Second-trimester biochemical screening

The past years have seen considerable progress in the area of biochemical screening. Increasing data have now clearly shown the advantages of multiple markers, particularly beta-hCG over AFP alone. There continues to be considerable controversy over the best mathematic algorithm and which markers are best (e.g., beta-HCG, uE3, and so forth). There seems to be a plateau of detection frequencies at about 65% to 70% with current methodologies. Further work needs to be done, however, including some new approaches, if there is to be substantial improvement of screening sensitivity. The combination of biochemical with biophysical parameters as discussed elsewhere in this issue represents the next level of sophistication in the attempt to identify the highest proportion of abnormalities with the fewest false-positives.

Use of an outcome by gestation table for extremely premature babies: a cross-sectional survey of the views of parents, neonatal nurses and perinatologists

OBJECTIVES

To promote family-centered care and strengthen the process of informed consent it is essential that parents have access to information on the problems their baby may face. We have constructed an Outcome by Gestation Table (OGT) with information on survival, short-term complications plus treatments of the most recent cohort of babies born at different gestations from 23 to 28 weeks. This study documents the views on the table from parents of babies < 29 weeks gestation, neonatal nurses, and doctors.

STUDY DESIGN

A copy of the OGT and a questionnaire seeking views regarding the OGT was sent to the parents' support group (Preemie-List), 71 randomly chosen perinatologists in Australia and to the 35 nurses working in our NICU. Differences between groups were analyzed using chi 2 analysis.

RESULTS

Forty-eight parents participated in the study. Forty-three (60.5%) doctors and 24 (68.5%) neonatal nurses replied. The three groups agreed that the OGT is not misleading. The majority of doctors feel that the table: is easy to understand but has too much information; is useful but they are ambivalent about using it in their practice. The results were highly significant with parents being most positive and accepting of the OGT, next nurses and finally doctors.

CONCLUSION

It is important to seek the views of both consumers and carers on any aid in communication in the NICU.

Paenibacillus associated with milky disease in Central and South American scarabs

Thirty-one isolates of bacteria causing milky disease in scarab larvae collected in Central and South America were identified as Paenibacillus popilliae or Paenibacillus lentimorbus by use of DNA similarity analysis. The isolates were more similar to each other than to the North American isolates that are the type strains of the species. All of the bacteria of both species produced parasporal bodies, a characteristic previously believed to be unique to P. popilliae. Screening of the bacteria using PCR with parasporal protein primers revealed differences among the parasporal protein genes of P. popilliae isolates and between the parasporal genes of P. popilliae and P. lentimorbus. In contrast to P. popilliae from North America, none of the isolates from Central and South America was resistant to vancomycin, an indication of an interesting geographic distribution of the resistance genes.

Management of acute surgical orbital haemorrhage: an otorhinolaryngological and ophthalmological perspective

This retrospective report describes the management and outcome of seven patients who suffered an acute surgical orbital haemorrhage (ASOH), secondary to a surgical procedure performed on either the sinuses, orbits or eyelids. All patients but one recovered their pre-operative vision. A management plan is outlined on how to assess and tackle this complication, so that the ENT surgeon may be better prepared to meet such an acute surgical emergency, should it arise.

ChildLine--the first twelve years

This brief article aims to give a history and overview of ChildLine's work in the first 12 years of its existence and to provide references to more detailed information on a range of issues that children and young people themselves have identified as important. All callers' names and identifying details have been changed to preserve confidentiality.

Where is UK general dental practice going?

Dentistry is a fundamental part of healthcare; without it a large proportion of the population would suffer severe detriment to their general health. However, in order to achieve our professional aims we have to pursue the business of dentistry.

