International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines

The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) formulated new evidenced-based recommendations for neonatal resuscitation. These guidelines comprehensively update the last recommendations, published in 1992 after the Fifth National Conference on CPR and ECC. As a result of the evidence evaluation process, significant changes occurred in the recommended management routines for: * Meconium-stained amniotic fluid: If the newly born infant has absent or depressed respirations, heart rate <100 beats per minute (bpm), or poor muscle tone, direct tracheal suctioning should be performed to remove meconium from the airway. * Preventing heat loss: Hyperthermia should be avoided. * Oxygenation and ventilation: 100% oxygen is recommended for assisted ventilation; however, if supplemental oxygen is unavailable, positive-pressure ventilation should be initiated with room air. The laryngeal mask airway may serve as an effective alternative for establishing an airway if bag-mask ventilation is ineffective or attempts at intubation have failed. Exhaled CO(2) detection can be useful in the secondary confirmation of endotracheal intubation. * Chest compressions: Compressions should be administered if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. The 2-thumb, encircling-hands method of chest compression is preferred, with a depth of compression one third the anterior-posterior diameter of the chest and sufficient to generate a palpable pulse. * Medications, volume expansion, and vascular access: Epinephrine in a dose of 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) should be administered if the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions. Emergency volume expansion may be accomplished with an isotonic crystalloid solution or O-negative red blood cells; albumin-containing solutions are no longer the fluid of choice for initial volume expansion. Intraosseous access can serve as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available. * Noninitiation and discontinuation of resuscitation: There are circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate.     

Providing general dentistry for people with disabilities: a demographic review

In the mid-1990s, approximately 54 million American people had some level of disability, including 26 million who had a severe disability. In addition, more than three-quarters of individuals with mental retardation/developmental disabilities were deinstitutionalized during the past 30 years and now reside in our communities, relying upon community practitioners for needed services. This review is provided to make dental practitioners aware of the magnitude and dimensions of the situations in which persons with special needs require their services.     

You may be treating children with mental retardation and attention deficit hyperactive disorder in your dental practice

Providing dental services for children with mental retardation is complicated further for those youngsters with the comorbidity of attention deficit hyperactivity disorder. A general introduction into these conditions is presented in an effort to extend practitioner awareness and ability to provide needed care.     

Laryngeal Activity During Swallow,Phonation, and the Valsalva Maneuver: An Electromyographic Analysis

To better understand the mechanisms of airway protection during swallow, the authors of this study performed an electromyographic (EMG) analysis on the thyroarytenoid (TA) and interarytenoid (IA) muscles during a variety of tasks. The tasks included high, low, and comfortable pitch phonation, the Valsalva maneuver, saliva swallow, and 5-and 10-mL water swallows. Raw EMG signals were analyzed to obtain root mean square data, which correspond to a relative magnitude of muscle activation. The data show that both TA and IA muscles generate a similar level of relative activation, with the greatest electrical activity observed during swallow tasks followed by the Valsalva maneuver and phonation. The duration, onset, offset, and pattern of activity during the swallowing tasks also showed close synchronization between the two muscles. These data can be used in designing therapy for voice disorders and pharyngeal dysphagia.     

The association between laryngopharyngeal sensory deficits, pharyngeal motor function, and the prevalence of aspiration with thin liquids.

