Potential hazard of the Neopuff T-piece resuscitator in the absence of flow limitation

OBJECTIVE

(1) To assess peak inspiratory pressure (PIP), positive end expiratory pressure (PEEP) and maximum pressure relief (P(max)) at different rates of gas flow, when the Neopuff had been set to function at 5 l/min. (2) To assess maximum PIP and PEEP at a flow rate of 10 l/min with a simulated air leak of 50%.

DESIGN

5 Neopuffs were set to a PIP of 20, PEEP of 5 and P(max) of 30 cm H(2)O at a gas flow of 5 l/min. PIP, PEEP and P(max) were recorded at flow rates of 10, 15 l/min and maximum flow. Maximum achievable pressures at 10 l/min gas flow, with a 50% air leak, were measured.

RESULTS

At gas flow of 15 l/min, mean PEEP increased to 20 (95% CI 20 to 21), PIP to 28 (95% CI 28 to 29) and the P(max) to 40 cm H(2)O (95% CI 38 to 42). At maximum flow (85 l/min) a PEEP of 71 (95% CI 51 to 91) and PIP of 92 cm H(2)O (95% CI 69 to 115) were generated. At 10 l/min flow, with an air leak of 50%, the maximum PEEP and PIP were 21 (95% CI 19 to 23) and 69 cm H(2)O (95% CI 66 to 71).

CONCLUSIONS

The maximum pressure relief valve is overridden by increasing the rate of gas flow and potentially harmful PIP and PEEP can be generated. Even in the presence of a 50% gas leak, more than adequate pressures can be provided at 10 l/min gas flow. We recommend the limitation of gas flow to a rate of 10 l/min as an added safety mechanism for this device.

The pool chlorine hypothesis and asthma among boys

Swimming pool sanitation has largely been concerned with the microbiological quality of pool water, which is normally treated using a number of chlorine products. Recent studies have pointed to the potential hazards of chlorine by-products to the respiratory epithelium, particularly in indoor, poorly ventilated, pools. The aim of our study was to elucidate whether chronic exposure to indoor chlorinated swimming pools was associated with an increased likelihood of the development of asthma in boys.

METHODS

The subjects were boys aged between 6 and 12 years. Data was collected by means of parental responses to a standardized asthma questionnaire (ISAAC: International Study of Asthma and Allergies in Childhood), supplemented with additional questions regarding frequency of attendance, number of years attendance, whether the child is a swimming team member. The questionnaire return rate was 71/% (n = 121). 23 boys were excluded on the basis that they had asthma before they started swimming (n = 97). There was a significant association between number of years a boy had been swimming and the likelihood of wheezing in the last 12 months (p = 0.009; OR = 1.351; 95% CI = 1.077-1.693) and diagnosed asthma (p = 0.046; OR = 1.299; 95% CI = 1.004-1.506). The greater the number the number of years a boy had been attending an indoor, chlorinated pool, the greater the likelihood of wheezing in the last 12 months or "had asthma". Age, parental smoking habits and being a swimming team member had no association with any of the asthma variables examined. Swimming pool attendance may be a risk factor in asthma in boys.

Neonatal resuscitation program guidelines 2006: ready, steady, can't go!

New evidence-based guidelines have been launched with recommendations that may impact how resuscitations, particularly of LBW infants, are enacted.

AIM

to determine current resuscitation practices in Maternity units in Ireland and benchmarked these results to a recent study in the United States.

METHODS

A 20-question survey was developed and mailed to a lead neonatologist/paediatrician in each of 19 maternity units in Ireland in May 2006.

RESULTS

There was 84% response rate to the surveys mailed which included 10 level II and 6 level III units. NRP qualification was considered obligatory for all paediatrics doctors in all units, with 14/16 units running at least one NRP course per year (range 1-9). Self inflating bags were more commonly used (44%), followed by T-piece resuscitators (31%) and flow inflating bags (25%). Pulse oximeters to alter the fraction of inspired oxygen were used by (25%) of units during the management of very low birth weigh infants, with a useful signal being achieved in one minute in most cases. Air/oxygen blenders were available for (44%) of units; however, all units use 100% O2 for initial resuscitation. CO2 detectors for ETT position were used in only 2 units (12%). A third of units (31%) used plastic wrap to prevent heat loss in VLBW infants. CPAP/PEEP were used by 44% of the surveyed units, generally with initiating pressure of 5 cm H2O.

