Joseph R Hageman

Intralipid alterations in pulmonary prostaglandin metabolism and gas exchange

To assess the role of Intralipid as a prostaglandin (PG) precursor, we infused Intralipid into 40 rabbits with long-term arterial and venous catheters; 24 other rabbits received a control saline infusion. One-half of the rabbits in both experimental and control groups had oleic acid-damaged lungs, and at least 5 in each of the 4 groups (Intralipid/saline in normal/damaged lungs) received indomethacin. Two vasodilating PGs (E2 and 6KF1α) and one vasoconstricting PG (F2α) were measured. Triglyceride levels increased significantly in all Intralipid groups, averaging 580 mg/dl. Intralipid-related alterations in PG levels and arterial oxygen tension (Pao2) were significant only in the lung-damaged group. The mean (± sem) decrease in Pao2 was 12 ± 1.5 torr (p < .001). For both vasodilating PGs, Intralipid infusion increased the pulmonary arteriovenous gradients for PG E2 and PG 6KF1α by 960 pg/ml (p < .05) and 697 pg/ml (p < .10), respectively. Both the Pao2 decrease and the vasodilating PG increases were blocked by indomethacin. In summary, Intralipid infusion in lung-damaged rabbits increased pulmonary production of vasodilating PGs and associated hypoxemia, presumably caused by an unblocking of hypoxic vasoconstriction and resultant increase in intrapulmonary right-to-left shunt.

CARING FOR THE GRADUATE FROM THE NEONATAL INTENSIVE CARE UNIT: At Home, In the Office, and In the Community

This article focuses on recent progress in the understanding of optimal care for the neonatal intensive care unit (NICU) graduate in three domains that have relevance to primary care pediatricians: the concept of developmentally supportive care for the immature central nervous system of fragile premature infants; an understanding of the function and systems of community-based early intervention available for medically complex, developmentally challenged and at-risk infants; and the management of technology-dependent children at home.

Acute renal failure in the newborn.

Recent advances in prenatal and neonatal care have increased the number of live births and extended the life expectancy of critically ill premature infants. These infants represent a formidable therapeutic challenge in that multisystem involvement and previously uncommon conditions, such as intravascular coagulation, acute tubular necrosis, and acute cortical necrosis are now seen with increased frequency. This review begins with a discussion of the development of renal function in the neonate followed by a description of the more common causes of acute renal failure (ARF) in this age group. Finally, the pathophysiology, diagnosis, and management of this condition are discussed.

Pulmonary complications of hyperventilation therapy for persistent pulmonary hypertension.

Hyperventilation has become a primary therapeutic modality in the management of neonates with persistent pulmonary hypertension (PPH). Of 51 PPH infants undergoing hyperventilation therapy, 45% developed pneumothorax. The subgroup which developed pneumothorax was exposed to assisted ventilation for significantly longer time periods and at higher peak inspiratory pressures. They were also exposed to longer periods of oxygen therapy at higher oxygen concentrations. Survival in the pneumothorax group was significantly lower.The incidence of bronchopulmonary dysplasia (BPD) in the 35 survivors was only 6%. These data indicate that the use of hyperventilation to treat PPH is associated with a significant incidence of pneumothorax but a low incidence of BPD.

The early involvement of pulmonary prostaglandins in hyperoxic lung injury

To further study the role of arachidonic acid metabolites in the development of hyperoxic lung injury and the function of PMNs and/or alveolar macrophages in facilitating this role, we exposed adult rabbits to greater than 95% O2 or air for 24, 40, 48, or 65 hours. At the end of each study, bronchoalveolar lavage [BAL] of the left lung was performed, and the right lung was inflated and fixed for light and electron microscopy. PGE2, 6-keto-PGF1 alpha and thromboxane B2 were measured by RIA in arterial and venous plasma at the beginning and end of each study and in BAL fluid obtained at sacrifice. Production of these three PGs by BAL cells placed in cell culture was also measured. Significant hyperoxic lung injury did not develop until 65 hours, as evidenced by significant increase in BAL total protein and percent PMNs, and by morphologic findings. At 40 hours, however, BAL fluid PGE2 and 6-keto-PGF1 alpha increased and BAL cell production of all 3 PGs was significantly increased (p less than .05). In summary, the early PG increases observed in these studies may directly contribute to the development of hyperoxic lung injury or, rather, may be representative of a generalized increase in all arachidonic acid metabolites, including the lipoxygenase pathway. The increase in BAL cell PG production and increased PG concentrations in BAL fluid prior to any increase in BAL PMNs suggest that the AM may be the source of the early arachidonic acid metabolite increase in response to hyperoxia.

