Circulating exosomal microRNA expression patterns distinguish cardiac sarcoidosis from myocardial ischemia

Objective

Cardiac sarcoidosis is difficult to diagnose, often requiring expensive and inconvenient advanced imaging techniques. Circulating exosomes contain genetic material, such as microRNA (miRNA), that are derived from diseased tissues and may serve as potential disease-specific biomarkers. We thus sought to determine whether circulating exosome-derived miRNA expression patterns would distinguish cardiac sarcoidosis (CS) from acute myocardial infarction (AMI).

Methods

Plasma and serum samples conforming to CS, AMI or disease-free controls were procured from the Biologic Specimen and Data Repository Information Coordinating Center repository and National Jewish Health. Next generation sequencing (NGS) was performed on exosome-derived total RNA (n = 10 for each group), and miRNA expression levels were compared after normalization using housekeeping miRNA. Quality assurance measures excluded poor quality RNA samples. Differentially expressed (DE) miRNA patterns, based upon >2-fold change (p < 0.01), were established in CS compared to controls, and in CS compared to AMI. Relative expression of several DE-miRNA were validated by qRT-PCR.

Results

Despite the advanced age of the stored samples (~5–30 years), the quality of the exosome-derived miRNA was intact in ~88% of samples. Comparing plasma exosomal miRNA in CS versus controls, NGS yielded 18 DE transcripts (12 up-regulated, 6 down-regulated), including miRNA previously implicated in mechanisms of myocardial injury (miR-92, miR-21) and immune responses (miR-618, miR-27a). NGS further yielded 52 DE miRNA in serum exosomes from CS versus AMI: 5 up-regulated in CS; 47 up-regulated in AMI, including transcripts previously detected in AMI patients (miR-1-1, miR-133a, miR-208b, miR-423, miR-499). Five miRNAs with increased DE in CS included two isoforms of miR-624 and miR-144, previously reported as markers of cardiomyopathy.

Conclusions

MiRNA patterns of exosomes derived from CS and AMI patients are distinct, suggesting that circulating exosomal miRNA patterns could serve as disease biomarkers. Further studies are required to establish their specificity relative to other cardiac disorders.

Chronic elevation of plasma vascular endothelial growth factor-A (VEGF-A) is associated with a history of blast exposure

Mounting evidence points to the significance of neurovascular-related dysfunction in veterans with blast-related mTBI, which is also associated with reduced [18F]-fluorodeoxyglucose (FDG) uptake. The goal of this study was to determine whether plasma VEGF-A is altered in veterans with blast-related mTBI and address whether VEGF-A levels correlate with FDG uptake in the cerebellum, a brain region that is vulnerable to blast-related injury 72 veterans with blast-related mTBI (mTBI) and 24 deployed control (DC) veterans with no lifetime history of TBI were studied. Plasma VEGF-A was significantly elevated in mTBIs compared to DCs. Plasma VEGF-A levels in mTBIs were significantly negatively correlated with FDG uptake in cerebellum. In addition, performance on a Stroop color/word interference task was inversely correlated with plasma VEGF-A levels in blast mTBI veterans. Finally, we observed aberrant perivascular VEGF-A immunoreactivity in postmortem cerebellar tissue and not cortical or hippocampal tissues from blast mTBI veterans. These findings add to the limited number of plasma proteins that are chronically elevated in veterans with a history of blast exposure associated with mTBI. It is likely the elevated VEGF-A levels are from peripheral sources. Nonetheless, increasing plasma VEGF-A concentrations correlated with chronically decreased cerebellar glucose metabolism and poorer performance on tasks involving cognitive inhibition and set shifting. These results strengthen an emerging view that cognitive complaints and functional brain deficits caused by blast exposure are associated with chronic blood-brain barrier injury and prolonged recovery in affected regions.

A systematic review on reported outcomes and outcome measures in female idiopathic chronic pelvic pain for the development of a core outcome set

BACKGROUND

A core outcome set (COS) is required to address inconsistencies in outcome reporting in chronic pelvic pain (CPP) trials.

OBJECTIVES

Evaluation of reported outcomes and selected outcome measures in CPP trials by producing a comprehensive inventory to inform a COS.

SEARCH STRATEGY

Systematic review of randomised controlled trials (RCTs) identified from Cochrane Central Register of Controlled Trials (CENTRAL), Embase and MEDLINE databases.

SELECTION CRITERIA

RCTs assessing efficacy and safety of medical, surgical and psychological interventions for women with idiopathic CPP.

DATA COLLECTION AND ANALYSIS

Two independent researchers extracted outcomes and outcome measures. Similar outcomes were grouped and classified into domains to produce a structured inventory.

