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Background: Vascular endothelial growth factor (VEGF) and its receptors (VEGFRs) regulate both vasculogenesis, the development of blood vessels from precursor cells, and angiogenesis, the formation of blood vessels from preexisting vessels. In the fetal lung, high-affinity receptors for VEGF are expressed mainly in alveolar epithelial cells and myocytes, suggesting a paracrine role for VEGF in modulating activities in adjacent vascular endothelium. Previous studies have shown that vascular growth is impaired in bronchopulmonary dysplasia (BPD)., Objective: The goal of this study was to examine tracheal (T-VEGF) and gastric (G-VEGF) levels in premature infants in the first and third day of life and examine if these levels were associated with the development of BPD., Design/methods: Tracheal aspirates from intubated infants and gastric samples from others were obtained on postnatal days 1 (D1) and 3 (D3) from 43 preterm infants (<2000 g birth weight, ≤34 wks gestation). VEGF was quantified by a VEGF Elisa Kit. Demographic, clinical, and pulmonary outcome data were collected including information on respiratory support (oxygenation index (OI) and ventilatory index (VI)) and on the development of BPD, determined at 36 weeks PMA using NICHD criteria., Results: The mean birth weight was 1060 ± 379 g and gestational age 27.5 ± 2.8 wks. BPD was diagnosed in 26 infants who were less mature than the 17 controls without BPD. Day 1 and day 3T-VEGF concentrations did not correlate, but day 3 levels correlated with gestational age ( r  = 0.75, p  < .05). BPD infants, characterized by longer ventilator, CPAP and oxygen days, had day 1T-VEGF levels similar to control infants (126.6 ± 194.7 vs. 149.7 ± 333.2 pg/ml) but day 3 levels were significantly lower (168.9 ± 218.8 vs. 1041.6 ± 676.7 pg/ml). Day 1G-VEGF levels reflected tracheal samples, trending lower in BPD infants. Mode of delivery, race, sex, antenatal steroid administration, chorioamnionitis, sepsis, or growth restriction did not impact VEGF levels. However, lower VEGF levels were associated with a lower VI and lower OI: Day 3 OI correlated with day 3T-VEGF ( r  = 0.72, p  > .05), albeit not significantly. T-VEGF increased from day 1 to day 3 in controls and decreased in BPD infants. There was no relationship between oxygen, CPAP and ventilator days and day 1 or day 3T-VEGF levels., Conclusions: BPD may be associated with low-serum VEGF levels during the first week of life. This finding is likely related to decreased expression in the lungs of the less mature infants, who are at the highest risk for BPD.

Channels in rivers and estuaries are the main paths of fluvial and tidal currents that transport sediment through the system. While network representations of multi-channel systems and their connectivity are quite useful for characterisation of braiding patterns and dynamics, the recognition of channels and their properties is complicated because of the large bed elevation variations, such as shallow shoals and bed steps that render channels visually disconnected. We present and analyse two mathematically rigorous methods to identify channel networks from a terrain model of the river bed. Both methods construct a dense network of locally steepest-descent channels from saddle points on the terrain, and select a subset of channels with a certain minimum sediment volume between them. This is closely linked to the main mechanism of channel formation and change by displacement of sediment volume. The two methods differ in how they compute these sediment volumes: either globally through the entire length of the river, or locally. We compare the methods for the measured bathymetry of the Western Scheldt estuary, The Netherlands, over the past decades. The global method is overly sensitive to small changes elsewhere in the network compared to the local method. We conclude that the local method works best conceptually and for stability reasons. The associated concept of alluvial connectivity between channels in a network is thus the inverse of the volume of sediment that must be displaced to merge the channels. Our method opens up possibilities for new analyses as shown in two examples. First, it shows a clear pattern of scale dependence on volume of the total network length and of the number of nodes by a power law relation, showing that the smaller channels are relatively much shorter. Second, channel bifurcations were found to be predominantly mildly asymmetrical, which is unexpected from fluvial bifurcation theory., Competing Interests: The authors identify no conflicts of interest., (© 2021 The Authors. Earth Surface Processes and Landforms published by John Wiley & Sons Ltd.)

Hurricanes are recurring high-energy disturbances in coastal regions that change community structure and function of mangrove wetlands. However, most of the studies assessing hurricane impacts on mangroves have focused on negative effects without considering the positive influence of hurricane-induced sediment deposition and associated nutrient fertilization on mangrove productivity and resilience. Here, we quantified how Hurricane Irma influenced soil nutrient pools, vertical accretion, and plant phosphorus (P) uptake after its passage across the Florida Coastal Everglades in September 2017. Vertical accretion from Irma's deposits was 6.7 to 14.4 times greater than the long-term (100 y) annual accretion rate (0.27 ± 0.04 cm y -1 ). Storm deposits extended up to 10-km inland from the Gulf of Mexico. Total P (TP) inputs were highest at the mouth of estuaries, with P concentration double that of underlying surface (top 10 cm) soils (0.19 ± 0.02 mg cm -3 ). This P deposition contributed 49 to 98% to the soil nutrient pool. As a result, all mangrove species showed a significant increase in litter foliar TP and soil porewater inorganic P concentrations in early 2018, 3 mo after Irma's impact, thus underscoring the interspecies differences in nutrient uptake. Mean TP loading rates were five times greater in southwestern (94 ± 13 kg ha -1 d -1 ) mangrove-dominated estuaries compared to the southeastern region, highlighting the positive role of hurricanes as a natural fertilization mechanism influencing forest productivity. P-rich, mineral sediments deposited by hurricanes create legacies that facilitate rapid forest recovery, stimulation of peat soil development, and resilience to sea-level rise., Competing Interests: The authors declare no competing interest.

Automatic extraction of channel networks from topography in systems with multiple interconnected channels, like braided rivers and estuaries, remains a major challenge in hydrology and geomorphology. Representing channelized systems as networks provides a mathematical framework for analyzing transport and geomorphology. In this paper, we introduce a mathematically rigorous methodology and software for extracting channel network topology and geometry from digital elevation models (DEMs) and analyze such channel networks in estuaries and braided rivers. Channels are represented as network links, while channel confluences and bifurcations are represented as network nodes. We analyze and compare DEMs from the field and those generated by numerical modeling. We use a metric called the volume parameter that characterizes the volume of deposited material separating channels to quantify the volume of reworkable sediment deposited between links, which is a measure for the spatial scale associated with each network link. Scale asymmetry is observed in most links downstream of bifurcations, indicating geometric asymmetry and bifurcation stability. The length of links relative to system size scales with volume parameter value to the power of 0.24-0.35, while the number of links decreases and does not exhibit power law behavior. Link depth distributions indicate that the estuaries studied tend to organize around a deep main channel that exists at the largest scale while braided rivers have channel depths that are more evenly distributed across scales. The methods and results presented establish a benchmark for quantifying the topology and geometry of multichannel networks from DEMs with a new automatic extraction tool., (©2019. The Authors.)

