Factors associated with the increased incidence of necrotising enterocolitis in extremely preterm infants in Sweden between two population-based national cohorts (2004-2007 vs 2014-2016)

OBJECTIVE

To investigate potential risk factors behind the increased incidence of necrotising enterocolitis (NEC) in Swedish extremely preterm infants.

DESIGN

Registry data from two population-based national cohorts were studied. NEC diagnoses (Bell stage ≥II) were validated against hospital records.

PATIENTS

All liveborn infants <27 weeks of gestation 2004-2007 (n=704) and 2014-2016 (n=895) in Sweden.

MAIN OUTCOME MEASURES

NEC incidence.

RESULTS

The validation process resulted in a 28% reduction of NEC cases but still confirmed a higher NEC incidence in the later epoch compared with the earlier (73/895 (8.2%) vs 27/704 (3.8%), p=0.001), while the composite of NEC or death was lower (244/895 (27.3%) vs 229/704 (32.5%), p=0.022). In a multivariable Cox regression model, censored for mortality, there was no significant difference in early NEC (0-7 days of life) between epochs (HR=0.9 (95% CI 0.5 to 1.9), p=0.9), but being born in the later epoch remained an independent risk factor for late NEC (>7 days) (HR=2.7 (95% CI 1.5 to 5.0), p=0.001). In propensity score analysis, a significant epoch difference in NEC incidence (12% vs 2.8%, p<0.001) was observed only in the tertile of infants at highest risk of NEC, where the 28-day mortality was lower in the later epoch (35% vs 50%, p=0.001). More NEC cases were diagnosed with intramural gas in the later epoch (33/73 (45.2%) vs 6/26 (23.1%), p=0.047).

CONCLUSIONS

The increase in NEC incidence between epochs was limited to cases occurring after 7 days of life and was partly explained by increased survival in the most extremely preterm infants. Misclassification of NEC is common.

One-year survival and outcomes of infants born at 22 and 23 weeks of gestation in Sweden 2004-2007, 2014-2016 and 2017-2019

OBJECTIVE

To explore associations between perinatal activity and survival in infants born at 22 and 23 weeks of gestation in Sweden.

DESIGN/SETTING

Data on all births at 22 and 23 weeks' gestational age (GA) were prospectively collected in 2004-2007 (T1) or obtained from national registers in 2014-2016 (T2) and 2017-2019 (T3). Infants were assigned perinatal activity scores based on 3 key obstetric and 4 neonatal interventions.

MAIN OUTCOME

One-year survival and survival without major neonatal morbidities (MNM): intraventricular haemorrhage grade 3-4, cystic periventricular leucomalacia, surgical necrotising enterocolitis, retinopathy of prematurity stage 3-5 or severe bronchopulmonary dysplasia. The association of GA-specific perinatal activity score and 1-year survival was also determined.

RESULTS

977 infants (567 live births and 410 stillbirths) were included: 323 born in T1, 347 in T2 and 307 in T3. Among live-born infants, survival at 22 weeks was 5/49 (10%) in T1 and rose significantly to 29/74 (39%) in T2 and 31/80 (39%) in T3. Survival was not significantly different between epochs at 23 weeks (53%, 61% and 67%). Among survivors, the proportions without MNM in T1, T2 and T3 were 20%, 17% and 19% for 22 weeks and 17%, 25% and 25% for 23 weeks' infants (p>0.05 for all comparisons). Each 5-point increment in GA-specific perinatal activity score increased the odds for survival in first 12 hours of life (adjusted OR (aOR) 1.4; 95% CI 1.3 to 1.6) in addition to 1-year survival (aOR 1.2; 95% CI 1.1 to 1.3), and among live-born infants it was associated with increased survival without MNM (aOR 1.3; 95% CI 1.1 to 1.4).

CONCLUSION

Increased perinatal activity was associated with reduced mortality and increased chances of survival without MNM in infants born at 22 and 23 weeks of GA.

Improving NICU staff decision-making with parents in medical rounds: a pilot study of reflective group dialogue intervention

Introduction

The communication skills of healthcare professionals play a crucial role in successful shared decision-making with parents in neonatal intensive care. Improving communication skills can be achieved through practice and reflection on personal experiences after authentic interaction events with parents. The process of reflection typically involves three phases: description, reflection, and critical reflection. In this study, our aim was to explore the acceptability of the Reflective Group Dialogue intervention and its effectiveness in supporting the reflective process.

Methods

This qualitative pilot study was conducted in the neonatal intensive care unit at Uppsala University Children's Hospital, Sweden. The sample consisted of nine medical rounds with seven families, five neonatologists, seven registered nurses, and five assistant nurses. Purposive sampling was used to collect the data. The intervention comprised four elements: (1) before the intervention, a recorded presentation on shared decision-making was given to the entire unit staff, (2) an observation of a normal medical round discussion with parents, (3) an interview with parents about their experience after the same round, and (4) a reflective discussion with the participating health care professionals after the round. The parent interviews and reflective discussions were audio-recorded and transcribed verbatim. They were analyzed using thematic analysis as a theoretical strategy.

