RESUMEN
OBJECTIVE: We compare the maternal and perinatal outcomes between 69 patients with oligohydramnios and 49 patients with adequate fluid at the time of initial evaluation for PROM. METHODS: One hundred and eighteen patients with spontaneous premature rupture of the membranes (PROM) at 18-28 weeks are included in the study. Inclusion criteria are singleton gestation, normal fetal anatomical survey and normal amniotic fluid prior to PROM, and absence of labor or abruption at the time of PROM. Oligohydramnios is defined as an amniotic fluid index (AFI) <5 cm of measurable pockets of amniotic fluid which are free of umbilical cord. Expectant management was carried during the 3-year period. The overall perinatal survival is 66%. Pulmonary hypoplasia is present in 18%, and skeletal deformities in 3% of all neonates. RESULTS: There is no significant difference between the two groups in the mean gestational ages at PROM (172+/-17 d vs. 171+/-14 d), latency periods (9+/-14 d vs. 8+/-13 d), incidences of chorioamnionitis (48 vs. 39%), endometritis (19 vs. 14%), neonatal sepsis (11 vs. 13%), or skeletal deformities (6 vs. 0%). Patients with oligohydraminos have significantly higher incidences of fetal heart rate decelerations (59 vs. 38%) and C-section (38 vs. 16%) (P < 0.05) than patients with adequate amniotic fluid. CONCLUSIONS: After adjusting for confounding variables, neonates with oligohydramnios are twice as likely to develop pulmonary hypoplasia (20 vs. 10%) and more likely to experience neonatal death (30 vs. 20%) when compared to those with adequate fluid, even though the difference is not statistically significant.
Asunto(s)
Rotura Prematura de Membranas Fetales , Oligohidramnios/mortalidad , Resultado del Embarazo , Adulto , Estudios de Casos y Controles , Femenino , Edad Gestacional , Humanos , Recién Nacido , Modelos Logísticos , Embarazo , Segundo Trimestre del Embarazo , Análisis de SupervivenciaRESUMEN
This study evaluated the effects of stimulus repetition rate, phase, and frequency on the auditory brainstem response (ABR) in normal-hearing neonates and adults. In both neonates and adults, the results clearly showed large ABR wave V latency differences between condensation and rarefaction for low-frequency stimuli. Phase dependent latency effects are believed to be a result of the phase-sensitive low-frequency neurons. Increasing stimulus repetition rate produced greater wave V latency shift in neonates than in adults. The consequences of rate changes were independent of stimulus phase and frequency.
Asunto(s)
Estimulación Acústica , Potenciales Evocados Auditivos del Tronco Encefálico/fisiología , Periodicidad , Adulto , Factores de Edad , Audición/fisiología , Humanos , Recién Nacido , Factores de TiempoRESUMEN
62 healthy women were studied mammographically before and after augmentation mammoplasty. Postaugmentation mammograms were done using both the implant compression and implant displacement technique. The amount of visualisable tissue was measured in all films before and after augmentation. We concluded: State-of-the-art film-screen mammography is extremely difficult to obtain in most patients augmented with silicone-gel-filled prostheses. On average, there is a decrease in measurable visualised breast tissue after augmentation mammoplasty with silicone-gel-filled prostheses. The area of mammographically measurable tissue is no different whether smooth or textured implants are used. Textured implants are less likely to form an early capsular contracture and are therefore preferred. However, the cancer-causing potential of polyurethane in humans is currently unknown. Anterior breast tissue is generally seen better with displacement mammography; posterior breast tissue with compression mammography. Better films are generally obtained when the implant is in the subpectoral position rather than subglandular. The more severe the capsular contracture, the poorer the mammogram. In addition 42 previously augmented patients developed breast carcinomas an average of 8.4 years after augmentation with silicone-gel-filled implants; 95% had palpable lesions (only 60% of which could be seen on mammography), 90% had infiltrating carcinomas, 45% had metastases to axillary nodes, and 7 patients have recurred, 5 of whom have died. We concluded: Augmented women who develop breast cancer are similar, in terms of tumour size and nodal positivity, to non-augmented breast cancer patients who present with palpable masses. When compared with non-augmented women whose breast cancers are found with screening mammography, augmented patients with breast cancer present with a higher percentage of invasive lesions and involved axillary lymph nodes, resulting in a poorer prognosis. The 40% false negative rate for mammography in this series is unduly high and alarming. Augmentation mammoplasty with silicone-gel-filled implants should be discouraged in women with a high risk of developing breast cancer.
