Comparison of Two Tourniquets on a Mid-Thigh Model: The Israeli Silicone Stretch and Wrap Tourniquet vs. The Combat Application Tourniquet.

Introduction: Experience from recent conflicts underlines the dramatic impact of effective tourniquet use on combat casualty mortality. Although the Combat Application Tourniquet (CAT) is replacing the silicone band tourniquets (IST; "Israeli Silicone Tourniquet") in the Israeli Defense Forces, no direct comparison was made between them. The purpose of this study is to compare the performance of the two tourniquets on a mid-thigh model. Methods: Participants were Israeli military recruits who previously had the military first aid course. Each participant applied both the CAT and the IST. Applications were assessed by the HapMed Leg Tourniquet Trainer, which measured the applied pressure and the time required to reach it. Results: IST application resulted in higher rates of effective occlusion pressure compared with the CAT (91% vs. 73.1%, p < 0.01), and a higher mean occlusion pressure (41 mmHg, p < 0.01) was recorded using the IST. Among effective attempts, application time did not differ significantly between the tourniquets. Conclusion: The IST was superior to the CAT in producing effective occlusion pressure while not prolonging application time. These results may indicate that the IST remains a valid option for controlling mid-thigh bleeding.

3D printed microfluidic circuitry via multijet-based additive manufacturing.

The miniaturization of integrated fluidic processors affords extensive benefits for chemical and biological fields, yet traditional, monolithic methods of microfabrication present numerous obstacles for the scaling of fluidic operators. Recently, researchers have investigated the use of additive manufacturing or "three-dimensional (3D) printing" technologies - predominantly stereolithography - as a promising alternative for the construction of submillimeter-scale fluidic components. One challenge, however, is that current stereolithography methods lack the ability to simultaneously print sacrificial support materials, which limits the geometric versatility of such approaches. In this work, we investigate the use of multijet modelling (alternatively, polyjet printing) - a layer-by-layer, multi-material inkjetting process - for 3D printing geometrically complex, yet functionally advantageous fluidic components comprised of both static and dynamic physical elements. We examine a fundamental class of 3D printed microfluidic operators, including fluidic capacitors, fluidic diodes, and fluidic transistors. In addition, we evaluate the potential to advance on-chip automation of integrated fluidic systems via geometric modification of component parameters. Theoretical and experimental results for 3D fluidic capacitors demonstrated that transitioning from planar to non-planar diaphragm architectures improved component performance. Flow rectification experiments for 3D printed fluidic diodes revealed a diodicity of 80.6 ± 1.8. Geometry-based gain enhancement for 3D printed fluidic transistors yielded pressure gain of 3.01 ± 0.78. Consistent with additional additive manufacturing methodologies, the use of digitally-transferrable 3D models of fluidic components combined with commercially-available 3D printers could extend the fluidic routing capabilities presented here to researchers in fields beyond the core engineering community.

Recommendations for involving the family in developmental care of the NICU baby.

Family involvement is a key to realize the potential for long-lasting positive effects on physical, cognitive and psychosocial development of all babies, including those in the neonatal intensive care unit (NICU). Family-centered developmental care (FCDC) recognizes the family as vital members of the NICU health-care team. As such, families are integrated into decision-making processes and are collaborators in their baby's care. Through standardized use of FCDC principles in the NICU, a foundation is constructed to enhance the family's lifelong relationship with their child and optimize development of the baby. Recommendations are made for supporting parental roles as caregivers of their babies in the NICU, supporting NICU staff participation in FCDC and creating NICU policies that support this type of care. These recommendations are designed to meet the basic human needs of all babies, the special needs of hospitalized babies and the needs of families who are coping with the crisis of having a baby in the NICU.

High-versus low-threshold surfactant retreatment for neonatal respiratory distress syndrome.

