Intracranial abnormalities in infants treated with extracorporeal membrane oxygenation: update on sonographic and CT findings.

PURPOSE: To determine the frequency of intracranial lesions in infants treated with extracorporeal membrane oxygenation (ECMO), to evaluate trends in frequency during an 8-year period, and to determine which infants are at highest risk for intracranial injury. METHODS: Daily sonograms were obtained in 386 infants during treatment with ECMO. Cranial CT scans were acquired after decannulation in 286 of 322 survivors. Abnormalities were classified as major or minor and hemorrhagic or nonhemorrhagic. Results were correlated with infant demographic data. RESULTS: Intracranial abnormalities were detected in 203 (52%) of the 386 infants; 73 (19%) hemorrhagic, 86 (22%) nonhemorrhagic, and 44 (11%) combined lesions. Eighty-two lesions (21%) were classified as major. Forty-six (94%) of 49 major hemorrhages were identified at sonography. CT contributed additional information in 73% of neonates with intracranial abnormalities, of which 17 were major lesions not identified at sonography. The frequency of intracranial hemorrhage was increased in infants who were septic or premature or weighed less than 2.5 kg. An increase in time spent on ECMO bypass increased the risk for nonhemorrhagic injury. During an 8-year period, the frequency of hemorrhagic and major nonhemorrhagic lesions remained constant, whereas minor nonhemorrhagic abnormalities increased significantly. CONCLUSION: Infants treated with ECMO continue to be at high risk for cerebrovascular injury. Although daily sonograms are useful in identifying major hemorrhages, follow-up CT scans are crucial for accurate evaluation of intracranial abnormalities.

Alcohol and drug use in teenagers with diabetes mellitus.

Alcohol and drug use in adolescents with diabetes mellitus was assessed by an anonymous self-administered questionnaire with verification by urine drug screening. Approximately 50% of these adolescents report having tried alcohol and 25% report ongoing use. Almost 25% have tried drugs of abuse and 5% report ongoing use. One of 97 consecutive urine specimens was positive for marijuana. In general, the frequency of alcohol and drug use was less than expected based on other studies of different clinical groups of patients in the same age range. Patients with diabetes who reported drug use or who reported they live in an environment of substance abuse had poorer diabetes control than patients who did not.

Surfactant (beractant) therapy for infants with congenital diaphragmatic hernia on ECMO: evidence of persistent surfactant deficiency.

Infants with congenital diaphragmatic hernia (CDH) on extracorporeal membrane oxygenation (ECMO) can have initial lung atelectasis which, in survivors, gradually improves over time. To test the hypothesis that these patients could benefit from surfactant therapy, infants with CDH (born at > 34 weeks' gestation) on ECMO received either four doses of modified bovine lung surfactant extract (beractant) (surfactant group, n = 9) or an equal volume of air (control group, n = 8). Tracheal aspirate surfactant protein-A (SP-A) concentrations were initially low, and then increased over time in both CDH groups (P = .0021); however, levels remained low when compared with those of infants on ECMO who had other diagnoses (P = .04). Lung compliance (CL), time to extubation, time on oxygen, and total no. of hospital days were not different between the two groups. Infants with CDH had persistently elevated right ventricular pressure (RVP) at cessation of bypass when compared with non-CDH infants on ECMO (RVP = 53.25 mm Hg +/- 19.52 in the CDH group, 32.90 +/- 10.63 in the non-CDH group; P = .0121). The findings suggest that the postnatal surfactant deficiency may be more persistent in CDH infants than in non-CDH infants on ECMO. However, CDH remains a multifactorial condition, with delayed improvement, because of persistence of pulmonary hypertension, difficulties with vascular remodeling, degree of lung hypoplasia, or compromised respiratory mechanics.

Assessing African American adolescents' risk for suicide attempts: attachment theory.

The threat of separation from a parent theoretically increases the risk of adolescent suicide attempts. The present study evaluated this and other hypothesized risk factors in a sample of adolescent suicide attempters and nonsuicidal controls, using the Psychiatric Consultation Checklist (Lyon, 1987). Stepwise logistic regression was used to predict group membership. It was found that threat of separation from a parental figure, insomnia, neglect, substance abuse, suicidal ideation, and failing grades were the strongest predictors of suicide attempt. Ten predictor variables correctly identified 97% of suicide attempters and 86% of nonattempters. Unexpected findings included high levels of truancy, threatening others, and separation from a parent before the age of 12 among nonattempters.

Neonates treated with ECMO: predictive value of early CT and US neuroimaging findings on short-term neurodevelopmental outcome.

