Osteocalcin, skeletal alkaline phosphatase, and bone mineral content in very low birth weight infants: a longitudinal assessment.

Serum osteocalcin (Gla) and skeletal alkaline phosphatase (SAP) concentration both reflect osteoblast activity in the dynamic process of bone formation. To assess the relation in premature infants between change in bone mineral content (BMC) and both Gla and SAP serum concentration, we longitudinally measured BMC via photon absorptiometry and serum Gla and SAP concentration from birth to 16 wk in 20 very low birth weight infants. Serum total calcium, phosphorus, parathyroid hormone, and vitamin D metabolite concentrations were also monitored. All serum values were measured in the 20 mothers at delivery. Cord blood Gla concentrations were significantly (p less than 0.03) greater than maternal levels, and by 1 wk had significantly (p less than 0.001) increased from birth values. Total calcium, parathyroid hormone, phosphorus, and vitamin D concentrations remained in the normal range throughout the study. The increase in serum Gla concentrations, birth to 1 wk, were significantly correlated with the simultaneous increase in 1,25-dihydroxyvitamin D concentrations. The correlation between the change in BMC, however, over the first 4 mo of life and both Gla and SAP serum concentrations failed to reach statistical significance. Finally, a significant (p less than 0.003) negative correlation was measured between serum Gla and SAP concentrations at wk 4, and, although not significant, a consistently negative correlation was measured from 1-16 wk of age.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical diagnosis and management of respiratory distress in preterm neonates: effect of participation in a controlled trial.

The ability to generalize the results of a clinical trial depends on the ability to compare a population of patients with the population described in the trial, emphasizing the importance of objective diagnostic criteria in study design and clinical medicine. However, clinical decisions are often based on subjective interpretations of data. There is concern that bias that an experimental therapy is beneficial might lead to alterations in clinical diagnosis and management. To evaluate this concern, the authors reviewed a preexisting database comprising information obtained by trained personnel by chart review to investigate prospectively the frequency of the diagnosis of hyaline membrane disease and the use of mechanical ventilation before and during participation in a clinical trial of surfactant therapy during which such therapy was available exclusively through clinical trials. Major eligibility criteria for a randomized trial at the Medical University of South Carolina included mechanical ventilation and the diagnosis of hyaline membrane disease. Both the diagnosis of hyaline membrane disease and the use of mechanical ventilation increased between pre-surfactant and randomized trial periods (hyaline: 47.2% to 55.9%, P less than .05; ventilation: 55.6% to 66.3%, P less than .01). The possibility that enthusiasm for surfactant influenced clinical diagnosis and management of respiratory distress during this period cannot be dismissed.     

Pneumothorax in cystic fibrosis

BACKGROUND: Spontaneous pneumothorax is a complication that is commonly reported in patients with cystic fibrosis (CF). An understanding of the pathophysiology of this complication and its consequences is important for the management of patients with CF. OBJECTIVE: To identify risk factors associated with pneumothorax and to determine the prognosis of CF patients following an episode of pneumothorax. DESIGN: A retrospective observational cohort study of the National Cystic Fibrosis Patient Registry between the years 1990 and 1999. PATIENTS: The registry contained data on 28,858 patients with CF who had been followed up over those 10 years at CF centers across the United States. RESULTS: Pneumothorax occurred with an average annual incidence of 0.64% and in 3.4% of patients overall. There was no increased occurrence by sex, but CF was more prevalent in older patients (mean [+/- SD] age, 21.9 +/- 9.1 years) with more severe pulmonary impairment (nearly 75% of patients with FEV1 of < 40% predicted). The principal risks associated with an increased occurrence of pneumothorax included the presence of Pseudomonas aeruginosa (odds ratio [OR], 2.3), Burkholderia cepacia (OR, 1.8), or Aspergillus (OR, 1.3) in sputum cultures, FEV1 < 30% predicted (OR, 1.5), enteral feeding (OR, 1.7), Medicaid insurance (OR, 1.1), pancreatic insufficiency (OR, 1.4), allergic bronchopulmonary aspergillosis (OR, 1.5), and massive hemoptysis (OR, 1.4). There is an increased morbidity (eg, increased number of hospitalizations and number of days spent in the hospital) and an increased 2-year mortality rate following pneumothorax. CONCLUSION: Pneumothorax is a serious complication in CF patients, occurring more commonly in older patients with more advanced lung disease. Nearly 1 in 167 patients will experience this complication each year. There is an attributable mortality to the complication and considerable morbidity, resulting in increased health-care utilization and a measurable decline in lung function.     

