Elizabeth A. Catlin

The Apgar score revisited: Influence of gestational age

We tested the hypothesis that Apgar scores are in part related to the newborn infants level of maturity. Seventy-three pregnant women with normal fetuses of gestational age 22 to 42 weeks were studied. Fetal well-being was documented by a prospectively designed recording of pregnancy history, labor complications, and birth outcome, including cord blood pH and base deficit measurements. The 1- and 5-minute Apgar scores were directly related to gestational age. Respiratory efforts, muscle tone, and reflex were the major determinants for a decreasing Apgar score with declining gestational age. We conclude that the 1- and 5-minute Apgar scores are influenced by the infants level of maturity and that our data may be useful in evaluating the true value of Apgar scores in assessing the fetal and neonatal condition of low birth weight infants.

Biochemical immaturity of lungs in congenital diaphragmatic hernia

Neonates with congenital diaphragmatic hernia (CDH) continue to have unacceptably high mortality rates. To better understand the associated pulmonary pathology we measured biochemical parameters of lung maturity in neonatal rats with or without congenital diaphragmatic hernia created by maternal feeding of a single dose of nitrofen on day 9.5 or day 11.5 of gestation. Lungs from neonatal rats with large CDH (n = 9, 5 right-sided, 4 left-sided) had a significantly lower lung weight (P = .0001), lung weight/body weight ratio (P = .0001), disaturated phosphatidylcholine (DSPC) per microgram DNA (P < .005), total DSPC (P = .0001), total DNA (P < .05), protein per microgram DNA (P < .05), and total protein content (P < .005) when compared with lungs from the litter mates without congenital diaphragmatic hernia (n = 10). The lungs of rats with hernia also had significantly higher DNA concentrations (P < .05) and glycogen concentrations (P < .05). These data demonstrate that lungs in neonatal rats with large CDH are biochemically immature. Treatment directed toward correcting the pulmonary biochemical immaturity of affected fetuses before birth may improve the prognosis for these babies.

The intensivist in a spiritual care training program adapted for clinicians

Background:Critical illness is a crisis for the total person, not just for the physical body. Patients and their loved ones often reflect on spiritual, religious, and existential questions when seriously ill. Surveys have demonstrated that most patients wish physicians would concern themselves with their patients’ spiritual and religious needs, thus indicating that this part of their care has been neglected or avoided. With the well-documented desire of patients to have their caregivers include the patient’s spiritual values in their health care, and the well-documented reality that caregivers are often hesitant to do so because of lack of training and comfort in this realm, clinical pastoral education for health care providers fills a significant gap in continuing education for caregivers. Objectives:To report on the first 6 yrs of a unique training program in clinical pastoral education adapted for clinicians and its effect on the experience of the health care worker in the intensive care unit. We describe the didactic and reflective process whereby skills of relating to the ultimate concerns of patients and families are acquired and refined. Design and Setting:Clinical pastoral education designed for clergy was adapted for the health care worker committed to developing skills in the diagnosis and management of spiritual distress. Clinician participants (approximately 10–12) meet weekly for 5 months (400 hrs of supervised clinical pastoral care training). The program is designed to incorporate essential elements of pastoral care training, namely experience, reflection, insight, action, and integration. Results:This accredited program has been in continuous operation training clinicians for the past 6 yrs. Fifty-three clinicians have since graduated from the program. Graduates have incorporated clinical pastoral education training into clinical medical practice, research, and/or further training in clinical pastoral education. Outcomes reported by graduates include the following: Clinical practice became infused with new awareness, sensitivity, and language; graduates learned to relate more meaningfully to patients/families of patients and discover a richer relationship with them; spiritual distress was (newly) recognizable in patients, caregivers, and self. Conclusions:This unique clinical pastoral education program provides the clinician with knowledge, language, and understanding to explore and support spiritual and religious issues confronting critically ill patients and their families. We propose that incorporating spiritual care of the patient and family into clinical practice is an important step in addressing the goal of caring for the whole person.

Spiritual and religious components of patient care in the neonatal intensive care unit: sacred themes in a secular setting.

