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•International travel can expose one to health risks and represents an important Public Health Issue.•The compliance to prophylactic measures and behavioral advice given during pre-travel consultation are fundamental preventive measures.•Pre-travel consultation is the only way to make travellers aware of specific risks that could occur during their trip and recommend specific prophylaxis, including immunization.

•International travel can expose one to health risks and represents an important Public Health Issue.•The compliance to prophylactic measures and behavioral advice given during pre-travel consultation are fundamental preventive measures.•Pre-travel consultation is the only way to make travellers aware of specific risks that could occur during their trip and recommend specific prophylaxis, including immunization.

Our objective was to evaluate the diagnostic and prognostic value of sonography in fetal intracranial hypoechoic lesions. A retrospective study revealed a total of 21 cases diagnosed over a period of 10 years. Most of the diagnoses were made in the third trimester. The presence of fluid‐filled lesions within the brain matter always predicted porencephaly and a poor outcome. In most of these cases (nine out of ten), the lesions were seen to communicate with the cavity of the lateral ventricles. Among the 11 cases of hypoechoic lesions that were external to the brain matter, Doppler ultrasound was always able to distinguish between arachnoid cysts (seven cases) and vein of Galen aneurysms (four cases). Arachnoid cysts were associated with a good outcome in four out of five pregnancies that delivered at term. Three of the four cases of vein of Galen aneurysm were associated with distortion of the cerebral architecture and/or hydrops: one pregnancy was terminated and two resulted in early postnatal death. One pregnancy with vein of Galen aneurysm and normal cerebral structures, without signs of hydrops, had a good outcome. It is concluded that current antenatal ultrasound has the capability of accurate differentiation between different clinical entities resulting in fetal intracranial hypoechoic lesions, and that the sonographic findings have practical clinical implications. Copyright © 1997 International Society of Ultrasound in Obstetrics and Gynecology

Background and aim: We report the strategies employed to contain an outbreak of non -extended-spectrum beta-lactamases producing Klebsiella pneumoniae.Methods: Six cases of primary bloodstream infection were identified (July-August 2008). Birth weights ranged from 820 to 2340 g and gestational ages from 26 to 36 weeks. C-reactive protein increased in all cases. 13 infants became colonized. Outcome was favourable in all patients. Numerous strategies were implemented and hand hygiene was emphasized. All neonates were screened in admission and biweekly using rectal, pharyngeal and conjunctival swabs. Infected patients and carriers were isolated. Nursing care was partially cohorted. Intensive education program was organized. Hand cultures from the staff and environmental cultures were collected. All neonates became colonized and the unit was closed to admissions.Results: 33 environmental samples were collected from the unit. One culture of a multiple-dose solution of saccharose was positive for /Klebsiella pneumoniae. No staff member resulted positive. All of the Klebsiella isolated were resistant only to ampicillin and piperacillin. Genomic typing of Klebsiella strains isolated were performed by pulsed-field gel electrophoresis. The results were confirmed by arbitrary primed polymerase chain reaction and random amplification of polymorphic DNA. Genotyping disclosed that the outbreak was polyclonal: 8 isolated from infants and the saccharose solution belonged to the same genotype. The other 7 profiles were different.Conclusions: Cohorting of nursing and/or medical care is the most efficient measure in the control of an outbreak. In our case, understaffing and lack of staff reinforcements played a part and ward closure was performed.

Introduction. Prediction of outcome in HIE could be very useful in counselling parents and selecting patients for possible therapeutic intervention. To compare the predictive performance of various diagnostic tools for identifying infants at risk of developing neurological sequelae we are performing a prospective follow-up study in newborns with HIE.Patients and methods. Newborns fulfilling the following criteria are eligible: 1)GA >=38 wks, 2) heart rate abnormalities during labour and/or meconium stained amniotic fluid and/or need for birth resuscitation, 3) 5 min AS <=5 or umbilical artery pH <=7.1 and BE >12 mmol/L. Clinical data were recorded; amplitude integrated EEG (aEEG), EEG, cranial US, 1H-MRS were performed in the neonatal period. Evaluation of general movements, physiatric examination, visual evoked potentials and ABR are scheduled at 3 months of age; psychomotor development (Griffith test) and Dubowitz examination are performed at 3, 6, 12, 24 months of age.Results. In one year 24 newborns were recruited. In 13 of them follow-up at 6 months is available; 8 newborns are under 6 months, 3 were lost at follow-up. N-acethyl aspartate/Creatine (NAA/Cr) at basal ganglia level in the first 24 hrs of life decreased in newborns with motor impairment (MI) compared to newborns without MI (0.77 vs 0.82, p> 0.05); moreover NAA/Cr showed a good correlation with developmental quotient (DQ) (r=0.88, p>0.05). At 1 week of age NAA/Cr was 0.3 in newborns with MI vs 0.86 in newborns without MI (p<0.01); there was a correlation between NAA/Cr and DQ (r=0.86 p=0.015). Grade HIE, aEEG and US anomalies were also associated with MI (p<0.05); in particular aEEG had a 100% sensitivity and specificity in early identifying newborns with MI.Discussion: These preliminary data show that Sarnat grading, aEEG and 1H-MRS performed together in the first 24 hours of life can predict outcome in HIE.

