Neonatal tetanus in the South-Eastern region of Turkey: changes in prognostic aspects by better health care

Neonatal tetanus is an important health problem with an estimated 500,000 deaths per year worldwide, particularly in developing countries. We analysed 56 cases of neonatal tetanus (NNT), retrospectively, who were admitted to Diyarbakir Children State Hospital between 1994 and 2001. In 1998 an intervention in a childcare intensive unit was conducted, which included a nurse education programme, increasing the number of nurses and other health staff, and more qualified management of cases. The mean age of patients was 7.9 days at admission, and the male:female ratio was 1:6. Eleven per cent of the cases had body weight under 2500 g. The mean hospitalization period was 9.9 days. All patients were born at home without medical help and 28.6 per cent were from urban areas. The case fatality rate that was formerly 88.5 per cent, decreased to 53.6 per cent by the intervention conducted in 1998. Based on our findings, we can say that improved hospitalization conditions and intensive care may reduce mortality. Enforcing preventive policies both in rural and urban areas is of great importance in the least developed regions.     

Transcatheter Embolization of a Coronary Fistula Originating from the Left Anterior Descending Artery by Using N-Butyl 2-Cyanoacrylate

In this report, we describe a successful percutaneous transcatheter n-butyl 2-cyanoacrylate embolization of a coronary fistula originating from the left anterior descending artery in an adolescent with unexpected recurrent attacks of myocardial ischemia.     

Cord blood cardiac troponin I as an early predictor of short-term outcome in perinatal hypoxia

BACKGROUND: In most perinatal-hypoxia survivors, myocardial dysfunction can be reversed with appropriate inotropic support and oxygenation. The main problem related to outcome is cerebral damage. OBJECTIVE: We tested the hypothesis that cardiac troponin I (cTnI), a known marker of myocardial injury, is also an early predictor of severity of cerebral damage and mortality in intrauterine hypoxia. METHODS: Venous and arterial cord blood samples were collected at delivery from 54 consecutive newborns with hypoxic-ischemic encephalopathy and from 50 consecutive healthy controls. Arterial blood gas analysis was performed and levels of cTnI, creatine kinase and creatine kinase-MB in venous cord blood were measured. The same serum parameters were also measured on the 3rd and 7th day of life. RESULTS: Infants with hypoxia had a significantly higher cord blood cTnI levels than controls (p < 0.0001). Cord blood and 3rd and 7th day serum cTnI values showed a significant increase with severity of HIE (p < 0.0001). In non-survivors cord blood cTnI levels were significantly higher than the survivors (5.9 ng/ml, range 2.1-12.8, and 1.6 ng/ml, range 0.4-5.8, respectively; p < 0.0001). Receiver-operator curve analysis revealed cord cTnI as the most sensitive factor for predicting early death (area under curve = 0.956; SE: 0.028; 95% CI: 0.9-1.01). Cord blood cTnI of 4.6 ng/ml was identified as the optimal cut-off level for predicting serious risk of early mortality. CONCLUSION: The results suggest that significant elevation of cord cTnI is an excellent early predictor of severity of hypoxic-ischemic encephalopathy and mortality in term infants.     

Plasma ionized magnesium levels in neonatal respiratory distress syndrome

Measurement of ionized magnesium (IMg) provides an accurate assessment of the free form of Mg, which is the physiologically active form and is most reflective of the biologically active and not easily measurable intracellular Mg fraction. Plasma levels of IMg were measured by ion-selective electrode method in premature newborns with respiratory distress syndrome (RDS), and relationships and correlations between IMg levels and various demographic, prognostic and laboratory characteristics were investigated by comparing the premature newborns with (study group; n = 19) and without RDS (control group; n = 20) in the present study. The values of the postnatal arterial pH and base excess and plasma IMg levels were significantly different between the study and control groups, and the number of newborns with any morbidity was significantly higher in the study group. Within the study group there were significant negative correlations between the plasma IMg levels and the values of the umbilical cord arterial pH (r = -0.621, p = 0.005) and base excess (r = -0.746, p = 0.001), and the value of the postnatal arterial base excess (r = -0.585, p = 0.008). The newborns who died later had higher plasma IMg levels than those who survived (0.89 +/- 0.45 vs. 0.63 +/- 0.24 mmol/l, p = 0.026). These findings suggest that increase of plasma IMg may be due to extracellular movement of Mg, which is a principally intracellular ion, as a result of acidosis, hypoxia and probable cellular injury during the early course of RDS. The exact pathophysiological mechanism responsible for IMg increase, and whether determination of plasma IMg level, including umbilical cord blood IMg measurement, can be used as an early or predictive indicator of RDS in the diagnosis remain to be determined in further large-scale studies.     

