Pontine hypoplasia in Carey-Fineman-Ziter (CFZ) syndrome

We describe an infant with multiple congenital anomalies including cleft palate and micrognathia, Möbius sequence, developmental delay, myopathy, hydronephrosis, and bilateral clubfeet. These features are consistent with Carey-Fineman-Ziter (CFZ) syndrome (MIM 254940), which has been previously reported in six children (including two sibling pairs). Cranial magnetic resonance imaging (MRI) revealed an unusually small pons, a finding not previously described in CFZ syndrome.

Advising parents about children's participation in clinical research

The pediatrician can assist a parent in evaluating the risks and potential benefits of clinical research, assessing the qualifications of the research team, clarifying a child's understanding of the research, and supporting the parent and child throughout the research study. To perform this role, the pediatrician should review with the parent and child (if appropriate) the consent document and any other available information about the research. If there are unanswered questions, the pediatrician should encourage a parent to contact the researcher, or offer (with the parent's permission) to contact the researchers on the parent's behalf.

Exception from informed consent for pediatric resuscitation research: community consultation for a trial of brain cooling after in-hospital cardiac arrest

OBJECTIVES

When prospective informed consent is not feasible, clinical research that presents more than minimal risk can proceed only after a community consultation and public disclosure process and the granting of exception from informed consent from the federal government. The applicability of exception from informed consent to pediatric resuscitation research has not been described. The objectives of this study were 1) to perform a community consultation and public disclosure process specific to a trial of induced hypothermia immediately after pediatric cardiac arrest and 2) to determine the applicability of exception from informed consent to randomized, controlled trials of emergency interventions after resuscitation from inpatient pediatric cardiac arrest.

METHODS

Focus groups, information sheets with options for written responses, posted notices, e-mails, and telephone conversations with parents of critically ill children and hospital staff were conducted at a tertiary care children's hospital. Data were stored, organized, and retrieved using NVivo qualitative analysis software (QSR International).

RESULTS

In focus groups (n = 8), parents (n = 23) and hospital staff (n = 33) concluded that prospective informed consent is not feasible for a trial of induced hypothermia after inpatient pediatric cardiac arrest. Focus group participants endorsed exception from informed consent for a trial of induced hypothermia but only if study information is easily available prospectively and if all parents have an explicit opportunity to decline participation in a verbal conversation before study enrollment. Separate from and without knowledge of the focus group results, 7 (100%) of 7 parents of past or current patients and 21 (50%) of 42 hospital staff who provided written opinions endorsed exception from informed consent for this study. Five (12%) of 42 hospital staff opposed, and 16 (38%) of 42 were neutral. In telephone conversations, 14 (70%) of 20 parents of children who were previously resuscitated from cardiac arrest endorsed exception from informed consent for this study, 3 (15%) of 20 opposed, and 3 (15%) of 20 were unsure.

CONCLUSIONS

Community consultation for inpatient resuscitation research can be conducted in a children's hospital, with hospital staff and parents of patients as the relevant community. Exception from informed consent is necessary and appropriate for a randomized trial of induced hypothermia begun within 30 minutes after pediatric cardiac arrest. A process in which families are informed prospectively and have a pre-enrollment option to decline participation will likely be acceptable to families, health care providers, and the institution.

Neuronal conduction studies of the median nerve in non-impaired humans: a comparison of accepted techniques

BACKGROUND AND PURPOSE

There are two commonly accepted techniques used for distal electro-stimulation placement when performing median motor nerve conduction studies. The purpose of this study was to compare latency using two commonly accepted sites of distal stimulation of the median nerve when performing motor nerve conduction studies on non-impaired adult humans.

PARTICIPANTS

The sample consisted of 36 non-impaired participants (15 female, 21 male) aged 20 to 40 years.

METHODS

Participants were randomly assigned to two groups and tested bilaterally for the median motor nerve. For distal stimulation of the median motor nerve, in the first group, 8 cm was measured from the center of the muscle diagonally to arrive at a point between the flexor carpi radialis and plamaris longus tendons. In the second group, 3.5 cm was measured from the distal wrist crease proximally along the median nerve for the distal stimulation of the median motor nerve. Distal latency of both techniques was obtained. Surface skin temperature of the palm was recorded throughout the procedures.

