Severe left diaphragmatic hernia limits size of fetal left heart more than does right diaphragmatic hernia.

OBJECTIVES: To assess whether severity of congenital diaphragmatic hernia (CDH) correlates with the degree of left heart hypoplasia and left ventricle (LV) output, and to determine if factors leading to abnormal fetal hemodynamics, such as compression and reduced LV preload, contribute to left heart hypoplasia. METHODS: This was a retrospective cross-sectional study of fetuses at 16-37 weeks' gestation that were diagnosed with CDH between 2000 and 2010. Lung-to-head ratio (LHR), liver position and side of the hernia were determined from stored ultrasound images. CDH severity was dichotomized based on LHR and liver position. The dimensions of mitral (MV) and aortic (AV) valves and LV were measured, and right and left ventricular outputs were recorded. RESULTS: In total, 188 fetuses with CDH were included in the study, 171 with left CDH and 17 with right CDH. Fetuses with severe left CDH had a smaller MV (Z = -2.24 ± 1.3 vs -1.33 ± 1.08), AV (Z = -1.39 ± 1.21 vs -0.51 ± 1.05) and LV volume (Z = -4.23 ± -2.71 vs -2.08 ± 3.15) and had lower LV output (26 ± 10% vs 32 ± 10%) than those with mild CDH. MV and AV in fetuses with right CDH (MV, Z = -0.83 ± 1.19 and AV, Z = -0.71 ± 1.07) were larger than those in fetuses with left CDH, but LV outputs were similarly diminished, regardless of hernia side. Severe dextroposition and abnormal liver position were associated independently with smaller left heart, while LHR was not. CONCLUSION: The severity of left heart hypoplasia correlates with the severity of CDH. Altered fetal hemodynamics, leading to decreased LV output, occurs in both right- and left-sided CDH, but the additional compressive effect on the left heart is seen only when the hernia is left-sided. Improved knowledge of the physiology of this disease may lead to advances in therapy and better risk assessment for use in counseling affected families.

Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia.

OBJECTIVE: To assess the value of antenatally determined observed to expected fetal lung area to head circumference ratio (LHR) in the prediction of postnatal survival in isolated, congenital diaphragmatic hernia (CDH). METHODS: Two groups of fetuses were examined. The first group included 650 normal fetuses at 12-32 weeks' gestation, and the data collected were used to establish a normal range of observed to expected LHR with gestational age. The second group included the data of a retrospective multicenter study of 354 fetuses with isolated CDH in which the LHR was measured on one occasion at 18-38 weeks' gestation. The patients were divided into those with left-sided CDH with and without intrathoracic herniation of the liver and right-sided CDH. Regression analysis was used to determine the significant predictors of postnatal survival. RESULTS: In both the normal fetuses and those with CDH the LHR increased but the observed to expected LHR did not change significantly with gestational age. In normal fetuses the mean observed to expected LHR in the left lung was 100% (95% CI, 61-139%) and in the right lung it was 100% (95% CI, 67-133%). In fetuses with CDH the mean observed to expected LHR was 39% (range 7-79%). Regression analysis demonstrated that significant predictors of survival were the observed to expected LHR (odds ratio (OR) 1.09, 95% CI, 1.06-1.12), side of CDH (left side OR 11.14, 95% CI, 3.41-36.39) and gestational age at delivery (OR 1.18, 95% CI, 1.02-1.36). CONCLUSION: In CDH, the LHR increases while observed to expected LHR is independent of gestational age. In fetuses with both left- and right-sided CDH, measurement of the observed to expected LHR provides a useful prediction of subsequent survival.

Early variable-flow nasal continuous positive airway pressure in infants < or =1000 grams at birth.

OBJECTIVE: To compare the incidence of chronic lung disease (CLD) in extremely low birth weight (ELBW, < or =1000 g) infants before and after the introduction of early, preferential application of nasal continuous airway pressure (NCPAP) utilizing a variable flow delivery system. STUDY DESIGN: A retrospective cohort study of ELBW infants 2 years prior to (Pre-early NCPAP, n=96) and 2 years following (Early NCPAP, n=75) the initiation of an early NCPAP policy. RESULTS: There were no significant changes (Pre-early NCPAP vs Early NCPAP) in the incidences of CLD (35 vs 33%, P=0.81) or CLD or death (50 vs 43%, P=0.34). Infants in the Early NCPAP group weaned off mechanical ventilation and supplemental oxygen more rapidly than infants in the Pre-early NCPAP group (hazard ratio (HR) 1.80, P=0.002 and HR 1.69, P=0.01). CONCLUSION: A policy of early NCPAP has not decreased the incidence of CLD despite a decrease in time to successful tracheal extubation.

Prenatal prediction of survival in isolated left-sided diaphragmatic hernia.

