Magnetic resonance cholangiography for evaluation of cholestatic jaundice in neonates and infants

Distinguishing extrahepatic biliary atresia from other causes of cholestasis in neonates and infants is important because surgical intervention before 2 months of age allows for long-term survival. The purpose of this prospective study was to evaluate the usefulness of magnetic resonance (MR) cholangiography in differentiating biliary atresia from other causes of cholestatic jaundice in neonates and infants. Nine anicteric infants (control group) aged 10 to 224 days (mean +/- SD, 8 +/- 65 days) and 15 neonates and infants with cholestatic jaundice, aged 22 to 142 days (mean +/- SD, 71 +/- 37) underwent MR cholangiography. The final diagnosis of extrabiliary atresia (6 patients) was based on laparotomy findings (4 patients) or autopsy (2 patients), while neonatal hepatitis (9 patients) was diagnosed according to the liver biopsy findings and clinical recovery during follow-up. Percutaneous liver biopsies were performed in all 15 patients. Results showed that the gall bladder and common bile duct (CBD) could be visualized using MR cholangiography in all patients in the control group. Nonvisualization of the CBD (6/6 patients) and demonstration of a small gall bladder (6/6 patients) characterized MR cholangiography findings in patients with biliary atresia. MR cholangiography failed to depict the CBD in one infant with hepatitis. We conclude that demonstration of the CBD by MR cholangiography in neonates and infants with cholestasis can be used to exclude the diagnosis of biliary atresia. In patients with cholestatic jaundice considered for exploratory laparotomy, preoperative MR cholangiography is recommended to avoid unnecessary surgery.     

Fundamental and clinical evaluation of cefozopran in low birth weight infants and neonates

We conducted fundamental and clinical evaluations of a cephem antibiotic, cefozopran (SCE-2787, CZOP), in infants with low birth weights and mature infants. (1) Blood concentrations CZOP was intravenously given in bolus dose of 20 mg/kg to the newborn. The blood antibiotic concentrations were 69.7 micrograms/ml at 30 minutes after administration and the elimination half life was 2.99 hours in mature infants aged 1 to 3 days. They were 38.7 micrograms/ml and 2.85 hours in those aged 4 to 7 days, and 40.8 micrograms/ml and 3.81 hours in those aged 8 days or elder, respectively. In infants with lower birth weights aged 4 to 7 days the blood antibiotic concentrations were 48.6 micrograms/ml at 30 minutes after i.v. administration and the elimination half life was 3.77 hours. The blood antibiotic concentrations at 30 minutes after intravenous doses of 10, 20 and 50 mg/kg in mature infants aged 8 days or elder were 21.1, 40.8 and 153.6 micrograms/ml (value at 60 minutes) and the elimination half lives were 2.24, 3.81 and 3.07 hours, respectively. Administration of CZOP at doses of 20 and 40 mg/kg by intravenous drip infusion over 30 minutes gave the blood drug concentrations of 48.0 and 103.2 micrograms/ml at the end of the infusion and the half lives were 2.60 and 3.33 hours, respectively. (2) Urinary excretion The urinary excretion rates after i.v. bolus doses of 10, 20 and 40 mg/kg were 28.4 to 58.6% of dose. The urinary excretion rate after i.v. drip infusion of 40 mg/kg over 30 minutes was 49.0% of dose. (3) Transfer into cereblospinal fluid The transfer of the antibiotic into cereblospinal fluid in patients with serous meningitis was 4.1 to 15.5 micrograms/ml at 1 hours after administration. (4) Clinical results The clinical efficacy was judged "good" or "excellent" in 2 of the 3 patients with septicemia and in all of the 10 patients with suspected septicemia. It was judged "excellent" in all of the 9 patients with pneumonia, 3 with urinary tract infections and 3 with intrauterine infections. Prophylactic use of the antibiotic was effective in all of the 12 patients. Of the patients in whom bacteriological evaluation was successful, 7 of the 10 causative organisms were confirmed to be eradicated. No adverse drug reactions of signs and symptoms were recognized. Fourteen abnormal alterations of the laboratory test values such as elevation of gamma-GTP and that of GPT were recognized in 8 patients (16.7%). None of them were particularly serious. These results indicate that CZOP is a drug useful for treatment and prevention of infections in infants with lower birth weights as well as in mature infants.     

