Heterosexual Self-Presentation, Identity Management, and Sexual Functioning Among Men Who Have Sex with Men

Research and clinical work on sexual functioning in men has traditionally focused on the presence or absence of erectile dysfunction (ED) or the inability to maintain an erection sufficient for satisfactory sexual performance. However, for men who have sex with men (MSM), receptive anal intercourse is a common form of sexual expression. Existing work on men's sexual dysfunction does not effectively address receptive anal sex functioning, and there is a need to understand how stressors can impact this common sexual behavior. The goal of the present study was to understand how stressors can impact erective and receptive anal sex functioning among MSM. In the present study, we hypothesized that minority stress (as operationalized by integrating identity management and heterosexual self-presentation) would have an impact on MSM's sexual functioning overall and adapted a previous measure of sexual dysfunction (International Index of Erectile Functioning) to better assess this relationship. Data were collected from 228 men (M_age = 31.74, SD = 9.41); exploratory factor analysis was used to create a new measure of sexual functioning, and regression analyses were used to examine the relationships between heterosexual self-presentation and identity management and sexual functioning. Results demonstrated that higher heterosexual self-presentation was associated with more functional impairment in erectile function and receptive anal sex functioning as well as use of functional enhancement medications or substances. The results of the present study extend extant work on minority stress to sexual functioning of MSM and are relevant to the sexual health concerns of MSM.

Characteristics of the Diffuse Astrophysical Electron and Tau Neutrino Flux with Six Years of IceCube High Energy Cascade Data

We report on the first measurement of the astrophysical neutrino flux using particle showers (cascades) in IceCube data from 2010-2015. Assuming standard oscillations, the astrophysical neutrinos in this dedicated cascade sample are dominated (∼90%) by electron and tau flavors. The flux, observed in the sensitive energy range from 16 TeV to 2.6 PeV, is consistent with a single power-law model as expected from Fermi-type acceleration of high energy particles at astrophysical sources. We find the flux spectral index to be γ=2.53±0.07 and a flux normalization for each neutrino flavor of ϕ_{astro}=1.66_{-0.27}^{+0.25} at E_{0}=100  TeV, in agreement with IceCube's complementary muon neutrino results and with all-neutrino flavor fit results. In the measured energy range we reject spectral indices γ≤2.28 at ≥3σ significance level. Because of high neutrino energy resolution and low atmospheric neutrino backgrounds, this analysis provides the most detailed characterization of the neutrino flux at energies below ∼100  TeV compared to previous IceCube results. Results from fits assuming more complex neutrino flux models suggest a flux softening at high energies and a flux hardening at low energies (p value ≥0.06). The sizable and smooth flux measured below ∼100  TeV remains a puzzle. In order to not violate the isotropic diffuse gamma-ray background as measured by the Fermi Large Area Telescope, it suggests the existence of astrophysical neutrino sources characterized by dense environments which are opaque to gamma rays.

Time-Integrated Neutrino Source Searches with 10 Years of IceCube Data

This Letter presents the results from pointlike neutrino source searches using ten years of IceCube data collected between April 6, 2008 and July 10, 2018. We evaluate the significance of an astrophysical signal from a pointlike source looking for an excess of clustered neutrino events with energies typically above ∼1  TeV among the background of atmospheric muons and neutrinos. We perform a full-sky scan, a search within a selected source catalog, a catalog population study, and three stacked Galactic catalog searches. The most significant point in the northern hemisphere from scanning the sky is coincident with the Seyfert II galaxy NGC 1068, which was included in the source catalog search. The excess at the coordinates of NGC 1068 is inconsistent with background expectations at the level of 2.9σ after accounting for statistical trials from the entire catalog. The combination of this result along with excesses observed at the coordinates of three other sources, including TXS 0506+056, suggests that, collectively, correlations with sources in the northern catalog are inconsistent with background at 3.3σ significance. The southern catalog is consistent with background. These results, all based on searches for a cumulative neutrino signal integrated over the 10 years of available data, motivate further study of these and similar sources, including time-dependent analyses, multimessenger correlations, and the possibility of stronger evidence with coming upgrades to the detector.

Association of No Promotion of Homosexuality Laws and Electronic Cigarette Use Disparities for Sexual Minority Youth

This study examines the disparities in e-cigarette use between heterosexual and sexual minority youth in US states with and without laws prohibiting positive portrayals of homosexuality in public school education.

Precursors to Heterophobia: An Examination of Temporal Sequence Among a Sample of Gay Men

Heterophobia, defined as gay men's fear and avoidance of heterosexual men, has been linked to behavioral health outcomes and could contribute to social disconnectedness and intergroup conflict. The Gay Male Heterophobia Scale assesses 3 meaningful aspects of gay male heterophobia: disconnectedness, expected rejection, and unease/avoidance. The current study sought to assess the development of heterophobia among gay men over 2 weeks using a longitudinal cross-lagged panel design. Using data gathered from 253 gay-identified men collected on MTurk, the results indicated that disconnectedness is an important mediator in the relationship between minority stress and unease/avoidance of heterosexual men but does not mediate the relationship between minority stress and expectations of rejection. Implications for future research and clinical applications are provided, in addition to a discussion of study limitations.

