White matter microstructure is differently associated with executive functioning in youth born with congenital heart disease and youth born preterm.

INTRODUCTION: Executive function deficits and adverse psychological outcomes are common in youth with congenital heart disease (CHD) or born preterm. Association white matter bundles play a critical role in higher order cognitive and emotional functions and alterations to their microstructural organization may result in adverse neuropsychological functioning. This study aimed to examine the relationship of myelination and axon density and orientation alterations within association bundles with executive functioning, psychosocial well-being, and resilience in youth with CHD or born preterm. METHODS: Youth aged 16 to 26 years born with complex CHD or preterm at ≤33 weeks of gestational age and healthy controls completed a brain MRI and self-report assessments of executive functioning, psychosocial well-being, and resilience. Multicomponent driven equilibrium single-pulse observation of T1 and T2 and neurite orientation dispersion and density imaging were used to calculate average myelin water fraction (MWF), neurite density index (NDI), and orientation dispersion index values for eight bilateral association bundles. The relationships of bundle-average metrics with neuropsychological outcomes were explored with linear regression and mediation analyses. RESULTS: In the CHD group, lower MWF in several bundles was associated with poorer working memory and behavioral self-monitoring and mediated self-monitoring deficits relative to controls. In the preterm group, lower NDI in several bundles was associated with poorer emotional control and lower MWF in the left superior longitudinal fasciculus III mediated planning/organizing deficits relative to controls. No significant relationships were observed for psychosocial well-being or resilience. CONCLUSION: The findings of this study suggest that microstructural alterations to association bundles, including lower myelination and axon density, have different relationships with executive functioning in youth with CHD and youth born preterm. Future studies should aim to characterize other neurobiological, social, and environmental influences that may interact with white matter microstructure and neuropsychological functioning in these at-risk individuals.

A comparison of altered white matter microstructure in youth born with congenital heart disease or born preterm.

Introduction: Alterations to white matter microstructure as detected by diffusion tensor imaging have been documented in both individuals born with congenital heart disease (CHD) and individuals born preterm. However, it remains unclear if these disturbances are the consequence of similar underlying microstructural disruptions. This study used multicomponent driven equilibrium single pulse observation of T1 and T2 (mcDESPOT) and neurite orientation dispersion and density imaging (NODDI) to characterize and compare alterations to three specific microstructural elements of white matter - myelination, axon density, and axon orientation - in youth born with CHD or born preterm. Methods: Participants aged 16 to 26 years with operated CHD or born ≤33 weeks gestational age and a group of healthy peers of the same age underwent a brain MRI including mcDESPOT and high angular resolution diffusion imaging acquisitions. Using tractometry, average values of myelin water fraction (MWF), neurite density index (NDI), and orientation dispersion index (ODI) were first calculated and compared between groups for 30 white matter bundles. Afterwards, bundle profiling was performed to further characterize the topology of the detected microstructural alterations. Results: The CHD and preterm groups both presented with widespread bundles and bundle segments with lower MWF, accompanied by some occurrences of lower NDI, relative to controls. While there were no differences in ODI between the CHD and control groups, the preterm group presented with both higher and lower ODI compared to the control group and lower ODI compared to the CHD group. Discussion: While youth born with CHD or born preterm both presented with apparent deficits in white matter myelination and axon density, youth born preterm presented with a unique profile of altered axonal organization. Future longitudinal studies should aim to better understand the emergence of these common and distinct microstructural alterations, which could orient the development of novel therapeutic approaches.

Incidence and risk factors for autism spectrum disorder among infants born <29 weeks' gestation.