RESULTS

No significant differences were found between the 8 cm and 3.5 cm techniques at p < or = 0. 05 level.

COMMENT

Even though no differences were found between the two techniques, the 3.5-cm technique is recommended because of its consistency as an anatomical landmark reducing the potential for measurement error.

Certificates of Confidentiality in Research: Rationale and Usage

Certificates of confidentiality (COCs) are a tool to protect researchers from being compelled to release identifying information about their subjects. Whereas institutional review board (IRB) review and informed consent procedures are mandatory tools to protect human subjects, COCs are voluntary. There are limited data about who procures COCs and why, and whether they are useful. Three Institutes of the National Institutes of Health (NIH) provided data on 114 research projects that had received COCs. Eighty-three researchers had procured a single COC and 11 researchers had procured 31 COCs. One hundred and four (91%) of the COCs were obtained by researchers at academic sites, and 17 institutions collectively accounted for 82 COCs. The most commonly cited sources of information about COCs came from colleagues (n = 18, 35%) and previous experience (n = 17, 33%). The most common reasons for procuring a COC were that the research involved genetics (n = 28, 54%), the research could lead to social stigmatization or discrimination (n = 22, 42%), or the research could damage an individual's financial standing, employability, or reputation (n = 21, 40%). These findings show that COCs are often congregated within institutions and by particular individuals. This may be because others are unaware of COCs or because others do not believe they are necessary or useful.

Parental decision-making in congenital heart disease

OBJECTIVE

To explore whether prenatal diagnosis of congenital heart disease is associated with lower levels of parental distress and greater satisfaction with decisions about cardiothoracic surgery when compared to postnatal diagnosis.

METHODOLOGY

A combined quantitative-qualitative design was used. Participants included the parents of 31 neonates (30 mothers and 22 fathers) admitted to the cardiac intensive care unit between 1 November 2001 and 1 May 2002 for repair of congenital cardiac malformations. Participants completed self-report measures of anxiety, optimism, and life events pre-operatively, and semi-structured qualitative interviews assessing satisfaction with decision-making within 1 week of the operation.

RESULTS

At the time of surgery, mothers of neonates receiving the diagnosis prenatally did not differ from mothers of neonates receiving the diagnosis postnatally on measures of anxiety, optimism, and life events. Fathers of neonates receiving the diagnosis prenatally, however, reported more optimism, lower state and trait anxiety, and fewer negative life events than fathers of neonates receiving the diagnosis postnatally. When we analyzed the interviews, we found that, regardless of the timing of the diagnosis, parents felt as though they made a genuine choice for their baby to have surgery.

CONCLUSIONS

In this pilot study, fathers who learned prenatally that their child had a congenital cardiac malformation were less distressed than those who discovered this fact only postnatally. From the parental perspective, nonetheless, distress and urgency do not impair their ability to make decisions about neonatal cardiac surgery.

Comparison of motor unit action potentials using monopolar vs. concentric needle electrodes in the middle deltoid and abductor digiti minimi muscles

Electromyography readings are analyzed noting abnormalities in the parameters of amplitude, duration, and number of phases. Previous studies have demonstrated variability between monopolar needle electrodes (MNEs) and concentric needle electrodes (CNEs) in regard to the above parameters. We hypothesized that a difference in measured parameters would be observed due to the physical differences between the needles. Twenty-three subjects participated in this study. Five readings were recorded from the middle deltoid and the abductor digiti minimi muscles using the MNE, and five readings were recorded using the CNE. A minimal isometric contraction of the tested muscle in the subjects dominant arm was performed. A significant difference was found in amplitudes recorded by the MNE and CNE in both muscles. A significant difference was found in the ADM, and not in the deltoid, with regard to duration. The difference found in the number of phases was clinically insignificant.

DISCUSSION

The MNE detected larger amplitudes and durations because of its larger recording territory. The duration may also be affected by the distance between the active/reference electrodes.