MAIN RESULTS

Twenty-four trials were identified including 136 reported outcomes and outcome measures. Rates of reporting outcomes varied (4-100%) and pelvic pain was the most frequently reported outcome (100%). All trials reported the pain domain; however, only half reported quality of life, clinical effectiveness and adverse events. No differences in outcome reporting were observed in five high-quality trials (21%). Univariate analysis demonstrated an association between quality of outcome reporting and methodological quality of studies (r_s  = 0.407, P = 0.048).

CONCLUSION

There is wide variation in reported outcomes and applied outcome measures in CPP trials. While a COS is being developed and implemented, we propose the interim use of commonly reported outcomes in each domain: pain (pelvic pain, dyspareunia, dysmenorrhoea), life impact (quality of life, emotional functioning, physical functioning), clinical effectiveness (efficacy, satisfaction, cost effectiveness, return to daily activities) and adverse events (surgical, perioperative observations, nonsurgical).

TWEETABLE ABSTRACT

There is significant variation in outcome reporting in CPP trials. Our systematic review forms the basis for the development of a core outcome set.

Circulating MicroRNAs and Extracellular Vesicle-Containing MicroRNAs as Response Biomarkers of Anti-programmed Cell Death Protein 1 or Programmed Death-Ligand 1 Therapy in NSCLC

INTRODUCTION

Anti-programmed cell death protein 1 (PD-1) or programmed death-ligand 1 (PD-L1) antibody therapy is a standard treatment for advanced NSCLC, and PD-L1 immunohistochemistry is used as a predictive biomarker for therapeutic response. However, because not all patients with NSCLC with high PD-L1 respond, and some patients with low PD-L1 expression exhibit durable benefit, more accurate predictive biomarkers are needed. Circulating microRNA (miRNA) and miRNA packaged in extracellular vesicles (EVs) are believed to play a role in intercellular communication among immune cells and between immune cells and tumor cells and may represent a good source of mechanism-related biomarkers.

METHODS

Pretreatment plasma of patients with advanced NSCLC treated with single-agent anti-PD-1 or anti-PD-L1 antibody was used in this study. Plasma EVs were isolated using size-exclusion chromatography. Whole plasma and EV-containing RNAs were extracted. The miRNA profile was analyzed with a next-generation sequencing platform.

RESULTS

Samples from 14 responders (patients who exhibited partial response or stable disease ≥6 mo) and 15 nonresponders (patients who exhibited progressive disease as per Response Evaluation Criteria in Solid Tumors) were analyzed. In total, 32 miRNAs (p = 0.0030-0.0495) from whole plasma and seven EV-associated miRNAs (p = 0.041-0.0457) exhibited significant concentration differences between responders and nonresponders. The results of some of these circulating miRNAs were validated in a separate cohort with eight responders and 13 nonresponders. The tumor PD-L1 level was also assessed using immunohistochemistry for patients involved in both cohorts.

CONCLUSIONS

Specific circulating miRNAs in whole plasma and plasma EVs are differentially expressed between responders and nonresponders and have potential as predictive biomarkers for anti-PD-1/PD-L1 treatment response.

Alterations in Plasma microRNA and Protein Levels in War Veterans with Chronic Mild Traumatic Brain Injury

Blast-related mild traumatic brain injury (mTBI) is considered the "signature" injury of the wars in Iraq and Afghanistan. Identifying biomarkers that could aid in diagnosis and assessment of chronic mTBI are urgently needed, as little progress has been made toward identifying blood-based biomarkers of repetitive mTBI in the chronic state. Addressing this knowledge gap is especially important in the population of military veterans who are receiving assessment and care often years after their last exposure. Circulating microRNAs (miRNAs), especially those encapsulated in extracellular vesicles (EVs), have gained interest as a source of biomarkers for neurological conditions. To identify biomarkers for chronic mTBI, we used next generation sequencing (NGS) to analyze miRNAs in plasma and plasma-derived EVs from 27 Iraq and Afghanistan war veterans with blast-related chronic mTBI, 11 deployed veteran non-TBI controls, and 31 civilian controls. We identified 32 miRNAs in plasma and 45 miRNAs in EVs that significantly changed in the chronic mTBI cohort compared with control groups. These miRNAs were predominantly associated with pathways involved in neuronal function, vascular remodeling, blood-brain barrier integrity, and neuroinflammation. In addition, the plasma proteome was analyzed and showed that the concentrations of C-reactive protein (CRP) and membrane metalloendopeptidase (MME) were elevated in chronic mTBI samples. These plasma miRNAs and proteins could potentially be used as biomarkers and provide insights into the molecular processes associated with the long-term health outcomes associated with blast-related chronic mTBI.

