Early Pulse Oximetry Data Improves Prediction of Death and Adverse Outcomes in a Two-Center Cohort of Very Low Birth Weight Infants.

BACKGROUND: We previously showed, in a single-center study, that early heart rate (HR) characteristics predicted later adverse outcomes in very low birth weight (VLBW) infants. We sought to improve predictive models by adding oxygenation data and testing in a second neonatal intensive care unit (NICU). METHODS: HR and oxygen saturation (SpO2) from the first 12 hours and first 7 days after birth were analyzed for 778 VLBW infants at two NICUs. Using multivariate logistic regression, clinical predictive scores were developed for death, severe intraventricular hemorrhage (sIVH), bronchopulmonary dysplasia (BPD), treated retinopathy of prematurity (tROP), late-onset septicemia (LOS), and necrotizing enterocolitis (NEC). Ten HR-SpO2 measures were analyzed, with first 12 hours data used for predicting death or sIVH and first 7 days for the other outcomes. HR-SpO2 models were combined with clinical models to develop a pulse oximetry predictive score (POPS). Net reclassification improvement (NRI) compared performance of POPS with the clinical predictive score. RESULTS: Models using clinical or pulse oximetry variables alone performed well for each outcome. POPS performed better than clinical variables for predicting death, sIVH, and BPD (NRI > 0.5, p < 0.01), but not tROP, LOS, or NEC. CONCLUSION: Analysis of early HR-SpO2 characteristics adds to clinical risk factors to predict later adverse outcomes in VLBW infants.

Assisted ventilation immediately after birth with self-inflating bag versus T-piece resuscitator in preterm infants.

OBJECTIVE: To compare proportions of target range tidal volumes achieved with the self-inflating bag vs. the T-piece in resuscitation of preterm newborns at delivery. STUDY DESIGN: This randomized controlled trial was conducted at a tertiary Children's Hospital. 20 preterm infants≤32 weeks' gestational age with no congenital anomalies who needed positive pressure ventilation after birth were enrolled. Positive pressure ventilation was provided with the self-inflating bag or T-piece resuscitator. The primary outcome was proportion of inflations within a target range of 4-8 ml/kg. Chi-square and logistical regression analyses were performed. RESULTS: In the self-inflating bag (SIB) group 29% of inflations (117/419) and in the T-Piece (TP) group 51% of inflations (300/590) delivered expiratory tidal volume (TVe) of 4-8 ml/kg (p < 65.001). In the SIB group 60% of all inflations (254/419), and in the TP group 35% of all inflations (204/590) delivered TVe < 4 ml/kg (p < 0.001). In the SIB group 11% of all inflations (48/419), and in the TP group, 15% of all inflations (86/590) delivered TVe > 8 ml/kg (p = 0.18). The OR of having expiratory tidal volume of 4-8 ml/kg using the T-piece was 1.8 (CI 1.1-3.1), p = 0.02. CONCLUSION: Manual inflations provided by the TP deliver expiratory tidal volumes in the range of 4-8 ml/kg more consistently than SIB.

Clinical and vital sign changes associated with late-onset sepsis in very low birth weight infants at 3 NICUs.

BACKGROUND: In premature infants, clinical changes frequently occur due to sepsis or non-infectious conditions, and distinguishing between these is challenging. Baseline risk factors, vital signs, and clinical signs guide decisions to culture and start antibiotics. We sought to compare heart rate (HR) and oxygenation (SpO2) patterns as well as baseline variables and clinical signs prompting sepsis work-ups ultimately determined to be late-onset sepsis (LOS) and sepsis ruled out (SRO). METHODS: At three NICUs, we reviewed records of very low birth weight (VLBW) infants around their first sepsis work-up diagnosed as LOS or SRO. Clinical signs prompting the evaluation were determined from clinician documentation. HR-SpO2 data, when available, were analyzed for mean, standard deviation, skewness, kurtosis, and cross-correlation. We used LASSO and logistic regression to assess variable importance and associations with LOS compared to SRO. RESULTS: We analyzed sepsis work-ups in 408 infants (173 LOS, 235 SRO). Compared to infants with SRO, those with LOS were of lower GA and BW, and more likely to have a central catheter and mechanical ventilation. Clinical signs cited more often in LOS included hypotension, acidosis, abdominal distension, lethargy, oliguria, and abnormal CBC or CRP(p < 0.05). HR-SpO2 data were available in 266 events. Cross-correlation HR-SpO2 before the event was associated with LOS after adjusting for GA, BW, and postnatal age. A model combining baseline, clinical and HR-SpO2 variables had AUC 0.821. CONCLUSION: In VLBW infants at 3-NICUs, we describe the baseline, clinical, and HR-SpO2 variables associated with LOS versus SRO.

