Prediction of hyperbilirubinemia in near-term and term infants.

OBJECTIVE: The purpose of this study was to determine whether end-tidal carbon monoxide (CO) corrected for ambient CO (ETCOc), as a single measurement or in combination with serum total bilirubin (STB) measurements, can predict the development of hyperbilirubinemia during the first 7 days of life. METHODS: From 9 multinational clinical sites, 1370 neonates completed this cohort study from February 20, 1998, through February 22, 1999. Measurements of both ETCOc and STB were performed at 30 +/- 6 hours of life; STB also was measured at 96 +/- 12 hours and subsequently following a flow diagram based on a table of hours of age-specific STB. An infant was defined as hyperbilirubinemic if the hours of age-specific STB was greater than or equal to the 95th percentile as defined by the table at any time during the study. RESULTS: A total of 120 (8.8%) of the enrolled infants became hyperbilirubinemic. Mean STB in breastfed infants was 8.92 +/- 4.37 mg/dL at 96 hours versus 7.63 +/- 3.58 mg/dL in those fed formula only. The mean ETCOc at 30 +/- 6 hours for the total population was 1.48 +/- 0.49 ppm, whereas those of nonhyperbilirubinemic and hyperbilirubinemic infants were 1.45 +/- 0.47 ppm and 1.81 +/- 0.59 ppm, respectively. Seventy-six percent (92 of 120) of hyperbilirubinemic infants had ETCOc greater than the population mean. An ETCOc greater than the population mean at 30 +/- 6 hours yielded a 13.0% positive predictive value (PPV) and a 95.8% negative predictive value (NPV) for STB >/=95th percentile. When infants with STB >95th percentile at <36 hours of age were excluded, the STB at 30 +/- 6 hours yielded a 16.7% PPV and a 98.1% NPV for STB >75th percentile. The combination of these 2 measurements at 30 +/- 6 hours (either ETCOc more than the population mean or STB >75th percentile) had a 6.4% PPV with a 99.0% NPV. Conclusions. This prospective cohort study supports previous observations that measuring STB before discharge may provide some assistance in predicting an infant's risk for developing hyperbilirubinemia. The addition of an ETCOc measurement provides insight into the processes that contribute to the condition but does not materially improve the predictive ability of an hours of age-specific STB in this study population. The combination of STB and ETCOc as early as 30 +/- 6 hours may identify infants with increased bilirubin production (eg, hemolysis) or decreased elimination (conjugation defects) as well as infants who require early follow-up after discharge for jaundice or other clinical problems such as late anemia. Depending on the incidence of hyperbilirubinemia within an institution, the criteria for decision making should vary according to its unique population.

A beta-galactosidase-like gene is expressed during tobacco pollen development.

cDNA clone (TP5) with significant homology to ss-galactosidases has been isolated from a mature tobacco pollen cDNA library by differential screening. The predicted protein of 715 aa shows high levels of homology to plant beta-galactosidases expressed during fruit ripening and senescence. Northern analysis shows that the TP5 transcript is expressed exclusively in developing anthers and mature pollen. The transcript is present at very low levels at meiosis and increases dramatically, late in microspore development after mitosis suggesting that the primary role for the protein is during pollen tube growth. beta-galactosidase activity, measured by scanning densitometry of histochemically stained tobacco microspores, is first detectable in the early to mid-vacuolate stage, and reaches a peak at microspore mitosis, thereafter decreasing as the microspores reach maturity. Southern analysis indicates that the TP5 gene is present in two copies, probably corresponding to the two ancestral genomes of N. tabacum.

Prediction of hyperbilirubinemia in near-term and term infants.

