Improving handover between the transport team and neonatal intensive care unit staff in neonatal transports using the plan-do-study-act tool.

OBJECTIVES: The aim was to achieve 100% effective handover from the critical care transport team to the neonatal intensive care unit (NICU) medical team. STUDY DESIGN: All patients transferred from referring hospitals by the critical care transport team to the Level IV NICU were included. Data for each infant was collected prospectively. The percentage of transported patients for which medical team and nursing handover occurred was recorded. A quality improvement project was launched using the Plan-Do-Study-Act (PDSA) tool. We implemented several processes including call from the transport team before arrival and the completion of a transfer of care form on arrival to the NICU. The process measures and the outcome measure of completion of handover were monitored. Run charts of process measures and the outcome measure were analyzed. RESULTS: Completion of medical handover increased from 95% (baseline) to 100% after 3 PDSA cycles and this has been maintained for 18 consecutive months. CONCLUSION: Medical handover from the critical care transport team to the NICU medical staff has been achieved and sustained for all neonatal transports.

Phonon density of states of LaFeAsO(1-x)Fx.

We have studied the phonon density of states (PDOS) in LaFeAsO(1-x)Fx with inelastic neutron scattering methods. The PDOS of the parent compound (x=0) is very similar to the PDOS of samples optimally doped with fluorine to achieve the maximum Tc (x approximately 0.1). Good agreement is found between the experimental PDOS and first-principles calculations with the exception of a small difference in Fe mode frequencies. The PDOS reported here is not consistent with conventional electron-phonon mediated superconductivity.

Adiabatic electron-phonon interaction and high-temperature thermodynamics of A15 compounds.

Inelastic neutron scattering was used to measure the phonon densities of states of the A15 compounds V3Si, V3Ge, and V3Co at temperatures from 10 to 1,273 K. It was found that phonons in V3Si and V3Ge, which are superconducting at low temperatures, exhibit an anomalous stiffening with increasing temperature, whereas phonons in V3Co have a normal softening behavior. First-principles calculations show that this anomalous increase in phonon frequencies at high temperatures originates with an adiabatic electron-phonon coupling mechanism. The anomaly is caused by the thermally induced broadening of sharp peaks in the electronic density of states of V3Si and V3Ge, which tends to decrease the electronic density at the Fermi level. These results show that the adiabatic electron-phonon coupling can influence the phonon thermodynamics at temperatures exceeding 1,000 K.

Phonons and thermodynamics of unmixed and disordered Li0.6FePO4.

The lithium-storage material Li(0.6)FePO(4) was studied by inelastic neutron scattering and differential scanning calorimetry. Li(0.6)FePO(4) undergoes a transformation from a two-phase mixture (heterosite and triphylite) to a disordered solid-solution at 200 degrees C. Phonon densities of states (DOS) obtained from the inelastic neutron scattering were similar for the two-phase sample measured at 180 degrees C and the disordered sample measured at 220 degrees C. The vibrational entropy of transformation is 1.8 +/-0.9 J/(K mol), which is smaller than the configurational entropy difference of approximately 3.1 J/(K mol). The measured enthalpy of the disordering transition was estimated as 2.5 kJ/mol. The phonon data show a small change in lattice dynamics upon disordering.

Developmental regulation of SP-A receptor in fetal rat lung.

We studied the ontogeny and developmental regulation of the recently isolated SP-A receptor in fetal and postnatal rat lung. Our results show that SP-A receptor protein levels are first detectable at 16-18 days' gestation in fetal rat lung. There is a biphasic change in its levels with an initial marked increase during late gestation, a decrease in the early postnatal period (4-7 days of age), followed by another rise in levels during the second postnatal week. The results of binding isotherms show that maximal binding of monoclonal antibody to the receptor increases with differentiation of the type II cell, indicating that the increase during fetal lung development is due in part to increased numbers of receptors per cell. Bombesin (10 nM-1 microM) enhanced SP-A receptor protein levels threefold in fetal lung explants as early as 6 hours in culture. This effect of bombesin was associated with increased proliferation of type II cells as measured by levels of proliferating cell nuclear antigen (PCNA). We conclude that the increase in SP-A receptor protein level in late gestation fetal rat lung is due to increased numbers of receptors per cell and increased numbers of type II cells. Bombesin may have an important role during lung development by paracrine mechanisms that result in proliferation of lung cells.

