Justification of hospital days and epidemiology of discharge delays in a department of neurology.

We have developed a protocol to identify unnecessary days of hospitalisation in the Department of Neurology of the Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland. Seventy-four parameters (medical, social, type of investigation and treatment, degree of disability and of dependence) potentially associated with the length of stay were studied prospectively in 511 nonselected patients consecutively admitted to the Department over a period of 5 months. Each day spent on the wards was analyzed on a day-to-day basis and was classified into one of two groups: those due to a medical reason (4,700 hospital days), and those due to a nonmedical reason (1,184 days). These delays resulted chiefly from difficulties in obtaining laboratory investigations, especially in patients who were not disabled and who had been admitted for investigations (3.8% of hospital days, compared to 1.5% for patients with severe or total dependence) or from awaiting transfer to either another department or a nursing home. This second cause of delay markedly increased the length of stay of patients with severe or total dependence and with limited mobility on the first day (26.0 days, compared with 7.4 days for nondisabled patients) and, above all, on the last day spent in our Department (27.0 days, compared with 8.0 days). The ongoing analysis of these data may provide information as to which parameters could be influenced by neurologists in order to reduce the length of stay in hospital.

[Opening of an emergency center in the University Hospital Center of Vaud]. / Ouverture d'un centre des urgences au C.H.U.V.

Previously decentralised, non-programmed attendances, followed or not by hospitalisation (emergency admissions) at the C.H.U.V. were seen in 7 different sectors. In the context of the opening of a new hospital building for the C.H.U.V., emergencies were concentrated in a new common area known as the "Emergency Centre". The article describes the organisation of this new sector as well as its activity during the first year of its working (7 months). The centre received approximately 1800 patients per month, 51% examined and treated in the department of surgery, 28% by the department of internal medicine, the rest being under the primary responsibility of services of otorhinolaryngology, paediatrics and paediatric surgery and dermatology. Description of the sector includes some maps to demonstrate the architectural concept and its use in case of mass casualties.

[Cerebral distress in full-term newborns: method of early prognosis of the quality of long-term survival]. / Détresse cérébrale du nouveau-né à terme: méthode de pronostic précoce quant à la qualité de la survie à long terme.

A study on 122 full-term newborns with cerebral distress has given the basis for a mathematical model allowing to calculate the risk of poor evolution due to neurological disorders occurring in the first week of life. For each patient a score on his neurological status is established at 3 or 7 days of age. Only four essential neurological characteristics have to be considered: primary reflexes, convulsions, apathy or swallowing disorders, respiratory disorders. All possible score combinations are listed, and each of them is associated with a risk factor (in percent) for poor evolution. A long-term prognosis can therefore be obtained by simple clinical observation, making a score and consulting the list.

[Disorders of the mother-child relationship in newborn infants with low birth weight]. / Troubles de la relation mère-enfant chez les nouveau-nés de petits poids de naissance.

The influence of premature birth or intrauterine growth retardation (IUGR) on the mother-child relationship has been studied in 80 children with birth-weight below 2000 g, treated in the Neonatology Unit of the Pediatric Department of Lausanne University. 40 children with birth-weight over 2500 g and without perinatal complications born in the Obstetrical Department of the same hospital were used as controls. The 80 infants with low birth-weight presented only minor neonatal disturbances and showed later on a normal psychomotor development. The mother-child relationship was evaluated by free and structured interviews accompanied by a questionnaire and by regular contacts throughout the first 12 months. With the exception of the professional work of the mother during and after pregnancy, all the family and social factors were not significantly different in the 3 groups. The mothers of premature children showed significantly more disturbances of their family relationship than the mothers in the control group. On the other hand, a significantly higher number of attachment problems is the only difference observed in the group of mothers of IUGR-babies. There was no mathematical correlation between these problems and the characteristics of the family and social-economic environment of the mothers. The importance of subjective, i.e. psychological, factors as cause of difficulties in the mother-child relationship is stressed.

[Ethics problems in neonatal medicine]. / Problèmes d'éthique en médecine néonatale.

In view of the recent advances in reanimation of the newborn infant, parents, physicians and nursing staff have now to face the ethical dilemma of the quality of the surviving infant with severe brain damage which excludes a further normal development. The author discusses the situation of an infant with trisomy 21 and a total intestinal atresia: a surgical intervention leads to a living human being with a severe mental, and physical handicap; a non-intervention will let the newborn die even if he could be saved. The decision has to be made with the parents in agreement with the nursing staff, but without involving a policy making outside committee.

Temporal lobe epilepsy and hemianopsia in childhood of perinatal origin. An overlooked and potentially treatable disease? Report of two cases, one with a demonstrable etiology.

