Perspectives and attitudes of pediatricians concerning post-discharge care practice of premature infants.

OBJECTIVE: Survival rates of premature infants are at a historical high and increasingly more pediatricians are caring for former premature infants. The goal of this study was to describe the perspectives and attitudes of pediatricians, as well as, the challenges of rendering post-neonatal intensive care unit (NICU) discharge care for premature infants. METHODS: An anonymous 22-question web-based survey was emailed to pediatricians who are current members of the American Academy of Pediatrics (AAP) and practicing in Kings County, New York. RESULTS: There were 148 completed surveys with 79% being general pediatricians. Of all respondents, 63% believed that premature infants should have a neonatal high risk follow-up visit within days after discharge and 64% were satisfied with the NICU discharge summary acquisition. While 74% of pediatricians felt comfortable following up with former extremely premature infants, 65% referred to specialists, most often to child development, neurology, and physical and/or occupational therapy. The majority (85%) were more likely to refer premature infants to early intervention. Participating pediatricians varied in their knowledge of immunization and breastfeeding guidelines. Finally, 88% of respondents acknowledged that caregivers of premature infants experience increased stress, with 53% stating that the stress should be addressed. CONCLUSIONS: Understanding the perceptions and challenges of pediatricians who care for premature infants may help improve post NICU quality of care. Transition to the outpatient setting is a crucial step in the management of premature infants and a focus on improved hand-off procedures between hospital and physicians may prove beneficial. Also, pediatricians must stay abreast of current recommendations for breastfeeding and vaccinations. Furthermore, emphasis should be given to stress reduction and management for caregivers of former premature infants.

Metabolic scaling and twin placentas.

OBJECTIVE: Do monochorionic (MC) and/or dichorionic (DC) twins show allometric scaling between placental and birth weight (PW, BW)? METHODS: We extracted BW, PW, gestational age (GA) and cord insertion type from 52 MC to 310 DC twins to calculate ß. DC twins were analyzed as summed and as individuals if placentas were separate. RESULTS: Mean ß for MC (0.78 ± 0.02), DC summed (0.78 ± 0.02), and DC with separate placentas (0.77 ± 0.03 and 0.76 ± 0.04) all non-significant. GA, summed BWs, total PW, BW discordance, and cord insertion sites did not differ between twin types or with ß. CONCLUSION: MC and DC twins show allometric scaling similar to singletons.

Superiority of targeted neonatal echocardiography for umbilical venous catheter tip localization: accuracy of a clinician performance model.

OBJECTIVES: To compare targeted neonatal echocardiography (TnECHO) and antero-posterior (AP) chest radiographs in the localization of the umbilical venous catheter (UVC) tip and to determine the accuracy of UVC tip localization by TnECHO when performed by a trained cohort of pediatric housestaff physicians. STUDY DESIGN: Prospective, observational study of consecutive neonates requiring UVC insertion, in a tertiary care center, in an 18-month period. Chest radiographs reporting optimal position of the UVC tip were compared with the TnECHO results of the pediatric cardiologist. The latter was also compared with the results of TnECHO performed by the pediatric housestaff physicians. RESULT: Thirty neonates with birth weight ranging between 270 and 4490 g and gestational age ranging between 24 and 44 weeks were enrolled. Nine patients (27%) required UVC tip repositioning as the cardiologist performed TnECHO revealed sub-optimal tip position despite optimal position on chest radiography. Among them, four had the UVC tip in the right atrium and five in the left atrium. Compared with the cardiologist, the housestaff physicians had reported TnECHO with a high-accuracy rate (area under the receiver operating characteristic curve=0.81). CONCLUSION: TnECHO is superior to chest radiography for identifying malpositioned catheters. TnECHO performed by pediatric housestaff physicians with basic training, demonstrated high-accuracy rates.

Issues in neonatal and pediatric oxygen therapy.

This article reviews the complex physiology of oxygen transport in the fetus and neonate, and how it differs from the older pediatric patient and adult. The common causes of respiratory distress unique to the neonatal and pediatric populations are reviewed in detail, including a brief discussion regarding the different modes of mechanical ventilation used in neonates. The increased susceptibility of infants to the toxic effects of oxygen is reviewed.

Synergistic cytotoxicity from nitric oxide and hyperoxia in cultured lung cells.

