Changing mortality and causes of death in infants 23-27 weeks' gestational age

OBJECTIVE

To contrast the mortality rates and changes in the causes of death of very preterm infants (23-27 weeks), before and after the introduction of exogenous surfactant in 1991, and to identify any preventable causes of death remaining in the 1990s.

METHODOLOGY

This was a cohort study on consecutive preterm infants of 23-27 weeks' gestational age born in the Royal Women's Hospital, Melbourne, a level III perinatal centre. The infants were livebirths free of lethal anomalies from two distinct eras, 1983-90, and 1992-96, inclusive. The main outcome measures were mortality during the primary hospitalization and the causes of death before and after the introduction of exogenous surfactant in 1991.

RESULTS

In 1983-90, 261 of 508 livebirths (51.4%) of 23-27 weeks' gestational age died, a significantly higher proportion than the 109 of 384 (28.4%) livebirths who died in the period 1992-96. The mortality rate fell significantly with increasing gestational age and was lower at each week of gestational age in 1992-96. More infants who died in 1992-96 were treated intensively in the neonatal intensive care unit (NICU). Of the group of infants who died or who were treated intensively in NICU, respiratory causes of death predominated. However, the causes of death changed over time. In 1992-96 proportionally fewer infants died from respiratory causes (1983-90, 82.5%; 1992-96, 60.0%; odds ratio (OR) 0.31, 95%; confidence interval (CI) 0.16-0.57), but more from septic causes (1983-90, 14.3%; 1992-96, 43.8%; OR 4.9, 95%; CI 2.6-9.2).

CONCLUSIONS

As the mortality rate has fallen over time, respiratory causes of death have diminished, but septic causes of death have increased. Further advances in the use of exogenous surfactant and respiratory support may reduce respiratory deaths. Effective strategies to reduce nosocomial infections are urgently required.

Two nursing home outbreaks of respiratory infection with Legionella sainthelensi

OBJECTIVE

To describe outbreaks of infection caused by Legionella sainthelensi occurring in older residents of two nursing homes and to determine risk factors for the development of infection.

DESIGN

Descriptive epidemiology and a case-control study.

SETTING

Two nursing homes (140 beds and 254 beds in nursing homes A and B, respectively) located in southern Ontario, Canada, experiencing outbreaks of respiratory tract infection in July and August 1994.

SUBJECTS

Case-residents of the two nursing homes who met clinical and laboratory criteria for Legionella infection. Control-residents were defined as those who were in the homes during the outbreaks and were asymptomatic.

MEASUREMENTS

Active surveillance was conducted in both nursing homes to identify symptomatic residents. Residents with fever or respiratory tract symptoms had nasopharyngeal swabs taken for viral antigen detection and culture, urine for Legionella antigen detection, and acute and convalescent serology for viruses, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella. Chest X-rays were performed, and an attempt was made to obtain blood and sputum cultures. Water samples from shower heads, faucets, and air conditioning units were collected for Legionella culture and polymerase chain reaction (PCR) assay. A case-control study was done to assess possible risk factors for legionellosis.

RESULTS

Twenty-nine cases -- 17 in nursing home A; 12 in nursing home B - were identified. Four (14%) case-residents had documented pneumonia and four case-residents died. Univariate analysis revealed that a history of stroke (odds ratio (OR) 2.3 (95% CI, 1.0-5.3)), eating pureed food (OR 4.6 (95% CI, 1.6-12.7)), and having fluids administered with medication (OR 2.5 (95% CI, 1.0-5.9)) were significant risk factors. Cases were less likely to wear dentures (OR .4 (95% CI, .2-.9)) or to eat solid food (OR .3, (95% CI, .1-.6)). Only eating pureed food remained significant in a multivariable analysis (OR 4.6 (95% CI, 1.6-13.0, P = .01)).

CONCLUSION

This report describes outbreaks of legionellosis in two nursing homes, representing the first reported outbreaks of infection caused by Legionella sainthelensi. The association with illness of dietary characteristics indicative of swallowing disorders suggests that aspiration was the most likely mode of infection. The diagnosis of legionellosis should be considered during outbreaks of respiratory infection in nursing homes.

Towards an integrated needs and outcome framework

The British National Health Service alongside many other western countries is faced with competing pressures for limited health care resources which reflect, along with an increased accountability of both purchasers and providers of health care, the need for a clear function of explicit prioritisation from those who purchase health care. To enable limited health resources to be thus allocated, purchasers of health care must, therefore, be able to quantify not only the needs of their populations, but to predict and measure the outcomes from a health care intervention. This paper is concerned with the value framework underlying the twin dimension of needs and outcome assessment and seeks to address this framework from the sociological, philosophical and economic perspective and to determine the implications for the underlying distributive ethic.