Results

Both parents and staff widely accepted the intervention and found it beneficial. We identified four discussions that remained in the descriptive phase of the reflection process, four that reached the reflective phase, and one that reached the critical reflection phase. The descriptive discussions were characterized by using a single perspective to reflect, often based on personal opinions. The reflective discussions included analyzing interaction sequences from both staff and parent perspectives and were primarily based on actual observations of communication during medical rounds. The critical discussion led to a new awareness of current practices concerning parental involvement in decision-making. These discussions also utilized "what-if" thinking to evaluate potential new practices and their pros and cons.

Conclusions

The intervention seems promising as it was perceived as beneficial by the recipients and facilitated reflection in most cases. However, to enhance the feasibility of the intervention, some improvements are discussed.

Clonidine as analgesia during retinopathy of prematurity screening in preterm infants (cloROP): protocol for a randomised controlled trial

INTRODUCTION

Preterm infants are at risk of negative consequences from stress and pain at the same time as they often are in need of intensive care that includes painful interventions. One of the frequent painful procedures preterm infants undergo is eye examination screening to detect early signs of ROP (retinopathy of prematurity). These examinations are both stressful and painful, and despite a multitude of research studies, no conclusive pain-relieving treatment has been demonstrated. The main aim of this trial is to investigate the analgesic effect of clonidine during ROP eye examinations.

METHODS AND ANALYSIS

The planned study is a multicentre randomised controlled trial with a crossover design. Infants will be recruited from two different neonatal intensive care units (NICUs) in Sweden. Infants born before gestation week 30 (and therefore eligible for ROP screening) and cared for in either of the NICUs will be eligible for inclusion in the study. The primary outcome will be Premature Infant Pain Profile-Revised score within 30 s after starting the examination. Secondary outcomes will be changes in the galvanic skin response parameters (area small peaks, area huge peaks, peaks per second and average rise time) within 30 s after starting the eye examination, together with the number and evaluation of adverse events reported within 72 hours after the examination and the examining physician's assessment of how easy the infant was to examine.

ETHICS AND DISSEMINATION

Approval from the Swedish Ethical Review Authority and the Swedish Medical Products Agency has been obtained for the study. Parents of eligible infants will be getting both verbal and written information about the study including that participation is voluntary. Data will be collected and treated in accordance with the European general data protection regulations. The results will be reported on group level and published in a scientific journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT04902859).EudraCT (2021-003005-21).

An international study on implementation and facilitators and barriers for parent‐infant closeness in neonatal units

Importance

Parent‐infant closeness and active parent participation in neonatal care are important for parent and infant health.

Objective

To give an overview of current neonatal settings and gain an in‐depth understanding of facilitators and barriers to parent‐infant closeness, zero‐separation, in 19 countries.

Methods

Neonatal intensive care unit (NICU) professionals, representing 45 NICUs from a range of geographic regions in Europe and Canada, were purposefully selected and interviewed June–December 2018. Thematic analysis was conducted to identify, analyze and report patterns (themes) for parent‐infant closeness across the entire series of interviews.

Results

Parent‐infant separation during infant and/or maternity care is very common (42/45 units, 93%), despite the implementation of family integrated care (FICare) practices, including parent participation in medical rounds (17/45, 38%), structured education sessions for parents (16/45, 36%) and structured training for healthcare professionals (22/45, 49%). NICU professionals encountered four main themes with facilitators and barriers for parent‐infant closeness on and between the hospital, unit, staff, and family level: Culture (jointly held characteristics, values, thinking and behaviors about parental presence and participation in the unit), Collaboration (the act of working together between and within different levels), Capacities (resources and policies), and Coaching (education to acquire and transfer knowledge and skills).

Interpretation

Implementing parent‐infant closeness in the NICU is still challenging for healthcare professionals. Further optimization in neonatal care towards zero‐separation and parent‐infant closeness can be achieved by enforcing the ‘four Cs for Closeness’: Culture, Collaboration, Capacities, and Coaching.

Outcomes of a uniformly active approach to infants born at 22-24 weeks of gestation

OBJECTIVE

To determine survival and outcomes in infants born at 22-24 weeks of gestation in a centre with a uniformly active approach to management of extremely preterm infants.

STUDY DESIGN

Single-centre retrospective cohort study including infants born 2006-2015. Short-term morbidities assessed included retinopathy of prematurity, necrotising enterocolitis, patent ductus arteriosus, intraventricular haemorrhage, periventricular malacia and bronchopulmonary dysplasia. Neurodevelopmental outcomes assessed included cerebral palsy, visual impairment, hearing impairment and developmental delay.

