Cardiac performance during insulin clamp: its evaluation by bioimpedance measurement

OBJECTIVE: The objective of this study was to know the most common organisms causing neonatal meningitis in a defined region of southern Madrid, the developmental outcome of these babies and the risk factors associated with the prognosis. PATIENTS AND METHODS: This was an observational study of 56 cases of meningitis diagnosed in our Neonatal Service between 1988 and 1994. In order to study the handicaps of these babies, only those who were born before May 1993 were considered so that they had a corrected age of at least 2 years when the neurological evaluations were done. RESULTS: The most common causative organisms were group B Streptococcus (27%), E. coli (11%) and enteroviruses (9%). In the premature infants the leading organisms were E. coli and Candida albicans. The age at diagnosis was 8 +/- 6 days in the group of preterm infants (p = 0.002). The mortality was associated with the prematurity (risk ratio: 17.8), the isolation of a gram-negative organism in the cerebral fluid (RR: 3.3) and the presence of abnormal findings in cerebral ultrasound studies (RR: 12.7). Sequelae were associated with the presence of abnormal findings in cerebral ultrasound studies (RR: 24.7) or in the neurologic examination (R: 7) and with the presence of previous cerebral lesions (RR: 5.7). CONCLUSIONS: Neonatal ultrasound examination, as well as the gestational age, the causative organisms, the presence of a previous cerebral lesion and the neurological examination, seem to be very important in predicting the prognosis of these babies.     

MR imaging of perinatal brain damage: comparison of clinical outcome with initial and follow-up MR findings

BACKGROUND AND PURPOSE: The purpose of our study was to determine whether MR studies in the neonatal period are predictive of the neuroradiologic sequelae and clinical outcome in premature and term infants with perinatal brain injury. METHODS: Thirty subjects (15 premature and 15 term infants) with abnormalities revealed by initial MR studies were reexamined approximately 1 year after birth with both MR imaging and a neurologic assessment. All initial MR studies were performed between 35 and 45 weeks corrected age in premature infants and within 28 days of life in term infants. The initial MR studies were evaluated for deep gray matter involvement, hemispheric parenchymal change, intracranial hemorrhage, and periventricular signal and/or morphologic changes. These MR findings were compared with the follow-up MR findings and with the neurologic outcome. RESULTS: The development of cerebral palsy in premature infants was related to the following initial MR findings: subependymal hemorrhage associated with parenchymal destruction, periventricular signal alteration with irregularity of the ventricular wall, and widespread cerebral infarction. These MR findings were predictive of the subtypes of cerebral palsy. In term asphyxiated infants, T2 signal alterations of the deep gray matter rather than T1 shortening and diffuse involvement of the hemispheres were predictive of an unfavorable outcome. Both in term and premature infants, focal hemispheric parenchymal lesions alone (including infarction and intracerebral, subdural, intraventricular, and subarachnoid hemorrhage) did not produce poor outcomes. CONCLUSION: MR studies performed at or near term in either premature or term infants with perinatal brain damage are effective in predicting both late neuroradiologic and clinical outcome.     

An early marker for neurological deficits after perinatal brain lesions

BACKGROUND: In normal awake infants, fidgety movements are seen from the age of 6 weeks to 20 weeks. The aim of the study was to test the predictive value of absent or abnormal spontaneous movements in young infants for the later development of neurological deficits. METHODS: In a collaborative study involving five hospitals we collected data on the normal and abnormal quality of fidgety movements of 130 infants and compared it with assessments of neurological development done longitudinally until the age of 2 years. On the basis of ultrasound scans infants were classified as at low-risk or at high-risk of neurological deficits. Infants were videoed for 1 h every week from birth to discharge and then for 15 min every 3 to 4 weeks; quality of general movements was assessed. Repeated neurological assessments were also done until 24 months of corrected age. FINDINGS: 67 (96%) of 70 infants with normal fidgety movements had a normal neurological outcome. Abnormal quality or total absence of fidgety movements was followed by neurological abnormalities in 57 (95%) of the 60 infants (49 had cerebral palsy and eight had developmental retardation or minor neurological signs). Specificity and sensitivity of fidgety movement assessment were higher (96% and 95%, respectively) than of ultrasound imaging of the infants' brain (83% and 80%, respectively). INTERPRETATION: Our technique of assessing spontaneous motor activity can identify and distinguish between those infants who require early intervention for neurological abnormalities and those who do not. Our technique is simple, non-intrusive, reliable, quick, and can be done on very young infants.     

