New Australian Neonatal Resuscitation Guidelines

New Australian Neonatal Resuscitation Guidelines highlight the recent advances in neonatal resuscitation. Resuscitation should start with air and only use oxygen if the infant does not respond. CPAP and PEEP should be considered for premature infants with meconium stained liquor. Sucking out the mouth and nose is not necessary. Infants less than 28 weeks gestation should be placed in a polyethylene bag or wrap to keep warm. Chest compressions, when required, remain at 3:1 inflation. The endotracheal tube position must be verified with a carbon dioxide detector.

A study of piglets born by spontaneous parturition under uncontrolled conditions: could this be a naturalistic model for the study of intrapartum asphyxia?

In order to evaluate how spontaneously born piglets could be a suitable model for the study of intrapartum hypoxia, 230 newborn piglets were studied. Out them, 8.3% (n = 19) died intrapartum, 21.7% (n = 50) were born with moderate-to-severe intrapartum hypoxia, and 70% (n = 161) were born with mild or no evidence of intrapartum distress. Piglets born without any evidence of intrapartum asphyxia weighed approximately 240 g lower than those born with intrapartum hypoxia and intrapartum-dead piglets (P<0.0001). The viability score was approximately 3 units lower and the latency to contact the udder was two times longer in the piglets surviving intrapartum hypoxia than in controls (P <0.0001). In comparison with the control group, metabolic acidosis was most severe among intrapartum-dead piglets followed by piglets surviving intrapartum asphyxia (P =0.002). According to a multiple linear regression analysis, pCO2 and lactate blood levels, and birth weight were identified as explanatory variables of viability score (r: 0.78; P <0.001). Viability score, K+ and lactate blood levels, and birth weight were identified as explanatory variables of latency to contact the udder (r: 0.80; P <0.001). In conclusion, the spontaneously-born asphyxiated piglet could be considered as a naturalistic model for the study of intrapartum asphyxia. Histopathologic and more rigorous functional and behavioral evaluations are still required to further characterize the model. (www.actabiomedica.it)

Animal responses to extreme conditions: a lesson to biomedical research

Various animals must cope with some specific extreme environmental conditions and, as a consequence, they developed extremely efficacious adaptive defence responses. The mechanisms of the specific defences are more clearly visible in some species than in humans. Therefore, animal models of the human defence mechanisms should be selected accordingly. The appropriate, well responding models may be regarded as "biological amplifiers". This review is focussed on examples of effective defence against: (i) parturitional asphyxia, which extends fertility of mammals; (ii) diving asphyxia, which extends access of food in aquatic birds and mammals; (iii) endotoxemia, which provides survival of the fittest in mammals showing top fertility; (iv) deep hypothermia, which enables hibernating mammals to arouse. Each of the defences needs close co-operation of the cardiovascular, respiratory and temperature regulatory systems. Underlined problems regarding a choice of appropriate experimental animal models should stimulate renaissance of comparative physiology.

Diagnosis of acute foetal distress does not preclude banking of umbilical cord blood units

Clinical diagnosis of acute foetal distress (AFD) is based on several parameters such as abnormal foetal heart rate (FHR) pattern and/or meconium liquid staining (MLS). Standards for cord blood (CB) banking indicate that AFD should be considered as exclusion criteria for CB collection, but precise guidelines on how to proceed with CB collection in the presence of AFD signs during labour are not available. We evaluated whether the presence of FHR abnormality and/or MLS during labour 1) reduced the CB collection activity; 2) were associated with the infant's acidaemia or asphyxia and 3) deteriorated the biological characteristics of CB units. Thirty-three units of CB were evaluated for biological parameters, gas values and newborn's Apgar score. The results were compared with a control group of 33 consecutive units previously banked. No differences were observed between the two groups and all but one newborn showed normal Apgar score and absence of metabolic acidaemia. The results showed that 1) AFD reduced the CB collection activity by 10% each year; 2) the majority of CB units collected in the presence of abnormal FHR and/or meconium have biological characteristics eligible for banking; 3) FHR alterations or meconium in the presence of normal gas analysis do not represent certain diagnosis of AFD.

Indicadores de saúde materno infantil em Belo Horizonte, Minas Gerais, Brasil, 2001: análise dos diferenciais intra-urbanos

A análise espacial de indicadores de saúde tem sido um importante instrumento na detecção de diferenciais intra-urbanos. O estudo objetivou traçar um perfil dos nascimentos em Belo Horizonte, Minas Gerais, Brasil, em 2001, analisando a presença de conglomerados espaciais de indicadores de saúde do recém-nascido e suas mães, a partir de dados do Sistema de Informações sobre Nascidos Vivos. Para cada área de abrangência das Unidades Básicas de Saúde, foram calculadas as proporções desses indicadores, utilizando-se o método Bayesiano empírico. Para análise espacial, foram utilizados os índices de Moran global e local (LISA). Áreas com índices de autocorrelação espacial significantes (p < 0,05) foram visualizadas através de mapas. Foram encontrados conglomerados de áreas com índices de autocorrelação espacial significativos para os indicadores adolescentes, menos de oito anos de estudo, filhos mortos em gestações anteriores, cesárea e menos de quatro consultas no pré-natal, guardando relação com as características sócio-demográficas das áreas. A metodologia utilizada configurou-se como um ótimo instrumento de detecção de conglomerados de áreas de risco à saúde materno infantil, podendo facilmente ser incorporada como mecanismo de monitoramento dos eventos relacionados aos nascimentos em Belo Horizonte.