Clinical correlates do not predict PaO2 response after tolazoline administration in hypoxic newborns.

In an attempt to determine which hypoxic newborns might benefit from administration of tolazoline hydrochloride (Tz), we identified all neonates known to have received Tz at four Chicago area perinatal centers over a 4-yr period. For each of 41 infants, five statistical analyses were used to correlate 31 clinical and ventilatory variables with PaO2 values before and after Tz administration. Fourteen neonates responded to Tz infusion with more than a two-fold increase in PaO2. None of 31 clinical variables successfully predicted a positive Tz response in these infants, and a positive response (increased PaO2) was not associated with increased likelihood of survival. BP fell after Tz in 72% of patients, while heart rate rose after Tz treatment in 66% of cases. These data suggest a need to re-evaluate the administration of Tz to hypoxic newborn infants.

A Mindfulness Intervention for Residents: Relevance for Pediatricians.

Physician burnout is a topic of growing importance in todays health care system. Tangible interventions aimed at reducing burnout and promoting wellness are now necessary components of medical training and practice. A study examined the feasibility and impact of a brief mindfulness intervention using a free smartphone application with a resident population. Participants used a free smartphone application to complete a 10-day program in mindfulness meditation, and completed surveys at the end of the program. Lack of time and knowledge were the top two barriers to regular meditation practice. More research in this area using a larger population is needed to further characterize the effects of mindfulness on medical trainees, as well as its utility for practicing pediatricians. [Pediatr Ann. 2016;45(10):e373-e376.].

Apparent Life-Threatening Events in Infancy

Apreviously healthy 5-weekold boy who was born at term is brought to the emergency department. His mother reports that she had placed him on his side with a support pillow after breast-feeding him before she went to take a shower. Upon returning to check on him, she found him in prone position, with his nose and mouth in the mattress, “struggling” to breathe; his face was red. The mother thought he looked “sleepy.” She picked him up, noting his tone was somewhat decreased; she ran his head under cold water with an increase in respiration but he still seemed sleepy. The mother watched him for an hour and breast-fed him. After discussing it with her son’s pediatrician, she brought him to the emergency department (ED). The infant’s medical history is signifi cant for noisy breathing (inspiratory and expiratory stridor) at 3 weeks of age. At that time, he was seen by his pediatrician and by ear, nose and throat (ENT) specialists who diagnosed him with mild laryngomalacia. On exam, he is well-appearing, well-perfused, pink, and in no acute distress. Vital signs are all within normal range. He has mild nasal sounds transmitted to the chest, and mild intermittent inspiratory and expiratory stridor when supine and occasionally

An adolescent with Graves' disease and thymic hyperplasia.

A 14-year-old female presented to our hospital for a second opinion regarding a recent diagnosis of Graves disease and a mediastinal mass. Four months prior to presentation, the patient developed difficulty with concentration. Historically she had been an A/B student; however, her school performance worsened suddenly, and she almost failed the eighth grade. One month later, she began complaining of increased sweating, diarrhea, difficulty with balance, jitteriness, and difficulty sitting still. During the previous 2 months, she had an increased appetite along with a 10-lb weight gain, increased hair loss, fatigue, and dry skin. Two weeks prior to her presentation, her mother noted that she had a large neck mass. At that time, the patient complained of dysphagia and tenderness of the anterior neck on palpation, but she had no respiratory difficulties. In addition, she had no symptoms of fever or night sweats.

Case Report Neonatal Spinal‐cord Dysfunction associated with Disseminated Intravascular Coagulation

A newborn with acute spinal‐cord dysfunction associated with disseminated intravascular coagulation (DIC) is presented. Spinal‐cord dysfunction in the newborn resulting from DIC or any other coagulopathy has not been previously reported in the English literature. This association should be considered in the differential diagnoses of neonatal hypotonia and neonatal paralysis.