Computerised analysis of intrapartum fetal heart rate patterns and adverse outcomes in the INFANT trial.

OBJECTIVE: To assess if a computerised decision support system reliably identified abnormal fetal heart rate (FHR) patterns in fetuses with adverse neonatal outcomes in the INFANT trial, and whether its use reduced substandard care. DESIGN: Prospective cohort study within a randomised controlled trial. SETTING: Twenty-four maternity units in the UK and Ireland. POPULATION OR SAMPLE: A total of 46 614 labours between January 6 2010 and August 31 2013 in the INFANT trial. METHODS: Panel review of intrapartum and neonatal care in infants with adverse outcome, and an assessment of the effectiveness of computerised interpretation of fetal heart rate in reducing substandard care. Descriptive analysis of other factors associated with adverse outcome. MAIN OUTCOME MEASURES: Incidence and detection rate of abnormal fetal heart rate patterns, other characteristics associated with perinatal adverse outcome, and frequency of substandard care. RESULTS: Computer interpretation of FHR patterns was deemed to be completely valid in only 24 of 71 (33.8%) cases of adverse outcome. On a scale of 0-10 (completely invalid to completely valid), 28 cases (39.4%) had a score of 6 or less, mainly due to lack of recognition of decelerations (15 cases), or reduced variability (seven cases), or failure to recognise tachysystole (five cases). There were multiple associated factors that modified the clinical assessment of FHR patterns. There was substandard care in 45/71 cases (63%). CONCLUSION: A significant proportion of abnormal fetal heart rate patterns were not detected accurately by computer analysis, and its use did not reduce the incidence of substandard care. FUNDING: UK National Institute for Health Research Health Technology Assessment Programme (project number 06.38.01). TWEETABLE ABSTRACT: Improved recognition of abnormal fetal heart rate patterns is insufficient to reduce the incidence of substandard care.

Routine individual monitoring of aircraft crew exposure; Czech experience and results 1998-2008.

Individual monitoring of aircrew of airline operators registered in the Czech Republic has been performed since 1998. In this work, annual effective doses and annual collective effective doses of aircrew from occupational exposure in the period from 1998 to 2008 are presented, methods used for their evaluation and verification are described, and general trends observed in the data are discussed. Annual effective doses were calculated using the computer code CARI from flight schedules provided by airline operators and typical flight profiles. The method was verified via a comparison with (i) measurements using different types of detectors and (ii) calculations using the CARI and EPCARD codes with actual flight data. It was found that average annual effective doses in the period from 1998 to 2008 were in the range from 1.2 to 2.0 mSv and followed the trend of the solar cycle. Annual collective effective doses increased from 1.4 manSv in 1998 to 4.1 manSv in 2008 as the number of aircrew increased from 857 to 2158 during this period. Combined relative uncertainties (coverage factor ) of reported individual and collective effective doses were ∼ 25 %, which is well within the range given by the factor of 1.5. More work is needed to achieve a higher accuracy of this estimate.

A case of hyperzincemia with functional zinc depletion: a new disorder?

We report the case of an 1l-y-old boy with a plasma Zn concentration greater than 200 micromol/L, but with symptoms consistent with Zn deficiency. He has had hepatosplenomegaly, rashes, stunted growth (<3rd centile), anemia, and impaired immune function since infancy. He also has vasculitis and osteoporosis. A plasma Zn-binding protein has been separated and characterized by a combination of size exclusion and ion exchange chromatography and electrophoretic studies and by immunologic methods. Antibodies to the partially purified protein have been raised in rabbits. Size exclusion chromatography shows that Zn is bound to a protein with a mass 110000-300000 kD. Electrophoretic and mass spectrometry studies suggest that the protein may be composed of several subunits. One component of the isolated protein reacts with antiserum to alpha2-macroglobulin; immunoprecipitation studies confirm that the protein is not alpha2-macroglobulin or a histidine-rich glycoprotein. Kinetic studies of zinc metabolism in the patient and his mother with stable Zn isotopes show the presence of increased exchangeable Zn, with a rapid flux from plasma to a stable pool. Liver and muscle Zn and Cu concentrations are raised, but with no abnormal liver histology. Immunoreactive metallothionein in the liver is increased. We suggest that this boy may suffer from a previously unrecognized inborn error of Zn metabolism causing symptomatic zinc deficiency.