Circulating RNAs as predictive markers for the progression of type 2 diabetes

Type 2 Diabetes Mellitus (T2DM) is the most prevalent form of diabetes in the USA, thus, the identification of biomarkers that could be used to predict the progression from prediabetes to T2DM would be greatly beneficial. Recently, circulating RNA including microRNAs (miRNAs) present in various body fluids have emerged as potential biomarkers for various health conditions, including T2DM. Whereas studies that examine the changes of miRNA spectra between healthy controls and T2DM individuals have been reported, the goal of this study is to conduct a baseline comparison of prediabetic individuals who either progress to T2DM, or remain prediabetic. Using an advanced small RNA sequencing library construction method that improves the detection of miRNA species, we identified 57 miRNAs that showed significant concentration differences between progressors (progress from prediabetes to T2DM) and non-progressors. Among them, 26 have been previously reported to be associated with T2DM in either body fluids or tissue samples. Some of the miRNAs identified were also affected by obesity. Furthermore, we identified miRNA panels that are able to discriminate progressors from non-progressors. These results suggest that upon further validation these miRNAs may be useful to predict the risk of conversion to T2DM from prediabetes.

mRNA transcript distribution bias between Borrelia burgdorferi bacteria and their outer membrane vesicles

Borrelia burgdorferi, a bacterium in the spirochete phylum, is the causative agent of Lyme disease. Borrelia burgdorferi has a linear chromosome with a number of circular and linear plasmids. Bacteria, including B. burgdorferi, release spherical outer membrane vesicles (OMVs) that are known to carry secretory products including metabolites, nucleic acids and proteins. Herein, we provide the first comparative transcriptomic analysis of the vesicles released from B. burgdorferi. We identified a total of ∼1200 unique transcripts with at least one mapped read from the bacterial cell and its OMVs. We compared the spectrum of transcripts between bacterial cell and its OMVs, and found a biased distribution based on the source of transcripts, i.e. plasmid-encoded transcripts are more likely to be enriched in the OMVs. We validated the distribution for some of the transcripts by qPCR. This analysis provides the first evidence that some of the B. burgdorferi transcripts are preferentially packaged in OMV, which further suggest that the bacteria might use its OMVs for bacteria-bacteria or bacteria-host communications. This report also suggests a possible involvement of Borrelia-derived OMVs in the development of Lyme disease in both early and post disease syndromes.

Study protocol: rationale and design of the community-based prospective cohort study of kidney function and diabetes in rural New Mexico, the COMPASS study

BACKGROUND

Rural areas in the state of New Mexico have been the "ground-zero" for the epidemic of diabetic Chronic Kidney Disease (CKD) in the United States. However, there is limited research about risk factors of diabetic CKD in this area and scarce data regarding the performance of emerging markers of renal filtration and epigenetic biomarkers of renal function and diabetes in this area with its unique ethnic/racial population. We designed the COMPASS study as a community-based program in rural New Mexico aiming to screen for CKD and to discover CKD-related translational biomarkers.

METHODS/DESIGN

The study involves a prospective, longitudinal cohort design involving individuals living in rural New Mexico. Participants undergo a screening for kidney disease using markers of abnormal renal filtration (impaired glomerular filtration rate) or damage (albuminuria). Those found to have CKD on the basis of these tests or those at risk for CKD are enrolled in a prospective longitudinal cohort. We measure markers of renal function, insulin resistance and epigenetics (microRNAs) on patients. Individuals are invited to participate in interviews and focus groups in order to characterize their attitudes towards research and barriers or facilitators to participation in future research studies about kidney disease.

DISCUSSION

This study will provide important data about the local epidemiology of kidney disease in a high-risk rural setting and the utility of emerging renal filtration markers (Beta 2 Microglobulin and Cystatin C), while generating data and methods for the analyses of microRNA biomarkers. The qualitative research subproject will identify factors associated with increased willingness to participate in future translational research projects. With its geographical focus, this study will address a critical disparity in kidney disease research, while generating novel epigenetic data that are relevant for future studies in the general population.

The C. elegans Spalt-like protein SEM-4 functions through the SoxC transcription factor SEM-2 to promote a proliferative blast cell fate in the postembryonic mesoderm

Proper development of a multicellular organism relies on well-coordinated regulation of cell fate specification, cell proliferation and cell differentiation. The C. elegans postembryonic mesoderm provides a useful system for uncovering factors involved in these processes and for further dissecting their regulatory relationships. The single Spalt-like zinc finger containing protein SEM-4/SALL is known to be involved in specifying the proliferative sex myoblast (SM) fate. We have found that SEM-4/SALL is sufficient to promote the SM fate and that it does so in a cell autonomous manner. We further showed that SEM-4/SALL acts through the SoxC transcription factor SEM-2 to promote the SM fate. SEM-2 is known to promote the SM fate by inhibiting the expression of two BWM-specifying transcription factors. In light of recent findings in mammals showing that Sall4, one of the mammalian homologs of SEM-4, contributes to pluripotency regulation by inhibiting differentiation, our work suggests that the function of SEM-4/SALL proteins in regulating pluripotency versus differentiation appears to be evolutionarily conserved.