RESULTS

Total survival was 64% (143/222), ranging from 52% at 22 weeks to 70% at 24 weeks. Of 133 (93%) children available for follow-up at 2.5 years corrected age, 34% had neurodevelopmental impairment with 11% classified as moderately to severely impaired. Treatment-requiring retinopathy of prematurity, severe bronchopulmonary dysplasia, visual impairment and developmental delay correlated with lower gestational age.

CONCLUSIONS

A uniformly active approach to all extremely preterm infants results in survival rates that are not distinctly different across the gestational ages of 22-24 weeks and more than 50% survival even in infants at 22 weeks. The majority were unimpaired at 2.5 years, suggesting that such an approach does not result in higher rates of long-term adverse neurological outcome.

A global point prevalence survey of antimicrobial use in neonatal intensive care units: The no-more-antibiotics and resistance (NO-MAS-R) study

BACKGROUND

Global assessment of antimicrobial agents prescribed to infants in the neonatal intensive care unit (NICU) may inform antimicrobial stewardship efforts.

METHODS

We conducted a one-day global point prevalence study of all antimicrobials provided to NICU infants. Demographic, clinical, and microbiologic data were obtained including NICU level, census, birth weight, gestational/chronologic age, diagnoses, antimicrobial therapy (reason for use; length of therapy), antimicrobial stewardship program (ASP), and 30-day in-hospital mortality.

FINDINGS

On July 1, 2019, 26% of infants (580/2,265; range, 0-100%; median gestational age, 33 weeks; median birth weight, 1800 g) in 84 NICUs (51, high-income; 33, low-to-middle income) from 29 countries (14, high-income; 15, low-to-middle income) in five continents received ≥1 antimicrobial agent (92%, antibacterial; 19%, antifungal; 4%, antiviral). The most common reasons for antibiotic therapy were "rule-out" sepsis (32%) and "culture-negative" sepsis (16%) with ampicillin (40%), gentamicin (35%), amikacin (19%), vancomycin (15%), and meropenem (9%) used most frequently. For definitive treatment of presumed/confirmed infection, vancomycin (26%), amikacin (20%), and meropenem (16%) were the most prescribed agents. Length of therapy for culture-positive and "culture-negative" infections was 12 days (median; IQR, 8-14) and 7 days (median; IQR, 5-10), respectively. Mortality was 6% (42%, infection-related). An NICU ASP was associated with lower rate of antibiotic utilization (p = 0·02).

INTERPRETATION

Global NICU antibiotic use was frequent and prolonged regardless of culture results. NICU-specific ASPs were associated with lower antibiotic utilization rates, suggesting the need for their implementation worldwide.

FUNDING

Merck & Co.; The Ohio State University College of Medicine Barnes Medical Student Research Scholarship.

Association Between Year of Birth and 1-Year Survival Among Extremely Preterm Infants in Sweden During 2004-2007 and 2014-2016

Importance

Since 2004-2007, national guidelines and recommendations have been developed for the management of extremely preterm births in Sweden. If and how more uniform management has affected infant survival is unknown.

Objective

To compare survival of extremely preterm infants born during 2004-2007 with survival of infants born during 2014-2016.

Design, Setting and Participants

All births at 22-26 weeks' gestational age (n = 2205) between April 1, 2004, and March 31, 2007, and between January 1, 2014, and December 31, 2016, in Sweden were studied. Prospective data collection was used during 2004-2007. Data were obtained from the Swedish pregnancy, medical birth, and neonatal quality registries during 2014-2016.

Exposures

Delivery at 22-26 weeks' gestational age.

Main Outcomes and Measures

The primary outcome was infant survival to the age of 1 year. The secondary outcome was 1-year survival among live-born infants who did not have any major neonatal morbidity (specifically, without intraventricular hemorrhage grade 3-4, cystic periventricular leukomalacia, necrotizing enterocolitis, retinopathy of prematurity stage 3-5, or severe bronchopulmonary dysplasia).

Results

During 2004-2007, 1009 births (3.3/1000 of all births) occurred at 22-26 weeks' gestational age compared with 1196 births (3.4/1000 of all births) during 2014-2016 (P = .61). One-year survival among live-born infants at 22-26 weeks' gestational age was significantly lower during 2004-2007 (497 of 705 infants [70%]) than during 2014-2016 (711 of 923 infants [77%]) (difference, -7% [95% CI, -11% to -2.2%], P = .003). One-year survival among live-born infants at 22-26 weeks' gestational age and without any major neonatal morbidity was significantly lower during 2004-2007 (226 of 705 infants [32%]) than during 2014-2016 (355 of 923 infants [38%]) (difference, -6% [95% CI, -11% to -1.7%], P = .008).

