In the need of a digital cicerone in healthcare? - Guidance for parents.

OBJECTIVE: To explore parents' experiences using digital tools in relation to pregnancy, labor and birth, and the child's first 18 months. BACKGROUND: Parents find relevant information using digital healthcare tools, material obtained from professionals, as well as personal opinions and experiences that vary in quality. METHOD: Fifteen parents were interviewed and data were analyzed beginning with content analysis and followed by thematic analysis. RESULTS: The main theme was insecurity and responsibility for own choices and knowledge. Parents use digital tools to take responsibility for their insecurity and need for knowledge when entering parenthood. CONCLUSION: The parents' experiences highlighted that (1) insecurity can be both eased and enhanced using digital tools, (2) they took responsibility for feelings of insecurity and the search for knowledge, and (3) they needed knowledge to make the right choices and feel secure that these choices are made in the best interest of their new family.

Safety of early postoperative hydrotherapy in dogs undergoing thoracolumbar hemilaminectomy.

OBJECTIVES: Hydrotherapy is a common part of the postoperative care after surgical treatment of thoracolumbar intervertebral disc extrusion in dogs. There are currently no guidelines on when to commence hydrotherapy after surgery. Early hydrotherapy may be associated with an increased risk of postoperative complications including surgical site infection and neurological deterioration. The goal of this study was to report the prevalence and types of postoperative complications in dogs receiving early hydrotherapy. MATERIALS AND METHODS: Eighty-three dogs commencing hydrotherapy within 5 days after surgical treatment for thoracolumbar intervertebral disc extrusion were included in a retrospective descriptive study. All postoperative complications were recorded. RESULTS: Ten minor and 16 major complications were recorded in a total of 26 dogs. The majority of recorded complications were unlikely, but not excluded to be, caused by the initiation time of hydrotherapy. One dog developed a surgical site infection and one dog had a confirmed further extrusion of the originally operated intervertebral disc, which may have been influenced by early initiation of hydrotherapy. CLINICAL SIGNIFICANCE: Early hydrotherapy is possibly associated with occurrence of postoperative complications. Associations between the reported complications and early hydrotherapy, and possible benefits of early hydrotherapy, need to be further investigated before early initiation of hydrotherapy can be recommended.

Links between early adrenal function and respiratory outcome in preterm infants: airway inflammation and patent ductus arteriosus.

OBJECTIVE: To investigate the relationship of cortisol concentrations during the first week of life to patent ductus arteriosus (PDA), markers of lung inflammation, and respiratory outcome in very low birth weight infants. METHODS: Newborns <1,500 g birth weight were prospectively enrolled at 2 centers. Serum cortisol was measured 3 times during days 2 to 7 of life. Tracheal lavage was performed on intubated infants and analyzed for interleukin-1beta, -6, and -8, and for total protein, albumin, and alpha-1 protease inhibitor. Infants receiving prenatal glucocorticoids were excluded. RESULTS: We obtained 337 cortisol values from 125 infants. Infants treated for PDA had lower cortisol values after day 2. One hundred thirty-three tracheal fluid samples were obtained on matching days from 71 intubated infants. Cortisol correlated inversely with tracheal interleukins and proteins. Lower cortisol values during the second half of the week correlated with longer duration of supplemental oxygen therapy and with subsequent development of chronic lung disease at 28 days and at 36 weeks. CONCLUSION: Infants with lower cortisol values in the first week of life had an increased incidence of PDA, increased lung inflammation, and an increased incidence of chronic lung disease. These findings suggest that early adrenal insufficiency may underlie the previously observed association of increased lung inflammation and PDA with adverse respiratory outcome in this population.

The media and AIDS: health elite perspectives of coverage.

