ДВОСТОРОННЯ КРОВОТЕЧА З НАДНИРКОВИХ ЗАЛОЗ У ПЛОДА: (клінічний випадок)

Background. Fetal supra renal mass revealed incidentally by routine antenatal ultrasound is a great challenge for diagnosis and management by a surgeon. This is a matter of parental anxiety and diagnostic dilemma to a physician. Indeed, such masses turn out to be complicated by an intra-tumor hemorrhage in neuroblastoma or antenatally diagnosed adrenal hemorrhage. The first one needs intensive management and the latter needs watchful observation. Objective. A case of bilateral fetal adrenal mass revealed by routine fetal ultrasound examination at 28th week of gestation which turned out to be adrenal hemorrhage is presented. This is aimed to make awareness to ensure that clinicians always keep benign etiologies first and thoroughly investigate in case of incidentally detected fetal adrenal mass. Methods. The study is a single case report of incidentally revealed supra renal mass. This case report encompasses differentiating features between the two and investigations that aid the surgeon to avoid unnecessary intervention in a benign hemorrhage. Results. The baby was kept on follow up with serial ultrasound scans in the postnatal period and by the second scan in a month, the hemorrhage had resolved completely. Conclusion. In cases of benign looking masses like adrenal hemorrhage or spontaneously resolving neuroblastoma, appropriate antenatal assessment and close monitoring with serial ultrasound scans can avoid surgery.Вступ. Утворення в наднирниках плода, випадково виявлені під час звичайного допологового ультразвукового дослідження, створюють для хірургів велику проблему в діагностиці та лікуванні. Вони викликають занепокоєння батьків і створюють діагностичну проблему для лікуючого лікаря. Такі утворення можуть виявитися ускладненим внутрішньопухлинним крововиливом у нейробластому або антенатально діагностованим крововиливом у надниркові залози. Перший потребує інтенсивного лікування, а другий потребує уважного спостереження. Мета. Представлено випадок двостороннього утворення в надниркових залозах плода, виявленого під час планового ультразвукового дослідження плода на 28-му тижні вагітності, які виявилися крововиливом у надниркові залози. Випадок представлено для того, щоб клініцисти завжди звертали увагу на доброякісну етіологію та проводили ретельне обстеження у випадку випадкового виявлення новоутворень надниркових залоз плода. Методи. Представлено випадок випадково виявлених утворень надниркових залоз. Описано відмінності між ними та дослідження, які допомагають хірургу уникнути непотрібного втручання при доброякісному крововиливі. Результати. У післяпологовому періоді дитину спостерігали за допомогою серійних ультразвукових досліджень. До другого УЗД через місяць крововилив повністю розсмоктався. Висновки. У випадках доброякісних новоутворень, таких як крововилив у надниркові залози або нейробластома, що спонтанно розсмоктується, відповідна антенатальна оцінка та ретельний моніторинг за допомогою серійних ультразвукових досліджень можуть допомогти уникнути операції

