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Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a challenging nosocomial pathogen in the last 50 years.To describe an investigation and containment of an MRSA outbreak in a neonatal intensive care unit (NICU).Our NICU is a 25-bed level III unit. Almost 540 neonates are admitted yearly. The index case was an 8 day old term baby. MRSA was isolated from his conjunctiva. Immediate infection control measures were instituted, including separation of MRSA+ carriers, strict isolation, separate nursing teams, and screening of all infants for MRSA. Healthcare workers and parents of positive cases were screened and re-educated in infection control measures. New admissions were accepted to a clean room and visiting was restricted. MRSA isolates were collected for molecular testing.MRSA was isolated from five infants by nasal and rectal swabs, including the index case. Screening of healthcare workers and families was negative. Two MRSA+ patients already known in the pediatric intensive care unit (PICU) located near the NICU were suspected of being the source. All NICU isolates were identical by pulsed-field gel electrophoresis but were different from the two PICU isolates. The NICU and one of the PICU isolates were defined as ST-5 strain by multilocus sequence typing. One PICU isolate was ST-627. All NICU isolates were Panton-Valentine leukocidin negative and SCCmec type IV. No further cases were detected, and no active infections occurred.A strict infection control policy and active screening are essential in aborting outbreaks of MRSA in the NICU.

Background: Late-preterm and early-term (LP-ET) infants, defined herein as 35⁰-376 weeks' gestation, often fail on 1st otoacoustic emissions (OAE) test. Hypothesis: LP-ET infants fail more than term infants (38⁰-42 weeks' gestation) on the 1st OAE test. Aim: To evaluate the effect of gestational age on the 1st OAE test. Methods: We studied 1,572 vaginally-delivered (VD) infants ≥35 weeks' gestation (1.1.2011-30.9.2011). Perinatal and neonatal variables and results of OAE tests were recorded. Results: LP-ET infants, compared to full-term infants, had a significantly 2-fold higher need for repeated hearing tests: 80.2 versus 43.3 tests/1,000 neonates, respectively (p = 0.026). Univariate analysis showed that late prematurity and age at 1st OAE were significantly associated with failure on 1st OAE. At age 24-42 h, failure on 1st OAE was 2-fold higher in the LP-ET infants than in full-term infants: 9.4 versus 4.7% (p = 0.02). Risk for failure on 1st OAE was age-dependent: 9-fold higher when 1st OAE was performed at 24-42 h of age (5.3%) versus 0.6% after age 42 h. Multivariate analysis showed that variables that were independently significantly associated with failure on 1st OAE included late prematurity (OR 2.0 (1.1-3.7)) and age at 1st OAE (OR 9.2 (1.2-70.7)). Conclusions: Compared to term infants, VD LP-ET infants had 2-fold higher rates of failure on 1st OAE (up to 42 h of life) and needed repeated hearing tests. Failure rates after 42 h become negligible in both groups. In VD LP-ET infants, 1st OAE is better performed after 42 h of age.

Autonomic nervous system modulation of heart rate is significantly altered during painful procedures in newborns. Most studies investigating pain employed only linear-based analysis methods, thus ignoring the complex, non-linear nature of heart rate control mechanisms. The emergences of dynamic, nonlinear analysis methods enable us to uncover information embedded in the fluctuations of heart rate not otherwise noticeable. Our objective was to examine how cardiac dynamics change in newborns who undergo heel lancing by analyzing linear and nonlinear characteristics of heart rate fluctuations. We used dynamic nonlinear analyses methods to reveal heart rate variability and complexity alterations during painful stimulus in newborns. Poincare plots were applied to examine the dynamics of the system, sample entropy to investigate the complexity of the system, and detrended fluctuation analysis, to reveal the fractal properties of the system. Heart rate significantly increased (165 vs.123 beats per minute, p

