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Purpose: To assess the effectiveness of an educational module as a tool for improving the knowledge of pediatric residents about newborn screening and its expansion in Texas. Methods: The study population consisted of 63 pediatric residents from the University of Texas at Houston, Baylor College of Medicine in Houston, and the University of Texas Medical Branch in Galveston. Residents were invited to participate in the study during daily scheduled didactic lectures in their respective residency programs. Questionnaires were distributed to the residents both before and after the presentation of an educational module about newborn screening in Texas to assess whether knowledge was gained from the presentation. Results: Analysis of questionnaires from the full group of participants showed a substantial increase in knowledge about newborn screening in Texas after the presentation of the educational module. This included a 45.4% increase in knowledge about pre-expansion newborn screening conditions and a 308.4% increase in knowledge about expanded newborn screening conditions (P 0.001). Conclusions: Our results suggest that an educational module about newborn screening like the one we created for this study would be an effective tool for improving the knowledge of pediatric residents on a larger scale. Genet Med 2009:11(3):163–168.

The objective of this study was to implement and evaluate a vertically integrated general pediatrics rotation that includes inpatient ward, newborn nursery, and ambulatory components in a format intended to mimic real-world pediatric practice. Separate ward, well-baby nursery, and ambulatory rotations were combined into a 4-month block rotation. Two parallel teams staff the inpatient ward and newborn nursery; on alternating days, the admitting team staffs an afternoon clinic, seeing ward and nursery patients in follow-up as well as regular clinic and referral patients. Two group meetings were held during each rotation for 2 years, and questionnaires were distributed to participating residents. All 90 residents who rotated through the combined service participated in at least 1 group meeting, only 26 returned questionnaires that limited evaluation of the program. The most important positive feature of the rotation was the continuity of patient care allowed by combining the venues into 1 rotation and by the longer duration of the rotation. Concerns included the challenges of time management and fluctuations in workload across the 3 patient care venues. Upper level residents reported that the rotation confirmed career decisions for primary care. These preliminary observations suggest that a vertically integrated rotation provides improvement in perceived continuity of care and introduces residents to the time management challenges of primary care pediatrics.

OBJECTIVE: Poor communication and teamwork may contribute to errors during neonatal resuscitation. Our objective was to evaluate whether interns who received a 2-hour teamwork training intervention with the Neonatal Resuscitation Program (NRP) demonstrated more teamwork and higher quality resuscitations than control subjects. METHODS: Participants were noncertified 2007 and 2008 incoming interns for pediatrics, combined pediatrics and internal medicine, family medicine, emergency medicine, and obstetrics and gynecology (n = 98). Pediatrics and combined pediatrics/internal medicine interns were eligible for 6-month follow-up (n = 34). A randomized trial was conducted in which half of the participants in the team training arm practiced NRP skills by using high-fidelity simulators; the remaining practiced with low-fidelity simulators, as did control subjects. Blinded, trained observers viewed video recordings of high-fidelity–simulated resuscitations for teamwork and resuscitation quality. RESULTS: High-fidelity training (HFT) group had higher teamwork frequency than did control subjects (12.8 vs 9.0 behaviors per minute; P < .001). Intervention groups maintained more workload management (control subjects: 89.3%; low-fidelity training [LFT] group: 98.0% [P < .001]; HFT group: 98.8%; HFT group versus control subjects [P < .001]) and completed resuscitations faster (control subjects: 10.6 minutes; LFT group: 8.6 minutes [P = .040]; HFT group: 7.4 minutes; HFT group versus control subjects [P < .001]). Overall, intervention teams completed the resuscitation an average of 2.6 minutes faster than did control subjects, a time reduction of 24% (95% confidence interval: 12%–37%). Intervention groups demonstrated more frequent teamwork during 6-month follow-up resuscitations (11.8 vs 10.0 behaviors per minute; P = .030). CONCLUSIONS: Trained participants exhibited more frequent teamwork behaviors (especially the HFT group) and better workload management and completed the resuscitation more quickly than did control subjects. The impact on team behaviors persisted for at least 6 months. Incorporating team training into the NRP curriculum is a feasible and effective way to teach interns teamwork skills. It also improves simulated resuscitation quality by shortening the duration.