Special needs of preterm infants in the management of pain and discomfort

Most infants born preterm are admitted to hospital neonatal intensive care units, where they undergo repeated multiple diagnostic and therapeutic procedures that result in pain and discomfort. Although there is convincing evidence to support the preterm infant's neurologic capacity for pain, management of pain often is not optimal. Accurate and reliable assessment of the preterm infant's pain is an important prerequisite for effective pain management. Pain assessment is a challenge for health professionals because the preterm infant's responses are less vigorous, more variable, and less consistent than are the responses of term neonates and older infants. Few reliable and valid assessment measures exist for this age group. There also is uncertainty in implementing pain-relieving intervention because of inadequate information on their safety and effectiveness and preconceived attitudes and beliefs of health professionals. The special needs of preterm infants related to the assessment and management of pain are discussed.     

Preterm and term births of small for gestational age infants: a population-based study of risk factors among nulliparous women

OBJECTIVE: To study risk factors for small for gestational age (SGA) infants by gestational age among nulliparous women and to estimate mortality rates among SGA and appropriate-for-gestational-age (AGA) infants by gestational age. DESIGN: A population-based study from the Swedish Medical Birth Register. Setting Sweden 1992 1993. POPULATION: Liveborn singleton infants to nulliparous women (n = 96,662). MAIN OUTCOME MEASURES: Crude and adjusted odds ratios of risk factors for SGA by gestational age. Rates of neonatal and postneonatal mortality. RESULTS: Older maternal age (> or = 30 years) was foremost associated with increased risks of very and moderately preterm SGA (> or = 32 weeks and 33-36 weeks, respectively), but also with term SGA (> or = 37 weeks). Risks of SGA increased with decreasing maternal height at all gestational ages. Smoking increased the risks of moderately preterm and term SGA. Short maternal education increased the risk of preterm SGA and low pre-pregnancy body mass index slightly increased the risk of term SGA. Pre-eclampsia and essential hypertension foremost increased the risk of very preterm SGA (OR = 40.5 and 32.4, respectively) and moderately preterm SGA (OR = 17.4 and 10.6, respectively), but also increased the risk of term SGA. Neonatal and postneonatal mortality rates of SGA infants were substantially influenced by gestational age, and mortality rates were consistently higher among preterm SGA infants compared with AGA infants. Conclusions: Risk factors for SGA and mortality rates among SGA infants vary by gestational age. A subdivision of risk factors by gestational age adds knowledge, particularly about risks of preterm SGA, where the highest rates of mortality were observed.     

Cervical ultrasonography compared with manual examination as a predictor of preterm delivery