Background. Glucocorticoids have been used successfully in the amelioration of chronic lung disease (CLD). Unfortunately, higher risk of adverse neurological outcome has been reported in newborns treated with systemic steroids. The ideal treatment of CLD would be a topical steroid with a low absorption given directly to the alveoli so improving clinical efficacy and decreasing side effects. Inhaled steroids have been used at this purpose but drug delivery was extremely variable ranging from 0.04 to 53.2%. Exogenous surfactant has been proposed as a possible vehicle for drugs such as antibiotics. Recently, it has been shown to be a good vehicle for steroids too, while maintaining its surface properties. We report a case of extremely severe respiratory insufficiency in a newborn affected by CLD in which a combined treatment with Curosurf® and beclomethasone was used.Case report. Male newborn, outborn, 495 g BW, GA 24 weeks born by cesarean section due to abruptio placentae. No antenatal steroids were given. He was intubated at birth and mechanically ventilated (MV). A prophylactic dose of Curosurf® was given. A patent ductus arteriosus was closed by i.v. ibuprofen. No others cardiac defects were present. Because of respiratory deterioration on the 2nd week of life (requirement of supplemental oxygen increased to 80% in MV) he received dexamethasone at tapering doses for 10 days. Microbiological cultures remained sterile. At the end of treatment no relevant improvement was seen, requirement for supplemental oxygen was 0.9–1 in MV. Chest X-ray showed severe CLD with a cystic pattern. Diverse treatment strategies such as low dose nitric oxide, Curosurf® instillation, bronchoalveolar lavage, chest physiotherapy were used without effect. On the 44th day of life due to respiratory deterioration and intractable hypoxemia (tcSatO2 75–85% with FiO2 1 in SIPPV, PIP 25 cmH2O, paO2 31.7 mmHg) parental consent was obtained and the newborn was treated with a mixture of Curosurf® (80 mg/kg) and beclomethasone (400 mcg/kg). Few hours after treatment the tcSatO2 was >90%, paO2 69 mmHg with FiO2 0.85. Treatment was continued for 6 days; the newborn remained stable, with a normal oxygenation in SIPPV (FiO2 0.85–1). There were no adverse effects during treatment. Systemic betamethasone was continued at tapering doses for others 10 days. He was extubated on the 70th day of life on nCPAP and later on reintubated several times to be broncho-aspirated. He was discharged at 3 months of age without supplemental oxygen. Cranial US shows no anomalies.Conclusions. Surfactant may be a useful vehicle for steroid administration in the prevention and treatment of CLD. This treatment has not shown short term adverse effects and has permitted survival in our extremely ill patient. Further studies are needed in order to evaluate the usefulness and safety of this approach.

Introduction: several neuropathological studies have documented brain damage following hypoglycaemia. In a few cases damage has been reported in vivo using CT, MRI and US. Here we report a functional and anatomic study of the brain in a case of transient symptomatic hypoglycaemia.Case report: term newborn, AS 9–10, LGA, of a non-diabetic primigravida was referred to NICU at 51 hrs of age due to hypoglycaemia (12 mg/dl); a bolus of 200 mg/kg followed by an infusion of 5 mg/kg/min of e.v. glucose was administered and blood glucose reached a normal value (> 40 mg/dl). Clinical and electric seizures were diagnosed on arrival in NICU and continued for 24 hrs despite glycemic normalisation and phenobarbital treatment. HIE, other metabolic diseases and meningoencephalitis were excluded. At age 3 days cranial US showed a patchy hyperecogenicity of the periventricular and subcortical white matter at the parieto-occipital level; ventricles were split-like. Lesions were confirmed by MRI and resolved at about one month of age without developing ventriculomegaly. The infant underwent 1H-MRS and DWI at 4, 11, 17 and 31 days after birth. N-acethyl aspartate/Creatine (NAA/Cr) reduction and severe lactate and lipid accumulation were present in the occipital cortex; adjusted diffusion coefficient in the occipital lobes was severely reduced (-50%) at first examination and progressively recovered at all later time points. Clinical follow-up at 4 years of age is normal.Discussion: For the first time by combining 1H-MRS, DWI and traditional imaging we have detected severe, transient, occipital lobe metabolic abnormalities in a hypoglycaemic neonate with a normal outcome at 4 years of age. US and MR were able to first detect these lesions and may be a good initial study in the hypoglycaemic neonate.

