Appearance of sleep cycling after birth in term neonates: an electro-physiologic study.

BACKGROUND: Appearance of sleep cycling has been associated with good outcome in term and preterm infants, but the normal time of its appearance has not been determined. The objectives of this study were, to correlate the time of sleep cycling appearance and the length of quiet sleep in neonates with different degrees of mild perinatal stress. METHODS: Three groups of term infants recorded with aEEG after birth were studied: infants delivered by planned cesarean section (group 1), infants with mild perinatal stress (group 2) and infants with mild neonatal encephalopathy (group 3). Groups were correlated with the appearance and length of quiet sleep. RESULTS: In all, 132 infants were assessed. Quiet sleep appearance differed significantly between groups (p < 0.001). All infants in group 1 developed quiet sleep before the age of 6 h compared to 81% in group 2 and 52% in group 3 (p < 0.001). No differences in the quiet sleep length was found between groups. Belonging to group 3 (p < 0.001) and 1-min Apgar score (p = 0.002) significantly predicted a delay in appearance of the first quiet sleep period. Cesarean delivery significantly predicted an earlier appearance of quiet sleep (p < 0.001). CONCLUSIONS: Appearance of quiet sleep after birth but not its length may be delayed in case of mild perinatal stress.

Risk factors for congenital heart defects in two populations residing in the same geographic area: a long-term population-based study, Southern Israel.

BACKGROUND: Congenital Heart Defects (CHD) are the most common structural defects of newborns. Southern Israel's population is comprised of Jews (75%) and Arab-Bedouins (25%). The latter has a high rate of consanguinity and low abortion rate compared with the Jewish population, which led us to suspect a higher CHD prevalence in this population. Our aim was to compare maternal risk factors that are associated with CHD in these populations. METHODS: All births during 1991-2011 in Soroka University Medical Center (n = 247, 289) with 6078 newborns having CHD were included. To account for same-woman deliveries, general estimating equation models adjusted for ethnicity, gender and birth number were used. RESULTS: The total prevalence of CHD was 24.6/1000 live births, with 21.4 and 30 among Jewish and Bedouin populations, respectively, (p = 0.001). Multi-variant analysis of risk factors for CHD revealed that risk factors common to both populations included conception with fertility medications, sibling CHD, maternal CHD, diabetes mellitus, hypertension and anaemia. Risk factors that were specific for the Bedouin population were - maternal age over 35 years, recurrent pregnancy loss and in vitro fertilisation. However, sibling CHD was more common as a CHD risk factor in the Jewish compared with the Bedouin population (Adjusted OR 10.23 versus 3.19, respectively). CONCLUSIONS: The prevalence of CHD is higher in both the Bedouin and Jewish populations than previously reported. Several maternal factors were associated with CHD specifically for a certain population. Risk factors for CHD vary in populations residing in the same geographic area.

Elevated birth prevalence of conotruncal heart defects in a population with high consanguinity rate.

BACKGROUND: The aetiology of conotruncal heart defects is poorly understood and the birth prevalence varies geographically. The known risk factors for developing conotruncal heart defects are as follows: CHD in siblings, genetic chromosomal abnormalities, paternal age >30 years, high parity, low birth weight, prematurity, and maternal diabetes. OBJECTIVE: The aim of this study was to characterise conotruncal heart defects, birth prevalence, mortality, and morbidity in the population of southern Israel, of whom 75% are Jewish and the rest are mostly Bedouin Arabs. METHODS: The data were obtained from Soroka University Medical Center database of births and newborns. Conotruncal heart defects cases were identified by ICD9 codes. RESULTS: During 1991-2011, there were 247,290 singleton live births and 393 conotruncal heart defects in Soroka University Medical Center. The birth prevalence per 10,000 live births of tetralogy of Fallot, transposition of the great arteries, and truncus arteriosus was 9.5, 5, and 1.8, respectively. In the multivariate analysis, Bedouin descent (adjusted odds ratio 2.40, p35 years (1.66, p=0.004), and siblings with congenital heart defects (1.98, p=0.005) were associated with tetralogy of Fallot, and Bedouin descent (1.61, p=0.05), siblings with congenital heart defects (2.19, p=0.004), and diabetes mellitus (7.15, p<0.001) were associated with transposition of the great arteries. In a univariate analysis, Bedouin descent (p=0.004) and congenital heart defects in siblings (p<0.001) were associated with truncus arteriosus. CONCLUSION: We observed higher birth prevalence of conotruncal heart defects compared with the birth prevalence reported worldwide, specifically among the Bedouins, a population characterised with high consanguinity rate. Therefore, genetic counselling and early fetal echocardiograms should be encouraged, especially in high consanguinity rate populations. Naturally, further educational efforts are needed in order to decrease consanguinity and its related consequences.

