Management of asymptomatic neonates born in the setting of chorioamnionitis: a safety comparison of the well-baby and intensive care setting.

BACKGROUND: Evaluate the safety of a change in care setting for asymptomatic neonates born to mothers with chorioamnionitis from the neonatal intensive care unit to the well baby nursery.Local problem:The neonatal intensive care unit evaluation and management of babies born to mothers with chorioamionitis often involves separation of the mother-baby dyad and more invasive interventions. METHODS: A single-center pre/post-intervention study of neonates born from January 2011 to November 2016, comparing safety outcomes in the neonatal intensive care unit (pre-intervention) and well baby nursery (post-intervention), following initiation of a triage protocol. INTERVENTIONS: A protocolized, systematic change was done in the practice location. RESULTS: Groups were similar for time to first antibiotic administration, sepsis symptom development and positive blood cultures. Length of stay (median 73.5 vs 64.4 h, P=0.0192) and % of neonates with intravenous fluid exposure (50.4% vs 7.6%, P<0.0001) were lower in the post-intervention group. Exclusive breastfeeding rates improved (pre-7.3% vs post-46.1%, P<0.0001). CONCLUSIONS: Asymptomatic neonates born to mothers with chorioamnionitis were safely treated in a well baby nursery under the guidance of a protocol for triage, thereby reducing NICU exposure for these neonates.

Adverse neurologic events associated with voriconazole use in 3 cats.

BACKGROUND: Voriconazole has a broader spectrum of activity in comparison to fluconazole, itraconazole, and amphotericin B. Little documentation regarding appropriate dosing, efficacy, or adverse effects exists for cats. Neurologic adverse effects have been reported as a result of administration in other species. HYPOTHESIS: Voriconazole administration resulted in neurologic abnormalities in 3 cats. ANIMALS: Three cats that received voriconazole. METHODS: Observational study of adverse effects associated with voriconazole administration. RESULTS: All 3 cats had ataxia, which in 2 cats progressed to paraplegia of the rear limbs. Two of the cats had visual abnormalities including mydriasis, decreased to absent pupillary light responses, and decreased menace response. Arrhythmia and hypokalemia were noted in 2 separate cats. CONCLUSIONS AND CLINICAL IMPORTANCE: Voriconazole has potential neurologic adverse effects in cats. Additional information regarding pharmacokinetics of the drug in this species must be gathered to help determine how it can be dosed most effectively with minimal adverse effects.

Predictors of survival in congenital diaphragmatic hernia patients requiring extracorporeal membrane oxygenation: CNMC 15-year experience.

OBJECTIVE: To review outcomes of patients with congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO) at a level IIIC neonatal intensive care unit and to determine if pre-ECMO respiratory status can help predict mortality. STUDY DESIGN: A single-center retrospective chart review was conducted on all infants with CDH treated with ECMO in the past 15 years. Demographic and clinical information, including pre-ECMO ventilatory and blood gas data, was collected. Differences between survivors and non-survivors were evaluated using independent samples t-/Mann-Whitney U-and Fisher's exact/chi (2)-tests for continuous and categorical data, respectively. Cox regression analysis was performed to evaluate predictors of survival while controlling for covariates. Significant predictors were further explored with receiver operating characteristic (ROC) curve and Kaplan-Meier survival analysis. RESULT: Overall survival of the population of 62 patients treated with ECMO was 50%. Survivor and non-survivors were similar in birth weight, gestational age, gender, race and Apgar scores. Approximately 80% of patients in both groups had a left-sided defect. Less than half of patients were prenatally diagnosed in either group. Patients in the non-survivor group had associated anomalies (42 vs 23% for survivors) but this was not statistically significant (P=0.303). Non-survivors were more likely to be put on ECMO earlier, stay on ECMO longer and be operated upon later. On pre-ECMO blood gas analyses, survivors had higher pH and PaO(2), and lower oxygenation index and PaCO(2) compared with non-survivors. After controlling for covariates, a lower minimum PaCO(2) and side of defect were the only independent predictors of survival. ROC curve for minimum pre-ECMO PaCO(2) had a significant area under the curve (0.72, P=0.003). Survival was 27% in babies unable to achieve a pre-ECMO PaCO(2) <60 mm Hg whereas no patients survived if their lowest pre-ECMO PaCO(2) was >70 mm Hg. CONCLUSION: Minimum achievable pre-ECMO PaCO(2) is an independent predictor of survival in patients with CDH requiring ECMO life support. These data provide useful prognostic information for counseling families and may facilitate direction of care in extreme cases where the degree of pulmonary hypoplasia may be incompatible with life.

Bioavailability of transdermal methimazole in a pluronic lecithin organogel (PLO) in healthy cats.

