The impact of very low-birth-weight infants on the family is long lasting. A matched control study.

OBJECTIVE: To test the hypothesis that parental stress associated with long-term morbidity of very low-birth-weight infants (VLBWIs) is long lasting. DESIGN: Matched case-control study. SETTING: High-risk newborn follow-up program, Winnipeg, Manitoba. PARTICIPANTS: Parents of 96 Manitoban VLBWIs born from July 1986 through June 1990, compared with parents of full-term controls matched for age, sex, race, domicile, singleton or multiple pregnancy, and birth order. MAIN OUTCOME MEASURES: Mailed questionnaire, including Stein's Impact on Family Scale, positive impact of parenthood, and attitudes toward treating VLBWIs. RESULTS: Families were demographically similar. The parents of VLBWIs had higher scores for financial burden, familial/social impact, personal strain, and mastery (P < .0001). The parents of VLBWIs experienced more impact when children had a functional handicap or low adaptive developmental quotient. Scores were highest when the adaptive developmental quotient was 70 to 85. High scores were associated with low family income and less parental education. Impact did not change over time. Only half of the parents in each group felt that "doctors should try to save every baby." The parents of VLBWIs felt more strongly that cost should never enter into the decision to treat a tiny baby (P < .005). The families of VLBWIs expressed a stronger desire for more children (P < .01), but control families were more likely to have given birth again (46.3% vs 28.2%). CONCLUSIONS: The birth and upbringing of a VLBWI is associated with more long-term stress, even for well-educated nuclear families whose health care is financed by government. Caregivers need increased awareness of the needs of these families so that their medical and social needs are met effectively. Support services should be targeted toward low income, poorly educated parents whose children have functional handicaps.

Neonatal portal vein thrombosis successfully treated by regional streptokinase infusion.

We report a case of portal vein thrombosis (PVT) in a term neonate following an exchange transfusion through an umbilical vein catheter which was left in situ for 16 h after the transfusion. The baby made a complete recovery after successful thrombolysis with regional streptokinase infusion. To our knowledge, this is the first reported case of a PVT following an indwelling portal venous catheter left in situ with complete resolution following thrombolysis with regional streptokinase infusion.

Randomized clinical trial of surfactant prophylaxis in retinopathy of prematurity.

Prophylactic lung surfactant is commonly used to reduce the severity of neonatal respiratory distress syndrome in premature infants. There is disagreement in the literature regarding the effect of prophylactic lung surfactant on the incidence of retinopathy of prematurity (ROP). Sixty-four infants, gestational age 23 to 32 weeks, birth weight 610 to 1250 g, were randomized to receive either intratracheal bovine surfactant prophylaxis or air control, at our institution, as part of a national double-masked multicenter trial. Forty-eight of these infants survived and underwent complete ophthalmologic examinations by a single masked examiner. ROP data were gathered retrospectively. ROP developed in 19 of the 23 (83%) who received surfactant and 15 of the 25 (60%) controls (P = .1). Analysis of the worst stage of ROP for each infant also revealed no difference between the surfactant and control groups (P = .4). Our retrospective analysis of ROP data in a prospective double-masked randomized study revealed no significant effect of surfactant on the incidence or severity of ROP.

Ocular findings in premature infants with grade IV intraventricular hemorrhage.

Grade IV intraventricular hemorrhage (IVH) is a severe complication of premature birth. We retrospectively performed serial exams on 13 infants with grade IV IVH and compared their ocular findings to 11 infants matched by gestational age and birth weight without an IVH. All children in the study were initially examined in the neonatal unit within 8 weeks after birth. Subsequent periodic eye exams were performed until 3 to 7 years of age. Of the 13 grade IV IVHs, there was a 92% incidence of ocular abnormalities, compared to a 73% incidence in the premature group without IVH. The children with grade IV hemorrhages had a statistically significant increased incidence of severe eye disease with resultant visual loss (38%) compared to the non-IVH group. Loss of vision was due to optic atrophy and retinopathy of prematurity. Grade IV IVH children are at high risk for severe eye disease and should have early and frequent ophthalmologic exams.

Basal and post-ACTH cortisol levels in preterm infants following treatment with dexamethasone.

