Candidemia in the neonatal intensive care unit

The hospital records of 18 infants (9 males & 9 females) with one or more positive cultures for Candida species were studied retrospectively in an attempt to define the characteristics, associated factors and treatment for candidemia in the neonatal intensive care unit. The number of patients have increased recently and the mortality rate is 56% (10/18). The Candida species isolated from blood were Candida albicans in 16 cases and Candida parapsilosis in 2 cases. Fever, not-doing-well, and abdominal distention were the most common presentations, prompting us to the initial impression of bacterial sepsis and/or necrotizing enterocolitis. Eleven associated factors for candidemia were relating to the measures and therapy in the neonatal intensive care unit, such as prolonged use of broad-spectrum antibiotics, parenteral hyperalimentation etc. All of these 18 patients were treated with intravenous amphotericin B. Six patients were given adequate total dose (> 25 mg/Kg), while 12 patients underwent inadequate treatment (3.7 +/- 2.9 mg/Kg). The 10 fatal patients belonged to the inadequate treatment group. As there is continual progress in neonatal intensive care units, candidemia is becoming an increasing common problem and which deserves attention.     

Plastic surgical problems in the neonatal intensive care unit

A Bayesian decision rule for early termination of an experimental study of binary responses is presented. This early termination occurs when the predictive probability of reversing the decision when utilizing the delayed observations is small. The proposed approach utilizes Bayesian inferential tools such as Bayes factors and predictive distributions. A simulation study is conducted to evaluate the performance of the proposed approach. Some guidelines are given to determine when the study should be terminated early and when the investigator should wait for delayed observations before making a conclusion.     

Frequency of neurologic disorders in the neonatal intensive care unit

Neonatal intensive care unit survival rates have improved significantly over the past decade. This improvement primarily reflects declining mortality rates among preterm infants. Neurologic morbidity increases with prematurity and is the major predictor of long-term disability. Accordingly, concern has been expressed that the burden of neurologic dysfunction among contemporary neonatal intensive care unit survivors may be increasing. To define the trends of neurologic disorders in the contemporary neonatal intensive care unit, all 4164 admissions between 1986 and 1995 to a tertiary neonatal intensive care unit were examined. Neonatal intensive care unit admissions (413 +/- 49 per year), proportion of births at less than 37 weeks (70 +/- 3% per year), and referral patterns were stable between 1986 and 1995. Over the study period, 773 (18%) of 4164 neonatal intensive care unit infants had a total of 1062 neurologic disorders. The neonatal intensive care unit mortality rate declined from 12% in 1986 to 4.2% in 1995 (P < .01). Neurologic disorders declined, from 27% of infants born in 1986 to 12% in 1995 (P < .001): 356 had seizures (14% in 1986 to 4% in 1995; P < .001), 235 had hypoxic-ischemic encephalopathy (8% in 1986 to 4% in 1995, P < .01), and 167 had intraventricular hemorrhage (7% in 1986 to 1.4% in 1995, P < .005). Frequency of congenital or chromosomal aberration affecting the nervous system was relatively constant (4.5% per year). Despite a three-fold improvement in neonatal intensive care unit survival between 1986 and 1995, the frequency of perinatally acquired neurologic disorders declined by more than 50%.     

Outbreak of influenza in a neonatal intensive care unit

An outbreak of influenza A/Victoria/3/75 (H3N2) involving five infants in a neonatal intensive care unit is described. The clinical signs and symptoms were indistinguishable from those seen in bacterial sepsis. There was no evidence of meningoencephalitis. All infants recovered without any sequelae.     

Electrocardiograph monitor artifacts in a neonatal intensive care unit

A wide variety of artifacts may be found when monitoring the ECG in a neonatal intensive care unit. Many of the artifacts resemble arrhythmias, and unless they are recognized as artifacts they may lead to serious errors of diagnosis and therapy. Many of the artifacts are caused by patient movement such as seizures, tremulousness, or hiccups. Others may be introduced by the monitor itself or be caused by electrical equipment in the vicinity. A group of ECG tracings is presented to illustrate the various artifacts encountered. Features that distinguish the artifacts from the arrhythmias they mimic are described, as are suggestions for elimination of the artifacts.     

Speech and language outcomes in preschool-aged survivors of neonatal intensive care

This paper reports on the second stage of a longitudinal follow-up of the speech and language outcomes in a cohort of children who required neonatal intensive care. From 3 years of age, when the first stage was completed, to preschool age, the rate for major overall communication problems rose from 13% to 17%. However, when children with frank neurological or intellectual problems were excluded, this figure dropped to 8%. The impact of perinatal, medical and environmental variables on speech and language outcomes was again investigated. Differences were found between those that were important at 3 years of age and those that were important at preschool age. New variables emerged as contributing to language expression, including gender and the perinatal variables, gestational age and respiratory distress syndrome. Maternal education level was even more important to language comprehension at preschool age than at 3 years of age. Factors that might explain improvement, or lack of improvement, in speech and language skills are discussed.     

