Early postnatal high-dose fat-soluble enteral vitamin A supplementation for moderate or severe bronchopulmonary dysplasia or death in extremely low birthweight infants (NeoVitaA): a multicentre, randomised, parallel-group, double-blind, placebo-controlled, investigator-initiated phase 3 trial.

BACKGROUND: Vitamin A plays a key role in lung development, but there is no consensus regarding the optimal vitamin A dose and administration route in extremely low birthweight (ELBW) infants. We aimed to assess whether early postnatal additional high-dose fat-soluble enteral vitamin A supplementation versus placebo would lower the rate of moderate or severe bronchopulmonary dysplasia or death in ELBW infants receiving recommended basic enteral vitamin A supplementation. METHODS: This prospective, multicentre, randomised, parallel-group, double-blind, placebo-controlled, investigator-initiated phase 3 trial conducted at 29 neonatal intensive care units in Austria and Germany assessed early high-dose enteral vitamin A supplementation (5000 international units [IU]/kg per day) or placebo (peanut oil) for 28 days in ELBW infants. Eligible infants had a birthweight of more than 400 g and less than 1000 g; gestational age at birth of 32+0 weeks postmenstrual age or younger; and the need for mechanical ventilation, non-invasive respiratory support, or supplemental oxygen within the first 72 h of postnatal age after admission to the neonatal intensive care unit. Participants were randomly assigned by block randomisation with variable block sizes (two and four). All participants received basic vitamin A supplementation (1000 IU/kg per day). The composite primary endpoint was moderate or severe bronchopulmonary dysplasia or death at 36 weeks postmenstrual age, analysed in the intention-to-treat population. This trial was registered with EudraCT, 2013-001998-24. FINDINGS: Between March 2, 2015, and Feb 27, 2022, 3066 infants were screened for eligibility at the participating centres. 915 infants were included and randomly assigned to the high-dose vitamin A group (n=449) or the control group (n=466). Mean gestational age was 26·5 weeks (SD 2·0) and mean birthweight was 765 g (162). Moderate or severe bronchopulmonary dysplasia or death occurred in 171 (38%) of 449 infants in the high-dose vitamin A group versus 178 (38%) of 466 infants in the control group (adjusted odds ratio 0·99, 95% CI 0·73-1·55). The number of participants with at least one adverse event was similar between groups (256 [57%] of 449 in the high-dose vitamin A group and 281 [60%] of 466 in the control group). Serum retinol concentrations at baseline, at the end of intervention, and at 36 weeks postmenstrual age were similar in the two groups. INTERPRETATION: Early postnatal high-dose fat-soluble enteral vitamin A supplementation in ELBW infants was safe, but did not change the rate of moderate or severe bronchopulmonary dysplasia or death and did not substantially increase serum retinol concentrations. FUNDING: Deutsche Forschungsgemeinschaft and European Clinical Research Infrastructures Network (ECRIN).

Investigating environmental transmission to resolve a Bacillus cereus group outbreak in a neonatal intensive care unit using core genome multilocus sequence typing.

BACKGROUND: We analyzed an outbreak of Bacillus cereus group (Bcg) at a single-center neonatal intensive care unit level IV by conducting comprehensive sampling of both patients and the environment. METHODS: Between 06/2020 and 10/2021, all Bcg isolates identified by both regular colonization screening and additional sampling of the environment were subjected to whole-genome sequencing, followed by in vitro extraction of MLST ST, resistance genes and virulence factors. Using publicly available genome sequences, we defined an ad hoc core genome multilocus sequence typing (cgMLST) scheme comprising 2759 target genes for Bcg typing, which we applied to the detected isolates. We have compared the results with a stable cgMLST that was published in the meantime and completed the investigation with a SNP analysis. RESULTS: We analyzed 28 Bcg isolates from patient and environmental samples using MLST and cgMLST. This revealed multiple sequence types, with ST127 being the most common (n = 13). Both cgMLST schemes grouped ten of the 13 ST127 isolates into a cluster, including two invasive isolates from two different patients and several environmental samples. SNP analysis postulated a screen from a ventilation machine as a possible reservoir. CONCLUSION: In sensitive settings such as neonatal intensive care units, considering the environment in outbreak analyses is crucial, especially when investigating potential transmission routes through shared devices. When dealing with widespread bacteria such as Bcg, high-resolution typing techniques are necessary. In this study, we successfully resolved an outbreak of Bcg infections using a custom cgMLST scheme combined with a SNP analysis.