Background: Lung epithelial cells express surfactant protein D (SP-D), a calcium-dependent lectin that plays an important role in antibody-independent pulmonary host defense. Previous studies have shown that it is found in the peripheral circulation in patients with pulmonary disease, likely because of translocation into the blood when lung epithelial barriers are disrupted by inflammation or acute injury. In adults, serum SP-D levels are biomarkers for the progression and severity of chronic lung disease. In neonates, elevated SP-D levels in cord blood and on day 1 have been associated with prenatal risk factors and with an increased risk of respiratory distress syndrome and infections. It is not known whether serum SP-D during the first week of life is a marker for bronchopulmonary dysplasia (BPD), a form of chronic lung disease of prematurity that is associated with lung parenchymal maldevelopment and injury., Objective: The goal of this study is to determine whether serum SP-D on days 3 and 7 of life are associated with the development of BPD in preterm infants., Design/methods: Serum samples were obtained on postnatal days 3 and 7 from 106 preterm infants (500-2000 g birth weight, 23-32-week gestation). SP-D was quantified by Western blot. BPD was determined at 36 weeks PMA using NICHD criteria., Results: The mean birth weight was 1145 ± 347 g and gestational age 29.2 ± 7.4 weeks. BPD was diagnosed in 7 and "BPD or death" in 16 infants. Days 3 and 7 values tracked significantly (r = 0.648), and did not correlate with birth weight or gestational age. Contrary to expectations, serum SP-D was not associated with BPD. Significant gender differences were noted, with SP-D dropping from day 3 to day 7 in males, while increasing in females (p < .05)., Conclusion: Elevated serum SP-D does not appear to be a useful marker for BPD. Decreasing serum SP-D levels in males, as compared to females, during the first week of life are likely related to gender differences in lung maturation, consistent with the higher incidence of BPD in males.

Shoal margin collapses of several million cubic meters have occurred in the Western Scheldt estuary, the Netherlands, on average five times a year over the last decades. While these collapses involve significant volumes of material, their effect on the channel-shoal morphology is unknown. We hypothesize that collapses dynamicize the channel-shoal interactions, which could impact the ecological functioning, flood safety, and navigation in the estuary. The objective is to investigate how locations, probability, type, and volume of shoal margin collapse affect the channel-shoal dynamics. We implemented an empirically validated parameterization for shoal margin collapses and tested its effect on simulated estuary morphological development in a Delft3D schematization of the Western Scheldt. Three sets of scenarios were analyzed for near-field and far-field effects on flow pattern and channel-shoal morphology: (1) an observed shoal margin collapse of 2014, (2) initial large collapses on 10 locations, and (3) continuous collapses predicted by our novel probabilistic model over a time span of decades. Results show that a single shoal margin collapse only affects the local dynamics in the longitudinal flow direction and dampen out within a year for typical volumes, whereas larger disturbances that reach the seaward or landward sill at tidal channel junctions grow. The direction of the strongest tidally averaged flow determined the redistribution of the collapsed sediment. We conclude that adding the process of shoal margin collapses increases the channel-shoal interactions and that in intensively dredged estuaries shoal margins oversteepen, amplifying the number of collapses, but because of dredging the natural morphological response is interrupted.

The cellular and molecular mechanisms that underpin regeneration of the human lung are unknown, and the study of lung repair has been impeded by the necessity for reductionist models that may exclude key components. We hypothesized that multicellular epithelial and mesenchymal cell clusters or lung organoid units (LuOU) could be transplanted to recapitulate proximal and distal cellular structures of the native lung and airways. Transplantation of LuOU resulted in the growth of tissue-engineered lung (TELu) that contained the necessary cell types consistent with native adult lung tissue and demonstrated proliferative cells at 2 and 4 weeks. This technique recapitulated important elements of both mouse and human lungs featuring key components of both the proximal and distal lung regions. When LuOU were generated from whole lung, TELu contained key epithelial and mesenchymal cell types, and the origin of the cells was traced from both Actin GFP and SPC GFP donors to indicate that the cells in TELu were derived from the transplanted LuOU. Alveolar epithelial type 2 cells (AEC2s), club cells, ciliated cells marked by beta-tubulin IV, alveolar epithelial type I cells, Sox-2-positive proximal airway progenitors, p63-positive basal cells, and CGRP-positive pulmonary neuroendocrine cells were identified in the TELu. The mesenchymal components of peribronchial smooth muscle and nerve were identified with a CD31-positive donor endothelial cell contribution to TELu vasculature. TELu successfully grew from postnatal tissues from whole murine and human lung, distal murine lung, as well as murine and human trachea. These data support a model of postnatal lung regeneration containing the diverse cell types present in the entirety of the respiratory tract., Competing Interests: Statement No competing financial interests exist.

Staphylococcus epidermidis is an opportunistic bacterium whose infections often involve the formation of a biofilm on implanted biomaterials. In S. epidermidis, the exopolysaccharide facilitating bacterial adherence in a biofilm is polysaccharide intercellular adhesin (PIA), whose synthesis requires the enzymes encoded within the intercellular adhesin operon (icaADBC). In vitro, the formation of S. epidermidis biofilms is enhanced by conditions that repress tricarboxylic acid (TCA) cycle activity, such as growth in a medium containing glucose. In many Gram-positive bacteria, repression of TCA cycle genes in response to glucose is accomplished by catabolite control protein A (CcpA). CcpA is a member of the GalR-LacI repressor family that mediates carbon catabolite repression, leading us to hypothesize that catabolite control of S. epidermidis biofilm formation is indirectly regulated by CcpA-dependent repression of the TCA cycle. To test this hypothesis, ccpA deletion mutants were constructed in strain 1457 and 1457-acnA and the effects on TCA cycle activity, biofilm formation and virulence were assessed. As anticipated, deletion of ccpA derepressed TCA cycle activity and inhibited biofilm formation; however, ccpA deletion had only a modest effect on icaADBC transcription. Surprisingly, deletion of ccpA in strain 1457-acnA, a strain whose TCA cycle is inactive and where icaADBC transcription is derepressed, strongly inhibited icaADBC transcription. These observations demonstrate that CcpA is a positive effector of biofilm formation and icaADBC transcription and a repressor of TCA cycle activity.

Background: Monitoring of the electrocardiogram (ECG) in premature infants with conventional adhesive-backed electrodes can harm their sensitive skin. Use of an electrode belt prevents skin irritation, but the effect of belt pressure on respiratory function is unknown. A strain gauge sensor is described which measures applied belt tension., Method: The device frame was comprised of an aluminum housing and slide to minimize the device weight. Velcro tabs connected housing and slide to opposite tabs located at the electrode belt ends. The slide was connected to a leaf spring, to which were bonded two piezoresistive transducers in a half-bridge circuit configuration. The device was tested for linearity and calibrated. The effect on infant respiratory function of constant belt tension in the normal range (30 g-90 g) was determined., Results: The mechanical response to a step input was second order (fn = 401 Hz, zeta = 0.08). The relationship between applied tension and output voltage was linear in the range 25-225 gm of applied tension (r2 = 0.99). Measured device sensitivity was 2.18 mV/gm tension using a 5 V bridge excitation voltage. When belt tension was increased in the normal range from 30 gm to 90 gm, there was no significant change in heart rate and most respiratory functions during monitoring. At an intermediate level of tension of 50 gm, pulmonary resistance and work of breathing significantly decreased., Conclusion: The mechanical and electrical design of a device for monitoring electrocardiogram electrode belt tension is described. Within the typical range of application tension, cardiovascular and respiratory function are not substantially negatively affected by electrode belt force.

The relations among early cumulative medical risk, cumulative environmental risk, attentional control, and brain activation were assessed in 15-16-year-old adolescents who were born preterm. Functional magnetic resonance imaging found frontal, temporal, and parietal cortex activation during an attention task with greater activation of the left superior-temporal and left supramarginal gyri associated with better performance. Individual differences in early cumulative risk are related to patterns of brain activation such that medical risk is related to left parietal cortex activation and environmental risk is related to temporal lobe activation. The findings suggest that early risk is related to less mature patterns of brain activation, including reduced efficiency of processing and responding to stimuli.