Constraints on Minute-Scale Transient Astrophysical Neutrino Sources

High-energy neutrino emission has been predicted for several short-lived astrophysical transients including gamma-ray bursts (GRBs), core-collapse supernovae with choked jets, and neutron star mergers. IceCube's optical and x-ray follow-up program searches for such transient sources by looking for two or more muon neutrino candidates in directional coincidence and arriving within 100 s. The measured rate of neutrino alerts is consistent with the expected rate of chance coincidences of atmospheric background events and no likely electromagnetic counterparts have been identified in Swift follow-up observations. Here, we calculate generic bounds on the neutrino flux of short-lived transient sources. Assuming an E^{-2.5} neutrino spectrum, we find that the neutrino flux of rare sources, like long gamma-ray bursts, is constrained to <5% of the detected astrophysical flux and the energy released in neutrinos (100 GeV to 10 PeV) by a median bright GRB-like source is <10^{52.5}  erg. For a harder E^{-2.13} neutrino spectrum up to 30% of the flux could be produced by GRBs and the allowed median source energy is <10^{52}  erg. A hypothetical population of transient sources has to be more common than 10^{-5}  Mpc^{-3}  yr^{-1} (5×10^{-8}  Mpc^{-3}  yr^{-1} for the E^{-2.13} spectrum) to account for the complete astrophysical neutrino flux.

Stress and substance use among sexual and gender minority individuals across the lifespan

Sexual and gender minority (SGM) individuals face marked disparities in substance use. The present narrative review explores research on substance use in SGM communities using a minority stress theory lens. We define the SGM population and minority stress, and explore stresses and substance use disparities in adolescence, adulthood, and older age. Though research on this topic is beginning to highlight the relationship between stress and substance use for SGM individuals, more work is needed on older SGM populations and in translating research findings to effective interventions.

Search for neutrinos from decaying dark matter with IceCube: IceCube Collaboration

With the observation of high-energy astrophysical neutrinos by the IceCube Neutrino Observatory, interest has risen in models of PeV-mass decaying dark matter particles to explain the observed flux. We present two dedicated experimental analyses to test this hypothesis. One analysis uses 6 years of IceCube data focusing on muon neutrino 'track' events from the Northern Hemisphere, while the second analysis uses 2 years of 'cascade' events from the full sky. Known background components and the hypothetical flux from unstable dark matter are fitted to the experimental data. Since no significant excess is observed in either analysis, lower limits on the lifetime of dark matter particles are derived: we obtain the strongest constraint to date, excluding lifetimes shorter than10 28 s at 90% CL for dark matter masses above 10 TeV .

Measurement of the ν μ energy spectrum with IceCube-79: IceCube Collaboration

IceCube is a neutrino observatory deployed in the glacial ice at the geographic South Pole. The ν μ energy unfolding described in this paper is based on data taken with IceCube in its 79-string configuration. A sample of muon neutrino charged-current interactions with a purity of 99.5% was selected by means of a multivariate classification process based on machine learning. The subsequent unfolding was performed using the software Truee. The resulting spectrum covers an E ν -range of more than four orders of magnitude from 125 GeV to 3.2 PeV. Compared to the Honda atmospheric neutrino flux model, the energy spectrum shows an excess of more than 1.9 σ in four adjacent bins for neutrino energies E ν ≥ 177.8 TeV . The obtained spectrum is fully compatible with previous measurements of the atmospheric neutrino flux and recent IceCube measurements of a flux of high-energy astrophysical neutrinos.

Constraints on Ultrahigh-Energy Cosmic-Ray Sources from a Search for Neutrinos above 10 PeV with IceCube

We report constraints on the sources of ultrahigh-energy cosmic rays (UHECRs) above 10^{9}  GeV, based on an analysis of seven years of IceCube data. This analysis efficiently selects very high- energy neutrino-induced events which have deposited energies from 5×10^{5}  GeV to above 10^{11}  GeV. Two neutrino-induced events with an estimated deposited energy of (2.6±0.3)×10^{6}  GeV, the highest neutrino energy observed so far, and (7.7±2.0)×10^{5}  GeV were detected. The atmospheric background-only hypothesis of detecting these events is rejected at 3.6σ. The hypothesis that the observed events are of cosmogenic origin is also rejected at >99% CL because of the limited deposited energy and the nonobservation of events at higher energy, while their observation is consistent with an astrophysical origin. Our limits on cosmogenic neutrino fluxes disfavor the UHECR sources having a cosmological evolution stronger than the star formation rate, e.g., active galactic nuclei and γ-ray bursts, assuming proton-dominated UHECRs. Constraints on UHECR sources including mixed and heavy UHECR compositions are obtained for models of neutrino production within UHECR sources. Our limit disfavors a significant part of parameter space for active galactic nuclei and new-born pulsar models. These limits on the ultrahigh-energy neutrino flux models are the most stringent to date.

