Ten-year trends in neonatal assisted ventilation of very low-birthweight infants.

OBJECTIVES: To examine ventilatory support for the VLBW infant over the past 10 years in a single academic NICU and determine factors that predicted length of ventilation, death, and CLD. STUDY DESIGN: A retrospective cohort review of neonatal blood gases, ventilatory support, and clinical outcomes. RESULTS: From 1992 through October 2002, 6254 infants were admitted, of whom 2388 required intubation for mechanical ventilation. Of these, 837 were <1500 g at birth (VLBW) infants and 453 were less than 1000 g (ELBW). Total duration of ventilation decreased in all weight groups. Noninvasive ventilatory support increased from 20 to 55% of total ventilation from 1997 to 2002. During this same period, CLD decreased from 20 to 11% in ventilated VLBW infants. Duration of total ventilation was best predicted by birth weight, with each 100 g increment decreasing the duration of ventilation by 71 hours. Lower birth weight, male sex, and a longer total duration of ventilatory support were significant factors in predicting the occurrence of CLD. Death alone was best predicted by lower birth weight and maximum oxygen index (OI). Transported infants had significantly increased maximal OIs, durations of ventilation, and incidence of death. A total of 48% of infants with a single OI >10 either died or survived with CLD. CONCLUSIONS: Birth weight is the best predictor of duration of ventilation, and CLD is best predicted by birth weight, duration of ventilation and male sex. The increasing use of noninvasive strategies has not been associated with an observable increase in respiratory morbidity. VLBW infants with a single OI>10 may benefit from inclusion in future interventional rescue studies.     

Longitudinal analysis of the relation between moderate long‐term stress and health

The main goal of the present work was to longitudinally examine consequences of long‐term moderately elevated levels of stress for various health outcomes. To address this issue, data covering 10 years was used from the ongoing Swedish population‐based prospective Betula Study. Based on the ratings on a validated self‐reported stress scale, matched subsamples between 40 and 65 years of age were divided into a high (n = 137) and low (n = 211) stress group. The reported incidence of cardiovascular, diabetes, psychiatric, tumour and musculoskeletal diseases was assessed 5 and 10 years after baseline (baseline = 1993–1995) without contaminating effects of past health history. The incidence of diseases 5 years after baseline assessment showed no differences between the groups. After 10 years, there was a significantly higher incidence of psychiatric diseases, mainly depression in the high‐stress group as well as a significant effect for tumours, although the number of cases was low. Although moderately elevated stress level may have a possible impact on psychiatric diseases especially depression and some tumours, it seems that prolonged moderate stress does not appear to be harmful to other stress‐related diseases. Copyright © 2007 John Wiley & Sons, Ltd.     

Ventricular rate smoothing for atrial fibrillation: a quantitative comparison study.

AIMS: To quantitatively compare the ventricular rate-smoothing (VRS) effects of different ventricular pacing (VP) protocols for atrial fibrillation (AF). METHODS AND RESULTS: Using a recently developed open-source model that can simulate the ventricular response in AF and VP, the performance of fixed-rate pacing and four previously published VRS algorithms were assessed by the mean RR (mRR), the root mean square of successive RR differences (RMSSD), the percentage of ventricular senses (VS%), and the percentage of short RR intervals (sRR%). All pacing protocols cause rate-dependent reduction of RMSSD, VS%, and sRR% with or without shortening of mRR compared to spontaneous AF. Fixed-rate pacing was more sensitive to the intrinsic rate than the VRS algorithms. The performance was generally comparable between different VRS algorithms, although higher mRR and VS% can be achieved at the expense of larger RMSSD and sRR%. CONCLUSION: The effect of VP on ventricular rhythm in AF depends on both intrinsic rate and the aggressiveness of the pacing protocol. Adequate rate control is necessary for effective operation of the VRS algorithm. Choosing VRS algorithm should balance between the beneficial effects of rate regularization and the negative effects of increasing heart rate and percentage of VP.     

Do commonly used oral antihypertensives alter fetal or neonatal heart rate characteristics? A systematic review.