OBJECTIVE: We hypothesized that spiritual distress was a common, unrecognized theme for neonatal intensive care unit (NICU) care providers.STUDY DESIGN: An anonymous questionnaire form assigned to a data table in a relational database was designed.RESULTS: Surveys were completed by 66% of NICU staff. All respondents viewed a familys spiritual and religious concerns as having a place in patient care. Eighty-three percent reported praying for babies privately. Asked what theological sense they made of suffering of NICU babies, 2% replied that children do not suffer in the NICU. Regarding psychological suffering of families, the majority felt God could prevent this, with parents differing (p=0.039) from nonparents.CONCLUSION: There exists a strong undercurrent of spirituality and religiosity in the study NICU. These data document actual religious and spiritual attitudes and practices and support a need for pastoral resources for both families and care providers. NICU care providers approach difficulties of their work potentially within a religious and spiritual rather than a uniquely secular framework.

Müllerian inhibiting substance inhibits branching morphogenesis and induces apoptosis in fetal rat lung.

Mullerian inhibiting substance (MIS) is a glycoprotein hormone required for normal male reproductive tract development; it is presumed to signal through a heteromeric complex of type I and type II receptors. MIS exposure produces a paracrine-mediated regression of the embryonic Mullerian duct with histological changes consistent with apoptosis. MIS has also been shown to inhibit fetal lung development in vitro and in vivo, although the mechanism of this inhibition is unknown. The primordial lung and gonad are anatomically proximate on embryonic day 13.5, raising the possibility of a paracrine-mediated influence of MIS in male embryos on lung as well as MIS effecting dissolution of the Mullerian duct. We hypothesized that a negative regulatory event(s) might occur in the lung, as occurs in the duct, at the onset of MIS protein expression; thus, apoptosis and branching morphogenesis were studied in explanted fetal rat lungs incubated with proteolytically activated MIS. MIS exposure resulted in reduced total...

Müllerian inhibiting substance blocks epidermal growth factor receptor phosphorylation in fetal rat lung membranes

Neonatal males develop respiratory distress syndrome more frequently than females for unknown reasons. The fetal testis secretes testosterone and müllerian inhibiting substance (MIS); MIS has been shown to inhibit fetal lung maturation in vitro and in vivo and to block phosphorylation of epidermal growth factor (EGF) receptors in A431 cells. We hypothesized that MIS would also inhibit membrane phosphorylation of EGF receptors in fetal lung, and that ultrastructural study of MIS-exposed lung might complement the biochemical data by assessing the effect of MIS on tissue morphology. Lung membranes were prepared from 19.5-day fetal rats and phosphorylation assays performed with 3 to 4 micrograms of membrane protein, with or without EGF (26 nmol/L), 0.025 mCi AT32P (0.136 mumol/L), and either recombinant human MIS (rhMIS, 30 pmol) from media of Chinese hamster ovary (CHO) cells, rhMIS dialysis buffer, or wild-type CHO media. The 170,000 molecular weight EGF receptor, visualized by autoradiography of polyacrylamide gels, was phosphorylated in both female and male membranes. rhMIS, when added to EGF-stimulated membranes, caused significant inhibition of EGF receptor phosphorylation (females: 32.42% +/- 11.5%; males: 32.3% +/- 19.1%, P less than 0.001; rhMIS-treated v EGF-stimulated state, P = NS, male v female, Cerenkov counting). Electron microscopy (EM) of rhMIS-exposed lung showed decreased lamellar bodies (LB) in both male alveolar spaces and female parenchyma, and, unexpectedly, increased numbers in female alveoli. Immunoabsorption experiments using coincubation of rhMIS with anti-rhMIS IgG polyclonal antibodies or equiprotein normal IgG demonstrated MIS antibody-specific reversal of rhMIS activity in membrane phosphorylation.(ABSTRACT TRUNCATED AT 250 WORDS)

Moral and Ethical Dilemmas in Critically Ill Newborns: A 20-Year Follow-Up Survey of Massachusetts Pediatricians

