Screening chest wall ultrasound in the mastectomy patient

BACKGROUND

While there are clear guidelines regarding chest wall ultrasound in the symptomatic patient, there is conflicting evidence regarding the use of ultrasound in the screening of women post-mastectomy.

OBJECTIVE

To assess the utility of screening chest wall ultrasound after mastectomy and to assess features of detected malignancies.

METHODS

This IRB approved, retrospective study evaluates screening US examinations of the chest wall after mastectomy. Asymptomatic women presenting for screening chest wall ultrasound from January 2016 through May 2017 were included. Cases of known active malignancy were excluded. All patients had at least one year of clinical or imaging follow-up. 43 exams (8.5 %) were performed with a history of contralateral malignancy, 465 exams (91.3 %) were performed with a history of ipsilateral malignancy, and one exam (0.2 %) was performed in a patient with bilateral prophylactic mastectomy.

RESULTS

During the 17-month period, there were 509 screening US in 389 mastectomy patients. 504 (99.0 %) exams were negative/benign. Five exams (1.0 %) were considered suspicious, with recommendation for biopsy, which was performed. Out of 509 exams, 3 (0.6 %) yielded benign results, while 2 (0.39 %) revealed recurrent malignancy, with a 95 % confidence interval (exact binomial) of 0.05 % to 1.41 % for screening ultrasound. Both patients who recurred had previously recurred, and both had initial cancer of lobular histology.

CONCLUSION

Of 509 chest wall screening US exams performed in mastectomy, 2 malignancies were detected, and each patient had history of invasive lobular carcinoma and at least one prior recurrence prior to this study, suggesting benefit of screening ultrasound in these populations.

Suspicious Ultrasound-Occult Non-Calcified Mammographic Masses, Asymmetries, and Architectural Distortions Are Moderate Probability for Malignancy

Suspicious non-calcified mammographic findings have not been evaluated with modern mammographic technique, and the purpose of this work is to compare the likelihood of malignancy for those findings. To do this, 5018 consecutive mammographically guided biopsies performed during 2016-2019 at a large metropolitan, community-based hospital system were retrospectively reviewed. In total, 4396 were excluded for targeting calcifications, insufficient follow-up, or missing data. Thirty-seven of 126 masses (29.4%) were malignant, 44 of 194 asymmetries (22.7%) were malignant, and 77 of 302 architectural distortions (AD, 25.5%) were malignant. The combined likelihood of malignancy was 25.4%. Older age was associated with a higher likelihood of malignancy for each imaging finding type (all p ≤ 0.006), and a possible ultrasound correlation was associated with a higher likelihood of malignancy when all findings were considered together (p = 0.012). Two-view asymmetries were more frequently malignant than one-view asymmetries (p = 0.03). There were two false-negative biopsies (98.7% sensitivity and 100% specificity). In conclusion, the 25.4% likelihood of malignancy confirms the recommendation for biopsy of suspicious, ultrasound-occult, mammographic findings. Mammographically guided biopsies were highly sensitive and specific in this study. Older patient age and a possible ultrasound correlation should raise concern given the increased likelihood of malignancy in those scenarios.

Diagnostic ultrasound of the chest wall in the symptomatic patient after mastectomy

BACKGROUND

Lack of standardized imaging recommendations among mastectomy patients has led to variability in how recurrences are detected.

OBJECTIVE

To describe the findings and assess the diagnostic efficacy of ultrasound in the evaluation of symptomatic post-mastectomy patients.

MATERIALS AND METHODS

This single institution, retrospective study included 749 consecutive diagnostic chest wall ultrasound examinations performed in mastectomy patients, from January 2016 to June 2017. Chest wall ultrasound evaluated the mastectomy bed with or without reconstruction. Electronic health records were queried for the primary breast cancer histology prior to mastectomy, clinical symptoms prompting the diagnostic ultrasound, ultrasound findings, subsequent cytology and pathology, and follow-up data. Excluded were patients with a known recurrence, asymptomatic patients, and those with <2 years of clinical or imaging follow-up. Descriptive and comparative statistical analyses were performed.