Chronic fatigue syndrome and/or fibromyalgia as a variation of antiphospholipid antibody syndrome: an explanatory model and approach to laboratory diagnosis

Chronic Fatigue and/or Fibromyalgia have long been diseases without definition. An explanatory model of coagulation activation has been demonstrated through use of the ISAC panel of five tests, including, Fibrinogen, Prothrombin Fragment 1+2, Thrombin/ AntiThrombin Complexes, Soluble Fibrin Monomer, and Platelet Activation by flow cytometry. These tests show low level coagulation activation from immunoglobulins (Igs) as demonstrated by Anti-B2GPI antibodies, which allows classification of these diseases as a type of antiphospholipid antibody syndrome. The ISAC panel allows testing for diagnosis as well as monitoring for anticoagulation protocols in these patients.

Gestation versus outcome table for parents of extremely premature infants

Parents of extremely premature babies may have problems understanding and remembering information on likely outcome. We have constructed a simplified evidence-based "gestation versus outcome" table that could be offered to the parents. Such a table may promote consistency in the information given to parents by different members of the perinatal team.

A randomized comparison of homoeopathic and standard care for the treatment of glue ear in children

OBJECTIVE

To pilot a model for determining whether homoeopathic treatment of children suffering from glue ear is more effective than standard GP care at producing a return to normal hearing (a hearing loss of less than 20 dB) within 12 months.

DESIGN

Non-blind, randomized controlled trial.

SETTING

General practice in two locations in southern England.

SUBJECTS

Thirty-three children aged 18 months to 8 years with otitis media with effusion, hearing loss > 20 dB and an abnormal tympanogram.

OUTCOME MEASURES

Hearing loss, tympanogram, referrals to specialists and number of courses of antibiotics at 12 month follow-up.

RESULTS

A higher proportion of children receiving homoeopathic care had a hearing loss less then 20 dB at follow-up (64 vs 56%), though this difference did not reach statistical significance (95% confidence interval for the difference between means of -25 and 42%). More homoeopathy patients than controls had a normal tympanogram (75 vs 31%, P = 0.015). Referrals to specialists and antibiotic consumption was lower in the homoeopathy group, though differences between groups did not reach statistical significance.

CONCLUSION

Further research comparing homoeopathy to standard care is warranted. Assuming recovery rates of 50 and 30% in homoeopathy and standard care groups respectively, 270 patients would be needed for a definitive trial.

The messenger case

Increasingly, parents are asking for the right to make resuscitation and treatment decisions for their newborn infants at high risk for mortality and morbidity. Failure of neonatologists to honor such parental wishes has led to criticism in the media and public disenchantment with neonatology. These issues were dramatized in a recent trial in which a father was charged with manslaughter after he removed his extremely premature son from life support to stop treatment administered against the family's wishes. Guidelines giving parents greater latitude in treatment decisions would help avoid similar tragic situations and would help restore public confidence in neonatology.

Bilirubinemia in asphyxiated term infants. A clinical observation

Recent clinical observations suggested that serum bilirubin levels remain low following perinatal asphyxia. This study was performed to determine the peak serum bilirubin concentrations in asphyxiated term infants and to compare these levels with those in a group of non-asphyxiated term infants. The medical records of 28 asphyxiated (Apgar < 7 at 5 minutes) and 947 non-asphyxiated term infants born during the same period of time were reviewed to obtain data on peak serum bilirubin concentrations for statistical comparison. The statistical mean for the peak serum bilirubin concentrations in the 28 asphyxiated infants was 5.0 mg/dl (+3.1 SD) while that for the 947 non-asphyxiated infants was 8.9 mg/dl (+3.7, p < .001). The findings in this study indicate that low peak bilirubin levels should be expected in asphyxiated term infants and may be helpful as a biochemical marker before the mechanism of action is known.

Prevalence of alcohol and illicit drug use by expectant mothers

BACKGROUND

Prevalence data of illicit drug and alcohol use during pregnancy in Alaska is limited. This study demonstrates the prevalence of perinatal drug and alcohol use at a single community hospital in Anchorage, Alaska.

METHODS

A convenience sample was used during a six month period. 351 anonymous urine samples were obtained from imminently delivering women. Screening toxicology tests were run and results were linked to demographic variables using a common random reference number.

RESULTS

16.2% (n = 57) of the samples were positive for drugs or alcohol. Cannabinoids and alcohol were found most frequently. Polydrug use was found in 22.8% of the positive samples. Medicaid recipients represented the highest users of illicit drugs and alcohol.