Exogenous nitric oxide (NO) is being tested clinically for the treatment of pulmonary hypertension in infants and children. In most cases, these patients receive simultaneous oxygen (O2) therapy. However, little is known about the combined toxicity of NO + hyperoxia. To test this potential toxicity, human alveolar epithelial cells (A549 cells) and human lung microvascular endothelial lung cells were cultured in room air (control), hyperoxia (95% O2), NO (derived from chemical donors), or combined hyperoxia + NO. Control cells grew normally over a 6-day study period. In contrast, cell death from hyperoxia was evident after 4-5 days, whereas cells neither died nor divided in NO alone. However, cells exposed to both NO and hyperoxia began to die on day 2 and died rapidly thereafter. This cytotoxic effect was clearly synergistic, and cell death did not occur via apoptosis. As an indicator of peroxynitrite formation, nitrotyrosine-containing proteins were assayed using anti-nitrotyrosine antibodies. Two protein bands, at molecular masses of 25 and 35 kDa, were found to be increased in A549 cells exposed to NO or NO + hyperoxia. These results indicate that combined NO + hyperoxia has a synergistic cytotoxic effect on alveolar epithelial and lung vascular endothelial cells in culture.

Recombinant human superoxide dismutase reduces lung injury caused by inhaled nitric oxide and hyperoxia.

We previously demonstrated that 48 h of 100 ppm inhaled nitric oxide (NO) and 90% O2 causes surfactant dysfunction and pulmonary inflammation in mechanically ventilated newborn piglets. Because peroxynitrite (the product of NO and superoxide) is thought to play a major role in the injury process, recombinant human superoxide dismutase (rhSOD, a scavenger of superoxide) might minimize this insult. Four groups of newborn piglets (1-3 days of age) were ventilated with 100 ppm NO and 90% O2 for 48 h. Piglets received no drug, 5 mg/kg rhSOD intratracheally at time 0, 5 mg/kg rhSOD intratracheally at 0 and 24 h, or 10 mg/kg rhSOD by nebulization at time 0. At 48 h, bronchoalveolar lavage (BAL) was performed, and lung tissue was analyzed for markers of inflammation, oxidative injury, acute lung injury, and surfactant function. There were significant differences between rhSOD-treated piglets and untreated controls with respect to BAL neutrophil chemotactic activity, cell counts, and protein concentration as well as lung tissue malondialdehyde concentrations. Minimum surface tension of BAL surfactant from all groups studied was increased, with no differences found among groups. These data suggest that rhSOD, at the doses used, mitigated the inflammatory changes, oxidative damage, and acute lung injury from exposure to 100 ppm NO and 90% O2 but did not appear to improve surfactant function. This has important clinical implications for infants treated with hyperoxia and NO for neonatal lung disorders.

alpha,beta-Dehydro-amino acid residues in the design of peptide structures: synthesis, crystal structure, and molecular conformation of two homologous peptides-N-Ac-dehydro-Phe-L-Leu-OCH3 and N-Ac-dehydro-Phe-NorVal-OCH3.

The dehydro-residue containing peptides N-Ac-dehydro-Phe-L-Leu-OCH3 (I) and N-Ac-dehydro-Phe-NorVal-OCH3 (II) were synthesized by the usual workup procedures. The peptides crystallize from their solutions in methanol in space group P6(5): (I) a = b = 12.528(2) A, c = 21.653(5) A; (II) a = b = 12.532(2) A, c = 21.695(4) A. The structures were determined by direct methods. Both peptides adopt similar conformations with phi,psi of dehydro-Phe as follows: (I) -57.0(5) degrees and -37.0(5) degrees; (II) -56.0(5), degrees, and -37.5(5) degrees. The observed data on dehydro-Phe when placed at the (i + 1) position show that the phi,psi values of dehydro-Phe are either -60 degrees, 140 degrees or -60 degrees, -30 degrees. The conformation of -60 degrees, 140 degrees can be accommodated only with a flexible residue at the (i + 2) position while the phi,psi values of -60 degrees, -30 degrees are obtained with a bulky residue at the (i + 2) position as in the present structures. The molecules are packed in a helical way along the c axis. These are held by two strong intermolecular hydrogen bonds involving both NH as donors and acetyl group and dehydro-Phe oxygen atoms as acceptors.

Molecular design of peptides. Synthesis, molecular structure and beta-turn II' formation of N-Boc-L-Phe-dehydro-Abu-NH-CH3 in crystals.