Cerebral Venous Thrombosis in COVID-19: A New York Metropolitan Cohort Study.

BACKGROUND AND PURPOSE: Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection is associated with hypercoagulability. We sought to evaluate the demographic and clinical characteristics of cerebral venous thrombosis among patients hospitalized for coronavirus disease 2019 (COVID-19) at 6 tertiary care centers in the New York City metropolitan area. MATERIALS AND METHODS: We conducted a retrospective multicenter cohort study of 13,500 consecutive patients with COVID-19 who were hospitalized between March 1 and May 30, 2020. RESULTS: Of 13,500 patients with COVID-19, twelve had imaging-proved cerebral venous thrombosis with an incidence of 8.8 per 10,000 during 3 months, which is considerably higher than the reported incidence of cerebral venous thrombosis in the general population of 5 per million annually. There was a male preponderance (8 men, 4 women) and an average age of 49 years (95% CI, 36-62 years; range, 17-95 years). Only 1 patient (8%) had a history of thromboembolic disease. Neurologic symptoms secondary to cerebral venous thrombosis occurred within 24 hours of the onset of the respiratory and constitutional symptoms in 58% of cases, and 75% had venous infarction, hemorrhage, or both on brain imaging. Management consisted of anticoagulation, endovascular thrombectomy, and surgical hematoma evacuation. The mortality rate was 25%. CONCLUSIONS: Early evidence suggests a higher-than-expected frequency of cerebral venous thrombosis among patients hospitalized for COVID-19. Cerebral venous thrombosis should be included in the differential diagnosis of neurologic syndromes associated with SARS-CoV-2 infection.

Interactions among peripheral perfusion, cardiac activity, oxygen saturation, thermal profile and body position in growing low birth weight infants.

AIMS: To investigate the correlation between the 'perfusion index' (PI) and other commonly used estimates of cutaneous blood flow [heart rate (HR), surface temperatures (ST) and central-to-peripheral thermal gradients (C-P grad)] and to use this new non-invasive tool to compare differences between prone and supine sleep position in low birth weight (LBW) infants. METHODS: Six-hour continuous recordings of pulse oximetry, cardiac activity and absolute ST from three sites (flank, forearm and leg), along with minute-to-minute assessment of behavioural states were performed in 31 LBW infants. Infants were randomly assigned to the prone or supine position for the first 3 h and then reversed for the second 3 h. PI data were correlated with HR and C-P grad, and compared across sleep positions during quiet sleep (QS) and active sleep (AS). RESULTS: Perfusion index correlated significantly with HR (r(2) = 0.40) and flank-to-forearm thermal gradient (r(2) = 0.28). In the prone position during QS, infants exhibited higher PI (3.7 +/- 0.9 vs. 3.1 +/- 0.7), HR (158.4 +/- 8.9 vs. 154.1 +/- 8.8 bpm), SpO(2) (95.8 +/- 2.6 vs. 95.2 +/- 2.6%), flank (36.7 +/- 0.4 vs. 36.5 +/- 0.4 degrees C), forearm (36.1 +/- 0.6 vs. 35.5 +/- 0.4 degrees C) and leg (35.4 +/- 0.7 vs. 34.7 +/- 0.7 degrees C) temperatures and narrower flank-to-forearm (0.6 +/- 0.4 vs. 0.9 +/- 0.3 degrees C) and flank-to-leg (1.3 +/- 0.6 vs. 1.8 +/- 0.7 degrees C) gradients, compared to those of the supine position. Similar differences were observed during AS. CONCLUSION: Perfusion index is a good non-invasive estimate of tissue perfusion. Prone sleeping position is associated with a higher PI, possibly reflecting thermoregulatory adjustments in cardiovascular control. The effects of these position-related changes may have important implications for the increased risk for sudden infant death syndrome in prone position.