Neurodevelopmental Sequelae of Neonatal Seizures in Newborn

INTRODUCTION: Clinical seizures are defined as paroxysmal alteration in neurological function i.e. behavioural, motor and/or autonomic function. Newborn period is the time when the incidence of seizures is the highest, yet their clinical recognition is difficult, therefore true incidence of neonatal seizures is difficult to determine. Its incidence varies from 1-5 per 1000 live births. 2-6 Neonatal seizures are very common in the first weeks of life. Clinical features of neonatal seizures are different from those in adults. Neonatal seizures are distinctive clinical manifestation of neurological dysfunction in the newborn.8 Newborn infants with seizures are at risk for neonatal death and survivors are at risk for neurological impairment, developmental delay, and later epilepsy. 8-12 Despite increasingly sophisticated neonatal intensive care, neonatal seizures remains a challenge. 8-13 Neonatal seizures can be due to various causes like hypoxicischemic encephalopathy, intracranial hemorrhage, meningitis, hypoglycemia, hypocalcemia, congenital malformation, etc. The most important factor that predicts their outcome is the underlying etiology.14 Patients with hypoxic encephalopathy (HIE), intraventricular hemorrhage (IVH) and neuronal migration disorders (NMD) are reported to have the worst prognosis. Etiologic profile of neonatal seizures is also changing over the years due to advanced development in obstetric and neonatal management that have changed the spectrum of insults to which the immature brain is exposed. The mortality of infants developing seizures during the neonatal period has shown a decreasing trend over time. In earlier studies, the mortality was as high as 40%, but decreased in subsequent reports to 20%. As opposed to this increase in survival, the prevalence of long-term neurodevelopmental sequelae in survivors has remained unchanged at 30%. However, neonatal seizures remain an important predictor of future neurological complications. In addition it may be associated with other permanent neurological disorders such as mental retardation and cerebral palsy. The occurrence of epilepsy after neonatal seizures varies in frequency as shown in previous studies from 3.5 to 56% according to sample selection. STUDY OBJECTIVES: 1. To assess the neurodevelopemental sequelae of neonatal seizure of newborns admitted in NICU at Govt. Stanley Medical College Hospital. 2. To identify the risk factors for poor neurodevelopemental outcome in neonatal seizures. DISCUSSION: The current study was undertaken between March 2010 and August 2011. In this study conducted at institute of social paediatrics, and Govt. RSRM NICU we studied the neurodevelopmental outcome of the babies who had neonatal seizure and analyzed the risk factors for the poor developmental outcome. A total of 1856 babies got admitted in NICU, among them 108 term newborns had neonatal seizure. 4 newborns with neonatal seizure expired during the hospital stay.Out of 108 newborns 91 completed the study, among the 91 infants 22 had developmental delay, 10 had microcephaly, 3 had microcephaly with developmental delay and 2 had macrocephaly with developmental delay. On analyzing data out of 22 infants with developmental delay 50% were male infants and 50% were female infants, among 10 microcephaly 60% were male and 40% were female infants. There was no predilection for sexes as observed in other studies.53% were delivered by normal vaginal delivery 41 % were delivered by caeserian section, 4% were born by forceps delivery. There was no difference in outcome between the two groups. Similar finding was observed in study conducted by Pisani et al SUMMARY: 1. A prospective study was conducted at NICU of Institute of Social Paediatrics and NICU of Govt. RSRM Hospital to assess the neurodevelopmental sequelae in infants who had neonatal seizure. 2. Out of 1856 newborn admission 108 newborn had neonatal seizure, of which 100 participated in the study, 91 infants completed the study, 4 newborns expired during the hospital stay and 5 were lost in follow-up. 3. 55% were delivered by spontaneous vaginal delivery, 41 % were born by LSCS, 4% were delivered by forceps and 2% by vacuum extraction. 4. 33% of neonatal seizure were due to birth asphyxia, 27 % due to septicemia, 20 % due to hypoglycemia. In 8% of cases cause was unknown. 5. Subtle seizure was the most common seizure(42%), followed by focal seizure(26%), tonic seizure(19%) Mixed type of seizure was observed in 8 % of cases. 6. 46% of seizure manifested within 24 hours of life, 34% of cases between 24 to 72 hours of life, 5% of cases occurred after 14 days. 7. 20% of hypoglycemic seizure had developmental delay and level of blood glucose did not have significant association with the outcome. CONCLUSION: From our study it may be concluded that 59% of infants with neonatal seizure had normal development, while 41% had adverse neurological outcome at the end of 1 year follow-up. The risk factors for developmental delay from our study was early onset of seizure, low 5 minute Apgar score and abnormal background EEG

Residual brain injury after early discontinuation of cooling therapy in mild neonatal encephalopathy

We examined the brain injury and neurodevelopmental outcomes in a prospective cohort of 10 babies with mild encephalopathy who had early cessation of cooling therapy. All babies had MRI and spectroscopy within 2 weeks after birth and neurodevelopmental assessment at 2 years. Cooling was prematurely discontinued at a median age of 9 hours (IQR 5-13) due to rapid clinical improvement. Five (50%) had injury on MRI or spectroscopy, and two (20%) had an abnormal neurodevelopmental outcome at 2 years. Premature cessation of cooling therapy in babies with mild neonatal encephalopathy does not exclude residual brain injury and adverse long-term neurodevelopmental outcomes. This study refers to babies recruited into the MARBLE study (NCT01309711, pre-results stage)

