American journal of perinatology
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Three pairs of female conjoined twins--a xiphoomphalopagus, a pygopagus, and a thoracopagus--were encountered during the past 10 years. Surgical separation was successful in the xiphopagus, and both twins survived. Separation was also successful in the pygopagus, but only one of the twins survived; the twin that died had sustained cerebral hemorrhage before the operation. ⋯ Separation surgery of conjoined twins is often successful with a high survival rate of both twins unless vital organs such as the brain or the heart are fused. However, unlike other operations, separation surgery entails ethical considerations pertaining to matters such as the distribution of organs in addition to surgical considerations. Furthermore, separation of conjoined twins is certain to cause various degrees of anatomical as well as functional disorders associated with the surgical procedure, and provision for the postoperative care for these disorders is indispensable.
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Xanthines are frequently being used in the management of premature babies. Studies in adult subjects have demonstrated a diuretic effect of aminophylline due to the inhibition of solute reabsorption in various segments of the nephron. We evaluated the effects of aminophylline on the developing kidney. ⋯ Most of the effects were no longer evident after 24 hours, despite continuing aminophylline maintenance therapy. In premature infants the aminophylline loading dose, but not maintenance therapy, affected renal functions. Because heart rate, blood pressure, and creatinine clearance did not change, it appears that aminophylline acts directly on tubular reabsorptive functions.
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It is standard practice for physicians to use blood gas (BG) evaluations when evaluating neonates with respiratory distress. In this study we addressed two questions: (1) What is the distribution of BG values in a population of infants receiving BG evaluation in the first 4 hours of life; and (2) How does the behavior of physicians correlate with BG values in these infants? We discuss the implications of our findings for claims about "standards" of medical care for newborn infants with respiratory distress. We reviewed medical records for 226 infants with birthweight > 2000 grams who were not intubated at the time of first BG determination. ⋯ Recognizing that anecdotal recall of experience, even by "experts," may be inaccurate and is often systematically biased (the "Monday morning quarterback" phenomenon), we propose that the testimony of expert witnesses ought to conform, whenever possible, to a data-based description of medical care that actually is "ordinary used in similar circumstances". Our current observations suggest that (1) expert opinions of the "standard" to evaluate neonatal respiratory distress with a BG sample should reflect that the time scale is 1 to 2 hours, not 10 to 20 minutes; and (2) expert opinions that "abnormal" BG values either "require" or "preclude" intubation for most newborn infants with respiratory distress find little support in data. Clinical observation, not BG values, appears to be the most powerful "standard" by which physicians determine whether to initiate mechanical ventilation for newborn infants with respiratory distress.
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Results of a national survey of the current use of steroids in newborns in 1993 showed that 95% of the neonatologists in the United States have used dexamethasone for neonates at risk for chronic lung disease. Dexamethasone therapy for a period of a week or longer is associated with suppression of the hypothalamic-pituitary-adrenal axis (HPAA) in a substantial number of premature infants. A review of our current understanding of the biochemical tests evaluating HPAA function in premature infants and suggested guidelines for HPAA evaluation and management following dexamethasone therapy are presented.
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Adenosine has been approved for intravenous use for paroxysmal supraventricular tachycardias (SVT) in adults and children. However, effectiveness and safety of intravenous adenosine in preterm infants are not well established. Thirteen episodes of SVT in three preterm and two full-term neonates were treated with intravenous adenosine. ⋯ No other side effects were noted. Adenosine is a safe and effective agent for treating preterm infants with SVT. However, further investigation of adenosine in this group of patients is warranted.