Significance of grunting respirations in infants admitted to a well-baby nursery.

OBJECTIVES: (1) To determine the frequency and duration of grunting in term and near-term newborns; (2) to determine the peripartum characteristics associated with grunting; and (3) to compare the short-term outcomes of newborns with and without grunting. DESIGN: Medical record review of all newborns admitted to a well-baby nursery during a 2-month period. SETTING: University well-baby nursery for term infants, with more than 2700 deliveries annually. MAIN OUTCOME MEASURES: Frequency and duration of grunting, maternal and newborn clinical characteristics, clinical course, and length of stay. RESULTS: Grunting respirations beginning during the first 4 hours of life were recorded for 81 (17.4%) of 466 newborns. Fifty-five (68%) stopped grunting within 30 minutes of birth, 69 (85%) by 1 hour, and 75 (93%) by 2 hours. More mothers of grunting infants received intrapartum antibiotics than mothers of nongrunters (33% vs 20%; P =.03). More grunting infants than nongrunters received bag and mask resuscitation (15% vs 5%; P =.01). More chest radiographs, blood cell counts, and blood cultures were ordered for grunting infants, and antibiotics were more often given to grunting than nongrunting infants (11.1% vs 4.6%; P =.04). Grunters' length of stay exceeded that of nongrunters (72 vs 55 hours; P =.01), but only 3 were transferred to a neonatal intensive care unit. CONCLUSIONS: All grunting infants should be carefully observed, but because nearly all otherwise healthy term or near-term infants will stop grunting and have a benign course, other interventions can be postponed for 1 or 2 hours to give the newborn a chance to stop grunting or show other signs of respiratory illness.

The drug-exposed infant in the well-baby nursery.

Maternal substance use can have medical and developmental consequences for the newborn. Many drug-exposed infants are admitted to term nurseries, and the newborn clinician who often has never previously met the mother must gather both objective and subjective information about problems in the pregnancy and delivery that may indicate maternal substance abuse. This article addresses the prevalence of maternal substance abuse in the United States, the long-term consequences of in utero drug exposure that makes early identification important, the identification of a drug-exposed neonate, and in-hospital care and discharge management of the drug-exposed newborn.

The effects of oral doses of lansoprazole and omeprazole on gastric pH.

We compared gastric pH values after therapeutic doses of lansoprazole and omeprazole in 17 healthy adult men. The pharmacokinetics of the two drugs were studied. A three-way crossover design compared the effects on gastric pH of 15 and 30 mg lansoprazole and 20 mg omeprazole--each given once daily for 5 days. Ambulatory 24-h intragastric pH levels were measured before dosing, after the first and fifth doses in each period, and 15 days after each dosing period. A positive relationship between the lansoprazole or omeprazole area under the curve (AUCs) and the 24-h mean pH values was found for each regimen. No differences in maximum concentration (Cmax) and AUC were noted from day 1 to day 5 for the two lansoprazole doses. With omeprazole, both Cmax and AUC levels were greater on day 5 than on day 1. All three regimens increased 24-h mean gastric pH, although 30 mg lansoprazole had the most significant effect. The percentage of time that gastric pH was >3, >4, and >5 was also significantly higher with 30 mg lansoprazole. All three regimens were associated with reversible elevations of serum gastrin, which more than doubled at some points. No clinically significant adverse events were documented.

Prenatal substance use in a Western urban community.

To assess the extent of prenatal substance use in a predominantly white population in an urban area of the western United States and to develop a risk profile for this population, a cross-sectional prevalence study was done. Prenatal clinics (10 public and 10 private) anonymously recorded demographic information about and collected aliquots of routinely obtained urine specimens from women during prenatal visits. Urine specimens were screened by enzyme immunoassay for amphetamines, marijuana, cocaine, opiates, and ethanol. Of the 935 women screened, 92 (9.8%) had urine specimens positive for one or more of these substances. Urine screens were positive in 56 (10.0%) of 562 women attending private clinics and 36 (9.6%) of 373 women attending public clinics. Only 7 of the 935 women (0.7%) had screens positive for cocaine. Ethanol was the most frequently detected substance in the private clinic group (6.4%), whereas marijuana was most common among women attending public clinics (5.1%). Although substance use in this group of pregnant women occurs at a lower rate and a different pattern from those found in other more densely populated areas, the rate is high enough to be of concern to all prenatal care professionals, who should incorporate substance use history taking and selective urine drug screening into their routine prenatal practices.