Conclusions and Relevance

Among live births at 22-26 weeks' gestational age in Sweden, 1-year survival improved between 2004-2007 and 2014-2016.

Reduced rate of treated retinopathy of prematurity after implementing lower oxygen saturation targets

OBJECTIVE

To evaluate an implementation of lower oxygen saturation targets with retinopathy of prematurity (ROP) as primary outcome, in infants at the lowest extreme of prematurity.

STUDY DESIGN

Retrospective cohort including infants born at 22-25 weeks of gestation in 2005-2015 (n = 325), comparing high (87-93%) and low (85-90%) targets; infants transferred early were excluded from the main analysis to avoid bias.

RESULTS

Overall survival was 76% in high saturation era, and 69% in low saturation era (p = .17). Treatment-requiring ROP was less common in low saturation group (14% vs 28%, p < .05) with the most prominent difference in the most immature infants. Including deceased infants in the analysis, necrotizing enterocolitis was more frequent in low saturation era (21% vs 10%, p < .05).

CONCLUSIONS

Implementing lower saturation targets resulted in a halved incidence of treatment-requiring ROP; the most immature infants seem to benefit the most. An association between lower oxygenation and necrotizing enterocolitis cannot be excluded.

Critically ill neonates displayed stable vital parameters and reduced metabolic acidosis during neonatal emergency airborne transport in Sweden

AIM

This study evaluated the medical quality of acute airborne transports carried out by a neonatal emergency transport service in a Swedish healthcare region from 2012 to 2015.

METHODS

The transport charts and patient records of all infants transported to the regional centre were reviewed for transport indications and vital parameters and outcomes.

RESULTS

We identified 187 acute airborne transports and the main indications for referral were therapeutic hypothermia after perinatal asphyxia, extremely preterm birth and respiratory failure. There were 37 deaths, but none of these occurred during transport and none of the deaths that occurred within 24 hours after transport were found to be related to the transport per se. No differences were found in vital parameters or ventilator settings before and after transport, except for an improvement in blood pH (7.22 ± 0.13 versus 7.27 ± 0.13, mean ± SD, p < 0.01), due to a decrease in base deficit (-8.0 ± 6.8 versus -5.4 ± 6.3 mmol, p < 0.001), while the partial pressure of carbon dioxide remained unchanged.

CONCLUSION

During air transport, critically ill neonates displayed stable vital parameters and reduced metabolic acidosis. No transport-related mortality was found, but the high number of extremely preterm infants transported indicates the potential for improving in-utero transport.

Parents' presence and parent-infant closeness in 11 neonatal intensive care units in six European countries vary between and within the countries

Aim

Little is known about the amount of physical parent–infant closeness in neonatal intensive care units (NICUs), and this study explored that issue in six European countries.

Methods

The parents of 328 preterm infants were recruited in 11 NICUs in Finland, Estonia, Sweden, Norway, Italy and Spain. They filled in daily diaries about how much time they spent in the NICU, in skin‐to‐skin contact (SSC) and holding their babies in the first two weeks of their hospitalisation.

Results

The parents' NICU presence varied from a median of 3.3 (minimum 0.7–maximum 6.7) to 22.3 (18.7–24.0) hours per day (p < 0.001), SSC varied from 0.3 (0–1.4) to 6.6 (2.2–19.5) hours per day (p < 0.001) and holding varied from 0 (0–1.5) to 3.2 (0–7.4) hours per day (p < 0.001). Longer SSC was associated with singleton babies and more highly educated mothers. Holding the baby for longer was associated with gestational age. The most important factor supporting parent–infant closeness was the opportunity to stay overnight in the NICU. Having other children and the distance from home to the hospital had no impact on parent–infant closeness.

Conclusion

Parents spent more time in NICUs if they could stay overnight, underlining the importance that these facilities play in establishing parent–infant closeness.

Parents experiences of discharge readiness from a Swedish neonatal intensive care unit

Aim

The aim of this study was to describe how parents experienced the support at, and preparation for discharge from, the NICU and how they experienced the first time at home.

Design

A qualitative design with quantitative elements was applied.

Methods

A questionnaire study. Data were analysed using qualitative content analysis with quantitative elements.

Results

The majority of included parents felt adequately prepared for going home and sufficiently supported during the first period home. Negative experiences were related to lack of time for preparation, lack of support and information, especially about the infant's food intake, breastfeeding, and tube feeding, and lack of follow‐up counselling post discharge. This study supports that parents who are closely involved in their infant's care at the NICU, and who stay with the infant at the NICU around the clock, are well prepared for the transition to home.

Intestinal microbial profiles in extremely preterm infants with and without necrotizing enterocolitis

AIM

Necrotizing enterocolitis (NEC) represents one of the gravest complications in premature infants. The suggested role of intestinal microbiota in the development of NEC needs to be elucidated.

