Clinical pharmacist practitioners on primary care teams play an important role in caring for complex patients with diabetes

PURPOSE

To evaluate whether clinical pharmacist practitioners (CPPs) are being utilized to care for patients with complex medication regimens and multiple chronic illnesses, we compared the clinical complexity of diabetes patients referred to CPPs in team primary care and those in care by other team providers (OTPs).

METHODS

In this cross-sectional comparison of patients with diabetes in the US Department of Veterans Affairs (VA) healthcare system in the 2017-2019 period, patient complexity was based on clinical factors likely to indicate need for more time and resources in medication and disease state management. These factors include insulin prescriptions; use of 3 or more other diabetes medication classes; use of 6 or more other medication classes; 5 or more vascular complications; metabolic complications; 8 or more other complex chronic conditions; chronic kidney disease stage 3b or higher; glycated hemoglobin level of ≥10%; and medication regime nonadherence.

RESULTS

Patients with diabetes referred to one of 110 CPPs for care (n = 12,728) scored substantially higher (P < 0.001) than patients with diabetes in care with one of 544 OTPs (n = 81,183) on every complexity measure, even after adjustment for age, sex, race, and marital status. Based on composite summary scores, the likelihood of complexity was 3.42 (interquartile range, 3.25-3.60) times higher for those in ongoing CPP care (ie, those with 2 or more visits) versus OTP care. Patients in CPP care also were, on average, younger, more obese, and had more prior outpatient visits and hospital stays.

CONCLUSION

The greater complexity of patients with diabetes seen by CPPs in primary care suggests that CPPs are providing valuable services in comprehensive medication and disease management of complex patients.

Clinical pharmacy practitioners' semi-visible labor: building referral relationships in interprofessional collaborative care

Clinical pharmacy practitioners (CPP) in the Veterans Health Administration (VHA) prescribe medications and help manage chronic conditions such as diabetes, and they are increasingly working as part of interprofessional clinical teams. The challenges of integrating a new role in a clinical team are documented, but we know less about strategies new healthcare providers use to overcome these challenges. We studied how clinical pharmacy practitioners integrated into clinical teams. We conducted telephone interviews with clinical pharmacy practitioners (n = 53) and members of their clinical teams (n = 74), which were recorded, transcribed, and coded for concepts and themes. We identified four major themes. We found CPP perceived VHA as a "safe haven" for interprofessional care but found it necessary to build other prescribers' trust and confidence in their clinical skills to establish the referral relationships they needed for full integration. To facilitate their integration, CPP engaged in relational, untracked labor, which we characterize as semi-visible labor. While both CPP and clinical team members perceived CPPs' semi-visible labor as vital for implementing and maintaining strong interprofessional collaborations, such labor may be unsustainable as a long-term strategy for integrating CPP in clinical teams.

Perceptions of clinical pharmacy specialists' contributions in mental health clinical teams

Introduction

Mental health (MH) clinical pharmacy specialists (CPS) are increasingly functioning as integral providers in MH care teams. MH providers may delegate many medication management tasks to the CPS. As there is a shortage of primary care and specialist MH providers, CPS are increasingly being utilized in MH care clinics. We assess provider and CPS perceptions of the contributions of CPS to MH clinical teams in the Veterans Health Administration.

Methods

We examined the roles and functions of CPS in MH clinics through surveys (n = 374) and semistructured interviews (n = 16) with MH CPS and other members of MH clinical teams (psychiatrists, nurse practitioners, registered nurses, social workers) to gain insight into how CPS were integrated in these settings. We assessed perceptions of CPS contributions to MH teams, interactions between CPS and other providers, and challenges of integrating CPS into MH clinical teams.

Results

Contributions of CPS in MH were received positively by clinical team members. Clinical pharmacy specialists providing comprehensive medication management were especially valuable in the management of clozapine. The knowledge and training of CPS reassured providers who frequently referred to them with questions about medication and medication therapy management. MH CPS were also perceived to be received well by patients.