Objective: This study was aimed to assess the incidence of and risk factors for autism spectrum disorder (ASD) among preterm infants born <29 weeks' gestational age (GA). Methods: A retrospective cohort study of infants born <29 weeks' GA admitted to two tertiary neonatal intensive care units (2009 to 2017) and followed ≥18 months corrected age (CA) at a neonatal follow-up clinic. The primary outcome was ASD, diagnosed using standardized testing or provisional diagnosis at ≥18 months CA. Patient data and 18-month CA developmental outcomes were obtained from the local Canadian Neonatal Follow Up Network database and chart review. Stepwise logistic regression assessed factors associated with ASD. Results: Among 300 eligible infants, 26 (8.7%) were diagnosed with confirmed and 21 (7.0%) with provisional ASD for a combined incidence of 15.7% (95% confidence interval [CI] 11.7 to 20.3). The mean follow-up duration was 3.9 ± 1.4 years and the mean age of diagnosis was 3.7 ± 1.5 years. Male sex (adjusted odds ratio [aOR] 4.63, 95% CI 2.12 to 10.10), small for gestational age status (aOR 3.03, 95% CI 1.02 to 9.01), maternal age ≥35 years at delivery (aOR 2.22, 95% CI 1.08 to 4.57) and smoking during pregnancy (aOR 5.67, 95% CI 1.86 to 17.29) were significantly associated with ASD. Among ASD infants with a complete 18-month CA developmental assessment, 46% (19/41) had no neurodevelopmental impairment (Bayley-III<70, deafness, blindness, or cerebral palsy). Conclusions: ASD is common among infants born <29 weeks' GA and possibly associated with identified risk factors. Such findings emphasize the importance of ASD evaluation among infants <29 weeks' GA and for continued reporting of developmental outcomes beyond 18-months of corrected age.

Coached, Coordinated, Enhanced Neonatal Transition (CCENT): protocol for a multicentre pragmatic randomised controlled trial of transition-to-home support for parents of high-risk infants.

INTRODUCTION: Having an infant admitted to the neonatal intensive care unit (NICU) is associated with increased parental stress, anxiety and depression. Enhanced support for parents may decrease parental stress and improve subsequent parent and child outcomes. The Coached, Coordinated, Enhanced Neonatal Transition (CCENT) programme is a novel bundled intervention of psychosocial support delivered by a nurse navigator that includes Acceptance and Commitment Therapy-based coaching, care coordination and anticipatory education for parents of high-risk infants in the NICU through the first year at home. The primary objective is to evaluate the impact of the intervention on parent stress at 12 months. METHODS AND ANALYSIS: This is a multicentre pragmatic randomised controlled superiority trial with 1:1 allocation to the CCENT model versus control (standard neonatal follow-up). Parents of high-risk infants (n=236) will be recruited from seven NICUs across three Canadian provinces. Intervention participants are assigned a nurse navigator who will provide the intervention for 12 months. Outcomes are measured at baseline, 6 weeks, 4, 12 and 18 months. The primary outcome measure is the total score of the Parenting Stress Index Fourth Edition Short Form at 12 months. Secondary outcomes include parental mental health, empowerment and health-related quality of life for calculation of quality-adjusted life years (QALYs). A cost-effectiveness analysis will examine the incremental cost of CCENT versus usual care per QALY gained. Qualitative interviews will explore parent and healthcare provider experiences with the intervention. ETHICS AND DISSEMINATION: Research ethics approval was obtained from Clinical Trials Ontario, Children's Hospital of Eastern Ontario Research Ethics Board (REB), The Hospital for Sick Children REB, UBC Children's and Women's REB and McGill University Health Centre REB. Results will be shared with Canadian level III NICUs, neonatal follow-up programmes and academic forums. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03350243).

Recovery, as Experienced by Women with Borderline Personality Disorder.

