Use of fraction flow reserve to predict changes over time in management of superficial femoral artery.

BACKGROUND: Peripheral arterial disease is a condition characterized by progressive arterial narrowing, which affects patients' quality of life. The purposes of this study were to (1) establish the feasibility of obtaining peripheral fractional flow reserve (pFFR) in the peripheral vascular circulation, (2) demonstrate an association between baseline pFFR and peak systolic velocity (PSV) measured by duplex ultrasound, and (3) correlate postintervention pFFR with future restenosis using the change in PSV over time as a surrogate. METHODS: Twenty patients underwent baseline ankle brachial index (ABI) and PSV testing. Pre- and postintervention pFFR was performed. Patients were followed with three ABI and PSV recordings during the 1 year follow-up period. The association between baseline PSV, ABI, and pFFR with changes in PSV over time were explored. Predictors of postprocedural PSV over time were determined. RESULTS: The baseline translesional-resting ratio was significantly different from the pFFR using adenosine (0.79 ± 0.08 vs. 0.71 ± 0.09, P = 0.01). Baseline PSV was significantly associated with preintervention pFFR (-0.77, P < 0.001). Compared to patients with a postprocedure pFFR > 0.95, patients with a postprocedure pFFR < 0.95 had a significantly more rapid rise in PSV over time (P = 0.009). CONCLUSION: This is the first study to demonstrate that the peripheral vascular bed does respond to vasodilatation thereby supporting the use of pFFR for this procedure. In our study, postintervention pFFR < 0.95 predicted a more rapid increase in PSV over time, which is a reasonably accepted surrogate for restenosis.

Impact of maternal medication for opioid use disorder on neurodevelopmental outcomes of infants treated for neonatal opioid withdrawal syndrome.

BACKGROUND: Increasing rates of maternal opioid use disorder has led to greater number of opioid exposed newborns (OENs). Maternal enrollment in medication for opioid use disorder (MOUD) program improves short term neonatal outcomes. This study aimed at assessing neurobehavioral outcomes for OENs. METHODS: Retrospective observational cohort study of OENs between Jul 2006 and Dec 2018. Two study groups were identified as initiation of medication for opioid use disorder (MOUD) prior to diagnoses of pregnancy or after. Primary outcome variables were enrollment in and duration of EI services. Secondary outcome variable was diagnoses of a behavioral and/or developmental disorder (BDD) during the study period. RESULTS: Of 242 infants, 113 were enrolled in EI and BDD diagnoses data was available for all infants [age range 6 to 12 years], 82% infants had exposure to maternal MOUD, while 18% were exposed to either maternal prescription non-MOUD opioids or illicit opioids. Maternal MOUD initiation prior to pregnancy was associated with improved short term outcomes for OENs. Almost a third of infants were diagnosed with a BDD with no differences between the two study groups. CONCLUSION: Early initiation of maternal MOUD improved short term outcomes and discharge disposition for OENs. Prolonged in-utero exposure to opioids presents a potential for negative impact on neurodevelopmental and behavioral outcomes. These risks must be considered to increase access and adherence to EI services, as well as to focus on non-opioid based maternal MOUD. Longitudinal studies assessing the safety of MOUD on short and long-term child health outcomes are needed.

NICU lactation consultant increases percentage of outborn versus inborn babies receiving human milk.

OBJECTIVE: To determine the effect of a dedicated lactation consultant (LC) on the percentage of neonates receiving any human milk in the neonatal intensive care unit (NICU) and at discharge over time. STUDY DESIGN: Retrospective chart review of three time periods of 3 months each; Time period 1 (before LC hire), Time period 2 (T2; after LC arrival) and Time period 3 (subsequent period after T2). RESULT: Percentage of infants receiving any HM during hospital stay and at discharge increased significantly over time after LC hire and with LC experience. Outborn (OB) infants receiving any HM in the NICU and at discharge increased over time, but there was no significant change for inborn infants, as the proportion receiving any HM remained consistently high over time. CONCLUSION: Addition of a dedicated LC to the NICU increased the percentage of neonates receiving any HM, specifically in the OB population.