Non-invasive inhaled nitric oxide in the treatment of hypoxemic respiratory failure in term and preterm infants.

OBJECTIVES: Inhaled nitric oxide (iNO) is effective in conjunction with tracheal intubation (TI) and mechanical ventilation (MV) for treating arterial pulmonary hypertension and hypoxemic respiratory failure (HRF) in near-term and term newborns. Non-invasive respiratory support with nasal continuous positive airway pressure (CPAP) is increasingly used to avoid morbidity associated with TI and MV, yet the effectiveness of iNO delivery via nasal CPAP remains unknown. To evaluate the effectiveness of iNO delivered via the bubble nasal CPAP system in term and preterm newborns with HRF. STUDY DESIGN: Electronic medical records from all infants admitted to the neonatal intensive care unit (NICU) during 2005 to 2014 (n=10, 895) were screened for treatment with iNO therapy for HRF. Detailed data on population characteristics and cardiorespiratory, iNO and respiratory support indices were abstracted for all infants, who were administered iNO non-invasively using bubble nasal CPAP. Change in relevant indices at baseline (before initiating non-invasive iNO) and at 3, 6, 12 and 24 h after non-invasive iNO therapy were analyzed using repeated measures analysis of variance. RESULTS: Of 795 infants treated with iNO (7.3% of total NICU admissions) over a 10-year period, 107 infants (13.4% of iNO treated) with birth weight 2448±1112 g and gestational age 35.3±5.8 weeks received iNO non-invasively. 25 infants received iNO exclusively non-invasively, whereas in remaining 82 infants non-invasive route followed invasive delivery via TI and MV. Indications for using non-invasive iNO included idiopathic pulmonary hypertension (39%), congenital heart disease (37%), bronchopulmonary dysplasia (10%), meconium aspiration syndrome (9%) and congenital diaphragmatic hernia (5%). Over the 24 h following initiation of non-invasive iNO, fractional oxygen requirements decreased (0.38 to 0.32; P<0.0005) and SpO2 increased (90.7 to 91.6%; P<0.01) with no significant changes in heart rate, respiratory rate, blood pressure, pH and PaCO2. On average non-invasive iNO was initiated on day of life 9 with a maximal dose was 20 p.p.m. The average duration of iNO therapy and the duration over which it was weaned off were 134 and 51 h, respectively. Analysis of environmental gases during non-invasive iNO therapy revealed median ambient nitrogen dioxide and nitric oxide levels of 0.30 and 0.01 p.p.m., respectively. CONCLUSIONS: Initiation of iNO in infants on bubble nasal CPAP or continuation of iNO in infants transitioning from MV to bubble nasal CPAP is associated with improved oxygenation during HRF in term and preterm infants. Non-invasive iNO may have a synergistic effect with airway recruitment strategies such as nasal CPAP.

Leflunomide: a possible alternative for gangciclovir sensitive and resistant cytomegalovirus infections.

The search for newer more cost effective treatments for infectious diseases remains a challenge. Cytomegalovirus (CMV) infection, which is especially common in the immunosupressed, is an important challenge for treating physicians. Gangciclovir's cost is a major hurdle in developing countries. Leflunomide is cheaper and is easily given orally. It works by a novel mechanism inhibiting virion assembly. It also has immunosuppressive properties. It and has been shown to be effective in both gangciclovir sensitive as well as resistant cases of CMV infection. Given these considerations we believe that leflunomide is an exiting new drug for CMV infection. However, hepatotoxicity and teratogenicity are known side effects. The exact dose and duration of treatment for CMV infection, for secondary prophylaxis, and in situations of gangciclovir resistance need further study.

