Outcome prediction in Greek neonatal intensive care units using a score for neonatal acute physiology (SNAP)

OBJECTIVES: This study was undertaken to evaluate the performance of the score for neonatal acute physiology (SNAP) in Greece, to examine the predictive power of SNAP calculated during the 12 hours after admission in comparison with customarily calculated SNAP during the first 24 hours, and to assess SNAP during the second 12 hours from admission as a measure of response to treatment. METHODOLOGY: A total of 579 newborns admitted to three neonatal intensive care units (NICUs) from two cities in Greece were enrolled in the study; SNAP was determined during the first 12 hours, the second 12 hours, and the first 24 hours from admission to the NICU and calculated using an algorithm based on deviations from normal values of 26 physiologic parameters. RESULTS: All three variants of SNAP were powerful predictors of vital status at discharge, as well as of duration of stay among survivors. A five-point increase in SNAP in the first 12 hours corresponds to a more than twofold ratio in the odds for death, whereas a five-unit difference in SNAP from the second 12 hours corresponds to a more than threefold ratio. The combined 24-hour score was similar to that for the first 12 hours. A considerable advantage of SNAP was its independence from more traditional predictors of neonatal death, notably gestational age, birth weight, and Apgar score. The combination of all of these predictors improved further the overall predictive potential. CONCLUSIONS: SNAP is a useful tool in medical research and can be applied in different population groups. Its independence from birth weight underlines its added value to predict fatality ratios. Moreover, the results of the present study indicate that SNAP can be estimated without loss of predictive efficiency during the first 12 hours from admission to the NICU, whereas SNAP during the second 12 hours adequately reflects the effectiveness of early medical interventions.

A randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation.

OBJECTIVE: To determine whether continuous intrapartum electronic fetal heart rate monitoring (EFM) is associated with decreased perinatal mortality and morbidity compared with intermittent auscultation. METHODS: The study was conducted simultaneously at two university hospitals in Athens, Greece (Alexandra and Marika Iliadi Hospitals) from October 1, 1990 to June 30, 1991. All patients with singleton living fetuses and gestational ages of 26 weeks or greater were eligible for inclusion. The participants were assigned to continuous EFM or intermittent auscultation based on the flip of a coin. Both groups were followed during labor according to the most recent ACOG guidelines. However, fetal scalp blood pH and crossover from one group to the other were not used. RESULTS: A total of 1428 patients were included, 746 in the EFM group and 682 in the auscultation group. There were no differences between the groups in terms of maternal age, gravidity, parity, gestational age, and number of antepartum high-risk factors. More patients monitored electronically received oxytocin for either augmentation (52.4 versus 38.1%; P = .0001) or induction (15.6 versus 7%; P = .0001). The length of labor was longer in the EFM group (first stage 6.1 +/- 4.3 versus 5.5 +/- 3.7 hours; P = .006; second stage 29.4 +/- 18.6 versus 26.9 +/- 16.9 minutes; P = .01). There was a higher incidence of nonreassuring fetal heart rate patterns in the EFM group (23.4 versus 10.7%; P = .0001) and a higher rate of surgical intervention (11.2 versus 4.8%; P = .0001). This difference pertained to both vacuum extraction (5.8 versus 2.4%; P = .002) and cesarean delivery for suspected fetal distress (5.3 versus 2.3%; P = .005). There were no differences in 1- and 5-minute Apgar scores, fetal acidosis at birth, need for neonatal resuscitation, neonatal intensive care unit admission, use of assisted ventilation, neonatal hospital stay, or any other neonatal complications. Two neonatal deaths occurred in the EFM group and nine perinatal deaths in the auscultation group (two intrapartum and seven neonatal deaths). The perinatal mortality rates were 2.6 per 1000 and 13 per 1000 total births, respectively (P = .04). The two deaths in the EFM group and three of the neonatal deaths in the auscultation group may not have been prevented by intrapartum monitoring; however, four neonatal deaths from the auscultation group occurred in depressed (5-minute Apgar scores less than 7), acidotic (cord artery pH at or below 7.13) infants. The perinatal death rate related to fetal hypoxia was significantly less in the EFM group (zero of 746 versus six of 682; P = .03). CONCLUSION: In this controlled trial, intrapartum EFM, as the primary and only method of intrapartum fetal surveillance, was associated with decreased perinatal mortality due to fetal hypoxia but also with higher rates of surgical intervention for suspected fetal distress.