CONCLUSIONS

The prevalence of positive drug screens and polydrug use in our sample is amongst the highest reported in the literature. The high prevalence of drug and alcohol use indicates that present prevention strategies are not working in Alaska. New and innovative outcome based strategies to decrease drug and alcohol use in pregnancy are needed.

Accuracy of intravenous infusion pumps in continuous renal replacement therapies

Most extracorporeal continuous renal replacement therapies (CRRT) require inflow pumping of either dialysate, filtrate replacement solution, or both. Outflow of spent dialysate and ultrafiltrate can be accomplished by gravity drainage or pump. Intravenous infusion pumps have been commonly used for these purposes, although little is known about the accuracy of these pumps. To evaluate accuracy of two different types of intravenous infusion pumps used in CRRT, we studied flow rates at nine different pressure variations in three piston type and three linear peristaltic pumps. The results showed that error of either pump was not different for flow rates of 4 and 16 ml/min. Both types of pumps were affected by fluid circuit pressures, although pressure conditions under which error was low were different for each pump type. The linear peristaltic pumps were most accurate under conditions of low pump inlet pressure, whereas piston pumps were most accurate under conditions of low pump pressure gradient (outlet minus inlet) of 0 or -100 mmHg. The magnitude of error outside these conditions was substantial, reaching 12.5% for the linear peristaltic pump when inlet pressure was -100 mmHg and outlet pressure was 100 mmHg. Error may be minimized in the clinical setting by choosing the pump type best suited for the pressure conditions expected for the renal replacement modality in use.

Apnea of prematurity: theophylline v. caffeine

During a fifteen month period, 401 two channel (heart rate and respiratory impedance), 12 hour pneumocardiograms on 277 preterm infants were performed. Each pneumocardiogram was evaluated according to the following set of criteria: prolonged apnea (apnea > 19 seconds or shorter if associated with heart rate of < 80bpm for > 2 seconds or observed cyanosis); short apnea (apnea 10-19 seconds); periodic breathing (normal respiratory pattern interrupted by > 2 breathing pauses of > 5 seconds during > 1 minute duration). Apnea density was used as prime measure in determining abnormal pneumocardiograms and was defined by total apnea time (seconds) x 100 divided by recording time while periodic breathing index defined by total periodic breathing time (minutes) x 100 divided by recording time. Sixty infants (24%) had apnea densities > or = 5 which prompted therapy with theophylline. Sixteen of these infants (27%) failed to resolve their apnea within 7 days (apnea density > or = 3) and were placed on caffeine citrate. Caffeine decreased the apnea density of fourteen of these infants (88%) to 0.8 (95% CI; 0-2.3). Efficacy of both methylxanthines to normalize the pneumocardiogram was similar (p = 0.5). Persistent apnea unresponsive to theophylline may respond to orally administered caffeine citrate.

Identification of a serum protein polymorphism via two-dimensional electrophoresis. Family and population studies in two genetically isolated groups: North American Hutterites and Australian aborigines

We report the identification and initial family and population studies of a previously undescribed serum protein polymorphism with two allelic forms. It was discovered in Hutterites, a reproductively isolated religious sect, and is also present in Australian aborigines and a sample of Chicago residents. A two-allele model is consistent with the segregation pattern observed in five kindreds within our initial study group. This polymorphism, provisionally designated SPPM-158, appears as a horizontal (charge-based) doublet in silver-stained ISO-DALT high-resolution two-dimensional electrophoresis gels. It is a low-concentration polypeptide (approximately 1 mg/dL) that has an apparent MWSDS of 43.6 kD and an isoelectric point of approximately 5.5. We infer that it circulates as a multimer or in a high-molecular-weight (greater than 200 kD) complex with other proteins because it is not observed in normal body fluids derived from physiologically ultrafiltered plasma such as amniotic fluid, urine, or cerebrospinal fluid; however, it is present in urine of patients with glomerular proteinuria. The high heterozygosity rates imply utility of this new serum protein marker for both forensic and population studies.