Asunto(s)
Neoplasias de la Mama/diagnóstico por imagen , Mamoplastia/efectos adversos , Prótesis e Implantes/efectos adversos , Siliconas , Adulto , Anciano , Neoplasias de la Mama/patología , Neoplasias de la Mama/terapia , Reacciones Falso Negativas , Femenino , Estudios de Seguimiento , Humanos , Mamografía , Persona de Mediana Edad , PronósticoRESUMEN
From 1979 to 1990, 227 patients with intraductal carcinomas (DCIS) without microinvasion were selectively treated; the least favourable (large lesions with involved biopsy margins) with mastectomy, the most favourable (small lesions with clear margins) with breast preservation. The preservation group was further subdivided into those who received radiation therapy (excision and radiation) and those who did not (excision alone). In the mastectomy group, there were 98 patients (43%) with an average lesional size of 3.3 cm; 41% had multifocal lesions, 15% had multicentric lesions. There has been one local invasive recurrence and no deaths. The 7-year actuarial disease-free survival is 98% with mastectomy. In the excision and radiation group, there were 103 patients (45%) with an average lesional size of 1.4 cm. 10 patients have had local recurrences (5 invasive and 5 noninvasive) one of whom has died. The 7-year actuarial disease-free survival is 84%, a statistically significant difference when excision and radiation is compared with mastectomy (P = 0.038). In the excision alone group, there were 26 patients (11%) with an average lesional size of 1.0 cm. There have been two local recurrences (8%), one of which was invasive and no deaths. The 7-year actuarial disease-free survival is 67%, but only 3 patients have been followed for more than 4 years. A total of 163 axillary node dissections were done; all were negative. Since DCIS without microinvasion rarely metastasizes to axillary lymph nodes, routine dissection should not be performed. Patients in this series with intraductal carcinoma treated with excision and radiation recurred locally at a statistically higher rate than those treated with mastectomy, in spite of the fact that those chosen for excision and radiation had clinically more favourable lesions. 6 of 12 (50%) local recurrences in conservatively treated patients were invasive. There was, however, no significant difference in overall survival in any subgroup regardless of treatment.
Asunto(s)
Neoplasias de la Mama/cirugía , Carcinoma in Situ/cirugía , Carcinoma Intraductal no Infiltrante/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/radioterapia , Carcinoma in Situ/radioterapia , Carcinoma Intraductal no Infiltrante/radioterapia , Terapia Combinada , Femenino , Humanos , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Estudios RetrospectivosRESUMEN
In our previous study of 14 premature infants, apnea occurred at the minimum phase of ventilatory oscillations. The apneas corresponded to cessation of airflow at the nose and mouth and were not distinguished as central, mixed, or obstructive. Changes in heart rate associated with the apneas were not identified. To determine whether ventilatory pattern characteristics might predict either the type of apnea or heart rate changes during the apnea, we analyzed measurements of chest wall movement and heart rate that were made during the earlier studies. Chest wall movement measured by magnetometers was compared with airflow measured with a face mask and pneumotachograph. Tidal volume, breath duration, and ventilation were calculated on a breath-by-breath basis, converted to time-axis data strings, and filtered with a comb of zero phase shift digital band-pass filters to detect breathing patterns. Of 182 apneas greater than or equal to 3 s duration, 55% were central, 31% were mixed, and 14% were obstructive. All three types of apnea were related to ventilatory oscillations. Multiple linear and logistic regressions showed that an apnea was more likely to be obstructive when it was long and when the underlying ventilatory oscillation was due primarily to an oscillation in breath duration. Multiple linear and logistic regressions showed that decreases in heart rate were related primarily to the duration of apnea and secondarily to the characteristics of the underlying breathing patterns.
Asunto(s)
Obstrucción de las Vías Aéreas/fisiopatología , Recien Nacido Prematuro/fisiología , Respiración , Síndromes de la Apnea del Sueño/fisiopatología , Humanos , Recién Nacido , Monitoreo FisiológicoRESUMEN
To investigate the regulation of end-expiratory lung volume (EEV) in premature infants, we recorded airflow, tidal volume, diaphragm electromyogram (EMG), and chest wall displacement during sleep. In quiet sleep, EEV during breathing was 10.8 +/- 3.6 (SD) ml greater than the minimum volume reached during unobstructed apneas. In active sleep, no decrease in EEV was observed during 28 of 35 unobstructed apneas. Breaths during quiet sleep had a variable extent of expiratory airflow retardation (braking), and inspiratory interruption occurred at substantial expiratory flow rates. During active sleep, the expiratory flow-volume curve was nearly linear, proceeding nearly to the volume axis at zero flow, and diaphragm EMG activity terminated near the peak of mechanical inspiration. Expiratory duration (TE) and inspiratory duration (TI) were significantly shortened in quiet sleep vs. active sleep although tidal volume was not significantly different. In quiet sleep, diaphragmatic braking activity and shortened TE combined to maintain EEV during breathing substantially above relaxation volume. In active sleep, reduced expiratory braking and prolongation of TE resulted in an EEV that was close to relaxation volume. We conclude that breathing strategy to regulate EEV in premature infants appears to be strongly influenced by sleep state.
Asunto(s)
Recien Nacido Prematuro , Pulmón/fisiología , Respiración , Sueño/fisiología , Diafragma/fisiología , Electromiografía , Humanos , Recién Nacido , Mediciones del Volumen Pulmonar , Músculos/fisiologíaRESUMEN
The occasional short apneas seen in full-term infants within the first postnatal week are related to the minimum phase of oscillatory breathing patterns. To determine the relationship between breathing patterns and the longer and more frequent apneas seen in premature infants, we monitored respiration in 14 premature infants using a face mask and pneumotachograph. Tidal volume, breath duration, and ventilation were calculated on a breath by breath basis, converted to time-axis data strings, and filtered with a comb of zero phase shift digital band pass filters to detect breathing patterns. Compared with full-term infants, premature infants had breathing patterns that occurred more often and had twice the average amplitude. Of 182 apneas greater than or equal to 3 s long, 94% occurred at the minimum phase of oscillatory breathing patterns. All of the 38 apneas greater than or equal to 10 s long occurred at the minimum phase of oscillatory breathing patterns. Duration of apnea was related to breathing pattern characteristics, e.g., longer apneas were related to stronger, longer cycle-time breathing patterns. Apnea in the premature infant is not an isolated event but is one aspect of an underlying pattern.
Asunto(s)
Apnea/fisiopatología , Respiración , Humanos , Recién Nacido , Recien Nacido Prematuro , Volumen de Ventilación Pulmonar , Factores de TiempoRESUMEN
We have investigated the effect of postural change on tidal volume (VT), inspiratory (TI) and expiratory (TE) duration, minute ventilation (VI), and end-tidal PCO2 in a group of 11 healthy full-term sleeping infants, 2-4 days of age. During tilts from the supine to upright posture, the average volume increase was 4.3 +/- 4.4 (SD) ml or 1.2 ml/kg in the maneuvers unassociated with sighs. In the 20% of tilts in which sighs occurred, the average volume change was slightly higher. Transition from supine to upright posture resulted in statistically significant increases in VT (6.45 +/- 0.06 to 6.72 +/- 0.06 ml/kg), TI (554 +/- 7 to 604 +/- 7 ms), and TE (629 +/- 12 to 777 +/- 14 ms), and decrease in VI (328 +/- 5 to 288 +/- 4 ml X kg-1 X min-1) (all means +/- SE, P less than 0.0005). Return to supine position resulted in statistically significant changes in the opposite direction. Tilting to the upright posture brought about a small (0.4 +/- 0.1 Torr, means +/- SE) but consistent statistically significant increase in end-tidal PCO2, which persisted through the first minute when the infant was returned to the supine position. The expiratory prolongation observed with tilting appears to minimize changes in end-expiratory lung volume, obviating the need for an effective compensatory muscle response to defend ventilation. Thus it appears that infants, in contrast to adults, adopt a breathing strategy to limit the extent of change in absolute lung volume, rather than to defend ventilation at increased lung volume.
Asunto(s)
Postura , Respiración , Dióxido de Carbono , Humanos , Recién Nacido , Presión Parcial , Volumen de Ventilación Pulmonar , Factores de TiempoRESUMEN
Cardiac tamponade is a rare complication of juvenile rheumatoid arthritis. Three cases seen in the last two years at the Children's Hospital of Philadelphia are reported and compared to four previously reported cases. All three children had systemic-type juvenile rheumatoid arthritis with tachypnea, shortness of breath, and chest pain. Cardiac signs in these children included decreased heart sounds, pericardial friction rub, jugular venous distention, and pulsus paradoxus greater than 12 mm Hg. Roentgenograms of the chest showed cardiomegaly with bilateral pleural effusions. Electrocardiograms showed sinus tachycardia and nonspecific ST-T wave changes. Echocardiograms demonstrated pericardial effusions in all subjects and poor ventricular movements in one child. All three children were treated with short-acting anti-inflammatory drugs and/or prednisone. Pericardiocentesis was performed in two cases. There was no significant morbidity after a mean follow-up of two years.