Objectives—The peak systolic velocity (PSV) of the middle cerebral artery was found to be predictive of fetal anemia and is routinely applied in the treatment of such fetuses. Our objective was to determine whether a correlation exists between the PSV in the neonatal middle cerebral artery and hemoglobin levels for possible future implementation in clinical practice. Methods—A prospective study on 151 neonates was conducted, examining their middle cerebral artery PSV concomitantly with their hemoglobin level during the first 36 hours after delivery. The study population included 122 normocythemic, 24 anemic, and 5 polycythemic neonates. An analysis of variance between normocythemic, anemic, and polycythemic neonates was performed, and a regression analysis of the PSV versus hemoglobin levels was conducted. Results—The normocythemic neonates had a mean middle cerebral artery PSV ± SD of 41.3 ± 11.4 cm/s, whereas the anemic neonates had a significantly higher PSV (63.8 ± 28.5 cm/s), and the polycythemic neonates had a significantly lower PSV (26.8 ± 7.4 cm/s; P < .001). A statistically significant correlation was found between hemoglobin levels and the middle cerebral artery PSV (P < .01). Conclusions—Neonatal anemia and polycythemia can be rapidly diagnosed at the bedside by examining the middle cerebral artery PSV. This technique can be used as an ancillary measure to promptly diagnose acute neonatal blood volume changes for an immediate intervention.

The objective of our study was to assess factors associated with iatrogenic events in Neonatal Intensive Care Units (NICUs). This was a retrospective analysis based on a cohort of patients who participated in our previous prospective study (Pediatrics 122:550–555, 2008), conducted in four tertiary university-affiliated NICUs in Israel, that included all consecutive infants (n = 615) hospitalized during the study period. Ongoing monitoring of iatrogenic events was performed by designated “iatrogenesis advocates.” The main outcome measures were the association of individual infant characteristics and NICUs’ environmental characteristics with iatrogenic events assessed by univariate and multiple logistic regression analysis. We found that four infant characteristics were significantly (p < 0.001) associated with iatrogenic events in a univariate analysis: gestational age, birth weight, severity of initial illness as assessed by the Score for Neonatal Acute Physiology and Perinatal Extension (SNAPPE II), and length of stay (LOS). All four factors demonstrated a significant (p < 0.001) dose–response relationship with iatrogenic events. Univariate analysis for environmental characteristics showed that type of shift, but not nursing workload, was significantly associated with iatrogenic events (p < 0.001). In a multiple logistic regression analysis, only LOS (adjusted OR 1.02 [95 % CI, 1.01–1.03]) and type of shift, morning vs. evening (adjusted OR 3.44 [95 % CI, 2.33–5.08]) and morning vs. night (adjusted OR 6.07 [95 % CI, 3.86–9.56]), remained independently associated with iatrogenic events (p < 0.001). Prolonged LOS and morning shifts were found to be significantly associated with iatrogenic events. Further prospective research is warranted to identify the specific causes for iatrogenic events in order to target active interventions to prevent them.

BACKGROUND:Neonatal hearing screening occasionally fails. We noticed that infants born by cesarean delivery (CD) appeared to fail the first otoacoustic emissions (OAE) test more frequently than infants delivered vaginally (VD). This might increase maternal anxiety. We aimed to evaluate the influence of mode of delivery on failure to pass the first OAE.METHODS:Overall, 1653 infants of >35 weeks’ gestation were evaluated. OAE was performed before discharge. Perinatal-neonatal variables and results of OAE were recorded retrospectively.RESULTS:Compared with VD infants, CD infants had lower gestational age and 1-minute Apgar, more small for gestational age (SGA), and earlier age at first OAE. Univariate analysis: CD, male gender, gestational age 35 to 37 weeks, birth weight ≤2500 g, SGA, and younger age at first OAE were significantly associated with failed first OAE. In infants weighing 2501 to 4000 g, CD infants had 3-fold higher rates of failed first OAE in comparison with VD infants (20.7% vs 7.1%) before 48 hours of age. In the multivariate analysis, variables independently significantly associated with failed first OAE were male gender (odds ratio [OR] 1.42 [1.02–1.98]), CD (emergency CD: OR 3.18 [2.21–4.57], elective CD: OR 3.32 [2.04–5.42]), age 12 to 23 hours at first OAE (OR 3.1 [2.1–4.58]) and SGA (OR 2.2 [1.15–4.28]).CONCLUSIONS:CD infants had significantly higher failure rates on first OAE. We speculate that CD is accompanied by retained fluid in middle ear which may impair neonatal hearing. The timing of first OAE after CD should preferably be postponed beyond 48 hours of age to improve OAE passage and minimize maternal anxiety and costs.