RESULTS

Among the 749 ultrasounds performed, 58 malignancies were identified for a 7.7% (58/749) malignancy rate, with a median tumor size of 20 mm. Patients diagnosed with a malignancy most often presented with a palpable abnormality (79.3%, 46/58) or skin changes (13.8%, 8/58) and rarely with pain (1.7%, 1/58). Patients who underwent a biopsy yielding a benign result most often presented with a palpable abnormality (41.5%, 287/691), pain (25.6%,177/691), or postoperative swelling/suspected fluid collection (17.8%, 123/691). Diagnostic ultrasound yielded a 91.4% sensitivity (95% CI 81.0, 97.1), 96.1% specificity (95% CI 94.4, 97.4), 66.3% PPV₃ (95% CI 57.4, 74.1), and 99.3% negative predictive value (95% CI 98.3, 99.7) for cancer detection. There were 5 false negative ultrasound cases after a skin punch biopsy was performed due to clinically suspicious skin changes.

CONCLUSIONS

Chest wall ultrasound has a high sensitivity and negative predictive value for detection of breast cancer recurrence in symptomatic patients after mastectomy. Skin changes remain an important clinical manifestation of a cancer recurrence.

Dense Sampling Approaches for Psychiatry Research: Combining Scanners and Smartphones

Together, data from brain scanners and smartphones have sufficient coverage of biology, psychology, and environment to articulate between-person differences in the interplay within and across biological, psychological, and environmental systems thought to underlie psychopathology. An important next step is to develop frameworks that combine these two modalities in ways that leverage their coverage across layers of human experience to have maximum impact on our understanding and treatment of psychopathology. We review literature published in the last 3 years highlighting how scanners and smartphones have been combined to date, outline and discuss the strengths and weaknesses of existing approaches, and sketch a network science framework heretofore underrepresented in work combining scanners and smartphones that can push forward our understanding of health and disease.

Pseudoangiomatous Stromal Hyperplasia: Radiologic-Pathologic Correlation

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast. PASH is postulated to be hormonally induced and predominantly occurs in premenopausal women and postmenopausal women on menopausal hormone therapy. Clinical presentation varies from screen-detected lesions to palpable masses. Imaging findings of PASH are nonspecific. The most common mammographic findings are an oval or round circumscribed non-calcified mass or developing asymmetry. On US, PASH is often seen as an oval hypoechoic mass that may be circumscribed and can have an echogenic rim, or, when manifest as mammographic asymmetry, US may show a corresponding non-mass focal area of echogenic tissue. Limited studies have investigated the MRI appearance, with PASH most often manifesting as non-mass enhancement, or, less often, as an oval or irregular mass with persistent kinetics. Histopathologically, PASH can be mistaken for a fibroadenoma or phyllodes tumor and has features overlapping low-grade angiosarcoma. Assessment of radiologic-pathologic concordance is particularly important as PASH is often an incidental finding, adjacent to the targeted lesion at histopathology. Surgical excision or repeat core-needle biopsy is necessary for discordant suspicious cases. After a benign, concordant diagnosis of PASH, the patient may resume routine screening.

Nipple Discharge Imaging Evaluation with Mammography, Ultrasound, Galactography, and MRI

RATIONALE AND OBJECTIVE

To determine the diagnostic yield of various imaging tests used to evaluate nipple discharge.

MATERIALS AND METHODS

A single institution, IRB-approved, retrospective study was performed of 320 consecutive patients presenting with nipple discharge. Imaging and pathology were reviewed to determine the yield for malignancy, atypical high-risk lesions (HRLs), and intraductal papillomas (IDPs).

RESULTS

Of the 320 patients, pathology or follow up confirmed 40 breast malignancies (40/320, 12.5%),14 atypical HRLs (14/320, 4.4%), 71 IDPs (71/320, 22.2%), 48 other benign pathologies (48/320,15.0%), and 147 unknown but benign cases (147/320, 45.9%). Physiologic discharge characteristics were observed in a minority of malignant cases: nonspontaneous (4/40, 10.0%); neither bloody nor clear (4/40, 10.0%); bilateral (3/40, 7.5%). Malignancy was associated with older age (p < 0.001) and bloody discharge (odds ratio 6.5, p < 0.0001). The combination of digital mammography and ultrasound had a 93% sensitivity and a 98% NPV, while contrast enhanced MRI (CE-MRI) had a 100% sensitivity and a 100% NPV for malignancy. Only three galactography examinations were performed among the malignant cohort, with minimal contribution (1 of 3) to the diagnostic evaluation. In this case, galactography findings helped determine imaging-pathology discordance, prompting a recommendation for surgical excision and subsequently a malignant diagnosis.