CONCLUSIONS

NRP is now an obligatory feature in all NICU's in Ireland compared to the 1990s when resuscitation training was disorganized and inconsistent. Variations in resuscitation practices still exist among different units. Many units may not be able to apply 2006 NRP guidelines especially for VLBW infants unless there is a significant investment in air/oxygen blenders, pulse oximeters, CO2 detectors and resuscitators that control peak pressures and CPAP/PEEP.

Persistent lactic acidosis in neonatal hypoxic-ischaemic encephalopathy correlates with EEG grade and electrographic seizure burden

BACKGROUND

Predicting at birth which infants with perinatal hypoxic-ischaemic injury will progress to significant encephalopathy remains a challenge.

OBJECTIVE

To determine whether lactic acidosis at birth in asphyxiated neonates could predict the grade of EEG encephalopathy by examining the relationship between time taken for the normalisation of lactate, severity of encephalopathy and seizure burden.

METHODS

Continuous early video-EEG monitoring was performed in babies at risk for hypoxic-ischaemic encephalopathy. Encephalopathy was graded from the EEG data. Total seizure burden (seconds) was calculated for each baby. Initial blood gas measurements of pH, base deficit and lactate were taken within 30 minutes of delivery. Time to normal serum lactate was determined in hours from birth for each infant.

RESULTS

All 50 term infants had raised initial serum lactate (median (lower, upper quartiles) 11.7 (10.2, 14.9)). There were no significant differences between the initial serum lactate, pH and base deficit in infants with normal/mildly abnormal (n = 24), moderately abnormal (n = 14), severely abnormal (n = 5) and inactive EEGs (n = 7). Time to normal lactate varied significantly with EEG grade (median (lower, upper quartile) 6.0 (4.1, 9.5) for mild/normal EEG, 13.5 (6.8, 23.5) moderate EEG, 41.5 (30.0, 55.5) severe group, 12.0 (8.1, 21.5) inactive group; p<0.001). Time to normal lactate correlated significantly with EEG seizure burden (seconds; R = 0.446, p = 0.002). Mean (SD) time to normal lactate was 10.0 (7.2) hours in infants who did not have seizures and 27.3 (19.0) hours in the 13 infants with electrographic seizures (p = 0.002).

CONCLUSIONS

Serum lactate levels in the first 30 minutes of life do not predict the severity of the ensuing encephalopathy. In contrast, sustained lactic acidosis is associated with severe encephalopathy on EEG and correlates with seizure burden.

Defining the gap between electrographic seizure burden, clinical expression and staff recognition of neonatal seizures

BACKGROUND

Neonatal seizures are often subclinical, making accurate diagnosis difficult.

OBJECTIVE

To describe the clinical manifestations of electrographic seizures recorded on continuous video-EEG, and to compare this description with the recognition of clinical seizures by experienced neonatal staff.

METHODS

Term infants, at risk of seizures, were monitored by continuous 12-channel video-EEG from <6 hours of birth for up to 72 hours. All clinical seizures were recorded by experienced neonatal staff on individual seizure charts. Video-EEG recordings were subsequently analysed. The number, duration and clinical expression of electrographic seizures were calculated (in seconds), and compared with the seizures clinically suspected by the neonatal staff.

RESULTS

Of 51 infants enrolled, nine had electrographic seizures. A further three had clinically suspected seizures, without associated electrographic abnormality. Of the total 526 electrographic seizures, 179 (34%) had clinical manifestations evident on the simultaneous video recording. The clinical seizure activity corresponded to 18.8% of the total electrographic seizure burden. Overdiagnosis also occurred frequently. Of the 177 clinically suspected seizure episodes documented by staff, 48 (27%) had corresponding electrographic evidence of seizure activity Thus, only 9% (48/526) of electrographic seizures were accompanied by clinical manifestations, which were identified and documented by neonatal staff.