Increased levels of unbound Free Fatty acid (FFAu) have been found in adults undergoing coronary angioplasty as a result of acute hypoxia-ischemia. We hypohesized that infants suffering from a 1-minute Apgar score of less than 5 will demonstrate elevated FFAu levels in the cord blood. One hundred ninety-nine infants between 25 and 41 weeks gestational age were enrolled in the study. Infants with an Apgar score of less than 5 at 1 minute served as the study group. Blood samples were collected from the umbilical cord and serum FFAu levels were measured with the fluorescent probe acrylodan-derivatized intestinal fatty acid binding protein. The low Apgar score group (n=32, birthweight 3153+/-780 g, gestational age 37.9+/-3.1 weeks) and normal Apgar score group (n=167, birthweight 3067+/-847 g, gestational age 37.5+/-3.5 weeks) were significantly different with respect to Apgar score at 1 minute (3.0+/-1.2 versus 8.4+/-1.1), Apgar score at 5 minutes (6.9+/-versus 8.9+/-0.5), cord pH (7.16+/-0.12 versus 7.28+/-0.07), and in the frequency of meconium passage (40.6% versus 14.9%). Cord FFAu levels were 4.4+/-1.7 versus 3.2+/-1.2 nM (p<0.001), respectively. Cord FFAu correlated inversely with Apgar score at 1 minute (r=-0.31, p<0.05) and with cord pH (r=-0.12, p<0.05), but not with birthweight or gestational age. In infants with low 1-minute Apgar scores, cord free fatty acid levels were significantly elevated compared with those from controls.

To assess the relationship between perinatal infection/inflammation as reflected by umbilical vein interleukin-6 (IL-6) levels and the development of periventricular-intraventricular hemorrhage (IVH) in very low birth weight (VLBW) infants, we tested the hypothesis that VLBW infants who develop IVH have higher concentrations of IL-6 in an umbilical vein sample compared to infants without IVH. An inception cohort of 69 VLBW infants was followed from birth until discharge or death to determine the development of IVH by serial neuroultrasounds. Umbilical vein IL-6 levels were measured using commercially available ELISA kit (Endogen Laboratories, Woburn, MA) and compared in IVH and control cohorts. Twenty-two (32%) infants developed IVH, including 18 (82%) with grade I or II and 4 (18%) with grade III or IV. One of these infants also developed periventricular leukomalacia. The umbilical vein IL-6 levels were significantly elevated in infants with IVH with median value of 87 pg/ml (25th percentile value 30 pg/ml and 75th percentile value 310 pg/ml) compared with infants without IVH, with a median value of 0 pg/ml (25th percentile value 0 pm/ml and 75th percentile value 4 pg/ml) (P = 0.007). Umbilical vein IL-6 levels are elevated in neonates who subsequently develop IVH.

This study assessed the feasibility of neonatal cerebral oxygen monitoring by near-infrared light spectroscopy (NIRS) using a light emitting diode (LED) based system. We aimed to measure the changes in cerebral oxygen saturation, as regional oxygen saturation and tissue oxygenation index, in response to auditory stimuli. Documenting changes in oxygenation in response to such stimuli will help validate the usefulness of LED-NIRS as a tool in the study of cerebral oxygen saturation in neonates.

Background: Human milk, which contains compounds beneficial to infants, is often expressed and stored before use. Changes in its antioxidant activity with storage have not been studied., Objectives: To measure antioxidant activity of fresh, refrigerated (4 degrees C), and frozen human milk (-20 degrees C), stored for two to seven days; to compare the antioxidant activity of milk from mothers delivering prematurely and at term; to compare the antioxidant activity of infant formulas and human milk., Methods: Sixteen breast milk samples (term and preterm) were collected from mothers within 24 hours of delivery and divided into aliquots. Fresh samples were immediately tested for antioxidant activity, and the rest of the aliquots were stored at -20 degrees C or 4 degrees C to be analysed at 48 hours and seven days respectively. The assay used measures the ability of milk samples to inhibit the oxidation of 2,2'-azino-di-3-(ethylbenzthiazolinesulphonate) to its radical cation compared with Trolox., Results: Antioxidant activity at both refrigeration and freezing temperatures was significantly decreased. Freezing resulted in a greater decrease than refrigeration, and storage for seven days resulted in lower antioxidant activity than storage for 48 hours. There was no difference in milk from mothers who delivered prematurely or at term. Significantly lower antioxidant activity was noted in formula milk than in fresh human milk., Conclusions: To preserve the antioxidant activity of human milk, storage time should be limited to 48 hours. Refrigeration is better than freezing and thawing.

An adaptation is presented of method 8261--from the Office of Solid Waste and Emergency Response Test Methods for Evaluating Solid Waste Physical/Chemical Methods (SW-846)-to analyze milk for an expanded list of volatile organic compounds is presented. The milk matrix exhibits a strong affinity for organic compounds and the surrogate based matrix normalization described in method 8261 provided accurate results. This method had the sensitivity necessary to detect volatile organic analytes at or below maximum contaminant levels (MCLs) set by EPA for drinking water. In a survey of milk samples available in Las Vegas, Nevada, 32 of 88 targeted volatile organic compounds (VOCs) were detected. Many of the detected VOCs have not previously been reported and a rationale for their presence in milk is presented.

Introduction: Premature infants are highly susceptible to 'oxygen radical diseases' (ORD), including bronchopulmonary dysplasia, intraventricular hemorrhage/white matter injury, retinopathy of prematurity, and necrotizing enterocolitis. The incidence of ORD is reduced following antenatal treatment with betamethasone. Oxidant-mediated injury is characterized at the cellular level by peroxidation of lipid membranes. This results in the generation of malondialdehyde (MDA), which can be quantified indirectly by measurement of thiobarbituric acid-reacting substances (TBARS). There is currently no effective way to quantify the risk for ORD. In this study, we analyzed the correlation of early urinary MDA and TBARS with prenatal betamethasone administration and with the development of ORD., Methods: Preterm infants (<30 weeks gestation, n = 25) born at St. Peter's University Hospital were enrolled. Urine samples were collected during the first 10 days of life and stored at -70 degrees C for 0-21 days. TBARS were quantified by spectrophotometric assay, and malondialdehyde levels measured by HPLC. Subjects were screened for the subsequent development of ORD. Betamethasone administration was defined as one or more doses > or =24 h prior to delivery., Results: Urinary MDA levels increased on days 2-3 and 5-10 relative to day 1 from birth. Maximal urinary MDA concentrations were significantly higher in the ORD group compared to controls, and there was a trend toward increased urinary TBARS in the presence of ORD. Infants receiving prenatal betamethasone demonstrated higher maximal urinary TBARS values during the first 10 days of life than control infants. The length of sample storage from 0 to 3 weeks at -70 degrees C did not significantly affect TBARS measurements., Conclusions: Elevated urinary MDA measurements in the first 10 days are correlated with the risk for ORD. Urinary TBARS concentrations, which are correlated with MDA measurements, can be quantified rapidly and are stable for short-term storage. Our findings suggest that urinary TBARS may be adaptable as a practical tool for assessing the risk for ORD in neonatal intensive care unit patients, allowing clinicians to optimize the use of preventive strategies. Antenatal betamethasone is associated with increased urinary TBARS in the first 10 days of life, indicating that the protective effects of corticosteroids are not mediated through reductions in oxidant-mediated lipid peroxidation., (Copyright 2004 S. Karger AG, Basel)