Studies examining recovery through the service users' perspectives have mainly included persons with schizophrenia or bipolar disorder. Giving voice to those with borderline personality disorder (BPD) would enrich our understanding of recovery, as their specific experiences may bring new dimensions, obstacles and facilitators. The objective of this study was to qualitatively capture the experience of recovery in women with BPD. Participants were women between 18 and 65 years old who had a diagnosis of BPD and completed at least 2 years in a program for persons with BPD. During the first meeting, they produced a picture collage, followed by an interview on their experience of recovery. The second meeting was a phone interview to discuss new thoughts. In addition, their medical records were reviewed. A thematic analysis of the interviews was conducted and organized with the Person-Environment-Occupation model. Although recovery was not the best term to name their experience, they all talked about a process towards stability and wellbeing (n = 12). Dimensions of recovery included, for example, letting go of the past (person), being involved in meaningful activities (occupation) and having healthy relationships (environment). Facilitators included social support and participation in a specialized therapy program. The main obstacle was unstable family relationships. The findings from this study showed similar dimensions to previous recovery studies, new perspectives on certain dimensions, as well as new ones. They also reinforced the importance to incorporate intervention outcomes that target the person with BPD, their social environment and meaningful occupations.

Health care professionals' attitudes about pregnancy termination for different fetal anomalies.

BACKGROUND: Health care professionals (HCPs) may be involved in counselling women after an antenatal diagnosis of various fetal anomalies. Many pregnant women consider termination of pregnancy (TOP) after antenatal diagnosis of various fetal anomalies. Little is known, however, about the attitudes of HCPs regarding TOP for specific antenatal diagnoses. OBJECTIVE: To determine the attitudes and opinions of HCPs in maternal and child health regarding TOP for fetal anomalies of varying severity. METHODS: AN ANONYMOUS QUESTIONNAIRE WAS DISTRIBUTED TO FOUR GROUPS OF HCPS: obstetric residents; paediatric residents; delivery room nurses; and neonatal intensive care nurses. Respondents were asked about TOP if they or their spouse were to receive an antenatal diagnosis for five prenatally diagnosed conditions: trisomy 21; trisomy 18; cleft lip and palate; Turner syndrome; and hypoplastic left heart syndrome. RESULTS: Two hundred eighty HCPs answered the questionnaire (90% response rate). Ten per cent of respondents would not consider TOP under any of the circumstances described. Among those who would consider TOP, they were most likely to do so for trisomy 18 and least likely for cleft lip and palate, and fairly evenly divided among the remaining three conditions (hypoplastic left heart syndrome [65%], trisomy 21 [56%] and Turner syndrome [37%]). Paediatric residents were less likely to choose TOP than other groups and obstetrics residents were most likely. CONCLUSIONS: Attitudes of HCPs toward TOP vary according to prenatally identified condition and professional group. More rigorous analysis should be performed regarding the process of counselling and the impact of HCPs beliefs on parental decisions.

HISTORIQUE: Les professionnels de la santé (PS) peuvent conseiller les femmes après un diagnostic anténatal de diverses anomalies fœtales. De nombreuses femmes enceintes envisagent une interruption de grossesse (IdG) après un tel diagnostic. Cependant, on ne sait pas grand-chose des attitudes des PS au sujet des IdG suscitées par des diagnostics anténatals précis. OBJECTIF: Déterminer les attitudes et les opinions de PS qui s'occupent des soins mère-enfant au sujet des IdG suscitées par des anomalies fœtales de diverses gravités. MÉTHODOLOGIE: Les chercheurs ont distribué un questionnaire anonyme à quatre groupes de professionnels de la santé : résidents en obstétrique, résidents en pédiatrie, infirmières en salle d'accouchement et infirmières en soins intensifs néonatals. Ils ont demandé aux répondants s'ils opteraient pour une IdG après qu'eux ou leur conjointe eût reçu un diagnostic anténatal de l'une des cinq pathologies suivantes : trisomie 21, trisomie 18, fissure labiopalatine, syndrome de Turner et hypoplasie du cœur gauche. RÉSULTATS: Deux cent quatre-vingts PS ont répondu au questionnaire (taux de réponse de 90 %). Dix pour cent des répondants n'envisageraient une IdG dans aucune des situations décrites. Les autres étaient plus susceptibles d'y avoir recours en cas de trisomie 18, mais moins en cas de fissure labiopalatine, et ils se répartissaient plutôt également entre les trois autres pathologies (hypoplasie du cœur gauche, 65 %, trisomie 21, 56 %, et syndrome de Turner, 37 %). Les résidents en pédiatrie étaient moins susceptibles d'opter pour les IdG que les autres groupes. Les résidents en obstétrique étaient les plus susceptibles de faire ce choix. CONCLUSIONS: Les attitudes des PS envers l'IdG varient selon la pathologie diagnostiquée pendant la période prénatale et selon le groupe professionnel. Il faudrait effectuer une analyse plus rigoureuse du processus de conseils et des répercussions des convictions des PS sur les décisions parentales.