Argon laser therapy for hemorrhagic radiation proctitis: long-term results.

In chronic radiation proctitis bleeding occurs from mucosal friability and neovascular telangiectasias. Fourteen patients with bleeding from chronic radiation proctitis underwent endoscopic argon laser therapy at 4 to 8 W. The goal of treatment was obliteration of all telangiectasias. The average follow-up was 35 months. Of the 51 procedures, 48 (94%) were performed on outpatients with enema preparation and little or no sedation. A median of three procedures was performed per patient, with two sessions required for initial control of bleeding. Ten patients (71%) required maintenance therapy for recurrent bleeding from telangiectasias that developed after initial therapy. The mean interval between maintenance sessions was 7 months. No immediate or late complications occurred.

Restoration of squamous mucosa after ablation of Barrett's esophageal epithelium.

BACKGROUND: Antireflux therapy has generally failed to induce regression of Barrett's epithelium. It was hypothesized that squamous epithelium could be restored if the columnar tissue was ablated while gastric acid secretion was suppressed. METHODS: Ten white men with Barrett's esophagus received 40 mg of omeprazole daily. Thereafter, every 2-5 weeks they underwent videotaped endoscopies to argon laser photoablate columnar tissue, obtain biopsy specimens, and assess results. Squamous re-epithelialization was assessed by correlation of videotapes and directed biopsies. RESULTS: Patients had one to eight areas ablated, totaling 0.5-12.0 cm2. Videotape assessments were corroborated by biopsy in all but one instance. Thirty-eight of 40 treatment locations partially or completely re-epithelialized with squamous tissue. Squamous regrowth appeared to occur by spread from contiguous squamous borders and de novo from glandular tissue. Regrowth was influenced by the extent of squamous borders and completeness of ablations. Nonablated glandular tissue persisted beneath squamous epithelium. CONCLUSIONS: Ablation of Barrett's epithelium and suppression of acid secretion facilitated squamous re-epithelialization. A progenitor cell within the metaplastic tissue has the potential to differentiate normally.

The prevalence of substance abuse among pregnant women in Utah.

OBJECTIVE: To determine the rate of substance use among Utah's pregnant women, who are primarily white and middle class, for comparison to rates reported in studies of inner-city populations. METHODS: Urine specimens and demographic data were obtained anonymously from women who delivered infants at ten hospitals in urban and suburban Utah. Urine samples were screened by enzyme immunoassay for amphetamines, marijuana, cocaine, methadone, opiates, benzodiazepines, and ethanol. RESULTS: Among 792 women screened, the mean age was 26.2 years, 86.1% were white, 62.9% were multigravidas, and 66.3% had private insurance. Cocaine was detected in nine samples (1.1%), illicit amphetamines in five (0.6%), marijuana in 23 (2.9%), ethanol in 32 (4.0%), over-the-counter amphetamines in 51 (6.4%), and benzodiazepines in seven (0.9%). The prevalence rate for women positive for illicit drugs and alcohol combined was 7.8%. Cocaine-positive and marijuana-positive women were more likely to be non-white or Hispanic and to have Medicaid or no insurance than were women negative for either substance. Women with Medicaid or no insurance were four times more likely to be positive for illicit substances (10.7%) than were those with private insurance (2.3%) (P = .0001). CONCLUSION: The rates and patterns of substance use differ between Utah's pregnant women and inner-city populations. The patterns in Utah may be more representative of many communities in the United States that have a predominantly middle-class, white population.

Shunt surgery versus endoscopic sclerotherapy for variceal hemorrhage: late results of a randomized trial.