We used spectral analysis of heart rate variability, as a measure of autonomic tone, to determine spectral power differences in infants sleeping supine and prone. We studied 29 infants with a birth weight of 1,915 +/- 939 g, at the postconceptional age of 36 +/- 2 weeks. We then calculated total power (TP), low-frequency power (LF, 0.03-0.15 Hz), and high-frequency power (HF, 0.5-1.0 Hz). TP corresponds to overall heart rate variability, LF to both sympathetic and parasympathetic activity, and HF to parasympathetic activity only. Median (25th, 75th percentile) TP (beats/min2) in the supine position was 32.60 (23.12, 59.90), which was significantly higher than the prone position of 25.87 (14.94, 35.57). Similarly, LF (beats/min2) in the supine position of 13.82 (8.63, 23.31) was significantly higher than the prone position of 9.79 (5.46, 14.33). No significant difference was seen in the HF. We conclude that the prone position is associated with decreased heart rate variability and probably decreased sympathetic tone, which imply decreased autonomic stability in this position., (Copyright 2004 S. Karger AG, Basel)

Objectives: To determine the impact of race/ethnicity on mortality and morbidity such as intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), bronchopulmonary dysplasia (BPD) and bacteriologically confirmed sepsis, assisted ventilation, surfactant administration, intrauterine growth retardation (IUGR), and patent ductus arteriosus (PDA) among very prematurely delivered infants., Study Design: Retrospective study of a cohort of 1006 preterm neonates with gestational age ranging from 22 to 32 weeks discharged from the Neonatal Intensive Care Unit (NICU) between 1998 and 2001. Subgroup analysis according to gestational age (GA) (22 to 24, 25 to 28, and 29 to 32 weeks) and plurality (singleton and multiple) was performed using the chi(2) test and an analysis of variance., Results: Of the 1006 infants, 54.3% were white, 21.7% black, 13.7% Hispanic, and 10.3% were classified as Other. Multiple births among white infants were approximately twice that in (42.4%) black infants (22.1%), and was also significantly higher than in the Hispanic (28.3%) and other race/ethnic groups (25.2%). Overall, a higher proportion of black infants were born with a GA

Tissue ischemia, necrosis, and gangrene are uncommon but well-described complications of arterial catheterization in the neonate. Treatment options for progressive tissue necrosis following arterial embolization and/or vasospasm are limited in these patients secondary to unpredictable pharmacokinetics and risks associated with systemic anticoagulation or vasodilatation in newborns. We report a case of a multidose regimen of topical 2% nitroglycerin ointment for reversing severe tissue ischemia following peripheral arterial line placement. The favorable response in this infant suggests that topical nitroglycerin therapy should be considered as potential therapy to ameliorate the effects of vascular compromise following arterial line placement in neonates.

Carbon dioxide (CO(2)) plays important roles in regulating both respiratory drive and cerebral blood flow. These effects are mediated, in part, by activity of the sympathetic nervous system. We hypothesized that the presence of acute life-threatening events or apnea in term or preterm infants, respectively, would serve as a marker for immaturity of cerebral autonomic innervation and that such infants would display a reduced cerebral vascular response to elevated pCO(2). Therefore, we evaluated the cerebral vascular response during CO(2) challenge tests in groups of term and preterm infants with primary apnea. In term infants (39 +/- 2 weeks gestation) with acute life-threatening events, elevated pCO(2) was accompanied by decreasing pulsatility index and increasing mean anterior cerebral blood flow velocity. However, in preterm infants (29 +/- 2 weeks' gestation) with apnea, pulsatility index and anterior cerebral artery flow velocity did not significantly change in response to CO(2) supplementation. We conclude that preterm, but not term, infants with apnea exhibit impaired vascular responses to hypercarbia., (Copyright 2003 S. Karger AG, Basel)

Introduction: We wished to determine whether cholestasis induced by total parenteral nutrition (TPN) in preterm newborn infants is associated with increased oxidative stress secondary to increased reactive oxygen intermediates. We hypothesized that elevated urinary thiobarbituric-acid-reacting substances (TBARS), a marker of oxidative stress, would be associated with hepatocellular injury as measured by serum alanine transaminase (ALT) and aspartate transaminase (AST) levels., Materials and Methods: Preterm infants (<35 weeks' gestation) admitted to the neonatal intensive care unit were enrolled (with their parents' informed consent) in either the 'cholestasis' group (if their direct bilirubin was >2 mg/dl [34.2 micromol/l] and duration of TPN was > or = 10 days [n = 27]) or in the control group. Urine samples for measurement of TBARS (proportionate to lipid peroxidation) and blood specimens for analysis of serum bilirubin, ALT, AST, and alkaline phosphatase were obtained within 24 hours of enrollment., Results: The cholestasis and control groups were comparable with respect to gestational age, birth weight, Apgar score, maximum FiO2, and duration of supplemental oxygen administration. Median serum direct bilirubin concentrations in the cholestasis and control groups were, respectively, 3.3 mg/dl (56.4 micromol/l) and 1.7 mg/dl (29.1 micromol/l) (P < 0.001). Serum ALT and AST levels were also elevated in the cholestasis group, but alkaline phosphatase levels did not differ significantly between the groups. Urinary levels of TBARS in all the infants were correlated with ALT and AST but did not differ significantly between cholestatic and control infants., Discussion: Our findings suggest that oxidant stress is associated with hepatocellular injury in preterm infants. This effect is not correlated with the degree of cholestasis.

Objective: To evaluate risks of cranial ultrasound abnormalities among very-low-birth-weight (VLBW) infants conceived with fertility therapy (ovulation induction only or with assisted reproductive techniques [ART]) and of multiple gestation pregnancies., Study Design: The incidences of cranial ultrasound abnormalities in 1473 VLBW infants conceived with and without fertility therapy and born of multiple versus singleton pregnancies were compared, using logistic regression models., Results: Infants conceived with ART were less likely to have intraventricular hemorrhage (IVH). Twins and triplets had risks of cranial ultrasound abnormalities similar to those of singletons. Twins and triplets conceived with ART were at lower risk of IVH., Conclusion: VLBW infants conceived with ART do not appear to be at increased risk of cranial ultrasound abnormalities. Likewise, twins and triplets were not at increased risk of these abnormalities.

Background: Currently available clinical tools cannot accurately identify the extent of perinatal hypoxic injuries. During hypoxia, reactive oxygen species cause lipid peroxidation of cell membranes, yielding oxidation products that constitute thiobarbituric acid-reacting substances (TBARS)., Objective: To see if the concentrations of TBARS excreted in urine would be elevated during the first day of life in term and preterm infants following chronic hypoxia or acute asphyxia., Design: Thiobarbituric acid-reacting substances levels were measured by a spectrophotometric assay in urine samples collected from term and near-term (>/= 34 weeks gestation, n = 22), and preterm (<34 weeks gestation, n = 52) infants on the first day of life., Patients: Infants were admitted to the St Peter's University Hospital (New Brunswick, NJ) neonatal intensive care unit from July 1997 to January 1999. Acute asphyxia was defined as umbilical cord blood pH values less than 7.05, or Apgar scores of less than 5 at 5 minutes. Chronic hypoxia was defined as intrauterine growth retardation or low birth weight (small for gestational age) associated with pregnancy-induced hypertension or reversal of umbilical arterial blood flow., Results: Among term infants, urinary TBARS levels were significantly increased following acute asphyxia (P =.02). Levels of TBARS also tended to be elevated following chronic hypoxia. Urinary TBARS levels in term infants tended to be increased in those requiring mechanical ventilation (P =.05) or delivery room resuscitation (P =.15), as well as in those passing intrauterine meconium (P =.13) or having clinical evidence of hypoxic-ischemic encephalopathy (P =.24)., Conclusions: The results show a correlation between elevated urinary TBARS levels in term and near-term infants, and perinatal hypoxia (as determined by low Apgar scores or umbilical cord blood acidosis). We speculate that TBARS concentrations may be useful as a biomarker for perinatal hypoxic injury in newborns. Further studies are needed to determine whether elevations in TBARS levels are better predictors of the extent of hypoxic injury than existing markers.