Most writers assessing AIDS have been critical of the media's coverage of this epidemic. To ascertain the views of key elites on media coverage of AIDS, the authors surveyed chief state public health officers, chairs of legislative health committees, and directors of hospital associations. In general, these groups tended to reject criticisms that media handling of AIDS is unbalanced. Conversely, however, they also generally rate the media as not doing a good job of educating the public about AIDS. The media's success in accurately communicating professional perspectives regarding AIDS might have accounted for their relative lack of independent influence in AIDS policymaking. The media exhibited a "guard dog" role-protecting the health professionals' positions-instead of an agenda-setting role-dictating to the decision-makers what issues they should be addressing.

Effect of five days of dexamethasone therapy on ventilator dependence and adrenocorticotropic hormone-stimulated cortisol concentrations.

OBJECTIVE: Our objective was to address the efficacy of 5 days of dexamethasone therapy in preterm infants dependent on ventilation and to measure adrenocorticotropic hormone-stimulated cortisol release after therapy. METHODS: This was a randomized, masked trial. Results were evaluated with Fisher's exact test and Wilcoxon test. Fifteen preterm infants in a newborn intensive care unit who were dependent on ventilation were enrolled at 8 to 24 days of age. Dexamethasone or normal saline solution was used for treatment. The main outcome measure was ventilator independence. RESULTS: Dexamethasone therapy correlated to successful extubation. Posttherapy peak adrenocorticotropic hormone-stimulated cortisol concentrations were lower in infants treated with dexamethasone than in infants treated with saline solution. CONCLUSIONS: A 5-day course of dexamethasone may be adequate to achieve ventilator independence. The difference in peak cortisol concentrations may reflect suppression of the hypothalamic-pituitary-adrenal axis by dexamethasone or a higher peak cortisol response in the infants treated with saline solution who have higher ventilatory acuity after therapy.

Effects of dietary alpha- and gamma-linolenic acids on liver fatty acids, lipid metabolism, and survival in sepsis.

The effects of dietary treatment for 3 weeks with soybean oil, linseed- and safflower oil (high alpha-linolenic acid, ALA), or borage oil (high gamma-linolenic acid, GLA) on the liver fatty acid profile and lipid metabolism in fed rats, in normal fasted rats, and septic fasted rats, and on survival from sepsis, were studied. The results were the following: 1) Dietary ALA increased incorporation of alpha-linolenic (18:3w3), eicosapentaenoic (20:5w3), and docosapentaenoic (22:5w3) acids in neutral lipids and phospholipids, and docosahexaenoic (22:6w3), dihomo-gamma-linolenic (20:3w6), arachidonic (20:4w6), stearic (18:0), oleic (18:1w9), and linoleic (18:2w6) acids in phospholipids in the livers of fed, fasted, and septic fasted rats. Dietary GLA increased all w6 fatty acids except 18:2w6, and reduced all w3 fatty acids in neutral lipids and phospholipids. 2) Dietary ALA increased liver phospholipid content in fasted as well as in septic fasted rats and was more potent than GLA in lowering serum cholesterol and liver neutral lipids. 3) Dietary ALA counteracted sepsis-related changes in liver weight, platelet count, body temperature, prekallikrein, serum glucose, beta-hydroxybutyrate, and free fatty acids. 4) Dietary GLA reduced survival from sepsis. The results suggest a role for w3 fatty acids to balance w6 fatty acids in the septic state.

Dexamethasone therapy is associated with a rise in urinary epidermal growth factor concentrations in the preterm infant.

The effect of glucocorticoid hormones on epidermal growth factor (EGF) concentrations has not been described in the premature infant. We examined this relationship in a group of infants treated with dexamethasone for airway edema (three to five doses) or chronic lung disease (six weeks of a tapering protocol). We collected urinary samples in 45 infants (25 for airway edema, 20 for chronic lung disease) before, during and after the use of dexamethasone. The EGF values were unchanged in infants that were given dexamethasone for airway edema. In contrast, all infants treated for chronic lung disease increased their EGF values by 1 week of therapy. At the end of the dexamethasone taper, ten of the infants had recovered successfully from ventilatory support. This group of infants had post-therapy EGF values that were significantly higher than pretherapy values. In the ten infants that were still ventilator dependent at the end of therapy, EGF values were not different from pretherapy values. We conclude that dexamethasone therapy was associated with an increase in urinary EGF values in the preterm infant treated for at least 1 week. The positive correlation of tapering from ventilatory support with increases in EGF values suggests that EGF may be a marker of dexamethasone effect or an effector of dexamethasone action.