Elevated risk of anaphylactoid reaction from radiographic contrast media is associated with both beta-blocker exposure and cardiovascular disorders.

BACKGROUND: A case-control study, with both retrospective and concurrent subject selection, was performed (1) to determine whether greater risk for anaphylactoid reaction from contrast media associated with beta-blocker exposure reflects presence, or is independent of underlying cardiovascular disorder; and (2) to characterize further the risk of anaphylactoid reaction from contrast media in patients with cardiovascular disorders and patients with asthma. METHODS: Adverse reactions from intravenous contrast media were recorded in accordance with quality assurance guidelines. Anaphylactoid reactions were classified as mild to moderate (urticaria/angioedema), severe (stridor, bronchospasm, or hypotension), or major and life-threatening (hypotension with or without the need for subsequent hospitalization). Medical records from reactors were compared with those from matched (gender, age, date, and type of contrast study) controls who received conventional contrast media without adverse reaction. RESULTS: Of 34,371 intravenous contrast media procedures performed, 122 anaphylactoid reactions were recorded. The risk of anaphylactoid reaction was significantly associated with asthma (odds ratio [OR], 8.74; 95% confidence interval [CI], 2.36 to 32.35; P = .0012). The risk of bronchospasm was associated with beta-blocker exposure (OR, 3.73; 95% CI, 1.18 to 11.75; P = .025) and with asthma (OR, 16.39; 95% CI, 4.30 to 62.46; P = .0001). The risk of major and life-threatening reaction was associated with the presence of cardiovascular disorder (OR, 7.71; 95% CI, 1.04 to 57.23; P = .046). Among patients with severe reactions, the risk of hospitalization was elevated by the presence of cardiovascular disorder (P = .001), exposure to beta-blockers (OR, 7.67; 95% CI, 1.79 to 32.85; P = .029), or asthma (OR, 20.7; 95% CI, 1.21 to 355.55; P = .065). Although beta-blocker exposure and the presence of cardiovascular disorder were highly associated (chi 2 = 49, P < .001), a greater risk of bronchospasm with severe reaction was observed in nonasthmatic patients with cardiovascular disorders receiving beta-blockers (OR, 15.75; P = .023). Among reactors with asthma, receiving beta-blockers, or with a cardiovascular disorder, 60.8% (31/51) experienced severe anaphylactoid reactions, compared with 35.2% (25/71) of patients without these risk factors (OR, 3.62; P = .005). CONCLUSIONS: beta-Blocker exposure and cardiovascular disorder are both statistically significant risk factors for severe anaphylactoid reaction from contrast media. Thus, patients receiving beta-adrenergic blockers and patients with asthma, on the basis of greater risk for bronchospasm, and patients with cardiovascular disorders, on the basis of elevated risk of major and life-threatening reaction, are appropriate target populations for risk reduction measures before receiving intravenous infusion of contrast media.

Open-ring imaging sign: highly specific for atypical brain demyelination.

OBJECTIVE: To test the specificity for demyelination of a new neuroimaging sign: contrast enhancement shaped as an open ring or a crescent circumscribed to the white matter. BACKGROUND: Brain demyelination can cause ring enhancement mimicking neoplasm or infection on CT or MRI. METHODS: A MEDLINE search of pathology-proved demyelination yielded 32 illustrated cases of ring-enhancing lesions published between 1981 and 1995. Controls consisted of the same number of published images of neoplasms and infections, pathology proved, and matched by year of publication, and age and gender of the patient. Two neuroradiologists read the images twice independently 1 year apart. RESULTS: Interrater agreement was good (kappa = 0.64 and 0.66 for either reading). Test-retest reliability was high (kappa = 0.75 and 0.74 for either rater). The open-ring sign clearly distinguished demyelinating lesions from neoplasms and infections. For demyelination versus neoplasm or infection, the specificity of the reading by the first neuroradiologist was 93.8 (95% CI, 86 to 98), and that of the second was 84.4 (95% CI, 74 to 92). The likelihood ratio of demyelination versus neoplasm averaged 5.2, and versus infection, 17.2. That is, if the lesions had the same incidence in the population, in the presence of an open-ring sign demyelination would be five times more likely than neoplasm and 17 times more likely than infection. However, given the much higher incidence of neoplasms and infections, these lesions are still frequently responsible for open-ring enhancement. CONCLUSIONS: The open-ring sign is often present in large, contrast-enhancing demyelinating lesions and helps to differentiate them from neoplasms and infections.