UNLABELLED: Surfactant therapy has become an effective standard therapy for infants with respiratory distress syndrome (RDS). The first dose may be given either as prophylaxis immediately after delivery, or as rescue after an infant has developed RDS. Second and subsequent doses are currently recommended by the manufacturers to be administered at minimal levels of respiratory support. PURPOSE: This study compared the relative efficacy of administering second and subsequent doses of Infasurf surfactant at a low threshold (FIO(2) >30%, still requiring endotracheal intubation) versus a high threshold (FIO(2) >40%, mean airway pressure >7 cm H(2)O) of respiratory support. METHODS: A total of 2484 neonates received a first dose of surfactant; 1267 reached conventional retreatment criteria and were randomized to be retreated according to low- or high-threshold criteria. They were then retreated at a minimum of 6-hour intervals each time they reached their assigned threshold until receiving a maximum of 4 total doses. Subjects were stratified by whether they received their first dose by prophylaxis or rescue and by whether their lung disease was considered complicated (evidence of perinatal compromise or sepsis) or uncomplicated. RESULTS: Among the patients randomized, 33% of prophylaxis and 23% of rescue subjects met criteria for the complicated stratum. Although infants allocated to the high-threshold strategy were receiving slightly more oxygen at 72 hours, there was no difference in the number receiving mechanical ventilation at 72 hours or in the secondary respiratory outcomes (requirement for supplemental oxygen or mechanical ventilation at 28 days, supplemental oxygen at 36 weeks' postconceptional age, inspired oxygen concentration >60% at any time). However, there was a significantly higher mortality for infants with complicated RDS who had received retreatment according to the high-threshold strategy. CONCLUSIONS: We conclude that equal efficacy can be realized by delaying surfactant retreatment of infants with uncomplicated RDS until they have reached a higher level of respiratory support than is the current standard. We speculate that this would result in a substantial cost-saving from less utilization of drug. Conversely, we believe that infants with complicated RDS should continue to be treated by the low-threshold retreatment strategy, which is currently recommended by the manufacturers of the commercially available surfactants.

Role of postnatal penicillin prophylaxis in prevention of neonatal group B streptococcus infection.

This prospective study was designed to identify the role of postnatal penicillin prophylaxis in the prevention of neonatal group B streptococcus (GBS) infection. We studied 10 998 infants. Of these, 5389 were in the penicillin prophylaxis group (PP) and 5609 infants did not receive penicillin prophylaxis (NPP). Infants were allocated to treatment by month of birth, alternating 3-mo blocks or 2-mo blocks to the two groups after the first block was randomly assigned. The use of PP reduced the incidence of clinical sepsis (1.7% PP versus 2.5% NPP, p < 0.01), GBS infection (0.4% PP versus 0.9% NPP, p < 0.001) and deaths from sepsis (0.1% PP versus 0.3% NPP, p < 0.05). We conclude that the routine use of postnatal penicillin prophylaxis appears to be effective in reducing the incidence of clinical sepsis and death from sepsis in neonates.

Measles, mumps, and rubella serology in premature infants weighing less than 1,000 grams.

BACKGROUND: This study was done to determine antibodies to measles, mumps, and rubella within the first 2 weeks of life and 3 months of age in premature infants. METHODS: All premature infants (< 32 weeks' gestation) weighing less than 1,000 g and admitted to the neonatal intensive care unit were eligible for inclusion in the study. Measles, mumps, and rubella titers were obtained from the mother and from the infant during the first 2 weeks of life and at 3 months of age. RESULTS: A total of 44 maternal-infant pairs were enrolled. At birth, 45% of the infants were seronegative for measles, 55% for mumps, and 48% for rubella. Maternal samples revealed seronegativity in 14%, 3%, and 17%, respectively. By 3 months of age, 100% of infants were seronegative for mumps and rubella, and 94% were seronegative for measles. CONCLUSIONS: The majority of prematurely born infants are seronegative for measles, mumps, and rubella by 3 months of age and therefore are presumably susceptible to infection during the first year of life.

Normal and atypical butyrylcholinesterases in placental development, function, and malfunction.

1. In utero exposure to poisons and drugs (e.g., anticholinesterases, cocaine) is frequently associated with spontaneous absorption and placental malfunction. The major protein interacting with these compounds is butyrylcholinesterase (BuChE), which attenuates the effects of such xenobiotics by their hydrolysis or sequestration. Therefore, we studied BuChE expression during placental development. 2. RT-PCR revealed both BuChEmRNA and acetylcholinesterase (AChE) mRNA throughout gestation. However, cytochemical staining detected primarily BuChE activity in first-trimester placenta but AChE activity in term placenta. 3. As the atypical variant of BuChE has a narrower specificity for substrates and inhibitors than the normal enzyme, we investigated its interactions with alpha-solanine and cocaine, and sought a correlation between the occurrence of this variant and placental malfunction. 4. Atypical BuChE of serum or recombinant origin presented > 10-fold weaker affinities than normal BuChE for cocaine and alpha-solanine. However, BuChE in the serum of the heterozygote and a homozygous normal were similar in their drug affinities. Therefore, heterozygous serum or placenta can protect the fetus from drug or poison exposure, unlike homozygous atypical serum or placenta. 5. Genotype analyses revealed that heterozygous carriers of atypical BuChE were threefold less frequent among 49 patients with placental malfunction than among 76 controls of the entire Israeli population. These observations exclude heterozygote carriers of atypical BuChE from being at high risk for placental malfunction under exposure to anticholinesterases.

Muscle rigidity due to fentanyl infusion in the pediatric patient.

Two cases of fentanyl-induced muscle rigidity are presented. Significant features of these cases include the unusual pattern of rigidity and the use of fentanyl doses lower than those usually associated with muscle rigidity.