Searches for Sterile Neutrinos with the IceCube Detector

The IceCube neutrino telescope at the South Pole has measured the atmospheric muon neutrino spectrum as a function of zenith angle and energy in the approximate 320 GeV to 20 TeV range, to search for the oscillation signatures of light sterile neutrinos. No evidence for anomalous ν_{μ} or ν[over ¯]_{μ} disappearance is observed in either of two independently developed analyses, each using one year of atmospheric neutrino data. New exclusion limits are placed on the parameter space of the 3+1 model, in which muon antineutrinos experience a strong Mikheyev-Smirnov-Wolfenstein-resonant oscillation. The exclusion limits extend to sin^{2}2θ_{24}≤0.02 at Δm^{2}∼0.3  eV^{2} at the 90% confidence level. The allowed region from global analysis of appearance experiments, including LSND and MiniBooNE, is excluded at approximately the 99% confidence level for the global best-fit value of |U_{e4}|^{2}.

Evidence for Astrophysical Muon Neutrinos from the Northern Sky with IceCube

Results from the IceCube Neutrino Observatory have recently provided compelling evidence for the existence of a high energy astrophysical neutrino flux utilizing a dominantly Southern Hemisphere data set consisting primarily of ν(e) and ν(τ) charged-current and neutral-current (cascade) neutrino interactions. In the analysis presented here, a data sample of approximately 35,000 muon neutrinos from the Northern sky is extracted from data taken during 659.5 days of live time recorded between May 2010 and May 2012. While this sample is composed primarily of neutrinos produced by cosmic ray interactions in Earth's atmosphere, the highest energy events are inconsistent with a hypothesis of solely terrestrial origin at 3.7σ significance. These neutrinos can, however, be explained by an astrophysical flux per neutrino flavor at a level of Φ(E(ν))=9.9(-3.4)(+3.9)×10(-19)  GeV(-1) cm(-2) sr(-1) s(-1)(E(ν)/100  TeV(-2), consistent with IceCube's Southern-Hemisphere-dominated result. Additionally, a fit for an astrophysical flux with an arbitrary spectral index is performed. We find a spectral index of 2.2(-0.2)(+0.2), which is also in good agreement with the Southern Hemisphere result.

On the origin of the invasive olives (Olea europaea L., Oleaceae)

The olive tree (Olea europaea) has successfully invaded several regions in Australia and Pacific islands. Two olive subspecies (subspp. europaea and cuspidata) were first introduced in these areas during the nineteenth century. In the present study, we determine the origin of invasive olives and investigate the importance of historical effects on the genetic diversity of populations. Four invasive populations from Australia and Hawaii were characterized using eight nuclear DNA microsatellites, plastid DNA markers as well as ITS-1 sequences. Based on these data, their genetic similarity with native populations was investigated, and it was determined that East Australian and Hawaiian populations (subsp. cuspidata) have originated from southern Africa while South Australian populations (subsp. europaea) have mostly derived from western or central Mediterranean cultivars. Invasive populations of subsp. cuspidata showed significant loss of genetic diversity in comparison to a putative source population, and a recent bottleneck was evidenced in Hawaii. Conversely, invasive populations of subsp. europaea did not display significant loss of genetic diversity in comparison to a native Mediterranean population. Different histories of invasion were inferred for these two taxa with multiple cultivars introduced restoring gene diversity for europaea and a single successful founder event and sequential introductions to East Australia and then Hawaii for cuspidata. Furthermore, one hybrid (cuspidata x europaea) was identified in East Australia. The importance of hybridizations in the future evolution of the olive invasiveness remains to be investigated.

Recovery of prostaglandin production associated with reopening of the ductus arteriosus after indomethacin treatment in preterm infants with respiratory distress syndrome

Increased PGE production has been demonstrated in 9 of 17 preterm infants with patent ductus arteriosus (PDA) associated with respiratory distress syndrome (RDS). Inhibition of PGE production in eight preterm infants with PDA and RDS was associated with marked improvement in the respiratory and circulatory function of all of them. However, in six of them this effect was only transient. In the posttreatment period of five and a half days reopening of the ductus arteriosus was frequently associated with increased PGE production and a drop of indomethacin serum levels. Three of these six infants were transferred for surgical ligation whereas the other three were successfully treated with a second course of indomethacin. However, the margin between closure of the ductus arteriosus and the deterioration of kidney function in preterm infants treated with a presently recommended indomethacin dosage was narrow. In conclusion, until an acceptable therapeutic serum level of indomethacin for ductal closure in preterm infants has been established and the duration of effective prostaglandin synthesis inhibition is known, it is too early for a general recommendation of a dosage regime of indomethacin for the pharmacological closure of PDA in infants with RDS.