CONCLUSION

The combination of mammography and ultrasonography detected 93% of breast malignancies associated with nipple discharge and had a 98% NPV for malignancy. The value of CE-MRI is its ability to detect the remaining malignancies, not detected on mammography or ultrasound, and its ability to obviate the need for surgical duct excision.

Finding positive meaning in memories of negative events adaptively updates memory

Finding positive meaning in past negative memories is associated with enhanced mental health. Yet it remains unclear whether it leads to updates in the memory representation itself. Since memory can be labile after retrieval, this leaves the potential for modification whenever its reactivated. Across four experiments, we show that positively reinterpreting negative memories adaptively updates them, leading to the re-emergence of positivity at future retrieval. Focusing on the positive aspects after negative recall leads to enhanced positive emotion and changes in memory content during recollection one week later, remaining even after two months. Consistent with a reactivation-induced reconsolidation account, memory updating occurs only after a reminder and twenty four hours, but not a one hour delay. Multi-session fMRI showed adaptive updates are reflected in greater hippocampal and ventral striatal pattern dissimilarity across retrievals. This research highlights the mechanisms by which updating of maladaptive memories occurs through a positive emotion-focused strategy.

The social value of positive autobiographical memory retrieval

Positive memory retrieval generates pleasant feelings that can counteract negative affective states and improve mood. However, not all positive memories are created equal. Our most treasured memories are likely experiences we shared with other people (e.g., birthday party) rather than something we did alone (e.g., receiving good grades). Here, we explored whether the social context within a positive memory enhanced its subjective value and contributed to an individual's well-being. In Study 1, participants were asked how much they would be willing to pay to reexperience positive memories that occurred with socially close others (high-social), with acquaintances (low-social) or alone (nonsocial). When controlling for the memory's positivity, participants were still willing to pay 1.5 times as much for high-social than for low-social or nonsocial memories. Likewise, participants chose to reminisce about high-social memories more frequently than less social ones of equal positive feeling. In Study 2, recalling memories rich in social context recruited regions previously implicated in mentalizing and reward (e.g., caudate), which further correlated with greater ability to savor positive emotions in daily life. Finally, we examined the benefit of social context by asking participants to recall positive memories that varied in social context after acute stress exposure. In Study 3, recalling memories that included higher social context led to a greater dampening of the physiological stress response (i.e., cortisol). Taken together, these findings suggest that social context inherent in a positive memory enhances its value, providing a possible mechanism by which positive reminiscence aids stress coping and enhances well-being. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

High risk breast lesions identified on MRI-guided vacuum-assisted needle biopsy: outcome of surgical excision and imaging follow-up

OBJECTIVE:

To determine whether breast MRI-guided vacuum-assisted biopsy (MRI-VAB) high-risk lesion histology influences surgical or long-term imaging follow-up outcomes.

METHODS:

Patients with imaging-concordant high-risk findings on 9-gauge breast MRI-VAB between January 2007 and July 2012 who had surgical histopathology or 2 year imaging follow-up were retrospectively reviewed.

RESULTS:

90 patients with 99 lesions were included. Lesions were atypical ductal hyperplasia (ADH) (n = 21), lobular neoplasia [n = 36; atypical lobular hyperplasia (ALH) (n = 22), lobular carcinoma in situ (LCIS) (n = 6), and ALH plus LCIS (n = 8)], and other high-risk lesion (n = 42; papillary lesions, radial scar, flat epithelial atypia, atypia unspecified). Of 53 excised lesions, 6 (11%) were upgraded to invasive cancer or ductal carcinoma in situ (DCIS). 4 of 21 (19%) ADH lesions were upgraded to DCIS. 2 of 36 (6%) lobular neoplasia lesions, both combined ALH and LCIS, were upgraded to DCIS, and invasive lobular carcinoma, respectively. The remaining 46 lesions were managed conservatively with imaging follow-up: 17 (37%) had mammography only, while 29 (63%) had mammography and MRI follow-up. There was no evidence of breast cancer development at the site of MRI-VAB in the cases with only imaging follow-up.

CONCLUSION:

We conclude that the upgrade rate for high-risk lesions at MRI-VAB at surgical excision is low. Surgical excision is warranted for ADH and combined ALH-LCIS lesions. For other lesions, a multidisciplinary approach to decide on personalized management may be appropriate.

