Early postpartum discharge in the postpartum

OBJECTIVE: To assess a policy of early discharge from hospital after a vaginal birth. DATA SOURCES: Reports of studies on this topic were identified in Medline and Cochrane Collaboration database (from 1985 to the beginning of 1995, in english or latin publications). This search was supplemented by referenced studies in book chapters and in other published bibliographies. Key words were: early discharge or ambulatory care and mother or infant or post-partum or obstetrics. STUDY SELECTION: One hundred and ten articles have been retrieved. We have included in the meta-analyse the randomized clinical trials comparing a group of women discharged early (less than 48-72 hours after delivery) with a control group leaving hospital after an usual stay (more than 48-72 hours). Quality of the studies was analysed through the Chalmers et al. recommendations. DATA EXTRACTION: Data were retrieved independently by two authors, and results were compared. Selected outcomes were: hyperbilirubinemia, infant feeding problems and skin rashes; breast feeding; maternal satisfaction on the hospital stay; readmission and non-routine clinics for both the mother and her child. DATA SYNTHESIS: Data from five included studies were pooled by the Peto method. There are no significant modifications of the risks of re-admission to hospital. The frequency of non-routine clinics and the risk of skin rash are not different in the two groups. The risk of hyperbilirubinemia and infant food problems are not different. The frequency of breastfeeding one month after delivery was higher in the early discharge group (OR = 1.88; 95% CI: 1.09-3.23), but this difference decreased over time. Women satisfaction on hospital stay was lower in case of early discharge (OR = 0.56; 95% IC: 0.44-0.72). CONCLUSION: The meta-analysis suggests an advantage of early discharge policy on breastfeeding at one month after the delivery, but mothers seem to prefer longer hospital stays. These results must be cautiously interpreted as included studies are of small sample size or rather old. This policy remains to be evaluated more thoroughly before recommendations could be made.     

Early discharge after open appendicectomy

This study was undertaken to characterize the interaction of porcine galanin (Gal) and some of its analogues with their receptors on rat gastric fundus muscle strips. Gal, galantide (M15) and Gal(1-14)-[Abu8]SCY-I evoked concentration-dependent contractions of gastric smooth muscle strips. Reproducible effects were observed in concentrations of 1-300, 3-1000 and 100-3000 nM, respectively. Specific EC50 for the contractile effect equalled 13.70 and 187 nM. Hill's coefficient for Gal is 1.03 indicating an interaction of one Gal molecule with one receptor, fulfilling the criteria of classical receptor theory. For M15 and Gal(1-14)-[Abu8]SCY-I Hill's coefficients are different from 1, namely 0.73 and 1.56, pointing out that the principle of interaction of one drug molecule with one receptor may not apply. The contraction induced by 300 nM of Gal was not significantly modified by tachyphylaxis to substance P (SP). On the contrary the introduction of tachyphylaxis to SP decreased the contractile effects of M15 and Gal(1-14)-[Abu8]SCY-I by about 57.7 +/- 3% and 39.6 +/- 5%, respectively. The findings suggest that contractile actions of M15 and Gal(1-14)-[Abu8]SCY-I are probably not only due to their agonist activities at Gal receptors but may result from a subsequent stimulation of receptors for SP or release of endogenous SP.     

Early and supported hospital discharge: the hospital and community interface

An agent pathogenic for laboratory albino Swiss mice was isolated from a pool of Haemaphysalis punctata ticks collected from cattle on a farm located in Alcácer do Sal county, southern Portugal. The isolated virus was shown to be distinct from but serologically related to virus members of the Bhanja antigenic group. This new virus in the family Bunyaviridae was named Palma for the farm where ticks have been collected for several studies.     

Early discharge. Risks, benefits, and who decides

Over the last several decades, there has been a significant decrease in the length of hospital stays for mothers and their newborns, ranging from the average of 7 to 10 days before World War II to approximately 2 days in recent years. Many women saw the benefit of early discharge as a means to demedicalize the birth process, to be home with their families sooner, and to have their deliveries be a more positive experience. Although the trend toward shorter hospital stays was originally initiated by consumer interest, the recent further shortening of maternity stays has escalated as a result of insurance and managed care plans attempting to contain health care costs. With this trend toward earlier discharge, a litany of problems have been reported, including missed newborn screening, jaundice, feeding problems, missed congenital anomalies, and readmissions. Although cost-efficient use of health care is vital, the ultimate goal should not only be the prevention of unnecessary morbidity and mortality, but the promotion of health and well being for the child and family.     