We report the effect of high glucose infusion on vascular resistance in isolated human placental cotyledons perfused with Krebs-Ringer-bicarbonate solution containing 80 mg/dl (4.4 mmol/L), 160 mg/dl (8.8 mmol/L), or 320 mg/dl (17.6 mmol/L) D-glucose (n = 6). Placental vascular resistance remained constant during 25-minute perfusion periods with 80 mg/dl followed by 160 mg/dl glucose solution. Subsequent perfusion with 320 mg/dl glucose produced a significant increase in placental vascular resistance. Placentas were also studied in which the placental cotyledon was sequentially perfused for 25-minute periods with solutions containing glucose at 80 mg/dl followed immediately by 320 mg/dl (n = 5). Placental vascular resistance remained constant throughout perfusion with 80 mg/dl glucose solution but increased significantly after beginning perfusion with 320 mg/dl glucose. We conclude that the increase in placental vascular resistance appears to be a function of the high glucose level rather than the duration of glucose perfusion.

In 18 chronically instrumented pregnant ewes in late gestation, umbilical extractions of glucose and lactate were determined before and during the continuous infusion of ovine insulin, 0.25 mU/kg . min, into one uterine artery. Studies were conducted in both well-nourished and fasting ewes. Exogenous insulin increased the umbilical extraction of glucose without altering the umbilical extraction of lactate over the range of concentrations of maternal blood glucose encountered in the fed and fasted states. Moreover, the efflux of lactate into the uterine venous circulation in two additional ewes was not altered by the administration of insulin. These studies support the hypothesis that maternal circulating insulin binds to insulin receptors on the microvillous brush border of the placenta to effect an increase in the carrier-mediated transfer of glucose rather than cause an intraplacental decrease in the catabolism of glucose to lactate. The results suggest that, as maternal levels of blood glucose and serum insulin spontaneously rise in concert over the physiologic range, both factors may contribute to the increasing umbilical extraction of glucose. Furthermore, these observations raise the possibility that decreased binding of insulin by placental insulin receptors, which is reported to occur in placentas from diabetic women, may be accompanied by a relatively decreased umbilical uptake of glucose for a given maternal concentration of glucose, but not of lactate.

Infusion of gastrin, G-17I, at 0.4 microgram/min into either the maternal or fetal venous circulation of six late gestation sheep was associated with increases in serum gastrin concentration in the infused circulation and reciprocal decreases in the serum gastrin concentration in the other circulation (contraplacental) that perfused the placenta. Pentagastrin infusion at 0.4 microgram/min was associated with an increase in C-terminal specific gastrin immunoreactivity in both the infused and the contraplacental circulations. These observations suggest that biologically active fragments of gastrin, but not the intact molecule, may cross the ovine placenta. An alternative explanation for our results is that gastrin infusion into either the maternal or fetal circulation which perfuses the placenta may result in the release of an inhibitor (i.e., somatostatin) into the other circulation. Of broad importance, these observations indicate that although intact polypeptide hormones may not traverse the placenta, their concentrations in maternal and fetal sera may not be as independent as previously believed. Serum gastrin half-life values in late gestation sheep fetuses, lambs, and ewes were determined to be 13.7 +/- 1.9, 16.7 +/- 2.6, and 15.2 +/- 2.8 min, respectively. These similar values indicate that the relatively high serum gastrin concentrations observed in near-term sheep fetuses are not the result of prolonged half-life in the fetus.

Total parenteral nutrition has become a mainstay in the management of infants following complicated abdominal surgery. As we have become sophisticated in our understanding of micronutrient nutrition, the term total parenteral nutrition has proved more a goal to be attained than a reality. In an effort to bypass the gastrointestinal tract and nurture critically ill postoperative patients intravenously, a new setting for the manifestation of deficiency states has emerged. This is illustrated by three infants who developed zinc deficiency during postoperative parenteral alimentation despite intravenous zinc supplementation (Fig 1). The pathogenesis of this syndrome and its complications are described, possible etiologies are considered, and recommendations for prevention and therapy are suggested.

Summary: Human and ovine placental tissue homogenates were assayed for dipeptidase activity in vitro. Glycyl-L-leucine, L-leucyl glycine, glycyl-L-lysine, and L-lysyl glycine were hydrolyzed by placental homogenates. The pH optimum for the reaction was 8.0. The relationship between enzyme activity and concentration was linear for placental homogenate concentrations between 0.01 and 0.10 mg protein/ml of reaction mixture. Enzyme activities were 1.92 ± 0.12 (S.E.) μoles/min/mg protein for hydrolysis of glycyl-L-leucine, 0.34 ± 0.06 (S.E.) μmoles/min/mg protein, for hydrolysis of glycy-L-lysine by human placenta, and 2.79 ± 0.8U μmoles/min/mg protein and 0.41 ± 0.25 μmoles/min/mg protein, respectively, by ovine placenta. The infusion of glycyl-L-lucine into the uterine artery of unstressed catheterized pregnant ewes yielded increased concentrations of both component amino acids in uterine venous blood and of leucine in umbilical venous blood. Speculation: The presence of dipeptidase activity in placental homogenates and the observation that glycyl-L-leucine when infused into the main uterine artery is hydrolyzed to its component amino acids support the hypothesis that leucine and possibly glycine extracted from the placenta by the umbilical circulation may be provided by placental hydrolysis of dipeptides which arise within the placenta from the degradation of larger peptides and proteins.