Background: Pulmonary hypertension (PH) is a major complication of chronic lung disease (CLD), and its treatment is based on the use of oxygen. Inhaled nitric oxide (iNO) is a highly selective pulmonary vasodilator and it has been used in the therapy of this condition via endotrachal tube during mechanical ventilation. Its use in CLD associated PH with non-invasive delivering methods has not yet been documented to our knowledge.Methods: We report the case of a newborn born prematurely (GA 27 wks BW 475 gms) who developed CLD. At 43 wks post conceptional age oxygen need increased to FiO2=0.7 in nasal CPAP (nCPAP) to maintain O2 saturation (SaO2) within the normal range. Chest X-ray showed cardiomegaly (CTI=0.66). Echocardiography showed indirect signs of PH (hypertrophy of the right ventricle, systolic “D” shaped interventricular septum, moderate pulmonary valve insufficiency) and the value of the mean pulmonary arterial pressure (mPAP) measured through pulmonary insufficiency (PI) was 40– 45 mm Hg immediately before starting iNO. INO (INOmax-INO Therapeutics) was administered via nCPAP (Infant Flow System-EME) in conjunction with a iNO delivery system (INOvent-Datex Ohmeda) at a starting dose of 10 ppm.Results: 5 minutes after starting iNO at 10 ppm via nCPAP, echocardiography showed a decrease of mPAP to 14–15 mm Hg and a significant reduction of PI. After 30 min the oxygen need decreased to FiO2=0.5 to keep SaO2 normal. Subsequently the dose of iNO was progressively decreased with no rebounds in mPAP and stopped 13 days from the start. At the end of treatment echocardiography showed a stable mPAP of 14–15 mm Hg. Met Hb on blood and NO2 in the inspiratory line of nCPAP circuit were never beyond safety levels. On the fifth day of iNO treatment, therapy with dexamethasone was started at the dose of 0.25 mg/kg/day in two doses. Dexamethasone dose was progressively decreased and stopped the day after iNO suspension. At the end of treatment the patient was off nCPAP and oxygen was needed only during feeding. 50 days after the start of iNO treatment echocardiographic PH was absent, chest X-ray showed a reduction of cardiomegaly (CTI=0.52) and the clinical status was stable with a minimal oxygen need.Conclusion: INO administered via nCPAP has been shown to be effective and safe in reducing CLD associated PH in our patient. On the basis of this experience non-invasive iNO administration can be suggested as an alternative therapy associated with CLD.

Background: Persistent pulmonary hypertension of the newborn (PPHN) can be primitive or a consequence of many lung diseases. We report the occurrence of PPHN after a rare disease: agenesis of the ductus venosus (ADV). Ductus venosus (DV) is a fetal vessel draining 20–30% of the oxygenated umbilical vein blood into the inferior vena cava bypassing the liver. Absent DV can be associated with a normal or abnormal umbilical vein connection to the portal vein. In the latter situation, venous umbilical blood bypasses completely the liver and drains 'unrestricted' into the inferior vena cava or into the right atrium. ADV can be associated with hydrops, chromosomal anomalies, atrial septal defects, facial clefts, kidney anomalies (1).Methods: Between 2000 and 2003, 6 cases of ADV (GA 31–37 weeks) with umbilical vein drainage into the right atrium were referred to our NICU.Results: In 4 cases PPHN, as shown by echocardiography, developed after birth; cardiomegaly was present in uterus but no hydrops. In two newborns PPHN was severe and required inhaled nitric oxide (NO); in the remaining 2 newborns mechanical ventilation and vasoactive amines were able to treat PPHN. Two newborn showed no cardiorespiratory diseases: one showed policytemia and the other mild hypoglicemia. Outcome was good in 5 newborns; in one severe encephalomalacia followed profound hypoxemia during PPHN. To our knowledge this is the first report of severe PPHN in newborns with ADV. Two main pathogenetic factors can explain this association: 1) liver bypassed by the oxygenated umbilical vein flow can result in liver hypoxia and/or in absent liver metabolism of vasoactive substances. It has been demonstrated that hypoxia enhances endothelin-1 (ET-1) gene expression in the liver (2); moreover, PPHN was found in a child with congenital porto-caval shunt suggesting a pathogenetic role of toxic metabolites reaching the pulmonary vascular bed (3); 2) in fetuses with ADV increased right cardiac output has been reported (1). Increased pulmonary blood flow can decrease NO production and increase ET-1 level in the lung as well as ET-1 receptors mediating vasoconstriction (4).Conclusion: Severe PPHN can complicate ADV. Timely and aggressive treatment of PPHN in such cases can lead to normal outcome. Understanding of the pathogenesis can help to optimise therapy.