Potential health risks of recreational fishing in new york city.

BACKGROUND: Fish in the rivers around New York City are contaminated with polychlorinated biphenyls (PCBs) that have been increasingly associated with neurodevelopmental abnormalities. The New York State Department of Health has recommended that the consumption of fish from the rivers around New York City not exceed one meal per month and that no pregnant women or children less than 15 years of age eat any fish from these waters. DESIGN/METHODS: We systematically surveyed anglers at Manhattan fishing sites over a 3-month period to estimate the exposure of anglers, children, and women of childbearing age to PCB-laden fish. RESULTS: One hundred sixty anglers completed the interview. Eighty percent of these anglers were unaware of any advisory to limit fish consumption in order to limit PCB exposure. Most anglers ate the fish they caught. Of the anglers who said that they took the fish home (72.5% of the total sample), 17.7% reported that children regularly eat the fish, and 15.4% reported that an individual had been pregnant while regularly eating the fish. CONCLUSION: Despite state advisories, New York City anglers report high rates of fish consumption by themselves, pregnant women, and children. Although determining the consequences of such consumption will require further study, this represents a worrisome environmental exposure.     

A framework for ethical decision making in neonatal intensive care

Intensive care for neonates with high risks of severe impairment and the possibility of a prolonged dying process represents a frequent ethical issue in neonatal units. The aim of this paper is to present a framework for structured decision making that has been developed in a neonatal intensive care unit and to demonstrate its impact on the healthcare team and on survival of critically ill neonates. This framework attempts to integrate the best interests of the infants and their parents, the possibilities of high-tech neonatal intensive care interventions, and the perspective of the nurses and doctors. An external evaluation of 84 sessions over 3 y revealed a beneficial effect on the quality of the decision-making process itself and on the quality of the teamwork in the unit. Survival time was shorter (median 2 d, interquartile range 1-7 d) in 26 infants that died after structured decision making compared with 26 controls matched for gestational age, malformation and intracranial haemorrhage (median 7 d, interquartile range 4-15 d).

Conclusion: The introduction of this framework for structured decision making involving doctors and nurses improved the quality of the teamwork. It shortened futile intensive care, and thereby suffering for both infants and parents.     

Between a ROC and a hard place: decision making and making decisions about using the SCQ

BACKGROUND: The Social Communication Questionnaire (SCQ), formerly the Autism Screening Questionnaire (ASQ), is based on a well-validated parent interview, the Autism Diagnostic Interview (ADI). It has shown promise as a screening measure for autism spectrum disorders (ASDs) in a research-referred older sample, though recent studies with younger children reported lower sensitivities when using the suggested cutoff of > or = 15 to differentiate ASDs from children with nonspectrum disorders (NS). METHODS: Diagnostic discrimination of the SCQ was evaluated alone and in combination with the ADOS (Autism Diagnostic Observation Schedule) in a clinical and research-referred sample of 590 children and adolescents (2 to 16 years), with best estimate consensus diagnoses of autism, pervasive developmental disorder, not otherwise specified (PDD-NOS) and non-ASD disorders. The SCQ was completed before the evaluation in most cases. Performance of the SCQ was also compared with the Autism Diagnostic Interview - Revised (ADI-R). RESULTS: Absolute scores and sensitivity in the younger children and specificity for all groups were lower than reported in the original study. Using receiver operating curves (ROC) to examine the area under the curve (AUC), the SCQ was more similar to the ADI-R total score in differentiating ASD from NS disorders in the older (8-10, >11) than younger age groups (<5, 5-7). Lowering the cutoff score in the 2 younger groups improved sensitivity, with specificity remaining relatively low in all groups. Using the SCQ in combination with the ADOS resulted in improved specificity. Diagnostic discrimination was best using the ADI-R and ADOS in combination. CONCLUSIONS: Those interested in using the SCQ should consider adjusting cutoff scores according to age and purpose, and using it in combination with another measure. Sensitivity or specificity may be prioritized for research or screening depending on goals.     

Approaches to ethical decision making in the neonatal intensive care unit

Despite the "Baby Doe" regulations, there is no consensus on principles for deciding the fate of severely handicapped neonates. This essay analyzes four alternate positions--value of life, parental authority, best interests, and personhood--and suggests for consideration a fifth, ie, proximate personhood. The latter position, building on the strengths of the first four, argues that a handicapped newborn must possess a reasonable potential for minimal personal capacities to have a unique claim to life. Projected minimal capacities include personal self-awareness and net physiological benefit. If newborns are not expected to develop such capacities, parents should be free to choose the option of nontreatment.     