Effectiveness of multidose antenatal steroids.

OBJECTIVE: To compare effectiveness between single and multiple courses of antenatal steroids in preterm births and determine adverse effects attributable to multiple courses. METHODS: We studied retrospectively the neonatal outcomes of infants who weighed 1750 g or less at birth between January 1990 and December 1997. Infants exposed to a single course were compared with those exposed to two or more courses of antenatal steroids, with respect to various perinatal outcome variables. RESULTS: Ninety-three neonates were exposed to two or more courses of antenatal steroids and 261 neonates had been given single courses. The mean (+/- standard deviation) gestational age (29.6 +/- 2.8 weeks compared with 28.7 +/- 2.7 weeks; P = .007) and birth weight (1252 +/- 321 g compared with 1159 +/- 339 g; P = .013) were significantly higher among neonates exposed to multiple courses. There were no significant differences between groups in perinatal outcomes; however, those exposed to multiple courses had a significantly lower rate of respiratory distress syndrome (RDS) (17 [18%] compared with 107 [41%]; P < or = .001) and surfactant use (40 [43%] compared with 149 [57%]; P = .02). Adjusting for confounding variables, multiple courses of steroids were significantly associated with a 65% reduction in the incidence of RDS (odds ratio 0.35; 95% confidence interval = 0.18, 0.70; P = .003). CONCLUSION: Compared with single courses, multiple courses of antenatal steroids reduced significantly the incidence of RDS with no apparent increase in neonatal sepsis or disturbances in fetal growth.

Histologic chorioamnionitis, antenatal steroids, and perinatal outcomes.

OBJECTIVE: To determine the perinatal effects of histologic chorioamnionitis on preterm neonates and the effectiveness of antenatal steroids in the presence of histologic chorioamnionitis. METHODS: We studied neonates at our institution who weighed 1750 g or less at birth from January 1990 through December 1997. The population was stratified primarily by presence of histologic chorioamnionitis and secondarily by exposure to antenatal steroids. Subgroups were compared by various perinatal outcomes and confounding variables. Student t test, chi(2), Fisher exact test, and logistic regression were used for analysis. RESULTS: Among 1260 neonates entered, the placentas of 527 had evidence of histologic chorioamnionitis and 733 did not. Those with histologic chorioamnionitis had a lower mean gestational age, lower birth weight, and higher rate of major neonatal morbidities than those without it. After adjusting for confounding variables, histologic chorioamnionitis independently associated with lower gestational age, lower birth weight, and neonatal death. Among neonates exposed to antenatal steroids who had histologic chorioamnionitis, there was a significantly lower incidence of low Apgar scores (18% compared with 33.5%, P <.001), respiratory distress syndrome (RDS) (39.6% compared with 55.9%, P <.001), intraventricular hemorrhage and periventricular leukomalacia (21.9% compared with 36.9%, P <.001), major brain lesions (7.7% compared with 18.4%, P <.001), patent ductus arteriosus (14.8% compared with 23.7%, P =.018), and neonatal death (8.3% compared with 16.2%, P =.02), with no increase in rate of proven neonatal sepsis (18.3% compared with 14%, P =.24). CONCLUSION: Histologic chorioamnionitis increases major perinatal morbidity through its association with preterm birth and is independently associated with neonatal death. In the presence of histologic chorioamnionitis, antenatal steroids significantly decreased the incidence of RDS, intraventricular hemorrhage and periventricular leukomalacia, major brain lesions, and neonatal mortality, without increasing neonatal sepsis.

Seronegativity to varicella-zoster virus in a tertiary care obstetric population.

