August 29, 2002
High-Frequency Oscillatory Ventilation in Premature Infants
Respiratory distress is common in premature infants. Many of these infants require mechanical ventilatory support for the first few weeks of life, but the best way to deliver this support is not known. In this randomized trial performed in the United Kingdom, there was no difference between the two ventilatory strategies in terms of survival, the need for oxygen treatment at 28 days of life, or other benefits or complications of ventilation. The risks and benefits associated with high-frequency oscillatory ventilation are not significantly different from those associated with conventional mechanical ventilation in very preterm infants requiring mechanical ventilatory support. The choice of a mode of ventilation for such infants is best guided by the experience of the medical staff caring for the neonate.
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High-Frequency Oscillatory Ventilation for Very-Low-Birth-Weight Infants
This randomized study, performed at multiple centers in the United States, compared high-frequency oscillatory ventilation with synchronized intermittent mandatory ventilation in babies who required mechanical ventilatory assistance. Ventilators were adjusted according to strict validated protocols. Among 234 infants assigned to high-frequency oscillatory ventilation, as compared with 250 assigned to synchronized intermittent mandatory ventilation, a small but significantly greater proportion were alive and not requiring supplemental oxygen at 36 weeks of postmenstrual age (P=0.046); there was no significant difference in the incidence of adverse events between the two groups. This study shows that high-frequency oscillatory ventilation, when delivered in centers experienced with the technique, offers a small advantage over synchronized intermittent mandatory ventilation. In experienced centers, high-frequency oscillatory ventilation offers a small advantage compared to conventional ventilation.
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Nephrogenic Adenomas in Renal-Transplant Recipients
Nephrogenic adenomas are benign growths in the urothelial mucosa that can cause hematuria or dysuria. Their origin is unknown. This detailed study of nephrogenic adenomas from recipients of kidney grafts showed that in all cases the adenoma had the sex chromosomes of the donor kidney and the immunohistochemical features of renal tubular cells. This study provides convincing evidence that the kidney sheds viable tubular cells that can seed the lower urinary tract, where they may grow into tumor-like masses. The authors' suggestion that such adenomas are really renal tubular satellites is both provocative and persuasive.
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Special Article: Insurance Coverage and Outcomes of in Vitro Fertilization
This study assessed associations between state requirements for insurance coverage of in vitro fertilization services and the utilization and outcomes of such services. Fertility clinics in states that required complete coverage performed significantly more in vitro fertilization cycles involving the transfer of fresh embryos than clinics in states that required partial coverage or none. The percentage of cycles that resulted in live births was lower in the states that required complete or partial coverage, but these states also had a lower number of embryos transferred per cycle and a lower rate of pregnancies with three or more fetuses. Mandated insurance coverage for in vitro fertilization is associated with increased utilization of these services, suggesting an unmet need. These data also suggest that financial constraints in states that do not require insurance coverage may result in the transfer of more embryos to maximize the chance of pregnancy, with the attendant risk of high-order multiple gestations.
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Clinical Practice: Adolescent Depression
A 16-year-old boy is brought by his parents to his primary care physician because of a decline in school performance, which began at least three years earlier but has become more severe in the past year. He reports boredom, a lack of enjoyment and motivation, poor selfesteem, a feeling of hopelessness, difficulty sleeping, poor concentration, and passive thoughts of suicide without a plan or intent. How should he be treated? About 5 percent of adolescents have major depression. This article reviews approaches to identifying and treating this disorder.
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