METHODS

This prospective single-centre case-control study applied barcoded pyrosequencing to map the bacterial composition of faecal samples from extremely preterm infants. Ten patients were diagnosed with NEC and matched to healthy controls with regard to sex, gestational age and mode of delivery prior to analysis of the samples.

RESULTS

Enterococcus, Bacillales and Enterobacteriaceae dominated the flora. Although not statistically significant, a high relative abundance of Bacillales and Enterobacteriaceae was detected at early time points in patients developing NEC, while healthy controls had a microbiota more dominated by Enterococcus. A low diversity of intestinal microbial flora was found without any differences between NEC patients and controls. In 16 healthy controls, Firmicutes (Enterococcus and Bacillales) dominated the faecal flora during the first weeks after birth and were then succeeded by Enterobacteriaceae.

CONCLUSION

No significant differences in the composition of intestinal microbiota of patients developing NEC were detected; however, some findings need to be scrutinized in subsequent studies.

Isolation of non-activated monocytes from human umbilical cord blood

PROBLEM

Methods for monocyte purification are common but few work with umbilical cord monocytes that do not activate the cell for subsequent culture analysis.

METHODS OF STUDY

The collection procedure avoids use of needles and procedures that variably activate blood clotting and uses a purification procedure that involves diluted Ficoll, autologous serum to remove platelets and 42% and 51% Percoll step gradients for the final purification. The resulting monocytes were stimulated with bacterial lipopolysaccharide and formalin-treated bacteria Escherichia coli and group B streptococci (GBS) to secrete TNF-alpha and IL-1beta, measured by ELISA.

RESULTS

The purification procedure results in non-active but stimulation-competent monocytes with high yields (2.3-9 x 10(7) cells) and purity (from 70% to 98%).

CONCLUSION

We describe a procedure that is easy, uses common reagents and provides a uniformly high yield and purity of non-activated fetal monocytes for studies of innate defense responses.

A novel mouse model of Ureaplasma-induced perinatal inflammation: effects on lung and brain injury

Chorioamnionitis is associated with increased lung and brain injury in premature infants. Ureaplasma is the microorganisms most frequently associated with preterm birth. Whether Ureaplasma-induced antenatal inflammation worsens lung and brain injury is unknown. We developed a mouse model combining antenatal Ureaplasma infection and postnatal oxygen exposure. Intraamniotic Ureaplasma Parvum (UP) increased proinflammatory cytokines in placenta and fetal lungs. Antenatal exposure to UP or broth caused mild postnatal inflammation and worsened oxygen-induced lung injury. Antenatal UP exposure induced central microgliosis and disrupted brain development as detected by decreased number of calbindin-positive and calretinin-positive neurons in the neocortex. Postnatal oxygen decreased calretinin-positive neurons in the neocortex but combined with antenatal UP exposure did not worsen brain injury. Antenatal inflammation exacerbates the deleterious effects of oxygen on lung development, but the broth effects prohibit concluding that UP by itself is a compounding risk factor for bronchopulmonary dysplasia. In contrast, antenatal UP-induced inflammation alone is sufficient to disturb brain development. This model may be helpful in exploring the pathophysiology of perinatal lung and brain injury to develop new protective strategies.

Association between Chlamydia pneumoniae antibodies and wheezing in young children and the influence of sex

BACKGROUND

The proposed association between Chlamydia pneumoniae (Cpn) infection and wheezing needs further clarification.

METHODS

Serum samples obtained from 1581 children aged 4 years in a population based cohort were tested for antibodies to Cpn and IgE antibodies to common allergens. Data on environmental factors and disease were collected prospectively from birth.

RESULTS

The occurrence of IgG antibodies to Cpn at 4 years of age was associated with reported wheezing at different ages; however, these findings were most often not significant. In girls, the occurrence of anti-Cpn IgG was associated with wheezing at the ages of 1, 2, and 4 years (odds ratios (ORs) 3.41 (95% confidence interval (CI) 1.46 to 7.96), 2.13 (95% CI 1.02 to 4.44), and 2.01 (95% CI 1.14 to 3.54), respectively), and even higher ORs were observed for each age category when only high level antibody responses to Cpn were analysed. At the time of blood sampling the association between anti-Cpn IgG and wheezing was restricted to girls without atopic sensitisation (OR 2.39 (95% CI 1.25 to 4.57). No associations with wheezing were detected in boys, in whom IgE sensitisation was inversely associated with the presence of anti-Cpn IgG (OR 0.49 (95% CI 0.26 to 0.90)).

CONCLUSIONS

This study suggests an association between evidence of earlier Cpn infection and a history of wheezing in young girls. Infection with Cpn may be an important risk factor for wheezing and possibly for non-atopic asthma, predominantly in girls.

