Effect of pulse dexamethasone therapy on the incidence and severity of chronic lung disease in the very low birth weight infant.

We conducted a prospective, randomized, double-blind trial to assess the efficacy and safety of pulse doses of dexamethasone on survival without supplemental oxygen in very low birth weight infants at high risk of having chronic lung disease. Seventy-eight infants with birth weights < or = 1500 gm who were ventilator dependent at 7 days of postnatal age were randomly assigned to receive pulse doses of dexamethasone, 0.5 mg/kg per day, divided twice daily (n = 39), or an equivalent volume of saline solution placebo (n = 39), for 3 days at 10-day intervals until they no longer required supplemental oxygen or assisted ventilation, or reached 36 weeks of postmenstrual age. At study entry, the groups did not differ by birth weight, gestational age, or severity of lung disease. At 36 weeks of postmenstrual age, there was both a significant increase in survival rates without oxygen supplementation (p = 0.03) and a significant decrease in the incidence of chronic lung disease (p = 0.047) in the group that received pulse therapy. Supplemental oxygen requirements were less throughout the study period in the group that received repeated pulse doses of dexamethasone (p = 0.013). The total numbers of deaths and the durations of supplemental oxygen, ventilator support, and hospital stay did not differ between groups. Recorded side effects in the pulse therapy group were minimal and included an increase in the use of insulin therapy for hyperglycemia (p < 0.05). We conclude that in this population of very low birth weight infants, treatment with pulse doses of dexamethasone resulted in improvement in pulmonary outcome without clinically significant side effects.

Regional distribution of myosin heavy chain isoforms in rib cage muscles as a function of postnatal development.

We studied the expression of myosin heavy chain (MHC) isoforms, utilizing electrophoretic methods, in rib cage (RC) muscles: the scalenus medius, the parasternal, cephalic, midthoracic, and caudal intercostal muscles; and in the diaphragm (DI) of rats during postnatal development and when mature. At day 1, all RC muscles and the DI expressed MHC neonatal/embryonic (69-92% of total MHC complement) with little MHC slow and 2A; the RC muscles alone expressed a small proportion of MHC 2B (2-4%). On day 4, MHC neonatal/embryonic expression still predominated (55-71%) but increased MHC 2A expression was observed in both the RC (11-21%) and DI (31%); MHC 2B (5-7%) was noted in the RC muscles but not the DI. By day 14, MHC neonatal/embryonic and 2A expression each comprised a third of the total MHC complement of the RC muscles, MHC 2X was first observed, and MHC 2B expression increased. The day 14 DI was comprised of equal proportions of MHC neonatal/embryonic, slow and 2A with little MHC 2X (11%). The adult and day 30 animals expressed comparable muscle-specific MHC phenotypes: the DI characterized by a proportional mixture of MHC slow, MHC 2A, and MHC 2X, with little MHC 2B, whereas the RC muscles expressed predominantly MHC 2B (40-62%). We conclude that the RC muscles and DI show comparable MHC phenotypes in the immediate newborn period but differ in their MHC expression during postnatal development and when mature. The RC muscles show only minor intermuscle variations in MHC phenotype during development, and when mature are characterized by fast MHC isoform expression, particularly MHC 2B.

Postnatal expression of myosin isoforms in an expiratory muscle--external abdominal oblique.

We studied the postnatal expression of heavy-chain (MHC) and native myosin isoforms in an expiratory abdominal muscle of the rat, the external abdominal oblique (EO). Moreover, we contrasted EO myosin expression with that of the costal diaphragm (DIA) to draw inspiratory vs. expiratory muscle comparisons during development. Examination of MHC gels demonstrated a mature phenotype of slow and adult fast myosin isoforms at an earlier age in the EO (day 60) than in the DIA [day > 115 (adult)]. The mature MHC phenotype of the EO was characterized by a preponderance of MHC 2B, whereas the DIA was characterized by approximately equal portions of MHC slow, MHC 2A, and MHC 2X. During early postnatal development, there was a delay in the expression of MHC 2A in the EO compared with the DIA. However, MHC 2B, expressed later in development in both muscles, was noted in the EO before the DIA. We conclude that 1) the EO mature myosin phenotype is characterized by a preponderance of fast myosin isoforms and 2) the EO and DIA muscles are subject to different temporal patterns of isoform expression during postnatal development.