[Influence of Fetomaternal Risk Factors on Mortality and Morbidity in Extremely Preterm Infants]. / Einfluss von fetomaternalen Risikofaktoren auf die Mortalität und Morbidität von Extremfrühgeborenen.

INTRODUCTION: The management of pregnant women at risk of preterm delivery poses a challenge to the interdisciplinary team. At the edge of viability, it is crucial to take into consideration maternal and fetal risk factors when determining individual counseling and therapeutic approaches. METHODS: At a level 4 perinatal center, all preterm infants (PI) born in the years 2017 to 2020 who had a gestational age between 230/7 and 246/7 weeks and were cared for with a curative therapeutic approach were enrolled in a retrospective observational study. Divided into two groups (230/7-236/7 and 240/7-246/7 weeks of gestation), the PI were compared in terms of mortality and morbidity based on maternal and fetal risk factors. Thirteen risk factors and their prognostic relevance for survival were analyzed. RESULTS: 41 mothers with 48 PI were included. 9 neonates received primary palliative treatment and were excluded from the analyses. The survival rates between the two groups (n=21, n=27) showed no significant difference (66.7% versus 74.1%, p=0.750). A significantly higher mortality was observed in PI with an increased number of risk factors (p=0.004), the most severe of which were hypertensive disorders of pregnancy and preterm premature rupture of membranes. Data regarding morbidity showed no significant difference. CONCLUSION: Data regarding mortality correlate with national findings. Observed morbidity in the study population was recorded. The prediction of probability of survival is more precise when risk factors are taken into consideration.

The miRNA transcriptome of cerebrospinal fluid in preterm infants reveals the signaling pathways that promote reactive gliosis following cerebral hemorrhage.

Introduction: Germinal Matrix-Intraventricular Haemorrhage (GM-IVH) is one of the most common neurological complications in preterm infants, which can lead to accumulation of cerebrospinal fluid (CSF) and is a major cause of severe neurodevelopmental impairment in preterm infants. However, the pathophysiological mechanisms triggered by GM-IVH are poorly understood. Analyzing the CSF that accumulates following IVH may allow the molecular signaling and intracellular communication that contributes to pathogenesis to be elucidated. Growing evidence suggests that miRs, due to their key role in gene expression, have a significant utility as new therapeutics and biomarkers. Methods: The levels of 2,083 microRNAs (miRs) in 15 CSF samples from 10 infants with IVH were measured using miRNA whole transcriptome sequencing. Gene ontology (GO) and miR family analysis were used to uncover dysregulated signalling which were then validated in vitro in human foetal neural progenitor cells treated with IVH-CSF. Results: Five hundred eighty-seven miRs were differentially expressed in the CSF extracted at least 2 months after injury, compared to CSF extracted within the first month of injury. GO uncovered key pathways targeted by differentially expressed miRs including the MAPK cascade and the JAK/STAT pathway. Astrogliosis is known to occur in preterm infants, and we hypothesized that this could be due to abnormal CSF-miR signaling resulting in dysregulation of the JAK/STAT pathway - a key controller of astrocyte differentiation. We then confirmed that treatment with IVH-CSF promotes astrocyte differentiation from human fetal NPCs and that this effect could be prevented by JAK/STAT inhibition. Taken together, our results provide novel insights into the CSF/NPCs crosstalk following perinatal brain injury and reveal novel targets to improve neurodevelopmental outcomes in preterm infants.

Preterm birth and neonatal white matter microstructure in in-vivo reconstructed fiber tracts among audiovisual integration brain regions.

Individuals born preterm are at risk of developing a variety of sequelae. Audiovisual integration (AVI) has received little attention despite its facilitating role in the development of socio-cognitive abilities. The present study assessed the association between prematurity and in-vivo reconstructed fiber bundles among brain regions relevant for AVI. We retrieved data from 63 preterm neonates enrolled in the Developing Human Connectome Project (http://www.developingconnectome.org/) and matched them with 63 term-born neonates from the same study by means of propensity score matching. We performed probabilistic tractography, DTI and NODDI analysis on the traced fibers. We found that specific DTI and NODDI metrics are significantly associated with prematurity in neonates matched for postmenstrual age at scan. We investigated the spatial overlap and developmental order of the reconstructed tractograms between preterm and full-term neonates. Permutation-based analysis revealed significant differences in dice similarity coefficients and developmental order between preterm and full term neonates at the group level. Contrarily, no group differences in the amount of interindividual variability of DTI and NODDI metrics were observed. We conclude that microstructural detriment in the reconstructed fiber bundles along with developmental and morphological differences are likely to contribute to disadvantages in AVI in preterm individuals.