OBJECTIVE: To examine fetal (FHR) and neonatal heart rate patterns following use of common oral antihypertensives in pregnancy. METHODS: A systematic review of randomized controlled trials (RCTs), observational studies (N >/= 6 women), and animal studies. Data were abstracted (two reviewers) to determine relative risk (RR) (or risk difference (RD) for low event rates) and 95% CI. RESULTS: Eighteen RCTs (1858 women), one controlled observational study (N = 22), and seven case series (N = 117) were reviewed. Most hypertension was pregnancy-induced (N = 14 studies). The FHR was assessed by cardiotocogram (CTG) (N = 17 studies (visual interpretation); 1 study (computerized CTG), or umbilical artery velocimetry (N = 4). Four studies examined neonatal heart rate. In placebo-controlled RCTs (N = 192 women), adverse FHR effects did not differ between groups [9/101 (drugs) vs. 7/91 (placebo); RD 0.02, 95% CI (- 0.06, 0.11); chi2 = 1.02]. In six drug vs. drug RCTs (295 women), adverse FHR effects did not differ between groups [29/144 (methyldopa) vs. 42/151 (other drugs); RR 0.72, 95% CI (0.49, 1.07); chi2 = 0.69]. In one labetalol vs. placebo trial, neonatal bradycardia did not differ between groups [4/70 (labetalol) vs. 4/74 (placebo); OR 1.06, 95% CI (0.26, 4.39)], while in three drug vs. drug RCTs, neonatal bradycardia was not observed (0/24 vs. 0/26). CONCLUSIONS: Available data are inadequate to conclude whether oral methyldopa, labetalol, nifedipine, or hydralazine adversely affect fetal or neonatal heart rate and pattern. Until definitive data are available, FHR changes cannot be reliably attributed to drug effect, but may be due to progression of the underlying maternal or placental disease.     

A case of congenital supratentorial tumor: Atypical teratoid/rhabdoid tumor or primitive neuroectodermal tumor?

Two embryonal CNS tumors, atypical teratoid/rabdoid tumor (AT/RT) and primitive neuroectodermal tumor (PNET), may be confused with each other and misdiagnosed. Here we report an infant with a congenital supratentorial tumor, which was detected by fetal MRI at 37 weeks gestation. On routine histological examination, the tumor was composed mainly of small undifferentiated cells, among which many rhabdoid cells and occasional sickle‐shaped embracing cells were observed. No mesenchymal or epithelial areas were evident. Our impression was that the tumor was an atypical example of AT/RT. Immunohistochemically, almost all the tumor cells were strongly positive for vimentin. However, epithelial membrane antigen was notably negative, and most of the tumor cell nuclei were clearly positive for INI1. In addition, many tumor cells were positive for neurofilament protein. There were also occasional small areas containing many tumor cells positive for glial fibrillary acidic protein. Finally, a diagnosis of PNET, with a rhabdoid phenotype and expression of neuronal and glial markers, was made. In the present case, application of INI1 immunostaining was very helpful for distinguishing PNET from AT/RT.     

ENDOSCOPIC MUCOSAL RESECTION AND SUBMUCOSAL DISSECTION METHOD FOR LARGE COLORECTAL TUMORS

The goal of endoscopic mucosal resection (EMR) is to allow the endoscopist to obtain tissue or resect lesions not previously amenable to standard biopsy or excisional techniques and to remove malignant lesions without open surgery. In this article, we describe the results of conventional EMR and EMR using an insulation‐tipped (IT) electrosurgical knife (submucosal dissection method) for large colorectal mucosal neoplasms and discuss the problems and future prospects of these procedures. At present, conventional EMR is much more feasible than EMR using IT‐knife from the perspectives of time, money, complication, and organ preservation. However, larger lesions tend to be resected in a piecemeal fashion; and it is difficult to confirm whether EMR has been complete. For accurate histopathological assessment of the resected specimen en bloc EMR is desirable although further experience is needed to establish its safety and efficacy. Further improvements of in EMR with special knife techniques are required to simply and safely remove large colorectal neoplasms.