Efforts of the United States' National Marrow Donor Program and Registry to improve utilization and representation of minority donors.

SUMMARY: Haematopoietic stem cell transplantation is often used as a therapy for patients with certain blood, metabolic or immune system disorders. The United States' National Marrow Donor Program (NMDP) works to facilitate such life-saving transplants by coordinating the donor search and match process. However, concern exists that the NMDP Registry is underutilized and under-representative of racial and ethnic minorities. African-Americans and Hispanics are somewhat under-represented within the total number of donors, and it is estimated that the Registry is used by only approximately one-third of patients needing transplants. The NMDP has instituted programmes that address such concerns, resulting in an increase in both the total number of donors and the minority representation on the Registry. It has also increased efforts to recruit donors of umbilical cord blood, often a viable alternative source of haematopoietic stem cells. Over the past 8 years, the Registry has grown by more than 30% to contain over seven million donors, and the proportional distribution of racial and ethnic groups on the Registry has steadily approached their proportional distribution in the US population. Continued efforts on the part of the NMDP to maintain a Registry that is large in number and ethnically diverse should help ensure access to haematopoietic stem cell transplants for all patients who need them. The procedures and experience of the NMDP and its Registry may have implications for registries elsewhere in the world as they confront similar issues of number and diversity.

Cord serum lipid and apolipoprotein levels in preterm infants with the neonatal respiratory distress syndrome.

OBJECTIVE: The purpose of this study was to evaluate the effects of birth weight on cord serum lipid and apolipoprotein levels in preterm infants with and without respiratory distress syndrome (RDS). METHODS: Cord serum lipid and apolipoprotein levels were evaluated in preterm infants (39 with RDS and 68 controls without RDS). Based on morbidity and mortality risk, RDS and non-RDS infants were separated into four birth weight groups (2,000-2,499 g, 1,500-1,999 g, 1,000-1,499 g, < 1,000 g) and evaluated for effects of birth weight on cord serum levels. RESULTS: RDS infants with birth weight of 2,000-2,499 g had significantly higher levels of cholesterol, triglyceride, total fatty acids and apolipoprotein A-I, but not arachidonic acid, than controls. RDS infants weighing 1,000-1,999 g had lower total fatty acids and apolipoprotein B levels, including arachidonic acid, than non-RDS infants. Cord serum lipid and apolipoprotein levels were significantly elevated in large (2,000-2,499 g) RDS infants, but lower levels were found in smaller (1,000-1,999 g) RDS infants. CONCLUSIONS: Cord serum arachidonic acid and apolipoprotein levels found in RDS infants suggest that lipid transport across the placenta may be abnormal. Inadequate total fatty acid supplies in utero could interfere with normal fetal growth and maturation, leading to development of neonatal RDS as one manifestation of risk for postnatal morbidity and mortality.

Increased survival in low birth weight neonates given prophylactic surfactant.

OBJECTIVE: To compare the effectiveness of a prophylactic surfactant treatment strategy (PRO) to the effectiveness of a rescue (RESC) surfactant treatment strategy in patients at high risk for developing hyaline membrane disease (HMD). STUDY DESIGN: We analyzed data from a retrospective cohort consisting of all patients admitted to the neonatal intensive care units at the centers participating in the recently completed Infasurf-Survanta Comparative Trial. To be in the cohort, a patient had to be admitted during the trial, be <48 hours of age on admission, have a gestational age of <30 weeks, have a birth weight of 501 to 1250 gm, and be free of congenital anomalies. Twelve centers participated in this study. They contributed 1097 patients of whom 381 were treated with a PRO strategy. RESULTS: Survival was significantly higher in the PRO-strategy patients (84% vs 72%, p < 0.05) as was survival without oxygen requirement at a postconceptional age of 36 weeks (60% vs 46%, p < 0.05). In addition, the patients with PRO had a lower prevalence of grade III and IV intraventricular hemorrhage (IVH, 9% vs 14%, p < 0.05). All analyses were controlled for birth weight and type of study center. CONCLUSION: These data support the conclusion that using a PRO treatment strategy results in improved survival in patients at risk for developing HMD. A PRO treatment strategy may also decrease the likelihood of developing a severe IVH.

Comparison of Infasurf (calf lung surfactant extract) to Survanta (Beractant) in the treatment and prevention of respiratory distress syndrome.

OBJECTIVE: To compare the relative safety and efficacy of Infasurf (calf lung surfactant extract; ONY, Inc, Amherst, NY, IND #27169) versus Survanta (Beractant, Ross Laboratories, Columbus, OH) in reducing the acute severity of respiratory distress syndrome (RDS) when given at birth and to infants with established RDS. DESIGN: A prospective, randomized, double-blind, multicenter clinical trial. SETTING: Thirteen neonatal intensive care units participated in the treatment arm: seven of these concurrently participated in the prevention arm. PATIENTS: The treatment arm enrolled infants of

Pneumococcal septicemia and pneumonia in the neonatal period.