Structural Aspects and Ion Transport Properties of a New Mixed System BiI 3 -Ag 2 WO 4

Abstract: An experimental attempt was made to analyze structural and ion transport properties in the case of a new mixed system viz., (BiI 3 ) y -(Ag 2 WO 4 ) 100-y where y = 10

Therapeutic hypothermia in mild neonatal encephalopathy: a national survey of practice in the UK

Although major cooling trials (and subsequent guidelines) excluded babies with mild encephalopathy, anecdotal evidence suggests that cooling is often offered to these infants. We report a national survey on current cooling practices for babies with mild encephalopathy in the UK. From 74 neonatal units contacted, 68 were cooling centres. We received 54 responses (79%) and included 48 (five excluded due to incomplete data and one found later not to offer cooling). Of these, 36 centres (75%) offered cooling to infants with mild encephalopathy. Although most of the participating units reported targeting 33-34°C core temperature, seven (19%) considered initiating cooling beyond 6 hours of age and 13 (36%) discontinued cooling prior to 72 hours. Babies were ventilated for cooling in two (6%) units and 13 (36%) sedated all cooled babies. Enteral feeding was withheld in 15 (42%) units and reduced below 25% of requirements in eight (22%) units. MRI and neurodevelopmental outcome evaluation were offered to all cooled babies in 29 (80%) and 27 (75%) units, respectively. Further research is necessary to ensure optimal neuroprotection in mild encephalopathy

Changes in the PQRST intervals and heart rate variability associated with rewarming in two newborns undergoing hypothermia therapy.

BACKGROUND: Little is known about the effects of hypothermia therapy and subsequent rewarming on the PQRST intervals and heart rate variability (HRV) in term newborns with hypoxic-ischemic encephalopathy (HIE). OBJECTIVES: This study describes the changes in the PQRST intervals and HRV during rewarming to normal core body temperature of 2 newborns with HIE after hypothermia therapy. METHODS: Within 6 h after birth, 2 newborns with HIE were cooled to a core body temperature of 33.5 degrees C for 72 h using a cooling blanket, followed by gradual rewarming (0.5 degrees C per hour) until the body temperature reached 36.5 degrees C. Custom instrumentation recorded the electrocardiogram from the leads used for clinical monitoring of vital signs. Generalized linear mixed models were calculated to estimate temperature-related changes in PQRST intervals and HRV. Results: For every 1 degrees C increase in body temperature, the heart rate increased by 9.2 bpm (95% CI 6.8-11.6), the QTc interval decreased by 21.6 ms (95% CI 17.3-25.9), and low and high frequency HRV decreased by 0.480 dB (95% CI 0.052-0.907) and 0.938 dB (95% CI 0.460-1.416), respectively. CONCLUSIONS: Hypothermia-induced changes in the electrocardiogram should be monitored carefully in future studies

Volumetric and anatomical MRI for hypoxic-ischemic encephalopathy: relationship to hypothermia therapy and neurosensory impairments.

OBJECTIVE: To relate volumetric magnetic resonance imaging (MRI) findings to hypothermia therapy and neurosensory impairments. STUDY DESIGN: Newborns \u3e or =36 weeks\u27 gestation with hypoxic-ischemic encephalopathy who participated in the National Institute of Child Health and Human Development hypothermia randomized trial at our center were eligible. We determined the relationship between hypothermia treatment and usual care (control) to absolute and relative cerebral tissue volumes. Furthermore, we correlated brain volumes with death or neurosensory impairments at 18 to 22 months. RESULT: Both treatment groups were comparable before randomization. Total brain tissue volumes did not differ in relation to treatment assignment. However, relative volumes of subcortical white matter were significantly larger in hypothermia-treated than control infants. Furthermore, relative total brain volumes correlated significantly with death or neurosensory impairments. Relative volumes of the cortical gray and subcortical white matter also correlated significantly with Bayley Scales psychomotor development index. CONCLUSION: Selected volumetric MRI findings correlated with hypothermia therapy and neurosensory impairments. Larger studies using MRI brain volumes as a secondary outcome measure are needed