Novel heart rate parameters for the assessment of autonomic nervous system function in premature infants.

Autonomic nervous system (ANS) balance is a key factor in homeostatic control of cardiac activity, breathing and certain reflex reactions such as coughing, sneezing and swallowing and thus plays a crucial role for survival. ANS impairment has been related to many neonatal pathologies, including sudden infant death syndrome (SIDS). Moreover, some conditions have been identified as risk factors for SIDS, such as prone sleep position. There is an urgent need for timely and non-invasive assessment of ANS function in at-risk infants. Systematic measurement of heart rate variability (HRV) offers an optimal approach to access indirectly both sympathetic and parasympathetic influences on ANS functioning. In this paper, data from premature infants collected in a sleep physiology laboratory in the NICU are presented: traditional and novel approaches to HRV analyses are applied and compared in order to evaluate their relative merits in the assessment of ANS activity and the influence of sleep position. Indices from time domain and nonlinear approaches contributed as markers of physiological development in premature infants. Moreover, significant differences were observed as a function of sleep position.

Sleeping position and electrocortical activity in low birthweight infants.

OBJECTIVE: To evaluate the effects of prone and supine sleeping positions on electrocortical activity during active (AS) and quiet (QS) sleep in low birthweight infants. DESIGN: Randomised/crossover study. SETTING: Infant Physiology Laboratory at Children's Hospital of New York. PATIENTS: Sixty three healthy, growing, low birthweight (birth weight 795-1600 g) infants, 26-37 weeks gestational age. INTERVENTIONS: Six hour continuous two channel electrocortical recordings, together with minute by minute behavioural state assignment, were performed. The infants were randomly assigned to prone or supine position during the first three hours, and positions were reversed during the second three hours. OUTCOME MEASURES AND RESULTS: Fast Fourier transforms of electroencephalograms (EEGs) were performed each minute and the total EEG power (TP), spectral edge frequency (SEF), absolute (AP) and relative (RP) powers in five frequency bands (0.01-1.0 Hz, 1-4 Hz, 4-8 Hz, 8-12 Hz, 12-24 Hz) were computed. Mean values for TP, SEF, AP, and RP in the five frequency bands in the prone and supine positions during AS and QS were then compared. In the prone sleeping position, during AS, infants showed significantly lower TP, decreased AP in frequency bands 0.01-1.0 Hz, 4-8 Hz, 8-12 Hz, 12-24 Hz, increased RP in 1-4 Hz, and a decrease in SEF. Similar trends were observed during QS, although they did not reach statistical significance. CONCLUSIONS: The prone sleeping position promotes a shift in EEG activity towards slower frequencies. These changes in electrocortical activity may be related to mechanisms associated with decreased arousal in the prone position and, in turn, increased risk of sudden infant death syndrome.

Effects of quality of energy on substrate oxidation in enterally fed, low-birth-weight infants.

BACKGROUND: Carbohydrate and fat may differ in their ability to support energy-requiring physiologic processes, such as protein synthesis and growth. If so, varying the constituents of infant formula might be therapeutically advantageous. OBJECTIVE: We tested the hypothesis that low-birth-weight infants fed a diet containing 65% of nonprotein energy as carbohydrate oxidize relatively more carbohydrate and relatively less protein than do infants fed an isoenergetic, isonitrogenous diet containing 35% of nonprotein energy as carbohydrate. DESIGN: Sixty-two low-birth-weight infants weighing from 750 to 1600 g at birth were assigned randomly and blindly to receive 1 of 5 formulas that differed only in the quantity and quality of nonprotein energy. Formula containing 544 kJ x kg(-1) x d(-1) with either 50%, 35%, or 65% of nonprotein energy as carbohydrate was administered to control subjects, group 1, and group 2, respectively. Groups 3 and 4 received gross energy intakes of 648 kJ x kg(-1) x d(-1) with 35% and 65% of nonprotein energy as carbohydrate. Protein intake was targeted at 4 g x kg(-1) x d(-1). Substrate oxidation was estimated from biweekly, 6-h measurements of gas exchange and 24-h urinary nitrogen excretion. RESULTS: Carbohydrate oxidation was positively (r = 0.71, P < 0.0001) and fat oxidation was negatively (r = -0.46, P < 0.001) correlated with carbohydrate intake. Protein oxidation was negatively correlated with carbohydrate oxidation (r = -0.42, P < 0.001). Fat oxidation was not correlated with protein oxidation. Protein oxidation was less in infants receiving 65% of nonprotein energy as carbohydrate than in groups receiving 35% nonprotein energy as carbohydrate. CONCLUSION: These data support the hypothesis that energy supplied as carbohydrate is more effective than energy supplied as fat in sparing protein oxidation in enterally fed low-birth-weight infants.