Secretory leukocyte protease inhibitor and lung inflammation in developing bronchopulmonary dysplasia.

OBJECTIVE: To investigate secretory leukocyte protease inhibitor (SLPI) concentrations in tracheal lavage fluids of neonates with an endotracheal tube in place during the first month of life, and to evaluate the relationship of SLPI to neutrophil counts and elastase activity in patients in whom bronchopulmonary dysplasia (BPD) developed versus those in whom it did not. DESIGN: A prospective, inception cohort study. SETTING: University children's hospital neonatal intensive care unit. PATIENTS: Fifty-three neonates who weighed < 2000 gm at birth, and who had an endotracheal tube in place, were enrolled. Forth-one patients survived to 28 days; BPD developed in 24 but not in 17 patients. MAIN OUTCOME MEASURES: Tracheal lavage was performed on days 1, 2, 4, 7, 14, 21, and 28, and analyzed for neutrophils, elastase activity, and SLPI. Results were evaluated longitudinally for 28 days, and were compared between BPD and no-BPD groups during the first week. RESULTS: SLPI concentrations increased significantly for all patients during the study period. During the first week, SLPI concentrations were similar between BPD and no-BPD groups; neutrophil counts and elastase activity were higher in the BPD group. CONCLUSIONS: Patients in whom BPD ultimately developed had early evidence of increased pulmonary inflammation and a significantly less favorable protease-antiprotease balance. If elastase-induced injury contributes to the development of BPD, early therapy with recombinant SLPI might be beneficial by increasing the antielastase capacity of epithelial lining fluid.

Lipid mediated modification of rat heart allograft survival.

The effect on allograft survival of intravenous fat emulsions that differed in the ratio of functionally important n-3 and n-6 fatty acids was studied in a heterotopic cardiac transplant model in rats. Twenty percent fat emulsions were administered by continuous infusion at a dosage of 9 g fat/kg body weight per day, starting immediately after transplantation and continuing until complete rejection. The n-6 and n-3 fatty acids represent 75%, 43%, 60%, and 59% of all fatty acids in safflower oil, fish oil, soybean oil, and a 1:1 mixture of safflower and fish oil, respectively. The n-6 fatty acids predominate in safflower oil (370/1) and soybean oil (6.5/1), while the n-3 fatty acids dominate in the fish oil (7.6/1). The 1:1 mixture of safflower and fish oil has the balanced composition (n-6/n-3 = 2.1/1) recommended by Kinsella and served as oil-treated controls. Continuous infusion of safflower oil, fish oil, and soybean oil prolonged graft survival time to 13.3, 12.3, and 10.4 days, respectively, compared to 6.8 days in the oil-treated controls (P < 0.01 for all comparisons). Another control group infused with saline rejected the allografts after 7.8 days (P = NS compared to oil-treated controls; P < 0.01 for all other comparisons). The data suggest that intravenous administration of polyunsaturated fat emulsions results in an immunosuppressive effect that seems to be dependent on the n-3/n-6 fatty acid ratio of the fat emulsion.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of state health departments in formulating policy: a survey on the case of AIDS.

OBJECTIVES: Public health departments have been criticized for not being on the cutting edge of health policy formation in the United States and, in particular, for being ineffective in dealing with acquired immunodeficiency syndrome (AIDS). This study examines the attitudes and influence of public health officials on this problem. METHODS: A survey of state health department officials was supplemented by surveys of state legislature health committee chairs and hospital association directors, as well as by interviews with key AIDS policymakers and observers in six states. RESULTS: Both in their own eyes and in the eyes of legislative leaders and hospital association officials, public health officials were considered to be the principal initiators of public policy on AIDS. CONCLUSIONS: Contrary to the Institute of Medicine's 1988 report, state health departments are leaders in the fight against AIDS at the state level. Moreover, we argue that public health departments should be judged on how effectively they perform functions for which they have primary legal responsibilities, not for other roles for which they have been given neither responsibility nor resources.