Infections due to Streptococcus pneumoniae are extremely rare in the neonatal period. A newly born infant with pneumococcal septicemia and pneumonia is described.

Apnea in subsequent asymptomatic siblings of infants who had an apparent life-threatening event.

Infants experiencing apparent life-threatening events (ALTE) have been reported to have elevated frequencies of periodic breathing and obstructive apnea when compared to presumably normal control groups. Whether these characteristics extend to the siblings of ALTE infants remains unknown. This study compared, retrospectively, the apnea indices of 13 first-born infants experiencing an ALTE with their subsequent asymptomatic siblings who had undergone polygraphic sleep apnea evaluations (including electrocardiogram, chest wall movements, expired CO2, and transcutaneous pulse oximetry). Gestation, birthweight, age at study, apnea and periodic breathing indices, and oxygen desaturations were compared. Regression analyses revealed that adjustments for gestational and postnatal age eliminated differences in apnea indices. ALTE infants and their subsequent siblings experienced similar rates of apnea. Neither group had elevated rates of prolonged central apneas (greater than 10 seconds duration) or periodic breathing (greater than 5% sleep time). Neither group had subsequent severe apneas. The use of polygraphic study and cardiac/apnea monitors in subsequent siblings of ALTE are unnecessary and should be considered only when there is parental disagreement.

Microphonic versus end-tidal carbon dioxide nasal airflow detection in neonates with apnea.

Impedance pneumography in combination with expired CO2 monitoring are commonly used techniques for detecting central and obstructive apnea in infants. In this investigation an American Telephone and Telegraph StarSet-1 3000-ohm self-actuating microphone connected to the end of an infant cannula was used to monitor neonatal nasal airflow to detect breaths and apnea. The microphone was placed in a soundproof container to eliminate environmental sound artifacts. Analyses of 100 breaths from five patient samples during active and quiet sleep showed that there was no significant difference between microphone and expired CO2 recording of respiration. The techniques were 98% and 96% sensitive, respectively. Microphonic detection of nasal airflow identified 27 of the 32 episodes of upper airway obstruction (84.2%) registered by end-tidal CO2 recording. Inspiratory and expiratory events could also be well documented. Microphonic recording of nasal airflow is a reliable and inexpensive technique to detect apnea.

Polymorphism of human plasma apolipoprotein C-III at birth and in early neonatal life.

Studies were carried out to investigate potential changes in apolipoprotein C-III (apoC-III) polymorphism from birth through the first month of life. Maternal serum at term and neonatal serum at birth, 3, 14, and 28 days were analyzed for the three principal polymorphic forms of apoC-III: apoC-III-0, apoC-III-1, and apoC-III-2. A two-dimensional electrophoretic procedure combining isoelectric focusing and electroimmunoassay was developed for this purpose. In maternal serum (n = 28), apoC-III-1 to apoC-III-2 ratios (1.45) were typical of normolipidemic adult serum, while the corresponding cord sera (n = 32) had a reversal of the apoC-III-1 to apoC-III-2 ratio (0.55). Basic polyacrylamide gel electrophoretic patterns of isolated cord sera lipoprotein density classes confirmed the reversal of the apoC-III-1 to apoC-III-2 ratio in each class. Following birth, the apoC-III-1 to apoC-III-2 ratio reached unity (1.04) at 3 days and did not change significantly thereafter. It can be concluded that the apoC-III-1 to apoC-III-2 ratio in the normal newborn increases shortly after birth primarily due to an increase in apoC-III-1, and this change appears to be associated with oral feeding, suggesting that intestinal factors may play a role in controlling the ratio of plasma apoC-III-1 to apoC-III-2.

Effects of maternal smoking and caffeine habits on infantile apnea: a retrospective study.

To evaluate the relationship of antecedent maternal smoking and caffeine consumption habits on the occurrence of apnea in their offspring, rates for central and obstructive apnea were analyzed in a cohort of mother-infant pairs. The mothers of 298 infants with apnea responded to a questionnaire completed prior to a nine-hour polysomnogram performed as part of the patients' evaluations. Cigarette consumption estimates were computed on a 20-cigarette per pack basis, and caffeine intake, based on dietary sources (coffee, tea, chocolate, and colas), was summarized as milligrams of caffeine consumed per day. Rates of central and obstructive apnea of 6 to 10 seconds in duration were calculated. Multiple linear regression analysis determined that smokers tended to be younger and have lower birth weight infants who presented earlier with apnea than infants of nonsmokers. Increased rates of central apnea occurred in infants of smokers as compared with infants of nonsmokers. During pregnancy, a pack per day increase in maternal smoking habit was associated with a 1.88/h increase in central apneas in their offspring (P less than .01). Maternal smoking after delivery had a similar relationship. Obstructive apnea rates were similar in both groups. Both central and obstructive apnea rates associated positively with increasing maternal caffeine consumption. Smoking habits and caffeine ingestion were correlated (P less than .01). Infants with apnea have greater rates of central apnea when their mothers smoke during pregnancy. Therefore, a history of nicotine consumption should be included in the medical history of infants presenting with apnea.