Effects of sleeping position and time after feeding on the organization of sleep/wake states in prematurely born infants.

Epidemiologic studies provide strong evidence for the conclusion that sleeping in the prone position places infants at greater risk for sudden infant death syndrome (SIDS). Prior studies in newborn infants found that in the prone sleeping position there is less time awake and more quiet sleep, but little change in the amount of active sleep. To determine whether the effects of sleeping position on state distribution vary with time after feeding, we studied prematurely born infants in both the prone and supine sleeping positions. Sleep states were recorded each minute during interfeed intervals. Results demonstrate expected effects of sleep position on state distribution: prone sleeping is associated with a 79% increase in quiet sleep and a 71% decrease in time awake. While the decreases in time awake are seen throughout the interfeed interval, increases in quiet sleep in the prone position are found only within the first hour and again near the end of the interfeed interval. These results are consistent with the hypothesis that prone sleeping could increase risk for SIDS by altering the organization of sleep, and that time after feeding may play an important role in the expression of these effects.

Weaning strategy with inhaled nitric oxide treatment in persistent pulmonary hypertension of the newborn.

AIM: To determine if infants who had become dependent on inhaled nitric oxide treatment could be successfully weaned off it if FIO2 was increased briefly during withdrawal. METHODS: Sixteen infants admitted for conditions associated with increased pulmonary vascular resistance responded well to inhaled nitric oxide treatment with a significant increase in PaO2 (maximum inhaled nitric oxide given 25 ppm). Weaning from inhaled nitric oxide in 5 ppm decrements was initiated once the FIO2 requirement was less than 0.5. When patients were stable on 5 ppm of inhaled nitric oxide, the gas was then discontinued. If a patient showed inhaled nitric oxide dependence-that is, oxygen saturation fell by more than 10% or below 85%-inhaled nitric oxide was reinstated at 5 ppm and the patient allowed to stabilise for 30 minutes. At this time, FIO2 was increased by 0.40 and weaning from inhaled nitric oxide was attempted again. RESULTS: Nine infants were successfully weaned on the first attempt. The seven infants who failed the initial trial were all successfully weaned following the increase in FIO2. After successful weaning, FIO2 was returned to the pre-weaning level in mean 148(SD 51) minutes and inhaled nitric oxide was never reinstated. CONCLUSION: Infants showing inhaled nitric oxide dependency can be successfully weaned by increasing FIO2 transiently.

Randomised controlled trial of thiopental for intubation in neonates.