ADVANCES IN KNOWLEDGE:

Surgical excision is warranted for ADH lesions and combined ALH-LCIS lesions identified at breast MRI-VAB. A multidisciplinary approach to patient management of other high-risk lesions may be appropriate.

Positive autobiographical memory retrieval reduces temporal discounting

People generally prefer rewards sooner rather than later. This phenomenon, temporal discounting, underlies many societal problems, including addiction and obesity. One way to reduce temporal discounting is to imagine positive future experiences. Since there is overlap in the neural circuitry associated with imagining future experiences and remembering past events, here we investigate whether recalling positive memories can also promote more patient choice. We found that participants were more patient after retrieving positive autobiographical memories, but not when they recalled negative memories. Moreover, individuals were more impulsive after imagining novel positive scenes that were not related to their memories, showing that positive imagery alone does not drive this effect. Activity in the striatum and temporo parietal junction during memory retrieval predicted more patient choice, suggesting that to the extent that memory recall is rewarding and involves perspective-taking, it influences decision-making. Furthermore, representational similarity in the ventromedial prefrontal cortex between memory recall and decision phases correlated with the behavioral effect across participants. Thus, we have identified a novel manipulation for reducing temporal discounting-remembering the positive past-and have begun to characterize the psychological and neural mechanisms behind it.

Toward a cumulative science of functional integration: A meta-analysis of psychophysiological interactions

Much of the work in cognitive neuroscience is shifting from a focus on single brain regions to a focus on the connectivity between multiple brain regions. These inter-regional connectivity patterns contribute to a wide range of behaviors and are studied with models of functional integration. The rapid expansion of the literature on functional integration offers an opportunity to scrutinize the consistency and specificity of one of the most popular approaches for quantifying connectivity: psychophysiological interaction (PPI) analysis. We performed coordinate-based meta-analyses on 284 PPI studies, which allowed us to test (a) whether those studies consistently converge on similar target regions and (b) whether the identified target regions are specific to the chosen seed region and psychological context. Our analyses revealed two key results. First, we found that different types of PPI studies-e.g., those using seeds such as amygdala and dorsolateral prefrontal cortex (DLPFC) and contexts such as emotion and cognitive control, respectively-each consistently converge on similar target regions, thus supporting the reliability of PPI as a tool for studying functional integration. Second, we also found target regions that were specific to the chosen seed region and psychological context, indicating distinct patterns of brain connectivity. For example, the DLPFC seed reliably contributed to a posterior cingulate cortex target during cognitive control but contributed to an amygdala target in other contexts. Our results point to the robustness of PPI while highlighting common and distinct patterns of functional integration, potentially advancing models of brain connectivity. Hum Brain Mapp 37:2904-2917, 2016. © 2016 Wiley Periodicals, Inc.

Cognitive reserve modulates ERPs associated with verbal working memory in healthy younger and older adults

Although many epidemiological studies suggest the beneficial effects of higher cognitive reserve (CR) in reducing age-related cognitive decline and dementia risk, the neural basis of CR is poorly understood. To our knowledge, the present study represents the first electrophysiological investigation of the relationship between CR and neural reserve (i.e., neural efficiency and capacity). Specifically, we examined whether CR modulates event-related potentials associated with performance on a verbal recognition memory task with 3 set sizes (1, 4, or 7 letters) in healthy younger and older adults. Neural data showed that as task difficulty increased, the amplitude of the parietal P3b component during the probe phase decreased and its latency increased. Notably, the degree of these neural changes was negatively correlated with CR in both age groups, such that individuals with higher CR showed smaller changes in P3b amplitude and less slowing in P3b latency (i.e., smaller changes in the speed of neural processing) with increasing task difficulty, suggesting greater neural efficiency. These CR-related differences in neural efficiency may underlie reserve against neuropathology and age-related burden.

