1/8. dexamethasone treatment during ventilator dependency: possible life threatening gastrointestinal complications.Corticosteroids in high doses have been used effectively to decrease the duration of ventilator dependency in very low birthweight infants at risk for chronic lung disease. Randomised prospective studies have shown benefit, with only minimal complications being reported. However, review of our experience over 2.5 years with high dose steroids in 80 premature neonates yielded three major complications: one case each of perforated duodenal ulcer, perforated gastric ulcer, and upper gastrointestinal haemorrhage. Two of the three patients died. Thus the use of steroids in neonates may not be without risk, and significant complications can occur. When high dose corticosteroids are to be used in very low birthweight neonates, H2 receptor antagonist treatment and gastric pH monitoring are recommended. The physician must remain alert to the possibilities of upper gastrointestinal bleeding and ulcer perforation in these patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/8. medical futility in the neonatal intensive care unit: hope for a resolution.Contemporary medical practice in the NICU sometimes leads to conflicts between providers and parents in which the parent demands continuation of life-sustaining treatment that the medical team deems medically inappropriate or futile. Such conflicts can be difficult to resolve and trying for all parties. Here we describe a conflict involving a 25-week-gestation, 825-g newborn with multiple intractable medical problems and resolution of the conflict through ethics consultation under provisions of the texas advance directives Act. The process established under texas law sets conceptual and temporal boundaries around the problem of medical futility and provides a legal safe harbor for physicians who seek to withdraw life-sustaining treatments in the setting of medical futility, allowing resolution of such conflicts in a timely and effective manner. As such, it may provide a model for physicians in other states to follow.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
3/8. Multifocal lymphangioendotheliomatosis with thrombocytopenia: a rare cause of gastrointestinal bleeding in the newborn period.Severe gastrointestinal bleeding in the newborn period is a serious but uncommon phenomenon that has a broad differential diagnosis. In the following case report we describe a rare phenomenon in which a newborn presents with severe hematemesis, hematochezia, and thrombocytopenia that are resistant to repeated platelet and packed red blood cell transfusions. Previous cases have been reported, but none of the patients described presented within the first 8 days of life. The early age of presentation and refractory nature of this disease entity to multiple therapies make it a diagnostic and therapeutic dilemma for all physicians involved in the care of newborns.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/8. oligohydramnios, renal insufficiency, and ileal perforation in preterm infants after intrauterine exposure to indomethacin.Three preterm infants exposed antenatally to indomethacin developed a characteristic syndrome consisting of edema and hydrops with a bleeding disorder at birth, oliguric renal failure during the first 3 postnatal days, and acute pneumoperitoneum resulting from localized ileal perforation(s) at the end of the first week of life. Despite the value of indomethacin for arresting preterm labor, the physician must take into account the potential hazards of drug toxicity.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/8. Transfusion-acquired plasmodium malariae infection in two premature infants.Several diseases can be transmitted to infants via transfusion. The risk of acquiring an infection via transfusion is greatly increased in sick premature infants because they receive frequent transfusions. The full-term infant is not fully competent immunologically, and the premature infant is even less able to deal with infection. Ideally, the transfusion of infected blood, especially into immunoincompetent recipients, should not occur. However, because screening for malaria in nonendemic regions is not practical, physicians caring for sick premature babies should consider transfusion-acquired malaria as a possible cause of illness, especially when there is no response to antibacterial therapy.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/8. Progressive hepatic injury in prolonged parenteral alimentation.A morphologic sequence of progressive hepatic injury is demonstrated in an immature infant who received TPN for 148 days. Because immature infants are susceptible to multiple pathophysiologic insults, it is presently impossible to isolate a single etiologic agent responsible for hepatic dysfunction. It is important for physicians caring for immature infants to establish through biochemical and morphologic monitoring that appropriate duration for TPN which is not likely to lead to irreversible hepatic injury.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/8. Neonatal vocal cord paralysis.The consultants agree that surgery is a common cause of unilateral vocal cord paralysis in neonates. In the absence of a history of surgery, they would evaluate a neonate for cardiovascular or central nervous system anomalies. None believes a relationship between laryngomalacia and vocal cord paralysis exists. But there is disagreement regarding the additional steps required to evaluate this child. The recommendations include endoscopy under general anesthesia with assessment of cricoarytenoid mobility, evaluation for other congenital anomalies, and observation of laryngeal dynamics (Dr. Benjamin), neurologic examination (Dr. Bailey), and no further testing (Dr. Gray). Laryngeal EMG in an infant is not an established technique and none of the consultants routinely performs this test. However, EMGs are part of the research protocol for one physician (Dr. Gray). The consensus is that aspiration is unlikely to be a problem in this case. However, if aspiration does occur, all would recommend conservative treatment. Feedings should be thickened and anti-reflux precautions taken. None was convinced that severe aspiration would be a problem. However, given the need for more aggressive treatment, the considerations would include collagen or Teflon injections or a tracheotomy (Dr. Gray) or a Nissen fundoplication, nasogastric tube feedings, or a gastrostomy (Dr. Bailey). Only one consultant would defer further treatment (Dr. Benjamin). The prognosis is generally good. Two consultants (Drs. Benjamin and Bailey) would follow a child with vocal cord paralysis by periodically repeating a laryngoscopic examination. A reinnervation procedure would be considered by one consultant at the age of 3 if the voice remains weak (Dr. Gray).- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/8. molecular epidemiology of staphylococcal scalded skin syndrome in premature infants.BACKGROUND: Outbreaks of nosocomial staphylococcal scalded skin syndrome (SSSS) in infants have been well-described associated with the well baby nursery or delivery room. We describe two cases of SSSS in very low birth weight infants in a neonatal intensive care unit (NICU) and the success of infection control strategies used to prevent an outbreak. methods: staphylococcal scalded skin syndrome was diagnosed in two infants in the NICU: Case I (a 47-day-old, formerly 530-g female); and Case II diagnosed 48 h later (a 41-day old, formerly 706-g female). Multiple infection control measures were implemented: (1) isolation and intravenous antibiotic treatment of cases; (2) placement of exposed infants into a cohort; (3) prophylactic mupirocin treatment of the anterior nares of all infants in the NICU and staff colonized with staphylococcus aureus; and (4) personnel hand washing with hexachlorophene. Detection of exfoliative toxin A and studies to determine the genetic relatedness of S. aureus strains isolated from patients and staff were performed. RESULTS: In addition to the two SSSS cases, S. aureus was isolated from 2 of 12 (17%) exposed asymptomatic infants, 2 of 20 (10%) ancillary staff, 8 of 30 (27%) nurses and 6 of 24 (25%) physicians. Exfoliative toxin A-producing strains were isolated from both cases and one asymptomatic infant. No toxin was expressed by strains isolated from staff. pulse field gel electrophoresis demonstrated genetically identical strains of S. aureus from the two SSSS cases and the asymptomatic infant, whereas three staff members harbored strains genetically related to the case strain. Unexpectedly two additional unique clusters of genetically related S. aureus strains were identified from the surveillance cultures. CONCLUSIONS: This report documents the rare occurrence of nosocomial SSSS attributed to transmission in the NICU among extremely low birth weight infants. Multiple infection control strategies were effective in limiting the outbreak. molecular epidemiology investigation supported a unique S. aureus strain responsible for this event and the presence of bidirectional spread between staff and patients of non-toxin-producing strains.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |