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Biomedical subjects

A R Fleischman

Publications and source records attributed to A R Fleischman.

At least 19 recordsLinked to original sources
PubMed1995

The treatment of non-HIV-related conditions in newborns at risk for HIV: a survey of neonatologists.

OBJECTIVES: The purpose of this study was to examine attitudes of neonatologists about treatment of conditions unrelated to the human immunodeficiency virus (HIV) for critically ill newborns at risk for HIV. METHODS: Questionnaires were mailed to the 1508 members of the Section on Perinatal Medicine of the American Academy of Pediatrics; 63% completed the survey (n = 951). The survey included structured questions about treatment for hypothetical cases and open-ended questions eliciting reasons for decisions. RESULTS: Differences in recommendations for treatment by both maternal and infant HIV status were substantial and statistically reliable. For example, 98% of respondents recommended life-saving cardiac surgery for a neonate with no risk for HIV, but only 93% recommended such surgery for a child of an HIV-positive mother; only 50% recommended the same surgery for a newborn known to be infected. The corresponding figures for chronic dialysis were 91%, 61%, and 26%. Most expected diminished quality of life for both infected and uninfected children of HIV-positive mothers. CONCLUSIONS: Recommendations about life-sustaining treatment for non-HIV-related conditions varied by HIV status. These data on physician attitudes raise the possibility that infants labeled as HIV positive, whether infected or not, may suffer discrimination.

Adult↗
PubMed1994

Caring for gravely ill children.

BACKGROUND: Much has been written about the care of the hopelessly ill adult, but there is little guidance for pediatric health care professionals in the management of children who are critically or terminally ill. METHODS: Through a 3-day meeting in Tarrytown, NY, attended by a group of pediatricians and others directly involved in these issues, a principled approach was developed for the treatment of, and health care decision-making for, children who are gravely ill. RESULTS: The group agreed that the needs and interests of the child must be the central focus of any treatment plan and that the child should be involved to as great extent possible, consistent with developmental maturity, in the decision-making process. Quality of future life should be viewed as being relevant in all decisions. Parents are believed to be the natural guardians of children and ought to have great latitude in making decisions for them. However, parental discretion is not absolute and professionals must maintain an independent obligation to protect the child's interests. CONCLUSIONS: Decision-making should be collaborative among patient, parents, and professionals. When conflict arises, consultation and ethics committees may assist in resolution. When cure or restoration of function is no longer possible, or reasonable, promotion of comfort becomes the primary goal of management. Optimal use of pain medication and compassionate concern for the physical, psychological, and spiritual well-being of the child and family should be the primary focus of the professionals caring for the dying child.

Adolescent↗
PubMed1991

Treatment choice for infants in the neonatal intensive care unit at risk for AIDS.

Many infants admitted to neonatal intensive care units are the children of women infected with the human immunodeficiency virus (HIV); they have approximately a 30% risk of infection. To investigate attitudes surrounding treatment for such newborns, we conducted a survey of professionals at six neonatal intensive care units in New York City. A significant proportion of the 247 respondents recommended less aggressive treatment for non-HIV-related conditions for infants at risk for HIV compared with those not at risk. For example, 97% of respondents recommended open heart surgery for an infant with no known HIV risk but only 77% recommended surgery for an infant whose mother had acquired immunodeficiency syndrome; if certain the infant was infected, 42% of respondents recommended surgery. We conclude that perceived HIV status may influence decision making about treatment for non-HIV-related conditions for critically ill patients, including infants not actually infected. Ethical issues concerning the relevance of HIV status need to be examined.

Acquired Immunodeficiency Syndrome↗
PubMed1991

Gentamicin interval in newborn infants as determined by renal function and postconceptional age.

We evaluated the relationship between gentamicin pharmacokinetics and glomerular filtration rate in newborn infants to estimate the appropriate interval of administration in neonates with renal insufficiency. Gentamicin half-life (Gt1/2) could be predicted from plasma creatinine concentration (PCr) (r = 0.78); the prediction was minimally but significantly increased (r = 0.81) by adding post-conceptional age to a multiple regression analysis. Infants with a postconceptional age of 29 weeks or more and a PCr of 1 mg/dl or more had significantly greater through and peak gentamicin levels than those with a PCr less than 1 mg/dl. If gentamicin is indicated in a patient with renal insufficiency, the interval of administration should be 2-3 Gt1/2, which can be estimated from PCr (Gt1/2 = 2.0 + 7.7 PCr). The interval can then be adjusted according to peak and trough gentamicin levels.

Acute Kidney Injury↗
PubMed1989

Early hyperkalaemia in very low birthweight infants in the absence of oliguria.

We reviewed 1552 admissions to a neonatal intensive care programme; seven, all with a birth weight less than 1500 g, developed early onset, non-oliguric hyperkalaemia (potassium concentration greater than 7.0 mmol/l). Although their perinatal variables were similar to those of a normokalaemic group, hyperkalaemic infants had a higher incidence of intraventricular haemorrhage and developed increased concentrations of plasma creatinine by 7 days of age.

Cerebral Hemorrhage↗
PubMed1988

Rickets of prematurity: controversies in causation and prevention.

Metabolic bone disease in the growing premature infant is an important disorder owing to inadequate intake of calcium or phosphorus over an extended period of time. Prevention of serious bone disease is an important goal in the care of the VLBW infant. Attempts to reproduce intrauterine bone accretion rates in intrauterine life may be unnecessary and may result in potential complications.