Comparison of motor unit action potential characteristics and hand dominance using monopolar needle electrodes in the abductor pollicis brevis and abductor digiti minimi muscles

This study examined specific electrical characteristics of voluntary single motor unit action potentials (SMUAPs): amplitude, duration, phase change, and rate of rise. These characteristics, which were detected from two intrinsic muscles of the hand--the abductor pollicis brevis and the abductor digiti minimi--were compared to hand dominance. Forty subjects participated in the study. Five characteristics were detected from each muscle using the quadrant technique while the subject produced a minimal isometric contraction. Based on results of an ANOVA [two-factor with replication] test, our study revealed no significant difference between muscles in the dominant and non-dominant hands. Descriptive statistics for each muscle characteristic are presented. This study has identified parameters for SMUAP characteristics detected in non-impaired individuals ranging in age from 20 to 43 years. The normative parameters serve as a valuable base from which one may examine potential neuronal damage from cumulative trauma disorders.

Child assent and parental permission in pediatric research

Since children are considered incapable of giving informed consent to participate in research, regulations require that both parental permission and the assent of the potential child subject be obtained. Assent and permission are uniquely bound together, each serving a different purpose. Parental permission protects the child from assuming unreasonable risks. Assent demonstrates respect for the child and his developing autonomy. In order to give meaningful assent, the child must understand that procedures will be performed, voluntarily choose to undergo the procedures, and communicate this choice. Understanding the elements of informed consent has been the paradigm for assessing capacity to give assent. This method leaves the youngest, least cognitively mature children vulnerable to waiver of assent and forced research participation. Voluntariness can also be compromised by the influence of authority figures who can exert undue influence and coerce children to participate in research. This paper discusses factors that may influence the decision to give assent/permission, potential parent-child conflict in the assent/permission process and how it is resolved, and potential parental undue influence on research participation. These issues are illustrated with quotations drawn from a larger qualitative study of parental permission and child assent (data not presented). We suggest a developmental approach, viewing assent as a continuum ranging from mere affirmation in the youngest children to the equivalent of the informed consent process in the mature adolescent.

Voluntariness of consent for research: an empirical and conceptual review

This article explores the vulnerability of research subjects either to undue influence or to coercion. The authors present a brief review of the requirement for voluntariness in research, and what is known about research participation. They then examine characteristics of potential subjects, researchers, researcher actions, and the research setting that can influence the voluntariness of subject's decisions to participate. Throughout the paper, empirical work that relates to voluntariness is used to illustrate the conceptual material. Voluntariness is viewed as an issue of self-control. Threats to voluntariness can arise from vulnerabilities of potential subjects as well as from characteristics of the researcher, the researcher's acts, and the research setting. Moral concerns about potential influences may be assessed by the likelihood that they will control or dominate a potential subject's decision to participate in research. Policy responses may be appropriate where the probability of control is too high.

Are research ethics standards satisfied in pediatric journal publications?

BACKGROUND

The requirements for institutional review board (IRB) review and informed consent (IC) for research involving human subjects have existed for more than 2 decades. Although many studies document them poorly, most published research undergoes IRB review and has IC procedures. Less is known about research published in pediatric journals, and how child health research is determined to be exempt.

METHOD

All full-length articles published in the paper edition of 3 pediatric journals between January and December 2000 were examined. Articles were excluded if they were case studies, meta-analyses, lacked empirical data, or did not include at least 1 US researcher or US subjects. The remaining articles were examined to determine if they documented IRB review and IC mechanisms. If either or both of these features were missing, authors were asked to participate voluntarily in a survey. In addition, all exempt articles were examined to determine if the exemptions were in accordance with the federal regulations for the protection of human subjects.

RESULTS

Three hundred seventy-nine of 575 articles met inclusion criteria. One hundred ninety-seven (52.0%) documented IRB review, 164 (43.3%) documented IC, and 131 (34.6%) properly documented the presence of both IRB review and IC. Two hundred fifty-one researchers were surveyed to clarify IRB review and/or IC mechanisms. Approximately 13.5% of the research had not undergone IRB review, and 12.4% had not had their consent methods reviewed by an IRB. We found that between 26.9% and 39.8% of exempted research did not meet federal regulations requirements.

CONCLUSIONS

We found that most research underwent IRB review and had a consent mechanism despite the lack of documentation in the articles. We also found that most research that did not undergo IRB review would have been exempt under current guidelines. However, a significant number of IRB- and researcher-exempted research were inappropriately classified. Improving research ethics standards will require additional education for researchers and IRB members, and greater adherence of researchers (and editors) to the journals' guidelines on these issues.

