Postnatal age at time of death in infants born at 24-32 weeks' gestation

Medical records of all 483 infants live-born at 24-32 weeks' gestation in our hospital during the years 1982-86 were reviewed in order to determine postnatal age at time of death for those who died in the first year after birth. Twenty-seven died from immaturity without receiving intensive care and 11 died from lethal congenital malformations. Eighty (18%) of the remaining 445 who received intensive care died: 31% on day 1, 45% on days 2-7, 12% on days 8-28 and 11% on days 29-365. The neonatal mortality rate for those receiving intensive care was 160/1000, and the postneonatal mortality rate was 20/1000. Delayed mortality was most common in infants of 26-27 weeks' gestation, with 20% (five) of their deaths occurring after 28 days. In each gestational age range, the majority of hospital admission days were occupied by survivors (24-25 weeks = 62%; 26-27 weeks = 91%; 28-29 weeks = 91%; 30-32 weeks = 99%) rather than non-survivors. Whilst postneonatal mortality is a significant concern, these data suggest that if infants born at less than 33 weeks' gestation are offered intensive care and survive the early neonatal period, the long-term outcome is more likely to be survival rather than delayed death. Furthermore, the majority of hospital admission days invested in such infants involves those who will be discharged home rather than those who will not.     

Determinants of pediatric injuries

Injuries are an important health issue for children. Previous research, however, has presented confusing and conflicting results on the determinants of childhood injuries, particularly psychosocial predictors, largely due to methodologic problems. The purpose of this analysis, based on a prospective follow-up study of 532 children, was to identify factors related to injuries encountered in a prepaid group practice during a 12-month period. Using logistic regression, we found four factors independently associated with the risk of at least one treated injury: high activity level, high rate of pediatric utilization for non-injury-related visits during the follow-up period, occurrence of a treated injury during the year preceding the follow-up period, and negative attitude toward medical care providers by the child's mother. In addition, four factors were found to be independent predictors of injuries judged severe enough to always warrant medical care: occurrence of a treated injury in the preceding year, high rate of pediatric utilization for non-injury-related visits during the follow-up period, working more than 15 hours a week outside the home by the child's mother, and more life events reported by the mother for the year preceding the follow-up period. Since family stressors are related specifically to the risk of more severe injuries, which are unlikely to escape medical attention, we conclude that these factors probably are related to the occurrence of common injuries of early childhood and not exclusively to utilization behavior. We therefore suggest that children from families with these characteristics be targeted for injury prevention strategies.     

Capillary and venous bilirubin values. Are they really different?

We measured total serum bilirubin values in paired capillary and venous samples from 79 untreated jaundiced newborn infants (group 1) and in 29 infants who were receiving phototherapy (group 2). While bilirubin values from the two sites correlated significantly for both groups, capillary samples underestimated venous bilirubin values when the latter exceeded 170 mumol/L (10 mg/dL) (mean and 95% confidence limits: group 1, -15.1 mumol/L [-0.9 mg/dL] and -24.7 to -5.5 mumol/L [-1 to -0.3 mg/dL]; group 2, -10.3 mumol/L [-0.6 mg/dL] and -17.1 to -3.4 mumol/L [-1 to -0.2 mg/dL]). Furthermore, capillary samples underestimated venous bilirubin levels by more than 17 mumol/L (1 mg/dL) in eight of 16 group 1 patients and five of 18 group 2 patients when venous bilirubin values exceeded 170 mumol/L (10 mg/dL). Lower capillary values at higher bilirubin levels might be due to the influence of environmental light. As clinical treatment decisions may be made on the basis of differences in serum bilirubin level of about 17 mumol/L (1 mg/dL) and as capillary samples may underestimate venous bilirubin levels by a similar amount, it may be prudent to measure venous rather than capillary bilirubin levels when the total serum bilirubin level exceeds 170 mumol/L (10 mg/dL).     

Low colloid osmotic pressure in very low birthweight infants receiving assisted ventilation

Plasma colloid osmotic pressure (COP) was measured in three groups of very low birthweight infants. Babies in Group 1 (n = 8) were breathing spontaneously and had no respiratory disease. Those in Group 2 (n = 9) received assisted ventilation for hyaline membrane disease (HMD), and those in Group 3 (n = 7) received assisted ventilation for other reasons (five apnoea, two pneumonia). Both assisted ventilation groups had lower mean COP values than spontaneously breathing infants. Mean values (s.e.m.) for Groups 1, 2 and 3, respectively, were: 15.3 (0.6), 11.3 (0.4) and 11.9 mmHg (0.5) (P less than 0.001) on Day 1; and 15.2 (0.4), 12.9 (0.4) and 12.8 mmHg (0.3) (P less than 0.001) on Day 2. The increase from Day 1 to Day 2 was significant for those with HMD (P less than 0.05). Colloid osmotic pressure correlated with mean blood pressure (r = 0.51; P less than 0.001) but not with birthweight, gestation, crystalloid fluid intake or pH. The role of low COP in the pathogenesis of acute respiratory failure in infants with uncomplicated HMD is unclear, but such low COP may contribute to development of pulmonary oedema as a complication, particularly if the ductus arteriosus is still patent and the infants are given high volume intravenous fluids.     

Protein, lactose and fat concentration of breast milk of mothers of term and premature neonates

The protein, lactose and fat concentrations in the milk of seven mothers giving birth at term and six mothers giving birth prematurely were determined. Samples were obtained during the first 31 days of lactation. The protein, lactose and fat concentrations of preterm milk were found to be similar to those of fullterm milk over this period. For both term and preterm groups, protein concentration decreased with increasing age, while lactose concentration increased. Fat concentration did not show a consistent pattern of change in the preterm group, but tended to increase with advancing age in the term group.     