Digoxin pharmacokinetics in premature infants

The use of camera renography under experimental conditions is described. The conductivity of the ileo-ureter formed by various surgical techniques in 24 dogs and the function of the operated kidney were studied. The non-invasive examination lasted for 20 minutes and was performed with two different labelled drugs (131I-iodohippurate and 99mTc-DTPA) and a gamma-camera calculator system. The results have shown that the ileo-ureter provided with a direct single layer uretero-ileal anastomosis ensured best the transport of urine and so it seems to be most promising for human application.     

Medical shortages and Confederate medicine: a retrospective evaluation

The Union's decision to treat medicines and medical supplies as contraband of war meant, for the Confederacy, the specter of medical shortages. The Confederate medical department significantly lessened the subsequent suffering through an energetic and resourceful program to supply its physicians' needs. Medicines and medical supplies were purchased abroad and smuggled through the Union blockade, obtained in an illicit trade with the North, captured from the enemy, and manufactured in the Confederacy. The search for home remedies, enthusiastically endorsed by Surgeon General Samuel P. Moore, was one of the most prominent features of the southern program. This paper surveys and analyzes medical shortages and Confederate medicine.     

Normal liver, spleen, and kidney dimensions in neonates, infants, and children: evaluation with sonography

OBJECTIVE: The objective of this study was to determine the normal range of dimensions for the liver, spleen, and kidney in healthy neonates, infants, and children. SUBJECTS AND METHODS: This prospective study involved 307 pediatric subjects (169 girls and 138 boys) with normal physical or sonographic findings who were examined because of problems unrelated to the measured organs. The subjects were 5 days to 16 years old. All measured organs were sonographically normal. At least two dimensions were obtained for each liver, spleen, and kidney. Relationships of the dimensions of these organs with sex, age, body weight, height, and body surface area were investigated. Suggested limits of normal dimensions were defined. RESULTS: Dimensions of the measured organs were not statistically different in boys and girls. Longitudinal dimensions of all three organs showed the best correlation with age, body weight, height, and body surface area. Height showed the strongest correlation of all. This correlation was a polynomial correlation. CONCLUSION: Determination of pathologic changes in size of the liver, spleen, and kidney necessitates knowing the normal range of dimensions for these organs in healthy neonates, infants, and children. Presented data are applicable in daily routine sonography. Body height should be considered the best criteria to correlate with longitudinal dimensions of these organs.     

Vancomycin cerebrospinal fluid concentrations after intravenous administration in premature infants

OBJECTIVE: Staphylococcal species are the most common cause of nosocomial infections in the neonate. Because of staphylococcal resistance patterns, vancomycin has become the drug of choice for treatment. Although the blood stream is the usual site of infection, premature infants are at increased risk for the development of meningitis. The aim of this study was to determine vancomycin cerebrospinal fluid (CSF) concentration and penetration following intravenous (IV) administration in critically ill premature infants. STUDY DESIGN: A multiple-dose, open-label, case series was performed at a level III neonatal intensive care unit in a university teaching hospital. Three critically ill premature infants, 26 to 31 weeks of gestation requiring a course of IV vancomycin for suspected or proved sepsis were studied. Vancomycin was administered intravenously at 20 mg/kg, every 18 to 24 hours over 60 minutes. Serum and CSF vancomycin concentrations were obtained and pharmacokinetic analysis and CSF penetration was calculated. RESULTS: Serum vancomycin pharmacokinetics were consistent with those previously reported. CSF vancomycin concentrations ranged from 2.2 to 5.6 micrograms/ml and the calculated vancomycin CSF penetration ranged from 26% to 68%. CONCLUSIONS: CSF penetration of vancomycin after IV administration was much higher than that reported in older infants and children. This higher penetration may improve clinical outcomes in neonates with central nervous system infections. These data should be encouraging to clinicians who choose to use IV vancomycin for neonatal meningitis.     