Roles of medical consultants and expert witnesses in cerebral palsy litigation: a review

What is the role of the medical consultant and expert witness during the litigation process associated with cerebral palsy (CP)? To address this question, a review was undertaken of the world literature published on CP between 1861 and 2004. The appropriate Medical Subject Heading terms were selected and used in a search of the MEDLINE, ACOGNET and Cochrane Library databases. Also, a manual search was performed. A total of 3,168 articles on CP were reviewed. Of them, 143 met the inclusion/exclusion criteria. Analysis of the pertinent articles revealed that this is the first article to address the role of the medical consultant. The literature on CP is predominantly observational studies. At best, they can be qualified as grade C in the ranking of evidence-based medicine. A clinical study on CP cannot be well designed methodologically because of ethical and technical problems. There is no literature available to determine the role of the consultant in CP cases. The appraisal of suboptimal obstetric care should not be omitted or dismissed when present. Preconceived conclusions about causation based simply on the poor outcome of a child should be avoided. A well-documented hypoxic-ischemic brain insult during the antenatal period does not automatically exclude intrapartum suboptimal obstetric care. Lack of uniformity in policies among U.S. hospitals on umbilical cord and newborn blood gas analysis (<1 hour of neonatal life), fetal membrane microbiologic cultures and placental histology creates difficult tasksfor medicolegal reviewers. Lack of vital diagnostic elements will limit the objectivity of a consultant and expert witness. The human emotional aspect plays a significant role in reaching a jury verdict for plaintiffs, regardless of the weakness of a case.

The Hippocampal Role in Spatial Memory and the Familiarity-Recollection Distinction: A Case Study

Memory for object locations and for events (comprising the receipt of an object) was tested in a case of developmental amnesia with focal hippocampal damage. Tests used virtual reality environments and forced-choice recognition with foils chosen to equalize the performance of control participants across conditions. Memory for the objects received was unimpaired, but the context of their receipt was forgotten. Memory for short lists of object locations was unimpaired when tested from the same viewpoint as presentation but impaired when tested from a shifted viewpoint. Same-view performance was disrupted by changing the background scene. These results are consistent with Jon having preserved matching to fixed sensory-bound representations but impaired reconstructed or manipulable representations underlying shifted-viewpoint recognition and episodic recollection.

Chorioamnionitis and cerebral palsy in term and near-term infants

CONTEXT

Half of all cases of cerebral palsy (CP) occur in term infants, for whom risk factors have not been clearly defined. Recent studies suggest a possible role of chorioamnionitis.

OBJECTIVE

To determine whether clinical chorioamnionitis increases the risk of CP in term and near-term infants.

DESIGN, SETTING, AND PATIENTS

Case-control study nested within a cohort of 231 582 singleton infants born at 36 or more weeks' gestation between January 1, 1991, and December 31, 1998, in the Kaiser Permanente Medical Care Program, a managed care organization providing care for more than 3 million residents of northern California. Case patients were identified from electronic records and confirmed by chart review by a child neurologist, and comprised all children with moderate to severe spastic or dyskinetic CP not due to postnatal brain injury or developmental abnormalities (n = 109). Controls (n = 218) were randomly selected from the study population.

MAIN OUTCOME MEASURE

Association between clinical chorioamnionitis and increased risk of CP in term and near-term infants.

RESULTS

Most CP cases had hemiparesis (40%) or quadriparesis (38%); 87% had been diagnosed by a neurologist and 83% had undergone neuroimaging. Chorioamnionitis, considered present if a treating physician made a diagnosis of chorioamnionitis or endometritis clinically, was noted in 14% of cases and 4% of controls (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.5-10.1; P =.001). Independent risk factors identified in multiple logistic regression included chorioamnionitis (OR, 4.1; 95% CI, 1.6-10.1), intrauterine growth restriction (OR, 4.0; 95% CI, 1.3-12.0), maternal black ethnicity (OR, 3.6; 95% CI, 1.4-9.3), maternal age older than 25 years (OR, 2.6; 95% CI, 1.3-5.2), and nulliparity (OR, 1.8; 95% CI, 1.0-3.0). The population-attributable fraction of chorioamnionitis for CP is 11%.