Effect of necrotizing enterocolitis on urinary epidermal growth factor levels.

The pattern of urinary epidermal growth factor/creatinine levels in necrotizing enterocolitis was examined in 75 infants (in 28 infants the diagnosis of necrotizing enterocolitis was considered; 47 infants were studied for effect of surgery or nutrition on epidermal growth factor levels). There was a consistent and significant increase in epidermal growth factor/creatinine values at the time of diagnosis of necrotizing enterocolitis compared with baseline values. Epidermal growth factor levels in infants without necrotizing enterocolitis and in early nutrition remained unchanged. These results suggested that urinary epidermal growth factor/creatinine levels may differentiate stage II and III necrotizing enterocolitis from stage I disease. The increased epidermal growth factor/creatinine levels may be related to the absorption into the circulation of preexisting gastrointestinal tract epidermal growth factor through damaged tissue or to increased synthesis by the gastrointestinal tract in response to the injury caused by necrotizing enterocolitis.

Effect of n-3 fatty acids on the key enzymes involved in cholesterol and triglyceride turnover in rat liver.

The effect of long-chain n-3 fatty acids on hepatic key enzymes of cholesterol metabolism and triglyceride biosynthesis was investigated in two rat models. In the first model, rats were intravenously infused for two weeks with a fat emulsion containing 20% of triglycerides in which either n-6 or n-3 fatty acids predominated. The treatment with n-3 fatty acids led to a reduction primarily of serum cholesterol (45%), but also of serum triglycerides (18%). HMG-CoA reductase activity and cholesterol 7 alpha-hydroxylase activity were reduced by 45% and 36%, respectively. There were no significant effects on diacylglycerol acyltransferase (DGAT) or phosphatidate phosphohydrolase (PAP) activities. In the second model, rats were fed a diet enriched with sucrose, coconut oil and either sunflower oil (n-6 fatty acids) or fish oil (long-chain n-3 fatty acid ethyl esters). The treatment with n-3 fatty acids decreased serum triglycerides (41%) and, to a lesser extent, serum cholesterol (17%). Neither glycerol 3-phosphate acyltransferase (GPAT) or DGAT were affected by n-3 fatty acids. In contrast, PAP activity was reduced by 26%. HMG-CoA reductase was not significantly affected, whereas cholesterol 7 alpha-hydroxylase activity was reduced by 36%. The results indicate that part of the TG-lowering effect of long-chain n-3 fatty acids may be mediated by inhibition of the soluble phosphatidate phosphohydrolase. The effect on serum cholesterol may be partly due to inhibition of HMG-CoA reductase.

Developmental pattern of urinary epidermal growth factor in the premature infant and the influence of gender.

We report the cross-sectional pattern of first day urinary epidermal growth factor/creatinine (EGF/Cr) levels in 159 appropriate for gestational age infants born at 26-41 weeks gestation. EGF/Cr levels rose significantly earlier in female infants than levels in male infants. In female infants levels were similar to term levels beginning at 30-32 weeks. Mean EGF/Cr levels in male infants were similar to term values beginning at 32-34 weeks. We could not demonstrate any influence from acute perinatal events on EGF/Cr levels. In a subset of 28 infants, a weekly longitudinal study of urinary EGF/Cr levels was undertaken. The urinary EGF/Cr pattern correlated significantly with both corrected gestational and postnatal ages. A significant change in the EGF/Cr pattern was observed at a corrected gestational age of 32 weeks and at 4 weeks postnatal age. There was no significant difference in EGF/Cr levels between males and females. Our results demonstrated a significant difference in first day urinary EGF/Cr levels between female and male preterm infants during the early third trimester. This difference was seen at a time in gestation when other gender-specific maturational and growth differences are noted. When infants born at less than 32 weeks gestational age were followed longitudinally, the urinary EGF/Cr pattern, when expressed by corrected gestational age, was significantly modified from that in the cross-sectional study.