Objective To report the outcome of transient abnormal cardiac flow patterns (ABCFP) at 13 to 17 weeks' gestation. Methods and Results Observational single operator study of transvaginal sonography scans of 13 183 fetuses. Of the 22 fetuses with ABCFP (1 : 600) high pulmonary valvular velocity was detected in 11 (8 of them transient), an abnormal blood flow in the coronary region in 6, mitral regurgitation in 3, and high aortic valvular velocity in 2 cases. In over 90%, these findings were transient. At birth, there were two cases of mild pulmonary stenosis, one meconium ileus, and two cases of asymptomatic bicuspid aortic valve without stenosis. All the remaining neonates were healthy. Conclusions The transient sonographic findings at 13 to 17 weeks' gestation of mitral regurgitation, pulmonary or aortic high valvular flow, and coronary sinus flow have a good prognosis, and in most cases are not associated with persistent cardiac anomalies. The etiology, incidence, and the prognosis of fetuses with transient ABCFP at 13 to 17 weeks' gestation are different from what is observed when the same occurs later in gestation. © 2012 John Wiley & Sons, Ltd.

Objective The purpose of this study was to describe a series of cases of transient changes in the female fetal external genitalia. Methods In our practice area, most pregnant women usually undergo a detailed sonographic survey of all fetal organs, including the external genitalia in early and mid pregnancy. Results During the study period (1987-2010), 62,145 consecutive pregnant women were scanned. We detected 4 fetuses with an isolated finding of clitoromegaly at 15 to 16 weeks' gestation, which disappeared at 22 to 26 weeks. Maternal hormonal study results were normal. There was 1 case of clitoromegaly and a cloacal anomaly at 15 weeks' gestation, in which the clitoris retuned to a normal size at 22 weeks. In addition, there were 3 cases of hypertrophy of the labia minora in early pregnancy, which disappeared at 26 to 32 weeks. All fetuses in these series had a normal XX karyotype and normal external genitalia at birth. Conclusions Transient changes in the appearance of the fetal external genitalia may occur in chromosomally normal female fetuses.

Objective To present sonographic findings in early and late appearance of fetal Ebstein's anomaly. Methods Fetal sonography was performed in 53 447 consecutive pregnant women at 14 to 16 weeks’ gestation. Results Ebstein's anomaly was detected in eight fetuses, in four of them additional anomalies were observed. All eight pregnancies were terminated. In an additional fetus, a normal four-chamber view without valvular regurgitation was visualized at 15 weeks’ gestation. At 24 weeks, a normal four-chamber view was depicted. No Doppler examination was performed at that time. The newborn was found to have Ebstein's anomaly with pulmonary stenosis. A balloon pulmonary valvuloplasty was performed with a good outcome at three months of age. Conclusion Fetal Ebstein's anomaly may be detected in early pregnancy. The incidence is higher than what is reported in newborns. Depiction of a normal fetal heart in early and midpregnancy does not exclude the possibility of subsequent development of Ebstein's anomaly. © 2012 John Wiley & Sons, Ltd.

Background: The etiology of intraventricular hemorrhage (IVH) in very-low-birth-weight (VLBW) infants is multifactorial and is associated with low gestational age (GA) and severity of neonatal respiratory disease. The role of admission hypothermia (AHT) in the pathogenesis of IVH in VLBW infants has not yet been elucidated. We searched risk factors for IVH in VLBW infants while focusing on AHT. Patients and Methods: VLBW infants ≤33 weeks’ gestation from three participating medical centers were included. From patients’ medical charts we collected variables known to be associated with IVH, focusing on AHT. AHT was defined as rectal temperature ≤35.5°C at admission to the NICU. Head ultrasound was performed at 2–5 and 6–10 days of age and before discharge. Results: 271 VLBW infants were studied. Univariate analysis showed that AHT at ≤35.5°C was not significantly associated with IVH (all grades; p = 0.16), but associated with IVH grade 3–4 (p = 0.034), while AHT at ≤35°C was significantly associated with IVH (p = 0.036) and with IVH grade 3–4 (p = 0.003). Multivariate logistic regression analysis showed that AHT (at ≤35.5 and at ≤35°C) were not associated with IVH. Only four variables were independently significantly associated with IVH: GA, use of nitric oxide, hypocarbia and base deficit >10. Four variables were strongly associated with severe IVH (grades 3–4): GA, hypotension, base deficit >10 and hyponatremia. Conclusions: In VLBW infants, AHT at ≤35.5 and at ≤35.0°C were not significantly associated with IVH. GA, use of nitric oxide, hypocarbia and base deficit >10 were strongly associated with IVH.