Effect of sleep state and position on the incidence of obstructive and central apnea in infants.

Sixty-four infants with a history of apnea were studied to determine the effects of sleeping position and sleep state (rapid eye movement [REM]) v (non-rapid eye movement [NREM]) on the occurrence of central and obstructive apneas. All-night polysomnographic studies were conducted on each infant, and the spontaneous occurrence of central and obstructive apneic events was determined in the prone, supine, and side positions. Sleeping position did not significantly affect the rate or duration of central or obstructive apneas. Furthermore, neither central nor obstructive apneic episodes were significantly altered by sleep state. These data suggest that, in spite of an ostensible predisposition to upper airway obstruction in the supine position and during rapid eye movement sleep, neither sleeping position nor sleep state appears to affect the rate of duration of apneic events.

Behavioral assessment of a hydranencephalic neonate.

This study attempted to clarify the role of the cerebral cortex in neonatal behavior by administering the Neonatal Behavioral Assessment Scale-Kansas revision to a hydranencephalic infant; particularly of interest were behaviors that are implicated in infant social responsiveness. The examination revealed extremely deviant responses on portions of the exam, including items that measure response decrement and orientation. However, this infant was observed to approximate normal neonatal responding on items relating to motor maturity and reactivity. Other findings included that some response decrement occurred in response to auditory and visual, but not tactile, stimulation. The discussion focuses on similarities and differences between this study and early research on both normal infants and infants with imperfectly formed nervous systems. Particular emphasis is placed on the response decrement results, as well as the utility of the NBAS-K in measuring infant behaviors in atypical infant samples.

Serum copper and ceruloplasmin in preterm infants: prospective study.

The postnatal time courses in preterm infants (30.0 weeks mean gestational age) of serum copper and ceruloplasmin (Cp) are described and compared. Serum copper was measured by nonflame atomic absorption spectrophotometry and serum Cp was measured by both immunodiffusion (Cpi) and enzyme assay (Cpe). With the exception of Cpe between 7 and 11 weeks of age, correlations among the three laboratory parameters were excellent. Following an early rise in all values, a plateau was seen in copper and Cpi between 5 and 11 weeks; Cpe showed a discordant fall at 7 to 11 weeks of age. After 11 weeks a secondary and definitive rise in all values was seen. Examination of individual time courses indicates the existence of a subgroup of infants with falling values between 5 and 11 weeks of age. Preterm infants had significantly higher serum copper (0.53 +/- 0.05 micrograms/ml) at a mean postnatal age of 10 weeks (39-41 weeks postconception) than did full-term infants (0.44 +/- 0.04 microns/ml) of similar postconceptional age. Low serum copper values were correlated with parenteral nutrition deficient in copper, with increased growth rates, and with twin pregnancies. It is concluded that extrauterine life in preterm infants is associated with precocious rises in serum copper and Cp values. The subgroup of infants with falling values may represent subclinically copper-deficient infants. This subgroup may bias the results of grouped data downwards. A role for nutritional factors in the delayed postnatal rise of serum copper and Cp values in preterm infants cannot be excluded on the basis of current knowledge.

Fetal scalp electrode complications: cerebrospinal fluid leak.

A newborn with cerebrospinal fluid leakage secondary to a fetal scalp electrode is presented. Although infrequent complications from fetal scalp electrode monitoring may be significant. Personnel using these monitoring devices should be alert to possible complications.

In utero distal pulmonary meconium aspiration.

We have recently had eight cases of severe meconium aspiration syndrome which occurred despite clearing of the posterior pharynx of meconium after delivery of the head but before delivery of the body. Seven of the eight cases had documented fetal distress before delivery. Two stillborns with meconium aspiration are presented and illustrate that electronic fetal monitoring and aggressive obstetric intervention should be coupled with the suctioning technic to prevent significant mortality and morbidity associated with meconium-stained deliveries.

Placental coccidioidomycosis without fetal disease.

We encountered two cases of maternal coccidioidomycosis with placental involvement. Altered cell-mediated immunity during pregnancy makes the diagnosis of desseminated coccidioidomycosis difficult by the routine serologic tests; placental examination provides specific information. A high index of suspicion regarding this disease and prompt institution of appropriate therapy are necessary in order to decrease maternal and neonatal mortality.