Dexamethasone (DEX) has been shown to decrease ventilator dependence in bronchopulmonary dysplasia (bronchopulmonary dysplasia). Abnormal metapyrone tests have been reported in 50% of infants who were weaned from a 45-day course of dexamethasone. We postulated that such infants would have adrenal suppression and would not respond to Cosyntropin (ACTH). We examined morning cortisol levels in 14 premature infants who had been treated with dexamethasone for 36 +/- 4 (mean +/- SEM) days, starting at 38 +/- 6 days of life, and performed ACTH stimulation tests in 12 of them. Morning cortisol levels were 87 +/- 36 nmol/L (range undetectable: 543; n = 14). Random basal cortisol levels were 109 +/- 42 nmol/L (range 34-540; n = 12). The mean cortisol level was 568 +/- 63 nmol/L (range 117-934) 60 min after adrenocorticotrophic hormone. In all cases, cortisol level increased three-fold after adrenocorticotrophic hormone. Low cortisol levels are almost universal in infants after treatment with dexamethasone, but the adrenal gland remains responsive to adrenocorticotrophic hormone stimulation. We speculate that dexamethasone causes secondary adrenal suppression at the hypothalamic-pituitary level. Normal adrenal function in the preterm infant needs to be defined.

Evolution of angioid streaks.

Angioid streaks of the fundus are not apparent at birth. In order to study their evolution, we examined in a retrospective manner the fundus pictures of 111 subjects with angioid streaks. The earliest form of angioid streaks became apparent at age 8 with findings of narrow short radial discontinuous hypopigmented streaks. Thereafter angioid streaks enlarged in length and width. The end-stage was disciform macular degeneration, helicoid peripapillary atrophy, or diffuse choroidal sclerosis with obscuration of the angioid streaks. We conclude that angioid streaks represent a dynamic manifestation of an underlying retinochoroidal degenerative process.

Splanchnic blood flow, oxygen delivery and oxygen consumption in hypotensive newborn piglets.

To investigate the relationship between splanchnic visceral oxygen supply and consumption, we altered O2 delivery by decreasing gastrointestinal blood flow during hypotension, and examined the effect on splanchnic oxygen consumption and extraction. We used 10 anesthetized newborn piglets, and measured blood flow using radioactive microspheres. Blood flow fell as perfusion pressure fell in all splanchnic organs, the correlation being most marked in the small intestine. Oxygen consumption was linearly related to blood pressure, and despite a rise in splanchnic oxygen extraction with low blood pressure, splanchnic oxygen consumption was highly dependent on oxygen delivery when oxygen delivery was below a critical value of 0.17 +/- 0.05 mmol/100 g/min. We conclude that the newborn piglet gut is incapable of maintaining a constant oxygen supply during the low-flow state produced by hypotension.

Risk factors associated with kernicterus in the newborn infant: importance of benzyl alcohol exposure.

The prevalence of kernicterus in our neonatal intensive care unit (NICU) decreased from more than 2/1000 live births in 1980 to none in 1984. To clarify predictors of kernicterus, we examined the medical records of infants born during that time who died between 2 and 28 days of age. Infants were divided into three groups: those with kernicterus, all born before June 10, 1982 (n = 29); contemporaneous controls (n = 28); and infants born after June 10, 1982 (n = 32). Benzyl alcohol was not used after June 10, 1982. Kernicteric infants were more likely than contemporaneous controls to have seizures (p less than 0.001). Indices of pulmonary disease, arterial partial pressure of carbon dioxide and end-expiratory pressure on the ventilator were higher after 1982. However, exposure to benzyl alcohol was not different in kernicteric infants and contemporaneous controls, suggesting that benzyl alcohol exposure was not the explanation for the decrease in the prevalence of kernicterus in our NICU.

Duane syndrome associated with oculocutaneous albinism.

A 5-year-old female presented with signs of Duane's retraction syndrome and oculocutaneous albinism. Duane's syndrome is associated with anomalous innervation of the lateral rectus by the oculomotor nerve. Oculocutaneous albinism is associated with an increased proportion of crossed retinal ganglion fibers at the chiasm. Because Duane's syndrome and oculocutaneous albinism are both examples of ocular miswiring, a common mechanism is suggested.

Blood flow distribution and brain metabolism during tolazoline-induced hypotension in newborn dogs.

Tolazoline is used in neonatal intensive care to treat hypoxia secondary to persistent pulmonary hypertension of the newborn. Its use is often complicated by systemic hypotension. We compared the effect of tolazoline-induced hypotension on organ blood flow, regional brain blood flow, and cerebral metabolism in hypoxic newborn dogs whose mean arterial pressure fell by more than 20% with a second group whose blood pressure fell by less than 20%. Blood flows were measured by the radioactive microsphere technique. We found no changes in organ blood flow, regional brain blood flow, and cerebral metabolism in hypoxic animals whose mean arterial blood pressure decreased less than 20% during tolazoline administration. However, in those animals whose mean arterial blood pressure decreased more than 20%, we found a decrease in cerebral blood flow. As a consequence of decreased cerebral blood flow, cerebral oxygen delivery decreased. However, oxygen extraction increased so that cerebral metabolic rate was preserved.

The effect of aminophylline on gastrointestinal blood flow and oxygen metabolism in the conscious newborn lamb.