The appropriate time and the optimal mode of delivery of twins are still controversial. We assessed the effect of gestational age and the mode of elective delivery of twins on the occurrence of neonatal respiratory morbidity (NRM) and of maternal morbidity. This study included twins born beyond 35 weeks' gestation. NRM was defined as respiratory distress syndrome (RDS) and transient tachypnea of the newborn (TTN). Additionally, maternal complications related to the different modes of delivery were taken into account. Of 711 twin pregnancies (1422 liveborn neonates) included, 74 (5.2%) experienced NRM. Maternal age > 25 years, delivery at an earlier gestational age, and delivery by emergency cesarean section maintained statistical significance with NRM. From the maternal point of view, increased length of hospitalization ( P = 0.045) and the need for postoperative antibiotics ( P = 0.0065) were significantly higher following an emergency cesarean section than after an elective cesarean birth. The risk of NRM in twins born beyond 37 weeks' gestation is rather low. We suggest considering elective cesarean delivery at completion of 37 weeks. This can be performed safely in regard to NRM, the trade-off being reduced maternal morbidity associated with elective cesarean delivery.

OBJECTIVE: Pain experience can alter clinical outcome, brain development, and subsequent behavior in newborns, primarily in preterm infants. The aims of this study were (1) to evaluate several simple, commonly used methods for pain control in newborns and (2) to evaluate the concordance between behavioral and autonomic cardiac reactivity to pain in term neonates during heel-lancing. METHODS: A prospective study was conducted of 180 term newborn infants who were undergoing heel-lancing for routine neonatal screening of phenylketonuria and hypothyroidism. Newborns were assigned to 6 groups: (1) control (no pain relief intervention); (2) nonnutritive sucking; (3) holding by mother; (4) oral glucose solution; (5) oral formula feeding; or (6) breastfeeding. Outcome measures included the Neonatal Facial Coding System score; cry duration; and autonomic variables obtained from spectral analysis of heart rate variability before, during, and after heel-lancing. RESULTS: Infants with no pain control showed the highest pain manifestation compared with newborns to whom pain control was provided. Infants who breastfed or received an oral formula showed the lowest increase in heart rate (21 and 23 beats per minute, respectively, vs 36; P < .01), lowest neonatal facial score (2.3 and 2.9, respectively, vs 7.1; P < .001), lowest cry duration (5 and 13 seconds, respectively, vs 49; P < .001), and lowest decrease in parasympathetic tone (−2 and −2.4, respectively, vs 1.2; P < .02) compared with the other groups. CONCLUSIONS: Any method of pain control is better than none. Feeding and breastfeeding during heel-lancing were found to be the most effective methods of pain relief.

Objective To determine the value of a first trimester fetal ultrasound examination in cases of an increased nuchal translucency (NT). Method A detailed fetal ultrasound examination was performed within 4 days of a detection of a first trimester increased NT. Results As many as 23 fetuses were evaluated. Severe anomalies were detected in eight and mild anomalies were detected in six fetuses. Two fetuses had trisomy 13, one had trisomy 21, and 16 fetuses had a normal karyotype. A chromosomal analysis was not available in four fetuses with major anomalies due to parental decision. In one fetus, craniosynostosis was detected only at 24 weeks' gestation. Conclusions The current study shows that a first trimester targeted scan of fetuses with an increased NT in an experienced center can shorten the parental decision-making process and spare parents a prolonged period of diagnostic uncertainty and anxiety, particularly when a structural anomaly is clearly diagnosed in the first trimester. Copyright © 2008 John Wiley & Sons, Ltd.