The peptide N-Boc-L-Phe-dehydro-Abu-NH-CH3 was synthesized by the usual workup procedure. The crystals grown from methanol at 4 degrees C belong to the space group P2(1)2(1)2(1) with a = 7.589(2), b = 13.690(4), c = 21.897(6) A, Z = 4 and dc = 1.149(5) g cm-3 for C19H29N3O5.CH3OH. The peptide crystals were highly sensitive to radiation. The final agreement factor R was 0.055 for 1109 observed reflections (I > or = 2 sigma) with data extending to a 2 theta value of 103 degrees. The methanol oxygen atom is split into two occupancies. Both sites are involved in identical hydrogen bonding. As a result of substitution of a dehydro-Abu residue at the (i + 2) position the peptide adopts an ideal beta-turn II' conformation with torsion angles of corner residues as phi 1 = 63(1) degrees, psi 1 = -127(1) degrees, phi 2 = -66(1) degrees and psi 2 = -10(1) degrees, and an intramolecular hydrogen bond N-H...O of length 3.01(1) A. This shows that the conformational constraints produced by dehydro-Abu are similar in nature to but different in magnitude than those produced by dehydro-Phe and dehydro-Leu. The methanol-peptide interactions show characteristic features of multiple hydrogen-bond formations involving polar sites of participating peptide and methanol molecules. The packing of the molecules in the unit cell is stabilized by interactions through methanol molecules with the help of several hydrogen bonds.

Fluid transport across cultured bovine corneal endothelial cell monolayers.

The mammalian corneal endothelium is known to transport fluid from the stromal compartment to the aqueous humor, thereby maintaining corneal transparency. Corneal endothelial cells have been cultured for some years now, but whether they preserve their in vivo ability to actively transport fluid is not known. We have now grown bovine corneal endothelial cell monolayers (BCECM) on permeable substrates (Transwell) and report that, just like their counterparts in vivo, these cultured cells pump fluid from the basal to the apical compartment and display measurable electrical resistance and potential difference across the monolayer. BCECM were grown on collagen-treated permeable supports using Dulbecco's modified Eagle's medium (DMEM)/20% fetal bovine serum with antibiotics. Cells grew to confluence in 5-7 days and displayed polygonal shape. Only cells from passages 1-3 were utilized. Inserts were fitted directly into Lucite chambers specially built. The rate of fluid pumping by BCECM was 3.96 +/- 0.49 (SE) microliter.h-1.cm-2 (n = 13) and could be measured continuously for several hours; fluid pumping was inhibited by 0.2 mM amiloride. The specific electrical resistance of the monolayers was 180 +/- 22 omega.cm2 (n = 11). A mean electrical potential difference of 63.8 +/- 3.7 microV (n = 15, range 40-100 microV, apical side negative) was recorded across the monolayers in DMEM. The availability of the commercial inserts makes this procedure practical; as a consequence, the rate of fluid transport by cultured corneal endothelium has been quantitated for the first time. This method can now be extended to other cultured layers.(ABSTRACT TRUNCATED AT 250 WORDS)

Synthesis, crystal structure, and molecular conformation of N-Ac-dehydro-Phe-L-Val-L-Val-OCH3.

The peptide N-Ac-dehydro-Phe-L-Val-L-Val-OCH3 (C22H31N3O5) was synthesized by the usual workup procedure and finally by coupling the N-Ac-dehydro-Phe-L-Val-OH to valine methyl ester. It was crystallized from its solution in acetonitrile-water mixture at 4 degrees C. The crystals belong to the space group P1 with a = 8.900(3) A, b = 11.135(2) A, c = 12.918(2) A, alpha = 90.36(1) degrees, beta = 110.14(3) 14(3) degrees, V = 1207.7(6) A, 3Z = 2, dm = 1.156(5) Mgm-3, dc = 1.148(5) Mgm-3. The structure was determined by direct methods using SHELXS86. The structure was refined by full-matrix least-squares procedure to an R value of 0.077 for 3916 observed reflections. The molecular dimensions and conformations of the two crystallographically independent molecules are in good agreement. In the dehydro residues, the average C alpha-C beta distance is 1.31(2) A whereas the bond angle C alpha-C beta-C gamma is 132(1) degrees. The average backbone torsion angles are omega 0 = 169(1) degrees, phi 1 = -40(1) degree, psi 1 = -50(1) degree, omega 1 = -177(1) degree, phi 2 = 54(1) degree, psi 2 = 46(1) degree, omega 2 = -174(1) degree, phi 3 = 103(1) degree, psi T3 = -139(1) degree, and theta T3 = -176(1) degree. The acetyl group is in the trans conformation, while the backbone adopts a right-handed and left-handed helical conformation alternatingly.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of pediatricians' attire on children and parents.

To evaluate perceptions of a pediatrician's attire, 50 children and parents in an outpatient facility were shown five photographs of a female or a male physician dressed differently (formal to informal). A list of positive and negative attributes was presented to the parents and children who were to match each picture to the attributes. Parents had a strong positive preference for the formally dressed female (short white coat and skirt), and the formally dressed male (short white coat and tie). More than 50% of the parents least preferred the most informal attire. Children had no clear preferences for males and preferred the female in the blouse and skirt. Children assigned negative attributes to informal attire but not to the same degree as did their parents. This study demonstrates that parents have stronger preferences than do their children. Although children had no strong positive preferences, they may feel negatively about informal attire.

