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Biomedical subjects

D L Stewart

Publications and source records attributed to D L Stewart.

At least 37 records · Page 2Linked to original sources
PubMed1997

Preoperative versus postoperative extracorporeal life support in neonatal cardiac patients.

The aim of this study is to document our experience with the use of extracorporeal life support (ECLS) in the neonatal cardiac patient, to detect differences in the morbidity and mortality between patients who required ECLS preoperatively and those who required ECLS postoperatively, and to determine the long-term effects of these morbidities. A chart review was undertaken of all neonatal cardiac patients who required ECLS between May 1985 and July 1994 at Kosair Children's Hospital, Louisville, Kentucky. Twenty-three neonatal cardiac patients had received preoperative or postoperative ECLS with an overall survival rate of 35%. Our preoperative and postoperative patients had similar demographics, diagnoses, decannulation rates and survival rates. However, patients receiving postoperative ECLS more frequently required more than two inotropes (p < 0.001), had an increased incidence of renal failure (p < 0.02), had more central nervous system abnormalities on brain imaging studies (p < 0.004), and had a longer hospital stay (p < 0.05). Follow-up testing of survivors yielded normal Bayley Scale of Infant Development (BSID) scores in half of the patients. Survival in the two groups was similar, but a significant difference in morbidity was found. Except for severe intracranial abnormalities, the morbidity was shown to be reversible on follow-up examination. We recommend the continued use of ECLS for neonatal cardiac patients who require preoperative or postoperative support even when severe renal failure ensues or minor abnormalities are detected on brain imaging studies.

Acute Kidney Injury↗
PubMed1996

Open lung biopsy in pediatric patients on extracorporeal membrane oxygenation.

Open lung biopsy has proven beneficial in the treatment of life-threatening pulmonary diseases. Its safety and efficacy in infants and children placed on extracorporeal membrane oxygenation (ECMO) for severe respiratory failure is not known. The authors reviewed eight cases (4 neonates, 3 infants, 1 child) who underwent open lung biopsy while on ECMO. The primary diagnoses were pneumonia (4), lymphoma (1), primary pulmonary hypertension (1), and complex congenital heart disease (2). The patients underwent biopsy after they had been on ECMO an average of 9.6 days (range, 1 to 14 days). Biopsy results confirmed the clinical diagnosis in five patients, two of whom had irreversible alveolar destruction resulting in ECMO withdrawal. Three patients had pathological diagnoses, which resulted in major therapy revisions (1 fungal infection and 2 noninfectious lesions that required steroid treatment). The overall average duration of ECMO treatment was 16.3 days (range, 10 to 24 days). Three patients were weaned successfully from ECMO, but only one infant survived to discharge. One nonlethal bleeding complication occurred after biopsy. Open lung biopsy is well tolerated during ECMO. It accurately determines pulmonary pathology and provides valuable prognostic information. Earlier biopsy for patients whose diagnoses are uncertain or who are not responding to ECMO may improve the mortality rate for this high-risk group.

Biopsy↗
PubMed1996

Response to high frequency jet ventilation may predict the need for extracorporeal membrane oxygenation.

The aim of this study was to determine predictors of response whilst using high frequency jet ventilation (HFJV) for infants in intractable respiratory failure, in order to avoid the utilization of extracorporeal membrane oxygenation (ECMO). We reviewed patient demographics, ventilator parameters, blood gas values, length of oxygen therapy and use of surfactant and outcome, in infants given a 4 h trial of HFJV as the minimum to eliminate those infants where HFJV is used as a bridge to ECMO. The study was carried out in the neonatal intensive care nursery at Kosair Children's Hospital in Louisville, Kentucky, which provides high frequency ventilation and ECMO. Thirty infants who were eligible for ECMO and who met the study criteria were divided into two groups based upon response to HFJV. Twenty two infants responded to HFJV and eight nonresponders required ECMO after a trial of HFJV. Infants responding during HFJV demonstrated a significant decrease in oxygenation index without an escalation of mean airway pressure within 4 h after the initiation of HFJV. These infants had lower birth weights and an increased incidence of respiratory distress syndrome. No statistical differences were found in length of ventilation, days of oxygen therapy or duration of HFJV between the groups. Infants in intractable respiratory failure, who are eligible for extracorporeal membrane oxygenation, should receive a trial of high frequency jet ventilation, especially if the cause is respiratory distress syndrome unresponsive to surfactant therapy. During high frequency jet ventilation, the oxygenation index and mean airway pressure should be monitored serially, since they may predict the need for extracorporeal membrane oxygenation.

