Validation of outcomes of different levels of neonatal care through the analysis of the relationship between process and outcome of care was attemped as part of an effectiveness study and quality assurance programme. Adequacy rates and outcome measures were calculated for second- and third-level units and centres. according to the babies‘ level of risk. Differences in adequacy rates were apparently Influenced by the differential distribution of babies by care level sectors among maternity centres. The comparison of mortality rates for “treated” and “untreated” subgroups did not show higher mortality rates for the “untreated” subgroups. This finding could be related to the phenomenon of “confounding by indication”. Consistency of differences in average rates of adequacy with differences In general outcomes was observed for most subgroups analysed; lack of consistency could be related to low effectiveness. Indications of low effectiveness related to secondary and more so to tertiary level technologies were observed. The study approach was found more useful for comparisons made at the level of maternity services as a whole, where “confounding by Indication” does not operate than at the level of sectors. ©1997 Elsevier Science Ltd. All rights reserved.

Validation of outcomes through the analysis of the process-outcome relation: limitations.

s of Papers Infections due to Mycoplasma pneumoniae i children. H. H. Bain (introduced), Sheila Stewart (introduced), and H. Simpson. (Royal Hospital for Sick Children, Edinburgh.) The aetiological importance of Mycoplasma pnewnoniae in acute respiratory disorders in children is recognized. Of 112 children with acute respiratory tract infections admitted to a single medical ward at the Royal Hospital for Sick Children, Edinburgh, during the period 1 October 1970 to 31 March 1971, 17 (15%) showed evidence of mycoplasma infection on the basis of blood complement-fixation tests. Positive tests were also obtained in 3 of 30 in-patients with asthma. The clinical, radiological, and epidemiological aspects of these and an additional 30 cases (total 50) were discussed. Neonatal bacteraemia. Margaret G. MacMillan (introduced). (University Department of Child Life and Health, Royal Hospital for Sick Children, Edinburgh.) During an 8-month period (June 1970-January 1971) 215 infants from a total newborn population of 3236 were subjected to blood culture and treated with antibiotics: 92 infants had positive blood cultures. In 38 (49%) positive cultures were from indwelling umbilical vessel catheters and, in 54 (39%) with no catheters, from sagittal sinus blood. Cultures from 38% of the catheter tips after removal grew bacteria. Most infants were treated with cephalexin. Plasma cephalexin concentrations well in excess of 8 ,g/ml were achieved within 2 hours and maintained for longer than 12 hours, after 15 mg/kg body weight orally. 12 infants (9 with umbilical catheters) had positive cultures while having adequate treatment, but septicaemia was a contributory factor in only 2 of 25 deaths recorded and the sole cause in 1. Studies of antibodies to food protein in coeliac disease. F. Carswell (introduced), Anne Ferguson (introduced). (University Department of Child Health, Royal Hospital for Sick Children, Glasgow.) Studies of antibodies to food protein were carried out using precipitin and tanned red cell agglutination tests on the blood and small intestinal secretions of children. Three major groups were studied, viz. those with coeliac disease, those in whom this diagnosis was initially suspected but subsequently rejected, and those without clinical evidence of coeliac disease. 10 food products were tested-gluten, wheat, cornflower, oats, rice, milk, sheep serum, calf serum, egg white, and egg yolk. The children with coeliac disease had a higher incidence of food antibodies in their sera and secretions than the other groups. Many had antibodies to more than one test substance. The antibodies detected in the intestinal secretions were sometimes different from the antibodies in the blood. Though the presence of food antibodies is not pathognomonic of coeliac disease, these tests could be useful in screening for the disease. Food antibodies were found in some patients, subsequently shown to have coeliac disease, who had normal whole blood folate levels or normal barium study appearances. The dystonic syndrome of the low birthweight infant. J. K. Brown and C. M. Drillien. (Royal Hospital for Sick Children, Edinburgh.) It is well documented that low birthweight confers a disadvantage and may result in major mental and neurological handicaps or in minor impairments of behaviour and learning abilities. In assessing the long-term effects of the more aggressive approach to management in special care units, it would obviously be an advantage to be able to diagnose minor cerebral damage or dysfunction before the child reaches school age. During a follow-up study of low birthweight infants, it was found that maturation ofsome infants followed an abnormal pattern. These infants showed an increase in extensor muscle tone and a retention of primitive reflexes, usually up to 8 to 10 months. This extensor dystonia was more common in males, in small-for-dates infants, and in those with congenital malformations. The incidence increased with decreasing birthweight; the earlier it appeared the more likely was it that there would be permanent sequelae. These infants may easily be diagnosed as having severe cerebral palsy in the first months of life, and yet prove to have no sianificant handicap at later ages. Follow-up studies

https://adc.bmj.com/content/archdischild/46/249/739.1.full.pdf

Infections due to Mycoplasma pneumoniae in children.

Sir, Mechanical ventilation with continuous positive airway pressure is used widely for treating neonates with respiratory distress syndrome (RDS). However, mechanical ventilation is frequently accompanied by pulmonary complications. In order to evaluate the pros and cons of the treatment in our hands, we have examined the outcome and pulmonary complications in neonates intubated and artificially ventilated in our Neonatal Intensive Care Unit. Two hundred and fifty-six neonates were investigated between 1980 and 1991. The infants had severe RDS requiring assisted ventilation at 3-6 h of age with FiOz > 0.40 producing Pa02 < 70 mmHg. Neonates with congenital malformations or requiring artificial ventilation owing to other pathologies or treated with surfactant were excluded from the evaluation. Of 256 neonates, 45 died ( 1 7.57%). The mortality rate was higher (30.39%) in the subgroup with pulmonary complications and lower (9.09%) in the group without complications. The complications observed were: pneumothorax (52 cases), interestitial emphysema (43 cases), pneumomediastinum (22 cases), atelectasis (29 cases), pneumonia (26 cases), pulmonary haemorrhage ( 1 1 cases) and bronchopulmonary dysplasia (1 6 cases). The total number of complications observed in 102 infants was 199, as a single infant could develop m0i-e than one complication. Bronchopulmonary dysplasia (BPD) was diagnosed according to the criteria established by the Bureau of Maternal and Child Health and Resources Development ( I ) . The incidence of BPD in our infants was low (6.25%) in comparison with that reported by Van Marter et al. ( 1 7'%)(2), Northway (3 1 %)(3) and Carlo et al. (44'%,)(4). As none of our infants was treated with oxygen for more than 60 days and all had received diuretics o r steroids only in the acute phase of RDS, we believe that limited use of mechanical ventilation (niinima1 FiOz producing PaOz>60 mmHg and minimal insufflation pressure to maintain pH > 7.30 and PaC02 < 50 mmHg) combined with moderate fluid intake (60 ml/kg in the first day of life, increasing by 10 ml/kg/day up to a maximum of 160 ml/kg/day) led to a low incidence of BPD. There was a significant difference ( p < 0.0005) between the mean birth weight of the survivors and that of the non-survivors in both subgroups (with and without complications) (Table I ) . Another important factor for survival was gestational age, which was significantly higher in the survivors (Table 1). There was a significant difference ( p < 0.0005) in the mean inaximum insufflation pressure between neonates without and with complications but no difference between survivors and non-survivors in each of the two subgroups (Table I ) . In conclusion, our results suggest that although mechanical ventilation increased the frequency of pulmonary complications, if used with special precautions, it improves the prognosis in infants a_ffected by RDS and therefore can be considered ,as an effective procedure for treating the disease.

Mechanical ventilation in respiratory distress syndrome.

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Mechanical ventilation in respiratory distress syndrome.