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Vaccinations and childhood cancer
June 2011 Volume 158 Number 6
Vaccinations and childhood cancer —Sarah S. Long, MD
Initial ventilation of VLBW infants —Alan H. Jobe, MD, PhD
Prediction of oxygen saturation from the capillary refill time —Robert W. Wilmott, M.D.
Copyright ª 2011 by Mosby Inc.
U
sing a novel study design of comparing odds of the childhood cancers with the rates of completion of routine infant-toddler vaccinations on the county level, investigators found what appears to be a protective effect of some vaccinations against childhood cancers, especially acute lymphoblastic leukemia. Biologic plausibility would more likely be based on immunology than protection against infection. With caution attendant to an ecological study, the report provides interest in the pathophysiology of cancer and impetus for further investigation. Article page 996<
U
ntil recently, there has been minimal research focused on how best to initially support ventilation during the birth transition for very low birth weight (VLBW) infants. Reports using animal models clearly demonstrate that these preterm lungs can be injured by high pressures and high tidal volumes. Clinicians are now avoiding high pressures and volumes as best they can. Questions remain about other variables such as the use of continuous positive airway pressure (CPAP), the use of an initial very long inspiratory hold, the initial amount of supplemental oxygen, and the devices for the initial ventilation. These questions exist because the transition of the preterm fluid filled lung to air breathing is a singular and complex series of physiological changes that are not well understood. Reports demonstrate that VLBW infants should receive some supplemental oxygen initially, but not 100% oxygen. A standard of care is evolving for the use of a saturation monitor to track heart rate and oxygen saturation for high risk deliveries. An initial long inspiratory hold will recruit lung gas volumes quickly, but the safety of this approach is unclear. Many clinicians prefer T-piece resuscitators because maximal pressures and CPAP can be delivered more precisely than with self-inflating bags. The assumption has been that CPAP should facilitate lung gas volume recruitment and retention, which should improve oxygenation. In this issue of The Journal, Dawson et al report that ventilation to assist respiratory transition of VLBW infants after birth with a T-piece device improved oxygenation similarly to a self-inflating bag, an unanticipated result. We need to learn more about the transition of the lung to air breathing after birth. Article page 912<
I
t would be very useful to have a way to target resuscitation in patients who do not have a central line, and pediatric advance life support guidelines recommend normalization of the capillary refill time (CRT). In this issue of The Journal, Raimer et al from the University of Michigan Medical School have tested the hypothesis that a normal CRT is associated with superior vena cava oxygen saturations > 70% in critically ill children. The results of a 2-year prospective study show that a CRT < 2 seconds is indeed predictive of superior vena cava oxygen saturations > 70%. This should be a useful clinical target in community hospitals and in the field. Article page 968<
A1
Vaccinations and childhood cancer —Sarah S. Long, MD
Initial ventilation of VLBW infants —Alan H. Jobe, MD, PhD
Prediction of oxygen saturation from the capillary refill time —Robert W. Wilmott, M.D.
Copyright ª 2011 by Mosby Inc.
U
sing a novel study design of comparing odds of the childhood cancers with the rates of completion of routine infant-toddler vaccinations on the county level, investigators found what appears to be a protective effect of some vaccinations against childhood cancers, especially acute lymphoblastic leukemia. Biologic plausibility would more likely be based on immunology than protection against infection. With caution attendant to an ecological study, the report provides interest in the pathophysiology of cancer and impetus for further investigation. Article page 996<
U
ntil recently, there has been minimal research focused on how best to initially support ventilation during the birth transition for very low birth weight (VLBW) infants. Reports using animal models clearly demonstrate that these preterm lungs can be injured by high pressures and high tidal volumes. Clinicians are now avoiding high pressures and volumes as best they can. Questions remain about other variables such as the use of continuous positive airway pressure (CPAP), the use of an initial very long inspiratory hold, the initial amount of supplemental oxygen, and the devices for the initial ventilation. These questions exist because the transition of the preterm fluid filled lung to air breathing is a singular and complex series of physiological changes that are not well understood. Reports demonstrate that VLBW infants should receive some supplemental oxygen initially, but not 100% oxygen. A standard of care is evolving for the use of a saturation monitor to track heart rate and oxygen saturation for high risk deliveries. An initial long inspiratory hold will recruit lung gas volumes quickly, but the safety of this approach is unclear. Many clinicians prefer T-piece resuscitators because maximal pressures and CPAP can be delivered more precisely than with self-inflating bags. The assumption has been that CPAP should facilitate lung gas volume recruitment and retention, which should improve oxygenation. In this issue of The Journal, Dawson et al report that ventilation to assist respiratory transition of VLBW infants after birth with a T-piece device improved oxygenation similarly to a self-inflating bag, an unanticipated result. We need to learn more about the transition of the lung to air breathing after birth. Article page 912<
I
t would be very useful to have a way to target resuscitation in patients who do not have a central line, and pediatric advance life support guidelines recommend normalization of the capillary refill time (CRT). In this issue of The Journal, Raimer et al from the University of Michigan Medical School have tested the hypothesis that a normal CRT is associated with superior vena cava oxygen saturations > 70% in critically ill children. The results of a 2-year prospective study show that a CRT < 2 seconds is indeed predictive of superior vena cava oxygen saturations > 70%. This should be a useful clinical target in community hospitals and in the field. Article page 968<
A1