Control of genioglossal muscle activity in the anesthetized piglet: the role of vagal afferents.

We examined genioglossal muscle electromyogram activity during room air breathing and hyperoxic hypercapnia in 10 anesthetized (halothane) newborn piglets before and after bilateral midcervical vagotomy. With vagal afferents intact, genioglossal activity was absent during room air breathing in 10/10 study animals and was recruited in only 4/10 piglets during carbon dioxide breathing. After vagotomy, genioglossal activity remained absent in 9/10 study animals during room air breathing but was recruited in 10/10 piglets during the hypercapnic gas exposure at arterial CO2 tensions comparable to prevagotomy levels. We conclude that vagal afferent feedback modulates genioglossal activity in anesthetized newborn piglets and exerts an inhibitory influence on the activity of this muscle during hyperpnea induced by carbon dioxide breathing.

Diaphragmatic electromyogram power-spectral analysis as a function of reduced end-expiratory lung volume.

We examined the centroid frequency (Fc) of the electromyogram power-frequency spectra from the costal (EMGco) and crural (EMGcr) diaphragms at functional residual capacity and at reduced end-expiratory lung volume (EELV) (induced by abdominal banding) in six anesthetized newborn piglets. EMGco and EMGcr were recorded from bipolar electrodes embedded in the costal and crural diaphragms respectively. A fast Fourier transformation of ECG free EMGco and EMGcr was used to compute the power-frequency spectra and calculate the Fc of EMGco and EMGcr. The nitrogen washout technique was used to measure EELV. Abdominal banding induced a reduction in EELV of 30.6% functional residual capacity (range 22-39%). The mean Fc of EMGcr was not significantly altered by the reduction in EELV, whereas the mean Fc of the EMGco fell in every animal at reduced EELV by 13 +/- 8% of baseline Fc (p less than 0.05). We conclude that alterations in lung volume alone can determine changes in the EMGco power spectrum and Fc. Investigators performing EMGco power spectral analysis should consider EELV status when interpreting their findings.

Hyperbaric oxygen use in neonates. A report of four patients.

We report the use of hyperbaric oxygen in four neonates with delayed wound healing. Three presented with cyanotic congenital heart disease and had wounds associated with surgical procedures; the fourth had a nonhealing wound as a result of a complication of an umbilical-artery catheter. All were treated in a hyperbaric chamber with 100% oxygen at 2 atmospheres absolute. All wounds healed after institution of hyperbaric therapy. There was no evidence of serious side effects in any patient. These observations suggest, but do not prove, the efficacy of hyperbaric oxygen therapy for neonates with delayed wound healing.

The effects of surgical technique and the radius of the eye on correction for horizontal strabismus.

A theory is developed that considers the effects of surgical technique and the radius of the eye on the values for the surgical amount that correct horizontal strabismus. By replacing the biologic system of the eye and the extraocular muscles with an idealized model eye, equations are derived that relate to the surgical amount. Using these equations, it is possible to show that small variations in the radius of the eyeball can have a significant effect on the surgical amount. It is also shown that for a recession, variations in the distance between the point where the sutures are tied on the muscle, before disinserting it, and the original insertion point of the muscle can have a significant effect on the final outcome of the surgery.

A computerized Three-Step Test.

A computerized Three-Step Test is described that uses a BCD integrated circuit chip instead of a computer with a software package. This is accomplished by coding the Three-Step Test in terms of a three-letter word. The operation of a device is described which is able to diagnose isolated cyclovertical muscle palsies, once the clinical data is known, by setting the position of three switches.

A graphic three-step test.

A graphic technique is used to analyze cyclovertical muscle palsies. This technique is similar to that presented in the Ophthalmology Basic and Clinical Science Course, but has the following advantages: only one diagram is required to apply the method, and knowledge of the actions of the cyclovertical muscles, when analyzing the Bielschowsky head tilt test, is not required.