Pre-emptive morphine during therapeutic hypothermia after neonatal encephalopathy: a secondary analysis

Although therapeutic hypothermia (TH) improves outcomes after neonatal encephalopathy (NE), the safety and efficacy of preemptive opioid sedation during cooling therapy is unclear. We performed a secondary analysis of the data from a large multicountry prospective observational study (Magnetic Resonance Biomarkers in Neonatal Encephalopathy [MARBLE]) to examine the association of preemptive morphine infusion during TH on brain injury and neurodevelopmental outcomes after NE. All recruited infants had 3.0 Tesla magnetic resonance imaging and spectroscopy at 1 week, and neurodevelopmental outcome assessments at 22 months. Of 223 babies recruited to the MARBLE study, the data on sedation were available from 169 babies with moderate (n = 150) or severe NE (n = 19). Although the baseline characteristics and admission status were similar, the babies who received morphine infusion (n = 141) were more hypotensive (49% vs. 25%, p = 0.02) and had a significantly longer hospital stay (12 days vs. 9 days, p = 0.009) than those who did not (n = 28). Basal ganglia/thalamic injury (score ≥1) and cortical injury (score ≥1) was seen in 34/141 (24%) and 37/141 (26%), respectively, of the morphine group and 4/28 (14%) and 3/28 (11%) of the nonmorphine group (p > 0.05). On regression modeling adjusted for potential confounders, preemptive morphine was not associated with mean (standard deviation [SD]) thalamic N-acetylaspartate (NAA) concentration (6.9 ± 0.9 vs. 6.5 ± 1.5; p = 0.97), and median (interquartile range) lactate/NAA peak area ratios (0.16 [0.12–0.21] vs. 0.13 [0.11–0.18]; p = 0.20) at 1 week, and mean (SD) Bayley-III composite motor (92 ± 23 vs. 94 ± 10; p = 0.98), language (89 ± 22 vs. 93 ± 8; p = 0.53), and cognitive scores (95 ± 21 vs. 99 ± 13; p = 0.56) at 22 months. Adverse neurodevelopmental outcome (adjusted for severity of encephalopathy) was seen in 26 (18%) of the morphine group, and none of the nonmorphine group (p = 0.11). Preemptive morphine sedation during TH does not offer any neuroprotective benefits and may be associated with increased hospital stay. Optimal sedation during induced hypothermia requires further evaluation in clinical trials

White matter injury after neonatal encephalopathy is associated with thalamic metabolite perturbations

Background Although thalamic magnetic resonance (MR) spectroscopy (MRS) accurately predicts adverse outcomes after neonatal encephalopathy, its utility in infants without MR visible deep brain nuclei injury is not known. We examined thalamic MRS metabolite perturbations in encephalopathic infants with white matter (WM) injury with or without cortical injury and its associations with adverse outcomes. Methods We performed a subgroup analysis of all infants recruited to the MARBLE study with isolated WM or mixed WM/cortical injury, but no visible injury to the basal ganglia/thalamus (BGT) or posterior limb of the internal capsule (PLIC). We used binary logistic regression to examine the association of MRS biomarkers with three outcomes (i) WM injury score (1 vs. 2/3); (ii) cortical injury scores (0/1 vs. 2/3); and (iii) adverse outcomes (defined as death, moderate/severe disability) at two years (yes/no). We also assessed the accuracy of MRS for predicting adverse outcome. Findings Of the 107 infants included in the analysis, five had adverse outcome. Reduced thalamic N-acetylaspartate concentration [NAA] (odds ratio 0.4 (95% CI 0.18–0.93)) and elevated thalamic Lactate/NAA peak area ratio (odds ratio 3.37 (95% CI 1.45–7.82)) were significantly associated with higher WM injury scores, but not with cortical injury. Thalamic [NAA] (≤5.6 mmol/kg/wet weight) had the best accuracy for predicting adverse outcomes (sensitivity 1.00 (95% CI 0.16–1.00); specificity 0.95 (95% CI 0.84–0.99)). Interpretation Thalamic NAA is reduced in encephalopathic infants without MR visible deep brain nuclei injury and may be a useful predictor of adverse outcomes. Funding The National Institute for Health Research (NIHR)