Combination HDACi and mTOR inhibitor therapy in poor-risk de novo and refractory elderly patients with AML

e18012

Background: Valproic acid (VPA, 2-propylpentanoic acid) is a histone deacetylase inhibitors (HDACi), which has in vitro activity against Acute Myeloid Leukemia (AML) blasts. HDACi produce epigenetic modifications, and may have antineoplastic effects in AML by activating transcriptional silenced genes. The mammalian target of rapamycin (mTOR) pathways constitutive activation has been involved in the pathogenesis of various cancers, including AML. We present a series of two cases of poor risk de novo and refractory elderly AML patients treated with a combination of HDACi VPA and mTOR inhibitor sirolimus (S). Methods: This is a retrospective chart review garnered data on two patients with de novo AML and refractory AML who were treated with a combination therapy of VPA 500 mg three times a day with sirolimus 1 mg by mouth daily. Patients continued to receive treatment until disease progression. Results: Patient 1 achieved transfusion independence and a 6 month CR with ECOG PS 1 without hospitalizations. Repeat BM demonstrated no morphologic or immunophenotypic evidence of AML. Persistent disease was still detectable by FISH. Patient 2 was started on the regimen after persistent disease was detected by day 14 bone marrow, post standard 7 + 3 induction. Repeat bone marrow after 23 days of treatment with VPA and Sirolimus showed no immunophenotypic, morphological or cytogenetic evidence of AML. The patient remained in remission for 9 months on therapy with normal blood counts. Conclusions: We postulate that the use of VPA with sirolimus, is an active combination therapy for elderly, poor risk AML patients who may not otherwise tolerate intensive chemotherapy. The mechanism of action may involve activation of the mTORC2 pathway by HDAC1. Given our observations, further studies are warranted to better define the activity of this or similar combination therapies in elderly AML patients. [Table: see text]

Transcriptional regulation of HLH-6-independent and subtype-specific genes expressed in the Caenorhabditis elegans pharyngeal glands

The Caenorhabditis elegans pharyngeal glands represent one of five cell types in the pharynx. We have previously shown that the bHLH transcription factor, HLH-6, is required for gland development and for expression of many, but not all, gland genes (Smit et al., 2008). Here, we have identified additional gland-expressed genes and find that transcriptional regulatory inputs other than HLH-6 are necessary for their regulation. We demonstrate that at least two hlh-6 independent gland genes, nas-12 and Y8A9A.2, require a cis-acting motif (HRL3- Hlh-6 Regulatory eLement 3), previously described based on its requirement for hlh-6 expression (Ghai and Gaudet, 2008). We also show that expression of the gland-expressed genes, ZK596.1, scl-3, wrt-3, and Y76B12C.3, rely on cis-elements and trans-acting factor(s) other than HLH-6 and HRL3. In addition, we show that negative regulatory mechanisms are employed to refine the spatial expression of some genes, resulting in expression in only a subset of the five gland cells. We show that one of these genes, Y8A9A.2, is negatively regulated by the NHR transcription factor encoded by nhr-48, which represses Y8A9A.2 expression in the g1A cells. We also show that another gene expressed in the reciprocal subset of gland cells, phat-5, is negatively regulated in the g1P and g2 cells by an unknown factor acting through a conserved cis-element in the phat-5 promoter. Overall, this work reveals levels of regulation of gene expression in a single cell type beyond that previously known, and suggests mechanisms by which the different gland sub-types are distinguished.

A retrospective study analyzing activity of ofatumumab in blastic variant mantle cell lymphoma

e18500

Background: The blastic variant (BV) form of mantle cell lymphoma (MCL) is a rare and aggressive subtype of non-Hodgkin's lymphoma (NHL) for which no standard of care exists. Ofatumumab is a CD20-directed monoclonal antibody (mAb) FDA approved for the treatment of patients with CLL. We retrospectively studied relapsed BV of MCL in patients treated with regimens containing ofatumumab and previous or concurrent epigenetic therapy (cladribine (2-CdaA) and vorinostat). Methods: BV was confirmed by histopathological patterns, ki-67 proliferation index, immunophenotyping, and t(11;14) by FISH and/or cyclin D1 overexpression. The primary endpoint was overall response rate (ORR). Secondary endpoints included progression free survival and complete response. Correlative studies to support the hypothesis that epigenetic modulation of multiple genes in multiple pathways can potentiate the activity of mAbs were performed. Results: Ofatumumab administered to 5 Stage IV BV of MCL patients (Table). 3/5 patients had a radiological complete response, lasting 21.1, 13.4 and 12 months, The other 2 patients had partial response and are on the maintenance. Observed PFS in this cohort is a median 13 months (2.7-20.7). Correlative studies following epigenetic therapy found upregulation of the following genes by RT-PCR: NOXA1 (3/5 patients), CEBP1 (2/5) and EZH2 (2/5). Conclusions: Epigenetic drugs can augment the activity of mAbs. In this case, a more potent mAb improves response in MCL. Correlative studies to support the hypothesis that epigenetic modulation of multiple genes in multiple pathways can potentiate activity of mAbs. The combination of 2-CdA and vorinostat synergistically activates genes silenced by histone deacetylation, histone methylation and DNA methylation and enhances the activity of the mAb ofatumumab. [Table: see text]