OBJECTIVE: To determine the seronegativity rate of varicella-zoster virus in a tertiary care obstetric population. METHODS: At their initial prenatal visit, all obstetric patients at Westchester County Medical Center have a varicella-zoster virus IgG antibody titer (Varicella Stat; Biowhittaker, Inc., Walkersville, MD) performed. A value of 0.99 or greater units is positive. Patients were divided into three groups: seronegative, seropositive, and those with no test results. Mean maternal age was compared among groups using the unpaired two-tailed Student t test, with P < .05 considered significant. RESULTS: From February 1, 1994, to May 30, 1996, 927 women had an initial prenatal visit. Ninety-nine patients were varicella-zoster virus antibody negative (seronegativity 11.6%, which is significantly higher than that reported in other studies); 755 were varicella-zoster virus antibody positive, and 73 had no results. The mean age of the seronegative patients was 27 years and of the seropositive patients 28 years, which was not significantly different. CONCLUSION: Varicella-zoster virus seronegativity is higher in our obstetric population than generally is reported in adults. This may reflect the number of immigrants from tropical countries attending metropolitan hospitals. Mathematic models evaluating the impact of varicella-zoster virus vaccination and decisions regarding screening and postpartum vaccination must be based on accurate epidemiologic data, particularly in view of the effect of varicella-zoster virus on pregnant women, their fetuses, and their neonates.

Effectiveness of antenatal steroids in obstetric subgroups.

OBJECTIVE: To determine the effectiveness of antenatal steroids in the reduction of neonatal morbidity and mortality in obstetric subgroups of preterm labor with intact membranes, preterm premature rupture of membranes (PROM), and pregnancy-associated hypertension. The secondary objective was to determine the effect of antenatal steroids in appropriate for gestational age (AGA) and growth-restricted neonates. METHODS: We studied the neonatal outcomes for all women who delivered infants weighing 1750 g or less at birth between January 1990 and July 1997 at our institution. The study population was divided primarily into three clinical groups: preterm labor with intact membranes, PROM, and pregnancy-associated hypertension. Secondarily, the total population was divided based on birth weight and gestational age into AGA and growth-restricted neonates. Within each obstetric subgroup, neonates exposed to antenatal steroids were compared with unexposed neonates for respiratory distress syndrome (RDS), intraventricular hemorrhage and periventricular leukomalacia, the incidence of major brain lesions, necrotizing enterocolitis, proved neonatal sepsis, patent ductus arteriosus, and neonatal death. The subgroups were also compared for gestational age at delivery, birth weight, birth weight percentile, Apgar scores, postnatal surfactant exposure, and clinical and histologic chorioamnionitis. Descriptive statistics, Student t test, chi2, Fisher exact test, and logistic regression were used for analysis. RESULTS: A total of 1148 neonates weighing 1750 g or less were delivered during the study period. There were 447 and 410 neonates delivered after preterm labor with intact membranes and PROM, respectively, and 245 neonates born to mothers with pregnancy-associated hypertension. Nine hundred twenty-eight neonates were AGA and the remaining 220 neonates were growth restricted. Antenatal steroids significantly decreased the incidence of RDS, the incidence and severity of intraventricular hemorrhage and periventricular leukomalacia, necrotizing enterocolitis, and neonatal mortality in preterm labor with intact membranes. In the presence of PROM, it significantly decreased the incidence and severity of intraventricular hemorrhage and periventricular leukomalacia and decreased neonatal mortality, with no apparent effect on the incidence of RDS. Antenatal steroids did not show any beneficial effect in pregnancy-associated hypertension and fetal growth restriction (FGR). Additionally, a significant increase was observed in the incidence of proved neonatal sepsis when antenatal steroids were used in pregnancy-associated hypertension. CONCLUSION: The effectiveness of antenatal steroids varies with the obstetric population studied. Antenatal steroids significantly decreased the incidence of major neonatal morbidity and mortality in the AGA preterm neonate delivered after preterm labor with intact membranes. Antenatal steroids did not show any benefit in cases of pregnancy associated with maternal hypertension or FGR. Its effect in the presence of PROM is limited to a significant reduction in the incidence and severity of intraventricular hemorrhage and periventricular leukomalacia and in neonatal death.