Hyperoxia causes an increase in antioxidant enzyme activity in adult and fetal rat type II pneumocytes.

It is well known that exposure to hyperoxia results in lung inflammation and damage, which leads to the development of chronic lung disease. Previous studies have shown increased activities of antioxidant enzymes (AOE) in lung tissue from animals exposed to hyperoxia. We propose the hypothesis that the fetal type II pneumocytes (TIIP) would be resistant to oxygen toxicity by virtue of increasing AOE activity on exposure to hyperoxia. The aim of this study was to measure the activities of catalase, glutathione reductase, glutathione peroxidase (GPX), and cytosolic superoxide dismutase (SOD) in cultures of adult and fetal rat TIIP exposed to 95% oxygen for 24 h. Control cells were incubated in room air. Hyperoxia exposure resulted in 53.4 +/- 1.2% of control viability (mean +/- S.E.M.; p = 0.001) in the adult TIIP with a significant threefold increase in the activities of all the AOE. The fetal TIIP were more resistant to hyperoxia (99.4 +/- 6.1% of control viability). However, in the fetal TIIP, only SOD and GPX levels were significantly increased (fourfold and 2.3-fold, respectively) compared with fetal controls. We conclude that fetal TIIP are more resistant to hyperoxia than adult TIIP in terms of viability; other protective antioxidant factors might account for the better survival of fetal TIIP in hyperoxia.

Effects of salmeterol on secretion of phosphatidylcholine by alveolar type II cells.

Beta-adrenergic agents enhance secretion of phosphatidylcholine (PC) by adult and fetal type II cells. We have previously shown that terbutaline stimulates secretion of PC by fetal type II cells, but the response wanes after 30 minutes. We studied the effects of salmeterol, a highly selective, long-acting beta2-adrenergic agonist that does not cause receptor desensitization, on PC secretion by adult type II alveolar cells in primary culture. Release of lactate-dehydrogenase was < 4% and did not vary with the concentration of salmeterol. Salmeterol stimulated PC secretion in a concentration-dependent manner. The maximum effective-concentration tested was 50 nM and the EC50 was 11.40 +/- 1.14 nM. Propranolol inhibited the effect of salmeterol on release of PC, confirming that the effects of salmeterol are mediated by beta-receptors. OT50, the time for onset of action, was 32.0 +/- 1.6 minutes. RT50, the time to achieve 50% recovery from maximal stimulation was, 393.0 +/- 20.2 minutes. We conclude that salmeterol stimulates PC secretion by type II cells through activation of beta-adrenergic receptors and has a longer duration of action (>6 hours) compared to other beta2-agonists. Salmeterol may be a useful drug with which to study the role of receptor desensitization in the developmental changes in PC secretion.

Bombesin inhibits apoptosis in developing fetal rat lung.

We have shown recently that apoptosis occurs during fetal and postnatal lung development. Our hypothesis that branching morphogenesis occurs through a delicate balance of cell proliferation and apoptosis predicts that substances that enhance branching of the airways would affect both cell proliferation and apoptosis in the lung. Bombesin-like peptides have a mitogenic effect on bronchial epithelium and fibroblasts, and bombesin has been shown to enhance branching morphogenesis in fetal lung. We used organ cultures of 16-day gestation fetal rat lung to study the effects of bombesin on apoptosis. Cultures were incubated in serumless medium alone or exposed to 1microM bombesin for 0-48 h. Levels of apoptosis were quantified using the TUNEL assay and expressed as percentage of apoptotic cells in paraffin sections of explants. Bombesin significantly inhibited apoptosis in fetal lung mesenchyme 48 h in culture by more than 50% (p < 0.05). The effects of bombesin on apoptosis were prevented completely if explants were exposed to the specific bombesin receptor antagonist, [D-Phe12]bombesin. To examine if the absence of serum in the media could have accounted for some of these effects, explants were cultured for 48 h in serumless medium, medium containing 10% fetal bovine serum, serumless medium with 1 microM bombesin, or medium containing both 10% fetal bovine serum and 1 microM bombesin. The addition of fetal bovine serum to the media reduced apoptosis significantly. The effect of fetal bovine serum on apoptosis was additive with bombesin. We conclude that bombesin inhibits apoptosis in developing fetal rat lung mesenchyme through its interaction with the bombesin receptor.