Significance of CA 27.29 (MUC 1 glycoprotein) levels in patients with breast cancer

e11579

Background: ASCO guidelines do not support the use of CA 15–3 and CA 27.29 for monitoring patients for recurrence after primary breast cancer therapy. However, several well-designed studies have shown that an increase in CA 15–3 or CA 27.29 after primary and/or adjuvant therapy can predict recurrence an average of 5 to 6 months before other symptoms or tests. We wanted to assess the significance of measuring the tumor marker (CA 27.29 levels) to monitor the clinical progress of breast cancer. Methods: After IRB approval, we conducted a retrospective chart review of 392 patients with breast cancer who had regular monitoring of CA 27.29 levels following the diagnosis of breast cancer. A total of 2671 values of CA 27.29 were evaluated from our institution over the past 5 years (2003–2008). Patient CA 27.29 levels were correlated with clinical progression of the disease (diagnostic imaging and history and physical examinations). Results: Out of 330 patients with Stage I, II, and III after treatment with adjuvant therapy, 316 had no evidence of disease (NED) and had normal levels(<38) of CA 27.29. Out of the14 patients with clinical evidence of disease recurrence, 3 had persistently elevated levels. Of the 62 patients with stage IV breast cancer following cheomotherapy, 29 patients had clinical progression of disease with 20 (69%) patients showing increasing levels. Out of the 33 patients with no evidence of progression of disease only 4(12%) had increasing levels. Conclusions: Our trend analysis concludes that a normal CA 27.29 level in patients with Stage I, II, and III, after adjuvant treatment, correlates well with clinically NED status and might be of reassuring benefit to the patients. However, increasing levels of CA27.29 in metastatic disease correlate well with clinical progression of the disease. A large multicenter prospective study is warranted to further assess the role of CA 27.29 for disease monitoring in locally advanced and metastatic breast cancer.

No significant financial relationships to disclose.

The CSL transcription factor LAG-1 directly represses hlh-6 expression in C. elegans

The Caenorhabditis elegans gene hlh-6 is expressed specifically in pharyngeal glands, one of five distinct pharyngeal cell types. Expression of hlh-6 is controlled by a discrete set of cis-regulatory elements, including a negative element called HRL1. Here we demonstrate that HRL1 is a functional binding site for LAG-1, the CSL transcriptional effector of Notch in C. elegans, and that regulation of hlh-6 by LAG-1 is direct. Regulation of hlh-6 by LAG-1 is strictly negative: removal of HRL1 or LAG-1 regulation results in ectopic expression of hlh-6, but does not affect expression in pharyngeal glands. Furthermore, direct regulation of hlh-6 expression does not appear to involve Notch signaling, contrary to the canonical mechanism by which CSL factors regulate target genes. We also identify an additional cis-regulatory element in the hlh-6 promoter that, together with previously identified elements, is sufficient to overcome repression by LAG-1 and activate hlh-6 expression in pharyngeal glands.

Fulminant Postcesarean Clostridium difficile Pseudomembranous Colitis

BACKGROUND

Pseudomembranous colitis due to Clostridium difficile infection is rarely reported in the obstetric literature. This disease process is associated with prior antibiotic exposure.

CASE

A term primigravida was delivered by primary cesarean for failed vacuum extraction. She received Intravenous cefazolin after cord clamping, which was continued for 36 hours for a presumptive diagnosis of endometritis. On day 3, oral amoxicillin and clavulanate was started for suspected cellulitis of the incision. She was readmitted 1 day after her discharge with severe diffuse abdominal pain and distention. Proctoscopy showed pseudomembranous colitis. Colectomy with temporary ileostomy was performed for worsening symptoms and imminent perforation.

CONCLUSION

The diagnosis of pseudomembranous colitis should be considered in postpartum women who have low-grade fever, abdominal and gastrointestinal symptoms, and recent antibiotic exposure.

Activity of Continuous Infusion Plus Pulse Interleukin-2 with Famotidine in Patients with Metastatic Kidney Cancer or Melanoma Previously Treated with Interleukin-2