The antithyroid drug methimazole is widely used for the medical management of feline hyperthyroidism. Recently, custom veterinary pharmacies have offered methimazole in a transdermal gel containing pluronic and lecithin (PLO), with anecdotal evidence of efficacy. The purpose of this study was to determine the bioavailability, relative to i.v. and oral routes of administration, of transdermal methimazole in a PLO gel in cats. Six healthy adult cats were assigned to receive 5 mg of methimazole by the i.v., oral, or transdermal routes, in a randomized triple crossover protocol with 1 week washout between doses. Blood samples were taken for high performance liquid chromatography (HPLC) determination of serum methimazole, at 0, 5, 15, 30, 60 min, and 2, 4, 6, 12 and 24 h after dosing. Methimazole absorption following transdermal administration was poor and variable, with only two of six cats achieving detectable serum methimazole concentrations at any time point following transdermal administration. Area under the concentration-time curve (AUC), maximum concentration (Cmax), and absolute bioavailability were all significantly lower for the transdermal route (0.39 +/- 0.63 microg h/mL, 0.05 +/- 0.09 microg/mL, and 11.4 +/- 18.7%, respectively) than for either i.v. (7.96 +/- 4.38 microg h/mL, 3.34 +/- 2.00 microg/mL, 100%) or oral routes (2.94 +/- 1.24 microg h/mL, 0.51 +/- 0.15 microg/mL, 40.4 +/- 8.1%). The results of this study indicate generally low to undetectable bioavailability of methimazole in a lecithin/pluronic gel given as a single transdermal dose to healthy cats, although one individual cat did achieve nearly 100% transdermal bioavailability relative to the oral route.

Geriatric and team training for podiatric residents.

The authors discuss the Interdisciplinary Team Training in Geriatrics program developed by the Department of Veterans Affairs. At the James A. Haley Veterans Hospital, this program provides funding to podiatric residents, enabling them to work with practitioners from other health care disciplines as a team that addresses all of the varied health needs of the elderly patient.

Campylobacter jejuni/coli in commercially reared beagles: prevalence and serotypes.

A 5 year longitudinal study involving 187 commercially reared beagles from three suppliers was undertaken to determine prevalence and serotypes of Campylobacter jejuni and C. coli. Campylobacter jejuni or C. coli was isolated from the feces in 62 of 177 asymptomatic beagles and 8 of 10 dogs with diarrhea for an overall prevalence of 37%. A total of 36 isolates were serotyped on the basis of thermostable antigens with 20 antisera prepared against frequently occurring serotypes isolated from humans with campylobacter associated enteritis (15 C. jejuni, 5 C. coli serotypes). Of these isolates, 17 (47%) serotyped with antisera to 7 C. jejuni serotypes frequently isolated in human cases of enteric campylobacteriosis (serotypes 1, 4, 10, 16, 18, 19, 37). One C. coli reacted to antisera 24, 34, 37, one strain of C. coli to antisera type 37, and another C. coli to antisera type 34. All three C. coli belonged to serotypes frequently encountered in diarrheic human patients.

Effects of branched chain amino acid-enriched total parenteral nutrition on amino acid utilization in rats bearing Yoshida sarcoma.

We have studied the ability of branched chain amino-acid enriched total parenteral nutrition solutions to improve nutritional status without stimulating tumor growth. Protein kinetics, nitrogen balance, tumor kinetics, fractional synthetic rates of individual tissues, and albumin synthesis were compared in male Sprague-Dawley rats (125-145 g) that had either s.c. Yoshida sarcoma (n = 15) or sham implantations (n = 18). Ten days postinjection, rats were randomly assigned to 2 diet groups and given parenteral infusions of 4 days at 170 kcal/kg.body wt.day as dextrose and 2 g N/kg.body wt.day as either 19 or 50% branched chain amino acid-enriched diet. During the last 4 h of feeding, protein kinetic values were studied using a constant infusion of [14C]tyrosine. Plasma tyrosine appearance, synthesis, and breakdown were unchanged by branched chain amino acid infusion. Percentage of tyrosine flux oxidized and tyrosine oxidation decreased (P less than 0.05) and net tyrosine balance improved (P less than 0.05) in rats receiving the branched chain amino acid-enriched diet. Greater nitrogen balance and lower tumor growth rates were also found in branched chain amino acid-infused rats although not statistically significant. Tumor intracellular specific activity was significantly higher in tumor animals receiving crystalline infusions, suggesting greater tumor protein breakdown with branched chain amino acid-enriched infusion. Fractional synthetic rates of liver, muscle, and tumor were unchanged. Hence, branched chain amino acid-enriched total parenteral nutrition increases amino acid utilization for net protein synthesis principally by reducing oxidation without stimulating tumor growth.