Should a school honor a student's DNR order?

Physicians first present the case of a sixteen-year-old cardiac patient who has refused a heart transplant and cardiac resuscitation. Her family and physicians accept the decision. The family has asked the school system to honor her do not resuscitate order if she goes into cardiac arrest in school The school system has refused to do so. Following the case presentation, a lawyer, a physician/ethicist, and an educator consider the important issues raised by this ongoing case.

Pseudohypoaldosteronism.

Shortly after birth, a 1,860-g premature male newborn with respiratory distress syndrome had brisk diuresis, rapid weight loss, and severe hyponatremia despite aggressive Na+ and fluid replacement. The serum cortisol level was normal, and the 17-OH progesterone concentration was low. He did not show any response to treatment with dexamethasone and desoxycorticosterone acetate. Results of renal function studies were within the normal range for his gestational age. The serum aldosterone level and plasma renin activity were grossly elevated, confirming the diagnosis of pseudohypoaldosteronism. This uniquely early and dramatic presentation was attributed to immaturity of the proximal renal tubule at 32 weeks' gestation. The subsequent improvement paralleled the rapid maturation of the kidney after birth.

Evolution of porencephalic cysts from intraparenchymal hemorrhage in neonates: sonographic evidence.

Ninety-four low-birth-weight neonates were screened consecutively with real-time sonography for evidence of cerebroventricular hemorrhage. Among them, 13 were found to have intraparenchymal hemorrhage beyond the area of the germinal matrix. Weekly follow-up sonograms revealed progression to porencephaly in every surviving infant. Four different sonographic patterns were observed during the evolution from the original hemorrhage to the porencephalic cyst. The size of the mature porencephalic cyst correlated directly with the size of the intraparenchymal hemorrhage. After ventriculoperitoneal shunting, the porencephalic cysts became smaller or remain unchanged. One small cyst was no longer identified after successful shunting, but reappeared with shunt failure.

Congenital esophageal atresia: lipase activity is present in the esophageal pouch and stomach.

Lipolytic activity was studied in aspirates from the esophageal pouch and from the stomach of eight infants with congenital esophageal atresia. Lipolytic activity, tested with doubly labeled ([3H]glyceryl, [14C]fatty acid) long-chain triglyceride was present in esophageal and gastric aspirates. The activity in esophageal aspirates was in the range of 2.7-130 nmol/min/ml aspirate and that in gastric aspirates was in the range of 2.9-40.4 nmol/min/ml aspirate. The reaction products of lipolytic activity in esophageal and gastric aspirates were a mixture of mono- and diglycerides, glycerol, and free fatty acids. The lipolytic activity at the two sites--esophagus and stomach--varied with respect to pH optimum (5.0-7.6 and 6.0-6.5, respectively) and reaction products (glycerol 41.6 +/- 20% and 7.3 +/- 4.6%, respectively). These findings confirm the earlier observations that digestion of dietary fat is initiated in the stomach and suggest that the lipolytic activity present in gastric contents originates concomitantly from the oral-esophageal area as well as from the stomach. These studies do not exclude the possibility that the lipolytic activity in the stomach of infants with esophageal atresia could originate in regurgitated intestinal contents.

Real-time ultrasonography of neonatal intraventricular hemorrhage and comparison with computed tomography.

Thirty-three low-birth-weight neonates were diagnosed prospectively as having an intraventricular hemorrhage, using a real-time sonographic sector scanner. Ultrasound findings were corroborated in 27 patients by computed tomography (CT) or autopsy. Intraventricular blood is hyperechoic and, in a fresh hemorrhage, a continuous cast-like pattern of increased echogenicity replaces the usually minute, echo-free lateral ventricles. After one to three days, the lateral ventricles begin to enlarge around the echogenic clot if hydrocephalus complicates the hemorrhage. The sonographic findings indicating intraventricular hemorrhage and its progression to hydrocephalus are presented. The accuracy of sonographic real-time sector scanning in the evaluation of neonatal intraventricular hemorrhage is discussed and compared to CT.