Cellular injury during tissue hypoxia is due, in part, to reactive intermediates released by activated leukocytes. We found that the inflammatory mediators tumor necrosis factor (TNF)-alpha, IL-6, and IL-1beta are elevated in situ in lung macrophages on day 14 following exposure of rats to intermittent or chronic hypoxia from birth. Because inflammatory mediators can increase lipolysis in adipocytes, we also measured serum unbound free fatty acids (FFAu)--the biologically active compartment of FFA--in rat pups exposed to intermittent or chronic hypoxia. FFAu values were markedly elevated during the first 2 days of life in all rats, displaying an approximately 3-fold decrease from day 2 to day 3. Exposure to chronic hypoxia significantly increased FFAu levels measured on day 13. Since elevated serum FFAu are known to suppress leukocyte activation, we speculate that increased FFAu levels represent a mechanism for attenuating inflammation and tissue injury following sublethal hypoxia in the perinatal period, either physiologically in the immediate newborn period, or as a late response to ongoing hypoxic insult.

Assisted reproductive techniques and fertility enhancing therapies have increased multiple births and, therefore, the risk of prematurity and its developmental consequences. Parent intervention is an effective source of compensation for the cognitive effects of prematurity. We hypothesized that relative to parents of preterm singletons, parents of preterm twins are less able to provide such enhancing care, resulting in a developmental disadvantage for preterm twins. Maternal-infant interactions of premature singletons (n = 22; birth weight = 1668 +/- 350 g, gestational age = 32.3 +/- 2.1 weeks) and premature twins (n = 8; birth weight = 1618 +/- 249 g; gestational age = 32.0 +/- 2.6 weeks) with comparable demographic and medical status were observed at home at 1 and 8 months corrected age using a 30 min checklist of developmentally facilitative behavior. Mental (MDI) and psychomotor (PDI) indices of the Bayley Scales of Infant Development and Caldwell Home Observations for Measurement of the Environment (HOME) inventories were administered (18 months corrected age). Compared with mothers of premature singletons, mothers of premature twins exhibited fewer initiatives (P < 0.001) and responses (P < 0.01) and were less responsive to positive signals (P < 0.01) and crying (P < 0.01). Unprompted by the infant, twin mothers lifted or held (P < 0.05), touched (P < 0.01), patted (P < 0.05) or talked (P < 0.01) less. Singleton MDIs surpassed twins (119.4 +/- 7.7 vs 103.6 +/- 7.7; P < 0.01). Maternal verbal behavior and the acceptance of child factor (HOME), both favoring singletons, correlated with MDI (R-square = 0.46, P < 0.0002). Mothers of premature twins exhibited fewer initiatives and responses toward offspring than did mothers of premature singletons. Maternal behavior was predictive of cognitive development.

Aim: To demonstrate that quantitative EEG (qEEG) can be used as a non-invasive measure of brain injury by establishing normative data in term infants and contrasting it with other modalities of brain imaging., Design: qEEG during quiet sleep was performed on 13 healthy full-term infants comprising a normal group and on 10 infants with neurological abnormalities identified on brain imaging studies (abnormal group) at 36-47 wk postconceptional age. Quantitative analysis was performed and topographic maps were produced for each patient. The EEG data from the normal group, after spectral analysis, yielded power data in the delta, theta, alpha, and beta frequency bands and coherence information, which then formed the normative database. qEEG from the infants in the abnormal group was then compared to this normative data., Results: The normal group's mean absolute power in the delta, theta, alpha, and beta bands for all EEG leads combined were 278.48+/-83.83, 31.71+/-10.12, 29.20+/-2.04, and 35.76+/-11.35 uv2, respectively. The median frequency was 1.49+/-0.07, 5.45+/-3.46, 9.74+/-5.11, and 18.01+/-3.38 Hz, respectively. The qEEG was abnormal in all 10 study infants, while abnormalities were noted in the clinical EEG in 4 of 10, in the neuroultrasound in 5 of 10, in the CT in one of 6, and in the MRI in 2 of 2 tested., Conclusions: qEEG appears to be a useful non-invasive method for measuring brain injury as it correlates well with other modalities of brain imaging and, if corroborated by further study, may, in fact, be more sensitive in determining abnormalities in brain function.

Background: Bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and retinopathy of prematurity may be different manifestations of oxygen radical diseases of prematurity (ORDP)., Objective: To test the hypothesis that the antioxidant capacity of cord blood serum will predict risk of ORDP., Design: An inception cohort of premature neonates was followed up from birth until discharge or death to determine if outcome was related to cord blood serum antioxidant capacity, as determined by a manual assay measuring the relative inhibition of oxidation of 2,2'-azino-di-(3-ethylbenzthiazoline)-6 sulfonic acid (ABTS). Possible correlations between antioxidant capacity and various perinatal factors were also tested., Setting: Level 3 newborn intensive care unit., Patients: All inborn very low-birth-weight neonates from whom cord blood was available and for whom maternal consent was obtained were included. Newborns who died in the first week of life or who had major congenital malformations were excluded. A convenience sample of newborns weighing more than 1500 g was used to perfect assay and explore confounders., Main Outcome Measures: Significant ORDP was defined as the presence of intraventricular hemorrhage greater than grade 2, retinopathy of prematurity greater than stage 1, bronchopulmonary dysplasia at the postconceptional age of 36 weeks, or necrotizing enterocolitis with the hypothesis that neonates with ORDP will have lower antioxidant capacity in cord blood serum., Results: Serum antioxidant capacity at birth correlated with gestational age for the entire sample of 41 neonates and for the 26 neonates born before 32 weeks' gestation. After correction for gestational age, cord serum antioxidant capacity did not correlate with maternal smoking, preeclampsia, chorioamnionitis, cord pH Apgar scores, or any of the ORDP studied., Conclusion: Cord serum antioxidant capacity correlates with gestational age but does not predict ORDP risk.

We investigated the relationship between spectral power and both mean heart rate (HR) and heart rate variability (HRV). Spectral power was calculated using digital heart rate recordings from term infants. Regression analysis revealed a positive correlation between low-frequency (LF) sympathetic power and HR, and a negative correlation between high-frequency (HF) parasympathetic power and HR. HRV correlated positively in all regions of the power spectrum. In awake infants, the contribution of HF power to total power (HF/TP) was significantly decreased. LF power tended to be greater, however, this trend was not statistically significant. By following expected autonomic patterns, the findings of this study confirm that spectral analysis provides a noninvasive method for the assessment of autonomic activity influencing the newborn heart. The correlation between spectral power and HRV can serve as an additional tool in the study of autonomic dysfunction., (Copyright 2000 S. Karger AG, Basel)

An elevated level of baseline parasympathetic activity was noted in a group of premature infants suffering from bradycardia during feeding. At approximately 34 wk post-conceptional age, the heart rates of 12 infants with feeding bradycardia (birth weight = 1539 +/- 279 g; gestational age = 31.0 +/- 1.6 wk) and 10 controls (birth weight = 1710 +/- 304 g; gestational age = 32.0 +/- 1.4 wk) were recorded 1 h before and 1 h after feeding. EKG data were digitized and 3.2-min segments of data were analyzed to determine the spectral power at very low (VLF = 0.003-0.03 Hz), low (LF = 0.03-0.39 Hz), and high (HF = 0.40-1.00 Hz) frequencies. In preterm infants with feeding bradycardia, an elevation in baseline parasympathetic activity was evident before feeding, as indicated by significantly higher HF power and a lower LF/HF ratio. This elevation in baseline parasympathetic activity may contribute to the observed bradycardia during feeding.