OBJECTIVE: Our purpose was to compare the accuracy of ultrasonographic and manual cervical examinations for the prediction of preterm delivery. STUDY DESIGN: One hundred two singleton pregnancies at high risk for preterm delivery were followed up prospectively from 14 to 30 weeks with both serial cervical ultrasonography measurements and manual examinations of the length of the cervix. The primary outcome studied was preterm (< 35 weeks) delivery. RESULTS: Excluding six induced preterm deliveries, 96 pregnancies were analyzed. The mean cervical length measured by ultrasonography was 20.6 mm in pregnancies delivered preterm (n = 17) and 31.3 mm in pregnancies delivered at term (n = 79) (p = 0.003); the mean cervical lengths measured by manual examination were 16.1 mm and 18.6 mm in the same preterm and term pregnancies, respectively (not significant). The sixteenth- and twentieth-week ultrasonographic cervical lengths predicted preterm delivery most accurately (p < 0.0005). The 25th percentiles of ultrasonographic (25 mm) and manual (16 mm) cervical lengths showed relative risks for preterm delivery of 4.8 (95% confidence interval 2.1 to 11.1, p = 0.0004) and 2.0 (95% confidence interval 0.5 to 4.7, p = 0.1), respectively; sensitivity, specificity, and positive and negative predictive values were 59%, 85%, 45%, 91%, and 41%, 77%, 28%, and 86%, respectively. CONCLUSION: Cervical length measured by ultrasonography is a better predictor of preterm delivery than is cervical length measured by manual examination. Cervical ultrasonography in patients at high risk for preterm birth seems to be most predictive of preterm delivery when it is performed between 14 and 22 weeks' gestation.     

Folic acid fortification: what does it mean for patients and physicians?

BACKGROUND: Although term and preterm infants have the capacity to secrete tears, the relative contribution of basal and reflex secretion of tears has not been previously assessed together in a prospective study. This information potentially has practical clinical importance. OBJECTIVES: To measure basal and reflex tear secretion in preterm (30-37 weeks after conception) and term (38-42 weeks) newborns and to determine the developmental pattern of tear production. METHODS: Tear secretion was evaluated by applying Schirmer tear test strips to the inferior fornix for 5 minutes before (reflex plus basal secretion) and after (basal secretion) applying a topical anesthetic agent. RESULTS: Seventy infants (36 preterm and 34 term) were tested. Mean (+/- SD) basal tear secretion was 6.2 (+/- 4.5) mm in preterm and 9.2 (+/- 4.3) mm in term infants and increased progressively with increasing weight (P<.001) for all newborns. Mean (+/- SD) reflex tear secretion was 7.4 (+/- 4.8) mm in preterm and 13.2 (+/- 6.5) mm in term infants and also increased with increasing weight (P<.001) for all newborns. CONCLUSIONS: Preterm infants have reduced reflex and basal tear secretion. This may mask the diagnosis of a nasolacrimal duct obstruction, concentrate topically applied medications, and allow corneas to quickly become dry during ophthalmological examination and treatment. By term, tear production in newborns is similar to that in adults.     

The organization of leg movements in preterm and full-term infants after term age

In a sample of 13 full-term and 10 preterm infants, the development of kicking movements was studied at 6, 12, and 18 weeks (corrected) age. In healthy full-term infants some characteristics are strikingly stable, such as the duration of the flexion and extension phase and the within-joint organization. These parameters did not differ in preterm compared to full-term infants. For other features, however, developmental changes and differences were observed. Full-term infants tended to decrease their kick frequencies slightly with age. In preterm infants much higher initial kick rates were found, followed by a steep decrease, which resulted in kick frequencies comparable to the full-term levels after the (corrected) age of 12 weeks. There is a tight coupling between the movements in the different joints of the leg in full-term newborns. Preterm infants, in contrast, initially show much lower cross-correlations between hip and ankle and between knee and ankle. This is particularly the case for those preterm infants who were born before 32 weeks gestation. Again, the differences resolved after the age of 12 weeks, which might be related to a transformation in neural functions reported previously around this age. The initial differences in the characteristics of kicking appeared to be more readily explainable by differences in neurological condition than by contrasts in leg volume or postural control.     