Extracorporeal Membrane Oxygenation↗
PubMed1995

The impact of major congenital malformations on mortality in a neonatal intensive care unit.

Neonatal mortality due to congenital malformations or genetic disorders has not decreased despite a decrease in overall neonatal deaths with recent advances in medical technology. As a consequence, an increasing percentage of neonatal deaths is attributable to congenital malformations and genetic disorders. This study retrospectively reviewed neonatal deaths associated with congenital malformations over an 11-year period in the neonatal intensive care unit (NICU) at Kosair Children's Hospital, Louisville, Kentucky. Presently, congenital malformations are responsible for approximately 45% (range 32% to 61%) of deaths in the NICU with congenital heart disease, lethal genetic disorders, and pulmonary hypoplasia being the main contributors. Other major causes of neonatal death included extreme prematurity, respiratory disorders, necrotizing enterocolitis, sepsis, asphyxia, and primary pulmonary hypertension. It is important that clinicians are aware that improved survival is expected for most diseases because of technological advances, but that further significant reductions in neonatal mortality will depend on genetic counseling and prevention of congenital malformations.

Congenital Abnormalities↗
PubMed1995

Knowledge of blood cholesterol reduction in community residents.

This study examined the cholesterol knowledge of inner-city community residents, who are representative of individuals in lower socio-economic groups. "Cholesterol Pursuit," a 10-item cholesterol knowledge test distributed by the National Heart, Lung, and Blood Institute, was administered to 316 residents in eight local grocery stores. The average percentage of correct answers was 65.8%. Community residents in a large, urban city were fairly knowledgeable about blood cholesterol reduction, but there were misconceptions concerning the importance of eggs, fish oil, and olive oil, and with foods marked "no cholesterol." White community residents appeared to be slightly better informed about reducing blood cholesterol. Identification of misperceptions concerning cholesterol will guide future education programs for these specific communities.

Adult↗
PubMed1995

Delayed diagnosis of congenital adrenal hyperplasia in a premature female infant.

A preterm female infant was diagnosed with congenital adrenal hyperplasia after the first month of life. Electrolyte abnormalities and prominent clitoris were originally attributed to the prematurity of the infant. Congenital adrenal hyperplasia was confirmed when the abnormalities persisted. Delay in diagnosis can be prevented with the installation of newborn screening programs.

Adrenal Hyperplasia, Congenital↗
PubMed1994

Newborn hearing screening.

Congenital deafness is a relatively common problem with an incidence of 1/300 to 1/1000. Most states have no mass screening program for hearing loss, but the state of Kentucky compiles a High Risk Registry which is a historical survey of parents relating to risk factors for hearing loss. Unfortunately this survey can miss 50% of those who have a hearing deficit. If not detected prior to discharge, there is often a delay in diagnosis of deafness which prevents early intervention. We report 2 years' experience at Kosair Children's Hospital where 1,987 infants admitted to well baby, intermediate, or intensive care nurseries were screened using the ALGO-1 screener (Natus Medical Inc, Foster City, CA) which is a modified auditory brain stem evoked response (ABR). Our screening of this population led to an 11% incidence of referral for complete audiological evaluation. There were no significant complications. Forty-eight infants were found to have nonspecified, sensorineural, or conductive hearing loss. The positive predictive value of the test was 96%. Therefore, we feel that the use of the modified ABR in the newborn is a timely, cost efficient method of screening for hearing loss and should be used for mass screening of all newborns.

Deafness↗
PubMed1994

HIV seroprevalence in a chronically mentally ill population.

This article describes a study undertaken to determine the prevalence of human immunodeficiency virus (HIV) infection and risk factors associated with HIV infection in a chronically mentally ill population. Patients were eligible for inclusion in the survey at their first outpatient or inpatient admission to a Maryland state psychiatric hospital between August 1990 and July 1991. Demographic and risk behavior information was collected, and unlinked HIV antibody testing was performed on blood specimens drawn for routine clinical purposes. Of 533 patients surveyed, 31 patients (5.8%) were infected with HIV. The prevalence of HIV infection was 36.4% among female patients reporting intravenous drug use and 14.5% among their male counterparts. The prevalence of HIV infection among homeless patients was 10.1%; 88.9% of those HIV infected also reported intravenous drug use. On admission, 90% of patients reported no knowledge of their HIV antibody status; 4.1% of these patients were HIV infected. The data confirmed the risk of HIV infection in this population of chronically mentally ill individuals. Risk reduction programs designed specifically for individuals with chronic mental illness need to be developed.

