Methemoglobinemia Associated with Late-Onset Neonatal Sepsis: A Single-Center Experience

Objective â Methemoglobinemia (MetHb) is a rare congenital or acquired cause of infantile cyanosis. We examined the role of MetHb in a neonatal intensive care unit (NICU). Study Design â A retrospective observational study was conducted reviewing blood gas analyses of hospitalized newborns over a 2-year period. MetHb-positive patients (MetHb >1.8%) were matched with a control group for gestational age, weight, disease, and illness severity at admission. Maternal, neonatal, clinical, and laboratory parameters were collected and analyzed in both groups. Results â MetHb incidence was 6%. The mean MetHb in the case group was 7.2%, and the first positive samples were observed at a mean of 22 days of life, 6 days prior to clinical or culture-proven sepsis. We identified low maternal age (31 vs. 34 years; p = 0.038), sepsis (90 vs. 45%; p = 0.022), and protracted parenteral nutrition (46 vs. 23 days; p = 0.013) as risk factors for MetHb, and early minimal enteral feeding as protective factor (12th vs. 9th day; p = 0.038). Conclusion â MetHb has a high occurrence in NICU and can be a helpful prognostic indicator of an infectious process. Understanding and prompt identification of MetHb can allow pediatricians to implement a life-saving therapy

Dilated azygos arch mimicking an aortic arch anomaly during thoracic surgery

Cardiovascular malformations are frequently associated in patients with esophageal atresia (EA). We observed azygos continuation mimicking an aortic arch anomaly in four newborns with type III EA. They presented concomitant rib anomalies indicating a common developmental defect. Foreknowledge is important for planning thoracotomy or interventional cardiac catheterization in this population

The PCAOB Audit Quality Indicator Framework Project: Feedback From Stakeholders

Audit Quality Indicators (AQIs), as defined by the Center for Audit Quality, include four different elements:firm leadership and tone at the top; engagement team knowledge, experience, and workload; monitoring; and auditor reporting. AQIs are quantitative and qualitative measures designed to improve audit quality and help audit committees select the best audit firm for their current needs. They are intended to increase the reliability and accuracy of financial reporting. The Public Company Accounting Oversight Board (PCAOB) has issued a concept release proposing twenty-eight potential AQIs for use in the United States. The PCAOB release describes the AQI reporting framework and asks for public opinion on whether or not it should be implemented. This study reviews the comment letters in response to PCAOB Docket 041,Concept Release on Audit Quality Indicators, and the AQI reporting frameworks currently in place in the United Kingdom, Singapore, and other countries. After reviewing the PCAOB’s proposed AQI framework, response letters to Docket 041, and the AQI frameworks used in other countries, this paper provides an opinion on how the PCAOB should proceed with the AQI framework initiative in the U.S. The analysis suggests that AQI reporting should not be mandated in the U.S., but should become a flexible and voluntary framework that provides valuable information, enhances transparency in the audit profession, and establishes a commitment to the improvement of audit quality

Il dosaggio del lattato in neonati con distensione addominale come fattore prognostico di sindrome da compartimento addominale