Discussion

The integration of MH CPS into MH teams was well received by team members and patients alike. The MH CPS have become important members of the MH team and are widely viewed as being able to improve access, quality, and workflow.

Introducing clinical pharmacy specialists into interprofessional primary care teams: Assessing pharmacists' team integration and access to care for rural patients

Clinical pharmacy specialists (CPS) were deployed nationally to improve care access and relieve provider burden in primary care.The aim of this study was to assess CPS integration in primary care and the Clinical Pharmacy Specialist Rural Veteran Access (CRVA) initiative's effectiveness in improving access.Concurrent embedded mixed-methods evaluation of participating CRVA CPS and their clinical team members (primary care providers, others).Health care providers on primary care teams in Veterans Health Administration (VHA).Perceived CPS integration in comprehensive medication management assessed using the MUPM and semi-structured interviews, and access measured with patient encounter data.There were 496,323 medical encounters with CPS in primary care over a 3-year period. One hundred twenty-four CPS and 1177 other clinical team members responded to a self-administered web-based questionnaire, with semi-structured interviews completed by 22 CPS and clinicians. Survey results indicated that all clinical provider groups rank CPS as making major contributions to CMM. CPS ranked themselves as contributing more to CMM than did their physician team members. CPS reported higher job satisfaction, less burn out, and better role fit; but CPS gave lower scores for communication and decision making as clinic organizational attributes. Themes in provider interviews focused on value of CPS in teams, relieving provider burden, facilitators to integration, and team communication issues.This evaluation indicates good integration of CPS on primary care teams as perceived by other team members despite some communication and role clarification challenges. CPS may play an important role in improving access to primary care.

Impact of Patient-Clinical Team Secure Messaging on Communication Patterns and Patient Experience: Randomized Encouragement Design Trial

BACKGROUND

Although secure messaging (SM) between patients and clinical team members is a recommended component of continuous care, uptake by patients remains relatively low. We designed a multicomponent Supported Adoption Program (SAP) to increase SM adoption among patients using the Veterans Health Administration (VHA) for primary care.

OBJECTIVE

Our goals were to (1) conduct a multisite, randomized, encouragement design trial to test the effectiveness of an SAP designed to increase patient engagement with SM through VHA's online patient portal (My HealtheVet [MHV]) and (2) evaluate the impact of the SAP and patient-level SM adoption on perceived provider autonomy support and communication. Patient-reported barriers to SM adoption were also assessed.

METHODS

We randomized 1195 patients at 3 VHA facilities who had MHV portal accounts but had never used SM. Half were randomized to receive the SAP, and half served as controls receiving usual care. The SAP consisted of encouragement to adopt SM via mailed educational materials, proactive SM sent to patients, and telephone-based motivational interviews. We examined differences in SM adoption rates between SAP recipients and controls at 9 months and 21 months. Follow-up telephone surveys were conducted to assess perceived provider autonomy support and self-report of telephone communication with clinical teams.

RESULTS

Patients randomized to the SAP had significantly higher rates of SM adoption than the control group (101/595, 17.0% vs 40/600, 6.7%; P<.001). Most adopters in the SAP sent their first message without a motivational interview (71/101, 70.3%). The 10-percentage point difference in adoption persisted a full year after the encouragement ended (23.7%, 142/600 in the SAP group vs 13.5%, 80/595 in the control group, P<.001). We obtained follow-up survey data from 49.54% (592/1195) of the participants. SAP participants reported higher perceived provider autonomy support (5.7 vs 5.4, P=.007) and less telephone use to communicate with their provider (68.8% vs 76.0%, P=.05), compared to patients in the control group. Patient-reported barriers to SM adoption included self-efficacy (eg, not comfortable using a computer, 24%), no perceived need for SM (22%), and difficulties with portal password or login (17%).