We analysed the data of difference in serum sodium (DIFNA) and glucose (DIFGLU) concentrations and difference in serum tonicity (DIFTON) following exchange transfusion (ET) with CPD blood during 122 consecutive procedures performed in 82 newborn infants. Mean (+/- SE) gestational age (GA) was 30.8 +/- 0.45 weeks, mean birthweight was 1,568.6 +/- 81.4 g. and mean age at time of ET (AGEH) was 60.6 +/- 4.3 h. Following the ET, mean serum sodium concentration increased in 110 cases, by 5.4 +/- 0.7 mmol/l, and the mean DIFTON rose by 14.6 +/- 1.46 mOsm/kg H2O. Mean DIFGLU rose in 11 cases by 3.8 +/- 0.3 mmol/l. Significant correlations were found between DIFNA and AGEH (p less than 0.02), and between DIFTON and AGEH (p less than 0.02). ET performed less than 48 h after birth produced higher DIFTON values than later transfusions (21.2 vs. 8.2 mOsm/kg H2O, p less than 0.001) particularly in the VLBW infants (31.1 in less than 28 weeks vs. 15.1 mOsm/kg H2O in greater than 28 weeks). VLBW neonates appear to be at greatest risk of developing extreme increments in serum tonicity following ET performed within the first 48 h of life.

OBJECTIVE To compare rates of a composite outcome of mortality or major morbidity in very-preterm/very low birth weight infants between 8 members of the International Network for Evaluating Outcomes. STUDY DESIGN We included 58 004 infants born weighing

Objective The purpose of this study was to present sonographic and pathologic findings in early and late onset fetal microphthalmia. Study design Fetal sonography was prospectively performed in 30,989 consecutive pregnancies at 14 to 24 weeks' gestation. In addition, we retrospectively reevaluated US recordings of 4 fetuses from other hospitals, in which normal eyes were observed in early and midgestation and microphthalmia was diagnosed only in the third trimester of pregnancy or after birth. Results Microphthalmia was detected in 13 fetuses in the prospective group. Twelve of 13 had additional structural and chromosomal anomalies. Termination of pregnancy was performed in 12 cases. In the retrospective group of late onset microphthalmia we confirmed the normal eye measurements performed in the early and midpregnancy. Severe vision impairment or blindness was noted in 3 of these children, while the fourth pregnancy was terminated. Conclusion Normal measurements of the fetal eyes in early and midpregnancy do not exclude the possibility of subsequent development of microphthalmia.

Objective This study was undertaken to describe the sonographic features of fetal glossoptosis in the Pierre Robin sequence. Study design Fetal sonography was prospectively performed in 8000 consecutive pregnancies at 14 to 24 weeks' gestation. In addition we retrospectively reevaluated ultrasound recordings of 4 fetuses from other hospitals, in which the diagnosis of Pierre Robin sequence was overlooked at 22 weeks' gestation. Glossoptosis was defined as a posteriorly displaced tongue that never reached the anterior mandibular alveolar ridge while watching the fetal profile. Micrognathia, which is a component of the sequence, was subjectively defined. Results Glossoptosis with micrognathia was detected in 2 fetuses in the prospective group at 14 and 15 weeks' gestation. Both pregnancies were terminated; the diagnosis was confirmed in 1 case where postmortem examination was performed. There were no false-negative diagnoses in the other 7.998 fetuses. Glossoptosis and micrognathia were observed in the 4 retrospective cases. Conclusion Sonographic identification of glossoptosis with fetal micrognathia suggests the possibility of Pierre Robin sequence.

Objectives To evaluate the impact of advances in perinatal and neonatal care in the past three decades on the outcome of triplet pregnancies. Study design We compared the outcome of 29 sets of triplets born in our medical center during 1978–1987 with 34 sets of triplets born in the same medical center during 2001–2011. Data were extracted from maternal and neonatal medical records. Results There were no significant differences in mortality or morbidity in any of the studied outcome measures between the two epochs. Of the 34 women with triplet pregnancies in the present cohort only 28 (82%) took all three born babies home, not different from the 86% found in the early cohort. The overall take-home baby rate was 93% (95/102) in the present cohort, not different than the 86% (74/86) in the early cohort. Conclusions Despite technological advances in perinatal and neonatal care, there was no significant improvement in the outcome of triplet pregnancies during the past three decades.