Neutrophil apoptosis during the development and resolution of oleic acid-induced acute lung injury in the rat.

The oleic acid (OA) model of acute lung injury in rats is characterized by a massive and rapid influx of polymorphonuclear neutrophils (PMN) within 1 h, with a peak inflammatory response at 4 h and resolution by 72 h. We hypothesized that PMN apoptosis is involved in the resolution of OA-induced acute lung injury. To test this hypothesis, healthy adult Fischer 344 rats were given 30 microl OA in 0.1% bovine serum albumin (BSA) intravenously; controls were given BSA alone and killed at 1, 4, 24, and 72 h after OA to obtain bronchoalveolar lavage fluid (BALF) and lung tissue. Cell pellets from BALF and formalin-fixed, paraffin-embedded tissue section samples were processed for terminal deoxyribonucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) to identify apoptotic cells. Propidium iodide was used to counterstain nuclei. Percentage of nuclei undergoing apoptosis was counted under a fluorescent microscope. Control rats showed only resident alveolar macrophages (AM) in the BALF with no apoptosis. At the peak of injury, 1 h and 4 h after OA injection, we observed a massive PMN response without any evidence of apoptosis. At 24 h, when the OA injury is clinically and histologically in early resolution, we observed intense apoptosis of PMN nuclei along with evidence of apoptotic bodies in the cytoplasm of AM. Some of the AM also showed apoptotic nuclei at 72 h. Similar observations were made in the lung tissue sections. The results of the TUNEL assay were confirmed by DNA ladders and electron microscopy. We conclude that apoptosis of PMN and clearance by AM is an important mechanism in resolution of OA- induced acute lung injury.

Meta-analyses of surfactant replacement therapy of infants with birth weights less than 2000 grams.

OBJECTIVES: We conducted a meta-analysis of surfactant replacement therapy to determine (1) the efficacy of surfactant therapy in the reduction of short-term morbidity and long-term outcome in terms of bronchopulmonary dysplasia (BPD) and mortality; (2) whether there are differences in efficacy between modified natural surfactant and synthetic surfactant; (3) the effectiveness of prophylactic surfactant therapy; and (4) whether there are differences in efficacy between the prophylactic approach and the rescue strategy. STUDY DESIGN: We included studies in which infants with birth weights between 500 and 1500 gm were eligible. Studies were grouped into the following categories: (1) rescue therapy with modified natural surfactant; (2) rescue therapy with synthetic surfactant; (3) prophylaxis with modified natural surfactant; (4) prophylaxis with synthetic surfactant; (5) prophylaxis versus rescue studies; (6) modified natural surfactant versus Exosurf (Burroughs-Wellcome Co., Research Triangle Park, NC) studies. The relative risk ratios, corrected for study size, were calculated for the outcome variables (pneumothorax, incidence of BPD, survival, survival without BPD, prevention of hyaline membrane disease [HMD], and intraventricular hemorrhage [IVH]). RESULTS AND CONCLUSION: Surfactant therapy is efficacious in reducing the risk for pneumothorax and increasing the chance for survival without BPD. Synthetic surfactant is not efficacious in the prevention of HMD. Modified natural surfactant is more effective in reducing the risk of pneumothorax and increasing the chance for survival without BPD than is synthetic surfactant. These data do not support the use of either synthetic or modified natural surfactant for routine prophylaxis.