Obstetric and neonatal outcomes in grand multiparity

OBJECTIVE: To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among grand multiparas with age-matched multiparas. METHODS: Six hundred twenty-one grand multiparas (para more than 4) women were prospectively compared with 621 age-matched multiparous (para 2-4) controls. RESULTS: Grand multiparity was associated with low socioeconomic status and education (odds ratio [OR]6.4; 95% confidence interval [CI] 4.5, 9.0), poorer prenatal care (OR 3.1; 95% CI 1.5, 6.1), smoking (OR 2.2; 95% CI 1.5, 3.2), and alcohol consumption (OR 9.0; 95% CI 2.1, 39.3). Grand multiparas had a higher body mass index (OR 1.5; 95% CI 1.2, 1.9) and rate of insulin-dependent gestational diabetes (OR 1.7; 95% CI 1.02, 3.1). They had more previous intrauterine (OR 4.2; 95% CI 1.5, 11.3) and perinatal deaths (OR 3.2; 95% CI 2.0, 5.0). They had fewer intrapartum complications (arrests of cervical dilatation [OR 0.19; 95% CI 0.06, 0.66], instrumental deliveries [OR 0.31; 95% CI 0.16, 0.59], and fever during labor [OR 0.47; 95% CI 0.26, 0.86]). Conditional logistic regression models found that grand multiparity was the most closely correlated factor to a previous history of fetal death (OR 4.3; 95% CI 1.6, 11.6), but it was not an independent predictor of insulin-dependent gestational diabetes mellitus (OR 1.3; 95% CI 0.75, 2.2). CONCLUSION: Grand multiparas, when compared with same-age multiparous controls, appear to have fewer intrapartum complications. However, they present several prenatal risk factors that require special antenatal care. LEVEL OF EVIDENCE: II-3     

Timely admits, transfers, and discharges

Nurse managers implemented a critical care patient coordinator program that's improved patient flow, staffing, and problem identification. The hospital has increased the new department from 7 to 12 critical care nurses and applied the program to other units.     

缺血性中风(中经络)证候分类与血脂、血压、血液流变学关系的研究

目的探讨缺血性中风证侯分类的客观量度。方法本研究对118例缺血性中风患者按中医证类进行分组,观察各证类组病例的血脂、血压及血液流变学改变。结果研究表明,风痰阻络证、痰热腑实证及气虚血瘀证组脂质变化较正常组明显升高(P<0.05～0.01),其中风痰阻络证、痰热腑实证与气虚血瘀证组存在显著差异(P<0.05);气虚血瘀证、风痰阻络证及痰热腑实证组血液流变学指标较正常组有显著差异(P<0.05～0.01);肝阳暴亢证、痰热腑实证组血压明显高于气虚血瘀证、风痰阻络证及阴虚风动证组(P<0.05～0.01)。结论血脂、血压及血液流变学指标可为缺血性中风证候分类提供客观量度。     

Use of femur length/abdominal circumference ratio in detecting the macrosomic fetus

The femur length/abdominal circumference ratio, expressed as FL/AC X 100, was determined in 156 fetuses and evaluated as a predictor of fetal macrosomia within one week prior to delivery. The normal range (mean +/- 2 SD) in the 105 normal-weight fetuses was 22.0 +/- 2, while the normal range in the 51 macrosomic fetuses was 20.5 +/- 2; these differences were highly significant (P = less than .0001). The predictive power of a positive ratio was 68%, with a sensitivity of 63%. This ratio was particularly useful in the subset (n = 9) of macrosomic fetuses whose mothers were diabetic, correctly identifying 89% of this group. Because it is age independent, this ratio should prove most helpful in identifying fetuses at risk for macrosomia in patients whose dates are not known, since it may become abnormal before the fetal weight falls above the 90th percentile at term (3,900 g). In patients whose dates are known, early fetal macrosomia is best predicted by evaluating the abdominal circumference against normal standards for age.