PURPOSE: To determine if neuroimaging findings in infants who undergo extracorporeal membrane oxygenation (ECMO) are predictive of developmental outcome. MATERIALS AND METHODS: At 1-2 years of age, 183 ECMO survivors (69 female, 114 male) underwent developmental examination. Neuroimaging studies obtained at time of ECMO were assigned a neuroimaging score. Neuroimaging findings were correlated with developmental outcome. RESULTS: Eighty-five infants had neuroimaging abnormalities. Development was normal in 105 infants, suspect in 37, and delayed in 41. Mean neuroimaging scores were significantly worse in survivors with delayed development (P < or = .0001). The sensitivity and specificity of normal neuroimaging findings in prediction of normal outcome were 65% and 63%, respectively. Survivors with nonhemorrhagic abnormalities had a higher risk of delayed development than did those with isolated hemorrhagic abnormalities (39% vs 21%). CONCLUSION: Although they cannot be used alone to predict outcome, early neuroimaging scores can be used to assign risk categories for developmental outcome.

HIV antibody responses in children of HIV-infected mothers.

About 25% of the children of untreated HIV-infected mothers are later determined to be HIV-infected. At birth, all of the children of HIV-infected mothers have HIV-IgG antibody, which is transferred transplacentally from the mothers to their children, and infected children produce HIV-IgG antibody in response to their infection. Most infected children have detectable HIV-IgA by 3 months of age. We have studied HIV antibody responses in three groups of children of HIV-infected mothers at 9 to 12 months and 15 to 24 months of age. The groups were classified by Centers for Disease Control and Prevention (CDC) criteria and included: (I) HIV seroreverters (SR); (II) HIV-infected; Non- to mildly symptomatic (N+A); and (III) HIV-infected; Moderately to Severely Symptomatic (B+C). HIV-IgG antibody was detected in some SR children at low titer levels (10 to 20) through 11 months of age but not at 12 or later. For both the N+A and B+C groups, there were no significant changes in the mean HIV-IgG titers from 9-12 to 15-24 months of age. Also, no significant difference in titers were found between the two infected groups for both age groups. HIV-IgA antibody responses were more frequently positive at 15 to 24 months for all seven antigens studied for the N+A than the B+C patients; however, statistical significance was attained only for gp41 (p < or = 0.01). N+A children showed more responses to the viral antigens at 15-24 months than at 9-12 months. This increase in HIV-specific IgA among the N+A children may be important in restricting their HIV infections. Total IgG levels were significantly higher in the HIV-infected groups than in the SR (p < or = 0.0001), but no differences were detected between the N+A and B+C groups. Total IgA increased over time in the N+A patients from 9-12 to 15-24 months. A similar trend was apparent in the B+C group, but did not reach statistical significance. Both N+A and B+C patients at 15-24 months had significantly higher total IgA levels than did the SR at 9-12 months of age. The B+C group had significantly lower CD4 counts for both age groups than did the N+A or SR groups (p < or = 0.0001).

Evaluation of colorimetric dipstick test to detect alcohol in saliva: a pilot study.

The Alco Screen Saliva Dipstick is an inexpensive, easy-to-use, colorimetric test that gives a semiquantitative estimation of the blood alcohol value by measuring the relative concentration of salivary alcohol. To evaluate its accuracy, we compared the results from tests with the Alco dipstick with values from simultaneously measured blood alcohol tests in 53 patients who were suspected of having ingested alcohol. The correlation between Alco dipstick results and blood alcohol values was strong (r [Spearman's rho], + .91). When the blood alcohol concentration was 0.1 g/dL or more, the Alco dipstick test was 90.9% sensitive, 71.4% specific, and 92% efficient. At Alco dipstick values of 0.02 and 0.05 g/dL, however, semiquantitative concordance was unsatisfactory. Nevertheless, even at the 0.05-g/dL value of salivary alcohol, the test was still valuable as a screen of de facto alcohol ingestion. Definitive diagnosis of relative alcohol intoxication requires confirmatory breath or blood alcohol concentrations by standard methodologies.

Pelvic inflammatory disease in the adolescent: comparison of transabdominal and transvaginal sonographic evaluation.

Transabdominal (TA) and transvaginal (TV) sonograms (n = 116) were obtained in 84 patients aged 12-21 years (mean, 16.2 years) with the clinical diagnosis of acute pelvic inflammatory disease (PID). The studies were compared for image quality and unique diagnostic information. TV sonography demonstrated superior resolution of 25 dilated fallopian tubes. Heterogeneous pelvic masses, described as tubo-ovarian abscesses on TA sonograms, could be separated on TV sonograms into various stages of PID including pyosalpinx, hydrosalpinx, tubo-ovarian complex, and tubo-ovarian abscess. Thirty-one TA and TV studies were normal despite patients fulfilling strict clinical criteria for PID. The level of severity of PID, as determined at TA sonography, was altered in 28 cases, with medical therapy changed in 23 cases because of additional TV sonographic findings. TV sonography provided superior anatomic detail in the evaluation of patients with PID, demonstrating abnormalities that were not seen at TA sonography in 71% of patients.