Outbreak of systemic aspergillosis in a neonatal intensive care unit

Clinical and manometric results of Delorme's operation and sphincteroplasty were assessed retrospectively in patients undergoing this procedure for fecal incontinence and rectal prolapse. A series of 33 patients (11 males, 22 females; aged 18-83 years, mean 59) with external rectal prolapse were treated by Delorme's operation between 1989 and 1996. Mean follow-up was 39 months (range 7-84). Sphincteroplasty was associated in 12 cases with severe fecal incontinence due to striated muscle defects. Good results were achieved in 27 patients (79%); prolapse recurrence was observed in 6 (21%), the mean recurrence time being 9 months (range 1-24 months). There were no postoperative deaths. Minor complications occurred in 15 patients. Changes in preoperative and postoperative manometric patterns were as follows (mean +/- SEM): voluntary contraction from 59 +/- 6.9 to 66 +/- 7.1 mmHg (P = 0.05), resting tone from 33 +/- 5 to 32 +/- 4.3 mmHg, rectal sensation from 59 +/- 5 to 61 +/- 5.2 ml of air (n.s.). A solitary rectal ulcer syndrome was detected in five patients. The histological pattern demonstrated pathological changes in 40% of cases. Fecal incontinence was resolved in 6 of 20 cases (30%) and chronic constipation in 4 of 9 (44%). Failure (n = 3) was related primarily to postoperative sepsis. The incontinence score showed a mean improvement of 35% decreasing, from 4.5 +/- 0.39 to 2.9 +/- 0.44 after surgery (P < 0.01). In conclusion, Delorme's procedure did not lead to constipation and improved anal continence when associated with sphincteroplasty.     

Radiology in the neonatal intensive care unit: dose reduction and image quality

This paper describes a prospective study of the diagnostic radiation doses received in a neonatal intensive care unit (NICU) for a representative radiological technique used at our institution for a number of years and a "low dose" technique similar to that recommended by the Commission of the European Communities (CEC). A 400 speed film-screen combination was used in both techniques. A total of 363 anteroposterior (AP) chest and abdominal films of 77 neonates were accrued. For each radiograph, the entrance skin dose (FSD), energy imparted (EI) and mean whole body dose were determined. For a neonatal AP chest, there was an 18% reduction in the mean ESD per radiograph from 20.0 muGy for the representative technique to 16.4 muGy for the low dose technique (p < 0.0005). The reduction in the mean EI per radiograph values for the two techniques from 7.9 muJ to 7.1 muJ (10%) was statistically significant at the p < 0.017 level, after compensating for the difference in mean field dimensions between the two patient cohorts. The mean whole body dose per radiograph reduction from 4.4 to 3.5 muGy (20%) was statistically significant at the p < 0.0028 level. It was determined that the ESD and EI could be fitted by an exponential function in the equivalent patient diameter, a single parameter indicative of neonate size. Absolute excess childhood cancer mortality risk per film was estimated using risk factors derived for fetal exposures. A "worst case" absolute excess mortality risk per chest radiograph was estimated to be 1.40 x 10(-7) for the conventional technique and was further reduced to 1.11 x 10(-7) for the low dose technique. A blind comparison of patient-matched film pairs for each technique was performed by three radiologists using criteria similar to those specified by the CEC. No statistically significant difference in clinical image quality was found between the two techniques.     

Central venous catheter bloodstream infections in the neonatal intensive care unit

The aim of the study was to investigate the social background of physicians, the reasons that influenced doctors to enter medicine, and the association between those reasons and satisfaction in career choice of young Finnish doctors. An extensive postal questionnaire was mailed to a random sample of 2632 young Finnish doctors in 1988 and to 2332 doctors in 1993. We found out that majority of the respondents reported that interest in people, a wide range of job opportunities, the fact that medicine is a highly-appreciated profession, and success at school had influenced their decision to enter medicine quite a lot or very much. In 1988, 8% and in 1993, 7% of the respondents reported that interest in people had not influenced their career choice at all or only slightly. More women than men were influenced quite a lot or very much by factors like interest in people, success at school and vocation, meaning the lifelong calling to physicians' profession. A total of 22% of respondents would not enter medicine again. Vocation, interest in people and wide range of job opportunities were significantly more rarely mentioned as an important career choice motive by these respondents. It seems that interest in human beings and vocation are important to would-be doctors, and also help them to get along in the physicians' profession. Medical schools should develop their curricula towards more humanistic medicine in order to maintain their students' interest in people.     