Neurologic Outcome Comparison between Fetal Open-, Endoscopic- and Neonatal-Intervention Techniques in Spina Bifida Aperta.

INTRODUCTION: In spina bifida aperta (SBA), fetal closure of the myelomeningocele (MMC) can have a neuroprotective effect and improve outcomes. In Europe, surgical MMC closure is offered by fetal-open (OSBAR), fetal-endoscopic (FSBAR), and neonatal (NSBAR) surgical techniques. Pediatric neurologists facing the challenging task of counseling the parents may therefore seek objective outcome comparisons. Until now, such data are hardly available. In SBA, we aimed to compare neurologic outcomes between OSBAR, FSBAR, and NSBAR intervention techniques. METHODS: We determined intervention-related complications, neuromuscular integrity, and neurologic outcome parameters after OSBAR (n = 17) and FSBAR (n = 13) interventions by age- and lesion-matched comparisons with NSBAR-controls. Neurological outcome parameters concerned: shunt dependency, segmental alterations in muscle ultrasound density (reflecting neuromuscular integrity), segmental motor-, sensory- and reflex conditions, and the likelihood of intervention-related gain in ambulation. RESULTS: Compared with NSBAR-controls, fetal intervention is associated with improved neuromuscular tissue integrity, segmental neurological outcomes, reduced shunt dependency, and a higher chance of acquiring ambulation in ≈20% of the operated children. Children with MMC-lesions with a cranial border at L3 revealed the most likely intervention-related motor function gain. The outcome comparison between OSBAR versus FSBAR interventions revealed no significant differences. CONCLUSION: In SBA, OSBAR- and FSBAR-techniques achieved similar neuroprotective results. A randomized controlled trial is helpful in revealing and compare ongoing effects by surgical learning curves.

Management of Enteral Feeding and Application of Probiotics in Very Low Birth Weight Infants - A National Survey in German NICUs.

BACKGROUND: The advantage of breast milk feeding, and supplementation of probiotics is well known and proven. However, the lack of reliable amounts of colostrum and/or transient breast milk during the first few postnatal days might inhibit timely enteral nutrition. METHODS: The aim of this nationwide survey in German Level-1 neonatal intensive care units (NICUs) was to collect data regarding the management of feeding in the first days of life in very low birth weight infants (VLBWIs, birth weight<1500 g). In addition, we analyzed differences in the use of probiotics. An online survey was sent to all 163 Level-1 NICUs in Germany. RESULTS: 110/163 (67.5%) hospitals participated in our study. One-fifth of all participants used exclusively breast milk. The reported incidence of necrotizing enterocolitis (NEC) was lower in NICUs that exclusively used breast milk in VLBWIs (p=0.08). Two-thirds start enteral feeding independent of gestational age during the first 12 hours postnatally with either breast milk or formula. 80% of all participants checked gastric residuals routinely. The use of probiotics differs widely concerning duration and interruption during antibiotic therapy. CONCLUSION: The exclusive use of breast milk is associated with a lower incidence of NEC. The result of our survey emphasizes the paramount importance of nutrition with mother`s milk. In case of insufficient availability of mother`s milk, the use of human donor milk still appears to be superior to formula feeding. The implementation of human donor milk banks should therefore be promoted.

Management of prolonged meconium evacuation in preterm infants: A survey-based analysis in German Neonatal Intensive Care Units.

