Bronchopulmonary dysplasia: then and now.

When bronchopulmonary dysplasia (BPD) was first described in 1967, the use of assisted ventilation in neonates was in its infancy. High concentrations of oxygen were implicated, and BPD was equated with 'pulmonary oxygen toxicity'. The etiologic role of not only oxygen but also peak inspiratory pressures and the duration of exposure to both was emphasized in the 1970s, but BPD remained a dreaded complication of managing respiratory distress syndrome in the 1980s. It was only after exogenous surfactant became commercially available for endotracheal administration that 'classical' BPD began to disappear and was replaced by the 'new' BPD. 'Classical' BPD was seen in more mature preterm infants (>28 weeks' gestational age) and in its severe form was characterized radiographically by micro- and macrocysts of the lung, lung hyperinflation and flattening of the diaphragms. In contrast, 'new' BPD is seen in less mature infants (<28 weeks' gestational age), has comparatively mild radiographic abnormalities and has been defined as continued oxygen requirement at 36 weeks' postmenstrual age. Pathologically, 'classical' BPD frequently revealed obstructive bronchiolitis and fibrosis of lung parenchyma, whereas 'new' BPD demonstrates minimal fibrosis but uniform arrest of development. Herein, factors which may contribute to the etiology of BPD are described, as well as possible preventative and therapeutic strategies.

Chronic lung disease of prematurity: a short history.

Chronic lung disease of prematurity (CLD) is commonly considered to be a consequence of assisted ventilation. However, prior to the description in 1967 of bronchopulmonary dysplasia (BPD), following ventilator therapy for respiratory distress syndrome, Wilson-Mikity syndrome (WMS) had been described in very preterm infants on minimal oxygen supplementation. In the 1970s and 1980s, many infants treated with assisted ventilation required prolonged mechanical ventilation after developing radiographic features of coarse infiltrates, severe hyperinflation, and microcystic changes, associated with hypercarbemia and the need for increased inspired oxygen concentrations. Some infants died and showed evidence of pulmonary fibrosis, obstructive bronchiolitis, and dysplastic change. The role of supplemental oxygen, positive pressure ventilation, and the immaturity of the lung have long been considered important in the etiology of CLD/BPD. More recently, the role of inflammation (particularly antenatal exposure to cytokines) and individual susceptibility (genetic predisposition) have assumed greater etiologic importance. The historical setting into which corticosteroid treatment for BPD was introduced is also discussed. After the licensing of exogenous surfactant to treat RDS in the early 1990s and more widespread use of prenatal corticosteroids in the mid-1990s, severe BPD became an unusual event. Gradually, the diagnosis of CLD, still often referred to as BPD, was based on an oxygen requirement at 36 weeks postmenstrual age. However, it is not clear that this 'new BPD' is substantially different from WMS. It is difficult to make prognostications about long-term lung function of these infants based on oxygen 'requirement' at 36 weeks, since supplemental oxygen is frequently used unnecessarily.

Depression and anxiety symptoms after lower limb amputation: the rise and fall.

OBJECTIVE: To examine the time course of anxiety and depressive symptoms over a three year period after amputation. DESIGN AND SETTINGS: A prospective study in inpatients admitted to a rehabilitation ward after lower limb amputation. SUBJECTS: Successive admissions over a one-year period of whom 68 were alive at follow-up, 2-3 years later. INTERVENTIONS: Nil. MAIN MEASURES: Hospital Anxiety and Depression Scale (HADS) on admission and discharge from inpatient rehabilitation and at a 2.7(SD=0.4) year mean follow-up period with correlation to demographic and patient features. RESULTS: Of the 68 responding patients, 12 (17.6%) and 13 (19.1%) had symptoms of depression and anxiety respectively. This compared to an original incidence of 16 (23.5%) for both on admission and 2 (2.9%) on discharge. This rise in incidence from time of discharge was highly significant for both depression (P<0.001) and anxiety (P<0.001). Depression at follow-up was correlated to depressive symptoms at admission (P=0.03) and to having other significant comorbidities (P=0.02). Anxiety symptoms were commoner in younger patients (P=0.03). There was no association with age, gender, living in isolation, vascular cause for amputation, wearing a limb prosthesis or length of original inpatient stay. CONCLUSIONS: Depression and anxiety are common after lower limb amputation but resolve during inpatient rehabilitation. The incidence then rises again after discharge.

Gender differences in amputation outcome.