Savoring the past: positive memories evoke value representations in the striatum

Reminders of happy memories can bring back pleasant feelings tied to the original experience, suggesting an intrinsic value in reminiscing about the positive past. However, the neural circuitry underlying the rewarding aspects of autobiographical memory is poorly understood. Using fMRI, we observed enhanced activity during the recall of positive relative to neutral autobiographical memories in corticostriatal circuits that also responded to monetary reward. Enhanced activity in the striatum and medial prefrontal cortex was associated with increases in positive emotion during recall, and striatal engagement further correlated with individual measures of resiliency. Striatal response to the recall of positive memories was greater in individuals whose mood improved after the task. Notably, participants were willing to sacrifice a more tangible reward, money, in order to reminisce about positive past experiences. Our findings suggest that recalling positive autobiographical memories is intrinsically valuable, which may be adaptive for regulating positive emotion and promoting better well-being.

Neonatal intensive care applications of near-infrared spectroscopy

Near-infrared spectroscopy (NIRS) is a noninvasive technique for assessing cerebral hemodynamic variables and oxidative status in the neonatal intensive care setting. It can be performed for extended periods of time at the bedside without interfering with routine patient care. NIRS appears to have the ability to not only assess relative changes in oxygenated and deoxygenated hemoglobin, total hemoglobin, and cytochrome aa3, but it can also produce estimates of cerebral blood volume and cerebral blood flow. Research data document significant changes in these hemodynamic variables with patient activity and clinical interventions in both premature and term infants. NIRS may evolve into an important diagnostic and prognostic tool for neonatal neurologic outcome.

Challenges in the NICU: questions or answers?

In the changing paradigm of medicine, the cost of health care has become the bellwether for effective health care delivery. Managed care and case management are proposed as the only methodology suitable for this new model. The concept of early discharge is advanced as appropriate care. A Neonatal Intensive Care Unit (NICU) associated with an academic health center is seen as more costly than an NICU in a nonacademic setting. Little data exists, however, that support or refute the above assertions. Measurement of relevant processes to determine the outcome of NICU care is essential to insure the delivery of quality health care within the cost-containment model.

Early detection of bacteremia in an outpatient clinic

A total of 570 patients, aged less than 24 months, who were seen in the emergency room at Texas Children's Hospital for evaluation of acute febrile illness had a WBC count, differential count, and a blood culture obtained. Bacteremia occurred in 7.7% (n = 44) (22 Haemophilus influenzae; 17 Streptococcus pneumoniae; three Escherichia coli; one group B Streptococcus; one Staphylococcus aureus). The sensitivity, specificity, and positive predictive value of morphologic changes (vacuolization and toxic granulation) of polymorphonuclear neutrophils (segmented neutrophils plus band cells), WBC count greater than or equal to 15,000/microL and band cells greater than or equal to 500/microL were examined. Additionally, abnormalities in three of four tests (WBC count greater than or equal to 15,000/microL, band cells greater than or equal to 500/microL, segmented neutrophils greater than or equal to 10,000/microL, and/or total polymorphonuclear neutrophils greater than or equal to 10,500/microL) were evaluated. Morphologic changes of polymorphonuclear neutrophils were noted frequently in patients with culture-proven bacteremia (63% and 51% positive predictive value for vacuolization and toxic granulation, respectively) and were more predictive of bacterial infection than traditional tests. If both vacuolization and toxic granulation were present, the positive predictive value increased to 76%. Examination of the peripheral blood smear may provide important adjunctive information for the presence of bacteremia prior to bacteriologic confirmation.

Intraventricular hemorrhage and vitamin E in the very low-birth-weight infant: evidence for efficacy of early intramuscular vitamin E administration

To determine whether early intramuscular vitamin E supplementation influences the incidence of intraventricular hemorrhage (IVH) in infants with birth weight less than or equal to 1,500 g, data were analyzed from 134 infants enrolled on a protocol to evaluate the efficacy of intramuscular plus oral vitamin E v oral supplementation alone in the treatment of retrolental fibroplasia. All 134 infants received, via nasogastric tube, 100 mg/kg/d of vitamin E daily (dl-alpha-tocopheryl acetate in MCT [medium-chain triglyceride] oil; 150 mosM) for at least 8 weeks with the first dose administered within the first eight hours of life. Sixty-four patients received, in addition, intramuscular vitamin E on days 1, 2, 4, and 6 of life and 70 patients received placebo injections in a randomized double-blind fashion. In the first week, vitamin E plasma levels were significantly higher in the 64 patients given intramuscular vitamin E. In spite of this difference no change in the incidence of sepsis or necrotizing enterocolitis was observed. Both the incidence and severity of intraventricular hemorrhage were reduced significantly in the patients given intramuscular vitamin E as compared to the patients given placebo (P = .013 and P = .04, respectively). The data suggest that vitamin E, a natural antioxidant, may play an important role in protecting the CNS microcirculation from the effects of hypoxic/ischemic injury.