OBJECTIVE: The purpose of this study was to determine whether end-tidal carbon monoxide (CO) corrected for ambient CO (ETCOc), as a single measurement or in combination with serum total bilirubin (STB) measurements, can predict the development of hyperbilirubinemia during the first 7 days of life. METHODS: From nine multinational clinical sites, 1370 neonates completed this cohort study from February 20, 1998 through February 22, 1999. Measurements of both ETCOc and STB were performed at 30+/-6 hours of life; STB also was measured at 96+/-12 hours and subsequently following a flow diagram based on a table of hours of age-specific STB. An infant was defined as hyperbilirubinemic if the hours of age-specific STB was greater than or equal to the 95th percentile as defined by the table at any time during the study. RESULTS: A total of 120 (8.8%) of the enrolled infants became hyperbilirubinemic. Mean STB in breast-fed infants was 8.92+/-4.37 mg/dl at 96 hours versus 7.63+/-3.58 mg/dl in those fed formula only. The mean ETCOc at 30+/-6 hours for the total population was 1.48+/-0.49 ppm, whereas those of nonhyperbilirubinemic and hyperbilirubinemic infants were 1.45+/-0.47 and 1.81+/-0.59 ppm, respectively. Seventy-six percent (92 of 120) of hyperbilirubinemic infants had ETCOc greater than the population mean. An ETCOc greater than the population mean at 30+/-6 hours yielded a 13.0% positive predictive value (PPV) and a 95.8% negative predictive value (NPV) for STB > or =95th percentile. When infants with STB > or =95th percentile at <36 hours of age were excluded, the STB at 30+/-6 hours yielded a 16.7% PPV and a 98.1% NPV for STB >75th percentile. The combination of these two measurements at 30+/-6 hours (either ETCOc more than the population mean or STB >75th percentile) had a 6.4% PPV with a 99.0% NPV. CONCLUSIONS: This prospective cohort study supports previous observations that measuring STB before discharge may provide some assistance in predicting an infant's risk for developing hyperbilirubinemia. The addition of an ETCOc measurement provides insight into the processes that contribute to the condition but does not materially improve the predictive ability of an hours of age-specific STB in this study population. The combination of STB and ETCOc as early as 30+/-6 hours may identify infants with increased bilirubin production (eg, hemolysis) or decreased elimination (conjugation defects) as well as infants who require early follow-up after discharge for jaundice or other clinical problems such as late anemia. Depending on the incidence of hyperbilirubinemia within an institution, the criteria for decision making should vary according to its unique population.

Managing the assessment of neonatal jaundice: importance of timing.

In view of the limitations in the accurate visual assessment of jaundice and its potential role as a predictive vector for serious neurologic sequelae, we propose that a universal screening of bilirubin be considered concurrent to the routine pre-discharge metabolic screening. Universal bilirubin screening in the term and near-term newborns when plotted on "Hour-specific Bilirubin Nomogram" in lieu of the usual "day-specific" value will predict the high-risk and the low-risk groups and facilitate cost-effective and individualized follow-up of those babies at risk. A percentile based bilirubin nomogram for the first week of age was constructed from hour-specific pre- and post-discharge bilirubin values of 2840 healthy term and near-term babies. The accuracy of the pre-discharge bilirubin values was determined as a predictive vector. Pre-discharge (18-72 hours age), 6.1% of the study population had bilirubin values in the high-risk zone (> 95th percentile). Of these, 39.5% remained in that zone (likelihood ratio ¿LR¿ = 14.08). Pre-discharge, 32.1% of the study population had bilirubin values in the intermediate risk zone (40-75th percentiles). In a clinically significant minority of these babies (6.4%), the post-discharge values moved to the high-risk zone (L-R = 3.2 for the move from the upper-intermediate zone and 0.48 from the lower-intermediate zone). In the remainder 61.8% of the population who were identified to be at low risk, there was no measurable risk for significant hyperbilirubinemia (L-R = 0). The bilirubin nomogram can predict which infant is at high, intermediate, and low risk for subsequent excessive hyperbilirubinemia and allows for the individualized follow-up of these high-risk babies with particular attention to those who may need evaluation and intervention. Whereas, identification of the low risk group allows for a less intense bilirubin follow-up and in whom a visual check by an experienced care-provider may suffice.

Noninvasive measurement of total serum bilirubin in a multiracial predischarge newborn population to assess the risk of severe hyperbilirubinemia.