Isolation and partial characterization of a receptor to surfactant protein A expressed by rat type II pneumocytes.

Surfactant protein A (SP-A), the most abundant protein component in pulmonary surfactant, has been shown to enhance surfactant phospholipid uptake by the type II alveolar epithelial cell. Recent evidence has shown that this process may be receptor-mediated. We undertook this study to isolate the putative receptor from type II cell membranes. We isolated two specific SP-A binding proteins from type II cells with apparent molecular weights (Mr) of 86 and > 200 kD under nonreducing conditions. Under reducing conditions, the higher-Mr protein was not present, but three proteins with apparent Mr of 65, 55, and 50 kD were visible, in addition to the 86-kD protein, indicating that the higher-Mr protein was composed of the smaller peptides which form disulfide bonds. The 86-kD protein is a glycoprotein with approximately 30% of its mass as carbohydrate. The 50-kD protein is also a glycoprotein (approximately 30% of its mass as carbohydrate), and SP-A binds to the protein core. Polyclonal and monoclonal antibodies to these peptides saturably bind to the surface of type II cells but not other lung cells, as shown by immunohistochemistry. SP-A competitively inhibits binding of one monoclonal antibody to type II cells, and the monoclonal antibody was able to block the effect of SP-A on phospholipid uptake by type II cells, indicating that this complex is a receptor to SP-A which is expressed on type II cells. This novel receptor is fundamental to the biology of surfactant metabolism in the lung.

Gestational age can predict the need for prophylaxis with surfactant therapy.

Controversy exists as to whether prophylactic or rescue therapy with surfactant should be used in infants born at less than 30 weeks gestation. We developed the hypothesis that gestational age can be used to predict a need for prophylactic surfactant therapy. We designed this retrospective study to determine whether there was a gestational age below which one could accurately predict the need for prophylactic surfactant therapy in almost all infants and limit unnecessary treatment of infants. We conducted a retrospective study of infants born at 23-34 weeks' gestation to determine the frequency with which surfactant therapy was used in a rescue strategy at each gestational age, and to ascertain the sensitivity, specificity, and predictive values of gestational age as a predictor of the use of surfactant therapy. There was a significant inverse correlation between gestational age and the proportion of infants treated with surfactant (r = -0.923, p < 0.001). A gestational age cut-off of 26 completed weeks' had a positive predictive value of 85% and a specificity of 96% for the need for surfactant therapy. We conclude that gestational age can be used to predict a need for surfactant therapy in premature infants. At our institution, the failure to attain 26 completed weeks' gestation will accurately predict the need for surfactant therapy and will result in unnecessary treatment of very few infants. We suggest that each institution caring for very low birth weight infants should examine its population to determine the gestational age at which they can accurately predict the need for prophylaxis with surfactant therapy.

Respiratory tract colonization with mycoplasma species increases the severity of bronchopulmonary dysplasia.

There is controversy regarding the role of mycoplasmas (MP) colonizing the neonatal respiratory tract in the development of bronchopulmonary dysplasia (BPD). To determine the association of respiratory MP colonization and BPD. Retrospective analysis of neonates (26-32 weeks of gestation) intubated for respiratory insufficiency. Tracheal aspirate cultures were obtained for MP if the lung disease was not improving by 7-10 days or there were radiographic changes suggestive of inflammation. Of 63 infants who had tracheal aspirates sent, 17 had positive MP cultures. We found no significant difference in the gestational ages (27.6 +/- 0.4 vs 27.8 +/- 0.2 weeks) or birth weights (1097 +/- 86 vs 997 +/- 42 grams) in MP positive vs negative infants. No differences were noted in antenatal or postnatal steroid use, gender, race, sepsis, RDS, PDA, air leaks, NEC, GER, days on positive pressure ventilation or days on oxygen. There were significantly (p = 0.04) more infants with severe BPD (defined as oxygen requirement at 36 weeks corrected post menstrual age) among MP positive (n = 14; 82%) versus MP negative (n = 25; 54%) infants. Presence of MP in the tracheal aspirates is associated with an increased likelihood of developing severe BPD.