Two children with a history of traumatic delivery developed severe temporal lobe epilepsy starting at age 4 and 10 respectively. The main neurological finding was total homonymous hemianopsia. The CAT Scan showed a large localised hypodensity in the occipital region on one side consistent with an old infarction in that region. A similar clinical syndrome was described in 1974 by Remillard as temporal lobe epilepsy and perinatal occlusion of the posterior cerebral artery (PCA). In one of our cases, the clinical course suggested that vascular occlusion in the PCA territory resulted from temporal lobe herniation related to a subdural hematoma at birth. It is proposed that this mechanism may apply to some instances of that condition. This clinical syndrome is now increasingly diagnosed as a large number of epileptics are now submitted to CAT. The diagnosis can be delayed until a seizure disorder develops because of the frequent absence of obvious neuromotor signs or visual complaints in the first years of life. Early recognition of this particular type of neonatal cerebral injury could possibly lead to prevention or early treatment.

[Necrotizing enterocolitis in the neonatal period. Revue of 19 cases proved by anatomopathologic examination]. / L'entérocolite nécrosante dans la période néonatale. Revue de 19 cas prouvés par examen anatomo-pathologique.

Nineteen newborn infants with necrotizing enterocolitis, proved by autopsy or surgical examination, are presented. In this study the absence of blood in the stools and of pneumatosis intestinalis did not exclude the diagnosis of necrotizing enterocolitis. The role of umbilical arterial and venous catheters and of exchange transfusion in the pathogenesis of the disease was less than has been previously reported. There was no evidence for emboli of thrombosis in the mesenteric vessels. On the other hand, the probable importance of nonocclusive mesenteric arterial insufficiency is supported by several observations, including the high incidence of antecedent hypoxaemic episodes, the time of onset of the subsequent gastrointestinal pathology and the localization of the lesions. An infectious component was demonstrated, but our results do not allow to state precisely the time of its occurrence.

Hypoglycorrhachia in neonatal intracranial hemorrhage. Relationship to posthemorrhagic hydrocephalus.

The level of cerebrospinal fluid (CSF) glucose may be lowered after subarachnoid hemorrhage. This was observed in each of 18 cases of proven posthemorrhagic hydrocephalus in infants (study group). In one of these children with a hemorrhagic spinal fluid and hypoglycorrhachia unaccompanied by clinical signs of intracranial hemorrhage or hydrocephalus, the axial tomography showed a significant although asymptomatic hydrocephalus. To further evaluate the significance of this finding (hypoglycorrhachia), we compared the incidence of hypoglycorrhachia (CSF glucose less than 40 mg) and lowered CSF glucose/blood glucose ratio (ratio less than 0.4) at three similar time intervals from the presumed time of the intracranial hemorrhage in the study group with that of a control group of 40 neonates with similar neonatal associated pathology (mainly premature infants with hyaline membrane disease) but who did not later develop posthemorrhagic hydrocephalus or cerebral palsy. There was a statistically greater frequency of these anomalies in the hydrocephalic group. Only 3 of the 40 control patients had hypoglycorrhachia and low ratio. Hypoglycorrhachia in the absence of other known causes for decreased CSF glucose is a good index of a probably significant meningeal hemorrhage with a high risk of secondary hydrocephalus which may or may not be symptomatic. Hypoglycorrhachia may be used as an indication of the frequency of clinically inapparent subarachnoid hemorrhage in these high risk newborns.

Intrauterine brain death. Neuraxial reticular core necrosis.

Report is given on the first example in which the clinical and electrographic criteria of brain death were obtained at birth. Global destruction of the central nervous system of a type seen only with anoxia and circulatory failure had occurred in utero without appreciable disturbance of maternal health. Neuropathologic reaction in fetal tissues was identical with that which has been observed in the child or adult in the brain death syndrome. Functional disturbance of cerebral spinal circulation of sufficient degree to destroy neuronal tissue had happened without change in maternal circulation and without demonstrable lesions in the placenta or the cardiovascular apparatus of the fetus.

Outcome of infants of very low birthweight treated in neonatal intensive care unit.

The neonatal survival rate of 500 VLBW (less than or equal to 1 500 g) treated in the neonatal unit of the Departement of Paediatrics in Lausanne (C.H.U.V.) was studied according to changing patterns of nursing and medical care occurring in four successive periods (1961 IX-1963, X-1963 - 1965, 1966-1968, IV-1971-1973). The survival rate at 28 days increased from 35.5% to 47.7% between 1961 and 1965. Earlier start of feeding, intravenous fluid therapy, better control of ambient temperature and better oxygenotherapy are the main changes during this period. Further improvement in neonatal care did not affect the 28-day survival rate. 213 VLBW out of 500 (42.6%) survived at 28 days, 13 (6.1%) out of these died within the first two years of life, 36 (16.9%) were lost for the follow-up. The remaining 164 VLBW were followed until ages between 18 months and 8 years. The improvement in neonatal care was associated with a decrease in the incidence of major neurological sequels from 21.1% to 12.2% between 1961 and 1973. Cerebral palsy and epilepsy are responsible for this decrease. The incidence of mental retardation (DQ or IQ less than 80) also decreased from 17.5% to 4.9% during the same period. However, the incidence of retrolental fibroplasia remained stable. The outlook for VLBW infants is now much more encouraging. Further improvement in perinatal care is likely to further reduce the incidence of major handicaps. but it is not clear whether they will affect the incidence of minor problems such as learning difficulties or poor school performances. More prospective studies are necessary to clarify these points and to ensure early detection of these developmental problems.