BACKGROUND: Jaundice in near-term and term newborns is a frequent diagnosis that may prompt hospital readmission in the first postnatal week. Hyperbilirubinemia, when excessive, can lead to potentially irreversible bilirubin-induced neurotoxicity. Predischarge risk assessment (at 24-72 hours of age) for subsequent excessive hyperbilirubinemia is feasible by a laboratory-based assay of total serum bilirubin (TSB). Hypothesis. Noninvasive, transcutaneous, point-of-care measurement of transcutaneous bilirubin (TcB) predischarge by multiwavelength spectral analysis, using a portable BiliCheck device (SpectRx Inc, Norcross, GA), is clinically equivalent to measurement of TSB in a diverse, multiracial term and near-term newborn population and predictive of subsequent hyperbilirubinemia. METHODOLOGY: We evaluated a hand-held device that uses multiwavelength spectral reflectance analysis to measure TcB (BiliCheck). The study population (490 term and near-term newborns) was racially diverse (59.1% white, 29.5% black, 3.46% Hispanic, 4.48% Asian, and 3.46% other) and was evaluated at 2 separate institutions using multiple (11) devices. The postnatal age ranged from 12 to 98 hours and the ranges of birth weights and gestational ages were 2000 to 5665 g and 35 to 42 weeks, respectively. All transcutaneous evaluations were performed contemporaneously and paired with a heelstick TSB measurement. All TSB assays were performed by high performance liquid chromatography, as well as by diazo dichlorophenyldiazonium tetrafluoroborate techniques. RESULTS: TSB values ranged from .2 to 18.2 mg/dL (mean +/- standard deviation: 7.65 +/- 3.35 mg/dL). The overall correlation of TSB (by high performance liquid chromatography technique) to TcB (by BiliCheck devices) was linear and statistically significant (r =.91; r(2) =.83; TcB =.84; TSB = +.75; standard error of regression line = 1.38; P <.001; n = 490 infants; 1788 samples). Similar regression statistics were evident in subset populations categorized by race (white: r =.91 [n = 289 infants]; black: r =.91 [n = 145 infants]) as well as by gestation (term: r =. 91 [n = 1625 samples]; near-term: r =.89 [n = 163 samples]). Intradevice precision was determined to be.59 mg/dL (2-3 measurements per infant with 1 device; n = 210 infants; 510 samples in a separate subset). Interdevice evaluation of 11 devices determined the precision to be.68 mg/dL (2-4 devices used for measurements per patient). In 23 of 419 of the study population infants who were in the 24- to 72-hour age range, the predischarge TSB values designated them to be at high risk for subsequent excessive hyperbilirubinemia (above the 95th percentile track on the hour-specific bilirubin nomogram). For these infants, the paired BiliCheck TcB values were all above the 75th percentile track (negative predictive value = 100%; positive predictive value = 32. 86%; sensitivity = 100%; specificity = 88.1%; likelihood ratio = 8. 43). CONCLUSIONS: Our data demonstrate the accuracy and reproducibility of the predischarge BiliCheck measurements in term and near-term newborn infants of diverse races and ethnicities. Infants with predischarge BiliCheck values above the 75th percentile of hour-specific TSB values on the bilirubin nomogram may be considered to be at high risk for subsequent excessive hyperbilirubinemia. Further studies are needed to assess the efficacy of this technique in preterm infants, those undergoing phototherapy, and those with TSB values of >/=15 mg/dL (>/=256 micromol/L).

Multi-analyte interrogation using the fiber optic biosensor.

The capabilities of the portable, automated fiber optic biosensor, RAPTOR, have recently been evaluated. Developed to perform rapid fluoroimmunoassays in the field, the RAPTOR was designed to test samples for up to four different target analytes simultaneously. Assay time could be varied from a 3-min rapid screen to a standard 10-min test. A trial of 203 blind samples tested for Staphylococcal enterotoxin B, ricin, Francisella tularensis, and Bacillus globigii has been conducted. Sensitivities obtained were 10, 50 ng/ml, 5 x 10(5), and 5 x 10(4) cfu/ml, respectively.