Infant mortality in Alaska: evidence of high postneonatal mortality rate

Improvements in infant mortality (death less than 1 year of age) have been experienced by the United States and Alaska over the past decade. The decline in the Alaska neonatal mortality (death less than 28 days of age) rate has been the major factor in our improved infant mortality rate. Alaska's neonatal mortality rate is one of the lowest in the U.S. However, postneonatal mortality (28 days to 1 year of age) rate has not declined and is one of the highest in the U.S. In this study we used vital statistics records to examine socio-demographic and inter-regional factors that may help to explain Alaska's apparently high postneonatal mortality rate. The study population consisted of all live born infants in Alaska for 1975 to 1985, who died in infancy. The Alaska neonatal mortality rate has been lower, but postneonatal mortality rate has been higher than the U.S. average for the period under consideration (p less than .05). Comparison of alaska postneonatal mortality rate from 1975 to 1985 with the U.S. found Alaska Non-natives have higher postneonatal mortality rates than U.S. White, and Alaska Native have higher postneonatal mortality rates than other U.S. minorities. The rural areas of Alaska have a higher postneonatal mortality rate than urban areas, a phenomenon also observed for the U.S. as a whole.

Trends and patterns of postneonatal mortality in Alaska 1977 through 1984

Several determinants of Alaska postneonatal mortality rate were examined to determine whether very low birth weight (less than 1500 g) and low birth weight (1500-2499 g) surviving neonates contributed to the lack of improvement in postneonatal mortality rate. For an eight year period (1977 through 1984), all infant deaths (n = 1020) of the 82,301 resident births were reviewed through vital statistics data. The infant's place of birth, ethnic group, birth weight and age at death were available. Ethnic and rural-specific postneonatal mortality rate (PNMR) significantly improved, but there was no change in birth weight distribution or birth weight-specific postneonatal mortality rate. However, surviving very low birth weight infant proportion of postneonatal mortality has increased from 5% to 8.2% and low birth weight proportion has remained unchanged (15.6%). These proportions were not offset by the decline in normal birth weight (greater than 2500 g) postneonatal mortality rate. This trend suggests that infants born weighing less than 2500 g have slowed the decline of the postneonatal mortality rate.

Surgical repair of atypical coarctation of the abdominal aorta in an infant

A seven-week-old infant with multiple areas of coarctation of the abdominal aorta and renal artery pathology underwent staged surgical repair of his malformations in our medical center. The clinical and routine echocardiographic evaluations suggested the diagnosis of atypical coarctation of the aorta. The exact anatomical characteristics of his vascular malformations were established by repeated angiocardiographic studies, which should be performed in any patient in which the diagnosis of atypical coarctation of the aorta is suspected.

Gastric heterotopia causing airway obstruction

Two infants are reported each with a mass of heterotopic gastric tissue in the hypopharynx causing airway obstruction. Endoscopic laser removal of the tumours proved a satisfactory method of treatment. Gastric heterotopia in the head and neck region is rare but should be considered as a cause of stridor in infants.