APN: evaluation behavioral scale of acute pain in newborn infants

AIM: This study was designed to validate a behavioral acute pain rating scale for term and preterm neonates (APN). METHODS: From January through June 1996, neonates requiring a heel lance or a venous puncture for blood sampling at the intensive care unit and the nursery of Poissy Hospital were recruited into the study. After a pilot study, a pain rating scale was developed. The scale score pain ranged from 0 to 10 and it evaluated three items: facial expression, limb movements, and vocal expression with ratings per item ranging from 0 to 4, 0 to 3 and 0 to 3, respectively. Two observers evaluated independently each infant during a painful procedure (puncture for a blood sample) and during a dummy procedure (rubbing the thigh softly). RESULTS: Forty-two neonates born between 25 and 41 weeks gestational age were included in the study. Medians (quartiles) of gestational age, birth weight, and corrected postmenstrual age at time of investigation were 34 (29-39) weeks, 1,850 (1,055-3,093) g, and 35.5 (31-39) weeks, respectively. Ten infants were intubated. The scale showed to be sensitive because all possible scores were obtained; during painful procedures scores ranged from 1 to 10, with 95% of scores > or = 3 while during dummy procedures they ranged from 0 to 5, with 88% of scores < or = 2. The medians (95% confidence interval) of scores were for painful procedures 5 (5 to 7) and for dummy procedures 1 (0 to 1). This indicates a good specificity of the scale. High intercorrelation of items (internal consistency) was confirmed by a Cronbach's coefficient alpha of 0.88. Inter-rater agreement was high since the Krippendorff R test was 91.2. CONCLUSION: This behavioral acute pain rating scale for newborns demonstrated a good specificity and sensitivity, internal consistency and inter-rater reliability. This scale could be used to test the analgesic effects of different therapies during painful procedures.     

Allelotype influence at glutathione S-transferase M1 locus on breast cancer susceptibility

PURPOSE: To compare development of visual acuity and binocular vision in preterm and full-term infants in a prospective study that used testers masked to subject's gestational age. METHODS: Seventy-nine healthy full-term infants, mean gestational age 40 weeks, and 18 low-risk preterm infants, mean gestational age 33 weeks, were examined biweekly between the 44th and 54th weeks of postmenstrual age. Ocular alignment, convergence, fusion, grating acuity, and onset of optokinetic nystagmus (OKN) were assessed at each examination. RESULTS: The mean postnatal ages of onset of ocular alignment, convergence, fusion, grating acuity to 1.6 cycles per degree, and OKN from temporal to nasal and nasal to temporal were, respectively, 5, 7, 7, 11, 6, and 9 weeks for the full-term and 12, 13, 14, 18, 13, and 16 weeks for the preterm infants. The mean postmenstrual ages of onset for the corresponding parameters were 46, 48, 48, 51, 46, and 50 weeks for full-term and 46, 47, 48, 52, 47, and 49 weeks for preterm infants. The onset of all parameters was earlier in full-term infants than in preterm infants of the same postnatal age (P < or = 0.0001). However, no differences were found when the parameters were compared at postmenstrual ages. CONCLUSIONS: Additional visual experience of preterm infants does not influence development of visual acuity or binocular vision during the first months of life as measured from the time of conception.     

Quantitative study on the effect of osthole on proximal tibiae in ovariectomized (OVX) rats

