Attitudes of neonatal clinicians towards resuscitation of the extremely premature infant: an exploratory survey.

OBJECTIVE: This study aims to explore the current attitudes of Australian neonatologists and nurses towards the resuscitation of extremely preterm infants. METHODOLOGY: An anonymous questionnaire regarding resuscitation of infants of less than 28 weeks gestation was sent to all neonatologists and three registered nurses in each perinatal centre in Australia. RESULTS: One hundred and thirty-three questionnaires were sent. A return rate of 93% and 73% was obtained from neonatologists and nurses, respectively. Twenty-two per cent of neonatologists would 'occasionally' resuscitate at 22 weeks while none of the nurses would. A considerable proportion of neonatologists (23%) but only a few nurses (6%) would 'quite often' resuscitate 23-week infants. The majority of neonatologists (85%) and nurses (88%) would 'almost always' resuscitate 24 week infants. More than half of the respondents would 'occasionally' resuscitate a 400-499 g infant and most would resuscitate infants weighing more than 500 g. Clinicians were not as optimistic of long-term outcome as they were for survival. Typically, only 52% of neonatologists and 38% of nurses thought babies of 25 weeks gestation had a greater than 50% chance of survival without major handicap. Parental wishes and the presence of congenital abnormalities were major influences on decision to resuscitate. Hypothetically, most respondents, more doctors than nurses, would consider initiating resuscitation without parental consent at a median gestation of 25 weeks. CONCLUSIONS: The majority of Australian clinicians would resuscitate at a gestation of 24 weeks or greater or at a birth weight of over 500 g despite conservative estimates of intact survival. This survey has brought to light the importance of communication with parents prior to extreme premature birth.

A randomized controlled trial of two methods for collection of sterile urine in neonates.

OBJECTIVE: To test whether urethral catheterization (UC) is better than suprapubic bladder aspiration (SPA) as a method for collection of sterile urine in neonates. METHODS: Thirty-three babies, requiring sterile collection of urine, were randomly assigned to either urethral catheterization (n=16), median gestation 28+/-3.9 weeks, median birth weight 968 g (range 650-4100) or SPA (n=17), median gestation 26+/-5.6 weeks, median birth weight 926 g (range 771-4070). The primary outcome was success in obtaining urine. Secondary outcomes were complications and urine culture results. RESULTS: Some urine was obtained in 11 (64.7%) babies in the SPA group and in 13 (81.2%) babies in the catheter group. Sufficient urine for analysis (>0.5 ml) was obtained in 10 (58.8%) in the SPA group versus 5 (31.2%) babies in the catheter group. There were more contaminated specimens in the catheter group but this was not significant in this small study. CONCLUSIONS: In this small randomized controlled trial urethral catheterization offered no significant advantage over SPA.

Complications of central venous access devices in children with and without cancer.

OBJECTIVE: Complications of indwelling central venous access devices (CVAD) were assessed in 63 children with cancer and 35 without cancer. METHODOLOGY: Central venous access devices placed surgically in 1991 were reviewed for complications. RESULTS: In cancer patients, the median CVAD duration was 211 days (range 9-924), compared to 37 days (range 3-339) in the non-cancer patients. Although significantly more CVAD, 41 of 72 (57%), were infected in the cancer patients compared to 14 of 40 (35%) CVAD in the non-cancer patients (OR = 2.46, 95% CI 1.03-5.93), the rate of line infection in cancer patients was lower: 2.8 per 1000 catheter days compared with 7.6 per 1000 in non-cancer patients (P = 0.0014). Infection was significantly more common in intensive chemotherapy cancer patients (P = 0.0002). CONCLUSIONS: Treating infected CVAD with antibiotics or hydrochloric acid (HCl), clearing occluded lines with streptokinase/HCl and repairing fractured lines, when successful, resulted in a considerable gain in the number of days of use for the CVAD.

Crisis in admission beds. A four-year survey of the bed state of Greater London's acute psychiatric units.

BACKGROUND: This study was carried out to measure bed occupancy in Greater London's psychiatric units, in response to the apparent shortage of admission beds. METHOD: The bed occupancy of London's 54 National Health Service (NHS) acute psychiatric units within 29 districts was ascertained by telephone on 16 bank holidays covering the period 1990-93. RESULTS: The mean occupancy level for all London over the 4 years was 97.54% (95% CI- +/- 0.94%). The number of beds occupied in inner London was significantly greater (99.79 +/- 1.11%) than in outer London (95.1 +/- 1.49%) (t = 3.85, d.f. = 462, P < 0.001). Bed occupancy for inner London units was > or = 100% on over 49% of occasions. There has been a steady decline in the number of beds over the four-year period. There was a clear correlation between occupancy levels and the Jarman UPA8 Underprivilege Score (r = 0.504) and between bed provision and the UPA8 (r = 0.67). CONCLUSION. Occupancy rates have become unacceptably high and require careful monitoring. Corrective action may be required in order to prevent a breakdown in services.

The Gospel Oak Study stage IV: the clinical relevance of subjective memory impairment in older people.

The prevalence rate of subjective memory impairment (SMI) and its value as a predictor of future depression or dementia was studied in a community sample of elderly residents in one electoral ward using the short-CARE. SMI was found to be common, occurring in 25% of subjects. Subjects with SMI were more likely to be suffering from either dementia or depression than those without the complaint, although 60% of subjects with SMI did not have evidence of either disorder. When followed up over a 2-year period, subjects with SMI were found to be at four-fold greater risk of developing future dementia and two-fold greater risk of developing a depression compared with those without SMI. The SMI scale was not found to be useful as a population screen for dementia or depression, although two of the nine items might have value as screening questions in clinical circumstances to determine those with memory complaints at risk for dementia.

Neurodevelopmental outcome in very low birthweight infants with necrotizing enterocolitis requiring surgery.

OBJECTIVE: To assess the effect of necrotizing enterocolitis (NEC) on neurodevelopmental outcome. METHODOLOGY: Neurodevelopmental outcome of 20 very low birthweight (VLBW) infants who developed NEC requiring surgery was compared with 40 matched infants controlled for gestation, birthweight, and year of admission. Twenty-nine VLBW infants who developed NEC and did not require surgery were also compared. RESULTS: Infants with NEC needing surgery were of 26 +/- 2 weeks gestation and weighted 892 +/- 192 g at birth. Infants with NEC managed medically were of higher gestation (27 +/- 2 weeks) but similar birthweights. More infants with NEC requiring surgery required inotropic support. At follow up, NEC surgery infants had a significantly higher incidence of developmental morbidity. 11 of 20 compared with 11 of 40 matched controls (Fisher's exact test P = 0.0493), and six of 29 infants with NEC managed medically (Fisher's exact test P = 0.0174). CONCLUSIONS: These findings stress the importance for close follow up for neurodevelopmental sequelae in VLBW infants who have had NEC requiring surgery.

Psychosis and destitution at Christmas 1985-88.

Surveys of the destitute were conducted over four successive Christmas periods in Central London, UK. Functional psychosis with hallucinations and/or delusions, either current (19%) or in the past (22%), were associated with extreme social isolation and imprisonment.

Serum carnitine in children with kwashiorkor.

Concentrations of free and acylcarnitine were measured in serum of children with kwashiorkor and compared with those obtained for well nourished children of similar age. The mean values (S.E.) for both free and acylcarnitine were significantly lower in the kwashiorkor group [32.6 (6.2) and 8.1 (2.2), respectively] than in the controls [53.2 (2.9) and 13.8 (3.1), respectively]. Serum albumin was also low in kwashiorkor patients, but there was no significant correlation with carnitine values.