Ewing's sarcoma masquerading as osteomyelitis

Ewing's sarcoma in the infant and young child is rare, highly malignant, and can be difficult to identify. An erroneous diagnosis of osteomyelitis may be considered first because the presentation may be similar to that of Ewing's sarcoma, and routine laboratory evaluation may not distinguish between these entities. Two such cases are presented, one involving the tibia in a 16-month-old child and another a finger phalanx in a 7-month-old child. In both cases the correct diagnosis of Ewing's sarcoma was delayed because of initial misdiagnosis of osteomyelitis. This diagnostic dilemma is summarized, and the literature reviewed. Special attention is given to recent advances in histochemistry and cytogenetics that assist in tumor identification. The conclusion highlights areas of remaining controversies for which additional study may facilitate distinction between osteomyelitis and Ewing's sarcoma.

Holidaying abroad: practical advice for a young family

Try to tailor your advice to the individual family. Keep it simple and practical. Find out who is going, where and whether the family has any particular health needs. Encourage the family to plan ahead, finding out as much as they can about facilities for young children at their destination. Likely discussion points are vaccinations, infant and toddler feeding, managing the journey, avoiding sunburn and diarrhoea, and contraception. Depending on destination it may be advisable for the family to take some items with them from the UK, e.g. infant formula and feeding equipment, contraceptives, sun protection and insect repellents.

A study of performance on tests from the CANTAB battery sensitive to frontal lobe dysfunction in a large sample of normal volunteers: implications for theories of executive functioning and cognitive aging. Cambridge Neuropsychological Test Automated Battery

Several tests from the CANTAB neuropsychological test battery previously shown to be sensitive to frontal lobe dysfunction were administered to a large group of normal volunteers (N = 341) ranging in age from 21 to 79 years. The main tests included a computerized form of the Tower of London test of planning, a self-ordered spatial working memory task, and a test of attentional set formation and shifting. A computerized form of the Corsi spatial span task was also given. Age-related graded declines in performance were seen, sometimes in a discontinuous manner, especially for the attentional set shifting task (at the extradimensional shift stage). Patterns of deficits reminiscent of frontal lobe or basal ganglia damage were observed in the oldest age group (74-79). However, overall the data were only partially consistent with the hypothesis that frontal lobe functions are the most sensitive to effects of aging. Factor analyses showed that performance in the executive tests was not simply related to a measure of fluid intelligence, and their performance had a factor loading structure distinct from that for the CANTAB tests of visual memory and learning previously administered to the same sample. Finally, only limited support was found for the hypothesis that cognitive aging depends on slowed information processing.

Can melatonin improve adaptation to night shift?

This study was undertaken to determine whether melatonin (N-acetyl-5 methoxytryptamine) is effective in helping emergency medical services (EMS) personnel who work rotating night shifts reset their biological clocks and minimize circadian rhythm disruption. A double-blinded, randomized, crossover study was performed using 22 volunteers. Participants were working a span of consecutive night (2300 to 0700 hours) shifts and received either a melatonin capsule (6 mg) or placebo to be taken before each of the consecutive day sleeps. Each participant completed a total of 4 spans of consecutive night shifts (2 melatonin, 2 placebo). Collected data included daily sleep diaries, quantification of alcohol/caffeine consumed, and drug side effects. Assessment of sleep quality, posttreatment mood, and workload ratings were measured daily by 10-cm visual analog scale (VAS). Analysis of sleep diaries found no significant difference (P > .05) between the two treatments with respect to mean sleep latency, duration, and efficiency, and subjectively rated sleep quality. Similarly, no significant benefits were noted between the median VAS scores for daily posttreatment mood or workload ratings. Adverse effects were rare; one patient taking melatonin reported a prolonged sedative effect. Despite recent interest in melatonin for treatment of circadian-based sleep disorders, no clinical benefits were noted in EMS personnel working rotating night shifts.