CONCLUSION

Only one-third of neonatal EEG seizures displays clinical signs on simultaneous video recordings. Moreover, two-thirds of these clinical manifestations are unrecognised, or misinterpreted by experienced neonatal staff. In the recognition and management of neonatal seizures clinical diagnosis alone is not enough.

Doctors' and nurses' attitudes towards neonatal ethical decision making in Ireland

OBJECTIVE

To explore the clinical staff attitudes towards ethical decision making in neonatal intensive care units (NICUs) in Ireland, to establish differences between doctors and nurses and to compare attitudes in Ireland with those in Europe.

DESIGN

Cross-sectional study by means of an anonymous questionnaire. 64 doctors and 228 nurses in seven NICUs participated (response rates 74% and 81%, respectively). Through factor analysis the staff answers to 12 attitude statements were used to build a score whose range varied from 0 (preservation of life in any case) to 10, indicating a more individualised approach according to the patient's best interests.

MAIN OUTCOME MEASURE

Staff attitudes to ethical decision making in NICU.

RESULTS

Mean values of attitude scores were 5.8 (95% CI 5.3 to 6.2) for doctors, and 6.0 (95% CI 5.5 to 6.5) for nurses. Respondents with experience in follow-up of NICU graduates had significantly higher scores (6.7 vs 5.4, p = 0.018), while the opposite was true among more religious staff (5.8 vs 6.9, p = 0.026) and particularly for minority religions such as Muslim (4.1, 95% CI 3.1 to 5.2). Scores were higher after age 30 for nurses, and after age 40 for doctors, suggesting the adoption of a less vitalistic viewpoint as respondents grow older and more experienced. Among doctors, a relationship was found between the attitude score and their self-reported non-treatment practices.

CONCLUSIONS

In Ireland, NICU doctors and nurses hold similar attitudes towards ethical decision making. Personal and professional factors have a statistically significant impact on attitude score. Compared with the rest of Europe, attitudes in Ireland appear more similar to those of southern rather than northern European countries.

Spin based heat engine: demonstration of multiple rounds of algorithmic cooling

We experimentally demonstrate multiple rounds of heat-bath algorithmic cooling in a 3 qubit solid-state nuclear magnetic resonance quantum information processor. By pumping entropy into a heat bath, we are able to surpass the closed system limit of the Shannon bound and purify a single qubit to 1.69 times the heat-bath polarization. The algorithm combines both high fidelity coherent control and a deliberate interaction with the environment. Given this level of quantum control in systems with larger reset polarizations, nearly pure qubits should be achievable.

Childhood cancer in Ireland: a population-based study

BACKGROUND

Population-based studies of childhood cancer incidence, survival and mortality make an important contribution to monitoring the successful implementation of new treatment guidelines and to understanding the epidemiology of these diseases.

METHODS

We analysed incidence and survival data for cancers diagnosed in children under 15 years of age in the Republic of Ireland during 1994-2000 (the first 7 years of National Cancer Registry coverage), and longer term mortality trends.

RESULTS

World age-standardised incidence rates in Ireland averaged 142 cases per million children per year, slightly higher than the European average and slightly lower than the US average, although differences varied by diagnostic group. Observed 5-year survival in Ireland (79% overall) was slightly higher than European and US averages, and was significantly higher for acute non-lymphocytic leukaemia (67%) and (compared with the USA) significantly lower for Hodgkin lymphoma (83%). No significant increases in incidence rates were evident from the available 7 years' data, either overall or for particular diagnostic groups. Rates of childhood cancer mortality have declined markedly since the 1950s.

CONCLUSIONS

Data presented here are in line with other developed countries and suggest major improvements in treatment and consequent survival.