Evaluation of gentamicin pharmacokinetics and dosing protocols in 195 neonates

Gentamicin pharmacokinetics and dosing protocols in neonates were studied. Demographic and pharmacokinetic data on 202 neonates treated with gentamicin at a 500-bed medical center were collected over a three-year period. Administered doses, gentamicin concentration measurements, and recorded times were used to calculate each patient's clearance, volume of distribution, elimination rate constant, and half-life. The performance of 15 dosing protocols, including 6 previously published ones and 9 developed on the basis of the study, was evaluated using the pharmacokinetic data. Of the 202 patients, 195 were included in the analysis. The mean +/- S.D. clearance, volume of distribution, elimination rate constant, and half-life were 0.047 +/- 0.015 L/hr/kg, 0.45 +/- 0.11 L/kg, 0.107 +/- 0.032 L/hr, and 7.19 +/- 2.64 hours, respectively. Weight, urine output, gestational age, and postconceptional age (PCA) had the highest correlation with the pharmacokinetic values. Blood urea nitrogen concentration (BUN) and Apgar score were poor predictors of the pharmacokinetic values. There were no significant differences among patient subsets based on race and BUN, but subset analysis based on PCA did indicate significant differences. In simulations, the protocols based on the study patients tended to perform better than the literature protocols, with all but three achieving therapeutic goals in 75% or more of the neonates. Of the published protocols, Murphy and Carter's produced the greatest percentage of neonates with peaks from 5 to 10 mg/L and troughs of <2 mg/L. The devised protocols tended to perform poorly in producing troughs between 1 and 2 mg/L, yet performed comparatively well in providing therapeutic peaks from 5 to 10 mg/L.     

Outcome of laryngeal paralysis in neonates: a long term retrospective study of 113 cases

Between 1985 and 1990, 113 children were diagnosed as having congenital vocal cord paralysis. Most of them were still being followed up in June 1994. Fifty two had bilateral paralysis, 61 had unilateral paralysis: 41 were on the left side and 20 on the right side. Forty two were idiopathic, 29 were associated with neurologic disorders, six were associated with heart malformations. Fifteen children were born after difficult delivery. Among the newborns with unilateral paralysis that occurred after an abnormal delivery, 73% recovered spontaneously; likewise 70% of the neurologic group and 74% of the idiopathic group recovered spontaneously. The prognosis of bilateral paralysis was worse with only 52% of spontaneous recovery in the neurologic disorders group and the idiopathic group. Seven percent of the children underwent a surgical procedure. They were all decanulated or extubated. In view of our experience the prognosis is poor for bilateral idiopathic laryngeal paralysis or those with neurological context.     

Long-term evaluation of root-resected molars: a retrospective study

Thirty-two consecutively treated patients were included in this study of 49 root-resected molars that were under regular recall of 3 to 6 months for a mean of 11.5 years (2 to 23 years). Treatment modalities for all patients were very similar. Endodontic treatment was conservatively performed prior to resection with maximum preservation of tooth structure. No threaded posts were used. Provisional restorations were in place prior to periodontal therapy (pocket reduction with or without osseous surgery). Most patients were treated with complete-mouth reconstructions. Ninety-two percent of all resected molars survived an average of 12 years. Teeth failed because of recurrent caries or for endodontic and strategic reasons. If proper treatment is rendered periodontically involved molars can be maintained for a long period of time and serve successfully as abutments in complete-mouth restorations. Great care must be taken throughout the whole process of case selection, reevaluation, and endodontic, periodontal, restorative, and maintenance therapies.     

Rice-starch oral rehydration therapy in neonates and young infants

Pulmonary embolism is a leading cause of morbidity and mortality that can occur in many clinical situations. For several years, spiral CT has represented a relatively non invasive modality for diagnosing this common disease. The present article is reviewing the CT features of acute and chronic pulmonary embolism, the technical aspects of spiral CT acquisition, the diagnostic accuracy and major limitations and pitfalls of the technique.     

The pharmacokinetics and physiological effects of buprenorphine infusion in premature neonates

Whereas some people appear to cope after learning that they have human immunodeficiency virus (HIV) infection, others experience depression and suicidal ideation. In this study, 142 persons with HIV infection were administered the Center for Epidemiological Studies Depression Scale (CES-D). High levels of depression were predicted by lower perceived social support, attributions that health was influenced more by chance, high-risk sexual behavior practices, and greater number of HIV illness symptoms and greater duration of time knowing of one's own positive serostatus. Ongoing high-risk sexual behavior practices were predicted by higher levels of recreational drug use and of depression. These findings highlight the need for improved mental health services for persons with HIV conditions.     