AIMS: To determine the effects of premedication with thiopental on heart rate, blood pressure, and oxygen saturation during semi-elective nasotracheal intubation in neonates. METHODS: A randomised, placebo controlled, non-blinded study design was used to study 30 neonates (mean birthweight 3.27 kg) requiring semi-elective nasotracheal intubation. The babies were randomly allocated to receive either 6 mg/kg of thiopental (study group) or an equivalent volume of physiological saline (control group) one minute before the start of the procedure. Six infants were intubated primarily and 24 were changed from orotracheal to a nasotracheal tube. The electrocardiogram, arterial pressure wave, and transcutaneous oxygen saturation were recorded continuously 10 minutes before, during, and 20 minutes after intubation. Minute by minute measurements of heart rate, heart rate variability, mean blood pressure (MBP) and transcutaneous oxygen saturation (SpO(2)) were computed. The differences for all of these between the baseline measurements and those made during and after intubation were determined. Differences in the measurements made in the study and the control groups were compared using Student's t test. RESULTS: During intubation, heart rate increased to a greater degree (12.0 vs -0.5 beats per minute, p < 0.03) and MBP increased to a lesser degree (-2.9 vs 4.4 mm Hg; p < 0.002) in the infants who were premedicated with thiopental. After intubation only the changes in MBP differed significantly between the two groups (-3.8 vs 4.6 mm Hg; p < 0.001). There were no significant changes in the oxygen saturation between the two groups during or after intubation. The time taken for intubation was significantly shorter in the study group (p < 0.04). CONCLUSIONS: The heart rate and blood pressure of infants who are premedicated with thiopental are maintained nearer to baseline values than those of similar infants who receive no premedication. Whether this lessening of the acute drop in the heart rate and increase in blood pressure typically seen during intubation of unmedicated infants is associated with long term advantages to the infants remains to be determined.

Motion resistant pulse oximetry in neonates.

BACKGROUND: Pulse oximetry is widely used in neonates. However, its reliability is often affected by motion artefact. Clinicians confronted with questionable oxygen saturation (SpO(2)) values often estimate the reliability by correlating heart rate (HR) obtained with the oximeter with that obtained by electrocardiogram. OBJECTIVE: To compare the effects of motion on SpO(2) and HR measurements made with Masimo signal extraction technology and those made with a Nellcor N-200. DESIGN: Continuous pulse oximetry and HR monitoring were performed in 15 healthy, term infants (mean (SD) birth weight 3408 (458) g) undergoing circumcision, using Masimo and Nellcor pulse oximeters and a standard HR monitor (Hewlett-Packard). Simultaneous minute by minute behavioural activity codes were also assigned. Baseline data were collected for 10 minutes when the infant was quietly asleep and then continued during and after circumcision for a total duration of one hour. The oximeter HR and SpO(2) values were compared and related to HR values obtained by ECG during all three periods. The effect of behavioural activity on SpO(2) and HR was also evaluated. RESULTS: When compared with results obtained with the Nellcor, the mean SpO(2) and HR were higher and the incidence of artefact lower with the Masimo during all three periods. Masimo HR more accurately predicted HR obtained with a standard monitor, with lower residual error. SpO(2) and HR values obtained with the Nellcor were lower and more variable during all behavioural states, especially crying, when excessive motion artefact was most likely. CONCLUSIONS: The data suggest that Masimo signal extraction technology may offer improvement in pulse oximetry performance, particularly in clinical situations in which extreme motion artefacts are likely.

Thickness of the human round window membrane in different forms of otitis media.

The thickness and morphologic characteristics of the round window membrane were evaluated in temporal bones from normal subjects as well as those with serous otitis media, purulent otitis media, and chronic otitis media. Temporal bones were studied in chronological order in six age ranges to determine the possibility of age-related differences. No significant difference in the mean thickness of the round window membrane was observed in terms of age groups in normal temporal bones or temporal bones from patients with otitis media; however, a significant difference in the mean thickness was observed in the various forms of otitis media compared with the normal round window membrane in all age groups. The membrane was thickest in patients with chronic otitis media when compared with that in normal subjects or those with serous or purulent otitis media. The epithelial layer (including the subepithelial space) and the fibrous layer were measured individually to determine in which layer the change in mean thickness occurred. These measurements showed an involvement of all layers of the round window membrane in those groups with otitis media, with maximal involvement of the combined epithelial layer and subepithelial space.

Body position, sleep states, and cardiorespiratory activity in developing low birth weight infants.