Degenerative changes in neutrophils: an indicator of bacterial infection

A review was made of 195 peripheral blood smears of 157 neonates who required sepsis work-up in the first month of life. Degenerative changes of neutrophils including vacuolization and toxic granulation were observed frequently in infants with culture-proven bacterial sepsis. Of 21 peripheral blood smears from 20 neonates subsequently proven to have bacterial infection, 17 had vacuolization present in the neutrophils for a sensitivity of 81%, a specificity of 93%, and a positive predictive accuracy of 59%. Toxic granulation changes in neutrophils showed similar results. This simple test can be performed easily in all hospitals; it does not require special laboratory facilities. The test appears to provide a valuable adjunct in the early detection of neonatal bacterial infection.

Fatal hepatoadrenal necrosis in the neonate associated with echovirus types 11 and 12 presenting as a surgical emergency

Two neonates presented to our service with suspected intraabdominal surgical emergencies. Both subsequently were found to have hepatoadrenal necrosis due to overwhelming echoviral infection. Echovirus types 11 and 12 were isolated postmortem. The latter virus has not been associated previously with fulminant neonatal illness.

Elevation of plasma concentrations of arginine vasopressin following perinatal asphyxia

Hypoxic ischemic encephalopathy is a major cause of mortality in neonates. Studies in experimental subjects have shown differing responses of plasma arginine vasopressin to hypoxia. Plasma arginine vasopressin levels, serum osmolality, urine osmolality and fluid intakes were measured in thirteen asphyxiated and nineteen control newborn infants during the first seventy-two hours of life. In the asphyxiated infants plasma arginine vasopressin was found to be elevated as compared to control infants on days one (p less than 0.001) and two (p less than 0.007) but not on day three of life. Urine osmolality was also elevated in the study patients on days one (p less than 0.01) and two (p less than 0.001) but not on day three, in spite of equal intakes of fluid on day one in both groups and significantly diminished fluid intake on days two and three in the study patients. Serum osmolality was not different between the two groups on any day studied, and was felt to be on the basis of diminished intake in the study infants. The data presented in this study support the concept that arginine vasopressin release occurs following perinatal asphyxia in term newborn infants.

Use of deglycerolized red blood cells to prevent posttransfusion infection with cytomegalovirus in neonates

In an effort to reduce the rate of posttransfusion infection with cytomegalovirus (CMV), 157 CMV-seronegative neonates were given deglycerolized red blood cells as their only source of red blood cells. Other blood products given to these patients received no special preparation. The 106 (67.5%) infants available for adequate evaluation received an average of 5.7 units (range, one to 39 units). Three hundred thirteen (51.4%) of the 609 transfused units were CMV-seropositive. When evaluated three months after their last transfusion, none of the 106 infants had virological or serological evidence of CMV infection. These results suggest that regardless of the serological status of the donor, deglycerolized red blood cells can reduce or possibly eliminate posttransfusion CMV infection and can serve as a safe alternative to CMV-seronegative blood. Freezing, depletion, and physical disruption of leukocytes may be responsible for the decreased infectivity of the deglycerolized product.

Retrolental fibroplasia and vitamin E in the preterm infant--comparison of oral versus intramuscular:oral administration

To evaluate the efficacy of four early intramuscular injections of vitamin E given in addition to continuous minimal oral vitamin E supplementation, 168 very low-birth-weight infants (less than or equal to 1,500 g) have enrolled in a randomized, double-masked, clinical study. All infants received vitamin E orally, 100 mg/kg/d. In addition, on days 1, 2, 4, and 6, seventy-nine infants received vitamin E intramuscularly, 15, 10, 10, and 10 mg/kg, respectively. On the same days, 89 control infants received placebo intramuscular injections. Multivariate analysis of the 135 infants who survived greater than or equal to 10 weeks showed no significant difference in the development of severe retrolental fibroplasia between these two supplementation schedules (P = .86). Plasma vitamin E levels never exceeded a mean of 3.3 mg/100 mL, and no toxicity was observed. Ultrastructural analyses of seven pairs of whole eye donations from infants receiving IM vitamin E demonstrated identical kinetics of gap junction formation between adjacent spindle cells as compared with 13 pairs of whole eye donations from control infants (P greater than .3). Therefore, oral vitamin E supplementation affords retinal protection against the development of severe retrolental fibroplasia when initiated on the first day of life and maintained continuously until retinal vascularization is complete.