CONCLUSIONS

The multicomponent SAP was successful in increasing use of SM 10 percentage points above standard care; new SM adopters reported improved perceptions of provider autonomy support and less use of the telephone to communicate with their providers. Still, despite the encouragement and technical assistance provided through the SAP, adoption rates were lower than anticipated, reaching only 24% at 21 months (10% above controls). Common barriers to adoption such as limited perceived need for SM may be more challenging to address and require different interventions than barriers related to patient self-efficacy or technical difficulties.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02665468; https://clinicaltrials.gov/ct2/show/NCT02665468.

Self-efficacy to avoid suicidal action: factor structure and convergent validity among adults in substance use disorder treatment

Individuals with substance use disorders (SUDs) are at high risk of suicidal behaviors, highlighting the need for an improved understanding of potentially influential factors. One such domain is self-efficacy to manage suicidal thoughts and impulses. Psychometric data about the Self-Efficacy to Avoid Suicidal Action (SEASA) Scale within a sample of adults seeking SUD treatment (N = 464) is provided. Exploratory factor analysis supported a single self-efficacy construct. Lower SEASA scores, or lower self-efficacy, were reported in those with more severe suicidal ideation and those with more suicide attempts, providing evidence for convergent validity. Implications of measuring self-efficacy in the context of suicide risk assessment are discussed.

Positive posttraumatic stress disorder screens among first-time medical cannabis patients: prevalence and association with other substance use

Twenty-one states and the District of Columbia have passed legislation allowing for the use of medical cannabis for those individuals with qualifying medical conditions, which include posttraumatic stress disorder (PTSD) for a growing number of states. Little information is available regarding PTSD among medical cannabis patients. This study seeks to provide initial data on this topic by examining the prevalence and correlates of positive PTSD screens among a sample of patients seeking medical cannabis certification for the first time (n=186). Twenty-three percent (42/186; 95% confidence interval [CI] =17%-29%) of the patients in the study sample screened positive for PTSD. Moreover, the group that screened positive for PTSD had higher percentages of lifetime prescription opioid, cocaine, prescription sedative, and street opioid use, as well as a higher percentage of recent prescription sedative use, than the group that screened negative for PTSD. These findings highlight the relatively common use of other substances among medical cannabis patients with significant PTSD symptoms, even when compared with other patients seeking medical cannabis for the first time. As a growing number of states include PTSD among the list of qualifying medical conditions for medical cannabis, additional research is needed to better characterize the longitudinal relationship between medical cannabis use and PTSD symptoms.

Individual differences in children's and parents' generic language

Generics ("Dogs bark") convey important information about categories and facilitate children's learning. Two studies with parents and their 2- or 4-year-old children (N = 104 dyads) examined whether individual differences in generic language use are as follows: (a) stable over time, contexts, and domains, and (b) linked to conceptual factors. For both children and parents, individual differences in rate of generic production were stable across time, contexts, and domains, and parents' generic usage significantly correlated with that of their own children. Furthermore, parents' essentialist beliefs correlated with their own and their children's rates of generic frequency. These results indicate that generic language use exhibits substantial stability and may reflect individual differences in speakers' conceptual attitudes toward categories.

Noncancer pain conditions and risk of suicide

IMPORTANCE

There are limited data on the extent to which suicide mortality is associated with specific pain conditions.

OBJECTIVE

To examine the associations between clinical diagnoses of noncancer pain conditions and suicide among individuals receiving services in the Department of Veterans Affairs Healthcare System.

DESIGN

Retrospective data analysis.

SETTING

Data were extracted from National Death Index and treatment records from the Department of Veterans Healthcare System.

PARTICIPANTS

Individuals receiving services in fiscal year 2005 who remained alive at the start of fiscal year 2006 (N = 4 863 086).

MAIN OUTCOMES AND MEASURES

Analyses examined the association between baseline clinical diagnoses of pain-related conditions (arthritis, back pain, migraine, neuropathy, headache or tension headache, fibromyalgia, and psychogenic pain) and subsequent suicide death (assessed in fiscal years 2006-2008).