AIM: Due to the functional immaturity of bowel motility, a delayed passage frequently requires evacuation of meconium in preterm infants. Often rectal enemas and oral laxatives are used to manage these bowel evacuation disorders. METHODS: An online survey was sent to all 163 high-level Neonatal Intensive Care Units (NICUs) in Germany. The participants were queried on rectal enemas, laxative therapy and outcome incidences. RESULTS: A total of 110/163 (67.5%) hospitals participated in the study. 103/110 (93.6%) participating sites applied rectal enemas in cases of delayed meconium evacuation and 63/110 (57.3%) additionally used oral laxatives. In total, 15 different solutions and 7 different application systems were used for rectal instillation. Preterm infants receiving enemas within the first 48 hours after birth were found to have a significantly lower incidence of FIP (p = 0.006). Altogether 8 different oral laxatives were utilised. CONCLUSION: Therapeutic approaches to the management of prolongated meconium evacuation differ widely among German NICUs. Our survey highlights the diversity of applied substances, means of application and differences in duration and frequency of interventions. Macrogol was commonly used in neonates as an oral laxative despite the lack of approval from the manufacturer.

Plasticity-Related Gene 5 Is Expressed in a Late Phase of Neurodifferentiation After Neuronal Cell-Fate Determination.

During adult neurogenesis, neuronal stem cells differentiate into mature neurons that are functionally integrated into the existing network. One hallmark during the late phase of this neurodifferentiation process is the formation of dendritic spines. These morphological specialized structures form the basis of most excitatory synapses in the brain, and are essential for neuronal communication. Additionally, dendritic spines are affected in neurological disorders, such as Alzheimer's disease or schizophrenia. However, the mechanisms underlying spinogenesis, as well as spine pathologies, are poorly understood. Plasticity-related Gene 5 (PRG5), a neuronal transmembrane protein, has previously been linked to spinogenesis in vitro. Here, we analyze endogenous expression of the PRG5 protein in different mouse brain areas, as well as on a subcellular level. We found that native PRG5 is expressed dendritically, and in high abundance in areas characterized by their regenerative capacity, such as the hippocampus and the olfactory bulb. During adult neurogenesis, PRG5 is specifically expressed in a late phase after neuronal cell-fate determination associated with dendritic spine formation. On a subcellular level, we found PRG5 not to be localized at the postsynaptic density, but at the base of the synapse. In addition, we showed that PRG5-induced formation of membrane protrusions is independent from neuronal activity, supporting a possible role in the morphology and stabilization of spines.

Fiber tracing and microstructural characterization among audiovisual integration brain regions in neonates compared with young adults.

Audiovisual integration has been related with cognitive-processing and behavioral advantages, as well as with various socio-cognitive disorders. While some studies have identified brain regions instantiating this ability shortly after birth, little is known about the structural pathways connecting them. The goal of the present study was to reconstruct fiber tracts linking AVI regions in the newborn in-vivo brain and assess their adult-likeness by comparing them with analogous fiber tracts of young adults. We performed probabilistic tractography and compared connective probabilities between a sample of term-born neonates (N = 311; the Developing Human Connectome Project (dHCP, http://www.developingconnectome.org) and young adults (N = 311 The Human Connectome Project; https://www.humanconnectome.org/) by means of a classification algorithm. Furthermore, we computed Dice coefficients to assess between-group spatial similarity of the reconstructed fibers and used diffusion metrics to characterize neonates' AVI brain network in terms of microstructural properties, interhemispheric differences and the association with perinatal covariates and biological sex. Overall, our results indicate that the AVI fiber bundles were successfully reconstructed in a vast majority of neonates, similarly to adults. Connective probability distributional similarities and spatial overlaps of AVI fibers between the two groups differed across the reconstructed fibers. There was a rank-order correspondence of the fibers' connective strengths across the groups. Additionally, the study revealed patterns of diffusion metrics in line with early white matter developmental trajectories and a developmental advantage for females. Altogether, these findings deliver evidence of meaningful structural connections among AVI regions in the newborn in-vivo brain.

The Role of Health Literacy in Health Behavior, Health Service Use, Health Outcomes, and Empowerment in Pediatric Patients with Chronic Disease: A Systematic Review.

About 8% of all children and adolescents worldwide are affected by chronic diseases. Managing chronic conditions requires pediatric patients to be health literate. The purpose of this review is to examine the existing evidence on the links between health literacy and its outcomes proposed by the model by Sørensen et al. in chronically ill pediatric patients. Four electronic databases (PubMed, Scopus, CINAHL, PsycINFO) were searched to identify pertinent articles published up to November 2021. The search was conducted independently by two researchers and restricted to observational studies. Of 11,137 initial results, 11 articles met eligibility criteria. Overall, 6 studies identified a significant association between health literacy and one of the considered outcomes. Regarding health behavior, none of the studies on adherence found significant associations with health literacy. The results in terms of health service use were inconclusive. Regarding health outcomes, health literacy did not affect most physiological parameters, but it significantly improved health-related quality of life. Overall, evidence remains inconclusive but suggests that health literacy is associated with self-efficacy, health-related quality of life, and health service use in pediatric patients. Further research should be undertaken to strengthen the evidence.