Between September 1982 and April 1988, 60 cirrhotic patients with prior variceal hemorrhage were randomized to undergo the placement of an elective shunt (distal splenorenal: 26; nonselective: 4) or long-term endoscopic sclerotherapy (n = 30). Eighty-six percent of patients had alcoholic cirrhosis, and 33% were classified as Child's class C. After a mean follow-up of 87 months, 60% of patients undergoing sclerotherapy and 17% of shunt patients experienced rebleeding (p < 0.001). Shunt patients have survived longer than those who had sclerotherapy (6-year survival rates of 53% and 26%, respectively; p < 0.05). In part because of the wide geographic distribution of patients, only 4 of 13 patients in whom sclerotherapy failed (31%) could undergo salvage by shunt surgery. Although hepatic portal perfusion was better maintained after sclerotherapy, there were no major differences between the groups in terms of post-therapy hepatic or psychoneurologic function. In a predominantly alcoholic cirrhotic patient population (half non-urban), the results of elective shunt surgery were superior to those of chronic endoscopic sclerotherapy with respect to the prevention of recurrent variceal hemorrhage and survival.

Vascular malformations of the gastrointestinal tract.

The advent of fiberoptic endoscopy, which became widespread in the evaluation of gastrointestinal bleeding throughout the late 1970s and 1980s, has dramatically changed both our understanding of the extent to which vascular malformations account for gastrointestinal blood loss and our ability to treat these lesions at the time of diagnosis. Colonic vascular malformations appear to be the single most common cause of acute or recurrent gastrointestinal bleeding episodes in patients over 60 years of age, being responsible for the bleeding in as many as 35% of such patients. Although less common as a cause of upper gastrointestinal bleeding, these lesions still account for 2% to 5% of bleeding lesions in older patients. Diagnosis is accomplished by endoscopy, and the vascular malformations can then be coagulated via the endoscope using one of a number of thermal systems. The argon laser, the heater probe, and the BICAP system are all effective and safe throughout the gastrointestinal tract, especially in the cecum and right colon, where the majority of sporadic vascular malformations occur. Monopolar cautery and the Nd:YAG laser are equally efficacious, but their greater and less predictable depth of coagulation make them much less safe in the cecum and right colon. There are no apparent advantages in terms of efficacy and safety between laser treatment and the other thermal modalities. The laser has the advantage of being quicker, which is especially important when treating large or multiple lesions. The other modalities have the advantages of portability and low relative cost. Endoscopic therapy with lasers or other thermal devices is nonspecific. The effects are achieved by thermally coagulating the mucosal vascular lesions, allowing the coagulated tissue to slough, and leaving a mucosal ulceration that subsequently heals with re-epithelialization. Endoscopic coagulation has thus been reported effective in the treatment of gastrointestinal mucosal vascular lesions regardless of their etiology or characteristics. It has been effective for sporadic vascular malformations, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), radiation proctocolitis, the blue rubber-bleb nevus syndrome, and diffuse gastric antral vascular ectasia (the watermelon stomach). As we move through the 1990s and beyond, these endoscopic modalities offer an effective, relatively safe, and clearly less invasive treatment option for the many patients who experience acute, recurrent, or chronic gastrointestinal bleeding from any of these lesions.

Endoscopic laser therapy of the watermelon stomach.

Endoscopic laser therapy has been used in the treatment of vascular lesions throughout the gastrointestinal tract. The "watermelon stomach" is a pattern of vascular ectasia in the gastric antrum that results in chronic gastrointestinal blood loss and iron deficiency anemia. We have treated 7 transfusion dependent patients with a watermelon stomach using endoscopic laser therapy. Four of these patients were treated with the argon laser and 3 with the Nd:YAG laser. Patient age and prior transfusion requirements were similar in both groups. The mean number of treatments to obliterate vascular lesions and eliminate the need for transfusions was 5.75 +/- 0.89 (SEM) for the argon laser and 2.33 +/- 0.27 for the Nd:YAG laser (P < 0.05). Lesions recurred and required retreatment in 1 patient treated with the Nd:YAG laser and 3 patients treated with the argon laser (mean follow-up of 35 months). We conclude that endoscopic laser therapy with either the argon or Nd:YAG laser is an effective treatment modality for antral vascular ectasia (watermelon stomach). The Nd:YAG laser requires fewer treatment sessions than the argon laser to obliterate the lesions without increased risk of complications.

Circadian rhythm of cellular proliferation in the human rectal mucosa.