Objective: To examine the relationship between umbilical vein plasma concentrations of interleukin 6 (IL-6) and tumor necrosis factor (TNF)-alpha and early neonatal sepsis in the very preterm infant, and the histopathologic findings of chorioamnionitis in the placentas from these pregnancies., Methods: A prospective study was conducted in 43 very preterm, singleton infants delivered at or before 32 weeks of gestation. IL-6 and TNF-alpha were measured by enzyme-linked immunoassay. Placentas from these pregnancies were histologically examined for the presence of chorioamnionitis. Infants were prospectively classified as confirmed sepsis group, clinical sepsis group or control group. IL-6 and TNF-alpha plasma concentrations were not normally distributed, so they were transformed to their natural log values for statistical analysis., Results: The enrolled infants had a mean gestational age of 27.2 +/- 2.7 weeks and a mean birth weight of 956 +/- 325 g. Three (7%) infants had confirmed sepsis, 18 (42%) were in the clinical sepsis group and 22 (51%) were in the control group. IL-6 concentrations but not TNF-alpha were significantly higher (P < 0.05) in the confirmed (8.9 +/- 1.7) and clinical sepsis (5.5 +/- 2.4) groups in comparison with the control group (2.1 +/- 1.6). We examined 42 placentas. Twenty-three (55%) had no evidence of chorioamnionitis, 1 (2%) had mild grade, 8 (19%) had a moderate grade and 10 (24%) had a severe grade of chorioamnionitis. IL-6 was significantly elevated in the moderate (5.9 +/- 1.6 vs. 1.9 +/- 1.6) and severe grade (7.2 +/- 2.3 vs. 1.9 +/- 1.6) of chorioamnionitis, in the presence of acute deciduitis (6.0 +/- 2.7 vs. 2.1 +/-1.8), chorionic vasculitis (6.8 +/- 2.1 vs. 2.2 +/- 1.9) and funisitis (7.3 +/- 1.9 vs. 2.7 +/- 2.3) (P < 0.05) TNF-alpha plasma concentrations were not significantly different., Conclusion: An elevated umbilical vein IL-6 concentration is a good indicator of sepsis syndrome in the very preterm infant and also correlates with histologic chorioamnionitis in these pregnancies.

The decision to salvage or amputate a severely injured limb is one of the most difficult an orthopaedic surgeon may face. The inclination to undertake heroic measures to save the limb should be tempered by the realization that doing so may lead to repeated hospitalizations, extensive complications, and a poor functional outcome. Several factors must be considered, including objective elements related to the patient's injury and physical condition and subjective considerations related to the patient's psychologic, social, and economic status. We present a framework, in the context of a case study, which may be used in deciding which patients can benefit from early amputation and review five predictive indices for limb salvage.

Background: To examine the antenatal and early neonatal correlates of low Apgar scores (<3 and <6 at 1 and 5 minutes) in preterm newborns (23-34 weeks' gestation)., Objective: The use of Apgar scoring for premature newborns remains widespread, despite controversy regarding its reliability as a measure of morbidity and mortality in the neonatal period., Design: A cohort of 852 preterm newborns born during a 34-month period between 1984 and 1987 was studied. Newborns were stratified into 2 groups by gestational age (23-28 weeks and 29-34 weeks), and data were analyzed, controlling for gestational age in single weeks., Setting: Two academic and 1 community hospital, which together accounted for 83% of all preterm births in a tri-county area of central New Jersey during the study period., Patients: All premature newborns (birth weight <2000 g and gestational age <35 weeks) born in the participating hospitals during the study period were evaluated., Main Outcome Measures: Antecedents included maternal illness during pregnancy, maternal complications of labor and delivery, and fetal heart rate abnormalities during labor and delivery. Consequences included delivery room resuscitation, abnormal physical findings, diagnoses, and therapeutic interventions in the first 6 to 8 hours of life., Results: Premature newborns with low Apgar scores received more cardiopulmonary resuscitation in the delivery room and in the first 6 to 8 hours of neonatal intensive care. Mortality was significantly increased among newborns with low Apgar scores (54% vs. 26% in the 23- to 28-week stratum, 30% vs 6% in the 29- to 34-week stratum). Newborns with low Apgar scores in the 29- to 34-week stratum more often required intubation, positive pressure ventilation, and umbilical vessel catheterization. Newborns with low Apgar scores had higher rates of bradycardia, pneumothoraces, acidosis, and increased oxygen requirement during the first 6 to 8 hours of life. Maternal illness, complications of labor and delivery;, and fetal heart rate decelerations did not correlate with subsequent Apgar scores of newborns. The presence of severe bradycardia (<90/min) and fetal heart rate accelerations correlated with low Apgar scores in the 29- to 34-week group., Conclusion: Low Apgar scores are associated with increased neonatal morbidity and mortality in preterm newborns. Antenatal maternal history, and pregnancy complications are not clearly associated with low Apgar scores. Therefore, the Apgar score is a useful tool in assessing neonatal short-term prognosis and the need for intensive care among preterm newborns.

The cost differences between film-based mammography (FBM) and digital mammography (DM) were estimated after discussions with hospital personnel and industry representatives. Human resource costs were not included. The fixed cost of FBM per machine was estimated to be $50,000 and the variable cost $4.60 per examination. The fixed cost of DM per machine was estimated to be $102,000 and the variable cost $0.10 per examination. The total number of examinations required to break even was therefore 11,556. At a rate of 15 examinations per machine per day and with 251 working days per year, it would take 3.1 years to break even. In the first year after the break-even point had been attained, $16,943 would be saved for every 3765 examinations performed. Extrapolating to the USA as a whole, in which 23 million mammographic examinations are performed each year, suggests that the annual savings from going filmless would be more than $103 million.

Echolucent images (EL) of cerebral white matter, seen on cranial ultrasonographic scans of very low birth weight newborns, predict motor and cognitive limitations. We tested the hypothesis that markers of maternal and feto-placental infection were associated with risks of both early (diagnosed at a median age of 7 d) and late (median age = 21 d) EL in a multi-center cohort of 1078 infants <1500 x g. Maternal infection was indicated by fever, leukocytosis, and receipt of antibiotic; fetoplacental inflammation was indicated by the presence of fetal vasculitis (i.e. of the placental chorionic plate or the umbilical cord). The effect of membrane inflammation was also assessed. All analyses were performed separately in infants born within 1 h of membrane rupture (n = 537), or after a longer interval (n = 541), to determine whether infection markers have different effects in infants who are unlikely to have experienced ascending amniotic sac infection as a consequence of membrane rupture. Placental membrane inflammation by itself was not associated with risk of EL at any time. The risks of both early and late EL were substantially increased in infants with fetal vasculitis, but the association with early EL was found only in infants born > or =1 after membrane rupture and who had membrane inflammation (adjusted OR not calculable), whereas the association of fetal vasculitis with late EL was seen only in infants born <1 h after membrane rupture (OR = 10.8; p = 0.05). Maternal receipt of antibiotic in the 24 h just before delivery was associated with late EL only if delivery occurred <1 h after membrane rupture (OR = 6.9; p = 0.01). Indicators of maternal infection and of a fetal inflammatory response are strongly and independently associated with EL, particularly late EL.

