Sandy M. Snedecor

National experience with extracorporeal membrane oxygenation for newborn respiratory failure. Data from 715 cases

In a national registry, data were collected on 715 newborn patients with severe respiratory failure supported by extracorporeal membrane oxygenation (ECMO) in 18 neonatal centers. This represents almost all infants treated with ECMO between 1980 and 1987. Eighty-one percent of the patients survived. This result is statistically significantly better than any other treatment which produces less than 78.4% survival. The most common diagnoses were meconium aspiration (310 patients, 91% survived), respiratory distress syndrome (96 patients, 78% survived), diaphragmatic hernia (121 patients, 65% survived), and sepsis (64 patients, 72% survived). Average pre-ECMO characteristics were: age 59 hours; PaO2 42 torr, PaCO2 41 torr, pH 7.40; ventilator settings FiO2 1.0, pressure 45/4 cmH2O, rate 93. Technical complications occurred in 23.1%, and physiologic complications occurred in 65.6%. Results improved with experience. Survival rate for the first ten patients from each center was 73.5% compared to 83.7% for all subsequent patients. Survival rate did not, however, significantly differ after an institutional experience of 20 patients. These observations were made on a large cohort that could not be accumulated at an individual center. These results indicate that ECMO and lung rest is appropriate and successful treatment for newborn respiratory failure unresponsive to other means of management, and that almost all respiratory failure is reversible in near-term neonates.

Association of a single nucleotide polymorphism in neuronal acetylcholine receptor subunit alpha 5 (CHRNA5) with smoking status and with ‘pleasurable buzz’ during early experimentation with smoking

Aims To extend the previously identified association between a single nucleotide polymorphism (SNP) in neuronal acetylcholine receptor subunit alpha-5 (CHRNA5) and nicotine dependence to current smoking and initial smoking-experience phenotypes. Design, setting, participants Case–control association study with a community-based sample, comprising 363 Caucasians and 72 African Americans (203 cases, 232 controls). Measurements Cases had smoked ≥ five cigarettes/day for ≥ 5 years and had smoked at their current rate for the past 6 months. Controls had smoked between one and 100 cigarettes in their life-time, but never regularly. Participants also rated, retrospectively, pleasurable and displeasurable sensations experienced when they first smoked. We tested for associations between smoking phenotypes and the top 25 SNPs tested for association with nicotine dependence in a previous study. Findings A non-synonymous coding SNP in CHRNA5, rs16969968, was associated with case status [odds ratio (OR) = 1.5, P = 0.01] and, in Caucasians, with experiencing a pleasurable rush or buzz during the first cigarette (OR = 1.6, P = 0.01); these sensations were associated highly with current smoking (OR = 8.2, P = 0.0001). Conclusions We replicated the observation that the minor allele of rs16969968 affects smoking behavior, and extended these findings to sensitivity to smoking effects upon experimentation. While the ability to test genetic associations was limited by sample size, the polymorphism in the CHRNA5 subunit was shown to be associated significantly with enhanced pleasurable responses to initial cigarettes in regular smokers in an a priori test. The findings suggest that phenotypes related to subjective experiences upon smoking experimentation may mediate the development of nicotine dependence.

Smoking patterns and abstinence effects in smokers with no ADHD, childhood ADHD, and adult ADHD symptomatology

Cigarette smokers are known to be overrepresented among adults with Attention Deficit Hyperactivity Disorder (ADHD). To date, however, no attempt has been made to determine the extent to which a lifetime diagnosis of ADHD may be associated with smoking even in the absence of current symptomatology. We hypothesized that nicotine dependence and abstinence effects-especially effects relevant to ADHD symptomatology-would be more pronounced in adult ADHD smokers in comparison with those who reported childhood ADHD symptoms only. Results indicated that, in contrast to controls without ADHD symptomatology, both adult and childhood ADHD groups were significantly more likely to experience a number of nicotine withdrawal symptoms, including irritability and difficulty concentrating; in no instance did the ADHD groups differ from one another in this regard. Thus, studying people with childhood symptoms of ADHD, even in the absence of an adult diagnosis, may shed light on the known association between smoking and ADHD.

Extracorporeal membrane oxygenation in term newborns : a prospective cost-benefit analysis

Clinicians reserve ECMO for neonates at >80% predicted mortality risk. The authors hypothesized that ECMO instituted at lower (50%) mortality risk would result in fewer intensive care unit days and a lower hospital cost compared with conventional therapy (including ECMO at high mortality risk). This was a randomized control trial, cost-benefit analysis in an academic newborn intensive care unit. The patients were a prospectively studied, consecutive sample of 41 term neonates with 1) age 24-72 hours, 2) “maximal medical management” for > 6 hours, 3) oxygenation index (OI) values > 25 but < 40. (Severity of illness measured by OI=((mean airway pressure X FiO2 X 100) PaO2)). All eligible patients entered. Thirty-two of 37 survivors were evaluated at 1 year. Intervention occurred when OI = 25. Patients were randomized to ECMO or continued medical management (ECMO possible at OI = 40). Planned primary outcome measures were ICU days and hospital charges. Secondary measures were pulmonary and neurologic outcomes at discharge and 1 year. Twenty-two early ECMO patients, 19 controls, 14/19 met late ECMO criteria. Four patients died (two each group). No statistically significant difference was seen in hospital charges (early ECMO =