Stavudine versus zidovudine and the development of lipodystrophy

The pathogenesis of some components of the lipodystrophy (LD) syndrome might be linked to the use of nucleosides. Earlier reports did not compare treatment regimens according to the nucleoside backbone. We studied a cohort of individuals who did not switch between stavudine and zidovudine. LD was defined to be present if one of three criteria was met: self-report by the patient, observation by an investigator who had known the patient since commencement of highly active antiretroviral therapy (HAART), or examination by a physician masked to therapy. The mean duration of therapy was 101 weeks (range: 26-234 weeks). Overall prevalence of LD was 48.7%. Lipoatrophy and lipohypertrophy occurred in 33.9% and 28.7% of patients, respectively. Logistic regression showed four parameters to be significantly associated with lipoatrophy: HAART longer than 2 years (p =.002, odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.608-11.965), baseline viral load >100,000 copies/ml (p =.004, OR = 4.3, CI: 1.726-11.197), age >40 years (p =.016, OR = 3.2, CI: 1.247-8.373), and white ethnicity (p =.041, OR = 5.4, CI: 1.070-28.184). Cholesterol levels of >200 mg/dl at baseline were associated with a risk reduction (p =.047, OR = 0.36, CI: 0.130-0.987). Use of lipohypertrophy as a dependent variable resulted in a significant association with HAART duration (p = 0.028, OR = 2.7, CI: 1.2-6.5) and protease inhibitor use (p =.014, OR = 3.8, CI: 1.3-11.2). LD prevalence is similar with both backbones using stavudine or zidovudine. This is the first time that baseline cholesterol was shown to be significantly associated with lipoatrophy.

Gender-specific health behaviors of German university students predict the interest in campus health promotion

This cross-sectional study aimed to provide an assessment of the needs for health promotion in university freshmen, based on lifestyle variables and the interest in health-promoting activities. A questionnaire survey was performed using a sample of 288 male and 362 female university freshmen from 19 to 33 years of age. Male students were significantly more likely to engage in drug-taking behaviors, referring to alcohol and cannabis use, and had a higher body mass index. No gender difference was noted in the numbers of regular smokers. Preventive behaviors with respect to healthy nutrition and dental hygiene were reported more often in females, whereas the duration of physical activity per week and the use of condoms with a new sexual partner showed no gender difference. There was a strong demand for group health-oriented programs (79.5% of respondents). Substantial proportions of students had a high interest in individual counseling aiming at stress management (24.5%), healthy nutrition (19.3%) and prevention of sexually transmitted diseases (18.2%). Women expressed a greater interest in most programs than men. Multivariate regression analyses showed that a disposition for alcohol abuse was the strongest predictor of interest in health counseling in male students (p < 0.001), while psychosocial stress was the most important predictor in female students (p < 0.001). From the prevalence of health risks and the students' interest in health promotion programs it was concluded that there is a strong need for health promotion in the university setting in Germany. Results suggested that individuals at risk would probably benefit most from an individual counseling program.

New approaches for genotyping of Helicobacter pylori based on amplification of polymorphisms in intergenic DNA regions and at the insertion site of the cag pathogenicity island

The population of the gastric pathogen Helicobacter pylori shows a high degree of genetic diversity. It is well established that heterogeneity at the isolate level is caused by nucleotide transitions within genes, differences in the gene order, and by genetic instability of single genes as well as of a large virulence-associated genomic DNA region, the cag pathogenicity island (PAI). Analysis of intergenic regions with specific PCR-assays developed in this study, revealed that DNA polymorphisms in the noncoding DNA localized in front of the genes ribA and vacA and at the insertion site of the cag PAI contribute to the genetic diversity of H. pylori and are useful for differentiation of individual isolates. Thirteen individual genotypes were identified by PCR analysis of these polymorphic loci in 487, 241, and 182 clinical H. pylori isolates. Sequence analysis revealed that genetic variability in front of genes ribA and vacA, and in the intergenic region at the PAI insertion site is caused by insertion and deletions of so-far-unknown DNA sequences as well as by parts of the H. pylori IS elements IS605 and IS606, respectively. The new genotypes identified could be used to differentiate antrum and corpus isolates from the same patients. Their combination with vacA allele subtypes and with the cagA status allowed to differentiate 140 isolates in 51 subtypes. In 36 cases the corresponding genotype patterns were isolate specific. In summary, the results confirm that DNA polymorphisms in intergenic regions contribute to the genetic diversity of H. pylori. Although individual H. pylori genotypes were not associated with peptic ulcer disease, the PCR-based approaches for their detection developed here should be of use for further investigation of genetic diversity in H. pylori and for epidemiological purposes.