OBJECTIVE: The study goal was to evaluate the association among laryngopharyngeal sensory deficits, pharyngeal motor function, and the prevalence of aspiration with thin liquids. STUDY DESIGN AND SETTING: We conducted a prospective study of 204 consecutive patients undergoing flexible endoscopic evaluation of swallowing with sensory testing and an assessment of pharyngeal motor function (pharyngeal squeeze). Patients were divided into 6 groups depending on the results of sensory and motor testing in the laryngopharynx. Subjects were given 5 mL of thin liquid, and the prevalence of aspiration in each group was compared. RESULTS: The mean age of the entire cohort was 65 years (58% female). The prevalence of aspiration in patients with intact laryngopharyngeal sensation was 2% (3 of 137) in persons with intact pharyngeal motor function and 29% (2 of 7) when pharyngeal motor function was impaired (P < 0.05). The prevalence of aspiration in patients with a moderate decrease in laryngopharyngeal sensation was 0% (0 of 9) in persons with intact pharyngeal motor function and 67% (2 of 3) when pharyngeal motor function was impaired (P < 0.05). The prevalence of aspiration in patients with severely diminished or absent laryngopharyngeal sensation was 15% (5 of 33) in persons with intact pharyngeal motor function and 100% (15 of 15) when pharyngeal motor function was impaired (P < 0.05). CONCLUSION: Patients with severely diminished laryngopharyngeal sensation and pharyngeal motor function are at an extremely high risk of aspirating thin liquids (100%). Moderate sensory deficits only appear to influence the prevalence of thin liquid aspiration in the presence of pharyngeal motor dysfunction. Severe laryngopharyngeal sensory deficits are associated with the aspiration of thin liquids regardless of the integrity of pharyngeal motor function. We assume that all persons with an insensate laryngopharynx aspirate thin liquids until proved otherwise. These results emphasize the relationship between laryngopharyngeal sensation and pharyngeal motor function in the evaluation of patients for suspected aspiration.     

Neonatal stroke: Clinical characteristics and cerebral blood flow velocity measurements

The clinical courses of 8 term infants with focal cerebral infarction or neonatal stroke were studied to determine whether such infants can be identified by current markers of perinatal distress, and whether changes in cerebral blood flow velocity (CBFV) occur during the acute phase of the disease. CBFV was measured from the middle cerebral artery (MCA) and anterior cerebral artery (ACA) utilizing duplex Doppler. Seven of the 8 patients required no resuscitation in the delivery room; 1 infant required brief bag and mask ventilation. No infant had evidence of severe fetal acidemia (i.e., cord pH <7). All 8 infants were initially admitted to the newborn nursery. Infants were identified on the basis of abnormal clinical findings observed during the first 48 hours: seizures (n = 6) and hypotonia and apnea (n = 2). Serum electrolytes, calcium, magnesium, and glucose levels were normal, and the sepsis evaluation including a spinal tap was sterile in all patients. Neuroimaging revealed nonhemorrhagic left focal MCA infarction (n = 6) and right focal MCA infarction (n = 2). Duplex Doppler demonstrated transient ipsilateral decreases in CBFV as compared to the contralateral unaffected side at clinical presentation in 4 infants. In 2 of these infants the decrease in CBFV involved both the MCA and ACA, and in 2 infants, only the MCA vessels. These side-to-side differences were not present at subsequent CBFV measurements. The data indicate that infants who develop neonatal stroke cannot be distinguished from infants who do not develop the lesion by current markers of perinatal distress. Because neonatal stroke frequently occurs as an unanticipated event, prevention may not be possible.     

Cone-rod dysfunction in patients with unexplained reduction in visual acuity

Electrophysiologic tests were performed in 233 patients who complained of reduced visual acuity with no satisfactory clinical explanation. The functional integrity of the retina was assessed from the light-and dark-adapted electroretinogram., Macular function and conduction in the optic nerves were estimated from the flash visual evoked potentials. Of the 233 patients 78 were grouped together on the basis of the electrophysiologic and clinical findings. They were characterized by subnormal electroretinogram responses with the cone system more affected than the rod system. The flash visual evoked potential responses were of abnormal waveform and prolonged implicit times. Most of these patients exhibited normal fundi. The reduction in visual acuity, the degree of electroretinogram deficits and the pattern of the visual evoked potential responses were similar in both eyes of each, patient, indicating a symmetric disorder. Slight deterioration of visual acuity and electrophysiologic variables were observed in 37 of the patients who were followed up over a period of up to 8 years. The electrophysiologic findings indicate that about 20% of patients complaining of unexplained reduction in visual acuity were suffering from a diffuse retinal disorder affecting the peripheral retina as well as the macular region. On the basis of electrophysiologic findings and clinical symptoms, we suggest grouping these patients under a new entity: cone-rod dysfunction.