RESULTS

Controlling for demographic and contextual factors (age, sex, and Charlson score), elevated suicide risks were observed for each pain condition except arthritis and neuropathy (hazard ratios ranging from 1.33 [99% CI, 1.22-1.45] for back pain to 2.61 [1.82-3.74] for psychogenic pain). When analyses controlled for concomitant psychiatric conditions, the associations between pain conditions and suicide death were reduced; however, significant associations remained for back pain (hazard ratio, 1.13 [99% CI, 1.03-1.24]), migraine (1.34 [1.02-1.77]), and psychogenic pain (1.58 [1.11-2.26]).

CONCLUSIONS AND RELEVANCE

There is a need for increased awareness of suicide risk in individuals with certain noncancer pain diagnoses, in particular back pain, migraine, and psychogenic pain.

The Medium is the Message: Pictures and Objects Evoke Distinct Conceptual Relations in Parent-Child Conversations

An important developmental task is learning to organize experience by forming conceptual relations among entities (e.g., a lion and a snake can be linked because both are animals; a lion and a cage can be linked because the lion lives in the cage). We propose that representational medium (i.e., pictures vs. objects) plays an important role in influencing which relations children consider. Prior work has demonstrated that pictures more readily evoke broader categories, whereas objects more readily call attention to specific individuals. We therefore predicted that pictures would encourage taxonomic and shared-property relations, whereas objects would encourage thematic and slot-filler relations. We observed 32 mother-child dyads (M child ages = 2.9 and 4.3) playing with pictures and objects, and identified utterances in which they made taxonomic, thematic, shared-property, or slot-filler links between items. The results confirmed our predictions and thus support representational medium as an important factor that influences the conceptual relations expressed during dyadic conversations.

Qualitative evaluation of suicide and overdose risk assessment procedures among veterans in substance use disorder treatment clinics

The objective of this study was to examine risk assessment practices for suicide and unintentional overdose to inform ongoing care in substance use disorder clinics. Focus groups were conducted via telephone among a random sample of treatment providers (N = 19) from Veterans Health Administration substance use disorder clinics across the nation. Themes were coded by research staff. Treatment providers reported consistent and clear guidelines for risk assessment of suicide among patients. Unintentional overdose questions elicited dissimilar responses which indicated a lack of cohesion and uniformity in risk assessment practices across clinics. Suicide risk assessment protocols are cohesively implemented by treatment providers. Unintentional overdose risk, however, may be less consistently assessed in clinics.

Effects of generic language on category content and structure

We hypothesized that generic noun phrases ("Bears climb trees") would provide important input to children's developing concepts. In three experiments, four-year-olds and adults learned a series of facts about a novel animal category, in one of three wording conditions: generic (e.g., "Zarpies hate ice cream"), specific-label (e.g., "This zarpie hates ice cream"), or no-label (e.g., "This hates ice cream"). Participants completed a battery of tasks assessing the extent to which they linked the category to the properties expressed, and the extent to which they treated the category as constituting an essentialized kind. As predicted, for adults, generics training resulted in tighter category-property links and more category essentialism than both the specific-label and no-label training. Children also showed effects of generic wording, though the effects were weaker and required more extensive input. We discuss the implications for language-thought relations, and for the acquisition of essentialized categories.

The Role of Representational Status and Item Complexity in Parent-Child Conversations about Pictures and Objects

Mother-child conversations about pictures systematically differ from mother-child conversations about objects: Pictures are more likely than objects to elicit talk about kinds, whereas objects are more likely than pictures to elicit talk about individuals. The purpose of the current study is to examine whether this difference between pictures and objects is explained by differences in item complexity. Mothers and their 4-year-old children were randomly assigned to one of two conditions: Simple or Complex. In each condition, participants viewed 12 toy objects and 12 pictures, matched for content. The items were either highly detailed (complex condition) or very plain (simple condition). Replicating previous research, mothers and children provided relatively more focus on kinds when talking about pictures, and relatively more focus on individuals when talking about objects. The current results go further, however, to demonstrate that this effect is independent of the items' complexity. We therefore propose that the picture-object difference is not due to low-level differences in amount of perceptual detail provided, but rather is due to the greater ease with which pictures serve as representations (DeLoache, 1991). These data indicate the ways in which a fundamental conceptual distinction between kinds and individuals arises in different linguistic expressions and in different contexts.