Lymphokine-activated killer (LAK) cells generated by high-dose continuous infusion interleukin-2 (IL-2) are able to nonspecifically lyse melanoma and kidney cancer cells. In vitro famotidine enhances cytotoxicity of LAK against tumor cells, possibly by increasing IL-2 uptake at the IL-2 receptor on lymphocytes. Outpatient IL-2 regimens typically have response rates of 15% or less, with most patients eventually experiencing progressive disease. Second-line therapy is, therefore, needed. We treated 11 patients (6 with metastatic melanoma; 5 having metastatic kidney cancer) who had previously experienced progressive disease on prior IL-2 regimens, with a combination of famotidine 20 mg intravenously (i.v.) twice per day and continuous-infusion IL-2 18 MIU/M2/24 hours x 72 hours, followed 24 hours later by a pulse IL-2 dose (18 MIU/M2 over 15 minutes). Cycles were repeated every 3 weeks. Patient characteristics were: 9 males, median age 63 years (range, 57-75), median Eastern Cooperative Oncology Group (ECOG) performance status: 1; most common metastatic sites: lungs, lymph nodes, and soft tissue/subcutaneous (s.c.); median number of cycles received: 4; most common toxicities were fever, nausea/emesis, hypophosphatemia, and hypomagnesemia. Five (5) patients (3 with melanoma, 2 with kidney cancer) have had partial responses. Two (2) patients with kidney cancer have been converted to complete responders with resection of residual disease, remaining without relapse at 5+ and 20+ months. Responding sites are lungs, lymph nodes, abdominal mass, and s.c. Median duration of response was 9.5 months. Median survival was 12 months. This combination has activity in patients with metastatic kidney cancer or melanoma who have received prior IL-2.

Mode of delivery and risk of respiratory diseases in newborns

OBJECTIVE

To determine whether there is an increased incidence of persistent pulmonary hypertension in neonates delivered by cesarean, with or without labor, compared with those delivered vaginally.

METHODS

We did a computerized retrospective review of 29,669 consecutive deliveries over 7 years (1992-1999). The incidences of persistent pulmonary hypertension of the newborn, transient tachypnea of the newborn, and respiratory distress syndrome (RDS) were tabulated for each delivery mode. Cases of persistent pulmonary hypertension were reviewed individually to determine delivery method and whether labor had occurred. The three groups defined were all cesarean deliveries, all elective cesareans, and all vaginal deliveries.

RESULTS

Among 4301 cesareans done, 17 neonates had persistent pulmonary hypertension (four per 1000 live births). Among 1889 elective cesarean deliveries, seven neonates had persistent pulmonary hypertension (3.7 per 1000 live births). Among 21,017 vaginal deliveries, 17 neonates had persistent pulmonary hypertension (0.8 per 1000 live births). chi2 analysis showed an odds ratio 4.6 and P <.001 for comparison of elective cesarean and vaginal delivery for that outcome.

CONCLUSION

The incidence of persistent pulmonary hypertension of the newborn was approximately 0.37% among neonates delivered by elective cesarean, almost fivefold higher than those delivered vaginally. The findings have implications for informed consent before cesarean and increased surveillance of neonates after cesarean.

Pediatrician attendance at cesarean delivery: necessary or not?

OBJECTIVE

To determine whether it is necessary for a pediatrician to attend all cesarean deliveries.

METHODS

We analyzed a database of 17,867 consecutive deliveries to determine the rates of low Apgar scores in the following three groups of patients: those with vaginal delivery, cesarean delivery using regional anesthesia without fetal indication, and cesarean delivery for fetal indications or using general anesthesia.

RESULTS

There was a significantly higher rate of low Apgar scores in the fetal indications or general anesthesia group when compared with vaginal deliveries. Specifically, 35 (5.8%) of 596 cesareans for fetal heart rate abnormality or using general anesthesia had 1-minute Apgars under 4 in contrast to 115 of 10,270 (1.1%) of vaginal deliveries. There was no significantly increased risk for low Apgar scores in the group of cesareans using regional anesthesia for nonfetal indications (33 of 2057, 1.6%). Results were similar for Apgar scores under 7 at 5 minutes.

CONCLUSION

Because there is no higher incidence of low Apgar scores in cesarean deliveries using regional anesthesia for nonfetal indications compared with vaginal deliveries, there is no convincing need for pediatrician attendance at such deliveries.

Intrapartum antibiotic prophylaxis increases the incidence of gram-negative neonatal sepsis

OBJECTIVE

To investigate the influence of the increased use of intrapartum chemoprophylaxis on the incidence of vertically transmitted neonatal sepsis.

METHODS

Multiple institutional databases were queried for the number of cases in which intrapartum antibiotics were used, the obstetric risk factors that were present, and the number of resultant cases of neonatal sepsis that occurred for deliveries from 1992 through 1997. Intrapartum antibiotic use was compared between the first and fourth quarter of 1997. Comparisons were made between the years 1992-1996 and 1997 for the incidence of the various pathogens causing neonatal sepsis; group B streptococcus (GBS), gram-negative sepsis, and others.

RESULTS

We found a significant increase in intrapartum chemoprophylaxis between the first and fourth quarters of 1997 corresponding to the increased physician awareness of published guidelines. As expected, the incidence of neonatal GBS sepsis was drastically reduced (from 1.7/1000 live births to 0 in 3730 births, P = 0.02). Unfortunately, there was a concomitant increase in the incidence of gram-negative sepsis (0.29/1000 vs. 1.3/1000, P = .02). The overall incidence of neonatal sepsis remained unchanged (2.7/1000 vs. 2.1/1000, P = .69).