The development of immunoassays to four biological threat agents in a bidiffractive grating biosensor.

A critical need exists for a field deployable biosensor to detect environmental infectious agents in collected air samples rapidly, with sensitivity and specificity approaching that of standard laboratory procedures. The ideal sensor would analyze unknown samples in minutes, have programmable operation for unattended sample analysis, and be capable of multiple agent analysis for a number of agents. The goal of this project was to further the development of the bidiffractive grating biosensor (BDG) created through collaboration between Battelle Memorial Institute (BMI), Hoffman LaRoche (HLR), and the Naval Medical Research Command (NMRC). This manuscript details the development, optimization, and evaluation of this device as a potential field deployable biosensor. Well-characterized immunochemical reagents developed by the Biological Defense Research Department (BDRD) at NMRI were employed to develop assays in the BDG. These results were compared to those obtained with antigen capture enzyme linked immunosorbent assays (ELISAs). Four separate antigens were evaluated: Staphylococcus aureus enterotoxin B (SEB), ricin (RIC), Francisella tularensis (FT), and Clostridium botulinum toxin (BOT).

Fostering hope in the elderly congestive heart failure patient in critical care.

This article presents a patient-centered framework applied to the elderly patient with congestive heart failure (CHF). Although the elderly have been the focus of numerous articles, the needs of the elderly CHF patient in the critical care setting, especially concerning hope versus hopelessness, have been neglected. Guidelines for the clinical management of patients experiencing hopelessness are explored. The four dimensions of hopelessness discussed herein are experiential, spiritual/transcendence, irrational, and relational processes. Nursing diagnosis, interventions, goal-setting, and family support also are discussed. Helping the elderly CHF patient maintain hope when confronted with repeated hospitalizations is a challenge for the critical care nurse.

Supporting hope in congestive heart failure patients.

Critically ill patients want to maintain hope in their life. The need for hope and a sense of hopefulness does not end when the patient is hospitalized. The nursing diagnosis of hopelessness is common for many critical care patients, and especially cardiac problems such as congestive heart failure. These author describe a model of hopelessness that suggests strategies for increasing the patient's sense of hope.

Hope facilitating strategies for the family of the head injury patient.

Approximately 200 new head injuries are reported per 100,000 population each year in the United States. These injuries are more common in younger men and caused most frequently by motor vehicle accidents. Head injuries occur suddenly and unexpectedly. Head injury affects not only the individual but the family as well. The family's functional abilities are threatened by the head injury of a family member. The family's adaptation to head injury and life-threatening events surrounding the injury has a significant impact on the patient's rehabilitation. A family's response of denial or lack of hope in the future has been identified as a major obstacle to successful adaptation. The hopeless family may be unable to make necessary changes at home or learn important aspects of the patient's care. Depending upon the extent of the head injury, the family needs to know that most head trauma patients make significant progress in the first six months. Progress usually continues, less dramatically, for the next two to three years.

A hope and hopelessness model applied to the family of multitrauma injury patient.

A hope and hopelessness model is applied to the family of multitrauma injury patient. The purpose of the article is to identify factors contributing to hopelessness and organize them into physiological, cognitive-temporal, affective-contextual, and affiliative-behavioral hopelessness. Personal experience with family's of multitrauma injury patients and research regarding hope, hopelessness, and family led to the development of a hope model. Nursing interventions are then delineated according to a hope model, which fosters the family's sense of hope in themselves and the patient's future. Assessment of factors contributing to hopelessness and utilization of the hope model will enable nurses and family members to combine their efforts in reducing hopelessness and facilitate a sense of hope.

A cognitive model for assessing depression and providing nursing interventions in cardiac intensive care.