Systematic review of case-control studies: oral contraceptives show no effect on melanoma risk

BACKGROUND

Parallel to the rising incidence of malignant melanoma in fair-skinned populations, intensive efforts are currently devoted to identifying risk factors for melanoma in addition to the well-known cutaneous factors and those variables related to UV-exposure.

OBJECTIVE

Systematic review of published results to elucidate the role of oral contraceptives in the development of malignant melanoma.

DATA SOURCES

Literature retrieval systems MEDLINE and CANCERLIT as well as reference lists of already collected studies.

STUDY SELECTION

All 18 (non-duplicate) case-control studies on the above relationship.

DATA EXTRACTION

From the published data, study-specific odds ratios (OR) and accompanying confidence intervals (CI) were recalculated. For a quantitative meta-analytical summarisation two different models have been applied: a "fixed effects" (FE) and a "random effects" (RE) model.

DATA SYNTHESIS

Study-specific ORs ranged from 0.13 up to 1.85; however, the majority of studies (14 of 18) yielded similar ORs within the interval [0.82, 1.15]. The summary ORs estimated from FE- and RE-models were both 0.95 (95% CI: [0.87, 1.04] for the FE-model, [0.87, 1.05] for the RE-model).

CONCLUSION

The systematic review of case-control studies revealed no evidence for an aetiological role of oral contraceptives in the development of malignant melanoma.

Cutaneous malignant melanoma in women and the role of oral contraceptives

The role of oral contraceptives (OC) in the aetiology of cutaneous malignant melanoma (CMM) has been controversially discussed over the last two decades. In an extensive literature search we identified 18 case-control studies, published between 1977 and 1996, offering information on this relationship. Using a meta-analytical approach we combined the study-specific risk estimates and derived a summary odds ratio of 0.95 (95% confidence interval: 0.87-1.04). Based on the data of 3796 cases and 9442 controls, we thus found no evidence for an aetiological role of OC use in the development of CMM.

[Fibrosing alveolitis in a 7-year-old girl with autoimmune hemolytic anemia and autoimmune hepatitis]

A Coombs-positive haemolytic anaemia with proof of heat autoagglutinins and autoantibodies against cell nuclei was diagnosed in a girl, now 7 1/2 years of age, in the sixth month of her life as a sequel to jaundice. Shortly afterwards liver biopsy yielded a confirmed diagnosis of giant cell hepatitis. The signs of the disease receded under treatment with decortin and imurek. An attempt to discontinue the medication at 5 1/2 years of age resulted in a histologically confirmed recurrence of autoimmune hepatitis. When the patient was 5 years old, the x-ray revealed a mainly interstitial pneumonia; at 6 years of age, bronchiectases in the region of the left lower lobe were confirmed by bronchography. Resection of the lower lobe was performed after occurrence of atelectasis. Histopathological findings confirmed fibrotic alveolitis associated with giant cells. Based on the overall clinical course and the histological and immunological findings, autoimmune etiology of fibrotic alveolitis must be discussed. Progression of the disease could be avoided during the past 6 months by intensifying the immunosuppressive prednisolone therapy.

Alteration of the lung parenchyma associated with autoimmune hepatitis

The clinical history, radiological and histomorphological alterations of the lung parenchyma associated with chronic active autoimmune hepatitis are described. A 6-month-old female infant developed chronic active autoimmune hepatitis associated with autoimmune haemolytic anaemia. She was treated with immunosuppressive drugs, including steroids, for more than 6 years and developed symptoms and radiological signs of interstitial pneumonitis 4 years after onset of the autoimmune hepatitis. Associated bronchiectasis was detected 1 year later. No abnormalities of lung defence mechanisms could be demonstrated. Resection of the sixth left segment and of the basal parts of the left lower lobe revealed honeycombing with changes in the lung parenchyma which included chronic interstitial pneumonitis with multinucleate giant cells, seen predominantly in the distal airways, marked diffuse interstitial mononuclear infiltrates and mild diffuse interstitial fibrosis as well as bronchiectasis and organizing pneumonia. Granulomatous lesions, angiitis and necrotic areas were absent. Immunohistochemistry for immunoglobulins was negative for IgA, IgG and IgM and positive for IgD in the multinucleate giant cells. A strong positive reaction to HLA-DR-specific monoclonal antibody was noted, whereas no specific sugar receptors (endogenous lectins) could be detected by use of biotinylated glyconeoproteins.