Nutritional effects on auditory brainstem maturation in healthy term infants

OBJECTIVE: To assess the effects of dietary long chain polyunsaturated fatty acid (LCPUFA) supplementation on auditory brainstem maturation of healthy term newborns during the first 16 weeks of life by measuring brainstem auditory evoked potentials (BAEPs). DESIGN: Throughout the 16 week study period, infants in the formula A group (n = 28) were assigned to be fed exclusively with the same formula supplemented with DHA, and infants in the formula B group (n = 26) were assigned to receive only a DHA unsupplemented but otherwise similar formula. During the study period, the first 26 consecutive infants to be fed exclusively on their mother's milk for at least the first 16 weeks of life were chosen as the control group. BAEP measurements were performed twice: at the first and 16th week of age. RESULTS: There were no significant differences among the study and control groups in the BAEP measurements performed at the study entry. At 16 weeks of age, all absolute wave and interpeak latencies in the study and control groups had significantly decreased. The decreases were significantly greater in the formula A and control groups than in the formula B group. CONCLUSIONS: Infants fed on human milk or a formula supplemented with LCPUFAs during the first 16 weeks of life show more rapid BAEP maturation than infants fed on a standard formula. Although the clinical importance and long term effects of these findings remain to be determined, routine supplementation of formulas with LCPUFAs should be considered.     

Subacute sclerosing panencephalitis with fulminating course: follow-up magnetic resonance spectroscopy (MRS) findings

The fulminating form of subacute sclerosing panencephalitis is an extremely rare condition. Imaging findings are usually not correlated with clinical staging. We describe a 4-year-old girl with severe neuronal loss, demyelination, and gliosis in subcortical white matter by magnetic resonance spectroscopic examination even though she was diagnosed as clinical stage II. In 2 months' time, her clinical status worsened significantly. Follow-up magnetic resonance spectroscopy revealed findings that were consistent with clinical status. It is our opinion that magnetic resonance spectroscopy could demonstrate a rapidly progressive fulminating course of subacute sclerosing panencephalitis even in the early clinical stages.     

Effect of paclitaxel administration on P wave duration and dispersion

Abstract. The prototypic taxane paclitaxel, which disrupts tubulin dynamics, has been widely used in the treatment of solid malignancies. However, it has been associated with adverse cardiac effects. Therefore, the effect of the paclitaxel infusion on P wave duration and dispersion (PWD) was investigated. Twelve-lead surface ECGs were recorded twice from 12 patients with breast, ovarian and non-small-cell lung carcinoma: one just before paclitaxel infusion and the other 1 hour after the end of the infusion. The changes in maximum (Pmax) and minimum P wave duration (Pmin) were measured manually and the difference between the two values was defined as PWD. The mean heart rate, Pmin, did not change after the infusion. However, Pmax, PWD and the average P wave duration significantly increased after infusion (122 ± 5 vs. 125 ± 5 p = 0.001 and 46 ± 7 vs. 53 ± 9 p = 0.03, 97 ± 5 vs. 101 ± 5ms p = 0.02 respectively). We found that paclitaxel infusion increased PWD and this may be a result of the drugs effect on cardiac autonomic modulation.     

The results of electrophysiological study and radio-frequency catheter ablation in pediatric patients with tachyarrhythmia