Psychological and neurodevelopmental outcome of high risk newborn infants.

Among 142 high-risk-newborns, 111 could be regularly followed-up to 3 years of age. 79 (71%) are normal, 6 (5.5%) have minor neurological sequels, 9 (8.1%) have major neurological sequels, associated in 4 cases with mental deficiency, 16 (14.5%) have developmental abnormalities (speech delay, behavioral problems, perceptual-motor and praxis disturbances), and one mental deficiency without neurological sequels. Neonatal cerebral distress proved to be the most dangerous clinical situation with regard to the ultimate neurodevelopmental prognosis (73.6% of neurological sequels or developmental abnormalities). The presence of transient abnormalities of tone in the course of the first year of life was associated with ultimate developmental abnormalities in 33.3% of the cases. Social and cultural status seemed to play a role in the intellectual, linguistic and perceptual-motor performance of this group of infants. In spite of these encouraging results, the need for a systematic long term follow-up of high risk newborns is stressed, since neurological sequels and developmental abnormalities are approximately 4 times more frequent in this group than in a normal infantile population.

Cerebral distress in full-term newborns and its prognostic value. A follow-up study of 90 infants.

The history of 90 full-term infants with neonatal cerebral distress was examined. Informations concerning pregnancy, delivery, neonatal status, clinical and laboratory evolution were compared with final outcome in each case. It was then possible to distinguish certain clinical features significantly associated with poor prognosis. After statistical analysis, different adverse criteria were selected, such as severe neonatal asphyxia, associated respiratory disorders, acute anemia, and especially neurological signs with regard to their chronology. This part of the study has resulted in a classification of the neurological signs and has permitted the description of both malignant and benign cerebral distress syndromes.

Relationship between body size, thermal balance and thermal insulation of term infants under various ambient conditions.

A gradient layer direct calorimetric study was made on the thermal balance of small-for-date, appropriate-for-date and large-for-date term newborn infants during the first 2 days of life. At ambient temperatures of 28 and 32 degrees C, the dry and total heat losses per kilogramme body weight were inversely related to body weight. There was a negative correlation between metabolic rate per kilogramme and body weight, whereas in terms of surface area the correlation became positive. A similar tendency without statistical significance was observed at an ambient temperature of 37 degrees C. In a cool environment (28 degrees C), a significant positive correlation was found between body weight and ambient or total thermal insulations. Tissue and total insulations were inversly related to the metabolic rate. It was concluded that small-for-date newborn infants are handicapped not only by the unfavourable surface-to-mass ratio but also by the limited specific body thermal insulation.

Neonatal intracranial hemorrhage in premature infants.

Since the advent of modern methods of neonatal care, intracranial hemorrhage in premature infants, which is usually intraventricular, is probably not as uniformly fatal as generally admitted and the survivors are likely to develop post-hemorrhagic hydrocephalus. This paper is a retrospective study of 11 premature babies born between 1968 and 1972 and diagnosed as having hydrocephalus secondary to neonatal intracranial hemorrhage. Nine of these are still alive and two have died, one at 3 and one at 17 months of age. Eight underwent permanant surgical drainage of hydrocephalus. The perinatal history, laboratory data, clinical evolution, and neurological outcome were studied. Two groups of infants were identified; those with signs of acute neurological deterioration in the neonatal period who had the most severe neurological sequellae (in four cases, periventricular lesions in addition to hydrocephalus were seen on the air study and in one case confirmed at autopsy) and those showing no obvious neurological signs in the neonatal period. Of this latter group, two appear to be developing normally. The therapeutic implications of the findings are discussed.

Leucocyte energy metabolism. V. Glycolytic and hexose monophosphate shunt enzymes in leucocytes from adults and newborn infants.

The activities of ATP-consuming and ATP-producing steps of the Embden-Meyerhof pathway, as well as other glycolytic enzymes (phosphoglucomutase and enolase) and glucose-6-phosphate dehydrogenase are lower in leucocytes from cord blood than in white cells from adults. These results are related to previous observations (reduced anaerobic glycolysis and nitroblue tetrazolium-test in leucocytes from newborn infants) and discussed in connection with the fact that newborn infants are more susceptible to infections than normal adults.