Relationship between site of training and residents' attitudes about neonatal resuscitation.

OBJECTIVE: To determine whether the attitudes of pediatric and obstetric residents concerning the resuscitation of extremely preterm infants, and their knowledge of outcomes, varies according to their center of training and its resuscitation practices. DESIGN: Anonymous questionnaire. SETTING: Four province of Quebec, Canada, university centers. PARTICIPANTS: A total of 165 pediatric and obstetric residents. INTERVENTIONS: Survey of attitudes about resuscitation of neonates born between 23 and 27 weeks of gestation, and knowledge of the prevalence of cerebral palsy in survivors. MAIN OUTCOME MEASURES: Proportion of residents who would resuscitate a depressed, very preterm infant, and the proportion who overestimated the prevalence of cerebral palsy. RESULTS: The percentage of residents who would resuscitate a depressed infant born at 24 weeks varied from 11% to 39% between centers, at 25 weeks between 26% and 69%, and at 26 weeks between 51% and 86%. At the center most likely to intervene for very immature infants, the greatest proportion of residents favored resuscitation at each gestational age. At the least interventionist center, the smallest proportion would resuscitate. The center of training was the only factor related to willingness to resuscitate at 24, 25, 26, and 27 weeks of gestation; not age, years of training, religion, sex, or parental status (whether the person surveyed has children). A total of 53% of residents thought the prevalence of cerebral palsy was 25% or 40% in this population. Residents with a more accurate knowledge of outcome were more likely to want to resuscitate very immature infants. CONCLUSION: Different treatment centers may develop their own ethos regarding resuscitation, which then shapes both the way the residents understand epidemiological data and how they make decisions.

Clinical predictors of positive urine cultures in young children at risk for urinary tract infection.

BACKGROUND: Urinary tract infections (UTIs) are a common source of bacterial infection among young febrile children. The diagnosis of UTI is challenging because the clinical presentation is not specific. OBJECTIVE: To describe clinical predictors to identify young children needing urine culture for evaluation of UTI. METHODS: Retrospective cohort study of all children younger than two years of age (719 hospital visits for 545 patients) suspected of having a UTI during a 12-month period. The outcome was UTI, defined as a catheterized urine culture with pure growth of 104 colonies/mL or greater, or suprapubic aspiration culture with 10³ colonies/mL or greater. Candidate predictors included demographic, historical and physical examination variables. RESULTS: The medical records of 545 children younger than two years of age were reviewed. Forty-six per cent were girls. Mean age was 9.1 months (SD 7 months). Four variables were found to predict UTI: absence of another source of fever on examination (odds ratio [OR]=41.6 [95% CI, 8.8 to 197.4]), foul smelling urine (OR=19.7 [95% CI, 5.7 to 68.2]), white blood cell count greater than 15,000/mm³ (OR=4.3 [95% CI, 2.0 to 9.3]), younger than six months old (OR=3.1 [95% CI, 1.3 to 7.1]). The sensitivity of an abnormal urine analysis was 0.77 (95% CI, 0.66 to 0.88) and the specificity was 0.31 (95% CI, 0.2 to 0.42). CONCLUSION: An incremental increase in risk for UTI is associated with younger age (younger than six months), having a white blood cell count higher than 15,000/mm³, parental report of malodorous or foul smelling urine and the absence of an alternative source of fever. In the present patient population, obtaining a urine culture from children with at least one of these clinical predictors would have resulted in missing one UTI (2%), and 111 negative cultures (20%) would have been avoided.