Sequential changes in lipid metabolism and the fatty acid profile in liver lipids during fasting and sepsis.

The sequential changes in lipid metabolism and in the fatty acid profile of liver lipids during fasting and sepsis were studied. Liver and blood specimens were taken from normally fed rats and from nonseptically and septically fasted rats at 5, 24, and 48 hr. Sepsis was induced by injecting live Escherichia coli bacteria intraperitoneally. Sepsis attenuated the fasting-induced increase in beta-hydroxybutyrate and reduced liver and serum triglycerides at 5 hr. There was a percentage decline in the most abundant fatty acids in neutral lipids, namely oleic (18:1w9) and linoleic (18:2w6) acids. This was seen throughout fasting and septic fasting. These results indicate that 18:1w9 and 18:2w6 are used as energy substrates and are oxidized to beta-hydroxybutyrate during fasting and mainly to carbon dioxide during septic fasting. On the contrary, the most abundant fatty acids in phospholipids, stearic (18:0), arachidonic (20:4w6), and docosahexaenoic (22:6w3) acids, accumulated in neutral lipids and in phospholipids throughout fasting. However, during sepsis this accumulation was reduced in neutral lipids and reversed to a level below that in the fed and fasted state in phospholipids. These results indicate that a disturbance in membrane integrity and function induced by septic fasting may have pathophysiological consequences for lipid metabolism and liver function during sepsis.

Quantification of neonatal cerebral ventricular volume by real-time ultrasonography. In vivo validation of the cylindrical coordinate method.

Posthemorrhagic ventricular dilation is a common clinical problem in preterm infants who have incurred an intraventricular hemorrhage. Presently there are no clinically applicable methods to follow quantitatively the progression of ventricular dilation at bedside. We describe the in vivo validation of a method to measure ventricular volume using bedside real-time cranial ultrasonography. Six infants undergoing either serial lumbar punctures or cerebral ventricular reservoir taps for posthemorrhagic hydrocephalus were studied. The cerebrospinal fluid (CSF) volume removed ranged from 5.5 mL to 30 mL. A strong correlation was found (r2 = 0.84) between the volume of CSF removed by reservoir tap and the change in ventricular volume calculated by the ultrasound method, whereas the correlation between the volume of CSF removed at lumbar puncture and the change in ventricular volume calculated by the ultrasound method was not as strong (r2 = 0.70). Limitations and sources of error in the method are discussed. We conclude that this procedure is accurate and offers a quantitative method to follow longitudinally posthemorrhagic progressive ventricular dilation.

The need for a loading dose of gentamicin in neonates.

We studied pharmacokinetic variables in 100 neonates to evaluate the need for a loading dose of gentamicin. The mean volume of distribution for gentamicin in this population was .542 +/- .205 L/kg. Forty-five percent of these patients would not achieve peak serum concentrations of greater than or equal to 5 micrograms/ml after one dose of 2.5 mg/kg. A loading dose of 4 mg/kg would result in a level of greater than or equal to 5 micrograms/ml in 92% of the patients. After this study, a 4 mg/kg loading dose was initiated at our institution. Peak and trough concentrations at steady state were compared in 50 patients receiving a loading dose and 40 patients who had not received a loading dose. No significant differences were found in peak or trough concentrations after three or more doses, verifying that a loading dose does not affect steady-state concentrations. Because gentamicin toxicities are related to accumulation over time, whereas therapeutic efficacy may be related to early attainment of therapeutic peak serum concentrations, we recommend a loading dose of 4 mg/kg in all neonates beginning gentamicin therapy.