To detect omphalocele and associated anomalies at ultrasonography (US) early in pregnancy and to describe the outcomes in fetuses with isolated and nonisolated omphalocele.Fetal endovaginal US was performed in 43,896 pregnant women at 12-16 weeks gestation. The women found to have fetal omphalocele were offered an amniocentesis to determine the fetal karyotype. For parents who decided to continue the pregnancy, repeat targeted transabdominal fetal US was performed at 20-24 weeks gestation. Additional follow-up US examinations performed until delivery were recommended. Postnatal pediatric examinations were performed in all of these fetuses. For the pregnancies in which no anomaly was detected at early US, the women were advised to undergo repeat US at about 24 weeks gestation for the detection of late-manifesting fetal anomalies. For pregnancies in which the baby was not delivered at the authors' affiliated hospital, the woman, her obstetrician, and her pediatrician were asked to inform the authors of any detected anomaly.Omphalocele was visualized at US in 38 fetuses, who were categorized into two groups. One group consisted of 22 (58%) fetuses with associated structural anomalies. According to the karyotype determined for 18 of these fetuses, 11 of them also had chromosomal anomalies. The pregnancy was terminated at the parents' request in 19 of these 22 cases. There were two cases of missed abortion, and a small omphalocele in one fetus disappeared at 21 weeks gestation. The second group consisted of 16 (42%) fetuses with a normal karyotype and an omphalocele as an isolated US finding. In eight of these fetuses, the omphalocele disappeared at 20-24 weeks gestation and no defect was seen at delivery. In six other fetuses, omphalocele was identified at delivery. There was one case each of missed abortion and pregnancy termination. There were no false-negative diagnoses of omphalocele.Isolated omphalocele diagnosed during the early stages of gestation typically has a good prognosis. In cases of a small defect, the anomaly may disappear later in the pregnancy.

Objective: The purpose of this study was to describe a characteristic cluster of sonographic features of fetuses with Turner syndrome in early pregnancy. Study Design: A targeted transvaginal ultrasound examination of all fetal organs was performed for 40,123 consecutive pregnant women at 14 to 16 weeks of gestation. Both low- and high-risk pregnancies were included. Fetal karyotyping was performed in 9348 cases. The main indications were major fetal anomalies, advanced maternal age, abnormal biochemical markers, maternal anxiety, and request. Results: Turner syndrome was detected in 13 fetuses (0.03%, 1/3086 early pregnancies). Huge septated cystic hygroma, severe subcutaneous edema, and hydrops were observed in all cases. A short femur was detected in 12 of 13 fetuses. A narrow aortic arch was visualized in all 8 fetuses who were scanned after 1995, when scanning of the aortic arch became mandatory in our institution. Four other fetuses had three or four of the five markers, 2 of the fetuses had trisomy 21, 1 fetus was normal, and one case of missed abortion occurred without a karyotype. Conclusion: A reliable diagnosis of Turner syndrome by sonographic means is possible in early pregnancy.

an adjusted surgical approach. However, a prospective study is warranted to determine the relative risk of this patient group. Importantly, although echocardiographic predictors were also found in some of the control cohort, these features are important in selecting a group of patients who require careful observation. In summary, the sub-AS that develops after initial AVSD repair is associated with increased displacement of the atrioventricular valve into the left ventricle and with less lateral angulation of the LVOT. This sub-AS may be progressive despite surgical resection.