Early discharge of premature infants. A critical analysis

Although significant advances in the medical management of acutely ill preterm infants have resulted in unprecedented rates of survival, issues surrounding the convalescent care, discharge preparation, and readiness of parents or other caregivers have been less well studied and represent the art of medicine. Recent consensus statements provide a degree of content validity; however, important areas of scientific inquiry remain. Much is left to understand about the pathophysiology, management, and outcomes of apnea, bradycardia, and oxygen desaturation episodes continuing at term. Why do the most immature infants have a delay in the maturation of respiratory control? Do breathing studies really provide information that predicts subsequent respiratory control abnormalities? If methylxanthines are used at discharge, what criteria should be adhered to regarding their discontinuation? How is nutrition best provided while transitioning to home? In infants whose mothers desire exclusive breast-feeding, should gavage feeds be used to supplement in order to avoid bottle-feedings? How long should breast milk be fortified, and when should supplemented artificial milks be used and for what period of time postdischarge should these more expensive special-discharge artificial milks be used? What other supplements, such as inositol, vitamins, or antioxidants, should be provided in order to achieve optimal growth and development? Technology-dependent infants pose even greater complexities. Some infants and families adapt to extensive use of technology in the home. In other situations, basic infant care is difficult to achieve. What are the essential components for successful early discharge, and how can the studies involving selected families be made universal? How can NICUs better prepare fathers and mothers for premature parenthood? To what extent are we overwhelming families with additional responsibilities and expectations that may compromise their competency in basic parenting? Furthermore, the degree of provider variation in evaluating and providing for discharge planning is now being more carefully studied. In some circumstances, integrated teams in the NICU have facilitated the discharge process saving days of hospitalization, whereas in others adherence to discharge planning guidelines has lengthened the stay in the NICU and resulted in higher costs. What is the ideal system for achieving coordination of care without co-opting parental choices in assuming more care responsibility than is comfortable? In the design of tertiary care facilities, more attention to space for rooming-in experiences needs to receive greater priority. Furthermore, because of intensity of care, adverse environmental stimuli, and for issues of better resource utilization, should not most previously ill infants be discharged from level II or intermediate care centers? Finally, issues of increasing decision-making responsibility placed on parents (with the reassurance and guiding hand of dedicated physicians and nurses focused on individual infants) must never be made subservient to the economic whims of insurers to decrease costs without understanding the value of the entirety of the care process for critical illness, through convalescence, to it is hoped a supportive and nurturing environment in the home. Our patients deserve no less. The questions posed present a sample of issues yet to be scientifically addressed. These and many other questions need to be answered before we fully understand the optimal process of discharge for the preterm infant.     

Endocrinology of the neonate

Endocrine disease in the neonate is uncommon, but, if it is not promptly recognised and treated, may be life-threatening or have profound long-term consequences. This article covers congenital adrenal hyperplasia, hypothyroidism, neonatal thyrotoxicosis and hypopituitarism. Other endocrine problems with which the MRCP(Paeds) candidate should be familiar are also listed.     

Pneumothorax in the neonate

Dynamic cardiomyoplasty has been performed to reinforce the myocardium in the treatment of patients with severe cardiomyopathies. At the Heart Institute of S?o Paulo University Medical School, 36 patients were submitted to cardiomyoplasty between May 1988 and December 1993. The indications were idiopathic dilated cardiomyopathy in 31, ischemic cardiomyopathy in 3, and Chagas' disease cardiomyopathy in 2 patients. Twenty-eight patients were categorized in New York Heart Association (NYHA) Class III and 8 in Class IV despite the use of maximal medical therapy. There were no hospital deaths, and patients were followed up from 2 to 70 months (mean, 24 months). Besides the improvement of NYHA functional class from 3.2 +/- 0.6 to 1.6 +/- 0.9 at 6 months of follow-up, patients also presented significant changes in the left ventricular systolic and diastolic functions. Nevertheless, 16 patients died, and 2 patients were submitted to heart transplantation during late follow-up. Actuarial survival rates were 82.3% at 1 year, 61.5% at 2 years, and 38.8% at 5 years of follow-up. Otherwise, the analysis of factors influencing the outcome showed that long-term survival was significantly affected by preoperative functional class and by pulmonary vascular resistance. The 26 patients operated in NYHA functional Class III and with pulmonary vascular resistance below 4 Wood units presented survival rates of 72.7% at 2 years and of 63% at 5 years of follow-up. In conclusion dynamic cardiomyoplasty improves functional class and left ventricular function in patients with severe cardiomyopathies. However, the long-term survival after this surgical procedure may be limited by the patients' condition before the operation.     