PURPOSE: To assess the influence of gender on the success of limb-fitting after amputation. METHODS: One-hundred and five successive in-patients admitted to an amputee rehabilitation ward were followed to assess the success of limb-fitting at discharge. The influence of demographic, clinical and social factors on the success of lower limb-fitting was assessed using linear regression analysis and group comparisons. RESULTS: There were 35 (33%) women in a cohort of 105 successive admissions. Men and women were comparable in terms of age, length of stay, medical comorbidity and level of amputation. Women were less likely to be successfully fitted with a prosthetic limb at discharge than men (42.9% vs. 68.6%, p = 0.011), and more women lived alone (57.1% vs. 38.6%, p = 0.021). Linear regression revealed that gender was an independent significant factor in the success of limb-fitting; age, level and cause of amputation, co-morbidity and length of stay were not significant factors. CONCLUSIONS: Women were less likely to be successfully fitted with a lower limb prosthesis after amputation.

The rapid resolution of depression and anxiety symptoms after lower limb amputation.

OBJECTIVE: To ascertain the course of depressive and anxiety symptoms shortly after amputation and again after a period of inpatient rehabilitation. DESIGN AND SETTINGS: A cohort study in inpatients admitted to a rehabilitation ward after lower limb amputation. SUBJECTS: One hundred and five successive admissions over a one-year period. INTERVENTIONS: Nil. MAIN MEASURES: Hospital Anxiety and Depression Scale (HADS) on admission and discharge with correlation to demographic and patient features. RESULTS: At admission, 28 (26.7%) and 26 (24.8%) patients had symptoms of depression and anxiety respectively. This dropped to 4 (3.8%) and 5 (4.8%) by time of discharge, a mean of 54.3 days later. These reductions were statistically significant, as was the association between patients having symptoms of both depression and anxiety (P < 0.001). Patient stay was longer in those with symptoms (depression, P < 0.03; anxiety P < 0.001). There was no association with level of amputation, success of limb-fitting, age or gender. Depressive symptoms were associated with presence of other medical conditions (P < 0.01) and anxiety scores with living in isolation (P < 0.05). CONCLUSION: Depression and anxiety are commonly reported after lower limb amputation and previously thought to remain high for up to 10 years. We have found that levels of both depression and anxiety resolve rapidly. It is possible that a period of rehabilitation teaching new skills and improving patient independence and mobility may modify the previous bleak outlook of amputees. This positive finding may be useful in the rehabilitation of even the most distressed of amputees.

Fluid collections in amputee stumps: a common phenomenon.

OBJECTIVES: To assess the incidence of fluid collections in postoperative amputee stumps and the impact on limb-fitting outcomes in patients with such collections. DESIGN: Cohort study. SETTING: Inpatient rehabilitation ward. PARTICIPANTS: Successive patients with amputation examined with ultrasound over 1 year. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The presence of discrete fluid collections on admission and outcomes of successful limb fitting, length of inpatient stay, and presence of psychologic symptoms. RESULTS: In 105 consecutive admissions, we detected discrete fluid collections in 28 (27%) of stumps with a median volume of 38.5 mL (range, 16-216 mL). All collections diminished and disappeared by discharge with 81% undetectable within 30 days since surgery. A transfemoral amputee was more likely to develop a collection than a transtibial amputee (P<.01). Patients with collections took 9.5 days longer to achieve limb fitting (P=.04) and had a 10-day longer inpatient stay (P=.02). However, the overall success of limb fitting was similar as was the incidence of psychologic distress. CONCLUSIONS: Discrete fluid collections are common in postoperative amputation stumps but regress by discharge. Although limb fitting may be delayed, the ultimate success of limb fitting is not reduced and patients can be reassured.

Alphabetical prejudice in team discussions (or would Zebedee ever get seen on a ward round).

PURPOSE: To ascertain whether the order in which patients are discussed in a team meeting determines the time spent on discussion. DESIGN: Prospective study over 18 consecutive multidisciplinary team meetings. SETTING/SUBJECTS: Multidisciplinary team meetings on a Brain Injury Rehabilitation Unit, Edinburgh. MAIN OUTCOME MEASURE: Time spent discussing each case. RESULTS: Patients discussed early on received 3-4 minutes more discussion time than those later on. This was highly significant on a one-way analysis of variance (P < 0.001). CONCLUSIONS: Preferential treatment of patients who come at the start of the team meeting is a real phenomenon. Such alphabetical prejudice, where it exists, should be addressed.