Circadian rhythms of DNA synthesis and cellular proliferation in the gastrointestinal mucosa have been well documented in animal models. This investigation was designed to determine whether similar rhythms could be demonstrated in the human rectal epithelium: 24 studies were performed in 16 healthy men under fasting (n = 14) and fed (n = 10) conditions. Rectal mucosal biopsy specimens were obtained through a proctoscope every 2 or 3 hours for a 24-hour span. Ex vivo measurements of tritiated thymidine incorporation into DNA were made on the mucosal samples. Feeding and time of day were each found to have an effect on the rate of thymidine incorporation into the DNA of rectal mucosal cells. Both fasted and fed subjects showed significant circadian rhythms in thymidine incorporation, which peaked at about 7 AM. Fasting lowered the overall mean thymidine uptake without altering the rhythm. Thymidine uptake generally reflects the amount of DNA synthesis in the sampled tissue. Therefore, these data may be important in the design of cancer chemotherapeutic regimens that use drugs specifically active during DNA synthesis.

Single-dose pharmacokinetics and tolerance of a cholesteryl sulfate complex of amphotericin B administered to healthy volunteers.

Twenty-three healthy volunteer subjects received a single dose of amphotericin B colloidal dispersion or placebo (4:2) in a double-blind, randomized, dose-escalating design. Doses ranged from 0.25 to 1.5 mg/kg of body weight. The medication was administered via intravenous infusion at a rate of 0.5 mg/kg/h. Plasma amphotericin B concentrations increased with increasing doses, resulting in a linear increase in the amphotericin B area under the curve. Concentrations in plasma decreased rapidly upon discontinuation of the infusion, indicating rapid tissue distribution. A log-linear biexponential elimination phase was observed. A three-compartment open model was used to describe the distribution and elimination of amphotericin B. The mean terminal elimination half-life ranged from 86 h at the 0.25-mg/kg dose level to 244 and 235 h at the 1.0- and 1.5-mg/kg dose levels, respectively. Mean total body clearance ranged from 219 to 284 ml/kg/h. The volume of distribution increased with dose, from 3.37 liter/kg at the 0.25-mg/kg dose to 7.92 liter/kg at the 1.5-mg/kg dose. At the lowest dose level, 0.25 mg/kg, the medication was generally well tolerated. Progressive increases in the dose led to increasing side effects. At the 1.5-mg/kg dose level, 50% of the patients on active medication experienced nausea, vomiting, and chills. Physical examinations, ophthalmologic examinations, and clinical laboratory parameters remained within normal limits compared with those obtained during prestudy examinations.

Percutaneous rotational contact biliary lithotripsy: initial clinical results with the Kensey Nash lithotrite.

The percutaneous rotary lithotrite introduces a new concept to fragmentation and percutaneous removal of gallstones. A fluid vortex is generated, pulling calculi into a high-speed blade that fragments stones to predominantly under 500 microns. The results of treating the first 10 patients with this instrument reveal that large stone burdens as well as small stones (2-3 mm) of any composition can be removed if the gallbladder is of sufficient size to accommodate the six-pronged basket. Rotation times of 7-39 minutes were required. Nine of 10 procedures were completed; access was lost in one case. One major complication occurred. At repeat oral cholecystography, the gallbladder was visualized after 3-6 weeks in eight of the nine patients. Ursodeoxycholic acid was administered from 3 to 12 months to five patients with either residual stones or aggregates. The hospital stay ranged from 48 to 72 hours. All patients (except the patient who underwent surgery) resumed light activity in 3-4 days and strenuous activity and full diet within 3 weeks.

Day-night and individual differences in response to constant-rate ranitidine infusion.