Multicenter analysis of platelet transfusion usage among neonates on extracorporeal membrane oxygenation

OBJECTIVE

Multiple platelet transfusions are invariably given to neonates on extracorporeal membrane oxygenation (ECMO), and no alternative to repeated transfusions exists. Before any alternatives, such as administration of thrombopoietic stimulators, could be contemplated, data regarding the number of platelet transfusions received by neonatal ECMO patients is needed, and the mechanisms that cause the thrombocytopenia of these patients must be better defined. As a step toward determining this, we analyzed the use of platelet transfusions in this group of neonates. We conducted a historic cohort study of neonates who were treated with ECMO to determine the number of platelet units received as a function of 1) days on ECMO, 2) medical diagnosis for which ECMO was instituted, and 3) type of ECMO used (venovenous [VV] vs venoarterial [VA]).

METHODS

We reviewed the hospital records of all neonates who were admitted to the neonatal intensive care units at Shands Children's Hospital, Arnold Palmer Hospital for Children and Women, and Tampa General Hospital and treated with ECMO between January 1, 1995, and June 30, 2000. Data were expressed as the number of platelet transfusions versus number of days on ECMO, diagnosis for which ECMO was instituted, and type of ECMO used.

RESULTS

Of the 234 ECMO patients, 81 were placed on VV, 138 were placed on VA, and 15 were converted from VV to VA. The average number of platelet transfusions received per day was 1.3 and varied by diagnosis and by type of ECMO. Neonates with meconium aspiration and sepsis required more platelet transfusions per day than neonates with other conditions. Infants who were converted from VV to VA required more transfusions per day (mean: 1.57) than did patients on VA (1.47) or VV (1.06).

CONCLUSIONS

Platelet transfusions among neonates on ECMO are dependent of their medical diagnosis; they average 1.3 transfusions per day and are higher on VA than VV ECMO.

Observations of comet 19P/Borrelly by the miniature integrated camera and spectrometer aboard Deep Space 1

The nucleus of the Jupiter-family comet 19P/Borrelly was closely observed by the Miniature Integrated Camera and Spectrometer aboard the Deep Space 1 spacecraft on 22 September 2001. The 8-kilometer-long body is highly variegated on a scale of 200 meters, exhibiting large albedo variations (0.01 to 0.03) and complex geologic relationships. Short-wavelength infrared spectra (1.3 to 2.6 micrometers) show a slope toward the red and a hot, dry surface (</=345 kelvin, with no trace of water ice or hydrated minerals), consistent with approximately 10% or less of the surface actively sublimating. Borrelly's coma exhibits two types of dust features: fans and highly collimated jets. At encounter, the near-nucleus coma was dominated by a prominent dust jet that resolved into at least three smaller jets emanating from a broad basin in the middle of the nucleus. Because the major dust jet remained fixed in orientation, it is evidently aligned near the rotation axis of the nucleus.

Determination of accuracy in neonates for non-invasive blood pressure device using an improved algorithm

BACKGROUND

New software (SuperSTAT(R) algorithm) with enhancements aimed at shorter determination times was developed for a non-invasive blood pressure (NIBP) device and a clinical evaluation was conducted to verify accuracy.

OBJECTIVE

To determine the accuracy of the new algorithm according to ANSI/AAMI SP10-1992 and SP10A-1996 American National Standard for Electronic or Automated Sphygmomanometers.

METHODS

The blood pressure values obtained from the test device were compared to the intra-arterial blood pressure reference standard (IBP).

RESULTS

The NIBP and IBP comparisons for systolic, diastolic, and mean arterial pressure met the 1992 ANSI/AAMI accuracy standards by being within a mean difference of +/- 5 mmHg and standard deviation of < or = 8 mmHg.

CONCLUSION

Non-invasive blood pressure determinations taken with the new algorithm, developed to provide greater patient comfort due to faster determinations, were accurate when compared to neonatal IBP.

Handling ethical conflicts in the clinical setting

Ethical conflict in the clinical setting generally arises in situation of uncertainty, ambiguity, and complexity. This report discusses 4 cases of conflict between clinicians, between clinicians and patient, and between clinicians and family. Presented in enough detail for the reader to appreciate the extent and nature of the conflict, these cases are difficult and in many ways unresolved. Some conflicts may be inevitable and would not be prevented by even the most conscientious clinician. The authors discuss various approaches and resources that may prevent or ameliorate conflict. However, no easy answers are offered, but the importance of open communication of differing viewpoints in an atmosphere of trust and respect are emphasized.