Chlamydia pneumoniae infection predicts a reduced risk for subsequent atopic disease

AIM

To investigate long-term effects on children previously infected with Chlamydia pneumoniae.

METHODS

A follow-up questionnaire was sent to all participants from a former population-based study in order to investigate health status during the 4 y that had elapsed between the two studies. In the original study, the prevalence of C. pneumoniae infection was 23% as determined by PCR analyses on throat swab specimens. These PCR results were found to have no detectable correlation for clinical disease. The main outcome measures in this follow-up study were the reported prevalence of respiratory tract infections, asthma and allergy.

RESULTS

Approximately 83% completed the follow-up questionnaire. No increase in respiratory tract infections was reported by children previously found to have C. pneumoniae infection. A diagnosis of allergy was more common in the former PCR-negative population (13.4% vs 4.7%, p<0.03). The differences were most apparent in the population with atopic heredity. In a logistic regression model with different suggested risk factors for allergy, earlier infection with C. pneumoniae reduced the risk for allergy (OR=0.13; 95% CI: 0.02-0.99). This was not found for asthma.

CONCLUSION

A positive PCR test for C. pneumoniae in young children was associated with a lower risk of developing allergic airway disease in this study population, and did not predict an increase in respiratory tract infections.

Regional cerebral blood flow in patients with primary hyperparathyroidism before and after successful parathyroidectomy

BACKGROUND

Single-photon emission computed tomography (SPECT) is used to study cerebral blood flow and cerebral metabolism in various neuropsychiatric disorders. Reduced regional cerebral blood flow has been demonstrated in patients with depression and chronic fatigue, symptoms that are common in primary hyperparathyroidism. The aim of this study was to reveal possible changes in regional cerebral blood flow in patients with primary hyperparathyroidism before and after operative treatment.

METHODS

This was a prospective study of regional cerebral blood flow in 16 consecutive women of median age 72 (range 50-82) years using SPECT with (99m)Tc-labelled hexamethylpropylenamine-oxime. The measurements were performed before and 2, 4 and 12 months after parathyroidectomy. The Montgomery and Asberg depression rating scale (MADRS) depression score was used as a parallel clinical test.

RESULTS

Reduced (pathological) regional cerebral blood flow was seen before operation in 14 patients, 13 with a solitary adenoma and one with double adenoma. After surgery, this improved to normal values in 13, but was further reduced in one. In two patients with preoperative normal regional cerebral blood flow, both of whom were asymptomatic and had diffuse hyperplasia, a slight reduction was demonstrated. Eight patients had a pathological preoperative MADRS score, which normalized in seven after surgical treatment.

CONCLUSION

The finding of reduced regional cerebral blood flow in patients with primary hyperparathyroidism followed by significant improvement after operation might influence the case for surgical treatment.

[Lithium treatment and hyperparathyroidism]

BACKGROUND

Lithium treatment, which is extensively used in bipolar affective disorders, may give rise to hypercalcaemia and sometimes to irreversible hyperparathyroidism.

MATERIAL AND METHODS

We present a patient who developed hyperparathyroidism following long-term treatment with lithium.

RESULTS

After 15 years on lithium the patient was diagnosed with hypercalcaemia; at the same time the patient stopped her lithium medication. Two years later she developed depression with psychotic symptoms and was given electroconvulsive treatment. Measurements of serum calcium and parathormon showed that she had developed hyperparathyroidism. Neck exploration was performed, and two parathyroid adenomas (weight 650 mg and 880 mg), which had been detected by scintigraphy, were removed. Lithium treatment was restarted. One year later she was normocalcaemic and her mood was normal.

INTERPRETATION

In lithium-induced hyperparamyroidism, lithium should be replaced with other mood stabilizers, preferably an antiepilepticum. If cessation of lithium therapy does not lead to normocalcaemia, parathyroidectomy is indicated.

Chlamydia pneumoniae in children undergoing adenoidectomy

Chlamydia pneumoniae is a common respiratory pathogen which is often found in paediatric populations. Little is known about the true colonization rate and the localization of the bacteria in the respiratory tract. In this study, immunohistochemistry was used to examine adenoids from 69 children undergoing elective adenoidectomy. Throat swabs for polymerase chain reaction (PCR) and blood samples for serology were also obtained. Chlamydia pneumoniae was demonstrated in the adenoids by immunohistochemistry in 68 of the children. Five children (7%) had a positive C. pneumoniae PCR test from throat swabs and 14 children (20%) had detectable antibodies by the microimmunofluorescence technique.

CONCLUSION

The results suggest that C. pneumoniae is a common finding in the adenoids of children undergoing adenoidectomy. Whether or not C. pneumoniae plays a pathogenic role in this patient population could not be determined from the data obtained in this investigation.