OBJECTIVE: To investigate the potential value of antenatally determined intrathoracic herniation of the liver and the ratio of fetal lung area to head circumference (LHR) in the prediction of postnatal survival in isolated, left-sided congenital diaphragmatic hernia (CDH). METHODS: In this multicenter study, we searched the antenatal-CDH-Registry for fetuses with isolated left-sided CDH that were liveborn after 30 weeks of gestation and were followed up postnatally for at least 3 months after discharge from hospital. The patients were subdivided into those with and those without intrathoracic herniation of the liver and into subgroups according to the LHR that had been measured between 22 + 0 and 28 + 0 weeks of gestation. The rate of survival in each group and subgroup of patients was determined and compared. RESULTS: The registry search identified 184 patients that fulfilled the entry criteria. Logistic regression analysis demonstrated that significant predictors of survival were the presence or absence of intrathoracic herniation of the liver and the LHR. In 86 cases there was liver herniation (Group A) and in 98 the liver was confined to the abdomen (Group B). In Group A, the survival rate was 50.0% and was significantly associated with LHR; in Group B the survival rate was 76.5% and was unrelated to LHR. CONCLUSION: In isolated, left-sided CDH, the postnatal mortality rate is substantially higher if there is intrathoracic herniation of the liver. In fetuses with liver herniation, measurement of LHR at 22-28 weeks of gestation is useful in the prediction of subsequent survival.

Bacterial isolates and antimicrobial susceptibilities in equine bacterial ulcerative keratitis (1993--2004).

REASONS FOR PERFORMING STUDY: Bacterial ulcerative keratitis is a common and often vision-threatening problem in horses. Emerging bacterial resistance to commonly used topical antibiotics has been demonstrated. Previous antibiotic use may alter the antimicrobial susceptibility of bacterial isolates. OBJECTIVES: To document aerobic bacterial isolates and associated bacterial susceptibilities from horses with ulcerative keratitis treated at the University of Tennessee between January 1993 and May 2004 and determine whether prior antibiotic therapy affected antimicrobial susceptibility of the isolates. METHODS: Medical records from horses with ulcerative keratitis and positive aerobic bacterial cultures and antimicrobial susceptibility were evaluated. Clinical history regarding antibiotic therapy prior to culture was documented. RESULTS: Fifty-one aerobic bacterial isolates from 43 horses were identified. Streptococcus equi subspecies zooepidemicus was the most commonly isolated organism, accounting for 33.3% of all isolates, followed by Pseudomonas aeruginosa (11.8%), Staphylococcus spp. (11.8%) and Gram-negative nonfermenting rods (7.8 %). No resistance was noted amongst S. equi ssp. zooepidemicus to cephalothin, chloramphenicol or ciprofloxacin. Only 64 % of S. equi ssp. zooepidemicus isolates were sensitive to bacitracin. No resistance was noted among P. aeruginosa to gentamicin, tobramycin or ciprofloxacin. Antibiotic therapy with neomycin-polymixin B-bacitracin prior to presentation and culture was documented in 11/17 horses in which S. equi ssp. zooepidemicus was isolated and in 4/6 horses in which P. aeruginosa was isolated. Three horses received topical corticosteroids prior to culture, of which 2 had polymicrobial infections. CONCLUSIONS: S. equi ssp. zooepidemicus and P. aeruginosa were the most frequently isolated bacterial organisms in equine ulcerative keratitis. No significant trends in aminoglycoside or fluoroquinolone resistance were noted among these organisms. However, the resistance of S. equi ssp. zooepidemicus to bacitracin with common use of this antibiotic suggests that previous antibiotic therapy probably affects antimicrobial resistance. POTENTIAL RELEVANCE: Therapy prior to culture may play an important role in antimicrobial susceptibility of corneal bacterial isolates. Corticosteroid use may increase the risk of polymicrobial infections of corneal ulcers, leading to a worse prognosis. Although significant fluoroquinolone resistance has not been documented in the veterinary literature, these antimicrobials should be reserved for known infected corneal ulcers and not used for prophylaxis. Empirical antibiotic therapy should not only be guided by clinical signs, but also take into consideration previous antimicrobial and corticosteroid therapy.

The lung-to-head ratio and fetoscopic temporary tracheal occlusion: prediction of survival in severe left congenital diaphragmatic hernia.

OBJECTIVES: To evaluate the reliability of sonographic lung-to-head ratio (LHR) measurement as a predictor of survival in fetuses with congenital diaphragmatic hernia (CDH) and to compare the probability of survival in those with temporary tracheal occlusion (TO) or standard care with respect to the LHR. METHODS: Fifty-six fetuses with left CDH with liver herniated into the thorax at complete prenatal evaluation were included in logistic regression analyses of antenatal predictors of survival to hospital discharge. Sixteen subjects underwent TO and 40 received standard care. RESULTS: LHR was a significant predictor of survival, with probability of survival increasing with increasing LHR (odds ratio (OR) 8.5, P = 0.04). When subjects with anomalies were excluded, the LHR effect was similar after adjustment for TO (OR 7.1, P = 0.11). Linear spline models suggested a plateau in survival at an LHR of 1.0 and all models suggested increased odds of survival with TO. Minimum LHR measurements had a high degree of inter- and intraobserver agreement (intraclass correlation coefficients of 0.70 and 0.80, respectively). CONCLUSIONS: Calculation of the LHR in fetuses with CDH is a reliable and powerful predictor of survival to hospital discharge, although improving odds of survival may plateau at an LHR of 1.0. TO may have an independent benefit on survival to hospital discharge.