Depression is an emotion experienced by each individual as some point in his or her lifetime. For some, the feelings are temporary, such as when one feels momentarily let down. For others, the feelings are deeper and may last for longer periods of time. Deeper and longer lasting depression may occur when individuals are confronted by certain unfavourable types of life situations such as a major physiological loss. For a once healthy individual, the depression associated with a physiological loss has penetrated through the individual's prior coping process and defences. Depression is a particularly common problem in individuals with a medical illness (Cavanaugh 1983). Heart disease is often experienced as a major loss for patients. Reports of depression in patients with coronary artery disease have ranged from 18% to 60% (Clark 1990). A broad range of physical disorders are commonly associated with depression. Among the most prominent disorders is congestive heart failure (Buckwater & Babich 1990). For depressed congestive heart failure (CHF) patients, a critical care nurse needs to assess the factors contributing to depression and recognise behaviours reflective of depression to be able to make appropriate nursing diagnoses and devise a plan to manage the patient's depression. To help critical care nurses accomplish this goal, this article contains an examination of depression as it applies to CHF patients according to Beck's cognitive triad (Ulerman et al 1984).

Hopelessness in the myocardial infarction patient.

Events that cause hopelessness following a myocardial infarction may include coronary heart disease, reality-based misperceptions, lack of future goals and lack of relatedness to others. The susceptibility to hopelessness will depend on how successful the patient has been in accepting previous cardiac-related problems. Once hopelessness occurs, the patient may perceive the future to be limited. Hopelessness centers around seven components: physiological, cognitive, temporal, affective, behavioral, affiliative and contextual loss of hope. This article outlines how hopeless patients may distort their immediate environment and future goals. Methods of identifying hopelessness and intervening with appropriate nursing interventions, which will assist with the management of hopelessness, are described.

Retinopathy of prematurity: prevalence and treatment over a 20 year period at Pennsylvania Hospital.

This paper presents the results of a 20 year survey of ROP among less than or equal to 2000 g BW infants cared for at Pennsylvania Hospital. It relates changes in perinatal care and nutrition, survival rates, and serial serum E levels with incidence and severity of ROP. It includes our protocol for monitoring E nutrition so as to optimize its effectiveness at physiologic serum levels for prophylaxis for ROP. Also presented are the promising results of our experience with vitamin E at pharmacologic serum levels as a treatment for severe ROP (defined as in the Cryo ROP Trial). These indicate the need for a multicenter trial to assess the effect of pharmacologic Vitamin E therapy as an alternative or supplement to therapy of severe ROP with laser or cryo surgery.

Monitoring techniques in non-insulin-dependent diabetes mellitus.

Monitoring of the diabetic patients' own blood sugar is now an important component in the management of diabetes of all degrees of severity. Education in proper monitoring techniques, attention to the continued quality of testing, and utilization of the information achieved by testing are important responsibilities of primary care physicians and their health care teams.

Evaluating group purchasing through a prime vendor.

Use of a prime vendor by a drug-purchasing group representing 17 community hospitals is described and evaluated for cost effectiveness. The group was formed in 1981 by 15 hospitals in Minnesota and one each in Wisconsin and Iowa. The group solicited bids to select one drug wholesaler (distribution center). Drug-product manufacturers submitted bids to the group, and contracts were awarded to low bidders who agreed to use the distribution center. All 17 hospitals were evaluated for differences in inventory value and inventory turnover before (1980) and after (1982) initiation of the prime-vendor system; hospitals in the group were paired with control hospitals to eliminate environmental bias. A detailed analysis of inventory and operating costs was conducted in one of the hospitals. The hospitals in the purchasing group reduced drug inventory value by 30.1%, increased inventory turns by 55.3%, and purchased 72.8% of all their pharmaceuticals (based on dollar value) through the distribution center. The group obtained a distribution center service fee reduction of 39.2%. Hospitals in this group showed greater decreases in inventory value and increases in inventory turnover than the controls. The detailed analysis at a single hospital showed that cost savings included direct savings on inventory investment and order handling and indirect savings from elimination of inventory carrying costs and costs of processing checks and purchase orders. Operating costs were reduced by group purchasing of drug products from a prime vendor. Inventory control and purchasing practices improved.