An evaluation of selected global (Q)SARs/expert systems for the prediction of skin sensitisation potential

Skin sensitisation potential is an endpoint that needs to be assessed within the framework of existing and forthcoming legislation. At present, skin sensitisation hazard is normally identified using in vivo test methods, the favoured approach being the local lymph node assay (LLNA). This method can also provide a measure of relative skin sensitising potency which is essential for assessing and managing human health risks. One potential alternative approach to skin sensitisation hazard identification is the use of (Quantitative) structure activity relationships ((Q)SARs) coupled with appropriate documentation and performance characteristics. This represents a major challenge. Current thinking is that (Q)SARs might best be employed as part of a battery of approaches that collectively provide information on skin sensitisation hazard. A number of (Q)SARs and expert systems have been developed and are described in the literature. Here we focus on three models (TOPKAT, Derek for Windows and TOPS-MODE), and evaluate their performance against a recently published dataset of 211 chemicals. The current strengths and limitations of one of these models is highlighted, together with modifications that could be made to improve its performance. Of the models/expert systems evaluated, none performed sufficiently well to act as a standalone tool for hazard identification.

Have we stopped looking for a red reflex in newborn screening?

Best medical evidence indicates that surgical treatment of significant congenital cataracts is required within the first 3 months of life for optimal visual outcome. The aim of the present study was to review when the diagnosis of congenital cataracts was made in our region, by whom it was made, and the visual outcome at 2 years of age or more. This was a retrospective study in a region with a population of 546,000 and approximately 8500 births per annum, served by a single Regional Ophthalmology centre. All children under 15 years, diagnosed with Congenital Cataract over a 10-year period (1991-2002), were identified using the Hospital In-Patient Enquiry [HIPE] database. Children with cataract(s) from infancy from a congenital cause and those first presenting outside infancy but with salient clinical features indicating early cataract were included in the study. 27 cases of congenital and infantile cataract 15 (56%) males, 12 (44%) females were retrieved. 17 infants (63%) were diagnosed with bilateral disease, while the remainder were unilateral 10 (37%). Most of the cases 17 (63%) were diagnosed following presentation with parental/carer concerns about visual function (usually a squint). However only 2 of these 17 cases presented before 3 months of age. The remaining cases of congenital cataracts were diagnosed by general practitioners 8 (24%), paediatricians 4 (12%), ophthalmologists 3 (9%) or School Medical Officer (1, 3%). No case of congenital cataract was diagnosed by newborn screening examination. Six of 8 infants diagnosed with congenital cataracts before three months of age had a good visual outcome, (visual acuity < 6/24 at 2 years or more). In contrast only 3 of 19 cases who were diagnosed after 3 months of age had good visual outcomes. Despite their relative rarity, it is imperative that congenital cataracts are diagnosed and treated within 3 months of birth. The onus of diagnosis rests with newborn screening examiners at birth and with general practitioners at the 6-8 week checks. Parental concerns about a possible squint should be addressed by performing a red light reflex examination and urgent specialist ophthalmological referral if a flaw is detected.

Understanding the role of the qualified professional: a comparison of medical and dental students' attitudes

The Royal College of Physicians & Surgeons of Canada developed a competency framework to assist future specialists in responding to challenges as health care providers. The CANMEDs project described 7 essential roles of Specialist Physicians include Health Advocate, Manager, Scholar, Medical Expert, Professional, Communicator and Collaborator (HMSEPC(2)). The object of the current study was to investigate whether medical students and dental students in Ireland recognised these responsibilities as essential to a qualified doctor/dentist.

METHODS

Ninety-eight medical and forty-six dental students (year 1 and year 4) were asked to mind map the responsibilities of qualified doctors/dentists. The comments on the mind map were applied to one of the 7 CANMED roles. There were 484 comments from 128 students. Students had the greatest number of responses referring to the Medical and Dental Expert (257, 30.4%) and Professional (227, 26.9%) roles. This was followed by Communicator (130, 15.4%), Scholar (107, 12.7%) and Health Advocate (82, 9.7%) roles. There were relatively few responses relating to Manager (12, 1.4%) and Collaborator (i.e. teamwork) roles (30, 3.6%). There were no differences in responses between Dental Students and Medical Students and between 1 st year and 4th year students. Similarly there were no differences between the responses of Irish students (n =95; 68%) and International students (n =45; 32%) Students are aware of their responsibilities as Medical or Dental experts (diagnostic and therapeutic skills) for ethical and effective patient care (professional role). They are somewhat aware of the Communicator (therapeutic relationships and effective listening), Scholar (personal continuing education strategies) and Health Advocate (contribute to improved community health) roles. In general they have little concept of the importance of Management skills (utilising resources effectively), and of Collaboration (teamwork and consulting effectively with other physicians and health care professionals). Medical and Dental Educators and Curriculum Committees should address these important deficiencies.