Amniotic fluid neuron-specific enolase: a role in predicting neonatal neurologic injury?

OBJECTIVE: To determine the relationship between amniotic fluid (AF) neuron-specific enolase and the development of neonatal intraventricular hemorrhage and periventricular leucomalacia. METHODS: Thirty-nine AF samples, obtained from women in preterm labor between 24 and 32 weeks' gestation, were analyzed for neuron-specific enolase. All women delivered preterm neonates who had neurosonograms on the 3rd and 7th days of life. The results of the neurosonograms were used to divide the study population first into normal and abnormal groups, then into normal, minor, and major brain lesion groups. The groups were compared for the median neuron-specific enolase, proportion with values of 6 microg/L or more, and other demographic characteristics. RESULTS: There were no differences between the groups' maternal and neonatal characteristics. However, the abnormal group had significantly higher median value of neuron-specific enolase than the normal group (9.5 microg/L and 2.0 microg/L, respectively; P < .001). The median neuron-specific enolase levels for the major, minor, and normal groups were 9.75 microg/L, 6.5 microg/L and 2.0 microg/L, respectively (P < .001). The optimum cutoff point, with a sensitivity of 89% and specificity of 100%, was 6 microg/L; 89% of the abnormals had values of 6 microg/L or more, compared with none of the normals (P < .001). The risk of developing intraventricular hemorrhage or periventricular leucomalacia was 11.5 times greater when AF neuron-specific enolase levels were 6 microg/L or more. CONCLUSION: Amniotic fluid neuron-specific enolase is a useful marker of neonatal neurologic injury.

Antenatal steroids and neonatal periventricular leukomalacia.

OBJECTIVE: To evaluate the effect of antenatal steroid treatment on the development of neonatal periventricular leukomalacia. METHODS: This retrospective cohort study included 1161 neonates with gestational ages of 24-34 weeks and birth weights of 500-1750 g, divided into two groups on the basis of antenatal steroid treatment. Neonatal neurosonograms were done on days 3 and 7 of life and labeled normal or abnormal. The abnormal outcomes evaluated were periventricular leukomalacia or intraventricular hemorrhage, periventricular leukomalacia with intraventricular hemorrhage, and isolated periventricular leukomalacia. The group treated with antenatal steroids was compared with the untreated group for these outcomes. RESULTS: Antenatal steroids were associated with significantly less periventricular leukomalacia or intraventricular hemorrhage (23% versus 31%, P =.005), periventricular leukomalacia with intraventricular hemorrhage (5% versus 11%, P =.001), and isolated periventricular leukomalacia (3% versus 7%, P =.009). Logistic regression analysis of antenatal steroid treatment, controlling for confounding maternal and neonatal characteristics, indicated that neonates treated with antenatal steroids had a 56% lower likelihood of periventricular leukomalacia with intraventricular hemorrhage (adjusted odds ratio [OR] 0.44, 95% confidence interval [CI] 0.25, 0.77) and a 58% lower likelihood of isolated periventricular leukomalacia (adjusted OR 0.42, 95% CI 0.20, 0.88). CONCLUSION: Antenatal steroid treatment was associated with over 50% reduction in the incidence of periventricular leukomalacia in preterm neonates. Increased use of antenatal steroid therapy might improve long-term neonatal neurologic outcomes.

Maternal magnesium sulfate and the development of neonatal periventricular leucomalacia and intraventricular hemorrhage.