The mandibular staple bone plate: a long-term retrospective evaluation

PURPOSE: Clinical and radiographic parameters and denture satisfaction were evaluated in a long-term retrospective study of patients treated with the mandibular staple bone plate. PATIENTS AND METHODS: Fifty-six edentulous patients were treated with the mandibular staple bone plate to stabilize their lower denture. The mean evaluation period was 103 months (range, 84 to 139 months). Peri-implant mucosa and bone height were scored, together with quality of the prosthesis and prosthodontic maintenance care. Denture satisfaction was assessed by using two questionnaires. RESULTS: Four staple bone plates were removed during the evaluation period, and one appeared to be fractured. The remaining 51 staple bone plates were functional without any signs of major complications (survival rate, 91%). No further alveolar resorption in the interforaminal region of the mandible took place during the evaluation period. Patients were very satisfied with the prosthetic construction. CONCLUSIONS: The mandibular staple bone plate is a good modality to stabilize the lower denture. However, endosseous implant systems are preferred because of comparable success rates with a more simple operative procedure.     

Percutaneous central venous catheters in neonates: a descriptive analysis and evaluation of predictors for sepsis

The article describes the experience with percutaneous central venous catheters in 565 neonates with birth weights of 400 to 6810 g. The catheter-related sepsis incidence was 19.1%, or 13.5 infections per 1000 catheter days. By discriminant function analysis, 86% of all neonates studied were correctly classified into the confirmed sepsis and no sepsis groups on the basis of six predictor variables. The model did not accurately predict the neonates who would develop confirmed sepsis. The weight at catheter insertion and length of time for which the catheter was in place were identified as variables that contributed significantly to differentiation between sepsis and no sepsis groups.     

Evaluation of a sparse sampling strategy for determining vancomycin pharmacokinetics in preterm neonates: application of optimal sampling theory

OBJECTIVE: To use optimal sampling theory to determine the fewest vancomycin concentrations required and the appropriate sampling times to calculate vancomycin pharmacokinetic parameters in neonates. DESIGN: Unblinded evaluation in neonates with presumed sepsis. SETTING: Level 3 community-based neonatal intensive care unit. PATIENTS: Eleven neonates with presumed sepsis. INTERVENTIONS: Twelve courses of intravenous vancomycin 20 mg/kg were administered. Blood samples were collected 3 and 9 hours after initiation of a 1-hour infusion of the first dose. MEASUREMENTS AND MAIN RESULTS: A two-compartment model was fit to vancomycin concentrations using iterative two-stage analysis. Pharmacokinetic parameter estimates were used for determination of optimal sampling times for two-, three-, and four-sample strategies with subsequent generation of two-, three-, and four-sample concentration data for 100 cases. Relative performance of strategies was compared through calculation and comparison of D efficiency for the determined strategies. Bias (median percent error) and precision (median percent absolute error) of pharmacokinetic parameter estimates for each strategy in the 100 simulated cases were determined. CONCLUSIONS: For estimation of total clearance and volume in the central and peripheral compartments, all strategies performed similarly with no difference in efficiency or bias and precision of estimates. Our results suggest that for clinical evaluations two appropriately timed samples (0.5 h after a 1-h infusion, trough concentration) are adequate for estimation of vancomycin clearance in neonates.     

Understanding sleep ontogeny to assess brain dysfunction in neonates and infants

The ontogenetic framework onto which a child's sleep is constructed undergoes significant developmental alterations during early life. Sleep state behaviors, in large part, reflect continuities from fetal through neonatal time periods. Major changes in sleep organization subsequently occur throughout infancy. Maturational expressions of sleep behaviors must be understood by the pediatric neurologist before specific physiologic phenomena can be assessed as transient sleep disturbances or clinically relevant sleep disorders. The first part of this two-part review article focuses on the major aspects of developmental sleep physiology in the first few months of life. Recognition of age-specific electroencephalographic/polysomnographic patterns will facilitate the child neurologist's evaluation of the newborn with suspected seizures and interictal encephalopathies, as well as the prediction of neurologic sequelae.     

Safe amounts of contrast medium for angiocardiography in neonates and infants

The results were analysed of 485 (biplane) cineangiocardiograms performed in 200 consecutive cardiac investigations on neonates (under 4 wk) and infants (4 wk to 1 yr). 10 deaths occurred during or within 24 h of cardiac catheterization, all in patients who were profoundly acidemic because of their hemodynamic disturbance. A total dose of Cardio-Conray at any one investigation of 4-5 ml/kg body weight was satisfactory and without undue risk. Single injections of 1.5-2.0 ml/kg body weight were safe whilst providing optimal diagnostic information. The interval between multiple injections did not appear to affect the risk to the patients.