Improved pulmonary outcome after exogenous surfactant therapy for respiratory failure in term infants requiring extracorporeal membrane oxygenation.

A blinded, randomized, controlled study was designed to test whether multiple-dose surfactant therapy would improve pulmonary outcome in term infants with respiratory failure, resulting in a shortened period of extracorporeal membrane oxygenation (ECMO). Infants > or = 34 weeks of gestational age in severe respiratory failure and receiving ECMO were stratified by diagnosis and then randomly assigned to the treatment or the control group. Four doses of modified bovine lung surfactant extract (beractant) were administered to the surfactant group (n = 28), and an equal volume of air was administered to the control group (n = 28). Lung compliance was initially low in both groups; after treatment, values were higher with time in the surfactant group (F = 5.40, p = 0.026). The ECMO treatment period was significantly shorter in the surfactant group (mean +/- SD: 107 +/- 33 hours vs 139 +/- 54 hours for the control group; U = 232, p = 0.023). Tracheal aspirate concentrations of surfactant protein A were low in both groups, and then increased steadily to a higher level in the surfactant group (F = 2.58, p = 0.04). The overall incidence of complications after ECMO was decreased in the surfactant group (18% vs 46% for the control group; chi-square value = 5.004, p = 0.025). Radiographic scores, echocardiographic findings, incidence of intracranial or pulmonary hemorrhage and bronchopulmonary dysplasia, time to extubation, duration of oxygen therapy, and duration of hospitalization did not differ between the two groups. Beractant in this population improved pulmonary mechanics, increased surfactant protein A content in tracheal aspirate, decreased time on ECMO duration, and reduced disease complications.

Coinfection with herpesviruses in young children of HIV-infected women.

Coinfection with herpesviruses in young children born to human immunodeficiency virus (HIV)-infected women was studied with blood samples from children who were 9-12 months and 15-24 months of age. Three groups of children were included: (I) HIV-uninfected, asymptomatic (HIV-); (II) polymerase chain reaction (PCR) and/or culture-positive and asymptomatic or mildly symptomatic (HIV+ asymptomatic); and (III) PCR and/or culture-positive and symptomatic (HIV+ symptomatic). Significantly more of the HIV+ symptomatic patients had cytomegalovirus (CMV) antibody than the HIV patients. In addition, CMV antibody levels were significantly higher in the HIV+ symptomatic patients than in either of the other two groups. Human herpesvirus 7 (HHV-7) antibody titers were significantly different among the three groups of patients; however, no pairwise comparisons were significant. No differences were found for HHV-6 or Epstein-Barr virus (EBV) antibody frequencies or titers. These findings suggest that infection with CMV is a cofactor or an opportunistic infection causing symptomatic HIV infections in young children.

HIV DNA blood levels in vertically infected pediatric patients: variations with age, association with disease progression, and comparison with blood levels in infected mothers.

Blood levels of HIV DNA in our vertically infected pediatric patients typically followed a characteristic age-related pattern: continuously increasing with increasing age to a peak between ages 4 and 8 months, and thereafter rather steadily declining. Median HIV DNA levels peaked about 3 months earlier in children who by age 24 months developed more severe rather than less severe HIV disease. Children at particular risk of developing severe HIV disease by age 24 months commonly had > 800 HIV DNA copies per 0.1 ml of blood at age 3 weeks to 2 months, > 1,000 copies at 2 to 4 months, and > 2,500 copies at ages 4 to 6 months. Near the time of delivery mothers who transmitted HIV had significantly higher median blood levels of HIV DNA than mothers who did not transmit, but median HIV DNA levels in infected mothers as a group were low compared with those in pediatric patients > or = 1 month of age.

Epstein-Barr virus DNA in the blood of infants, young children, and adults by age and HIV status.

Polymerase chain reaction (PCR) methodology was used to detect Epstein-Barr virus (EBV) DNA in peripheral blood mononuclear cells (PBMCs) from children and adults whose HIV status (i.e., infected or uninfected) is known. Initial EBV infections especially occurred in children between the ages of 7 and 24 months. EBV-positive children with vertically acquired HIV infection tended to have a detectable blood level of EBV DNA for a period of years, and their EBV DNA blood levels often exceeded 10,000 copies/0.1 ml of blood--hundreds of times higher than levels typically found in EBV-positive, HIV-uninfected children of the same age. EBV DNA was found in PBMCs in 26% of 49 HIV-infected mothers who were sampled during their pregnancy, but the median EBV DNA level in their EBV-positive samples was low--only 50 copies/0.1 ml blood. In limited tests with specimens from children infected with both HIV and EBV, high blood levels of EBV DNA unexpectedly appeared to be associated with decreased blood levels of HIV DNA (p = .063).