Extracorporeal life support for pediatric respiratory failure

49,500 versus control=

Long-term Prognosis (15 to 26 Years) after Repair of Tetralogy of Fallot: I. Survival and Symptomatic Status

53,7000), (95% confidence intervals= -

Prolonged nicotine patch use in quitters with past abstinence-induced depressed mood

3200 to +

Validity and reliability of the Weight Control Smoking Scale

5100 more for controls) or ICU days (early =14 + 5 days versus control=19 + 12 days) (95% CI=- 0.8 to +10 more for controls). At 1 year the early group had a higher mental developmental index score (115 + 11) versus (103 + 18), (p = 0.07). Secondary analyses comparing early, late, and no ECMO showed trends toward decreased use of hospital resources and lower morbidity in the early group. The early use of ECMO does not increase hospital cost or utilization and suggests a lower morbidity rate for patients so treated.

New method for describing the performance of cardiac surgery cannulas

ObjectivesThe purposes of this report are to a) describe the University of Michigan experience with venoarterial or venovenous extracorporeal life support for severe pediatric pulmonary rescue therapy, and b) examine survivors and nonsurvivors for differences that might be useful for examination in future, prospective studies. DesignCase series report. Phase I study of safety and effectiveness of extracorporeal life support for pediatric respiratory failure. SettingUniversity of Michigan Medical Center. PatientsNon-neonatal pediatric patients treated with extracorporeal life support for severe respiratory failure at the University of Michigan. InterventionsExtracorporeal life support for pulmonary failure. Measurements and Main ResultsFrom November 1982 until May 1991, 25 pediatric patients underwent extracorporeal life support for severe pulmonary failure. Twenty patients were treated in the last 36 months. Sixty percent (15/25 patients) survived their life-threatening respiratory illness, were weaned from mechanical ventilation, and were discharged home. The mean patient age was 4.1 yrs, and mechanical ventilation duration before extracorporeal life support was 5.9 days. Mean blood gas data and mechanical ventilation pressures before extracorporeal life support were: peak inspiratory pressure of 48.6 cm H2O, mean airway pressure of 21.9 cm H2O, positive end-expiratory pressure of 9.7 cm H2O, PaCO2 of 43 torr (5.7 kPa), PaO2 of 69 torr (9.1 kPa), estimated alveolar-arterial oxygen gradient of 563 torr (75 kPa), and FIO2 of 0.98. Variables associated with survival included: age of survivors vs. nonsurvivors, 2.1 vs. 7.1 yrs (p < .02); peak inspiratory pressure of survivors vs. nonsurvivors, 43.1 vs. 57.9 cm H2O (p < .03); mean airway pressure of survivors vs. nonsurvivors, 18.4 vs. 27.2 cm H2O (p < .03); and positive end-expiratory pressure of survivors vs. nonsurvivors, 8.1 vs. 12.1 cm H2O (p < .01). There were no differences detectable in the blood gas values (PaO2, PaCO2, P[A-a]O2) in survivors and nonsurvivors before extracorporeal life support. The number of days mechanical ventilation was used before extracorporeal life support in survivors and in nonsurvivors was similar. ConclusionExtracorporeal life support is an effective rescue therapy for pediatric patients with severe respiratory failure (University of Michigan survival rate of 60%). (Crit Care Med 1992; 20:1112–1118)

Actual versus perceived risk of cervical cancer among college women smokers.

One hundred eighty-two patients with tetralogy of Fallot repaired before or during 1967 were studied by interview, physical examination, and noninvasive testing. Twenty were excluded from the final analysis because review of cineangiograms and operative reports disclosed that they had had double-chambered right ventricle rather than tetralogy of Fallot. On follow-up ranging from 15 to 26 years (mean, 20.2 years), there were 86 patients in New York Heart Association Functional Class I, 53 in Class II, 5 in Class III, and none in Class IV. There were 9 late deaths. Functional classification was not ascertained in the remaining 9 patients. Cumulative survival at 25 years postoperatively was 94.4%. There was no significant relationship between survival and year of operation, age at operation, sex, or presence of a prior shunt. The 9 late deaths occurred between 6 and 23 years after operation and were due to late-onset complete heart block in 2 patients, congestive failure in 4, suicide in 1, accident in 1, and an unknown cause in 1. We conclude that long-term survival after repair of tetralogy of Fallot is excellent and not influenced by prior shunt.