OBJECTIVE: Neonatal periventricular leucomalacia and intraventricular hemorrhage are strong correlates of cerebral palsy. Our objective was to evaluate the effect of maternal magnesium sulfate exposure on the incidence and severity of periventricular leucomalacia and intraventricular hemorrhage in preterm neonates. METHODS: Nine hundred eighteen consecutive inborn neonates with birth weights from 500 to 1750 g were divided primarily into two groups on the basis of maternal exposure to magnesium sulfate. The groups were divided secondarily into two clinical groups, a physician-initiated group, which consisted of neonates delivered for maternal or fetal indications, and a preterm delivery group, which included neonates delivered as a result of preterm labor or preterm premature rupture of membranes. These clinical groups were stratified further into magnesium sulfate-exposed and -unexposed subgroups. Neonatal neurosonograms were performed on days 3 and 7 of life and described as normal or abnormal. Abnormal sonograms included any periventricular leucomalacia or intraventricular hemorrhage. Severe lesions included periventricular leucomalacia, periventricular leucomalacia with intraventricular hemorrhage, or grades 3 or 4 intraventricular hemorrhage. The magnesium sulfate groups and the clinical groups with their magnesium sulfate strata were compared for the incidence and severity of abnormal sonograms. They also were compared for maternal and neonatal characteristics. RESULTS: Maternal magnesium sulfate exposure was not associated with reduction in the incidence of abnormal sonograms when compared with the unexposed group (27% compared with 33%, P = .06). However, fewer severe lesions were observed in the exposed group (14% compared with 21%, P = .004). When clinical groups were examined, magnesium sulfate was not associated with a decrease in abnormal sonograms (adjusted odds ratio [OR] 1.09, 95% confidence interval [CI] 0.78, 1.52, P = .40) or severe lesions (adjusted OR 1.11, 95% CI 0.73, 1.68, P = .42). Logistic regression analyses of magnesium sulfate exposure within clinical groups controlling for the confounding effects of maternal and neonatal characteristics revealed no protective effect of magnesium sulfate exposure on the incidence of abnormal sonograms (adjusted OR 1.01, 95% CI 0.70, 1.44, P = .97) or severe lesions (adjusted OR 1.01, 95% CI 0.70, 1.74, P = .69). Within clinical groups, the preterm delivery group exhibited an increased risk for abnormal sonograms (adjusted OR 1.63, 95% CI 1.01, 2.67, P = .05) and severe lesions (adjusted OR 9.79, 95% CI 3.27, 29.29, P = .001) when compared with the physician-initiated delivery group, independent of maternal magnesium sulfate exposure. CONCLUSION: Maternal magnesium sulfate exposure had no protective effect on the incidence or severity of periventricular leucomalacia and intraventricular hemorrhage in preterm neonates. The prevalence of these lesions was correlated better with the clinical group of origin and indication for its use.

Reduced risk of low weight births among indigent women receiving care from nurse-midwives.

STUDY OBJECTIVE: To examine the effect of a comprehensive prenatal and delivery programme administered by nurse-midwives on the risk of low weight births among indigent women. STUDY DESIGN: Historical prospective study. Birth outcomes among the cohort were compared with all county births during the same period, adjusting for maternal age and race. Results are expressed as relative risks with 95% confidence intervals. SETTING: An enhanced Medicaid funded pre-natal programme administered by nurse-midwives from 1992 to 1994 in Westchester County, New York. PARTICIPANTS: Indigent mothers (n = 1443), between the ages of 15 and 44, who were residents of Westchester County and indicated having Medicaid or no health care coverage. RESULTS: There were 1474 live births among cohort mothers. Mean (SD) gestational age was 39.4 (1.9) weeks. Less than 6% of births occurred before 37 weeks gestation. The mean birth weight of cohort infants was 3365.6 (518.6) g. Only 4.1% of the cohort births were less than 2500 g. Compared with all county births, the cohort showed a 41% reduction in the risk of low weight births (RRlbw = 0.59, 95% CI: 0.46 to 0.73, p < .001) and a 56% reduction when compared with county Medicaid births only (RR = 0.44, 95% CI: 0.34 to 0.57, p < .005) adjusting for maternal age and race. Larger reductions were found for very low weight births. CONCLUSIONS: Mothers need not be considered at high risk for adverse pregnancy outcomes based on their socioeconomic status alone. Moreover, a comprehensive prenatal programme administered by nurse-midwives may promote a reduction in adverse pregnancy outcomes among indigent mothers.