Adolescent↗
PubMed1994

Clinical comparison of localized intestinal perforation and necrotizing enterocolitis in neonates.

OBJECTIVE: To better define the prognosis of neonates with gastrointestinal perforation and improve their management. METHODS: We reviewed the results of physical examinations, laboratory results, and radiographic tests of 42 patients in whom gastrointestinal perforation was diagnosed in our neonatal intensive care unit. RESULTS: Twenty-one patients had necrotizing enterocolitis and 21 had localized intestinal perforation. Perinatal history, gender, race, birth weight, and estimated gestational age were similar for both groups. Patients with localized perforation were more likely to have had an umbilical artery catheter in place within 48 hours of perforation, to have received higher doses of indomethacin, to have undergone primary surgical repair, and to have survived until discharge from the hospital. Patients with necrotizing enterocolitis were more likely to have received enteral feedings and to have had a metabolic acidosis and leukopenia at the time the perforation was diagnosed. CONCLUSIONS: We conclude that localized intestinal perforation and necrotizing enterocolitis, although similar in the organ system they affect, are distinctly different in clinical correlates and outcome. The increased awareness of localized perforations may help those taking care of neonates to diagnose this condition more accurately and to discuss its implications with family members.

Enterocolitis, Pseudomembranous↗
PubMed1993

Attitudes of graduating seniors at one medical school toward family practice.

BACKGROUND AND OBJECTIVES: Senior medical students' interest in family practice as a career choice has declined in recent years. METHODS: A questionnaire about attitudes toward family practice was mailed to the 1990 graduating class at the University of Maryland (N = 143), and 84 completed questionnaires were returned (59% response rate). RESULTS: Seniors believed that family practice was challenging (89%) and had intellectual content (integrity) comparable to other specialties (81%). Furthermore, students believed that family physicians provided comprehensive care (88%), were not replaceable by other health professionals (86%), and were able to keep abreast with technological medical advances (52%). However, only 4% of the graduating seniors selected family practice as a career. Most students believed that family practice lacked prestige (82%), and about one half (55%) believed that it was too broad in scope. CONCLUSIONS: Lack of prestige, stressful life-style, difficulty in mastering medical knowledge, and poor potential income were the main reasons given by students for not selecting family practice.

Adult↗
PubMed1992

Extracorporeal membrane oxygenation and early-onset group B streptococcal sepsis.

Recently, extracorporeal membrane oxygenation (ECMO) has been used as rescue therapy for newborns with overwhelming early-onset group B streptococcal sepsis. To determine which clinical factors best predict mortality and to evaluate the outcome of this therapy, a retrospective examination of the clinical course and outcome of ECMO-eligible newborns with early-onset group B streptococcal sepsis was undertaken. The study period was divided into two phases based on when ECMO was initially used at Kosair Children's Hospital as therapy for septic neonates. Phase 1 (pre-ECMO) was the period from January 1, 1982, through June 15, 1986, and phase 2 (ECMO) from June 16, 1986, through December 31, 1989. Newborns with gestational age greater than or equal to 34 weeks, birth weight greater than or equal to 2000 g, and evidence of early-onset group B streptococcal sepsis were eligible for study. Only newborns who received mechanical ventilation were evaluated. Sixteen patients from phase 1 met the above criteria. Of those, 10 exhibited no sign of hypotension and all survived. Of the 6 patients with hypotension, 3 died. Forty patients were identified from phase 2. Seven patients remained normotensive and all survived. Thirty-three patients were hypotensive, of which 15 received ECMO and 13 survived. Of the 18 who did not receive ECMO, 7 died. Regarding all hypotensive newborns, those who did not receive ECMO had a trend toward lower survival (P less than .06) and were more likely to die if they were of lower birth weight, manifested a persistent acidosis (pH less than or equal to 7.25), and had an absolute neutrophil count less than 500 cells/mm3.(ABSTRACT TRUNCATED AT 250 WORDS)

Acidosis↗