Calcification of superficial scalp veins secondary to intravenous infusion of sodium bicarbonate and calcium chloride

Soft tissue calcification has been reported following the intramuscular injection of calcium salts and the intravenous administration of calcium gluconate. The present case report describes a neonate in whom calcification of the superficial scalp veins developed following administration of calcium chloride and sodium bicarbonate through a scalp vein needle.

Retrolental fibroplasia: further clinical evidence and ultrastructural support for efficacy of vitamin E in the preterm infant

To further evaluate the efficacy of oral vitamin E in preventing the development of severe retrolental fibroplasia (RLF) in very low-birth-weight infants, 100 infants treated with 100 mg/kg/d of vitamin E (dl-alpha-tocopheryl acetate) were compared with 75 infants treated with 5 mg/kg/d of vitamin E (dl-alpha-tocopherol) in the same nursery during the previous year. All 175 infants weighed less than or equal to 1,500 g at birth and required supplemental oxygen. A total of 120 infants (69 treatment; 51 control) survived greater than or equal to 10 weeks. Multivariate analysis of the control population identified five risk factors (P less than or equal to .10): gestational age, level and duration of oxygen administration, intraventricular hemorrhage, sepsis, and birth weight. When multivariate analysis was applied to both control and treatment groups, the severity of RLF was found to be significantly reduced in infants given the treatment dose of vitamin E (P = .003). Ultrastructural analyses of 58 pairs of whole-eye donations from high-risk infants surviving less than 10 weeks suggest that the initial morphologic event is gap junction increases between the plasma membranes of adjacent spindle cells of the van-guard retina. Such extensively gap junction-linked spindle cells are apparently removed from the vasoformative process as early as 4 days of life, forming a barrier to further normal vascular development and triggering retinal and vitreal neovascularizations approximately 8 weeks later. These events are maximally suppressed by elevated plasma vitamin E levels in infants greater than or equal to 27 weeks gestational age.

Pharmacology of kanamycin in the newborn

We studied the pharmacologic effects of kanamycin in three groups of newborn infants: group 1--birth weight (BW) less than or equal to 2,000 gm, chronologic age (CA) less than 7 days; group 2--BW greater than 2,000 gm, CA less than 7 days; and group 3--BW greater than 2,000 gm, CA 7 to 28 days. The dose of kanamycin was 15 mg/kg/day, administered in two intramuscular doses. Serum kanamycin levels were measured 15 minutes before the dose and 1/2, 1, 6, and 8 hours after the dose. Infants in group 1 had a mean peak concentration of 18.7 micrograms/ml, those in group 2, 19.6 micrograms/ml, and those in group 3, 15.6 micrograms/ml. The mean peak concentrations varied inversely with chronologic age but were not influenced by birth weight. Mean serum half-life varied inversely with birth weight, gestational age, and chronologic age. We recommend a standard dose of 15 mg/kg/day for newborn infants. Modification of this dose may be required for individual infants.

Examination of the anterior vascular capsule of the lens: III. Abnormalities in infants with congenital infection

The disappearance of the anterior vascular capsule of the lens (tunica vasculosa lentis) in the preterm infant has been established to be useful in accurately estimating gestational age between the twenty-seventh and thirty-fourth weeks in infants appropriate or small for gestational age. Six infants have been studied with abnormalities of the anterior vascular capsule of the lens in which congenital TORCH infection has been documented (1 toxoplasmosis, 2 rubella, 2 cytomegalovirus, and 1 herpes simplex virus). Since the anterior vascular capsule generally atrophies symmetrically and completely after the thirty-fourth week of gestation, the findings of marked asymmetry and/or persistence and hypertrophy of the anterior vascular capsule of the lens warrants initiation of TORCH studies in the newborn infant.