Infant orthotopic cardiac transplantation

Infant orthotopic cardiac transplantation has been recently applied to various forms of congenital heart disease with encouraging short-term results. Between June 1986 and September 1987 we evaluated 16 infants for orthotopic cardiac transplantation. Fourteen had hypoplastic left heart syndrome, one had endocardial fibroelastosis with aortic atresia, and one had anomalous pulmonary arterial origin of the left main coronary. Eight families accepted the treatment program and eight families refused (two because of associated anomalies and six on philosophical grounds). Of the eight patients who were candidates for orthotopic cardiac transplantation, one died 6 hours after diagnosis, one was allowed to die after 60 days because of acquired neurologic complications, and another had congenital cytomegalic virus infection. The remaining five patients (four with hypoplastic left heart syndrome, one with anomalous pulmonary arterial origin of the left main coronary) had orthotopic cardiac transplantation. The operation was performed with absorbable polydioxanone suture with deep hypothermia and circulatory arrest in four neonates for hypoplastic left heart syndrome (average time 47 minutes) and bicaval cannulation and continuous bypass in one 11-month-old infant for anomalous origin of the left main coronary. In-house retrieval was used in all. One neonate died of complications as a result of pretransplant donor heart dysfunction and size discrepancy, whereas the remaining three neonates and one infant survived and are home 23 months, 12 months, and 8 months (the patients with hypoplastic left heart syndrome) and 17 months (the patient with anomalous origin of the left main coronary) postoperatively. Triple-drug immunosuppression included cyclosporine, azathioprine, and prednisone. Rejection was diagnosed by clinical evaluation of child activity and monocyte cell cycle analysis from peripheral blood samples without myocardial biopsies. Routine echocardiograms, electrocardiograms, and chest x-ray films were not helpful. Six episodes of rejection were successfully treated in four patients. Twelve-month postoperative catherization in one patient (hypoplastic left heart syndrome) showed appropriate graft growth, no aortic or pulmonary anastomotic strictures, normal right and left ventricular function, and no coronary artery disease. We conclude that infant orthotopic cardiac transplantation is an acceptable procedure for severe forms of untreatable congenital heart disease. The excellent short-term results warrant continued application of orthotopic cardiac transplantation.

Alpha-interferon (Wellferon) as an adjunct to standard surgical therapy in the management of recurrent respiratory papillomatosis

Ten patients received lymphoblastoid alpha-interferon (Wellferon) in a crossover study so that Wellferon and standard microsurgical laryngeal laser therapy could be compared to laser therapy alone. Wellferon was administered initially at an intravenous high dose of 15 megaunits/m2 for 5 days followed by a daily dose of 2 megaunits/m2 subcutaneously for 6 months. Dosage was adjusted according to predefined toxicity. One patient was withdrawn from the study. Of the others, all but one received over 75% of the planned total dose. At follow-up of the nine assessable patients, complete remission was achieved in two of them, partial remission in four, and no response in the remainder. The two complete remissions were sustained for 2 years, but the four partial remissions were not sustained. Thus, a role for alpha-interferon in the kind of regimen used here remains to be established.

Examining reliability and validity of the Preschool Play Scale with handicapped children

This study examined the reliability and validity of the Preschool Play Scale (PPS), a measure of the developmental level of play, on a sample of 60 handicapped children. Results demonstrated acceptable reliability and validity for the scale as a whole. However, the need for some refinement of the scale was revealed by the findings. Categories of play that can be observed only infrequently need to be reconsidered. The data also suggest that the criteria for deciding whether a behavior is absent or whether there was no opportunity to observe the behavior need to be spelled out more clearly for the scale.

Treatment of nephrogenic diabetes insipidus with prostaglandin synthesis inhibitors

The antidiuretic effect of two prostaglandin synthetase inhibitors, ibuprofen (25 mg/kg/day) and indomethacin (2 mg/kg/day), was studied in patients aged 8 to 18 years with hereditary nephrogenic diabetes insipidus. Ibuprofen (studied in five patients) did not have demonstrable effects on urine volume, free water clearance, or osmolar clearance, but fractional excretion of sodium decreased from a mean of 0.38% to 0.19% (P less than 0.05). In contrast, indomethacin (studied in three patients) was associated with a decrease in mean urine volume from 5.8 to 2.8 mL/min and a decrease in mean free water clearance from 3.1 to 1.1 mL/min (both P less than 0.05). Fractional excretion of sodium decreased from 0.77% to 0.27% (P less than 0.01) and was accompanied by an increase in serum urea nitrogen level (P less than 0.01) and a decrease in urea nitrogen clearance (P less than 0.025). Thus, prostaglandin synthetase inhibitors are not uniformly effective in treatment of nephrogenic diabetes insipidus. The inhibitory effect of indomethacin on urine volume and free water clearance in our patients may have been mediated by an enhancement of antidiuretic hormone (ADH)-stimulated cyclic adenosine monophosphate generation, or by increased ADH-independent water reabsorption resulting from an increase in solute reabsorption and consequent medullary hypertonicity.