Aim Red reflex eye examinations often require opening the eyelids, risking infection. We evaluated links between this procedure and neonatal conjunctivitis. Methods We divided 18 872 neonates of more than 35 weeks of gestation into two birth periods, 2008–2009 and 2010–2011, before and after red reflex examinations were carried out by our facility. The rates of clinical conjunctivitis, bacterial conjunctivitis and bacterial growth percentage were compared between the two periods. Results The 2010–2011 period included more Caesarean deliveries and longer lengths of stay (LOS) than the 2008–2009 period. The clinical conjunctivitis rate increased significantly during 2010–2011 (p = 0.029), but the bacterial conjunctivitis and bacterial growth percentages did not differ between the two periods. Variables that were independently and significantly associated with clinical conjunctivitis included being born in 2010–2011, with an odds ratio (OR) of 1.22, male gender (OR 1.31) and LOS (OR 1.19). Bacterial conjunctivitis was associated with vaginal delivery (OR 3.65), males delivered by Caesarean (OR 2.68) and LOS (OR 1.37). Conclusion Clinical conjunctivitis was significantly associated with the later study period, male gender and LOS. Conjunctival swab sampling increased significantly following the implementation of red reflex examinations, but without changes in the bacterial conjunctivitis rate and the bacterial growth percentage.

Primary human cells enter senescence after a characteristic number of population doublings (PDs). In the current study, human skin fibroblasts were propagated in culture under 5.5mM glucose (normoglycemia); addition of 16.5mM D-glucose to a concentration of 22 mM (hyperglycemia); and addition of 16.5mM L-glucose (osmotic control). Hyperglycemia induced premature replicative senescence after 44.42+/-1.5 PDs compared to 57.9+/-3.83 PDs under normoglycemia (p

Objective: To evaluate outcomes of fetuses with antepartum sonographic diagnoses of persistent intrahepatic right umbilical veins. Methods: A detailed fetal sonographic examination was done in 30,240 consecutive pregnancies at 14–26 weeks’ gestation. High- and low-risk pregnancies were included and persistent right umbilical veins specifically were recorded. Results: Sixty-nine fetuses had persistent intrahepatic right umbilical veins, of which 60 had no additional sonographic abnormalities, four had transient nuchal findings, and four had minor anomalies or anatomic variants. Only one of the 69 fetuses had a major anomaly (diaphragmatic hernia), and died after surgery. The remaining 68 fetuses were normal and healthy after birth. Conclusion: Persistent intrahepatic right umbilical vein is a fetal anatomic variant that is not rare and usually associated with a favorable outcome.

With the escalation of terrorism worldwide in recent years, situations arise in which the perpetration of violence and the defense of human rights come into conflict, creating serious ethical problems. The Geneva Convention provides guidelines for the medical treatment of enemy wounded and sick, as well as prisoners of war. However, there are no comparable provisions for the treatment of terrorists, who can be termed unlawful combatants or unprivileged belligerents. Two cases of severely injured terrorists are presented here to illustrate the dilemmas facing the medical staff that treated them. It is suggested that international legal and bioethical guidelines are required to define the role of the physician and auxiliary medical staff vis a vis injured terrorists. There are extreme situations where the perpetration of violence and the defense of human rights come into conflict, leading to serious ethical and psychological discord. Terrorists, using violence to create fear in order to further their political objectives, might require life-saving medical care if injured during the course of their terror activities.

Summary: A 29 week preterm infant weighing 1350 gm with suspected Candida albicans sepsis is reported. No specific treatment was administered. Deformation, thickening and discoloration of most finger nails was observed during the fifth week of life. C. albicans was cultured from the nails. Gradual improvement was achieved after local treatment with nystatin. To our knowledge this is the youngest reported case of onychomycosis. Zusammenfassung: Bericht uber ein Fruhgeborenes (1350 g) mit Verdacht auf Candida-albicans-Sepsis. Es wurde keine spezifische Behandlung durchgefuhrt Wahrend der funften Lebenswoche traten Deformierung, Verdickung und Verfarbung der meisten Fingernagel auf. Von alien Nageln konnte Candida albicans isoliert werden. Unter ortlicher Therapie mit Nystatin langsame Besserung. Nach unserem Wissen ist dies der jungste Bericht der Befall einer Onychomykose.

Thirty-six term neonates born after maternal intrapartum fever, with premature rupture of membranes18 hours and unknown maternal group B Streptococcus status had blood samples for complete blood count, C-reactive protein, culture, and 16S rRNA gene polymerase chain reaction amplification. Only 2 neonates were symptomatic and none had leukopenia, C-reactive protein1.0 mg/dL, bacteremia, or positive polymerase chain reaction.