Quantitative phase contrast images to quantitate flow in a rat model of microgravity.

A magnetic resonance angiographic (MRA) technique for noninvasive measurement of flow in the inferior vena cava (IVC) was used to study blood flow changes in a simulated microgravity model. Microgravity was simulated in adult male Fischer 344 rats (n = 12, with each rat acting as its own control) using a tail harness to elevate the hindquarters, producing a non-weight bearing hindlimb (NWH) model. Quantitative phase contrast images of flow within the IVC were obtained initially and after a 2-week NWH protocol. Inferior vena cava blood flow was determined by converting the intensity at the respective magnetic resonance pixels into a corresponding flow by Doppler techniques. Average values for flow determined with MR angiography were 351.8 (SEM = 49) mm3 x s(-1) initially and 524.5 (SEM = 46) mm3 x s(-1) after exposure to 2 weeks of the NWH protocol. Post 2-week NWH flow increased 49.1% over the initial NWH value. Using a paired t-test, a significant difference was found between the rats' IVC flow values in the initial and post-NWH groups (p < 0.004). The changes in IVC blood flow due to 45 degrees NWH may contribute to the overall changes observed in the cardiovascular system during simulated microgravity.

Response to 45 degrees head-down tilt as measured by organ weight/body weight ratios and spiral computed tomography.

BACKGROUND: Exposure to microgravity or simulated microgravity causes significant shifts in body fluids which may initiate physiological adaptations to the microgravity stressor. It is imperative to understand the physiological adaptations to microgravity in order to develop appropriate countermeasures to the deleterious aspects (i.e., muscle and bone wasting) of long-term spaceflights. HYPOTHESIS: The significant shifts in body fluids by 45 degrees head-down tilt can be measured by changes in organ weight/body weight (OW/BW) ratios and non-invasively by spiral computed tomography. METHODS: In a previous study (14), rats were weighed and exposed to either 45 degrees head-down tilt (45HDT) or a prone control position for one of the following experimental times: 0.5 h, 1 h, 2 h, 4 h, 8 h, or 24 h. A radioactive tracer was injected intramuscularly immediately prior to the start of the experimental time periods. At the end of the experiment, the major organs were harvested, weighed, and measured for gamma radiation levels. We used the organ weights from this previous study to calculate OW/BW ratios for the present study. Additionally, in the present study, rats in the 14-d experimental groups were weighed, lightly anesthetized to facilitate placement in the 45HDT position, and placed in a specially designed 45HDT cage (45HDT group) or left unrestrained in the cages (control group). At the end of the 14-d experimental time period, the rats were anesthetized and their lung densities measured with spiral computed tomography. RESULTS: The OW/BW ratios for the liver, kidneys, and spleen of 24 h 45HDT rats were significantly lower (p<0.05) than control values while at 1 h the 45HDT rats had a higher kidney OW/BW ratio. Lung density from the 14-d 45HDT rats was 24.4% greater than control rats' values. CONCLUSIONS: The physiological change due to the 45HDT position to simulate microgravity begins as early as 1 h, and the kidney appears to be the first organ affected. Spiral computed tomography may offer a viable method of non-invasively measuring organ densities in the 45HDT model. The OW/BW data generated in the present study does not correlate with the changes in radioactive tracer distribution data from our previous study.

AIDS education intervention utilizing a person with AIDS: examination and clarification.

The utility of a person with AIDS (PWA) in conveying AIDS information to college students is assessed. Mode of transmission of HIV is proposed to serve as a moderating variable in students' receptivity to the AIDS information and perception of the source of AIDS information. Two-hundred-sixty undergraduate students received a standardized lecture by a confederate, posing as a PWA, who revealed HIV positive status through either heterosexual transmission, homosexual transmission, needle-sharing, or a blood transfusion. Control conditions received the lecture from a neutral presenter (no HIV status disclosure) or no contact. All the HIV conditions were superior to the Control condition in increasing knowledge about AIDS and AIDS prevention. Additionally, students rated the PWA more positively than the neutral presenter on a number of evaluative dimensions. Mode of transmission served a mediating effect, with the confederate viewed most favorably in the Heterosexual and Transfusion conditions, and less favorably in the i.v. Drug and Homosexual conditions. Implications for educational programs are discussed.