Reduction of fecal shedding and egg contamination of Salmonella enteritidis by increasing the number of heterophil adaptations

Serial passage of Salmonella enteritidis (SE) in chicken heterophils resulted in heterophil-adapted SE (HASE). We now report that an additional five heterophil passages have further reduced the number and frequency of fecal shedding of HASE. Eleven-times HASE (11 x HASE) given to 12 laying hens for three consecutive days reduced fecal shedding of 11 x HASE to three isolations from fecal samples during the 70-day postexposure observation period. Hens were exposed to challenge SE 74 days after treatment with 11 x HASE. Three of 12 11 x HASE-treated hens were positive for challenge SE (11/396 fecal samples, or 2.8%) between days 5 and 40 postchallenge, whereas all 12 challenge control birds were positive (118/420 fecal samples, or 28.1%) for SE. None of 12 11 x HASE-treated hens was fecal positive from day 9 postchallenge, whereas 10 of 12 challenge control hens (82/372 fecal samples, or 22.0%) remained positive until day 40, the termination of the experiment. None of 525 eggs and eggshells cultured after 11 x HASE exposure was positive for Salmonella, and none of 422 eggs and eggshells cultured after challenge SE exposure was positive for Salmonella. Eggs or eggshells from challenge control hens were positive for Salmonella in 12/479 (2.5%) cases after challenge SE exposure.

Effects of a potent melanocortin agonist on the diabetic/obese phenotype in yellow mice

OBJECTIVE

To test the hypothesis that a melanocortin agonist can reverse obesity and insulin resistance in mice overexpressing the agouti protein. EXPERIMENTAL MODEL: Mice overexpressing the agouti protein either by transgene introduction (beta-actin promotor) or by mutation (Ay).

DESIGN

NDPMSH was tested for pharmacokinetic suitability. NDPMSH at various doses was administered subcutaneously twice a day for 2-3 weeks.

MEASUREMENTS

Fur pigmentation, various fatness parameters (core temperature, fat pad weight and body weight), blood glucose and hormones, fatty acid synthase measurement.

RESULTS

NDPMSH caused fur pigmentation and core temperature changes, but failed to affect any metabolic parameters in agouti-dependent manner.

CONCLUSION

NDPMSH, as a representation melanocortin agonist, does not compete with agouti in reversing agouti-dependent metabolic effects. This suggests that 1) agouti works via a receptor other than a melanocortin receptor to mediate its metabolic effects, 2) agouti-dependent metabolic effects are mediated through melanocortin receptors but not via antagonism of these receptors, or 3) NDPMSH is pharmacodynamically an inappropriate molecule for these types of studies.

Serial transvaginal ultrasonography following McDonald cerclage and repeat suture insertion

The aim of this study was to explore the hypothesis that serial transvaginal ultrasonography identifies early evidence of suture failure and that repeat cerclage delays delivery. We undertook a review of our policy of transvaginal ultrasonographic cervical surveillance after McDonald cerclage and of repeat suture insertion if persistent cervical effacement developed. Data from 26 pregnancies in 26 women are analyzed. The women had had a total of 57 mid-trimester miscarriages with a median of 2 (1-6) mid-trimester losses per woman. Twelve (46%) of the 26 women developed cervical changes at scan and underwent repeat cerclage. All 14 women who had a single suture inserted progressed to live births but 1 of the 13 women who had repeat cerclage had a mid-trimester miscarriage (p>0.05). The median gestation at delivery for the women who had repeat cerclage was 35 (22-39) weeks compared with 38 (36-40) weeks for those who had a single suture (p>0.05). The median interval from the detection of cervical changes at scan to delivery was 13 (4-19) weeks. Serial transvaginal ultrasonography after cervical cerclage identifies a group of women who are more likely to deliver preterm, and provides an opportunity for intervention (repeat cerclage) which appears to delay delivery by an average of 7 weeks.

"Can you recommend a sunscreen?": the mysteries explained

Ratings and tests for the effectiveness of sunscreens are becoming more consistent and scientifically based. This reflects the growing recognition of the health hazards from sunburn and excessive tanning. Health professionals should be aware of the classic six skin types and their susceptibility to burning. As well as Sun Protection Factors (SPFs), long-wave ultra-violet radiation needs to be taken into account. UVA rays cause long-term damage to the skin. No agreed test for UVA protection exists as yet, but some manufacturers have introduced a star rating system for UVA protection. The more UVA stars, the greater the protection. Children's skin is more vulnerable to burning so they need special protection and a high SPF and UVA rating. The first line of defence is avoiding strong sunlight and covering the head and body. Remember that sunscreens need reapplying after swimming. Always follow the manufacturers' directions carefully.