Experience in a neonatal intensive care unit affects pain response

OBJECTIVE: To determine the effect of being in the neonatal intensive care unit (NICU) on pain responses in infants of 32 weeks' postconceptual age (PCA). DESIGN: A cross-sectional comparative design was used. SETTING: Two level III NICUs, each in metropolitan, university teaching hospitals. PATIENTS: Infants of 32 weeks' PCA born within the past 4 days (the newly born group; n = 53) were compared with infants of the same PCA who had been born 4 weeks earlier (the earlier-born group: n = 36) and had spent that time in an NICU. OUTCOME MEASURES: Heart rate, oxygen saturation levels, and facial actions were used as outcomes in a between-group repeated measures analysis of variance across the heel stick procedure. Background variables of Apgar, weight at birth and data collection, severity of illness, age group, and total number of invasive procedures were entered into a stepwise regression. RESULTS: The two groups responded differently to the heel stick: the earlier-born infants had less behavioral manifestations of pain than the newly born infants. The number of invasive procedures was the primary factor that explained those behavioral differences, with Apgar as a second explanatory factor. The earlier-born infants had higher heart rates and lower oxygen saturation than the newly born infants before as well as during the procedure. These physiological differences were explained by the perinatal factors of age at birth and birth weight. CONCLUSION: Preterm infants who spend PCA weeks 28 through 32 in an NICU are less mature in their pain response than newborn premature infants of 32 weeks' PCA. Greater frequency of invasive procedures is associated with behavioral immaturity, whereas birth factors are associated with physiological immaturity.     

Fluoroscopic examination in the neonatal intensive care unit using an inverted C-arm

Fluoroscopic studies can be performed in the Neonatal Intensive Care Unit (NICU) using a portable C-arm. The C-arm is inverted so that the infant lays directly on the image intensifier. In all our cases, the images obtained were of good enough quality to allow for prompt diagnosis and management of the patient's condition. Furthermore, measured entrance doses were lower using the inverted C-arm than they were using conventional fluoroscopy.     

Septicaemia in an Austrian neonatal intensive care unit: a 7-year analysis

The results of blood cultures and clinical data of 101 neonates with 110 episodes of septicaemia during a 7-y study period were reviewed. The overall incidence of culture-proven sepsis within the study period was 6.0 per 100 neonatal intensive care unit admissions and the mortality rate was 14%. Three groups of pathogens accounted for 70% of all isolates: coagulase-negative staphylococci (27%), aerobic Gram-negative rods (24%) and Enterococcus faecalis (19%). Group B streptococcus was the major pathogen of very early-onset septicaemia (within 24 h of birth), whereas late-onset infections were most commonly caused by coagulase-negative staphylococci. Birthweight <1500 g, gestational age <30 weeks of gestation and early onset of symptoms within the first week of life were associated with poor prognosis. In addition, the case fatality rate of episodes caused by Gram-negative organisms was significantly higher than that of Gram-positive bacteraemia.     

Multiple-resistant Salmonella group G outbreak in a neonatal intensive care unit

The prevalence of antibodies against cytomegalovirus (CMV) and the incidence of CMV infection were tested in 98 children aged 5 to 36 months who attended the day-care center of a University hospital in S?o Paulo. At the beginning of the study the overall prevalence of anti-CMV IgG antibodies was 44% (43/98). Saliva and/or urine samples were obtained from 38 of the 43 children that were seropositive at the beginning of the study for isolation of the virus, and 52.6% of these children were found to excrete CMV in one of the two materials. Among the 37 children that were initially seronegative from whom it was possible to obtain a new blood sample 6 to 12 months later, 22 (59.5%) presented seroconversion. The rate of viral excretion through urine or saliva from the children that seroconverted was 50%. These results indicate that CMV infection is frequent and occurs early among the children who attend this day-care center. However, controlled studies using molecular epidemiology techniques are needed to define more precisely the role of day-care centers in CMV dissemination.     

Nondepolarizing neuromuscular blocking drugs in the intensive care unit: a clinical review

BACKGROUND: The use of nondepolarizing neuromuscular blocking drugs (NDNMBDs) via continuous infusion in the intensive care unit (ICU) is gaining in popularity. Several new NDNMBDs have been developed recently; these drugs vary in their elimination, metabolism, and half-lives. METHODS: A review of the recent English language literature was done, with those articles relevant to the ICU being incorporated into this paper. RESULTS: The six most frequently used NDNMBDs, consisting of atracurium, cisatracurium, doxacurlum, pancuronium, rocuronium, and vecuronium, were reviewed. The neuromuscular junction and impulse transmission, clinical monitoring, clinical pharmacology, the elimination and metabolism, the adverse reactions, and the drug interactions of these NDNMBDs are reviewed. CONCLUSIONS: The use of NDNMBDs is progressively increasing in ICUs. Proper understanding of normal neuromuscular physiology, clinical pharmacology, and drug interactions is essential to optimize patient care and to minimize the risk of adverse reactions.     

Principles of organization of a neonatal intensive care unit from scratch

The relative amounts of brain-specific antigens, S-100, glial fibrillary acidic protein (GFA), 14.3.2, synaptin C1, D1, D2 and D3 were determined by crossed immunoelectrophoresis in bulk-prepared neuronal, glial and synaptosomal fractions from 35-day-old rat brains. Little enrichment was ontained for any antigen in the neuronal perikaryal fraction. The glial fraction showed a 3.5-fold enrichment in GFA but had levels similar to whole brain with respect to S-100. Synaptosomes were somewhat enriched in the synaptin C1 protein, but did not differ markedly from whole brain with respect to the most antigens. The extent of cross-contamination in the various fractions could be judged only tentatively, partly due to differences in extractability of the proteins.