Obstructive Sleep Apnea in Acute Stroke: A Role for Systemic Inflammation.

BACKGROUND AND PURPOSE: Sleep-disordered breathing is common among patients with stroke resulting in 4- to 6-fold higher prevalence of obstructive sleep apnea (OSA). We prospectively evaluated clinical characteristics and laboratory markers of inflammation and coagulability associated with OSA severity during the acute post stroke period. METHODS: Consecutive patients admitted to the department of Neurology after an acute ischemic stroke were evaluated during the first 48 hours of symptom onset using Watch peripheral arterial tonometry, a wrist-worn ambulatory sleep study device that utilizes peripheral arterial tonometry. Morning blood samples of the patient were tested for tumor necrosis factor, interleukin-6, and plasminogen activator inhibitor-1 levels. RESULTS: A total of 43 patients with acute stroke were admitted during the study period, 22 (51%) of which have been found to have moderate sleep apnea (apnea hypopnea index [AHI]≥15), AHI≥5 was found in 86% of the patients, and severe OSA (AHI≥30) in 32.5%. Patients with OSA (AHI≥15) did not differ from the rest in stroke severity or symptoms, yet they had higher prevalence of recurrent stroke and atrial fibrillation. All 3 biomarkers levels were higher among patients with AHI≥15: tumor necrosis factor (6.39 versus 3.57 pg/mL), interleukin-6 (6.64 versus 3.14 pg/mL), and plasminogen activator inhibitor-1 (176.64 versus 98.48 pg/mL). After the stratification of AHI into 3 groups (AHI<5, 5-14, and ≥15), the analysis showed that only the highest AHI group differed from the other 2 groups in biomarkers levels. CONCLUSIONS: Use of bed-side somnography technology revealed that in an unselected sample of patients with acute ischemic stroke, almost 90% had sleep-disordered breathing with third having severe form of the disorder. Sleep-disordered breathing was associated with significantly increased levels of inflammatory biomarkers, providing possible pathophysiological explanation of OSA-associated stroke risk. These results warrant prospective screening of patients with stroke for the presence of sleep-disordered breathing and lay the rationale for an interventional trial.

Early onset preeclampsia and cerebral palsy: a double hit model?

BACKGROUND: Cerebral palsy (CP) is a late sequel of pregnancy, and the role of preeclampsia is debatable. OBJECTIVE: The aims of this study were to determine the association between preeclampsia and cerebral palsy and to determine the risk factors for the development of cerebral palsy in these patients. STUDY DESIGN: A retrospective population-based cohort study was designed that included 229,192 singleton pregnancies. The study population was divided into 2 groups: (1) patients with preeclampsia (n = 9749) and (2) normotensive gestations (n = 219,443). Generalized Estimating Equation multiple logistic regression models were performed to study the associations among preeclampsia, small for gestational age, gestational age at delivery, and the risk factors for the development of cerebral palsy in neonates of women with preeclampsia. RESULTS: The rate of cerebral palsy was double in patients with preeclampsia than in the normotensive group (0.2% vs 0.1%; P = .015); early onset preeclampsia and small for gestational age were independent risk factors for the subsequent development of cerebral palsy (odds ratio, 8.639 [95% confidence interval, 4.269-17.480]; odds ratio, 2.737 [95% confidence interval, 1.937-3.868], respectively). A second model was conducted to determine the risk factors for the development of cerebral palsy in women with preeclampsia. Birth asphyxia, complications of prematurity, and neonatal infectious morbidity, but not small for gestational age or gestational age at delivery, were independent risk factors for the development of cerebral palsy. CONCLUSION: In a comparison with normal pregnant women, the rate of cerebral palsy is double among patients with preeclampsia, especially those with early-onset disease. Early-onset preeclampsia is an independent risk factor for cerebral palsy. Among women with preeclampsia, the presence of neonatal infectious morbidity, birth asphyxia, and complications of prematurity are independent risk factors for the development of cerebral palsy, which further supports the role of a multi-hit model in the pathogenesis of this syndrome.