Ontogeny of apoptosis during lung development.

Apoptosis has been shown to be involved in several processes during embryogenesis, but the ontogeny of apoptosis during lung development ahs not been studied. The goals of the current study were to determine if apoptosis occurs during lung development, and to determine the ontogeny of the changes in apoptosis that occur. We studied the ontogeny of apoptosis in vivo using lungs from 14-18-d gestation fetal rats, newborn rats, and 1-d-, 2-d-, 5-d-, and 10-d-old rat pups. Apoptosis was assessed by electron microscopy and the terminal deoxyribonucleotidyl transferase dUTP nick end-labeling assay. We compared the in vivo results with explants of 14-d gestation fetal rat lung placed in culture for 1-4 d because the biochemical development of the lung in organ culture has been shown to closely parallel the development of the lung in vivo. We found apoptosis of mesenchymal cells at the periphery of distal lung buds in early fetal lung (14-16-d gestation). Apoptosis of both mesenchyme and epithelium was present in later fetal lung (18-d gestation). There were no qualitative differences in apoptosis between in vivo fetal lung and explant cultures of fetal lung. There was a 14-fold increase in apoptosis at birth and in the first postnatal day of life (9-12% of cells) compared with fetal lung (0.6-1% of cells). This was followed by a rapid decline in the percentage of apoptotic cells to fetal levels at postnatal d 2-10. We conclude that apoptosis occurs in a spatially, temporally, and cell-specific manner during lung development. The number of cells undergoing apoptosis increases dramatically in the first day after birth.

Developmental regulation of the effects of surfactant protein A on phospholipid uptake by fetal rat type II pneumocytes.

Surfactant protein A (SP-A) enhances the uptake of phospholipid by type II cells derived from adult and late gestation fetal rat lung. The present study was performed to examine more fully the developmental biology of the effects of SP-A on phosphatidylcholine (PC) uptake, to determine the effect of SP-A on the cellular location of bound and internalized phospholipid and on the metabolism of internalized phospholipid by morphologically undifferentiated (18-day) and morphologically differentiated (19-day) fetal type II cells. SP-A enhanced uptake almost two-fold in a dose-dependent manner in 19-day fetal cells, but it had no effect on uptake by 18-day fetal cells at any concentration. Stimulation of uptake by 19-day fetal cells was saturable at concentrations above 1 microgram/ml SP-A. Maximal uptake was 1.12 nmol of PC/mg of protein, and the effective concentration that yields 50% maximal response, K phi, was 58.9 ng/ml (84.1 pM). The effect of SP-A on uptake by 19-day fetal cells was detectable as early as 1 min of exposure. Uptake correlated significantly with time both in the absence (r = 0.98, p < 0.001) and presence of 5 micrograms/ml SP-A (r = 0.979, p < 0.001). The rate of uptake in the presence of SP-A (0.019 +/- 0.002 nmol of PC/mg of protein/min) was twice the rate of uptake in controls (0.009 +/- 0.001 nmol of PC/mg of protein/min). SP-A had no effect on binding to plasma membranes and uptake of phospholipid into lamellar bodies by 18-day fetal cells. On the other hand, SP-A significantly enhanced binding of dipalmitoyl phosphatidylcholine to plasma membranes (two- to threefold) and uptake into lamellar bodies (threefold) of 19-day fetal cells. SP-A caused a significant reduction in the degradation of internalized phospholipid by differentiated fetal type II cells. Based on the lack of effect of exogenous SP-A on 18-day fetal cells, we conclude that the response to SP-A is under developmental control. SP-A enhances the initial binding to the plasma membranes of fetal type II cells and subsequent internalization into the lamellar bodies. This effect is associated with a protection of internalized phospholipid from metabolic degradation. Both of these processes are developmentally regulated during the transition from the canalicular to the saccular phase of lung development.