This study examined the concurrent validity of the Millon Adolescent Clinical Inventory (MACI; Millon 1993) in the assessment of depression among 88 adolescent inpatients. Doleful Personality and Depressive Affect scales were moderately predictive of a clinical diagnosis of depression, but both scales were strongly associated with scores on the Children's Depression Inventory (Kovacs, 1992). The Suicidal Tendencies scale was weakly associated with placement on suicide precautions. Overall, these results provide moderate support for the use of the MACI in the assessment of hospitalized adolescents.

Two commonly used thrombolytic agents are streptokinase (SK) and tissue plasminogen activator (t-PA), which have different impacts on the incidence of mortality and thrombolysis-related acute intracranial hemorrhage. A decision-analytic model was developed to compare the use of SK and t-PA in the treatment of a patient with suspected acute myocardial infarction (AMI). The outcome was health-related quality of life as quantified in a measure of utility from the patient's point of view. The model included three outcome states: death, nonfatal yet disabling stroke, and survival with no disabling stroke. The utility for disabling stroke was determined relative to the reference states of no disabling stroke (1.00) and death (0.00) by means of the time trade-off estimation technique. Probabilities were derived from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Artery trial, which revealed that although administering t-PA results in a lower percentage of deaths compared to SK, it may lead to a higher percentage of strokes. A decision tree was constructed to model the options and outcomes. The tree was analyzed by standard decision analytic techniques using SMLTREE software, and the stability of the results was examined as values of parameters were varied systematically in a sensitivity analysis. In the baseline analysis, SK yielded 0.9235, whereas t-PA yielded 0.9329. The sensitivity analysis revealed that if the probability of a disabling stroke attributable to t-PA were greater than 2.08%, SK would yield the higher expected utility. This threshold value, however, was much greater than the probability established in major trials. The administration of t-PA leads to a slightly better outcome than does the administration of SK in a patient with suspected AMI.

Objective: To analyze the effects of apnea duration on changes in heart rate and oxygen saturation and to examine the temporal relationships among these variables., Study Design: An event analysis sheet was designed to analyze numerous variables reflecting changes in heart rate and oxygen saturation associated with infant apnea. From July 1, 1991 through June 30, 1992 we identified 32 infants enrolled in The Infant Apnea Program at St. Peter's Medical Center, New Brunswick, NJ who had apnea > or = 15 seconds in duration on consecutive 12-hour multichannel recordings of heart rate, thoracic impedance, nasal thermistry, and oxygen saturation. The apnea epochs of these patients were subdivided into apnea of short (10 to 14 seconds), medium (15 to 19 seconds), and long (> or = 20 seconds) duration, and a total of 236 apnea epochs were analyzed. The significance of differences was assessed by analysis of variance and Newman-Keuls multiple comparisons., Results: We found that the duration of apnea has significant effects on perturbations in both heart rate and oxygen saturation, however, the degree of oxygen desaturation can not be predicted by the perturbation in heart rate. Analysis of the temporal relationship of apnea, bradycardia, and oxygen desaturation reveals that, although apnea precedes both heart rate and oxygen saturation drops in most infants as the length of apneic interval increases, the interval between apnea onset and associated drops in heart rate and/or oxygen saturation also increases., Conclusion: Oxygen saturation monitoring may provide important physiologic data that can not be assessed by cardiorespiratory monitoring alone.

Samples of air and leaves were taken at the University of Nevada [Formula: see text] Las Vegas campus and analyzed for volatile organic compounds using vacuum distillation coupled with gas chromatography/mass spectrometry. The data were used to estimate the bioconcentration of volatile organic compounds (VOCs) and to characterize the equilibration of VOCs between the leaves and air. The bioconcentration of volatiles in the leaves of some species can be predicted using the partition coefficients between air and octanol (K(oa)) and only considering VOC absorption in the lipid fraction of leaves. For these leaves, the bioconcentration factors agreed with existing models. Leaves of some species displayed a bioconcentration of volatiles that greatly exceeded theory. These hyperbioconcentration leaves also contain appreciable concentrations of monoterpenes, suggesting that a terpenoid compartment should be considered for the bioconcentration of organic compounds in leaves. Adding an additional "terpenoid" compartment should improve the characterization of volatile organic compounds in the environment. The uptake of VOCs from air by leaves is rapid, and the equilibration rates are seen to be quicker for compounds that have higher vapor pressures. The release of VOCs from the leaves of plants is slower for hyperbioconcentration leaves.

Objective: The Apgar score is well-characterized in full-term infants but not in premature infants. The objective of this study was to assess the Apgar score in preterm infants with respect to the relationships between the 1- and 5-minute scores, the correlation of the Apgar score with pH and with other variables, and the relationship among the individual Apgar components., Methodology: We recorded Apgar scores at 1 and 5 minutes in a population-based cohort of preterm infants (n = 1105) with birth weight <2000 g, from three intensive care nurseries in central New Jersey. Linear correlation analysis was used to examine the relationship between 1- and 5-minute Apgar scores and between the individual components of the Apgar score. Multiple regression analysis was used to explore the relationship between various perinatal characteristics and the Apgar score, and between pH and Apgar score. Stepwise logistic regression analysis was used to assess the determinants of mortality., Results: The 1-minute Apgar score median (25%, 75%) was 6(4,8) and correlated with the 5-minute score of 8(7,9) at r = .78. Slight but significant differences were seen between male (n = 557) and female (n = 508) infants in the 1-minute (6[4,8] and 7[4,8]) Apgar scores. One- and 5-minute scores of white infants (7[4,8] and 8[7,9]; n = 713) were significantly higher than those of black infants (5[3,7] and 8[6,9]; n = 280). Birth weight and gestational age were both linearly related to both Apgar scores. Low Apgar score (<3 at 1 minute and <6 at 5 minutes) was significantly associated with birth weight, gestational age and mode of delivery. Low arterial blood pH (<7.01) at birth was significantly related to low Apgar score. One hundred fifty-nine infants died; these infants were significantly smaller (983 +/- 382 vs 1462 +/- 369 g), less mature (27 vs 31 weeks), had lower arterial blood pH (7.20 +/- 0.18 vs 7.31 +/- 0.11), had lower 1- (3[2,6] vs 7[4,8]) and 5-minute Apgar scores (6[4,8] vs 8[7,9]), and a greater incidence of low Apgar score (32% vs 6%) than did survivors., Conclusions: Among the components of the Apgar score, respiratory effort, muscle tone, and reflex activity correlated well with one another; heart rate correlated less well; and color the least. Our data confirms the limited use of the Apgar score in preterm infants and demonstrates the different responses of the Apgar score's components.

The specific aims of this research project were to (a) describe selected verbal, nonverbal, and physiological arousal indicators of the child's pain; (b) describe which pain indicators were most influential to nurses in decision-making about interventions for managing the child's pain; (c) describe pain interventions used by nurses; (d) compare postoperative analgesic orders to recommended dosages for the children; and (e) explore relationships between the child's self-report of pain and medication dosages administered. Subjects included 19 children aged 5-17 years who experienced 20 orthopedic surgical procedures (one child had two surgeries one week apart). Data were collected by staff nurses for the first five days after surgery. Pain levels were reported using the Oucher Scale. Postoperative pain was reported at moderate levels and showed only a gradual decrease throughout the hospital stay. Nonverbal pain indicators included crying and tense face. The child's complaint of pain and reported Oucher scores were most influential in influencing nurses to intervene in the child's pain. Nonpharmacological comfort measures included positioning and reassurance. All children received medications for pain; 49% of the orders were within the recommended therapeutic dosage range. A small but significant correlation was found between the child's reported pain level and the morphine equivalents of pain medication received. Recommendations included development of nursing flow charts that provide space to record pain levels and nursing interventions, in-service education for nurses on nonpharmacological interventions, and further research with a larger sample and a single pain rating scale.