Postnatal penicillin prophylaxis and the incidence of group B streptococcal sepsis in neonates.

We conducted a retrospective chart review of infants, born over a 3-year period, who had positive urine latex agglutination and/or positive blood culture for group B streptococci (GBS). Infants routinely received intramuscular aqueous penicillin for the first half of the study period, and no penicillin was given for the subsequent 18 months. Overall, infants who received penicillin prophylaxis had a decreased incidence of clinical sepsis and positive blood culture for GBS (4.8/1,000 versus 8/1,000 and 1.3/1,000 versus 5.4/1,000, respectively). The incidence of GBS sepsis during the time of penicillin prophylaxis was not different from that in previously reported studies. When analyzed by weight groups, no difference in clinical sepsis or positive blood cultures for GBS was seen in the subset of infants weighing < or = 2,500 g at birth. There were fewer positive blood cultures in the infants who received penicillin and met the criteria for clinical sepsis. Mortality from GBS sepsis was unchanged during these two study periods in all weight groups.

Neonatal fungemia and amphotericin B.

Disseminated candidemia is a common nosocomial infection in the neonatal intensive care unit, though only a few studies have reported the outcome of amphotericin B therapy in neonatal candidiasis. Our treatment regimen consisted of an initial daily amphotericin B dose of 0.5 mg/kg. (For infants weighing > 1 kg, the second dose was increased to 1 mg/kg.) At 3 to 5 days, if the blood culture was negative, amphotericin B therapy was changed to every other day and continued for a total of 10 doses. Records of 36 patients given this regimen were reviewed for signs of toxicity or treatment failure. The mean birth weight was 988 +/- 510 g, and the gestational age was 28 +/- 3.9 weeks. The patients were ventilated for 13 +/- 15 days and had central lines for 6.7 +/- 9.3 days before development of candidemia. The mean age at onset of candidemia was 29.1 +/- 19.8 days. The interval from culture to treatment was 2.9 days. Six of 36 patients died, 2 of candidal meningitis and 4 of complications unrelated to candidal infection. Thirteen (36%) of the patients had candidal pustules during the course of their disease; 1 had osteomyelitis. There was no evidence of toxicity from this drug regimen and no apparent treatment failures. There were no changes in BUN and creatinine before or during therapy and no change in total urinary output. Blood cultures became sterile except in one patient who died on the first day of therapy. Most of the patients in this study had candidemia in the absence of a central indwelling catheter. Further prospective pharmacokinetic and therapeutic studies are warranted for this regimen of amphotericin B, which carries a low risk for toxicity.

Torulopsis glabrata in the neonate: an emerging fungal pathogen.

Fungi are becoming increasingly common nosocomial pathogens in the neonatal intensive care patient. The fungus Torulopsis glabrata, a common skin inhabitant, is a potential pathogen in the high-risk neonate. In this report we have reviewed the cases of two infants in which systemic T glabrata infection was diagnosed. One patient survived without apparent sequelae; the other died before diagnosis and initiation of therapy. Five other cases of systemic infection by T glabrata in neonates have been reported previously, with only one survivor. Early recognition and treatment of this nearly uniformly fatal infection is imperative.

Cardiovascular responses of heart transplant patients to exercise training.

Orthotopic heart transplantation (OHT) represents an effective alternative for individuals with end-stage heart disease. The current literature reports only the responses of OHT patients to greater than or equal to 4 mo of exercise training (ET) and frequently lacks adequate controls. Most programs currently treating OHT patients usually provide 6-12 wk of ET. This study describes the effects of a 10-wk supervised ET program in 12 male OHT patients and 5 other male OHT patients who served as a comparison group. Graded exercise tests were performed before and after ET. After ET, maximal O2 consumption was significantly greater for the ET group than the comparison group (P less than 0.05) and the mean increase in peak heart rate was 18 +/- 4 and 6 +/- 4 (SE) min-1 for ET and comparison groups, respectively (P less than 0.05). Maximal ventilation was also significantly greater for the ET group at after ET, while resting heart rate and blood pressure and peak blood pressure, O2 pulse, respiratory rate, and ventilatory equivalents for O2 and CO2 were not significantly changed. We conclude that after OHT a 10-wk ET program improves maximal O2 consumption and, by improving peak heart rate, improves O2 delivery.

Transvenous reservoir catheter mimicking right atrial mass lesion.

A reservoir (Mediport) catheter in the superior vena cava and right atrium can present as a right atrium mass lesion by echocardiography. Unlike pacemaker or transvenous catheters, these are not easily detected because the implant sites are not obvious and they are not attached to external intravenous device. Transvenous reservoír catheters should be considered in the echocardiographic diagnosis of right atrial mass lesion.