Benchmarking quantum control methods on a 12-qubit system

In this Letter, we present an experimental benchmark of operational control methods in quantum information processors extended up to 12 qubits. We implement universal control of this large Hilbert space using two complementary approaches and discuss their accuracy and scalability. Despite decoherence, we were able to reach a 12-coherence state (or a 12-qubit pseudopure cat state) and decode it into an 11 qubit plus one qutrit pseudopure state using liquid state nuclear magnetic resonance quantum information processors.

Characterization of complex quantum dynamics with a scalable NMR information processor

We present experimental results on the measurement of fidelity decay under contrasting system dynamics using a nuclear magnetic resonance quantum information processor. The measurements were performed by implementing a scalable circuit in the model of deterministic quantum computation with only one quantum bit. The results show measurable differences between regular and complex behavior and for complex dynamics are faithful to the expected theoretical decay rate. Moreover, we illustrate how the experimental method can be seen as an efficient way for either extracting coarse-grained information about the dynamics of a large system or measuring the decoherence rate from engineered environments.

Experimental implementation of heat-bath algorithmic cooling using solid-state nuclear magnetic resonance

The counter-intuitive properties of quantum mechanics have the potential to revolutionize information processing by enabling the development of efficient algorithms with no known classical counterparts. Harnessing this power requires the development of a set of building blocks, one of which is a method to initialize the set of quantum bits (qubits) to a known state. Additionally, fresh ancillary qubits must be available during the course of computation to achieve fault tolerance. In any physical system used to implement quantum computation, one must therefore be able to selectively and dynamically remove entropy from the part of the system that is to be mapped to qubits. One such method is an 'open-system' cooling protocol in which a subset of qubits can be brought into contact with an external system of large heat capacity. Theoretical efforts have led to an implementation-independent cooling procedure, namely heat-bath algorithmic cooling. These efforts have culminated with the proposal of an optimal algorithm, the partner-pairing algorithm, which was used to compute the physical limits of heat-bath algorithmic cooling. Here we report the experimental realization of multi-step cooling of a quantum system via heat-bath algorithmic cooling. The experiment was carried out using nuclear magnetic resonance of a solid-state ensemble three-qubit system. We demonstrate the repeated repolarization of a particular qubit to an effective spin-bath temperature, and alternating logical operations within the three-qubit subspace to ultimately cool a second qubit below this temperature. Demonstration of the control necessary for these operations represents an important step forward in the manipulation of solid-state nuclear magnetic resonance qubits.

Pharmacokinetics and pharmacodynamics of pantoprazole in clinically normal neonatal foals

REASONS FOR PERFORMING STUDY

Proton pump inhibitors (PPIs) are a mainstay of treatment for acid-related ulceration in man and horses. Currently, only an oral preparation of omeprazole is approved for use in horses in the USA. Intravenous administration of a PPI would provide a useful therapeutic alternative for those foals in which oral medication is not feasible.

OBJECTIVE

To investigate the pharmacokinetics and pharmacodynamics of pantoprazole following i.v. or intragastric administration in healthy neonatal foals.

METHODS

Seven healthy foals age 6-12 days at the start of the study were evaluated. Treatments included no drug administration, i.v. pantoprazole (1.5 mg/kg bwt) and intragastric pantoprazole (1.5 mg/kg bwt). Intragastric pH was recorded for 24 h after drug administration for pharmacodynamic evaluation. Plasma pantoprazole concentrations were measured using high-performance liquid chromatography.

RESULTS

Plasma concentrations of pantoprazole were detectable at the 5 min sampling point following i.v. or intragastric administration. Bioavailability of intragastric-administered pantoprazole was 41%. Baseline mean hourly pH was 1.5-6.1. There was a statistically significant increase in mean hourly pH relative to untreated foals 2-24 h after i.v. or intragastric pantoprazole administration.