Serum levels of creatine kinase and its isoenzymes during the 1st postpartum day in healthy newborns delivered vaginally or by cesarean section.

The purpose of this study is to investigate the relationship of creatine kinase (CK) and its isoenzyme levels in the newborn to the mode of delivery, time interval from birth (divided in four 6-hour time periods), parity and sex of the neonates. During the 1st postpartum day, serum levels of CK and its isoenzymes (CK-MM, CK-MB, CK-BB) were determined from 115 healthy full-term neonates born consecutively either by spontaneous vaginal delivery (VD, n = 85) or by elective cesarean section (CS, n = 30). The multiple regression analysis was applied. Total CK levels were positively correlated with VD (p < 0.0003). This was mainly attributed to a rise in the CK-MM activity which presented a similar pattern to CK. CK-MB activity was also positively correlated with VD. In contrast, CK-BB was negatively correlated to the postpartum time period. Neonatal sex and parity did not influence CK and its isoenzyme levels significantly. In conclusion, VD contributes significantly to an increase in CK levels during the 1st day of extrauterine life.

Complex chromosome rearrangement in a retarded girl with malformations.

An apparently balanced unusual chromosome rearrangement involving chromosomes 2, 3, 4, 5 and 10 is reported in a 13 months old girl with multiple malformations and mental retardation.

Unusual ocular findings in an infant with cri-du-chat syndrome.

A newborn male with cri-du-chat syndrome, congenital nuclear cataracts, microspherophakia, and probably ectopic lenses is reported. Microspherophakia in cri-du-chat syndrome has not been previously described. The congenital cataracts were inherited from his mother who had a balanced 5;13 translocation; the two events are considered to be coincidental and a possible 'position effect' was excluded, since the other members of her family with congenital cataracts, were chromosomally normal. This is the fourth case reported where familial cri-du-chat syndrome involves chromosomes 5p and 13q.

Treatment of severe neonatal infections with cefotaxime. Efficacy and pharmacokinetics.

We studied the pharmacokinetics and efficacy of cefotaxime in 32 neonates with severe gram-negative infections. Many of these patients had been treated unsuccessfully with combinations of antibiotics. Eighty-one percent of these patients were cured, 6% improved, and 13% had treatment failures; there were three deaths. Eighteen patients received cefotaxime alone; 16 were cured and two improved. These data indicate an efficacy of cefotaxime sufficient to warrant more rigorous future trials. The elimination half-life of cefotaxime ranged from 2.0 +/- 0.4 hours in term neonates more than one week of age to 5.7 +/- 0.8 hours in preterm neonates less than one week of age. A volume of distribution of approximately 0.63 L was similar for all infants irrespective of age and maturity. These kinetic data can be used in design of future therapeutic regimens in more rigidly controlled trials assessing indications for cefotaxime therapy in neonates. We recommend dosing as follows, using a dose of 25 mg/kg: every 12 hours for preterm infants less than one week of age, every 8 hours for preterm infants one to four and term infants less than one week of age, and every 6 hours for term infants more than one week of age.

Coupled-mode theory approach to nonlinear pulse propagation in optical fibers.

The formalism of coupled-mode theory is adopted for describing nonlinear pulse propagation in optical fibers, the coupling being induced by the nonlinear part of the refractive index. This approach describes in a natural way the influence of the waveguide, and in principle allows of the possibility of investigating soliton propagation when more than one mode is excited.

Role of intensity fluctuations in nonlinear pulse propagation.

The effect of intensity fluctuations and the finite coherence time of the field on the propagation of nonlinear optical pulses is discussed. In particular, the statistical properties of the carrier are shown to affect the power level for soliton propagation.