Factors affecting the neonatal response to artificial surfactant

Objective : To define the individual neonatal response to the artificial surfactant, Exosurf, and factors that may influence the response.
Methodology : Eighty-two consecutive, preterm neonates with respiratory distress syndrome, who received Exosurf at <12h of age were studied. Their response was categorized from the graphical change in the oxygenation index with postnatal age, for 12h after each of two doses of surfactant and assessed independently by two observers. Clinical factors were analysed for their effect on the four pre-defined categories of response, namely: none; mild; good; relapsed; and good: sustained.
Results : Within the first 12h, 11% of the neonates showed no response, 5% a mild response and 84% a good response, but 34% relapsed. By 24h, 6% still showed no response (all died), 11% showed a mild response and 83% a good response, of whom half relapsed. At 24h, no response was significantly associated with low gestational age and asphyxia mild response with less severe lung disease. According to the response there was a gradation in the risk of death during the first week.
Conclusions : The response to Exosurf can be individually and reproducibly categorized and demonstrated that 83% of neonates had a good response but half relapsed. No response was associated with extreme prematurity and asphyxia     

Neurocognitive consequences of a paediatric brain tumour and its treatment: a meta‐analysis

Aim This meta‐analysis provides a systematic review of studies into intellectual and attentional functioning of paediatric brain tumour survivors (PBTS) as assessed by two widely used measures: the Wechsler Intelligence Scale for Children (3rd edition; WISC‐III) and the Conners’ Continuous Performance Test (CPT). Method Studies were located that reported on performance of PBTS (age range 6–16y). Meta‐analytic effect sizes were calculated for Full‐scale IQ, Performance IQ, and Verbal IQ as measured by the WISC‐III, and mean hit reaction time, errors of omission, and errors of commission as measured by the CPT. Exploratory analyses investigated the possible impacts of treatment mode, tumour location, age at diagnosis, and time since diagnosis on intelligence. Results Twenty‐nine studies were included: 22 reported on the WISC‐III in 710 PBTS and seven on CPT results in 372 PBTS. PBTS performed below average (p_s<0.001) on Full‐scale IQ (Cohen’s d=?0.79), Performance IQ (d=?0.90), and Verbal IQ (d=?0.54). PBTS committed more errors of omission than the norm (d=0.82, p<0.001); no differences were found for mean hit reaction time and errors of commission. Cranial radiotherapy, chemotherapy, and longer time since diagnosis were associated with lower WISC‐III scores (p_s<0.05). Interpretation PBTS have seriously impaired intellectual functioning and attentiveness. Being treated with cranial radiotherapy and/or chemotherapy as well as longer time since diagnosis leads to worse intellectual functioning.     

Impact of infarct artery patency on the relationship between electrocardiographic and ventriculographic evidence of acute myocardial ischaemia

Routine invasive evaluations are being abandoned, and thus simplenon-invasive methods for estimating the extent of jeoparizedmyocardium during evolving myocardial infarction are neededfor risk stratification to guide the appropriate therapeuticintervention. With this in mind the aim of the paper was toevaluate the association between ischaemic changes in the standardelectrocardiogram and the function of acutely infarcted myocardiumin relation to infarct artery patency status. Forty consecutive patients with a first acute myocardial infarction,admitted within 6 h of symptom onset and without bundle branchor fascicular block were included. Summated ST segment elevationin 11 electrocardiographic leads (aVR excluded) was measuredto the nearest 005 m V and compared to regional wall motion,estimated by the centreline method (SDIchord) and global leftventricular ejection fraction (% LVEF) after thrombolytic therapy.Acute angiographic and ST segment measurements were performedat a median 254 min (range 70–485) after the onset ofsymptoms. Patients were grouped according to infarct artery patency statusafter intravenous thrombolysis. Of the 40 patients, 27 had apatent (Thrombolysis In Acute Myocardial Infarction trial (TIMI)grade 2-3 flow) and 13 had persistently occluded (TIMI 0–1flow) infarct arteries. Anterior myocardial infarction was presentin 13 and seven patients in the two groups. In the TIMI 2-3group, the summated ST elevation did not correlate with % LVEFor SDIchord (r_s=0.08; and r_s= – 0.17, respectively). Inthe TIMI0–1 group the summated ST elevation correlatedinversely with both % LVEF and SDIchord (r_s= –0.70; andr_s= –0.56, respectively). These results show that acute summated ST segment elevationcorrelates with both global and regional left ventricular functionin patients with persistently occluded infarct arteries, thusproviding a non-invasive method for estimating the amount ofjeopardized myocardium.     

Increased Fetal Activity and Heart Rate During and Immediately After Pulsed Doppler Echocardiography

Introduction: Previous reports have suggested that the use of continuous-wave Doppler for nonimaging heart rate monitoring or in utero Doppler imaging increased fetal activity. In this study, 11 fetuses (EGA 20–28 weeks) underwent a cardiac 2-D ultrasound and pulsed Doppler examination (since pulsed Doppler is more often used for fetal cardiac diagnosis) with 2-D and Doppler performed in a randomized order and with 10-minute ultrasound observation periods with as little transducer movement as possible before, during, and after 2-D only, and Doppler evaluation. Methods: All studies were performed with informed consent at the lowest available Doppler power < 90 mW/cm² spatial peak temporal average. Fetal heart rate, the number of fetal gross movements / min, and the percent time occupied by fetal movements were evaluated by two blinded observers from video taped records. Patients had been referred to rule out fetal heart disorders but all echoes showed normal cardiac anatomy. Results: Fetal heart rate after pulsed Doppler study was statistically higher by analysis of variance (mean 127 beats/min) than in the pre-Doppler evaluation period (mean 120) and was highest during the Doppler exam period (mean 136; P < 0.05) in 10 of 11 fetuses. The percent time of fetal movements was highest during the Doppler exam period and in 9 of 11 fetuses movement increased. The raw number of gross movements / min, however, was highest after the Doppler. No such changes occurred during or after 2-D alone. Conclusion: Whether associated with slightly higher energy output, minimal thermal changes, or audible switching or electronic output sounds transmitted from the instrumentation through the uterus, fetal heart rate and activity increased in our study both during and after pulsed Doppler examination.