Thrombocytopenia in the neonate

Pediatricians caring for newborns will eventually be confronted with the problem of thrombocytopenia in the neonatal period. Familiarity with the differential diagnosis of neonatal thrombocytopenia and understanding the pathogenesis of the more common entities allows physicians to design a selective diagnostic and therapeutic plan to benefit these thrombocytopenic infants.     

Early supported hospital discharge following acute stroke: pilot study results

The effect of high-dose cranial- and craniospinal irradiation and chemotherapy on the gonadotropin-sex steroid axis was studied during different stages of puberty by measuring pulsatile secretion of luteinizing hormone (LH), follicle-stimulating hormone (FSH) and testosterone. The patients were thirteen boys who had been treated for malignant brain tumor residing well away from the hypothalamo-pituitary region. The median time to follow-up was 9 (1-16) years. The onset of puberty was early in the patients, median 10.5 years, compared to the average age for Swedish boys, which is at median 12.4 years. There was, before puberty, no significant difference in LH and FSH secretion between patients and a control group of normal boys. In early, mid- and late stages of puberty, however, LH and FSH secretion was increased in the patients overall, whereas testosterone secretion was maintained within the normal range in spite of signs of gonadotoxocity with small testicular volumes. These results indicate that the vulnerable parts of the gonadotropin releasing hormone (GnRH)-gonadotropin (LH, FSH)-gonadal axis are the regulatory system that determines the timing of pubertal induction and the gonads. The GnRH-LH, FSH-releasing neurons appear relatively resistant to cranial irradiation as they are able to respond with supranormal LH and FSH levels for long periods of time after treatment.     

Early discharge of patients with new-onset atrial fibrillation after cardiovascular surgery

The feasibility of monitoring intracellular sodium changes using Na triple quantum filtered NMR without a chemical shift reagent (SR) was investigated in an isolated rat heart during a variety of interventions for Na(i) loading. Perfusion with 1 mM ouabain or without K+ present in the perfusate for 30 min produced a rise of the Na TQF signal with a plateau of approximately 190% and approximately 228% relative to the preintervention level, respectively. Stop-flow ischemia for 30 min resulted in a TQF signal growth of approximately 147%. The maximal Na TQF signal increase of 460% was achieved by perfusion without K+/Ca2+, corresponding to an elimination of the Na transmembrane gradient. The observed values of Na NMR TQF growth in the physiological and pathological ranges are in agreement with reported data by other methods and have a linear correlation with intracellular sodium content as determined in this study by Co-EDTA method and by sucrose-histidine washout of the extracellular space. Our data indicate that the increase in Na TQF NMR signal is determined by the growth of Na(i), and the extracellular Na contribution to the total TQF signal is unchanged at approximately 64%. In conclusion, Na TQF NMR without using SR offers a unique and noninvasive opportunity to monitor alterations of intracellular sodium. It may provide valuable insights for developing cardioprotective strategies and for observing the effects of pharmaceutical treatments on sodium homeostasis.     

Aesthetics and lateral thoracotomy in the neonate

BACKGROUND: Lateral thoracotomy is a relatively common procedure in the neonate. Early reports on the incidence of shoulder deformity, scoliosis, and winged scapula rapidly led to a muscle-sparing approach. Scar cosmesis, however, received less attention. Better education and increasing sophistication have led to a higher aesthetic expectation by the public. METHODS: Since 1988 the authors have combined both principles in the high axillary skin crease approach to lateral thoracotomy in 27 children with esophageal atresia and tracheoesophageal fistula and two children with a patent ductus arteriosus. RESULTS: Access was not restricted, and early healing was uncomplicated by wound breakdown or infection. Scar aesthetics is excellent and is enhanced by the natural tendency of the scar to migrate into the axilla. Long-term morbidity has been singularly absent. CONCLUSION: Parent appreciation and operator satisfaction have been noteworthy.     

Subgaleal hemorrhage in the neonate

Subgaleal hemorrhage in the neonate, a possible complication of vacuum extraction, is a medical emergency. Neonates delivered with the assistance of vacuum extraction and displaying any signs of neurologic disturbance, blood loss, or anemia should be evaluated promptly for the possibility of hemorrhage. A case report is provided in this article to describe recognition and management of a neonate in hypovolemic shock after vaginal birth assisted by vacuum extraction.     

Treatment of sepsis in the neonate

Angiotensin is an important regulator of blood pressure and exerts both pressor actions and influences growth in the cardiovascular system via the AT1 receptor. This review describes a number of signalling mechanisms involved in vasoconstriction and growth in response to AT1 receptor activation in vascular smooth muscle.