Cardiorespiratory function in asymptomatic survivors of neonatal respiratory distress syndrome

We measured cardiopulmonary function at rest and during exercise in 15 healthy survivors of neonatal respiratory distress syndrome (RDS) and compared the results with those in 15 normal subjects. The mean birth weight of the RDS group was 1,771 g, and 12 of the 15 patients had required endotracheal intubation. The oxygen scores ranged from 79 to 3,322. Five of the 15 RDS patients had abnormal results of pulmonary function studies at rest. Peak expiratory flow was lower (P less than 0.05) in the RDS group (2.98 liters/min) than in the control group (3.57 liters/min). A negative correlation was noted between the forced expiratory flow between 25 and 75% of vital capacity and the oxygen score in these patients. Exercise tolerance was below normal in two of the RDS patients, both of whom also had abnormal pulmonary function at rest. One patient in the RDS group had systemic arterial hypertension at rest and during exercise. No significant differences in exercise tolerance or the cardiorespiratory response to exercise were observed between the two groups.

Effects of drugs and chemicals on the fetus and newborn (2)

Physicians have become increasingly aware of the side effects of specific drugs. Obstetricians and family physicians should especially be cognizant of the implications of the administration of any drug, not only for the pregnant mother but also for the unborn child. In this second installment of our two-part article, we conclude our review of drugs, chemicals, and environmental pollutants that may affect the fetus or newborn.

Effects of drugs and chemicals on the fetus and newborn (1)

Drug teratogenicity has been demonstrated experimentally for more than 30 years. After the discovery of the thalidomide-induced embryopathies, the fetal dangers of maternal drug ingestion were overemphasized. Accumulation of additional information during the past 15 years has led to a more balanced viewpoint concerning drug teratogenicity. A complex set of circumstances must prevail for a specific teratogenic effect to result. Not only the drug or environmental pollutant in question but also its dose, timing, and frequency of administration as well as the genetic and individual susceptibility of the embryo are important factors. Herein we review the currently available information on drug and environmental effects on the fetus and neonate.

Treatment of defects of the anterior abdominal wall in newborns

Primary closure of an omphalocele or gastroschisis may cause respiratory compromise in the neonate. Some authors recommend primary closure of the defect with prolonged respiratory support because of dissatisfaction with staged visceral reduction and use of a Silastic pouch. Our experience with use of a Silastic pouch from 1975 to 1982 was reviewed. Twenty-three newborns with major defects of the abdominal wall (14 omphaloceles and 9 gastroschisis anomalies) were surgically treated, and only one death occurred. The mean birth weight of the infants was 2,927 g; nine of them were premature. Seven infants had major associated anomalies. The goal of the surgical procedure was closure of the abdominal wall without compromise of the cardiorespiratory status. During the operation, muscle relaxants were avoided and the infants breathed spontaneously. If progressive visceral reduction caused tachypnea (rate of more than 70/min) or hemodynamic instability, a Silastic pouch was constructed. Ten patients were treated with primary fascial closure, and 13 were treated with a Silastic prosthesis. The neonates with the prostheses required three to eight reductions, and the prostheses were in place for 4 to 22 days. No patient had wound dehiscence, wound infection, or an intestinal fistula. The one death occurred in an infant with trisomy 18 syndrome and multiple anomalies. Thus, the Silastic pouch was effective when the defect could not be closed primarily without respiratory compromise.

Prognostic value of brainstem auditory evoked potentials in neonates

The clinical outcome in 74 children at risk for audiologic or neurologic sequelae of a variety of perinatal insults was correlated with brainstem auditory evoked potentials (BAEPs) in the newborn period. No constant relationship was found between BAEP findings and later hearing status in preterm infants or in infants with severe brain damage. However, persistent patterns of wave I abnormality correctly predicted the presence and type of hearing loss in other infants. Central BAEP abnormalities recorded in preterm infants or in infants who had just suffered anoxia had little predictive value. The abnormalities had greater prognostic value when there was a delay between acute injury and testing. Prognostic errors could be minimized in this population by obtaining repeated recordings at least one month post term and after injury from infants who showed BAEP abnormalities in the neonatal period.