We investigated the perinatal ontogenic changes in ovine serum and tissue gastrin concentration. Fetal and maternal serum gastrin levels in serums obtained from indwelling catheters in the fetal and maternal circulations and tissue gastrin levels were assessed by radioimmunoassay and immunohistochemistry. Fetal serum gastrin concentration was undetectable until the 107th day of gestation and significantly increased to levels surpassing maternal values. Neonatal serum hormone concentration continued to rise, reaching a peak during the 4th postnatal wk and decreasing after the 4th wk coincident with weaning. Maternal serum gastrin concentration did not vary during pregnancy and did not correlate with fetal serum gastrin levels. Fetal abomasal and duodenal gastrin concentrations and abomasal G-cell number increased in parallel with the developmental alterations in fetal serum hormone levels during gestation. The developmental increase in abomasal gastrin concentration was not associated with a shift in the molecular form of the hormone. These findings support the hypothesis that circulating gastrin in the fetus is of fetal origin.

Umbilical glucose and lactate extractions were determined in previously instrumented pregnant ewes into some of which D-glucose was infused to produce graded levels of maternal hyperglycemia as great as 20 mM. While fetal arterial glucose concentration continued to increase linearly as a function of maternal arterial glucose concentration during maternal hyperglycemia, the umbilical venoarterial difference in blood glucose concentration did not, and umbilical glucose extraction approached a plateau at approximately 0.063 mmol X min-1 X kg fetus-1 at maternal glucose concentrations greater than approximately 8 mM. The observed plateau in glucose extraction is consistent with saturation at high maternal glucose concentrations of the carrier mechanism for transport of glucose from the maternal to the fetal aspects of the trophoblast. The observed value of the plateau in umbilical extraction of glucose is slightly less than the maximum extraction predicted from previously published equations for this species, but the maternal blood glucose concentration at which the observed maximum occurred agrees closely with the value predicted by those equations. Umbilical lactate extraction, 0.031 +/- 0.021 mmol X min-1 X kg fetus-1, was independent of maternal arterial blood glucose and lactate concentrations and was independent of umbilical glucose extraction.

Umbilical artery catheterization in the newborn can lead to perforation of the bladder or urachal remnant with extravasation of urine into the peritoneal cavity. We present a case of such an injury that led to uroascites and respiratory distress. This injury usually requires prompt surgical repair for resolution.

To determine the relationship between fetal and maternal plasma insulin concentrations (If, Im) and umbilical uptake of glucose (Qg) and lactate (Ql) in sheep, 6 ewes of 120-130 days gestation were prepared with indwelling catheters in the umbilical vein, fetal pedal artery and vein, and maternal uterine and femoral arteries. Fed state Qg, Ql, If, and I were determined at intervals from the 2nd to the 11th postoperative day (POD). Qg and Ql were determined by the Fick principle employing steady state diffusion of antipyrine to determine umbilical blood flow. Studies were performed before (control n=15) and after (n=15) the perfusion of the uterine artery with ovine insulin 7.5 mU/kg ewe/30 min. Insulin was measured by radioimmunoassay. Results: Control If and Im in μ U/ml increased with increasing POD as described by the following regression equations: If = 0.76 POD + 3.74, (F ratio, p < .025), and Im = 1.86 POD + 8.61, (p < .05). Uterine artery insulin infusion increased Im but did not affect If or Ql. The postoperative increase in If from 5.5-16.0μ μ U/ml was associated with a decrease in Ql in mM/min/kg fetus: Ql = -0.004 If + 0.072 (p < .025). Qg was unrelated to POD, Ql, or If. Conclusions: These studies (1) confirm the lack of ovine insulin transfer across the ovine placenta in vivo, (2) demonstrate increasing Im and If for as long as 11 days after surgery and resumption of maternal nutrition, and (3) show that umbilical lactate uptake is inversely related to fetal plasma insulin concentration, but is independent of umbilical glucose uptake and of maternal plasma insulin concentration.