The open ring. A new imaging sign in demyelinating disease.

Because demyelinating disease of the brain occasionally presents with large ring-enhancing lesions on computed tomography (CT) scans and magnetic resonance images (MRIs), the authors sought to determine whether the ring pattern differed from that found in other common brain lesions with ring enhancement. Published MRI and CT scans of patients with adrenoleukodystrophy (23), and multiple sclerosis or similar demyelinating disorders (21), as well as a variety of tumors (44) and infections (44) matched to the demyelinating lesions by year of publication, in which ring enhancement was evident, were photographed. Photographs without diagnostic identification were presented randomly to two independent observers. The observers rated the contrast enhancement pattern as (1) open ring, with enhancement in the border of the lesion abutting the white matter; (2) closed ring; or (3) uncertain. For all diagnostically certain cases (n = 112), inter-rater agreement was excellent (kappa = 0.75). As an average of the two reviewers, scans for 11 of 132 cases were read as uncertain; 89% of adrenoleukodystrophy cases, 41% of the multiple sclerosis cases, 3% of tumors, and 9% of infections were classified as having the open-ring pattern. Overall, 66% of demyelinating lesions had an open-ring pattern compared with 7% of the non-demyelinating lesions (chi2 = 41.2, p < 0.0001). An open-ring pattern of enhancement is more likely to be associated with demyelinating lesions than with nondemyelinating lesions.

Proportionate mortality study of Vietnam-era veterans of Michigan.

This study examines the proportion of deaths from major diseases among Michigan Vietnam veterans. The distribution of deaths among Michigan Vietnam veterans was compared to deaths among veterans serving elsewhere for 1974-1989 to generate a proportionate mortality ratio (PMR). PMRs were estimated overall and for Black versus non-Black veterans. Overall, Vietnam veterans had significantly elevated PMRs for infectious and parasitic diseases and endocrine disease and lower PMRs for all malignant neoplasms combined. Vietnam veterans overall and non-Black specifically had elevated PMRs for non-Hodgkin's lymphoma. Black Vietnam veterans had elevated PMRs for cancer of the digestive organs, peritoneum, and pancreas. The elevated PMR for non-Hodgkin's lymphoma is consistent with results of individuals exposed to phenoxy herbicides. Results suggest that future studies should examine risks among racial groups separately.

Reliable assessment of cognitive impairment in dementia patients by family caregivers.

Caregivers (n = 53) of patients with mild to moderate dementia administered a modified version of a cognitive examination at home to their patients. Comparisons between caregiver-administered examinations and the associated clinical examinations revealed a high degree of interrater reliability that was not affected by age or level of education of the caregiver. Reliable assessment of cognitive functioning by caregivers can provide clinicians with an alternative method for monitoring cognitive function of dementia patients.

Transcranial Doppler analysis of cerebral hemodynamics in primary craniosynostosis: study in progress.

BACKGROUND: Regional elevations in intracranial pressure (ICP) have been monitored adjacent to areas of cranial stenosis by some authors [9,19,20]; however, noninvasive techniques such as transcranial Doppler (TCD) would be preferable if increased ICP could be detected just as reliably. METHODS: TCD examinations of basal cerebral arteries were performed in 31 children with skull deformities. Skull X rays and computed tomography (CT) scans or magnetic resonance imaging (MRI) were analyzed for degree of cranial vault abnormality, as well as for presence or absence of intracranial pathology. Neurodevelopmental examination and clinical signs of increased ICP, if any, were recorded. RESULTS: The overall incidence of increased resistivity indices (RI) was 70%. Patients with asymmetric skull deformities (plagiocephaly) or sagittal synostosis (scaphocephaly) were statistically more prone to exhibit increased RI compared to previously reported prevalences. CONCLUSIONS: Because TCD is a convenient, rapid, accurate, and noninvasive method by which to gauge ICP, it should be considered in the preliminary work-up of a patient with craniosynostosis.

Aniseikonia in relation to strabismus, anisometropia and amblyopia.