Of 8791 consecutive newborns, we studied 205 (2.3%) women with a history of prolonged rupture of membranes (PROM) greater than 24 hr to assess the incidence of infection, to identify the rate of clinical symptoms, and to examine the use of the white blood count (WBC) and neutrophil values as screening tools to predict infection. Blood culture and complete blood counts (CBC) were obtained in 175 (85%). Fifteen (8.2%) had positive blood cultures including group B streptococcus, streptococcus viridans, streptococcus pneumoniae, staphlococcus epidermidis, and staphlococcus aureus. In the remaining 8586 infants born to mothers without PROM, 10 had positive blood cultures for an incidence of 0.1%. In the PROM group, the six who manifested clinical symptoms had abnormal CBCs; abnormal white blood count (2), abnormal neutrophil count (5), high band/metatamyelocyte count (4), and increased immature to total neutrophil ratio (4). Of the nine asymptomatic infants, seven (78%) had abnormal CBCs, five (56%) with a high WBC, five (56%) had a high neutrophil count, two (22%) had a high band/metatamyelocyte count, and one a high immature to total neutrophil ratio. CBC values were obtained from infants with PROM and negative blood cultures. Five of these 15 controls had an abnormal CBC. In the term newborn, PROM is associated with significantly increased incidence of positive blood cultures. The sensitivity of the CBC was 86% and specificity 66%. In view of this data a conservative clinical approach utilizing blood cultures and CBC evaluations in the management of PROM is warranted.

Objective: To investigate whether in utero exposure to magnesium sulfate is associated with a lower incidence of cranial ultrasonographic abnormalities that predict cerebral palsy in infants who weigh less than 1501 g at birth., Design: For a prospective study of the antecedents of cranial ultrasonographic abnormalities, we enrolled infants who weighed 500 to 1500 g when born at five institutions. Data were collected by interview of the mothers and review of medical records. Protocol cranial ultrasonograms were obtained as close as possible to postnatal days 1, 7, and 21. Abnormality on cranial ultrasound scans was determined by a consensus committee of three sonologists., Results: Of the 1518 infants for whom we knew whether the mothers received magnesium sulfate, the first protocol cranial ultrasound scan was available for 1409 infants, the second for 1274 infants, and the third for 1050 infants. Forty-five percent of infants were exposed to magnesium sulfate before delivery. The major correlates of magnesium sulfate exposure were receipt of antenatal corticosteroids and a diagnosis of preeclampsia and/or pregnancy-induced hypertension. Maternal magnesium receipt was not associated with a reduced incidence of hypoechoic or hyperechoic images of white matter parenchyma, intraventricular hemorrhage, or ventriculomegaly, even when the sample was stratified by each of six potential confounders. When adjustment was made for gestational age, a measure of birth weight for gestational age, antenatal corticosteroid exposure, preeclampsia and pregnancy-induced hypertension, route of delivery, and the occurrence of any labor, the risk ratios for each cranial ultrasonographic abnormality associated with magnesium sulfate exposure hovered close to 1., Conclusion: Maternal receipt of magnesium sulfate does not seem to be associated with an appreciably reduced risk of cranial ultrasonographically defined neonatal white matter damage, intraventricular hemorrhage, or ventriculomegaly.

Background: Fatty acids (FFA) are key nutrients in maintaining physiologic homeostasis and in the form of Intralipid administration, they are important sources of nutrition in the premature newborn infant. Complexed with albumin, fatty acids have a small but important fraction that remains unbound in the aqueous phase., Objective: The goal of this study was to examine the levels of serum levels of unbound free fatty acids (FFAu) in premature newborns following Intralipid administration., Method: A fluorescent probe acrylodated intestinal fatty acid binding protein (ADIFAB) was used to measure (FFAu) before Intralipid and during increasing rates of infusion., Results: There were significant differences between (FFAu) values obtained before Intralipid and levels after the infusion of 1.0, 2.0, and 3.0 g/kg/day (p < 0.05). Regression analysis of Intralipid dose and FFAu yielded an r = 0.438 and the following relationship: [FFAu] = 26.39 + 3.60 * IL (g/kg/day)., Conclusions: Intralipid administration results in significant elevation of FFAu in the very low birth weight infant.

Background: Free fatty acids (FFA) play essential roles in maintaining physiologic homeostasis in the newborn infant. Most of the FFA in serum is carried in complex with albumin, but a small fraction remains unbound in the aqueous phase., Objective: This study's goal is to report the values of serum levels of unbound free fatty acids (FFAu) in pregnant women and their newborn infants at term gestation., Methods: The measurements were made possible by the availability of the fluorescent probe for unbound FFA, acrylodated intestinal fatty acid binding protein (ADIFAB). Twenty-two mother-infant pairs were enrolled in the study. Maternal levels were obtained immediately before delivery, cord levels at the time of delivery, and infant levels after 24 hours of age., Results: The level of FFAu measured in maternal samples was 11.8 +/- 4 nM, in cord samples 9.2 +/- 4 nM, and in infants 13.9 +/- 3 nM. These population averages are considerably greater than those observed in healthy adults (7.5 +/- 2.5 nM). No correlation was found between cord levels and birthweight, gestational age, labor duration, mode of deliver, and infant or maternal temperature., Conclusions: This investigation is the first to measure FFAu in a group of mothers and their infants and provides the technique for future investigations of the biologic activity of free fatty acids.

Increasingly, clinicians obtain data from tests across modalities. Little actual information, however, exists as to normal patterns. An example is auditory and visual recall of digit span. The effects of modality on recall of digit span, sequence, and order were examined with 80 subjects (M age 24.3 yr.). Subjects were given the Wechsler Adult Intelligence Scale-Revised, and a research version of MicroCog: Assessment of Cognitive Functioning. Both contain forward and backward digit spans. Recall for visual presentation was significantly stronger than for auditory presentation of backward digit span. Recall for visual backward digit span was also superior to auditory backward digit span when the sequence of presentation was controlled. The mean number of digits recalled was higher when visual digit span was preceded by auditory digit span.

Objective: To examine the arterial blood pressure in the first week of life in a healthy premature population., Design: Population-based cohort study., Setting: Three intensive care nurseries in central New Jersey., Patients: Premature infants with birth weights less than 2000 g., Main Outcome Measures: We documented daily maximum and minimum systolic and maximum and minimun diastolic blood pressures during the first 7 days of life. To examine the effects on the ranges of blood pressure, we identified four groups of infants: (1) healthy infants without any of the major risk factors (n = 193); (2) infants who were mechanically ventilated but free of any of the other conditions (n = 225); (3) infants with histories of maternal hypertension or preeclampsia (n = 38) and (4) infants with low Apgar scores (less than 3 at 1 minute and less than 6 at 5 minutes) regardless of the presence of other conditions (n = 86)., Results: Blood pressure increased steadily in the first week of life in all four groups. There was no relationship between any of the four blood pressure variables, or trends in blood pressure over time, with birth weight, gender, or race. Regression equations (based on all infants with available data) for blood pressure ranges by day of life revealed that the maximum systolic blood pressure increased by 2.6 mm Hg/d, the minimum systolic blood pressure increased by 1.8 mm Hg/d,the maximum diastolic blood pressure increased by 2.0 mm HHg/d, and the minimum diastolic blood pressure increased by 1.3 Hg/d., Conclusions: Infants with birth asphyxia and ventilated infants had significantly lower systolic and diastolic blood pressures than healthy infants.