Serum levels of creatine phosphokinase and its isoenzymes in normal and stressed neonates

Twenty-six normal newborns (13 male, 13 female) with normal prenatal histories, no perinatal stress, and normal vaginal deliveries had creatine phosphokinase (CPK) activity and isoenzyme activities assayed in cord blood and in 24-hour postpartum serum. Total CPK activity was high in cord blood when compared with adult control values. Moreover, the total CPK was significantly higher in serum at 24 hours of age compared with cord blood. There was a significant increase in both the skeletal muscle isoenzyme and the cardiac muscle isoenzyme from birth to 24 hours of age. There was a decrease in the brain isoenzyme at 24 hours of age which was not statistically significant. These results were compared with values obtained in a group of 10 neonates with severe cardiac problems. Three of the ill neonates had significant elevation of total serum CPK and the skeletal muscle isoenzyme when compared with the normal newborns. There were no significant differences between the normal infants and the ill neonates for the cardiac isoenzyme and the brain isoenzyme. These data suggest that caution should be used in the diagnosis of certain neonatal cardiac syndromes based on serum CPK levels and isoenzyme alone.

Gastrointestinal mucormycoses in infants and children: a cause of gangrenous intestinal cellulitis and perforation

Gastrointestinal mucormycosis has been a uniformly fatal disease in children. Diagnosis has been difficult, resulting in inadequate therapy. Histologic and bacteriologic confirmation of invasive infection, followed by systemically administered amphotericin B and surgical excision, are the hallmarks of effective treatment.

False-positive rubella hemagglutination-inhibition (HAI) titers in neonates and children with conjugated hyperbilirubinemia

Two neonates, one with extrahepatic biliary atresia and one with cystic fibrosis, and a 9-year-old child with atresia of the common bile duct had conjugated hyperbilirubinemia and elevated rubella HAI titers when kaolin pretreatment of serum was used. A beta-lipoprotein fraction of the serum that is frequently found in association with biliary obstruction was shown to be the probable source of the rubella HAI inhibitor. This beta-lipoprotein was not removed by standard kaolin treatment of serum, but was removed almost completely by dextran sulfate--calcium chloride treatment. In the presence of conjugated hyperbilirubinemia, routine kaolin pretreatment of serum is an inadequate measure for the removal of interfering substances, as false-positive rubella HAI results are obtained consistently.

Intraventricular hemorrhages in full-term and premature infants

Intraventricular hemorrhages were the most common neuropathologic findings in both full-term and premature infants in a retrospective study of neonatal deaths. In general, the intraventricular hemorrhages of full-term infants were less frequent, originated from veins of the choroid plexus, were small, and rarely caused death. Intraventricular hemorrhages of premature infants usually originated in the germinal matrix and were large enough to be fatal. Intraventricular hemorrhages were most frequently found when death occurred between 24 and 72 hours of age.

Use of tolazoline in newborn infants with diaphragmatic hernia and severe cardiopulmonary disease. A preliminary report

Two newborn infants with congenital diaphragmatic hernia, one of whom died, had significant improvement in arterial oxygen tension (Pao2) after intravenous administration of tolazoline (Priscoline) (1 to 2 mg. per kilogram). In both infants, systemic hypotension developed within minutes of administration of the drug and required pharmacologic and hemodynamic intervention. The response to tolazoline was more dramatic in the infant who survived, and his oxygen requirements were significantly reduced after the use of this drug. The infant who died also had a significant response to tolazoline. Tolazoline appears to be an important pharmacologic agent for use in the postoperative care of infants with diaphragmatic hernia and associated hypoxemia and acidosis.