A total of 135 consecutive pediatric patients (pts) with tachyarrhythmia ranging from two to 21 years of age (median age 11 years) underwent electrophysiological study (EPS) between January 1994 and July 2001. Tachycardia could not be induced in 38 of 135 pts (28%) and studies in these patients were accepted as the normal EPS. Supraventricular tachyarrhythmia mechanisms were atrioventricular (AV) accessory pathways in 47 patients (manifest accessory pathways in 23 patients, concealed accessory pathways in 17 patients, permanent junctional reciprocating tachycardia in 7 patients), re-entry without accessory pathway in 26 patients (AV nodal reentry tachycardia in 20 patients, atrial flutter in 5 patients, sinus node re-entry tachycardia in 1 patient) and atrial ectopic tachycardia in eight patients. The diagnosis of ventricular tachycardia (VT) was made in 16 patients. Seventy-three of the 97 patients with the diagnosis of tachyarrhythmia as a result of EPS underwent radiofrequency (RF) catheter ablation. The indications, early results, complications, safety and efficacy of RF catheter ablation were reviewed in these patients. Among the 73 patients who underwent RF ablation (85 procedures), the overall final success rate for all the diagnoses was 82% (60 of 73 patients). The median follow-up period for all patients was 16 months (range 2 to 60 months). Total recurrence rate in 73 patients was 4% (3 patients). Re-ablation was performed in only one of them and was successful. Procedure-related complications occurred in eight patients (11%): transient third-degree AV block in one patient, transient second-degree AV block in one patient, atrial flutter in two patients (1 needed direct current cardioversion), and atrial fibrillation in three patients (2 needed defibrillation and transient pacemaker implantation). In one patient with permanent third-degree AV block a transvenous pacemaker implantation was required. These midterm results suggest that RF catheter ablation has a good success rate and a low complication rate in pediatric patients, especially when it is carried out in experienced pediatric cardiology centers.     

Intraorbital encephalocele: an important complication of orbital roof fractures in pediatric patients

Orbital roof fractures are uncommon, and traumatic intraorbital encephalocele formation is a very rare complication of this type of injury. We treated 43 pediatric patients with orbital roof fractures at our center over a 4-year period. The aim of this study was to retrospectively investigate conditions that may lead to intraorbital encephalocele formation in children with orbital roof fractures. Each case was reviewed, and the cause of injury, associated clinical and computerized tomography findings, the Glasgow Coma Scale score on admission, neurological status, other bodily injuries, hospitalization time and type and width of the orbital roof fracture were recorded. The findings in 6 patients who developed encephaloceles were compared to corresponding findings in the 37 patients who did not develop this complication. A total of 44 orbital roof fractures were diagnosed by axial and coronal computed tomography scanning. Six of the 43 children developed intraorbital encephaloceles in the first month after head trauma. In each of these cases, magnetic resonance imaging demonstrated the intraorbital cystic lesion in communication with the subarachnoid space. The width of each orbital roof fracture was measured on axial and coronal computed tomography slices and was confirmed by measurements during surgery. The width of the fractures in the encephalocele cases ranged from 2-4 mm. Duraplasty and orbitoplasty were performed in all the patients with encephalocele. Pediatric patients with orbital roof fractures that exhibit more than 2 mm diastasis and are associated with frontal cerebral contusion may be at greater risk for developing intraorbital encephalocele. All such cases should be monitored closely and investigated further with magnetic resonance imaging.     

Complications and outcome in left-sided endocarditis in children

We retrospectively assessed the clinical course and outcome of left-sided endocarditis in pediatric patients to find out the prognostic significance of the presence and size of echocardiographically detected vegetations. Among the children admitted to our institution with endocarditis between January 1987 and October 1999, 16 patients (mean age 9.03 +/- 4.95 years) who met the Duke criteria for the diagnosis of infective endocarditis (IE) were included in this study. Rheumatic valvular disease was the most frequent underlying heart disease (10 patients: 62.5%). Five patients were operated at a mean of 13.9 months before endocarditis, and all had residual defects. Vegetation was detected in 11 cases (69%). Ten patients had major complications (within 2 weeks in 6 patients). Three patients developed congestive heart failure (CHF), six had intracranial and one had lower extremity emboli. Among them four were operated because of complications (CHF: 3 cases, intracranial emboli: 1 case). All the operated cases are doing well. The association between intracranial embolic events and echocardiographically detected vegetations was determined by calculating specificity (40%), sensitivity (100%), positive predictive value (50%), and negative predictive value (100%). No intracranial embolism occurred in patients without vegetations. All vegetations were < or = 6 mm in patients with systemic embolism. There were four deaths, three of which were because of intracranial embolism. This study suggests that intracranial emboli have a major risk of mortality in left-sided endocarditis. The larger size of the vegetation is not a predictor of complications; furthermore, the absence of vegetations predicts that the patient is safe from embolic events. Therefore all patients with left-sided IE should be considered for earlier surgical intervention.