[Fetal and neonatal ascites: a report of 15 cases and a review of the literature]

Fifteen patients with non-immune fetal or neonatal ascites and absence of generalized edema are described. Nine patients were diagnosed prenatally. Nine patients were preterm. Artificial ventilation was necessary in twelve infants immediately after birth. In five cases, including two cases of transitory ascites, the etiology could not be established. In accordance with previous reports, we found the following underlying disorders in our patients: urinary tract obstruction, polycystic disease of the kidneys, chylous ascites, sepsis, intrahepatic atresia of the biliary ducts, hepatic and renal failure following severe asphyxia. 8 out of 15 patients died. A survey of the literature shows a variety of underlying disorders. Therefore, several diagnostic tests are necessary, in order to identify the etiology. Causative treatment is possible in some cases of urogenital , gastrointestinal, infectious and chylous ascites. Sophisticated perinatal management is essential for the outcome of patients with fetal or neonatal ascites; nevertheless the mortality rate is still about 50%.

[Early prognosis of intracranial hemorrhage in premature infants]

Between July 1979 and June 1984 an intracerebral haemorrhage developed in 87 premature infants (mean gestational age 29.5 weeks, mean birth weight 1156g). 46 of these died, 41 infants survived. Their psychomotoric development was followed up to a mean age of 19 months. In 63% of the patients the haemorrhage occurred during the first four days of life. Its frequency was highest in premature infants of 27 to 30 weeks of gestation. The survival rate was influenced by the gestational age and by the grade of haemorrhage. Early complications such as ventricular dilatation, hydrocephalus occlusus and porencephaly were seen especially in very immature infants (less than 31 weeks). The frequency of abnormal psychomotoric development in 55% of these infants contrasts with 13.5% in premature infants (less than 1 500 g) without intracerebral haemorrhage.

[Non-immunologic hydrops fetalis--report of 14 cases and literature review]

With the advent of prenatal diagnosis and the feasibility of intrauterine treatment, non-immune hydrops fetalis (NHIF) is gaining increasing importance. 14 patients are reported 10 of whom having been diagnosed prenatally. 13 were born prematurely severe asphyxia being a frequent occurrence. 7 out of 14 infants survived. In 5 cases no definite etiology could be established. In 7 patients NHIF was attributable to cardiovascular diseases, predominantly associated with brady- or tachycardia. A survey of the literature reveals that etiology remains unidentified in about 40%. For the rest fetal, maternal or placental diseases are the primary causes. The abundance of underlying diseases are operative via three pathophysiological pathways: hemodynamic disturbances, decreased oncotic pressure and increased capillary permeability. By ultrasound examination, NHIF can be detected prenatally permitting intrauterine treatment in selected cases. In combination with improved postnatal management, this might contribute to a better outcome of NIHF which is still associated with a high mortality rate. Meticulous diagnostic work-up facilitates genetic counseling and the pursuit of prenatal diagnosis in subsequent pregnancies.

Intestinal perforation associated with indomethacin treatment in premature infants

Within 9 months we observed intestinal perforations in three very low birth weight (VLBW) infants undergoing indomethacin treatment for symptomatic patent ductus arteriosus (sPDA). The three patients exhibited striking similarities in their clinical courses and predisposing factors. Although clinical and histological criteria did not differentiate the perforations from necrotising enterocolitis (NEC), a well-known entity in premature infants, these events were remarkable to us since we had observed no other cases of NEC in recent years. From animal experiments and pathophysiological data, a role for indomethacin in gastrointestinal ischaemic damage must be considered. This communication is not meant to discredit indomethacin treatment. However, awareness of potential complications and careful monitoring during treatment is warranted.

Urinary excretion rates of 6-keto-PGF1 alpha in preterm infants recovering from respiratory distress with and without patent ductus arteriosus

Patency of the ductus arteriosus in preterm infants is mediated by vasodilating prostanoids; however, reliable methods to monitor prostanoid activity or production in preterm infants are lacking. We measured the excretion rates of major and characteristic urinary metabolites of prostacyclin (PGI2), PGE1, and PGE2, 6-keto-PGF1 alpha, and 7 alpha-hydroxy-5,11-diketotetranorprostane-1,16-dioic acid (PGE-M), respectively. Besides these parameters which reflect total body prostanoid turnover and production, the urinary levels of PGE2 and PGF2 alpha, the primary prostaglandins, were measured as an index of renal prostanoid synthesis. There were four study groups. One contained 11 thriving preterm infants; a second, six preterm infants with respiratory distress syndrome (RDS); a third, 30 preterm infants with RDS and patent ductus arteriosus (PDA); and a fourth, nine fullterm infants. All infants with RDS required artificial ventilation. There were no significant differences in PGE-M, PGE2, and PGF2 alpha excretion rates among the various groups; however, a significant increase of the 6-keto-PGF1 alpha excretion rates was observed in the groups of infants with RDS and with and without PDA (P less than 0.01 and P less than 0.02, respectively). Spontaneous (n = 2) or indomethacin-induced (n = 6) closure of PDA was associated with weaning from the respirator and a concomitant drop into the normal and subnormal range of the excretion rates of 6-keto-PGF1 alpha (P less than 0.01) and PGE-M (P less than 0.02).