[Primary hyperparathyroidism--a 16-year material from a central hospital]

BACKGROUND

In Norway, population 4.3 million, approximately 160 patients a year have undergone surgery for primary hyperparathyroidism during the last ten years. Previous reports are rare.

MATERIAL AND METHODS

A retrospective analysis of all patients operated for primary hyperparathyroidism during 16 years at Vestfold Hospital, which serves a population of 200,000. Late recurrences and persisting hypocalcaemia were evaluated with laboratory tests median eight years after surgery.

RESULTS

104 patients were operated (88 females and 16 males; median age 64 years, range 22-78). Adenomas were found in 88 patients, of which four had double adenomas, and hyperplasia in 16 patients. Three patients died postoperatively, within 30 days, all of them high-risk patients. Two patients were reoperated because of bleeding. In one patient an infection was drained. Median hospital stay was five days. Two patients had persisting hypercalcaemia; eight patients needed permanent vitamin D substitution. Four recurrences were detected. Normocalcaemia was achieved in 91 patients (90%).

INTERPRETATION

Surgical treatment leads to normocalcemia in 90% of patient, but is not risk-free in severely ill patients. To assess the true benefit of the operation for the individual patient, better preoperative mapping of symptoms and better follow-up protocols should be implemented.

Severe pancreatitis after parathyroidectomy

Cope showed in 1957 that pancreatitis may be the presenting symptom in hyperparathyroidism. Since then, the literature has reported a coincidence of primary hyperparathyroidism and pancreatitis between 1% and 19%, but the true relationship has not been fully established. When severe pancreatitis follows parathyroidectomy, a condition familiar to parathyroid surgeons, reports are mostly anecdotal and by many authors considered to be coincidental. We present the case history of a 58-year-old man with a longstanding history of untreated primary hyperparathyroidism who developed severe pancreatitis immediately after removal of a 400-mg parathyroid adenoma. He was the first in a series of 108 operated patients to develop this complication. His preoperative levels of parathormone and serum calcium were the highest in our material. We believe that pancreatitis after parathyroidectomy is a real but rare complication that might be predicted by preoperative high values of serum calcium and parathormone.

Vaginal disinfection with chlorhexidine during childbirth

The purpose of this study was to determine whether chlorhexidine vaginal douching, applied by a squeeze bottle intra partum, reduced mother-to-child transmission of vaginal microorganisms including Streptococcus agalactiae (streptococcus serogroup B = GBS) and hence infectious morbidity in both mother and child. A prospective controlled study was conducted on pairs of mothers and their offspring. During the first 4 months (reference phase), the vaginal flora of women in labour was recorded and the newborns monitored. During the next 5 months (intervention phase), a trial of randomized, blinded placebo controlled douching with either 0.2% chlorhexidine or sterile saline was performed on 1130 women in vaginal labour. During childbirth, bacteria were isolated from 78% of the women. Vertical transmission of microbes occurred in 43% of the reference deliveries. In the double blind study, vaginal douching with chlorhexidine significantly reduced the vertical transmission rate from 35% (saline) to 18% (chlorhexidine), (P < 0.000 1, 95% confidence interval 0.12-0.22). The lower rate of bacteria isolated from the latter group was accompanied by a significantly reduced early infectious morbidity in the neonates (P < 0.05, 95% confidence interval 0.00-0.06). This finding was particularly pronounced in Str. agalactiae infections (P < 0.0 1). In the early postpartum period, fever in the mothers was significantly lower in the patients offered vaginal disinfection, a reduction from 7.2% in those douched using saline compared with 3.3% in those disinfected using chlorhexidine (P < 0.05, 95% confidence interval 0.01-0.06). A parallel lower occurrence of urinary tract infections was also observed, 6.2% in the saline group as compared with 3.4% in the chlorhexidine group (P < 0.01, 95% confidence p interval 0.00-0.05). This prospective controlled trial demonstrated that vaginal douching with 0.2% chlorhexidine during labour can significantly reduce both maternal and early neonatal infectious morbidity. The squeeze bottle procedure was simple, quick, and well tolerated. The beneficial effect may be ascribed both to mechanical cleansing by liquid flow and to the disinfective action of chlorhexidine.

Chlamydia pneumoniae in children attending day-care centers in Gävle, Sweden

BACKGROUND

The epidemiology of Chlamydia pneumoniae in healthy children has not been established.

METHODS

This investigation used polymerase chain reaction (PCR) to study the epidemiology of C. pneumoniae in presumed healthy children. Four hundred fifty-three children and 142 personnel at 9 day-care centers were investigated for carriage of C. pneumoniae. Children found to be positive by PCR were also investigated with serology, and their family members were tested with PCR.