CONCLUSIONS

Published guidelines have encouraged physicians to increase the use of intrapartum chemoprophylaxis to reduce vertical transmission of GBS. This study confirms the efficacy of this approach. Unfortunately, this reduction comes at the cost of increasing the incidence of ampicillin-resistant gram-negative neonatal sepsis with a resultant increased mortality. These data provide compelling evidence that the policy of providing ampicillin chemoprophylaxis in selected patients needs to be reconsidered.

Intrapartum antibiotic prophylaxis increases the incidence of gram-negative neonatal sepsis

OBJECTIVE

To investigate the influence of the increased use of intrapartum chemoprophylaxis on the incidence of vertically transmitted neonatal sepsis.

METHODS

Multiple institutional databases were queried for the number of cases in which intrapartum antibiotics were used, the obstetric risk factors that were present, and the number of resultant cases of neonatal sepsis that occurred for deliveries from 1992 through 1997. Intrapartum antibiotic use was compared between the first and fourth quarter of 1997. Comparisons were made between the years 1992-1996 and 1997 for the incidence of the various pathogens causing neonatal sepsis; group B streptococcus (GBS), gram-negative sepsis, and others.

RESULTS

We found a significant increase in intrapartum chemoprophylaxis between the first and fourth quarters of 1997 corresponding to the increased physician awareness of published guidelines. As expected, the incidence of neonatal GBS sepsis was drastically reduced (from 1.7/1000 live births to 0 in 3730 births, P = 0.02). Unfortunately, there was a concomitant increase in the incidence of gram-negative sepsis (0.29/1000 vs. 1.3/1000, P = .02). The overall incidence of neonatal sepsis remained unchanged (2.7/1000 vs. 2.1/1000, P = .69).

CONCLUSIONS

Published guidelines have encouraged physicians to increase the use of intrapartum chemoprophylaxis to reduce vertical transmission of GBS. This study confirms the efficacy of this approach. Unfortunately, this reduction comes at the cost of increasing the incidence of ampicillin-resistant gram-negative neonatal sepsis with a resultant increased mortality. These data provide compelling evidence that the policy of providing ampicillin chemoprophylaxis in selected patients needs to be reconsidered.

Intrapartum management relating to the risk of perinatal transmission of group B streptococcus

OBJECTIVE

To review the incidence of neonatal group B streptococcal (GBS) sepsis and its associated risk factors in our obstetrical population.

METHODS

A computerized perinatal database of over 17,000 births (from 1992 to 1996) was queried for the incidence of neonatal GBS sepsis. A more detailed review of 895 births (from the first quarter of 1997) was undertaken to identify the incidence of risk factors known to be associated with neonatal GBS sepsis.

RESULTS

In our institution, 30 cases of neonatal early-onset GBS sepsis were identified in over 17,000 births (or 1.7/1,000 deliveries). Risk factors were identified in 17 of those cases (56%). There were two neonatal fatalities. Chemoprophylaxis was provided in 15% of the total deliveries.

CONCLUSIONS

In spite of the lack of a uniform policy for identifying patients suitable for GBS chemoprophylaxis, we found only a 43% incidence of neonatal GBS sepsis occurring without risk factors present. Identification of antepartum or intrapartum risk factors in our series, therefore, would have identified the majority of cases resulting in neonatal GBS sepsis, which may have benefited from intrapartum therapy. Some negative potential consequences of chemoprophylaxis are discussed, raising questions regarding the recent recommendations of the Centers for Disease Control and Prevention.

Intrapartum management relating to the risk of perinatal transmission of group B streptococcus

OBJECTIVE

To review the incidence of neonatal group B streptococcal (GBS) sepsis and its associated risk factors in our obstetrical population.

METHODS

A computerized perinatal database of over 17,000 births (from 1992 to 1996) was queried for the incidence of neonatal GBS sepsis. A more detailed review of 895 births (from the first quarter of 1997) was undertaken to identify the incidence of risk factors known to be associated with neonatal GBS sepsis.

RESULTS

In our institution, 30 cases of neonatal early-onset GBS sepsis were identified in over 17,000 births (or 1.7/1,000 deliveries). Risk factors were identified in 17 of those cases (56%). There were two neonatal fatalities. Chemoprophylaxis was provided in 15% of the total deliveries.

CONCLUSIONS

In spite of the lack of a uniform policy for identifying patients suitable for GBS chemoprophylaxis, we found only a 43% incidence of neonatal GBS sepsis occurring without risk factors present. Identification of antepartum or intrapartum risk factors in our series, therefore, would have identified the majority of cases resulting in neonatal GBS sepsis, which may have benefited from intrapartum therapy. Some negative potential consequences of chemoprophylaxis are discussed, raising questions regarding the recent recommendations of the Centers for Disease Control and Prevention.