Prevention of preterm birth by ambulatory assessment of uterine activity: a randomized study

Tocodynamometry, used on an ambulatory basis, has been shown to detect uterine activity. The objective of this study was to assess the effectiveness of ambulatory tocodynamometry in the early identification of preterm labor. In this investigation 67 women at risk for preterm labor were randomly divided into two groups: 34 received a uterine activity monitor while 33 patients used palpation. Approximately two thirds of the study sample developed preterm labor. Upon diagnosis of preterm labor, parturients in the control group had cervical dilatation of less than 3 cm (p less than 0.001) and effacement of greater than 50% more often than the monitored group (p less than 0.01). As a result there was a significant decrease in the number of patients who responded to tocolytic therapy in the unmonitored group. Among those with preterm labor the time gained in utero was greater in the monitored group (8.2 +/- 2.7 weeks) compared to the control group (4.2 +/- 2.9 weeks) (p less than 0.05). Subsequently 29 of 34 monitored patients attained term (36 completed gestational weeks) versus only 18 of the 33 patients in the unmonitored group (p less than 0.01). Although the sample size is relatively small, uterine activity monitoring in these very high risk patients resulted in an increased number of suitable candidates for tocolysis and allowed a significantly greater percentage of women to reach term.     

Otoadmittance changes following glycerol dehydration in Meniere's disease

Otoadmittance studies were undertaken in 76 patients with Meniere's disease and 8 control subjects undergoing glycerol dehydration. Baseline otoadmittance values were significantly higher in ears with fluctuant hydrops compared to the non-fluctuant ears (p less than 0.01), suggesting that there is a pathophysiological difference between these clinical Meniere's groups. Significant maximum conductance changes were seen in 53.4% of hydroptic ears, and were associated with subjective audiometric threshold shifts in 23.2%. Similar changes were not seen in the control ears. These findings provide further clinical evidence to support an underlying physical basis for the auditory symptoms of endolymphatic hydrops and the effects of glycerol dehydration on the inner ear. Objective otoadmittance changes appear to be a more sensitive indicator of reversible hydrops than conventional audiometry. Possible mechanisms to explain the somewhat paradoxical increase in the resistance to the flow of sound energy through the cochlea following reduction of the endolymphatic hydrops by glycerol dehydration are discussed.     

Significance of tomography in meniere's disease: Periaqueductal pneumatization

The revival of endolymphatic sac surgery has led to many investigations in Meniere's disease, including lateral tomography of the periaqueductal pneumatization. We radiologically assessed a series of Meniere's patients and a control group, and found hypocellularity to be more common in Meniere's disease as the literature has stated. However, we found this finding bilaterally in patients with unilateral disease. Our assessment of this information in regard to the etiology and treatment of Meniere's disease is presented.     

Endometrial stromal sarcoma metastatic to the lung: a detailed analysis of 16 patients

Pulmonary metastases of endometrial stromal sarcoma (ESS) are uncommon and can pose diagnostic problems. We reviewed lung specimens from 16 patients with metastatic ESS. Patients were 31-77 years of age at the time of lung biopsy. Uterine ESSs were diagnosed an average of 9.8 years before lung biopsy in 11 patients. Uterine ESSs were originally called smooth muscle tumors in three additional patients. Thirteen patients were evaluated for new pulmonary nodules, seven of whom were asymptomatic. Nodules were multiple in 14 and solitary in four, ranging from 1.0 to 8.0 cm in greatest dimension. One patient died of metastatic disease; 14 were alive and seven of these were without disease (mean follow-up 4.1 years). Diagnostic considerations in 12 consultation cases included ESS, sclerosing hemangioma, carcinoid tumor, lymphangioleiomyomatosis, endometriosis, hemangiopericytoma, and lymphoma. Tumors were well circumscribed and usually solid, composed of plump spindle cells arranged in short fascicles. Two tumors were predominantly cystic. Sex cord-like stromal differentiation was identified in three. Neoplastic cells stained for vimentin (93%), estrogen and progesterone receptor (100%), smooth muscle actin (57%), desmin (50%), and keratin (46%). Metastatic ESS should be included in the differential diagnosis of nonepithelial neoplasms in women.     

Usual interstitial pneumonia: histologic study of biopsy and explant specimens

The pathologic findings in biopsy and subsequent explant specimens from 20 patients with usual interstitial pneumonia (UIP) were reviewed to refine histologic criteria for diagnosis, to identify factors that may confound diagnosis, and to assess the relationship of UIP and nonspecific interstitial pneumonia (NSIP). One case of NSIP was also identified and included for comparison. Surgical biopsies from 15 of the 20 UIP cases were diagnosed as UIP, whereas 5 showed only nondiagnostic changes. An important new observation is that areas resembling nonspecific interstitial pneumonia (NSIP-like areas) are present in the majority of UIP cases in both biopsy and explant specimens, and they are extensive in some. Ten of the 15 UIP biopsies were considered straightforward, with typical patchy interstitial fibrosis, honeycomb change, and fibroblast foci. Five cases were considered difficult because of prominent NSIP-like areas in two, extensive honeycomb change in one, superimposed diffuse alveolar damage in one, and superimposed bronchiolitis obliterans-organizing pneumonia in one. The most helpful feature for diagnosing UIP in difficult cases was the presence of a distinct patchwork appearance to the characteristic uneven or variegated parenchymal involvement along with evidence of architectural derangement. No explant showing UIP was preceded by biopsy findings of NSIP, and the one NSIP case appeared similar at biopsy and explant. NSIP or NSIP-like areas and UIP may reflect different mechanisms of fibrosis related either to different severity of injury or to different injuries.