The objective of this study was to determine the effects of body position (supine vs prone) on cardiorespiratory activity during quiet and active sleep in growing low birth weight (LBW) infants. The effect of postconceptional age on cardiorespiratory activity in the two positions was also evaluated. Fifty-one healthy, growing, appropriate for gestational age LBW infants (795-1600 g), ranging from 26-37 weeks in gestational age, were evaluated. All subjects were enrolled in an ongoing study of the effects of quality of dietary energy on the rate and composition of weight gain. Infants were randomly assigned to the supine or prone position for the first 3 h of the 6-h studies; the position was reversed for the second 3 h. Continuous recordings of cardiorespiratory activity were performed along with simultaneous minute by minute assignment of behavioral sleep state. Measurements of heart rate (HR), heart period variability (RR-SD), respiratory rate (f), and respiratory variability (fSD) were made each minute. Low birth weight infants had higher HR and f and lower RR-SD and fSD in the prone position compared to the supine position, during both quiet and active sleep. With increasing postconceptional age, positional differences in HR increased during quiet sleep and differences in RR-SD increased during both sleep states. These data demonstrate systematic differences in cardiorespiratory control related to body position during sleep. We speculate that such positional differences are due to variations in autonomic control, and may, in turn, contribute to variations in susceptibility to sudden infant death syndrome.

Long-term efficacy of percutaneous transluminal angioplasty on incidence of myocardial infarction, relief of symptoms and survival.

This study was conducted to determine the long-term effects of percutaneous transluminal coronary angioplasty (PTCA) on the incidence of myocardial infarction, survival, and relief of symptoms. A total of 124 patients were included in the study and were followed for 16 to 25 months. The success rate of PTCA was 91.2% and 160 stenoses were dilated. Fifty-nine patients had multivessel disease (MVD) and 54 had single-vessel disease (SVD). There was no difference in survival when patients with SVD were compared with those with MVD. The cardiac survival rate for both groups was greater than 98%. Nine patients had myocardial infarction in the area of the dilated artery: 3 patients (5.5%) with SVD and 6 patients (10.1%) with MVD. Ninety-six patients (84.9%) remained free of symptoms: 46 patients (85.2%) with SVD and 50 patients (84.7%) with MVD. These data demonstrate the long-term efficacy of PTCA in patients with SVD and MVD with regard to control of symptom of angina, improved survival, and prevention of myocardial infarction.

Frequency of perinatal transfer by day of the week and holidays.

OBJECTIVE: To describe the pattern of obstetric transfers to a rural tertiary center relative to weekends and holidays. METHODS: A 2-year retrospective cohort study. RESULTS: A total of 903 patients were received in transfer over the study period. Tuesday was the most frequent day (17.4%) for transfer and Sunday was the least frequent day (9.2%). Friday was the most frequent day for transfer of patients who did not deliver (18.6%) and Sunday the least frequent day for transfer (7.6%). Subset analysis by delivery status found no statistical difference in the frequency of transfer by delivery status and day of the week (p = 0.28). Tuesday had the highest mean at 1.51 +/- 1.13 and Sunday had the lowest mean at 0.8 +/- 0.89. No difference in transfer volume by day of the week was observed by ANOVA (p = 0.25). The number of transfers occurring around the 7 days surrounding the six major holidays averaged 7.67 +/- 3.63, which did not differ significantly from the weekly average of 8.59 +/- 2.74 (p = 0.29). CONCLUSION: There is no apparent bias to transfer of patients based on the day of the week or holidays. Individual assessment by regional centers may assist in planning for staffing of transport services and resources.

Congenital diaphragmatic hernia: survival treated with very delayed surgery, spontaneous respiration, and no chest tube.

This report suggests that stabilization of the intrauterine to extrauterine transitional circulation combined with a respiratory care strategy that avoids pulmonary overdistension, takes advantage of inherent biological cardiorespiratory mechanics, and very delayed surgery for congenital diaphragmatic hernia results in improved survival and decreases the need for extracorporeal membrane oxygenation (ECMO). This retrospective review of a 10-year experience in which the respiratory care strategy, ECMO availability, and technique of surgical repair remained essentially constant describes the evolution of this method of management of congenital diaphragmatic hernia.