Prenatal diagnosis of amniotic band syndrome in a methadone user: review of the literature and a case report.

We present a case and review of the literature of an amniotic band causing malformation in the distal forearm in a baby born to a methadone-dependent mother. This diagnosis was made prenatally at the routine 18-20-week gestation anomaly ultrasound scan. Histology of the amniotic band postpartum revealed hair shafts within its structure. This has not previously been documented, nor has an association of this syndrome with systematic abuse of methadone. The fact that this anomaly could be detected by prenatal ultrasound scanning is of value in the counselling of high-risk pregnancies such as this.

Acute endocarditis following pneumococcal meningitis.

Acute mitral valve endocarditis, presenting as a new murmur and haematuria, complicated pneumococcal meningitis in a 20-month-old child with a normal heart. Awareness of this rare complication of pneumococcaemia and its early diagnosis, using cross-sectional echocardiography, improves the clinical outcome of a condition associated with a high mortality.

Plasma amino acid profiles in preterm infants receiving Vamin 9 glucose or Vamin infant.

Amino acid profiles were measured in 29 low-birth-weight infants receiving either Vamin 9 glucose (n = 18, group A) or Vamin Infant (n = 11, group B) as the amino acid source in parenteral nutrition; intake was otherwise identical. Infants were sampled when receiving 430 mgN/kg per day (3.2 g/kg per day amino acids) and 90 non-protein kcal/kg per day. There was no difference between groups in birth weight, gestational or postnatal age. The percentage N retention was similar in both (68 and 60%, groups A and B respectively). Phenylalanine and tyrosine levels were higher in those who received Vamin 9 glucose but 55% of infants given Vamin Infant had tyrosine levels below the lower limit of the target range. Cysteine levels were low in both groups. Further modification of the amino acid composition of parenteral solutions for the newborn is necessary. If sufficient non-protein energy can be provided the risk of abnormally high amino acid levels is reduced.

Bleomycin-detectable iron in the plasma of premature and full-term neonates.

The bleomycin assay measures non-transferrin-bound iron, able to catalyze free radical reactions, in human plasma. No bleomycin-detectable iron is present in plasma from healthy adults. However, plasma from 3/15 premature babies was positive in this assay. Plasma from 52 apparently-healthy term babies was analyzed and 11 were positive in the bleomycin assay. Hence not only some premature but also some full-term apparently-healthy babies may be at risk of severe oxidative damage.

Introduction of intravenous lipid administration on the first day of life in the very low birth weight neonate.

OBJECTIVE: To investigate lipid tolerance in sick, ventilator-dependent, very low birth weight infants from the first day of life and the effects of early introduction of intravenously administered lipid (IVL) on glucose homeostasis. METHOD: Twenty-nine infants in the neonatal intensive care unit with birth weight less than 1500 gm received isocaloric, isonitrogenous parenteral feedings from day 1 with either IVL, 1 gm/kg from day 1 to 3 gm/kg from day 4 (group I; n = 16), or IVL added only from day 8 (group II; n = 13). Possible adverse clinical effects were monitored. Blood metabolites, nonesterified fatty acids, serum triglycerides, and insulin levels were determined daily. Arterial blood gases were measured and changes in partial pressures of oxygen and of carbon dioxide in arterial blood were compared between the two groups. RESULTS: Early lipid infusion did not appear to have deleterious effects on blood gas tensions or to increase respiratory morbidity. The incidence of other adverse clinical effects that may be associated with IVL was not increased by earlier introduction of lipid. Serum lipid values were comparable to those of preterm infants receiving IVL at a later postnatal age. Blood glucose concentrations were higher in group II (mean, 7.50 (SEM 0.43) mmol/L) than in group I (mean, 6.01 (SEM 0.28) mmol/L; p less than 0.05). There was no evidence of increased gluconeogenesis in infants in group I and no correlation between blood glucose concentrations and serum nonesterified fatty acid concentrations. CONCLUSION: When given infusion rates not exceeding 0.15 gm/kg/hr, sick, very low birth weight infants can tolerate IVL with stepwise dose increases from the first day of life without an increased incidence of possible adverse effects.