CONCLUSIONS

Based on these data, i.v. or intragastric administration of pantoprazole results in a significant, prolonged increase in intragastric pH.

POTENTIAL RELEVANCE

The i.v. formulation of pantoprazole may provide a clinically useful alternative means of acid suppression in foals unable to tolerate enteral administration of a PPI, such as those with pyloric outflow obstruction.

Nondiarrheal Disorders of the Gastrointestinal Tract in Neonatal Foals

Neonates can have a variety of gastrointestinal disorders, primary and secondary in nature. Important primary disorders include con-genital abnormalities and meconium retention. One of the most important secondary lesions is generalized ileus. Gastric ulceration can occur as a primary or secondary event. This article addresses the pathophysiology, diagnosis, and treatment of gastrointestinal problems commonly observed in neonatal foals.

Sex work, drug use, HIV infection, and spread of sexually transmitted infections in Moscow, Russian Federation

Rates of HIV-1 infection are growing rapidly, and the epidemic of sexually transmitted infections is continuing at an alarming rate, in the Russian Federation. We did a cross-sectional study of sexually transmitted infections, HIV infection, and drug use in street youth at a juvenile detention facility, adults at homeless detention centres, and women and men at a remand centre in Moscow. 160 (79%) women at the remand centre were sex workers. 91 (51%) homeless women had syphilis. At least one bacterial sexually transmitted infection was present in 97 (58%) female juvenile detainees, 120 (64%) women at the remand centre, and 133 (75%) homeless women. HIV seroprevalence was high in women at the remand centre (n=7 [4%]), adolescent male detainees (5 [3%]), and homeless women (4 [2%]). In view of the interaction between sexually transmitted infections and HIV infection, these findings of high prevalence of sexually transmitted infections show that these disenfranchised populations have the potential to make a disproportionately high contribution to the explosive growth of the HIV epidemic unless interventions targeting these groups are implemented in the Russian Federation.

Octadecanoid-derived signals in plants

Signalling pathways that regulate the expression of plant genes are poorly understood. Recent evidence indicates that octadecanoid-derived signals may be parts of signalling pathways in plants in which C(18) fatty acids, liberated from membranes in response to environmental or developmental cues, are converted to intracellular signalling molecules such as jasmoric acid and traumatin. These events are analogous to prostaglandin and leukotriene synthesis in animals.

Comparison of three manual ventilation devices using an intubated mannequin

OBJECTIVE

To compare three devices for manual neonatal ventilation.

DESIGN

Participants performed a two minute period of ventilation using a self inflating device, an anaesthesia bag with attached manometer, and a Neopuff device. An intubated neonatal mannequin, approximating a 1 kg infant with functional lungs, was used for the study. Target ventilation variables included a rate of 40 breaths per minute, peak inspiratory pressure (PIP) of 20 cm H2O, and positive end expiratory pressure (PEEP) of 4 cm H2O. The circuit was attached to a laptop computer for data recording.

RESULTS

Thirty five participants were enrolled, including consultant neonatologists, paediatricians, and anaesthetists, paediatric and anaesthetic registrars, and neonatal nurses. The maximum PIP recorded using the self inflating bag, anaesthetic bag, and Neopuff device were 75.9, 35.5, and 22.4 cm H2O respectively. There were significant differences between the devices for mean PIP (30.7, 18.1, and 20.1 cm H2O), mean PEEP (0.2, 2.8, and 4.4 cm H2O), mean airway pressure (7.6, 8.5, and 10.9 cm H2O), % total breaths < or = 21 cm H2O PIP (39%, 92%, and 98%), and % total breaths > or = 30 cm H2O PIP (45%, 0, and 0). There was no difference between doctors and allied health professionals for the variables examined.

CONCLUSION

The anaesthetic bag with manometer and Neopuff device both facilitate accurate and reproducible manual ventilation. Self inflating devices without modifications are not as consistent by comparison and should incorporate a manometer and a PEEP device, particularly when used for resuscitation of very low birthweight infants.