Effect of prolonged indomethacin therapy on renal function and selected vasoactive hormones in very-low-birth-weight infants with symptomatic patent ductus arteriosus

Renal function and changes in the activity of selected vasoactive hormones during prolonged indomethacin therapy (1 week) were studied in 11 very-low-birth-weight infants with symptomatic patent ductus arteriosus. The initiation of indomethacin therapy was associated with a reduction in diuresis, a transient decrease in creatinine clearance, and an increase in body weight (P less than 0.01). Furthermore, there was a transient trend toward hyponatremia and hyperkalemia. This acute renal dysfunction was compatible with a complex picture of renal hypoperfusion associated with a fall of plasma renin activity from high levels prior to indomethacin treatment, with a transient rise in the plasma level of arginine vasopressin and with suppressed renal and systemic prostaglandin synthesis. During treatment, an effective circulatory volume was restored by closing the ductus. In parallel, PRA and AVP plasma concentrations returned to nearly normal values. Subsequently, kidney function was not further impaired despite continued indomethacin therapy. These observations suggest that prolonged indomethacin therapy for prevention of sPDA relapse probably constitutes no further risk to kidney function after successful pharmacologically induced ductal constriction.

[Infusion-associated kidney and liver failure in undiagnosed hereditary fructose intolerance]

Appendectomy was performed in a 14 1/2-year-old boy with undiagnosed hereditary fructose intolerance because of chronic recurrent abdominal pain. During and after operation fructose containing solutions were infused. The patient received a total of 250 g fructose intravenously over 30 hours. Hours after onset of infusion he became soporous, hypoglycaemic and acidotic and was anuric after one day. Although the diagnosis was suspected by the end of the first postoperative day and fructose had been cancelled and haemodialysis been started, the boy died after a further 3 days with signs of acute kidney and liver failure. The diagnosis of hereditary fructose intolerance was biochemically established in post mortem liver tissue. This case recalls the fact that fructose, sorbitol or invert sugars should not be added to infusion solutions as they may be toxic for healthy persons and imply a lethal risk for patients with undiagnosed hereditary fructose intolerance, even well beyond the baby and infant period.

[Therapeutic problems with indomethacin in preterm infants with persistent ductus arteriosus]

Inhibition of PGE production in eight preterm infants with persistent ductus arteriosus and respiratory distress syndrome was associated with marked improvement in the respiratory and circulatory function in all of them. However, in six of them this effect was only transient. In the posttreatment period of five and a half days reopening of the ductus arteriosus was frequently associated with increased PGE production and a drop of indomethacin serum levels. Three of these six infants were transferred for surgical ligation and the other three infants were successfully treated with a second course of indomethacin. The margin between closure of the ductus arteriosus and the deterioration of kidney function in preterm infants treated with a presently recommended indomethacin dosage is too narrow. Before an improved therapeutic procedure has been developed indomethacin treatment for the closure of persistent ductus arteriosus should not generally be recommended in preterm infants.

Variability of serum indomethacin concentrations after oral and intravenous administration to preterm infants

Fifteen preterm infants with patent ductus arteriosus and respiratory distress syndrome were given indomethacin (0.2 mg/kg) at 12 h intervals up to three times, either orally or intravenously, in an uncontrolled, non-randomized study. Serum indomethacin concentrations were determined in blood samples taken 12 h after dosing. There was considerable variability in the serum indomethacin concentrations, especially after oral administration, although the mean concentrations after each of the three doses were similar after both oral and intravenous administration. The frequency of closures and transient closures of the ductus arteriosus was also similar for both routes of administration. There was, however, no relation between concentration and effect in individual patients. The sustained exposure to indomethacin which appears to be necessary for ductal closure can sometimes be attained by oral administration.

[Pyrexia during delivery (author's transl)]

Amnionitis with pyrexia during labor and delivery and the perinatal complications of this syndrome are described. In our series the incidence of pyrexia during delivery was 0.54%. In 70 of 83 cases (84%) an intra-uterine infection was assumed to be the cause of the pyrexia. In 13 of 83 cases (16%) an extra-genital infection was the presumed cause. Intra-uterine infections are a grave danger for the mother and the newborn and constitute a severe complication. The mortality in cases with pyrexia during labor and delivery was elevated to 7 of 83 newborns (9%). Rapid delivery and the timely administration of antibiotics in sufficiently high dosages can prevent the manifestations of severe infections. Recommendations for the obstetric management of cases with pyrexia during labor and delivery are given.