Cerebrospinal fluid concentrations of aqueous procaine penicillin G in the neonate

Simultaneous serum and CSF samples were obtained following the intramuscular administration of 50,000 units/kg of aqueous procaine penicillin G in 25 neonates. Penicillin activity was detected in the sera and CSF of all patients. Peak serum levels were noted at four hours (mean +/- SEM, 17.1 +/- 6.3 micrograms/ml). Peak CSF levels were noted at 12 hours (0.70 +/- 0.35 microgram/ml). The serum level at 24 hours was 2.1 +/- 0.98 microgram/ml (range, 0.2 to 5.8 micrograms/ml); the CSF level at 24 hours was 0.12 +/- 0.05 micrograms/ml (range, 0.03 to 0.27 microgram/ml). These results demonstrate that spirocheticidal levels (greater than or equal to 0.03 microgram/ml) are achieved for at least 24 hours in the CSF following the intramuscular administration of aqueous procaine penicillin G in neonates.

Candida endophthalmitis: a manifestation of candidiasis in the neonate

Candida endophthalmitis is a frequent complication of systemic candidiasis. The case reported emphasizes the usefulness of indirect ophthalmoscopy in evaluating infants suspected of having disseminated candidal infection and describes the pathologic findings of Candida endophthalmitis in the neonate.

Characterization of the cardiomyopathy in infants of diabetic mothers

A transient form of hypertrophic cardiomyopathy has been previously described in infants of diabetic mothers (IDMs). The purpose of this study was to determine the incidence, natural history and pathologic features of this cardiomyopathy in symptomatic and asymptomatic IDMs. We studied 47 IDMs for evidence of cardiomyopathy. Among 24 symptomatic IDMs, five had marked septal hypertrophy with echocardiographic features suggesting left ventricular outflow obstruction and five had hypertrophy of the right ventricular free wall. With the exception of mild septal hypertrophy, these abnormalities resolved during the first 6 months of life, and echocardiograms in the first-degree family members were normal. Of 23 asymptomatic IDMs, three had septal hypertrophy and two had right ventricular free wall hypertrophy; none of the asymptomatic IDMs had evidence of outflow obstruction. One symptomatic IDM died, and autopsy revealed a hypertrophic septum that distorted both ventricular cavities. Microscopic examination revealed hypertrophic fibers and occasional areas of cellular disarray in the septum. Despite the clinical and pathologic similarities of the cardiomyopathy in IDMs to the hypertropic cardiomyopathies in older children and adults, its transient and nonfamilial nature suggest that it is a separate disease. We speculate that it is a manifestation of the generalized organomegaly in IDMs.

Bacterial colonization of radial artery catheters

In 147 radial artery catheterizations performed, blanching or embolization was noted in 10.8% of the patients. Only a single episode of catheter-related septicemia was observed (0.6%) Mean duration of catheterization was 48 +/- 6 hours. Of 110 catheters cultured 25.4% grew bacteria; most organisms cultured were nonpathogenic. Duration of catheterization and intravascular infusion did not alter the incidence of catheter colonization.

The foam stability test on gastric aspirate in the prediction of respiratory distress syndrome

To evaluate the usefulness of the foam stability test (FST) on gastric aspirate for predicting respiratory distress syndrome (RDS) in premature infants, samples were collected at delivery or within 30 min from 194 infants less than or equal to 36 weeks gestation. Of 123 samples adequate for complete testing, 44 were positive at 1 : 2 dilution, 43 were positive only at dilutions less than 1 : 2 and 36 were negative at all dilutions. RDS was found in 2%, 21% and 25% of each group respectively. The FST on gastric aspirate at birth gives useful information only if positive at 1 : 2 when a very low incidence of RDS may be expected. However, a large proportion of infants with FST negative at 1 : 1 do not develop RDS, and hence the test is of limited value in screening for those with highest risk.

Fulminant neonatal sepsis and necrotizing enterocolitis associated with a "nonenteropathogenic" strain of Escherichia coli

During 1973 a nonendemic mucoid strain of Escherichia coli entered the nursery of a hospital in Houston. This organism caused septicemia and was associated with a high incidence of necrotizing enterocolitis. The illness was fulminant and characterized by apnea, abdominal distension, and shock. Diarrhea was not a feature of the symptom complex. The epidemic organism was nontypable. Assays for invasiveness, enterotoxin production, and Kl antigen were negative. Surveillance revealed a colonization rate of 14%, an attack rate in colonized infants of 19.5%, and a mortality rate of 87.5%. These data suggest that in certain instances the specific bowel flora may increase the incidence and severity of NEC.