CONCLUSION

Our data suggest that chorioamnionitis is an independent risk factor for CP among term and near-term infants.

Using the Nordic-Baltic perinatal death classification to assess perinatal care in Ukraine

OBJECTIVE

To identify health care issues important to reduce the perinatal mortality rate (PMR) in Ukraine.

STUDY DESIGN

Perinatal deaths in the Donetsk region (Ukraine) in 1997-1998 were compared with those in Denmark in 1996 by using the Nordic-Baltic classification for perinatal deaths. Clinical guidelines, use of technology and rates of interventions in the two regions were described.

RESULTS

A two-fold increase in PMR was found in Ukraine compared to Denmark, mainly explained by higher rates of antenatal deaths of growth restricted fetuses, intrapartum deaths, and neonatal deaths due to asphyxia. Vacuum extraction is rarely used in Ukraine. The clinical guidelines for care differ significantly between the two regions.

CONCLUSION

Appropriate use of technology and implementation of evidence-based guidelines should be a matter of high priority in the Donetsk region, Ukraine.

Deciding for imperilled newborns: medical authority or parental autonomy?

The ethical issues around decision making on behalf of infants have been illuminated by two empirical research studies carried out in Scotland. In-depth interviews with 176 medical and nursing staff and with 108 parents of babies for whom there was discussion of treatment withholding/withdrawal, generated a wealth of data on both the decision making process and the management of cases. Both staff and parents believe that parents should be involved in treatment limitation decisions on behalf of their babies. However, whilst many doctors and nurses consider the ultimate responsibility too great for families to carry, the majority of parents wish to be the final arbiters. We offer explanations for the differences in perception found in the two groups. The results of these empirical studies provide both aids to ethical reflection and guidance for clinicians dealing with these vulnerable families. They demonstrate the value of empirical data in the philosophical debate.

Importance of hypoxic/ischemic conditions in the development of cerebral lenticulostriate vasculopathy

BACKGROUND

We have observed many infants with lenticulostriate vasculopathy (LSV) on neurosonograms who do not have classic histories of prenatal infection, trisomy, or prenatal drug exposure.

OBJECTIVE

To investigate the underlying clinical conditions in patients with LSV.

MATERIALS AND METHODS

Sixty-three cases of LSV were identified among approximately 2,400 neurosonograms performed over 42 months. All neurosonograms were reviewed. Medical records were reviewed for information regarding prenatal infection, chromosomal abnormality, respiratory and cardiac disease, and other pertinent diagnoses.

RESULT

Hypoxic/ischemic conditions accounted for 33 cases: cardiac disease in 13, respiratory distress syndrome in 15, and perinatal asphyxia in 5. Twelve of these 33 had initially normal or minimal findings, with LSV developing or progressing on subsequent neurosonograms. The remaining 30 cases had varied clinical associations: congenital infection in 5, trisomies in 9, fetal substance exposure in 4, and unclear etiology in 12. Coexistent anomalies included posterior urethral valves, MCDK, myelomeningocele, placental abruption, and others. Thirty patients were premature. Fifteen patients died; histologic changes of LSV were found at autopsy in one patient.

CONCLUSION

LSV has varied clinical associations. The common association with hypoxic/ischemic conditions and the progressive changes seen in 12 patients with cardiac and pulmonary disease suggest that postnatal hypoxia/ischemia is an important etiologic factor.

Fetal heart rate monitoring: is it salvageable?

Fetal heart rate monitoring was introduced in the 1960s. After a number of randomized controlled trials in the mid 1980s, doubt arose regarding the efficacy of fetal heart rate monitoring in improving fetal outcome. The potential reasons why fetal heart rate monitoring has not been shown to be efficacious are (1) use of an outcome measure that is not related to variant fetal heart rate monitoring patterns, (2) lack of standardized interpretation of fetal heart rate patterns, (3) disagreement regarding algorithms for intervention of specific fetal heart rate patterns, and (4) the inability to demonstrate the reliability, validity, and ability of fetal heart rate monitoring to allow timely intervention. A recent National Institutes of Health committee proposed detailed, quantitative, standardized definitions of fetal heart rate patterns, which can serve as a basis for determining whether fetal heart rate monitoring is reliable and valid. In this article we examine reasons why fetal heart rate monitoring did not live up to its original expectations and why the randomized controlled trials did not demonstrate efficacy, and we make suggestions for determining whether electronic fetal heart rate monitoring should be abandoned.

Homologous bone graft for expansion thoracoplasty in Jeune's asphyxiating thoracic dystrophy

Adult tibial shaft from a bone graft bank was used as a solid homologous bone graft for midsternal expansion thoracoplasty in an infant with Jeune's asphyxiating thoracic dystrophy. The technique appeared successful, but the child grew out of her chest in her second year of life. Expansion thoracoplasty for Jeune's disease probably should only be reserved for children who survive their first year of life without major surgery.