[Technique for intraventricular application of antibiotics in bacterial meningitis of the newborn (author's transl)]

A new technique for intraventricular application of antibiotics by means of an indwelling catheter is described for the treatment of bacterial meningitis in the newborn. In cases of neonatal gram-negative meningitis with proven ventriculitis resistant to systemic therapy alone, a ventricular tap is performed. Through the needle an indwelling catheter is inserted into the right lateral ventricle. After removal of the needle the remaining catheter is used for obtaining ventricular fluid for diagnostic purposes as well as for direct intraventricular injection of antibiotics. This catheter can easily be inserted while the child is in the incubator in a neonatal intensive care unit, avoiding neurosurgery. Our present treatment procedure for neonatal meningitis is described.

[Retrolental fibroplasia--a preventable disease? (author's transl)]

Retrolental Fibroplasia has a high incidence in premature infants of low gestational age. The most susceptible period for developing retrolental fibroplasia is the immature vascularisation of the retina during the 28th to 40th gestational week. The disease is caused by the direct effect of oxygen administration. Retrolental fibroplasia is associated with the concentration of oxygen administered and the length of time in supplemental oxygen. There is also a significant association between its development and severe apnea requiring bag and mask resuscitation maintaining ambient oxygen concentration during the procedure. Furthermore there is an association between retrolental fibroplasia and the amount of adult blood transfused. Infants with these factors are at high risk to develop retrolental fibroplasia. Preductal PaO2-level should be kept between 60 and 70 mm Hg and supervised by continuous transcutaneous readings. There is some concern about intermittent arterial sampling. Problems of interpreting PaO2-analyses are discussed. 25 mg Vitamin E are recommended for prevention. There are many management protocols and techniques during neonatal intensive care of premature infants for prevention of the disease. Premature infants at risk should have a close time schedule for ophthalmoscopy.

[Intensive care in pediatrics (author's transl)]

Centralized treatment of critically ill pediatric patients and related problems are presented. Pediatric intensive care allows to overbridge deranged or interrupted organ functions while simultaneously treating the disease causing the disturbance. Its efficiency depends on continuity of medical care. Medical and nursing staff should be trained in the use of specialized equipment, especially monitoring equipment and ventilators. Medical and nursing staff must know who is responsible for the patients all the time. Undivided medical responsibility and coordinated specialist care are essential. Some general points concerning design features, equipment and organisation of a pediatric intensive care unit are made. Some special aspects such as staffing, transportation of high-risk neonates, economy of operation and personal training programm are discussed. Results of pediatric intensive care at the University Children's Hospital Heidelberg are documented. Regionalisation of neonatal care is discussed based on the actuell situation in Baden-Württemberg.

Hemothorax in the newborn

Twenty cases of hemothorax in newborns, including 4 of our own patients, are reviewed in detail. This unusual cause of acute respiratory distress within the neonatal period was observed in 14 males and 6 females. Most of the patients were fullterm newborns. As causal factors hemorrhagic disease of the newborn (vitamin K deficiency), disseminated intravascular coagulation, arteriovenous malformations and pleural/vascular rupture are considered. The time of occurrence of bleeding symptoms ranged from 1 to 28 days of life. Sixteen out of 20 patients survived without sequelae, but in 4 cases the outcome was lethal.

Neonatal respiratory insufficiency due to centronuclear myopathy

Two neonates showing generalized hypotonia, weakness of limbs, trunk, and oral musculature died because of muscular respiratory distress. The diagnosis of centronuclear (or myotubular) myopathy was established by histological and histochemical techniques. The genetic situation and routine laboratory data including electromyography were compared with similar cases in the literature; findings were inconclusive with respect to this diagnosis. These results indicate the need for a muscle biopsy and the use of histochemical stainings and/or electronmicroscopical investigation for a proper diagnosis in hypotonic newborns under respiratory distress after exclusion of etiologies other than neuromuscular diseases. Still the diagnosis of centronuclear myopathy in a neonate does not allow a precise prognosis. Increased awareness of this disorder and adequate diagnostic workup is needed in order to extend our understanding and to clarify the prognosis.

Systemic air embolism in the respiratory distress syndrome of the newborn

Details of 25 cases of neonatal systemic air embolism, including three of our patients, are reviewed. This rare complication of respiratory distress syndrome (RDS) was observed in 21 premature infants and 4 fullterm newborns, of whom 23 required intermittent positive pressure ventilation (IPPV). In 21 of these patients air embolism was preceded by pulmonary interstitial emphysema, pneumomediastinum, pneumothorax and/or pneumopericardium. Air embolism occurred between 3 and 288 hours after delivery. The outcome was lethal in 24 cases, only one patient survived. Two main pathogenic mechanisms are discussed; entrance of air from ruptured alveoli into the lung capillaries and introduction of air via catheters in umbilical vessels.