Maintenance of elevated lead levels in drinking water from occasional use and potential impact on blood leads in children

The variation in lead concentration was measured by thermal ionisation mass spectrometry isotope dilution in household tap water throughout the day when the plumbing system was not fully flushed. After collection of an initial 125-ml water sample containing 119 micrograms/l and a 2-l sample, 125-ml samples were collected at hourly intervals for 8 h. The concentrations in the hourly samples remained in the range 35-52 micrograms/l compared with 1.7 micrograms/l for fully flushed water. High precision lead isotopic measurements showed that approximately 50% of the lead in these water samples derives from the tap 'housing' compared with the overall household system. A health risk assessment was performed employing the US Environmental Protection Agency Integrated Exposure Uptake Biokinetic Model. Predicted blood lead levels in infants only exceeded the 'levels of concern' of 10 micrograms/dl when 100% of the water consumed contained 100 micrograms Pb/1. It would appear that unless the infant consumed 100% of first flush water at lead concentrations of approximately 100 micrograms/l, the blood lead would not exceed the recommended 'level of concern'. However, if more than 0.51 was consumed in drinks and formulae using first flush water, then the blood lead could easily exceed the recommended level. Likewise, a pregnant mother could be at risk of consuming considerably more than the 0.51/day first flush water of the concentrations measured, or throughout the day, if the system were not fully flushed.

Detection of glove puncture and skin contamination during caesarean section

Measures that can be taken to reduce exposure to potentially infected body fluids are of particular relevance in obstetric and gynaecological surgery due to high rates of glove puncture and relatively higher prevalence of human immunodeficiency virus seropositivity in the obstetric age group. We describe the use of a simple electronic device that alarms following puncture of surgical gloves or the creation of a fluid bridge between surgeon and patient. Further exposure to potentially infected body fluids is thus prevented. This present study was performed in the context of caesarean section, but the application of the technique to gynaecological procedures is appropriate.

Cardiac baroreceptor sensitivity is impaired after acute stroke

BACKGROUND AND PURPOSE

The blood pressure (BP) fall and increased BP variability after acute stroke have been previously described. The underlying pathophysiological mechanisms producing these findings are unclear but may include abnormalities of cardiac baroreceptor reflex arc and/or changes in sympathetic nervous system activity. To date, evidence of impaired cardiac baroreceptor sensitivity (BRS) after stroke is limited to patients with chronic disease as determined by invasive methodology. Therefore, it was proposed to assess cardiac BRS and sympathovagal balance with the use of novel noninvasive techniques after acute stroke.

METHODS

Thirty-seven acute stroke patients underwent simultaneous surface electrocardiographic and noninvasive beat-to-beat BP recording. Cardiac BRS was assessed by power spectral analysis techniques, and sympathovagal balance was determined from the ratio of the low- to high-frequency powers for pulse interval variability. The responses were compared with a control group matched for age, sex, and BP.

RESULTS

Median cardiac BRS was significantly lower in stroke patients than in control subjects (high-frequency alpha-index, 4.89 versus 6.50 ms/mm Hg; P = .007; combined alpha-index, 4.65 versus 5.46 ms/mm Hg; P = .02). Median normalized high- but not low-frequency power of systolic BP variability was significantly greater in stroke patients (11.0 versus 6.7 normalized units; P < .001), probably reflecting differences in the mechanical effects of respiration on BP in stroke patients. No significant differences were observed in the power spectrum of pulse interval variability between stroke patients and control subjects. Patients with tight hemisphere strokes, however, had a significant reduction in median high-frequency pulse interval power compared with patients with left hemisphere strokes (8 versus 20 normalized units; P = .03), which may reflect a change in sympathovagal balance in favor of increased sympathetic tone in this group.

CONCLUSIONS

The impairment of cardiac BRS may be important in explaining the increased BP variability after stroke. There was no significant difference in surrogate measures of sympathovagal activity between acute stroke patients and control subjects, but right hemisphere stroke patients had a significant alteration in the sympathovagal balance of pulse interval variability compared with left hemisphere stroke patients. This sympathetic predominance in right hemisphere strokes may be important in the development of cardiac arrhythmias after stroke. The prognostic implications of these findings need to be further explored.

Single session effects of treatment components within a specialized inpatient posttraumatic stress disorder program

This study examined the potential contributions of individual treatment components within one inpatient posttraumatic stress disorders (PTSD) program. Fifteen treatment components were assessed by a self-report instrument administered to a cohort of veterans just before and immediately after each session approximately halfway through the program. Components with an external focus, action modality, and, secondarily, little Vietnam content were associated with more improvement than components with an internal focus, verbal modality, or high Vietnam content. Improvement was greatest in veterans with fewer PTSD symptoms. Short-term improvement was not correlated with veterans' ratings at discharge of component effectiveness. These results were later confirmed on a second cohort. This study supports the potential roles of distraction and physical release, as opposed to exploratory verbal discussion, in the treatment of chronic combat-related PTSD.