Oral insulin promotes intestinal maturation and may prevent diabetes in animal models. The aim of this study was to evaluate the concentration of insulin in human milk and in different infant formulas. Our results show that the concentration of insulin in human milk is significantly higher (60.23 +/- 41.05 microU/ml mean +/- SD) compared with cow's milk (16.32 +/- 5.98 microU/ml mean +/- SD) and that insulin is hardly detectable in infant formulas. We propose the addition of human insulin to infant formula to match its composition more closely to human milk.

Twenty-one fetuses with an enlarged fourth ventricle were detected by ultrasound at 14-16 weeks' gestation. No other central nervous system anomalies were observed and a normal size fourth ventricle was noted in all cases on follow-up scans at 22-23 weeks' gestation. Five fetuses had associated structural anomalies: a single umbilical artery in two cases, non-septated cystic hygroma in two cases and ventricular septal defect in one fetus. All fetuses had a normal brain sonogram after delivery. Nineteen newborns who were followed up to the age of one year had no developmental problems. It is concluded that an isolated enlarged fourth ventricle might be a physiological variant in early fetal life.

Our objective was to construct a nomogram of the fetal lingual size in early pregnancy and to assess the size of the tongue in abnormal fetuses. The lingual width was measured by using transvaginal ultrasonography in 80 normal fetuses at 13 and 18 weeks' gestation. In addition the tongue was measured in 22 fetuses at these gestational ages who had an abnormal karyotype or oro-facial malformations. A linear relationship was found between the lingual width and gestational age in normal fetuses. The lingual size was within the normal range in cases of trisomy 13, trisomy 21 and Turner syndrome. A small tongue was observed in fetuses with micrognathia. Correlation between lingual width and gestational age was observed in early pregnancy. The relationship between the size of the tongue and oro-facial malformations needs further evaluation. © 1998 John Wiley & Sons, Ltd.

Reduction of fetal number has been offered in high order multiple gestations but is still controversial in triplets. Since recent advances in neonatal and obstetric care have greatly improved outcome, the benefits of multifetal pregnancy reduction (MFPR) may no longer exist in triplet gestations.To evaluate if fetal reduction of triplets to twins improves outcome.We analyzed the outcome of 80 triplet gestations cared for at Rambam Health Care Campus in the last decade; 34 families decided to continue the pregnancy as triplets and 46 opted for MFPR to twins.The mean gestational age at delivery was 32.3 weeks for triplets and 35.6 weeks for twins after MFPR. Severe prematurity (delivery before 32 gestational weeks) occurred in 37.5% and 7% of twins. Consequently, the rate of severe neonatal morbidity (respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage) and of neonatal death was significantly higher in unreduced triplets, as was the length of hospitalization in the neonatal intensive care unit (31.4 vs. 15.7, respectively). Overall, the likelihood of a family with triplets to take home all three neonates was 80%; the likelihood to take home three healthy babies was 71.5%.MFPR reduces the risk of severe prematurity and the neonatal morbidity of triplets. A secondary benefit is the reduction of cost of care per survivor. Our results indicate that MFPR should be offered in triplet gestations.

Agenesis of the vermis as detected during gestation by ultrasonography may indicate the existence of various malformation arrays or syndromes. We report on our observations of five cases of complete vermal agenesis that were detected at 22-31 weeks of gestation. All had a vertex presentation and transvaginal sonography established the diagnosis of vermal agenesis. Two of the vermal agenesis cases had no associated anomalies outside the central nervous system (CNS). In one, the cerebellar cleft was the only abnormality present and the other also had lobar holoprosencephaly. The three remaining fetuses had trisomy 13 and featured various additional extra-CNS anomalies. The association of complete vermal agenesis and trisomy 13 has not been previously reported. Our experience with this series suggests that supplementation with vaginal fetal sonography is a valuable tool for obtaining a more accurate view of the posterior fossa whenever a cyst or a cyst-like abnormality is detected by transabdominal sonography. A finding of isolated vermal agenesis appears to mandate a careful search for additional anomalies and the performance of karyotype analysis.