PURPOSE: To study the interrelationships among these four entities which are critical to binocular vision and its precision. SUBJECTS AND METHODS: 102 selected patients (for their ability to have stereoscopic depth perception, a requisite for space eikonometry) were evaluated. Patient testing included stereoscopic testing, Essilor Projection Space Eikonometry, ultrasonic echographic axial length measurements and orthoptic evaluation. Aniseikonia was measured on the Essilor Projection Space Eikonometer. RESULTS: 1. Anisometropia alone was correlated with a marked increase in amblyopia, a moderate increase in aniseikonia and no noteworthy increase in strabismus. Statistical analysis (chi square ratio) showed that persons with elevated anisometropic values had a 4.4 fold increased risk of aniseikonia (p=.003). 2. Aniseikonia alone was not responsible for marked variations in strabismus. 3. Amblyopia was correlated with increases in anisometropia and aniseikonia. 4. Adding aniseikonia to anisometropia produced a possible increase in strabismus and a great increase in amblyopia (using Fisher's Exact Test, 2-tailed). 5. Spearman correlations of the "absolute values" (the mean of the mathematical difference between the two eyes of anisometropia and amblyopia) were as follows: anisometropia (abs) vs. aniseikonia r=.294, p=.006; anisometropia (abs) vs. amblyopia (abs) 4=.555, p=<.001; amblyopia (abs) vs. aniseikonia r=.234, p=.02. CONCLUSIONS: Aniseikonia per se does not appear to have a major causal role in amblyopia or strabismus, but anisometropia does for amblyopia. This role is greatly augmented by aniseikonia and this combination may then produce strabismus.

Efficacy of clonidine versus phenobarbital in reducing neonatal morphine sulfate therapy days for neonatal abstinence syndrome. A prospective randomized clinical trial.

OBJECTIVE: To compare the efficacy of clonidine versus phenobarbital in reducing morphine sulfate treatment days for neonatal abstinence syndrome (NAS). STUDY DESIGN: Prospective, non-blinded, block randomized trial at a single level III NICU (Neonatal Intensive Care Unit). Eligible infants were treated with a combination of medications as per protocol. Primary outcome was treatment days with morphine sulfate. Secondary outcomes were the mean total morphine sulfate dose, outpatient phenobarbital days, adverse events and treatment failures. RESULTS: A total of 82 infants were eligible, of which 68 were randomized with 34 infants in each study group. Adjusting for covariates phenobarbital as compared with clonidine had shorter morphine sulfate treatment days (-4.6, 95% confidence interval (CI): -0.3, -8.9; P=0.037) with no difference in average morphine sulfate total dose (1.1 mg kg(-1), 95% CI: -0.1, 2.4; P=0.069). Post-discharge phenobarbital was continued for an average of 3.8 months (range 1 to 8 months). No other significant differences were noted. CONCLUSION: Phenobarbital as adjunct had clinically nonsignificant shorter inpatient but significant overall longer therapy time as compared with clonidine.

Association of necrotizing enterocolitis with anemia and packed red blood cell transfusions in preterm infants.

OBJECTIVE: To determine association of anemia and red blood cell (RBC) transfusions with necrotizing enterocolitis (NEC) in preterm infants. STUDY DESIGN: A total of 111 preterm infants with NEC ≥ stage 2a were compared with 222 matched controls. In all, 28 clinical variables, including hematocrit (Hct) and RBC transfusions were recorded. Propensity scores and multivariate logistic regression models were created to examine effects on the risk of NEC. RESULT: Controlling for other factors, lower Hct was associated with increased odds of NEC (odds ratio (OR)=1.10, P=0.01). RBC transfusion has a temporal relationship with NEC onset. Transfusion within 24 h (OR=7.60, P=0.001) and 48 h (OR=5.55, P=0.001) has a higher odds of developing NEC but this association is not significant by 96 h (OR=2.13, P=0.07), post-transfusion. CONCLUSION: Anemia may increase the risk of developing NEC in preterm infants. RBC transfusions are temporally related to NEC. Prospective studies are needed to better evaluate the potential influence of transfusions on the development of NEC.