Surveys of Massachusetts pediatricians in the 1970s and 1980s indicated changing attitudes concerning life-saving treatment of newborns, from less to increased intervention.OBJECTIVE:To replicate the 1987 survey, referring to the original 1977 study, regarding opinions about treatment for critically ill neonates.STUDY DESIGN:A long-term follow-up survey of American Academy of Pediatrics Massachusetts membership, maintaining the 1987 instrument, was initiated.RESULTS:A notable demographic shift in respondents from a majority of male practitioners in 1977 (89.6%), to 73% in 1987, to more equal numbers of men and women in 1997 (55% and 45%, respectively; p < 0.001; 1987 vs 1997) was apparent. Pediatricians’ attitude changes over the 20-year period were relatively modest and were statistically associated with active medical intervention. In 1997, 75% of respondents rejected review committees as mediators, a marked change from 1987. Regardless of healthcare maintenance organization affiliations, 95% indicated that restrictive fiscal policies would not affect decision-making.CONCLUSION: This study indicates stability and consensus in pediatricians’ attitudes toward active intervention for critically ill neonates compared with 1977 and 1987 surveys and reveals several claims to professional autonomy.

Updated Parental Viewpoints on Male Neonatal Circumcision in the United States

Through a questionnaire, the authors sought to elicit information about initial attitudes concerning circumcision after reading a summary of the American Academy of Pediatrics (AAP) Policy Statement and, again, after reading a description of recent HIV/HPV studies. Predictors of increased support for circumcision included having a prior circumcised boy and being US born. Predictors of decreased support included being of Hispanic ethnicity and believing that the uncircumcised penis was more culturally normal. After reading the AAP statement, 86% of respondents remained favorable of elective circumcision, whereas 13% viewed it less favorably. After reading the passage about the HIV/HPV studies, the majority maintained their initial level of support. Certain characteristics were associated with an individual’s desire to perform circumcision on his/her infant. Despite a slight decrease in support to perform circumcision after reading the AAP policy summary, respondents’ initial attitudes toward circumcision were unchanged after subsequent review of recent HIV/HPV research.

Postnatal growth and fatty acid synthesis in overgrown rat pups induced by fetal hyperinsulinemia

Fetal hyperinsulinemia in the rat results in increased body weight, lipid content, and enhanced lipogenesis in liver and carcass. The purpose of our study was to determine whether the macrosomia and enhancement of fatty acid (FA) synthesis and/or content persisted postnatally in this animal model. Fetal hyperinsulinemia was produced in Sprague-Dawley rats by injecting fetuses with 2 units of insulin at 20.5 days of gestation. Alternate pups in the same litter were injected with saline. Pups were delivered surgically at 22.5 days of gestation, were weighed daily and sacrificed on day 15. FA content and synthesis rates of liver and skeletal muscle were measured. We found: (1) At birth, insulin-treated pups were 12% heavier than saline littermates, (5.88 +/- 0.14 g v 5.26 +/- 0.14 g, P less than .01); and (2) The enhanced growth associated with prenatal insulin treatment persisted during the suckling period, ie, compared with saline-treated controls, insulin pups were 15.7% heavier at 15 days of age (P less than .01); growth velocity of insulin pups, beginning on day 3, significantly exceeded that of control pups (P less than .05). FA contents of liver and muscle in insulin pups, (62.6 +/- 5.7 mumol/g and 62.7 +/- 13.2 mumol/g) were significantly greater (P less than .05) than in saline littermates (45.1 +/- 5.6 mumol/g and 30.2 +/- 4.7 mumol/g, respectively). We conclude that.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduction of epidermal growth factor receptor phosphorylation by activated mullerian inhibiting substance is vanadate-sensitive☆☆☆

The carboxy-terminal domain of recombinant human Mullerian inhibiting substance (MIS) inhibits cellular proliferation in vitro and decreases epidermal growth factor (EGF)-dependent phosphorylation of the EGF receptor. Proteolytically cleaved and undissociated MIS is more potent than carboxy-terminal MIS alone, supporting a functional role for the amino-terminal region of the molecule. MIS does not block EGF binding to the EGF receptor, thus, MIS reduction of EGF receptor phosphorylation must occur distal to receptor ligand binding. The effect of proteolytically cleaved MIS on reduction of EGF receptor phosphorylation in membrane preparations is decreased by a specific phosphatase inhibitor, vanadate, thus implicating a membrane phosphatase in this MIS action at the EGF receptor.