OBJECTIVE: To determine if a correlation exists between the level of maternal serum alpha-fetoprotein (MSAFP) elevation and the rate of adverse pregnancy outcome, to examine the timing of pregnancies ending in fetal or neonatal death, and to develop a protocol for antepartum surveillance in an effort to prevent these adverse outcomes. STUDY DESIGN: Singleton pregnancies with a single second-trimester elevated MSAFP > or = 2.0 multiples of the median (MoM) were eligible if a targeted ultrasound evaluation (< 24 weeks) was in agreement with the dates and no fetoplacental anomaly was detected. Three groups were established based on the second-trimester MSAFP elevation: 2.0-2.49, 2.5-2.99 and > or = 3.0 MoM. RESULTS: Among the 383 patients enrolled, delivery data were available on 333 infants. Stratified by MSAFP elevations of 2.0-2.49, 2.5-2.99 and > or = 3.0 MoM, the rates of adverse pregnancy outcome were: (1) preterm birth: 14.3%, 15.6%, 20.3%; (2) small for gestational age at birth: 7.4%, 11.1%, 22.2%; and (3) perinatal deaths (neonatal and fetal): 2.6%, 3.3%, 5.6%. Seven pregnancy losses (three neonatal and four fetal deaths) occurred prior to 28 weeks. Of these seven, six fetuses exhibited intrauterine growth retardation by 23-26 weeks' gestation, and five of six were associated with MSAFP levels > or = 2.5 MoM. Four losses (two neonatal and two fetal deaths) occurred after 28 weeks. Of these, three involved structurally normal infants with normal growth who died after 34 weeks. All three of these pregnancies exhibited MSAFP elevations < 2.5 MoM. CONCLUSION: In pregnancies with an unexplained elevated second-trimester MSAFP, the rate of adverse pregnancy outcomes is increased with higher elevations. Any proposed program to improve pregnancy outcome in patients with unexplained MSAFP elevations must include efforts aimed at preventing preterm delivery, repeat ultrasound at 24-26 weeks to rule out early-onset intrauterine growth retardation in pregnancies with elevations > or = 2.5 MoM and fetal biophysical monitoring, even in normally grown fetuses, instituted at 32 weeks to detect fetuses at risk for intrauterine death.     

Neuroanatomical changes in the rat bladder after bladder outlet obstruction

OBJECTIVE: To evaluate the perinatal and 2-year outcomes in pregnancies complicated by preterm premature rupture of membranes (PROM) during the second trimester. METHODS: Fifty-three consecutive singleton pregnancies with PROM at 14 to 28 weeks of gestation were studied retrospectively. Management goals were to prolong the pregnancies to 32 weeks through expectant management and to avoid fetal compromise through closer monitoring and active intervention, when necessary, after 23 weeks. Outcome of the surviving infants was based on neurologic, audiometric, and ophthalmologic examinations at 2 years of corrected age. RESULTS: Rupture of membranes occurred at 14-19 weeks (mean 17.4 weeks) in 10 women, at 20-25 weeks (mean 24.0 weeks) in 24, and at 26-28 weeks (mean 27.6 weeks) in 19. The median latency periods to delivery were 72 days, 12 days, and 10 days when rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, respectively. The overall incidence of chorioamnionitis was 28%. There were no fetal deaths and nine neonatal deaths. When rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, the perinatal survival rates were 40%, 92%, and, 100%, respectively. Pulmonary hypoplasia accounted for seven deaths. Of the live-born infants, 81% were alive at 2 years of corrected age. Survival without major impairment was observed in 75%, 80%, and 100% of the survivors when rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, respectively. CONCLUSION: Expectant management of second-trimester PROM offers better perinatal and long-term survival than previously thought.     

High-speed digital videoimaging of fast eardrum motions during Valsalva maneuver

OBJECTIVE: To determine health and disabilities of preterm infants at age 10. DESIGN: Prospective follow-up study. SETTING: TNO Preventive en Gezondheid, sector Jeugd. Leiden, the Netherlands. METHOD: A questionnaire on medical consumption and physical disabilities was sent to the parents of a Dutch cohort of infants born alive in 1983 with a gestational age < 32 weeks and (or) a birth weight < 1500 g. The data were compared with outcomes at 5 years of age and with a peer group in mainstream education (data collected in a representative sample from the school health care system). RESULTS: Questionnaires on 75% of the eligible children were returned. Almost 40% of the preterm children had been admitted to hospital after the age of 5. Children in special education were significantly more often treated by a physiotherapist and (or) speech therapist. Overall 45% of the children suffered from a physical disability. This was six times as frequent as in a peer group from the school health survey. Although the assessment of physical disabilities was based on a paediatric examination at age 5 and on a parental questionnaire at age 10, differences were small. CONCLUSION: Mild developmental problems and learning disabilities are frequent in preterm infants. Research of preventive methods and timely interventions are needed and should be incorporated in the facilities for neonatal intensive care.     