Fluid Supply and Feeding Practices in Cooled Asphyxiated Newborns.

Therapeutic hypothermia (TH) for 72 h is the standard treatment to reduce neurological deficits in term newborns with hypoxic-ischemic encephalopathy. There is a large variability regarding nutritional supply during TH treatment in asphyxiated newborns. We performed a retrospective multicentre study in four level I (highest level of care in Germany) NICUs, including 135 asphyxiated term newborns undergoing TH. We analyzed enteral and parenteral nutritional supply during and after TH. We correlated nutritional supply with risk factors for encephalopathy, pH, Sarnat score, mechanical ventilation, seizures, and sedation. A total of 120 of 135 neonates received enteral nutritional supply within the first 24 h, and the majority of children were fully enterally fed within the first 10 days. The grade of encephalopathy and mechanical ventilation had a significant influence on the amount of enteral fluids (p = 0.01), whereas the pH and appearance of seizures did not affect the amount of nutritional supply significantly. Furthermore, we did not observe any correlation between enteral intake and abdominal complications such as necrotizing enterocolitis. We observed a large variability of feeding regimes in the four participating NICUs. Early enteral feeding among newborns undergoing TH was performed in each NICU and was well tolerated without increased rates of complications.

Population Pharmacokinetics of Intraventricular Vancomycin in Neonatal Ventriculitis, A Preterm Pilot Study.

AIM: Intraventricular vancomycin is an effective treatment for neonatal ventriculitis, as the cerebrospinal fluid (CSF) vancomycin levels reach adequate concentrations to achieve microbiological cure. There is no robust data on intraventricular vancomycin pharmacokinetics in the preterm population. This pilot population pharmacokinetic modelling study examines the pharmacokinetic behaviour of intraventricular vancomycin in the preterm population of < 28 weeks gestation, to inform the feasibility of future prospective studies. METHODS: The study comprised 8 preterm infants with neonatal ventriculitis (median gestation age 25.3 weeks; range 23.9 - 27.7). Population pharmacokinetics (non-linear mixed effects modelling) were described with one- and two-compartment models to fit plasma concentrations of vancomycin. A CSF compartment was added to the plasma modelling and mass transfer examined. Three covariates (serum creatinine, ventricular index (VI) and CSF protein) were tested on the final model. Area under the curve (AUC) and average CSF concentration (C average) predictions were generated from the final model and compared with time to microbiological cure. RESULTS: A one-compartment model provided the best fit to the data. There was no appreciable transfer between plasma and CSF. None of the covariates provided a significant reduction in the objective function value (OFV). Generally, time to sterilisation with higher CSF AUC (0-24) and C average tends to be shorter, however this should be interpreted with caution as data is erratic. CONCLUSION: This pilot population pharmacokinetic analysis provides important information to warrant changes in the management of intraventricular vancomycin treatment in the preterm population, such as the current use of VI as a dosing parameter. Further study with a larger data pool is necessary to investigate the influence of VI on CSF vancomycin and ascertain dosing strategies.

Randomized Controlled Early versus Late Ventricular Intervention Study in Posthemorrhagic Ventricular Dilatation: Outcome at 2 Years.