Hyperoxia inhibits fetal rat lung fibroblast proliferation and expression of procollagens.

The direct effects of hyperoxia on collagen production by fetal lung fibroblasts are unknown and would be important to the understanding of the molecular mechanisms involved in bronchopulmonary dysplasia in premature infants. We studied the effect of hyperoxia on 1) proliferation, 2) mRNA levels for type I and III procollagens, and 3) net collagen production in primary cultures of fetal rat lung fibroblasts. Fibroblasts from 19-day-old rat fetuses (term is 22 days) were obtained. Test plates were incubated in hyperoxia and controls in room air for varying time periods. Cell viability in both conditions was >97% as determined by trypan blue exclusion. Fibroblast proliferation in nonconfluent cultures was found to be significantly reduced with exposure to hyperoxia (P < 0.001). Steady-state levels of type I and III procollagen mRNAs, analyzed on Northern blots hybridized to [32P]cDNA probes, were significantly decreased in hyperoxia (P < 0.01). This effect was noted as early as 4 h of exposure to hyperoxia and persisted for 5 days. There was a significant inverse correlation between duration of exposure to O2 and steady-state levels of mRNA for alpha1(I)-procollagen (r = -0.904) and alpha1(III)-procollagen (r = -0.971). There were no significant changes in steady-state levels of beta-actin mRNA. We also found a significant decrease in collagen synthesis in hyperoxia-exposed fibroblasts (P < 0.05). We conclude that hyperoxia directly effects a reduction in fetal lung fibroblast proliferation and net collagen production at a pretranslational level.

Actin depolymerization is developmentally regulated in rat type II cells exposed to terbutaline.

The type II alveolar epithelial cell synthesizes and secretes pulmonary surfactant. Terbutaline enhances phospholipid release from adult and fetal type II cells. Our hypothesis is that the actin network of microfilaments regulates the secretory activity of the type II cell. To examine the developmental regulation of the changes in actin subfractions associated with secretory activity, cultures of type II cells derived from adult and 19-d fetal rat lung were incubated with or without 10 microM terbutaline for 1, 30, and 60 min. Dose-response effects of terbutaline were examined in adult type II cells. Effects of phorbol ester were also examined Globular (G-actin) and filamentous (F-actin) fractions were extracted from the cells and analyzed separately. Specified cellular equivalent volumes of each subfraction were analyzed by Western blotting, visualized by a color reaction, and quantified by densitometry. There was a decrease in the cytoskeletal F-actin pool along with an increase in the G-actin fraction within I min in adult type II cells exposed to terbutaline, indicating that depolymerization of F-actin occurs. Values returned to control levels by 60 min. In contrast, the decrease in F-actin, with a concomitant increase in G-actin, was maximal at 60 min in fetal cells exposed to terbutaline. There was a dose-dependent increase in actin depolymerization with maximal effects at 10 microM terbutaline. Phorbol ester also caused an increase in actin depolymerization. Depolymerization of the actin microfilament network may regulate transport and exocytosis of lamellar bodies in type II cells. We speculate that there is an early secretory mechanism that involves depolymerization of actin microfilaments and a late, actin-independent secretory mechanism present in adult type II cells. The timing of the response of the actin-dependent pathway is developmentally regulated. This may explain the developmental differences in the secretion of surfactant that we have previously shown.

Neonatal herpes simplex virus infection after cesarean section with intact amniotic membranes.

We describe a preterm neonate delivered by cesarean section with intact membranes who had herpes simplex virus (HSV) encephalitis at 9 days of age and whose twin with a separate amniotic membrane that was pierced for insertion of a fetal scalp electrode simultaneously had HSV infection of the scalp. That no histologic evidence of HSV infection was seen in either placenta suggests the potential for HSV penetration of intact amniotic membranes as a mode of transmission of HSV to the neonate. Although the extent of risk of HSV infection in a second twin remains unclear, we believe that when infection is suspected in one of a set of twins, appropriate cultures should be obtained from both infants, and acyclovir therapy should be considered for both.