L'ipertensione intraaddominale (IAH) e la risultante sindrome da compartimento addominale (ACS), caratterizzata da incremento della pressione >20 mmHg e insufficienza d’organo o multiorgano, sono state descritte in neonati con patologie addominali chirurgiche. La gestione effettiva e preventiva dell'IAH è associata a minore morbidità. In uno studio retrospettivo abbiamo analizzato 20 neonati con distensione addominale persistente per individuare fattori predittivi di IAH ed ACS. Il Gold-Standard della misurazione dell'IAH è la misurazione pressoria intravescicale ancora non standardizzata c/o le UTIN. Per definire l'IAH abbiamo quindi utilizzato il monitoraggio della saturazione di ossigeno (SpO2) prossimale e distale rispetto all’addome e 2 segni di compromissione d’organo (oliguria, ipotensione, insufficienza respiratoria, acidosi metabolica). Abbiamo riscontrato un rischio tendenzialmente elevato di disfunzione multiorgano e decesso in neonati di età gestazionale maggiore (p=0,09) e con una causa congenita di ACS (p<0,05), e in neonati in correzione con bicarbonati (p=0,05). Alti valori di lattato già al ricovero correlano con un deficit di basi maggiore nelle fasi avanzate di ACS (p<0,05) e con una distensione tardiva (p<0,05) associata, a sua volta, a valori di lattato più elevati nelle fasi di distensione ed acidosi (p<0,05) rispetto alla distensione precoce. Il lattato alla distensione è tendenzialmente più alto in chi avrà eventi più gravi (p=0,06) pur non correlando con il decesso (p=0,2). Solo nella fase successiva di acidosi i valori di lattato sono predittivi di decesso (p<0,05). In nessuna fase sono state riscontrate correlazioni con l’insufficienza respiratoria. L’unico fattore predittivo per un decorso sfavorevole è l’insulto tissutale perfusionale precoce misurato tramite il lattato che tuttavia non correla con il decesso perché probabilmente neonati, soprattutto con difetti della parete addominale, possono sopportare pressioni intraaddominali più elevate senza andare incontro ad insufficienza multiorgano. Al contrario sembra che neonati con ACS secondaria o con età gestazionale maggiore tollerino meno l’IAH sviluppando ACS a pressioni più basse poichè gli spazi intraaddominali sono già definiti

A New Dissimilarity Measure for Clustering Seismic Signals

Hypocenter and focal mechanism of an earthquake can be determined by the analysis of signals, named waveforms, related to the wave field produced and recorded by a seismic network. Assuming that waveform similarity implies the similarity of focal parameters, the analysis of those signals characterized by very similar shapes can be used to give important details about the physical phenomena which have generated an earthquake. Recent works have shown the effectiveness of cross-correlation and/or cross-spectral dissimilarities to identify clusters of seismic events. In this work we propose a new dissimilarity measure between seismic signals whose reliability has been tested on real seismic data by computing external and internal validation indices on the obtained clustering. Results show its superior quality in terms of cluster homogeneity and computational time with respect to the largely adopted cross correlation dissimilarit

Early intestinal perforation secondary to congenital mesenteric defects

Gastrointestinal perforation (GIP) in preterm neonates may be idiopathic, due to necrotizing enterocolitis (NEC), or mechanical obstruction. The predominant cause of GIP in the neonatal period is NEC. Differential diagnosis with congenital malformations, including mesenteric defects leading to internal hernias, is mandatory if the onset is early. We describe two newborns with trans-mesenteric herniation resulting in GIP, and we discuss the presence of possible additional risk factors such as prematurity and predisposing vascular disruption in connective tissue disorders (Ehlers-Danlos syndrome), twinning, and use of assisted reproductive technologies. These cases prompted us to review our exploratory laparotomies performed for intestinal obstruction, complicated/or not with perforation, to identify the frequency of neonatal trans-mesenteric hernias in a referral hospital. The prevalence of GIP and of internal hernia was 25% and 3.3%, respectively. In conclusion, time-onset and particular conditions associated with GIP should lead to a high index of suspicion for internal hernias in order to achieve appropriate diagnosis and therapy

Predictive Factors of Abdominal Compartment Syndrome in Neonatal Age

In the pediatric population, abdominal compartment syndrome (ACS) is a known complication of abdominal wall defect repair. However, there are only few reports on ACS in newborns and only a proposal of critical intra-abdominal pressure value (IAP) in term newborns, absent in preterm newborns. Although the prevalent clinical sign is tense abdominal distension, it may be difficult to distinguish ACS from pathologies that will not require decompression. The purpose of this study was to identify predictors for ACS and therefore morbidity or mortality indicators. We reviewed newborns presenting with tense abdominal distension and end organ failure. Anamnestic, clinical, laboratory, and instrumental investigations were analyzed to extrapolate predictors. Outcomes were compared with a control group. The incidence of ACS in our neonatal intensive care unit was 5% in the overall population of babies, 16% in tracheal-ventilated newborns, and 57% in infants with abdominal wall defects. We found that, with onset of acidosis or high gastric residuals, the lactate values will be predictive for mortality. We can also suggest paying particular attention to high lactate values just at the onset of distension, in infants with more advanced gestational age, with previously surgical repair, to determine early surgical intervention independently of a specific IAP measurement