Congenital hydrocele: prevalence and outcome among male children who underwent neonatal circumcision in Benin City, Nigeria

ObjectiveTo determine the prevalence and spontaneous resolution of congenital hydrocele diagnosed in male neonates who underwent circumcision at our centre.Patients and methodsAll male neonates presented for circumcision at the University of Benin Teaching Hospital, Benin City, Nigeria between January 2002 and December 2006 were examined for the presence of hydrocele. Those diagnosed with this condition were recruited and followed up in a surgical outpatient clinic for 2 years. The number of cases of spontaneous resolution and age at which this occurred were documented on a structured pro forma.ResultsA total of 2715 neonates were circumcised and 128 (4.7%) were diagnosed with 163 cases of hydrocele, while 27 cases in 25 (0.9%) children failed to resolve at the age of 2 years. Neonatal hydrocele was bilateral in 112 (68.7%), and there were 20 (12.3%) right and 31 (19.0%) left. Among those with hydrocele, 28.1% were delivered preterm and resolution was spontaneous in many of them, with no observed significant statistical difference to those delivered full term (P = 0.4740). Of the 163 hydrocele cases, 136 (83.4%) resolved spontaneously by age 18 months with peak resolution at 4–6 months. No spontaneous resolution occurred after 18 months and no hydrocele-related complication occurred during follow up.ConclusionNeonates with congenital hydrocele should be observed for spontaneous resolution for at least 18 months before being subjected to surgery.     

Incidence of meatal stenosis following neonatal circumcision in a primary care setting

The objective of this study was to prospectively document the incidence of meatal stenosis in boys. The study included a consecutive sample of boys whose visit with the physician included a genital examination in a private primary care pediatric practice in rural northern Wisconsin. Meatal stenosis was diagnosed in boys from 1.94 to 12.34 years of age. The diagnosis was made in 24 of 329 circumcised boys who were Tanner I development and older than 3 years of age (7.29%, 95%CI=4.48-10.10%). Nearly all required meatotomy to resolve their symptoms. All of the boys with meatal stenosis were circumcised neonatally (exact OR=3.54, 95%CI=0.62-infinity). The ratio of circumcised boys to noncircumcised boys in this study provided 80% power to demonstrate a 21.4% difference in the incidence of meatal stenosis between circumcised and noncircumcised Tanner I boys 3 years and older. Meatal stenosis may be the most common complication following neonatal circumcision. The frequency of this complication and the need for surgical correction need to be disclosed as part of the informed consent for neonatal circumcision. A careful meatal examination is indicted in any circumcised boy with abdominal or urinary complaints.     

Ethical problems in neonatal intensive care unit--medical decision making on the neonate with poor prognosis.

In current NICU (neonatal intensive care units), it is inevitable that ethical decisions on neonates with a poor prognosis will have to be made. At Tokyo Women's Medical College, we have been applying our own policy of medical decision making, which is somewhat different to those of most western countries. Most families are not asked to make final decisions, and the ethical committee is not actively involved. Staff in the NICU make the decision after plenary discussions. The position after decision making is not to discontinue the life supporting system but to observe, with no additional treatments and with routine care (class C). From October 1984 to September 1989, 58 out of 1589 neonates admitted to the NICU at Tokyo Women's Medical College died and 32 (55%) of them were classified as class C. The main causes of medical decision making were; non-viable (4/4, 100%), lethal malformations (13/20, 65%) and birth asphyxia (15/19, 79%).     

Decision making and modes of death in a tertiary neonatal unit

AIMS: To study the frequency and reason for withdrawal/withholding of life sustaining treatment (LST) and do not resuscitate (DNR) orders in infants who died in a tertiary neonatal unit. METHODS: Infants who died at Homerton University Hospital between January 1998 and September 2001 were studied by retrospective analysis of patient records. RESULTS: The case notes of 71 (84%) of 85 infants who died were studied. Mode of death was withdrawal of LST in 28 (40%), DNR in 11 (15%), withholding of LST in two (3%), and natural in 30 (42%) infants. Withdrawal of LST was discussed with the parents of 39 seriously ill infants; 28 (72%) parents agreed. There was no difference in birth weight and gestational age of babies whose parents agreed or refused withdrawal of LST. White and Afro-Caribbean parents and those from the Indian subcontinent (20 of 23) were more likely to agree to withdrawal of LST than Black African or Jewish (eight of 16, p = 0.015) parents. The median age at withdrawal of LST was 4 days (range 1-57). The median duration between discussion and the parents agreeing to withdrawal of LST was 165 minutes (range 30-2160), and median duration between withdrawal of LST and death was 22 minutes (range 5-210). The most common reason for withdrawal of LST was complications of extreme prematurity (68%). CONCLUSION: The most common mode of death was withdrawal of LST, and the most common reason was complications of extreme prematurity. The ethnic and cultural background of the parents influenced agreement to withdrawal of LST.     