Calcium and phosphorus metabolism in the premature infant.

During the last trimester of pregnancy, there is a sixfold increase in fetal calcium and phosphorus accumulation. Unsupplemented human breast milk may not provide sufficient calcium and phosphorus for the rapidly growing preterm infant to match the accumulation that should have taken place in utero and to permit normal bone mineralization. Rickets of prematurity may present clinically between the 6th and 12th postnatal week. The clinical diagnosis may be confirmed using simple biochemical tests. Inadequate mineral substrate intake, particularly of phosphorus, is the most common cause, although a delay in the maturation of the renal enzyme, 1-alpha hydroxylase, with low plasma concentrations of 1,25-dihydroxyvitamin D, may also occur. The biochemical response to treatment can be determined by documenting a fall in plasma alkaline phosphatase activity and a rise in plasma phosphate concentration and urinary phosphate excretion.

Twin very low birth weight infants: a study of nutritional and hormonal status.

Nonidentical twin male infants (twin 1,950 g birth weight, twin 2,970 g) had their nutritional and hormone status studied for up to 59 days. Both infants received parenteral nutrition up to 32 days postnatally; enteral feeding was then established in twin 1; in twin 2 parenteral feeding was recommenced on day 35, for the remainder of the study. Serial 72-hr metabolic balances were performed in both infants at 4, 32, 45, and 56 days postnatally. Insulin-like growth factor I (IGF-I) and growth hormone were assayed on day 2 of each balance. During the course of the study growth was similar in each infant. Overall mean daily energy intakes were 90 kcal/kg/day and 84 kcal/kg/day and percentage nitrogen retention was 62% and 55% in twin 1 and twin 2, respectively. No differences were observed between the two infants in IGF-I or growth hormone. Despite low energy intakes incremental weights were within an acceptable range for both infants.

Mosaic trisomy 16 in a live newborn infant.

Trisomy 16 is thought to be incompatible with fetal survival. A boy with mosaic trisomy 16 who lived for 11 weeks is reported. Chromosome analysis was carried out on skin fibroblasts grown during life and confirmed on samples taken at necropsy. We believe that this is the first report of mosaic trisomy 16 that has been confirmed by cytogenetic banding.

Calcium and phosphorus solubility in neonatal intravenous feeding solutions.

The limited solubility of calcium and phosphorus in standard parenteral nutrition formulations has restricted the ability to provide sufficient minerals to preterm infants to prevent substrate deficient metabolic bone disease. We determined the solubility limits of calcium and phosphorus in a total of 160 formulations under carefully controlled conditions. By increasing the concentrations of dextrose, amino acids, and by using Addiphos instead of 8.7% dipotassium hydrogen phosphate as the phosphorus source, higher concentrations of both calcium and phosphorus were held in solution. This should permit the delivery of increased concentrations of these minerals at rates which approximate fetal accretion.

Acid-base state of the preterm infant and the formulation of intravenous feeding solutions.

An acidic intravenous source of phosphorus (Addiphos) was compared with dipotassium hydrogen phosphate in 25 preterm infants to study acid-base state. Eight infants were given either Addiphos or dipotassium hydrogen phosphate alternately for 48 hour periods and similar amounts of calcium and phosphorus were delivered. There were no significant differences in calcium and phosphorus intake, calcium and phosphate plasma concentrations, or acid-base state between study periods on the two solutions. Seventeen infants were given the two solutions alternately for 72 hour periods; Addiphos was used to increase the amounts of calcium and phosphorus being delivered. Calcium and phosphorus intake was decreased on dipotassium hydrogen phosphate, but Addiphos significantly increased calcium and phosphorus intake and plasma calcium and phosphate concentrations. It also lowered the pH of the urine and raised the titratable acidity. Acid-base state, however, was not significantly different. It is therefore possible to increase intake of calcium and phosphorus in preterm infants without causing a significant metabolic acidosis.