RESULTS

One hundred and three (22.7%) children had a positive PCR, as had 33 (23.2%) personnel. Fourteen percent of the children younger than 3 years had a positive PCR test compared with 26% of the older children (P < 0.01). No correlation was found between respiratory symptoms and carriage of C. pneumoniae. Mothers were more often positive in the PCR test as compared with fathers (relative risk, 2.59; 95% confidence interval, 1.16 to 5.78). Antibodies to C. pneumoniae were found in 27 of 97 PCR-positive children; only 2 of whom were younger than 3 years.

CONCLUSION

C. pneumoniae can be commonly found in young children attending day care. Most of the youngest children did not develop specific antibodies. Children may have subclinical infections with C. pneumoniae. The organism seems to be easily communicable among individuals living in close proximity.

Chlamydia pneumoniae in children with acute respiratory tract infections

Children seeking medical attention for acute respiratory tract infections were investigated for evidence of Chlamydia pneumoniae infection. Blood samples were obtained from 367 children. Nasopharyngeal or throat swabs for PCR analysis (polymerase chain reaction) were taken from 360 children. Serology was found to be useful for diagnosis of infection only in children aged > 5 y. Using PCR, a prevalence of 8 and 10% of C. pneumoniae was found in male and female children aged < 2 y; 17 and 19%, respectively, in the age group 2-4 y and 32 and 21%, respectively, in the age group 5-16 y. We conclude that Chlamydia pneumoniae is a common finding in young children with respiratory tract infections. Younger children were more often found to have a moderate disease, but may have been ill for a long period.

Bilateral primary bronchial carcinoma

Three cases of bilateral primary bronchogenic carcinomas, one simultaneous and two consecutive, were encountered among 1033 patients treated for primary lung malignancies. Consecutive bilateral surgical resections were performed in two instances. The third case underwent irradiation therapy alone. The risk of developing a second primary bronchogenic carcinoma increases during survival time. Therefore, all patients successfully treated for lung cancer should have lifetime follow-up examinations.

Stones in renal transplants

In a 50-year-old man (case 1) and a 17-year-old girl (case 2) stones developed in a functioning renal transplant. The respective intervals from transplantation to appearance of stone were seven years and six months. The serum calcium was elevated to approximately 3.00 mmol/l in case 1 and 2.65 mmol/l in case 2. The concentration of parathyroid hormone in serum was increased in case 1. Subtotal parathyroidectomy was performed in both patients, with removal of 2550 mg (case 1) and 150-160 mg (case 2) parathyroid tissue. In case 2 slight hypercalcaemia reappeared two months later. When stones in a transplanted kidney are associated with only slight hypercalcaemia and there is no deterioration of the renal function, conservative measures to reduce the serum calcium should be tried before subtotal parathyroidectomy is undertaken.

Dose dependent uptake of 125I-toluidine blue of 75Se-selenomethionine in the parathyroids of rabbits

Different dosages of 125I-toluidine blue and 75Se-selenomethionine were injected intravenously into rabbits, and the concentration of radioactivity was measured in the parathyroids and surrounding tissues. The response of i.v. injected glucagon was also determined. It was found that 0.16 mg 125I-toluidine blue gave a concentration ratio of parathyroid/thyroid and parathyroid/muscle which was significantly higher than both lower and higher doses at 1 minute after i.v. injection of the labelled dye. Glucagon had little or no effect on the uptake of 125I-toluidine blue and 75Se-selenomethionine.

Clinical results with 131I-toluidine blue and triple radionuclide subtraction for preoperative localization of enlarged parathyroid glands

Clinical results from the application of a triple radionuclide subtraction study for preoperative localization of enlarged parathyroid glands are presented in this paper. A scintillation camera image was recorded after i.v. injection of 131I-toluidine blue. The contributions to this image from activity in the thyroid gland and in blood were determined after recording of additional images (obtained after injection of 99mTcO4- and 113mIn, respectively) using an iterative computer algorithm that also provides an estimate for a uniform background. Subtraction of these contributions gives an image that may be interpreted as an image of the selective accumulation of 131I-toluidine blue in the parathyroids. One or more enlarged glands were correctly localized in 17 of 21 cases, but in four cases there were only false positives. In ten cases the correctly localized glands weighed 900 mg or less.

Pindolol (Viscén) in persistent ventricular fibrillation. A case report

The beneficial effect of a beta-blocking agent (pindolol), given as an adjuvant to DC-shock and lidocaine therapy in a case of heart resuscitation is reported. A 65-year-old female patient was operated for an abdominal aortic aneurysm. At the conclusion of the operation, which was prolonged and difficult, the patient developed alternating ventricular tachycardia and fibrillation. Within a time interval of 50 min electrical defibrillation was performed 20 to 25 times, and as much as 1100 mg of lidocaine was administered. Simultaneously, combined internal/external cardiac massage was performed. The patient's arrhythmia continued to recur after defibrillation until pindolol in dosages of 0.2 mg had been given twice intravenously. A permanent sinus rhythm was then achieved.