Confidence intervals and p-values in clinical decision making

Clinical trials are usually performed on a sample of people drawn from the population of interest. The results of a trial are, therefore, estimates of what might happen if the treatment were to be given to the entire population of interest. Confidence intervals (CIs) provide a range of plausible values for a population parameter and give an idea about how precise the measured treatment effect is. CIs may also provide some useful information on the clinical importance of results and, like p-values, may also be used to assess 'statistical significance'. Although other CIs can be calculated, the 95% CI is usually reported in the medical literature. In the long run, the 95% CI of an estimate is the range within which we are 95% certain that the true population parameter will lie. Despite the usefulness of the CI approach, hypothesis testing and the generation of p-values are common in the medical literature. The p-value is often used to express the probability that the observed differences between study groups are due to chance. p-values provide no information on the clinical importance of results. CONCLUSION: It is good practice for authors of research articles to report CIs with their estimates instead of just p-values as p-values are less informative and convey no information on clinical importance.     

Usefulness of electrocardiographic screening in a neonatal population

IntroductionCongenital long QT syndrome is a rare disease, but is responsible for nearly 10% of Sudden Infant Death Syndrome. It is characterized by an abnormal prolonged QT interval in the basal electrocardiogram (ECG) with life-threatening arrhythmias which occur in previously asymptomatic patients and are preventable with an appropriate treatment.AimsThe impact of introducing ECG-screening in newborns is studied and main ECG-measurements are described in our population.Material and methodsTwelve-lead ECG was carried out. Measurements: RR, PR and QT interval, heart rate corrected QT interval, R wave voltage in V1, AVR and AVL, Q wave in I and AVL, P amplitude and voltage, right bundle branch block and ST elevation (Brugada pattern) and delta wave. It was considered pathological: QTc >0.44 or <0.30 seconds; R >12 in V1 and >8 mm in AVR; R >7.5 mm in AVL; Q >25% QRS in I and AVL; Brugada pattern; delta wave.ResultsA total of 1061 healthy children were born in our hospital between 29 May 2007 and 12 December 2008, of which 50.3% were males. An ECG was performed on 1006 (94.8%). Five ECG were pathological (0.5%): 2 long QT interval, 2 Wolf-Parkinson-White, 1 pathological Q-wave. A second ECG confirmed except for 2 long QT. No structural heart disease was found.ConclusionsECG-screening in newborns is an innocuous, low-cost and parent-well-accepted test that allows us to diagnose asymptomatic but potentially lethal and preventable heart disease; main intervals and waves in our population are describes in this study.     

Ureaplasma urealyticum in a neonatal intensive care population

The incidence of Ureaplasma colonization at birth and its effect on the development of chronic lung disease (CLD) and on mortality was studied in a neonatal intensive care population. Ureaplasma colonization was associated with a birthweight < 1000 g (odds ratio [OR] 3.45 confidence intervals [CI] 2.13-5.60) and a gestational age < 30 weeks (OR 2.54 CI 1.71–3.79). In a case-controlled study of 112 infants, significant associations with Ureaplasma colonization were maternal pyrexia in labour ( n = 38 vs 21; P = 0.015), the requirement for antibiotics in labour ( n = 39 vs 16; P = 0.0005) and vaginal delivery ( n = 78 vs 58; P = 0.009). Risk factors associated with the development of CLD were birthweight < 1000 g (OR 3.77 CI 2.53–5.62) and delivery by Caesarean section (OR 1.65 CI 1.11–2.43). Within the group delivered by Caesarean section. Ureaplasma colonization was also associated with an increased risk of CLD (OR 1.97 CI 1.08–3.62). Ureaplasma colonization of infants at birth is associated with factors suggestive of maternal chorioamnionitis as well as preterm birth and low birthweight. In infants delivered by Caesarean section, Ureaplasma colonization is associated with an increased risk of chronic lung disease.