The interaction of AR-A008055 and its enantiomers with the GABA(A) receptor complex and their sedative, muscle relaxant and anticonvulsant activity

AR-A008055 [(+/-)-1-(4-methyl-5-thiazolyl)-1-phenylmethylamine] is structurally related to clomethiazole and has been used to probe the mechanism of the neuroprotective effect of clomethiazole. Clomethiazole, (+/-)-AR-A008055 and (S)-(-)-AR-A008055 all displaced [35S]-t-butyl-bicyclophosphorothionate ([35S]TBPS) from rat cerebral cortex tissue (IC50 values: GABA, 8.1+/-0.04 microM; clomethiazole, 130+/-30 microM; (+/-)-AR-A008055, 494+/-7 microM; (S)-(-)-AR-A008055, 221+/-14 microM. (R)-(+)-AR-A008055 was without significant effect (IC50>1000 microM). None of the compounds interacted with NMDA or AMPA receptors or with sodium or calcium (N, P/Q) channels. Brain penetration of both enantiomers following their i.p. administration was excellent, with brain and plasma concentrations being similar. Clomethiazole dose-dependently inhibited spontaneous locomotor activity in rats and was approximately 10 times more sedative than either enantiomer of AR-A008055. Clomethiazole was more potent than (S)-(-)-AR-A008055 in the "pull-up" test (muscle relaxation) and in producing loss of righting reflex, while (R)-(+)-AR-A008055 had little effect. The time animals remained on a Rota-rod was of the order: clomethiazole<(S)-(-)-AR-A008055<(R)-(+)-AR-A008055. (S)-(-)-AR-A008055 (210 micromol/kg) raised seizure threshold to pentylenetetrazole (i.v.) by 119+/-21%. The (R)-(+)- enantiomer was not anticonvulsant. Overall, (S)-(-)-AR-A008055 exhibited a similar pharmacology to clomethiazole. However, its sedative and muscle relaxant effects were substantially less than clomethiazole, emphasising that these properties are not directly related to neuroprotective efficacy. The current data suggest that the proposed GABA uptake inhibitory property of (R)-(+)-AR-A008055 fails to produce significant sedative, myorelaxant or anticonvulsant activity.

Neuroprotective efficacy of AR-A008055, a clomethiazole analogue, in a global model of acute ischaemic stroke and its effect on ischaemia-induced glutamate and GABA efflux in vitro

We have investigated the neuroprotective properties of AR-A008055 [(+/-)-1-(4-methyl-5-thiazolyl-1-phenyl-methylamine], a novel compound structurally related to clomethiazole. Administration (i.p.) of (+/-)-AR-A008055 60 min after 5 min of global cerebral ischaemia in gerbils produced a dose-dependent protection of the hippocampus from damage. Both enantiomers [(R)-(+)-AR-A008055 and (S)-(-)- AR-A008055] at 600 micromol/kg produced similar protection to that following clomethiazole (600& micromol/kg) and both produced similar and sustained neuroprotection, at 4, 7 and 21 days post-insult. When infused intravenously over a 2-h period, both enantiomers produced concentration-dependent neuroprotection, with the enantiomers providing similar protection at every plasma concentration (50-200 nmol/ml). The efficacy of (S)-(-)-AR-A008055 was similar to clomethiazole, but it was slightly less potent. Ischaemia-induced glutamate efflux from rat brain cortical prisms in vitro was inhibited by both isomers (100 microM). The inhibitory effect of (R)-(+)-AR-A008055 was blocked by bicuculline (10 microM) and picrotoxin (100 microM), while the effect of (S)-(-)-AR-A008055 was only antagonised by picrotoxin. This indicated that (S)-(-)-AR-A008055, like clomethiazole, is able to open the GABA(A)-chloride channel in the absence of endogenous GABA. (R)-(+)-AR-A008055 was more potent than (S)-(-)-AR-A008055 in enhancing the concentration of GABA in the medium following 30 min exposure of tissue to the ischaemic conditions, suggesting that it is an effective GABA uptake inhibitor. This action may explain both its effect on glutamate efflux in vitro and its neuroprotective effect in vivo.