Aminophylline, widely used in the neonatal period, has been reported to be associated with necrotizing enterocolitis. We hypothesized that aminophylline might alter gastrointestinal blood flow and oxygen delivery. The effects of this drug on gastrointestinal (GI) blood flow and oxygen delivery, consumption, and extraction were examined using the radioactive microsphere method in ten chronically catheterized, unanesthetized lambs aged 5-12 days. While cardiac output and systemic oxygen consumption did not change, we found statistically significant increases (p less than 0.05) in small intestinal blood flow as a function of lamb weight and as a percentage of cardiac output. Splanchnic oxygen consumption also increased significantly. The oxygen reserve available to the GI tract can be compromised by aminophylline at levels similar to those used in the human neonate for treatment of apnea.

Comparative evaluation of the three commercially available transdermal nitroglycerin delivery systems.

We comparatively evaluated the patient preference for each of the three commercially available transdermal nitroglycerin delivery systems using a randomized crossover study design. Preference was determined by ease of application, adhesion, occurrence of local irritation at the site of application, and systemic toxicities. In addition, we recorded the number of nitroglycerin tablets taken and angina attacks reported per treatment course. Each treatment course was one month long, with each patient participating for a total of three months. This allowed all patients to be exposed to each of the three products for one treatment course, thereby serving as their own controls. Thirty-eight patients completed the three-phase crossover and expressed a preference. Results showed that Transderm-Nitro was significantly preferred over both Nitro-Dur and Nitrodisc (p less than 0.005). Most of the preferences were based on cosmetic appearances or adhesive qualities. Additionally, results showed that there was no difference in efficacy among the three products when number of angina attacks reported and number of nitroglycerin tablets taken were compared.

Evaluation of a multiple-dose syringe pump system for intermittent i.v. drug delivery.

The feasibility of implementing a multiple-dose, multiple-flow-rate syringe pump system in a large teaching institution and a community hospital is described. The new syringe pump system was evaluated on medical and surgical wards in each hospital for a period of time sufficient to evaluate 40 courses of therapy in each hospital. At the time the new syringe pump system was implemented, the teaching hospital was using a gravity-dependent bottle and burette system and the community hospital was using a single-dose syringe pump system. At the end of the study period, the material costs of the existing i.v. infusion systems were compared with the material costs of the new syringe pump system, and the nurses involved in the study were questioned about their attitudes toward the new system. Use of the multiple-dose syringe pump system resulted in a savings of $934.81 in material costs compared with the bottle and burette system and $9.70 in material costs compared with the single-dose syringe pump system (based on 40 doses). When the cost of wasted drug was considered, the cost per day of the multiple-dose syringe pump system was substantially less (70%) than the cost per day of the bottle and burette system and approximately the same as the cost per day for the single-dose syringe pump system. The majority of nurses indicated that the new system was easier or no more difficult to use than the existing i.v. infusion system and were in favor of switching to the new system. Implementation of a multiple-dose, multiple-flow-rate syringe pump system may result in cost savings over a traditional bottle and burette system and could complement an existing single-dose syringe infusion system.

Transection of the inferior rectus muscle.

Four cases of isolated inferior rectus transection secondary to trauma are presented. The clinical and CT scan findings are illustrated. The CT scan findings are very useful in the surgical management and prognosis of these cases.

Transdermal scopolamine in motion sickness.

Motion sickness is a common clinical malady. Until recently, the use of scopolamine, the drug of choice for the treatment of motion-induced nausea and vomiting, has been sometimes associated with a variety of unacceptable side effects. These side effects could result from the unpredictable blood levels attained with oral dosage (pulse delivery). A new system of drug delivery, the transdermal therapeutic system (TTS)--Transderm-V--has been developed. The TTS delivers scopolamine across the skin at a constant rate. This permits a drug with a very short half life to be administered over prolonged periods, thereby maintaining blood concentrations at the defined therapeutic level. This precludes the necessity for frequent dosing and increases patient acceptability and compliance while minimizing the untoward effects associated with conventional dosage forms of the drug.

Levonantradol for chemotherapy-induced emesis: phase I-II oral administration.

Thirty five patients were enrolled into a Phase I-II study of oral levonantradol being tested as an antiemetic for chemotherapy patients who were refractory to the aggressive use of standard antiemetic agents. Sixty-nine total courses were given. Dysphoric reactions (fear, anxiety, hallucinations) were the most serious side effects, and were most prevalent at the highest dose tested (2.0 mg q4h). Somnolence, a "high" feeling, hypotension were also noted. Antiemetic responses were seen at 0.5, 1.0, 1.5 and 2.0 mg dose levels: the two intermediate doses gave responses comparable to those previously reported for oral THC. It is suggested that a combination of oral and parenteral levonantradol may prove to be a very effective program to relieve the otherwise disabling problems of persistent nausea and vomiting.