Randomised clinical trial of parenteral selenium supplementation in preterm infants

AIM: To determine whether selenium supplementation of parenteral nutrition with 3 micrograms/kg/day of selenious acid is safe and effective in improving the selenium status of preterm infants. METHODS: Thirty eight preterm infants with mean (SEM) birthweight of 1171 (38) g and gestational age 29 (0.3) weeks were randomly allocated to a non-supplemented (PN-selenium, n = 19) or supplemented (PN+selenium, n = 19) group. The study began at 2.8 (0.2) (range 1-5) days of age. Term breastfed (n = 23) and formula fed (n = 8) infants were used as a reference group. RESULTS: Initially there was no difference between the preterm groups in plasma or erythrocyte selenium or glutathione peroxidase activity. Plasma selenium declined by a mean (SEM) of -13.3 (3.2) micrograms/l from 28 (4) to 16 (3) micrograms/l over the first three weeks in the PN-selenium group, but there was no fall in the supplemented infants and no net change in either group over six weeks. Over six weeks, there was a net decline in erythrocyte selenium of -106 (27) ng/g haemoglobin in the PN-selenium group, but no change in the PN+selenium group, such that at week 6 erythrocyte selenium was lower in the PN-selenium group (401 (17) ng/g haemoglobin) than the PN+selenium group (493 (25) ng/g haemoglobin). Urinary selenium was substantially higher in the PN+selenium group at each week. Initially term and preterm plasma selenium concentrations were similar, but they increased in term breastfed infants (+17 (2) micrograms/l), with both groups of preterm infants having lower plasma selenium concentrations at week 6 compared with term breastfed infants (PN-selenium 22 (3) micrograms/l; PN+selenium 23 (4) micrograms/l and term breastfed 49 (2) micrograms/l). CONCLUSIONS: Selenium supplementation of PN at 3 g/kg/day prevented depletion in newborns, but was inadequate to achieve selenium concentrations equivalent to those of breastfed term infants. Whether higher doses are more effective remains to be determined, particularly in light of the high urinary selenium secretion in supplemented infants. Selenium supplementation of both parenteral nutrition and formulas is recommended, but the optimal form and dose remain unclear.     

A randomised multicentre study of human milk versus formula and later development in preterm infants

Whether breast milk influences later neurodevelopment has been explored in non-randomised studies, potentially confounded by social and demographic differences between feed groups. Here in a strictly randomised prospective multicentre trial, Bayley psychomotor and mental development indices (PDI and MDI) were assessed at 18 months postterm in survivors of 502 preterm infants assigned to receive, during their early weeks, mature donor breast milk or a preterm formula. These diets were compared as sole enteral feeds or as supplements to the mother's expressed breast milk. No differences in outcome at 18 months were seen between the two diet groups despite the low nutrient content of donor milk in relation to the preterm formula and to the estimated needs of preterm infants. These results contrast with those reported from our parallel two centre study that compared infants randomly assigned a standard term formula or the preterm formula during their early weeks; those fed standard formula, now regarded as nutritionally insufficient for preterm infants, were substantially disadvantaged in PDI and MDI at 18 months post-term. It is shown here that infants from that study fed solely on standard formula had significantly lower developmental scores at 18 months than those fed on donor breast milk in the present study; yet the standard formula had a higher nutrient content than the donor milk. Thus, donor milk feeding was associated with advantages for later development that may have offset any potentially deleterious effects of its low nutrient content for preterm infants. As these outcome advantages were not confounded by the social and educational biases usually associated with mothers' choice to breast feed, our data add significant support to the view that breast milk promotes neurodevelopment.     