Erythrocyte catechol-0-methyltransferase and plasma dopamine-beta-hydroxylase in human umbilical cord blood

Plasma dopamine-beta-hydroxylase enzymatic activity and immunoreactive protein levels in human umbilical cord blood are only about 2% as great as values in the blood of older subjects. Erythrocyte catechol-0-methyltransferase activity levels in umbilical cord blood are very similar to those in the blood of adult subjects.

False aneurysm of the descending aorta: a complication of umbilical artery catheterization

A patient had an aneurysm of the descending aorta secondary to aortitis arising from umbilical artery catheterization and in association with coarctation of the aorta. The aortitis probably was the direct result of bacterial contamination of the umbillicus and catheter with Staphylococcus aureus and the placement of the catheter tip just distal to a coarctation of the aorta. The patient required surgical resection of the coarctation and aneurysm of the descending aorta and placement of a tubular Dacron graft at 6 month of age. This is, to our knowledge, a hitherto unreported complication of umbilical artery catheterization.

The effect of time of cord clamping and maternal blood pressure on placental transfusion with cesarean section

We measured the residual placental blood volume (RPBV) of 20 infants delivered at term by cesarean section of women not in labor. In all cases, the umbilical cord was clamped within 40 seconds of birth. RPBV decreased significantly with increasing age at cord clamping. In addition, RPBV for infants with cords clamped within 20 seconds of birth correlated inversely with maternal systolic blood pressure (mean RPBV = 54.8 ml. per kilogram at 105 torr and 28.4 ml. per kilogram at 148 torr). However, RPBV did not correlate with maternal blood pressure for the whole group of 20 infants or for those with cords clamped later than 20 seconds after birth. These data indicated that in infants delivered by cesarean section placental transfusion is time related during the first 40 seconds of life and that maternal blood pressure also influences the magnitude of placental transfusion during the first 20 seconds after birth. Analysis of data from this study combined with data from a previous study shows that after 40 seconds the net flow between placenta and infant reverses and that cord clamping delayed beyond this point is accompanied by a rise in RPBV back to the level found when the cord was clamped before 20 seconds.

Inclusion blennorrhea: a case report

The case described here represents the first laboratory-confirmed case of inclusion blennorrhea at the Mayo Clinic since laboratory isolation of Chlamydia trachomatis was instituted in 1974. Treatment with a sulfonamide preparation proved effective. Further aspects of the diagnosis and treatment of inclusion blennorrhea are discussed.

A volume-displacement plethysmograph to measure limb blood flow in the newborn infant

An instrument is described that measures limb blood flow in newborn infants by venous occlusion plethysmography. The plethysmograph is filled with air and a pneumotachygraph measures the volume displaced during venous occlusion. The response of the system is linear for flows over the range 1 to 100 ml/min and the frequency response to a square wave pressure change is 22 Hz with a 95% response time of 0.5 second. The average flow in the forearm of 10 normal newborn infants was 5.9 ml/min per 100 ml of tissue.

The pathogenesis and management of massive pulmonary hemorrhage in the neonate. Case report of a normal survivor

A 1,760-G MALE INFANT SURVIVED MASSIVE PUlmonary hemorrhage. The literature is reviewed and the pathophysiologic changes and pathologic findings of this usually lethal complication of prematurity are discussed. Aggressive pulmonary toilet and ventilation seems warranted for these infants.

Neonatal pneumopericardium

Three cases of neonatal pneumopericardium are presented. Detailed ventilatory measurements and chest roentgenographic changes are described for each of the three patients. The literature of neonatal pneumopericardium is reviewed, and based on that review and our own cases, we offer guidelines for managing these patients.

Cesarean section prevents placenta-to-infant transfusion despite delayed cord clamping

We have adapted and calibrated an accurate method for measuring residual placement blood volume (RPBV). We used this method in 33 normal vaginal deliveries and 18 cesarean section deliveries in which the umbilical cord was clamped from 5 to 118 seconds after delivery. Infants born vaginally received 10 to 20 ml. per kilogram of body weight of placental transfusion when umbilical cord was not clamped until 30 seconds or more after delivery. Equivalent delay of umbilical cord clamping in cesarean section infants produced no placental transfusion.