Alpha,beta-dehydro residues in the design of peptide and protein structures.

The results of X-ray studies on 19 structures containing dehydro residues have been analysed. The observed average C alpha = C beta distance in the dehydro residues is 1.331 (2) A. The average values of the C alpha = C beta - C gamma bond angle in dehydro-Phe and dehydro-Leu are 131.2 (2) and 127.3 (1) degrees, respectively. The dehydro residue is essentially planar. A beta-turn of type II is formed if the dehydro residue is placed either at the (i + 1) or at the (i + 2) corner position of the beta-turn. If the dehydro residues occur consecutively in an amino-acid sequence, the backbone folds into an alternating right- and left-handed alpha-helix. The peptide bond is planar in all these structures. The beta-turn is stabilized by an intramolecular hydrogen bond between CO of the ith and NH of the (i + 3)th residue.

Synthesis, crystal structure, and molecular conformation of N-Boc-L-Phe-dehydro-Leu-L-Val-OCH3.

The peptide N-Boc-L-Phe-dehydro-Leu-L-Val-OCH3 was synthesized by the usual workup procedure and finally by coupling the N-Boc-L-Phe-dehydro-Leu-OH to valine methyl ester. It was crystallized from its solution in methanol-water mixture at 4 degrees C. The crystals belong to the triclinic space group P1 with a = 5.972(5) A, b = 9.455(6) A, c = 13.101(6) A, alpha = 103.00(4) degrees, beta = 97.14(5) degrees, gamma = 102.86(5) degrees, V = 690.8(8) A, Z = 1, dm = 1.179(5) Mg m-3 and dc = 1.177(5) Mg m-3. The structure was determined by direct methods using SHELXS86. It was refined by block-diagonal least-squares procedure to an R value of 0.060 for 1674 observed reflections. The C alpha 2-C beta 2 distance of 1.323(9) A in dehydro-Leu is an appropriate double bond length. The bond angle C alpha-C beta-C gamma in the dehydro-Leu residue is 129.4(8) degrees. The peptide backbone torsion angles are theta 1 = -168.6(6) degrees, omega 0 = 170.0(6) degrees, phi 1 = -44.5(9) degrees, psi 1 = 134.5(6) degrees, omega 1 = 177.3(6) degrees, phi 2 = 54.5(9) degrees, psi 2 = 31.1(10) degrees, omega 2 = 171.7(6) degrees, phi 3 = 51.9(8) degrees, psi T3 = 139.0(6) degrees, theta T = -175.7(6) degrees. These values show that the backbone adopts a beta-turn II conformation. As a result of beta-turn, an intramolecular hydrogen bond is formed between the oxygen of the ith residue and NH of the (i + 3)th residue at a distance of 3.134(6) A.(ABSTRACT TRUNCATED AT 250 WORDS)

Crystal structure and molecular conformation of the peptide N-Boc-L-Gly-dehydro-Phe-NHCH3.

The peptide N-Boc-L-Gly-dehydro-Phe-NHCH3 was synthesized by the combination of N-Boc-L-Gly-dehydro-Phe azlactone and methylamine. The peptide crystallizes in orthorhombic space group P2(1)2(1)2(1) with a = 5.679(2) A, b = 16.423(9) A, c = 19.198(10) A, V = 1791(2) A3, Z = 4, dm = 1.212(5) Mg m-3, dc = 1.237(1) Mg m-3. The structure was determined by direct methods using SHELXS 86. The structure was refined by full-matrix least squares procedure to an R value of 0.049 for 1509 observed reflections. The molecular dimensions are, in general, in good agreement with the standard values. The bond angle C alpha-C beta-C gamma in the dehydro-Phe residue is 133.6(5) degrees. The peptide backbone torsion angles are theta 1 = -171.4(4) degrees, omega 0 = 178.2(4) degrees, phi 1 = -57.2(6) degrees, psi 1 = 141.2(4) degrees, omega 1 = -174.4(4) degrees, phi 2 = 71.5(6) degrees, psi 2 = 7.2(6) degrees, and omega 2 = -179.8(5) degrees. These values show that the backbone adopts the beta-bend type II conformation. The Boc group has a trans-trans conformation. The side-chain torsion angles in dehydro-Phe are chi 2 = 1.6(9) degrees, chi 2(2, 1) = 0.5(9) degrees, and chi 2(2, 2) = 179.8(6) degrees. The plane of C2 alpha-C2 beta-C2 gamma is rotated with respect to the plane of the phenyl ring at 0.5(6) degrees, which indicates that the atoms of the side chain of the dehydro-Phe residue are essentially coplanar.(ABSTRACT TRUNCATED AT 250 WORDS)