Improvement in oxygen tensions and pulmonary blood flow with intermittent distal aortic compression during normoxia, hypoxic hypoxia, and hyperoxia in neonatal piglets

BACKGROUND AND METHODS

We investigated the hypothesis that, in a newborn piglet during normoxia, hypoxia, and hyperoxia, increasing aortic pressure transiently by intermittent short-duration aortic compression would affect left-to-right shunting of blood and thus increase pulmonary artery blood flow, pulmonary arterial PO2, and aortic PO2 proximal to the point of compression. We also investigated whether a balloon atrial septostomy, by providing an open channel for communication between the right- and left-sided circulations, would further improve pulmonary blood flow and aortic PO2. Studies were performed in eight 7- to 10-day-old newborn piglets in three phases (FIO2 of 0.21, 0.12, and 1.0) before and after balloon arterial septostomy in each piglet. Blood gas measurements and hemodynamic variables were recorded before and at the end of a 30-sec period of aortic compression.

RESULTS

During aortic compression, all the animals demonstrated a 50 to 70 mm Hg increase in aortic pressure proximal to the compression. Before balloon septostomy, there were 21%, 41%, and 8% increases in aortic PO2 in the room air, hypoxic, and hyperoxic phases of the experiment, respectively. There were also statistically significant increments in pulmonary blood flow and arterial pressures. After balloon septostomy, there were 35%, 25%, and 21% increments in aortic PO2 during the room air, hypoxic, and hyperoxic phases of the experiment, respectively. However, there was no statistically significant further improvement in the effects of aortic compression on PO2 with septostomy compared with those effects before septostomy.

CONCLUSIONS

Our results suggest that increasing systemic arterial pressures in order to forcibly affect left-to-right shunting of blood may be potentially beneficial in the management of hypoxia in situations where low pulmonary artery blood flow may be contributing to hypoxia, e.g., in persistent pulmonary hypertension of the newborn.

In vivo distribution of human milk leucocytes after ingestion by newborn baboons

The in vivo distribution of enterally administered human milk leucocytes labelled with indium hydroxyquinoline (111In) was studied in premature baboons. The animals were killed at 72 hours of age and tissue samples examined for radioactivity. Maximum activity was found in the luminal contents, and activity in the liver and spleen was higher than in bone marrow, the site where free isotope is normally deposited. These findings suggest that some intact milk leucocytes may cross from the gastrointestinal tract into the neonatal circulation. Also the high activity in gastrointestinal tissue that had been washed several times indicates that leucocytes adhere to mucosa or lie intramurally. We speculate that the presence of leucocytes in the gastrointestinal tract 60 hours after a single breast feed can provide an important defence mechanism against infection.

Circle of Willis blood velocity and flow direction after common carotid artery ligation for neonatal extracorporeal membrane oxygenation

The velocity and direction of blood flow in the circle of Willis arteries were measured in three infants who underwent right common carotid artery ligation for extracorporeal membrane oxygenation treatment. Within 15 minutes of common carotid artery ligation, blood flow was detected in one infant's right middle cerebral artery; however, the velocity was reduced to 50% of the preextracorporeal membrane oxygenation level. The velocity remained 50% to 70% lower than normal during the 88 hours of extracorporeal membrane oxygenation therapy. In the other two infants, the velocity changes were less severe. By 2 to 10 weeks after weaning from extracorporeal membrane oxygenation, the velocities in the left cerebral arteries were increased to 116% to 217% of the corresponding right cerebral vessels. Following common carotid artery ligation, a retrograde direction of flow was noted in the first (A1) segment of the right anterior cerebral artery and in the right posterior communicating artery, whereas the direction of flow was normal in the corresponding vessels on the left. After common carotid artery ligation, the vertebrobasilar and the contralateral internal carotid systems appear to be the main sources of reperfusion of the right cerebral hemisphere via the circle of Willis. Furthermore, because of the known variants of the circle anatomy, a noninvasive pulsed Doppler method could be used to evaluate the flow patterns in the circle of Willis arteries, both before and after common carotid artery ligation for extracorporeal membrane oxygenation.

Morbidity and mortality factors in twins. An epidemiologic approach

Some epidemiologic characteristics of twin pregnancies and twin infants have been reviewed. We found that twins are prone to be born prematurely and have lower birth weights than their singleton counterparts after 30 to 34 weeks of gestation. Twins are also more prone to birth asphyxia, hyaline membrane disease, respiratory disorders, and seizures. Congenital anomalies and nonrespiratory morbidity were not found to be increased in twins. Twins have a six times higher perinatal mortality rate than do singletons. This is accounted for by prematurity in the main. A part of the excess mortality in twins is accounted for by a higher mortality in larger, near-term twins. Efforts should be directed toward decreasing the incidence of prematurity in twins and understanding and managing the problems of near-term twins better.