Management of multiple pregnancy with an affected twin

Newborns from multiple pregnancies demonstrate a higher perinatal morbidity and mortality compared to singletons. Prematurity is more frequent in twins and therefore birth weight is significantly lower compared to singletons [1]. Thus, twins are more exposed to prema- turity related diseases (respiratory, cardiovascular, infec- tious, etc.) and to long-term complications [2]. It is very difficult to estimate the increased risk of neonatal mor- bidity related to twinning independently to the increased risk of prematurity. Prematurity is the main reason for most neonatal diseases in twins, but other variables may play a role. Fetal growth restriction [3] and congenital malformationsare major issues in offspring of multiple pregnancies. Specific risks vary according tozigosity (monozygotic >dizygotic) and kind (genetic, vascular, multifactorial, etc.) and site (systems and organs involved) of malformation. Accurate risk assessment strategies and adequate obstetrical-neonatological man- agement of multiple pregnancies may reduce the increasing need for neonatal intensive care and for health resources in the long-term follow-up that has been observed over the last decades. Careful analysis of both twins for a pathological condi- tion is mandatory to address the most appropriate man- agement. Twin discordance for the presence of a severe pathological condition raises serious concern in terms of bioethical and psychological impact on the parents and medical staff[4]. Different management choices can be considered: termination of pregnancy, selective embryo reduction of the affected twin, anticipation of delivery or natural course of the pregnancy. Each choicehides difficult clinical and legal implications. Accurate clinical, laboratory and ultrasonographic evaluation together with pregnancy follow-up are essential for reaching the correct diagnosis and consider prognosis and therapeutic options [5]. The risk of intrauterine death and potential risks for the other twin and the mother must be taken into account. Some- times it is possible to wait until the natural end of preg- nancy and then provide suitable treatment to the affected twin. Other times, parents opt to terminate the pregnancy and loose both twins. A selective reduction (after accurate evaluation of placentation) of the affected twin only carries a high risk of complication for the healthy twin, especially in monochorionic pregnancies. In the late third trimester of pregnancy, the option of a preterm delivery can be con- sidered and may contribute to the increase of prematurity and prematurity related diseases in twins. The management of multiple pregnancies is a very com- plex task for medical staff and requires parental support with adequate counselling and psychological help [6]

Genotyping and antifungal susceptibility of Dipodascus capitatus isolated in a neonatal intensive care unit of a sicilian hospital

In August 2015, Dipodascus capitatus was isolated from two patients admitted to the neonatal intensive care unit. Nosocomial acquisition of the fungus was suspected and epidemiological studies were undertaken. The patients were simultaneously hospitalized, and the comparison of the two isolates by two independent molecular typing methods have confirmed clonal dissemination of a single strain of D. capitatus. Antimicrobial susceptibility testing was useful for identifying the appropriated antifungal therapy in micafungin. To our knowledge these are the first described cases of neonatal D. capitatus infection and also the first report of successful treatment by micafungin.In August 2015, Dipodascus capitatus was isolated from two patients admitted to the neonatal intensive care unit. Nosocomial acquisition of the fungus was suspected and epidemiological studies were undertaken. The patients were simultaneously hospitalized, and the comparison of the two isolates by two independent molecular typing methods have confirmed clonal dissemination of a single strain of D. capitatus. Antimicrobial susceptibility testing was useful for identifying the appropriated antifungal therapy in micafungin. To our knowledge these are the first described cases of neonatal D. capitatus infection and also the first report of successful treatment by micafungin