OBJECTIVE: To compare the effect of intervention at low vs high threshold of ventriculomegaly in preterm infants with posthemorrhagic ventricular dilatation on death or severe neurodevelopmental disability. STUDY DESIGN: This multicenter randomized controlled trial reviewed lumbar punctures initiated after either a low threshold (ventricular index of >p97 and anterior horn width of >6 mm) or high threshold (ventricular index of >p97 + 4 mm and anterior horn width of >10 mm). The composite adverse outcome was defined as death or cerebral palsy or Bayley composite cognitive/motor scores <-2 SDs at 24 months corrected age. RESULTS: Outcomes were assessed in 113 of 126 infants. The composite adverse outcome was seen in 20 of 58 infants (35%) in the low threshold group and 28 of 55 (51%) in the high threshold (P = .07). The low threshold intervention was associated with a decreased risk of an adverse outcome after correcting for gestational age, severity of intraventricular hemorrhage, and cerebellar hemorrhage (aOR, 0.24; 95% CI, 0.07-0.87; P = .03). Infants with a favorable outcome had a smaller fronto-occipital horn ratio (crude mean difference, -0.06; 95% CI, -0.09 to -0.03; P < .001) at term-equivalent age. Infants in the low threshold group with a ventriculoperitoneal shunt, had cognitive and motor scores similar to those without (P = .3 for both), whereas in the high threshold group those with a ventriculoperitoneal shunt had significantly lower scores than those without a ventriculoperitoneal shunt (P = .01 and P = .004, respectively). CONCLUSIONS: In a post hoc analysis, earlier intervention was associated with a lower odds of death or severe neurodevelopmental disability in preterm infants with progressive posthemorrhagic ventricular dilatation. TRIAL REGISTRATION: ISRCTN43171322.

Lycium ruthenicum Murr polysaccharide protects cortical neurons against oxygen-glucose deprivation/reperfusion in neonatal hypoxic-ischemic encephalopathy.

Neonatal hypoxic-ischemic encephalopathy (HIE) is a complex condition that remains the leading cause of mortality and morbidity among infants. Polysaccharide has been reported to possess diverse biological activities, however, the neuro-protective activity of polysaccharide isolated from Lycium ruthenicum remains unknown so far. However, the role of Lycium ruthenicum polysaccharide 3 (LRP3) in HIE has not been evaluated. Herein, we investigated the effect of LRP3 on oxygen-glucose deprivation/reoxygenation (OGD/R)-induced primary cortical neurons. Our results demonstrated that LRP3 significantly improved the cell viability of OGD/R-induced cortical neurons. The OGD/R-caused increase in ROS production and decrease in the activities of anti-oxidative enzymes including catalase (CAT), superoxide dismutase (SOD) and glutathione peroxidase (GPx) were mitigated by LRP3. Besides, the caspase-3 activity in OGD/R-induced cortical neurons was markedly decreased after LRP3 treatment. The increased bax expression and decreased bcl-2 expression caused by OGD/R stimulation were alleviated by pretreatment with LRP3. In addition, LRP3 significantly induced the expressions of nuclear factor erythroid 2-related factor (Nrf2) and heme oxygenase-1 (HO-1) in OGD/R-induced cortical neurons. However, inhibition of Nrf2/HO-1 signaling pathway through transfection with siRNA targeting Nrf2 reversed the protective effects of LRP3. In conclusion, LRP3 exerts a neuroprotective effect against OGD/R-induced neuronal injury in rat primary cortical neurons.

Elevated International Normalized Ratio (INR) is Associated With an Increased Risk of Intraventricular Hemorrhage in Extremely Preterm Infants.

INTRODUCTION: The international normalized ratio (INR), a standardized method of reporting the prothrombin time, can be a surrogate marker of the vitamin K-dependent coagulation pathways. OBJECTIVE: To evaluate the relationship between INR measurements in the first 48 hours of life and subsequent development of intraventricular hemorrhage (IVH) in extremely preterm infants. MATERIALS AND METHODS: A single-center retrospective, observational cohort study of infants born at <28 weeks gestation. The main outcome measure was defined as the degree of IVH seen on cranial ultrasound examinations at day 7 postnatal age. RESULTS: Of 200 infants, 109 (mean gestational age, 25.2 wk [SD, 1.27]) had coagulation results available. Of 109, 26 developed IVH. Elevated INR was associated with increased risk of a severe IVH (odds ratio [OR] 6.50; 95% confidence interval [CI], 1.65-25.62; P=0.008) adjusted for gestation, birth weight, and sex. INR was significantly associated with severe IVH in infants who did not receive blood products (OR, 64.60; 95% CI, 1.35-3081.25; P=0.035), but not in those who did (OR, 2.93; 95% CI, 0.67-12.71; P=0.151) (Pinteraction=0.086). CONCLUSION: An elevated INR in the first 48 hours of life may be useful to identify preterm infants at risk of severe IVH and may guide strategies to prevent the development, or limit the extension, of IVH.