Twelve ulcer patients with inactive disease received constant-rate infusions of ranitidine, in doses of 6.25 and 10.0 mg/hr, during separate 24-h spans. Gastric pH and serum ranitidine concentrations were monitored. Serum ranitidine concentrations did not vary significantly after attainment of steady-state. For the group, gastric acidity was controlled above pH 4 during the day; however, at night, when gastric acid secretion was greatest under placebo conditions, ranitidine less effectively controlled gastric pH. There was individual variation in response to ranitidine. Patients (8/12) evidencing control of gastric acidity (pH greater than or equal to 4) for at least 16 h when infused with ranitidine (6.25 mg/h) were considered responders. Those (4/12) not so well controlled were designated poor responders. With parenteral infusion of 6.25, as well as 10.0 mg/h ranitidine, responders evidenced a relatively high 24-h mean pH and only minor day-night variation in gastric acidity. In contrast, poor responders were characterized by a low 24-h mean pH and high-amplitude circadian variation in gastric acidity. Poor responders evidenced statistically significant (p less than 0.05) lower gastric pH responses to parenteral infusions than did responders. A similar, significant difference between the two groups was observed when the percentage of time that gastric pH was maintained below 4 was considered. Differences between responders and poor responders to ranitidine infusion are unknown. Since Zollinger-Ellison syndrome patients were not included in the study, observed differences in drug response cannot be ascribed to hypersecretion of gastric acid.

Pharmacodynamics of intravenous ranitidine after bolus and continuous infusion in patients with healed duodenal ulcers.

Fifteen adult men who had histories of duodenal ulcer disease were studied for 24 hours during treatment with varying intravenous doses of ranitidine (50 mg every 8 hours, 100 mg every 12 hours, 6.25 mg/hr continuous infusion, and 10 mg/hr continuous infusion) and placebo. Gastric pH was monitored under fasting conditions by means of an indwelling pH sensitive electrode. The continuous infusion regimens provided the most constant level of acid suppression. A "breakthrough" decrease in gastric pH began at approximately 6 PM at the 6.25 mg/hr dose level. The drop in pH at the 10 mg/hr dose level was less impressive. Ranitidine, 100 mg every 12 hours, resulted in better acid suppression than the regimen of 50 mg every 8 hours. A gastric pH greater than or equal to 4 was achieved 35 to 50 minutes after the start of administration for all regimens. The median effective concentration (EC50) of ranitidine was approximately 45 ng/ml. Continuous infusion regimens, with a dosage adjustment for the time of day, may be the optimal dosage regimen for patients requiring continuous protection from gastric damage by hydrochloric acid. Bolus loading doses are not required to speed the onset of effect in the clinical setting.

High prevalence of adenomatous polyps of the duodenal papilla in familial adenomatous polyposis.

Eighteen consecutive asymptomatic patients with familial adenomatous polyposis (both familial polyposis coli and Gardener's syndrome) were studied over a 12-month period; side-viewing upper endoscopy and biopsy were used to assess the frequency of adenomatous polyps of the duodenal papilla. Nine of the 18 patients demonstrated adenomatous polyps of the papilla, varying in size and appearance from microadenomas in normal-appearing duodenal papillae (two) to a sessile polyp 3 cm in diameter. Two were tubulovillous adenomas (0.5 cm and 2 cm in diameter) and the remainder were tubular adenomas. Severe atypia and malignancy were not encountered. These findings reveal that adenomas of the duodenal papilla are common in individuals with familial adenomatous polyposis. Because of these findings and because of the known risk of periampullary adenocarcinomas and nonmalignant complications of polyps of the duodenal papilla in patients with familial adenomatous polyposis, upper gastrointestinal screening of such patients should include examination of the duodenal papilla with a side-viewing endoscope.

Effects of 180 micrograms and 250 micrograms norgestimate on pituitary-ovarian function and cervical mucus.

A double-blind cross-over study of 16 healthy women was carried out to evaluate the effects of norgestimate, a new progestogen, on pituitary ovarian function and cervical mucus. Treatment from cycle day 7 to 16 with 180 micrograms and 250 micrograms norgestimate led to suppression of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, while progesterone (P) remained suppressed in 28 of 32 cycles studied, indicating inhibition of ovulation. Lack of ovulation in 30 cycles was associated in all but 3 with functional follicles, 2 of which luteinized. With 250 micrograms norgestimate, estradiol (E2) concentrations reached levels similar to those achieved during control follicular phase, but significantly higher concentrations of E2 were achieved with 180 micrograms norgestimate. Cervical mucus score was significantly depressed in all but 5 cycles (3 norgestimate 180 micrograms and 2 norgestimate 250 micrograms cycles). In conclusion, both dosages of norgestimate show good suppression of the hypothalamic-pituitary axis and cervical mucus.