Postheparin lipolytic activity and Intralipid clearance in very low-birth-weight infants.

The effect of heparin (10 U/kg) on serum lipolytic activity, triglyceride and FFA levels, during four hours infusion of 0.5 gm/kg Intralipid was measured in 18 AGA infants, 25 to 32 weeks' gestational age. PHLA, TG, and FFA were measured at 0, 10, 30, 120, and 240 minutes of infusion of Intralipid, before and following a bolus of 10 U/kg heparin iv. Lipolytic activity, measured by hydrolysis of activated tri-3H-oleate and expressed in mumol FFA released per milliliter serum per hour, was not detected in serum before heparin administration. Ten minutes after heparin administration peak PHLA was significantly higher in infants of 27 to 32 weeks' gestation than in infants of 25 to 26 weeks' gestation. There was no significant difference in peak PHLA between infants of 27 to 28 and 29 to 32 weeks' gestation. PHLA returned to baseline (zero) two hours after heparin administration in all infants. Infants of 25 to 26 weeks' gestational age had significantly higher concentrations of serum triglycerides before and during Intralipid infusion than in infants of 27 to 32 weeks' gestational age. Although there was a transient rise in FFA 10 and 30 minutes after heparin administration, the levels of FFA and triglycerides were not different at the end of infusion with or without heparin in either group, suggesting that a single bolus of heparin has only a transient effect on Intralipid clearance.

Real-time sonography of the neonatal and infant head.

Fifty neonatal and infant heads were examined using a 5 MHz real-time sector scanner. Anatomic detail superior to that previously described was achieved by this method. Normal structures routinely imaged included the entire ventricular system and many parts of the subarachnoid spaces. The gray scale detail of parenchymal structures was usefully demonstrated. Routinely visualized vascular structures included the anterior cerebral artery system, the middle cerebral arteries, the choroid plexus, and the posterior cerebral arteries. Hydrocephalus, as well as intraventricular hemorrhage and its sequelae, were investigated. Computed tomography (CT) is considered diagnostic in hydrocephalus and intraventricular hemorrhage, but evaluation by sonography compares favorably. Among other advantages of sonography are the feasibility of bedside scans without removing the patient from the intensive care nursery and the elimination of ionizing radiation.

Behavioral and dermatologic changes and low serum zinc and copper concentrations in two premature infants after parenteral alimentation.

Two premature infants were observed to develop behavioral and dermatologic changes and low serum zinc and copper concentrations following cessation of prolonged parenteral alimentation, while being fed exclusively with human milk. Following treatment with exogenous oral zinc supplementation, prompt relief of symptoms and increases of serum zinc and copper concentrations were observed in both infants. These patients comprise about 5% of our premature infants who are treated with parenteral alimentation for more than two weeks. We recommend that premature infants on prolonged parenteral alimentation should be monitored for changes in serum zinc and copper concentrations and, if a marked fall is observed, supplementation should be considered.

Fat digestion in the stomach of premature infants. I. Characteristics of lipase activity.

Lipolytic activity was studied in gastric aspirates of 13 premature infants of birth weight 1,050 to 1,786 gm. All infants received a diet of infant formula fed by gastric tube. Gastric aspirates were collected after irrigating the stomach with 2 to 5 ml sterile saline before regular feeding. Lipolytic activity, tested with doubly labeled 3H glyceryl-14 C tripalmitin substrate, was 55.6 +/- 11.7 n mol/min/ml (range 4.2 to 140). The lipolytic activity had a pH optimum of 5.4 and produced partial glycerides (mono and diglycerides), glycerol, and free fatty acids. Lipolysis was inhibited by bile salts. Our findings show that in premature infants, as in adults, digestion of dietary fat starts in the stomach. Since bile salt concentrations are low in premature infants, the amphiphilic reaction products formed (monoglyceride and FFA) could play a significant role in the stabilization of lipid emulsions.