Recent advances in skeletal-muscle-based gene therapy

OBJECTIVE: To determine the sensitivity and specificity of postmortem dementia diagnoses based on a retrospective informant interview by comparison with criterion standard neuropathological diagnoses and the results of previous clinical examinations. SETTING: Three university-based academic research centers. SUBJECTS: Fifty-four deceased elderly persons with Alzheimer disease, another dementing disorder, a neurologic disease resulting in functional impairment but no dementia, or no neurologic disorder. METHODS: Blinded nonclinician interviewers administered the Dementia Questionnaire (DQ) by telephone to informants, typically close relatives, who were familiar with the intellectual and functional status of the subjects before death. Two senior clinicians (LJ.T. and C.K.) rated each DQ for the presence or absence of a dementia syndrome during life and for the specific disorders causing the dementia, if present. Raters were blinded to the neuropathological findings and based their assessments only on data provided by responses to the DQ. Comparison was made with diagnoses based on neuropathological assessment. In most cases, the results of antemortem clinical examinations were also available as a check on the clinical diagnosis of the dementia syndrome. Sensitivity and specificity of the DQ diagnoses were computed, and chance-corrected agreement measures were calculated for the 2 independent DQ raters (LJ.T. and C.K.). RESULTS: Compared with antemortem clinical diagnosis, the average sensitivity of the DQ for the clinical syndrome of dementia was 92.8%, the specificity was 89.5%, and the interrater agreement was 98% (kappa = 0.96). Among 7 subjects with mild dementia (Mini-Mental State Examination score > or = 24 at the last clinical examination), 5 (71%) were correctly identified using the DQ. The DQ correctly indicated the absence of dementia in 8 (80%) of 10 subjects with other neurologic disorders causing functional impairment. Compared with the neuropathological diagnoses, the DQ differentiated Alzheimer disease from other primary causes of dementia with a sensitivity of 89% and a specificity of 72%. The interrater agreement was 93.8% (kappa = 0.85). CONCLUSIONS: Compared with the results of the antemortem clinical examinations, the DQ was sensitive to the presence of dementia, detected most cases of mild dementia, and discriminated dementia from other neurologic disorders causing functional impairment. Compared with the neuropathological diagnoses, the ability of the DQ to differentiate Alzheimer disease from other dementing disorders indicates that it may be useful as a research tool.     

Secular trends in preterm birth: a hospital-based cohort study

CONTEXT: Canada and the United States have reported a recent increase in the incidence of preterm birth, but the reasons for this increase are unknown. OBJECTIVE: To assess secular trends in preterm birth and its potential determinants. DESIGN: Hospital-based cohort study. SETTING: Canadian tertiary care university teaching hospital, 1978-1996. PARTICIPANTS: A total of 65574 nonreferred live births and stillbirths. MAIN OUTCOME MEASURES: Changes in occurrence of preterm birth, before and after adjustment for changes in method of gestational age assessment, obstetric intervention, registration of births weighing less than 500 g, and sociodemographic, behavioral, and clinical determinants. RESULTS: A crude secular increase in preterm births was seen for births less than 37, 34, and 32 completed weeks using 3 alternative gestational age estimation methods. Based on an algorithm incorporating both menstrual and early ultrasound gestational age estimates, rates increased from 6.6% to 9.8% for births at less than 37 weeks' gestation, 1.7% to 2.3% at less than 34 weeks, and 1.0% to 1.2% at less than 32 weeks. Exclusion of births weighing less than 500 g and those with induction or preterm cesarean delivery without labor before each of the corresponding gestational age cutoffs eliminated the secular trends for births before 34 and 32 weeks and attenuated the trend for births before 37 weeks. Nearly half of the remaining trend for births before 37 weeks was accounted for by the increasing use of early ultrasound dating. The residual trend was eliminated after controlling for secular increases in unmarried status and the proportion of women aged 35 years or older. These factors, combined with a decrease in alcohol consumption and increases in histological chorioamnionitis and cocaine use, appear to have counteracted a reduction in preterm birth since the mid-1980s that otherwise would have been observed. CONCLUSIONS: This hospital's increase in preterm births since 1978 parallels increases reported in population-based national studies from the United States and Canada. This trend appears largely attributable to the increasing use of early ultrasound dating, preterm induction and preterm cesarean delivery without labor, and changes in sociodemographic and behavioral factors.     