Predicting those who will walk after rehabilitation in a specialist stroke unit.

OBJECTIVE: To establish whether the ability to use a wheelchair shortly after a stroke or continence are related to the likelihood of walking by time of discharge. DESIGN AND SUBJECTS: An observational study in patients admitted to a stroke rehabilitation unit for under-65s over a three-year period. METHODS: Functional Independence Measure (FIM) subscores for walking were examined on all patients at time of admission and discharge. Walking was defined by an FIM > or = 5 in that section. Comparisons were then made between those who could self-propel a wheelchair within a week of admission with those who could not. Continence (defined by an FIM subscore of > or = 6 in that category) was also correlated to walking at discharge. MAIN OUTCOME MEASURE: Walking at time of discharge defined by an FIM > or = 5 in that section. RESULTS: From 393 admissions, 135 were excluded because they could already walk (FIM subscore > or = 5 in that particular section) and three died during their admission. Out of the remaining 255 patients, 108 could self-propel on admission and 147 could not. While 105 (97%) of the self-propellors could walk by time of discharge, only 91 (62%) of the non-propellors could do so (chi2 = 42.237, df = 1, P < 0.001, odds ratio (OR) 21.54 (6.52-71.51)). Although continence also predicted improved likelihood of walking, this was at a lower level of significance and correspondingly lower odds ratio (chi2=5.894, df = 1, P= 0.015, OR 1.94 (1.13-3.32)). CONCLUSIONS: The ability to self-propel a wheelchair shortly after a stroke is a significant predictor of eventually being able to walk. Our data suggest that it is even more significant than continence, which is the most consistent predictor previously found.

The evolution of neonatology.

In 1960, the terms "neonatology" and "neonatologist" were introduced. Thereafter, an increasing number of pediatricians devoted themselves to full-time neonatology. In 1975, the first examination of the Sub-Board of Neonatal-Perinatal Medicine of the American Board of Pediatrics and the first meeting of the Perinatal Section of the American Academy of Pediatrics were held. One of the most important factors that improved the care of the neonate was the miniaturization of blood samples needed to determine blood gases, serum electrolytes, glucose, calcium, bilirubin, and other biochemical measurements. Another factor was the ability to provide nutrition intravenously, and the third was the maintenance of normal body temperature. The management of respiratory distress syndrome improved with i.v. glucose and correction of metabolic acidosis, followed by assisted ventilation, continuous positive airway pressure, antenatal corticosteroid administration, and the introduction of exogenous surfactant. Pharmacologic manipulation of the ductus arteriosus, support of blood pressure, echocardiography, and changes in the management of persistent pulmonary hypertension, including the use of nitric oxide and extracorporeal membrane oxygenation, all have influenced the cardiopulmonary management of the neonate. Regionalization of neonatal care; changes in parent-infant interaction; and technological changes such as phototherapy, oxygen saturation monitors, and brain imaging techniques are among the important advances reviewed in this report. Most remarkable, a 1-kg infant who was born in 1960 had a mortality risk of 95% but had a 95% probability of survival by 2000. However, errors in neonatology are acknowledged, and potential directions for the future are explored.

Prevention of intraventricular hemorrhage by indomethacin in male preterm infants.

Our multicenter Indomethacin Intraventricular Hemorrhage (IVH) Prevention Trial demonstrated a reduction of IVH in preterm infants. Analysis of our cohort by sex showed indomethacin halved the incidence of IVH, eliminated parenchymal hemorrhage, and was associated with higher verbal scores at 3 to 8 years in boys.

Frequency and timing of symptoms in infants screened for sepsis: effectiveness of a sepsis-screening pathway.

To determine the frequency and timing of symptoms and to evaluate the effectiveness of a sepsis-screening pathway in term and near-term infants, data were collected prospectively for a period of 1 year from December 1, 2000, to November 30, 2001. Results confirmed that a sepsis-screening pathway using a combination of at least 2 serial complete blood cell count and C-reactive protein measurements in both symptomatic and asymptomatic infants is a safe, simple strategy that prevents unnecessary treatment of infants with risk factors with antibiotics. However, most infants with presumed or suspected early-onset sepsis are symptomatic. Routine treatment of asymptomatic infants with risk factors or prior treatment with intrapartum antibiotics is unnecessary. A combined approach of screening in the presence of risk factors and /or symptoms of sepsis and adequate follow-up for infants discharged at less than 72 hours of age may help reduce unnecessary treatment of infants with antibiotics.