Birth Weight↗
PubMed1988

Perinatal law and ethics rounds.

Advances in perinatal medicine have increased the complexity of the clinical decision-making process. Medical education curricula have paid little attention to exploring the ethical and legal aspects of these decisions. In response to this perceived need, we initiated a case-oriented teaching program in perinatal law and ethics. The goals of the program included the following: to develop skills in "moral diagnosis" and analysis (the ability to interpret and analyze clinical cases from a moral point of view); to understand the relevant laws; to appreciate the ethical and legal relationships between the pregnant woman, her fetus, and the professionals; and to encourage open and frank discussion of these important issues. The teaching rounds, led by a lawyer and ethicist, were held monthly, and included all professionals who care for pregnant women and their newborns. A patient was presented in lay language, stressing the ethical or legal issue raised by the case. Cases could be separated into five categories: questions concerning abortion, issues of maternal-fetal conflict, labor management in extreme prematurity or fetal abnormality, innovative therapy, and the psychological concerns of difficult decisions. Careful case analysis with an in-depth discussion of the ethical principles and legal precedents on which decisions are based appears to be an effective and useful educational exercise. This approach to perinatal teaching can prepare professionals to deal with exigent situations that may occur in practice.

Abortion, Induced↗
PubMed1987

Bioethical review committees in perinatology.

Infant bioethical review committees have been proposed as an option to review decisions for critically ill neonates to ensure the best interests of infants. This approach has evolved out of a concern that there have been some wrong decisions made by physicians and parents in which infants have died after treatments were inappropriately withheld or withdrawn. Infant bioethics committees consisting of multidisciplinary professional and lay members will attempt to assure the best interests of infants while maintaining parental discretion concerning decision making in most cases. It is our belief that these committees not only protect the interests of infants who might have treatment inappropriately withheld but also protect the interests of infants who can no longer be benefited by medical intervention. Furthermore, by increasing discussion and deliberation of these complex moral issues, the professional staff will be better able to deal with exigent situations and to provide thoughtful decision making in difficult cases. Finally, the role of the ethics committee will be to provide ethical comfort for staff and family alike in carrying out these difficult decisions for some of the most critically ill patients in our hospitals.

Bioethics↗
PubMed1987

Teaching medical ethics in perinatology.

The past 15 years has seen the resurgence of an interest in biomedical ethics and an awareness of the importance of teaching this discipline in medical curricula at varying levels. Physicians and philosophers can work together to achieve an integration of clinical case material and philosophical theory, in order to teach bioethics optimally. This article describes a clinical program of ethics rounds for residents and fellows training in neonatal and perinatal medicine.

Ethical Analysis↗
PubMed1986

Early neonatal hypocalcemia in extremely preterm infants. High incidence, early onset, and refractoriness to supraphysiologic doses of calcitriol.

Nineteen preterm infants born at or before 32 weeks of gestation were studied to determine the dose of calcitriol that would be effective in the prophylaxis of early neonatal hypocalcemia (serum calcium level, less than 7.0 mg/dL [less than 1.75 mmol/L]). In these infants the course of early neonatal hypocalcemia was not modified by calcitriol administration. Serum 1,25-dihydroxyvitamin D level rose in response to intramuscular administration of calcitriol. The incidence of hypocalcemia in these infants was 37% by 12 hours, 83% by 24 hours, and 89% by 36 hours. Thus, in extremely preterm infants, the incidence of early neonatal hypocalcemia is higher and the onset earlier than in larger preterm infants; furthermore, in these infants the hypocalcemia is refractory even to high doses of calcitriol.

Calcitriol↗
PubMed1986

A simple estimate of glomerular filtration rate in low birth weight infants during the first year of life: noninvasive assessment of body composition and growth.

The management of the preterm infant often requires rapid assessment of glomerular filtration rate (GFR). We sought to develop a screening test using GFR = kL/Pcr, where GFR is expressed as ml/min/1.73 m2, L is body length in centimeters, Pcr is plasma creatinine concentration, and k is a constant that depends on muscle mass. The value for k in 118 appropriate for gestational age preterm infants (0.34 +/- 0.01 SE) was significantly less than that of full-term infants (0.43 +/- 0.02, P less than 0.001). There was no difference between 12- to 24-hour single-injection inulin clearance and either 0.33 L/Pcr or creatinine clearance in preterm infants. We compared the body habitus of preterm and full-term infants using the assessment of muscle mass from urinary creatinine excretion (UcrV) and from upper arm muscle area (AMA) and volume (AMV), and that of fatness from the sum of five skinfold thickness measurements. During the first year of life, premature infants were found to have a lower percentage of muscle mass than term infants did. On the other hand, they took on a relatively greater amount of subcutaneous fat. There was a very good correlation between AMA or AMV and urinary creatinine excretion (r = 0.91 and 0.94, respectively) in 68 infants with heterogeneous body composition during the first year, indicating the validity of the urinary creatinine measurement. Absolute GFR (ml/min) was also well estimated from AMA or AMV factored by Pcr. We conclude that GFR can be well estimated from 0.33 L/Pcr in preterm infants. The lower value for k reflects the smaller percentage of muscle mass in preterm versus term infants. As a screening test, 1.5 X k or 0.05 L/Pcr predicted low values of GFR with an efficiency of 73%, specificity of 67%, and sensitivity of 88%.

Body Composition↗