Maternal hypertension and neurodevelopmental outcome in very preterm infants

AIM: To determine the outcome of preterm infants born to mothers with hypertension during pregnancy, and preterm controls. METHODS: 107 infants of 24-32 weeks gestation, born to hypertensive mothers, and 107 controls matched for gestational age, sex, and multiple pregnancy, born to normotensive mothers, were prospectively enrolled over 2 years. Information on maternal complications and medication was obtained and neonatal mortality and morbidities recorded. Survivors were followed up to at least 2 years, corrected for prematurity. RESULTS: One third of the hypertensive mothers were treated with antihypertensive drugs, while 18% received convulsion prophylaxis with phenytoin. Magnesium sulphate was not prescribed. Both groups had a mean gestational age of 29.9 weeks, with the study infants having a significantly lower birthweight than the controls. Four study and three control infants died in the neonatal period. Cerebral palsy was not diagnosed in any infant of a hypertensive mother compared with five of the controls. The mean general quotient for the two groups was very similar and no difference in the incidence of minor neuromotor developmental problems was shown. CONCLUSIONS: Maternal hypertension seems to protect against cerebral palsy in preterm infants without increasing the risk of cognitive impairment. This was independent of the use of maternally administered magnesium sulphate.     

Incidence of typical nephrocalcinosis ultrasound findings in premature infants during enteral calcium and phosphate administration

Supplementation of calcium and phosphate is recommended in nutrition of low birth weight infants to ensure a physiological development of postnatal bone mineralisation. To investigate whether high dose calcium supplementation increases the risk of renal calcification in preterm infants, serial ultrasound examinations were performed in 30 preterm infants (gestational age 29.5 (26-35) weeks; birth weight 1382 (610-2010) g) before, during and after oral calcium and phosphate supplementation. Total calcium input was on average 3.1 mmol/kg/d, total phosphate input on average 2.1 mmol/kg/d). All children showed normal kidney ultrasound before entering the study. During mineral supplementation three children developed hyperechoic renal medullary pyramids, the typical ultrasound pattern of nephrocalcinosis. Supplementation was stopped immediately and pathologic ultrasound patterns disappeared in all 3 children.     

Binding of properdin to solid-phase immune complexes: critical role of the classical activation pathway of complement

OBJECTIVE: Our objectives were to assess the clinical and microbiological aspects of septic osteoarthritis in children admitted to our center from 1987 until July 1997 and to determine the sensitivity of ultrasound in this age group. PATIENTS AND METHODS: The medical records of 36 children diagnosed as having septic osteoarthritis of the hip were reviewed retrospectively. The diagnosis had been based on clinical criteria, along with synovectomy and drainage of purulent material from the affected joint. An X-ray and/or ultrasound had been performed when the diagnosis was suspected. RESULTS: Nineteen children were diagnosed during the neonatal period, 8 between the ages of 1 and 12 months and 9 older than one year of age. Mean age at diagnosis was 16.8 +/- 6.2 months (median 29 days, range 6 days to 13 years). The hip was involved in 32 children, the ankle in 3 and the elbow in 1. A microbiological diagnosis was achieved in 22 cases (61%) by culture from blood, CSF, and/or synovial fluid. The most common isolates were Gram positive cocci (S. aureus in 9 cases and coagulase negative Staphylococcus in 3). The diagnostic value of the X-rays was very low (18%). The ultrasound was initially considered abnormal in 64.5% of the patients, with a lower sensitivity in the neonatal period. After a mean follow-up period of 36 months, the outcome was good in 86% of the cases, although three children continue with sequelae. Two preterm infants died due to sepsis associated with the osteoarthritis. CONCLUSIONS: At the time of diagnosis of septic arthritis of the hip, the ultrasound is frequently normal. Due to the poor outcome when there is a delay in surgery, we suggest immediate synovectomy and drainage when there is clinical suspicion of septic arthritis despite an apparently normal ultrasound.