. The authors conclude that ultrasound is an efficient screening method for intracranial abnormalities in low birth weight infants.