The impact of medical clowns exposure over postoperative pain and anxiety in children and caregivers: An Israeli experience.

While postoperative pain management was shown to reduce unwanted physiological and emotional outcomes, pediatric postoperative pain management remains suboptimal. Medical-clowns were shown to be beneficial in many medical contexts including reduction of stress, anxiety and pain. This study was set to assess the effectiveness of medical-clowns on pediatric postoperative pain reduction. Children age 4 or above, planned for elective hernia repair surgery were recruited. Children were randomly divided to a control or medicalclown escorted groups. Demographical and clinical data were collected using questionnaires and electronic sheets. Children escorted by clowns reported lower levels of pain upon admittance, discharge and 12- hours post-surgery. Statistically significant reduction of parental distress and significantly higher serum cortisol levels were observed in the clown-therapy group. Although small, our study supports the possibility that preoperative medical-clown therapy might be a cheap, safe and yet beneficial method for postoperative pain reduction.

Induction of labor in cases of late preterm isolated oligohydramnios: is it justified?

OBJECTIVES: To analyze in a retrospective cohort study the outcomes of pregnancies with isolated oligohydramnios at the late preterm period (34-36.6 weeks of gestation). STUDY DESIGN: This retrospective cohort study included three groups of women: (1) Women with isolated oligohydramnios whose pregnancy was managed conservatively (n = 33 births); (2) women with isolated oligohydramnios who were managed actively (i.e. induction of labor) (n = 111 births); and (3) a control group including women with normal amount of amniotic fluid who had a spontaneous late preterm delivery (n = 10,445 births). Maternal and fetal characteristics and obstetrics outcomes were collected from a computerized database of all deliveries at Soroka University Medical Center during the study period. RESULTS: Our cohort included 10,589 births. The rate of inducing labor was higher in the oligohydramnios groups compared to the controls (p < .001). There was an increase in the rate of cesarean section (CS) in the conservative treatment group (p < .001), compared with the other groups. Conservative management was associated with higher rates of maternal infection (p = .026), chorioamnionitis (p = .01), and transitory tachypnea of the newborn (p = .02). After controlling for confounding factors, mal presentation (OR = 19.9), and a prior CS (OR = 2.4) were independently associated with an increased risk for CS, while induction of labor was associated with a reduced risk for CS (OR = 0.28). CONCLUSIONS: Women with late preterm isolated oligohydramnios had a higher rate of induction of labor than women with a normal amount of amniotic fluid. Induction of labor seems to be beneficial to both the neonate and the mother as seen by a lower rate of CS conducted in this group, as well as lower maternal and neonatal morbidity in comparison to the conservative group. Therefore, women with oligohydramnios at late preterm may benefit from induction of labor.

Cerebral Palsy-Trends in Epidemiology and Recent Development in Prenatal Mechanisms of Disease, Treatment, and Prevention.

Cerebral palsy (CP) is the most common motor disability in childhood. This syndrome is the manifestation of intrauterine pathologies, intrapartum complications, and the postnatal sequel, especially among preterm neonates. A double hit model theory is proposed suggesting that an intrauterine condition along with intrapartum or postnatal insult lead to the development of CP. Recent reports demonstrated that treatment during the process of preterm birth such as magnesium sulfate and postnatal modalities such as cooling may prevent or reduce the prevalence of this syndrome. Moreover, animal models demonstrated that postnatal treatment with anti-inflammatory drugs coupled with nanoparticles may affect the course of the disease in pups with neuroinflammation. This review will describe the changes in the epidemiology of this disease, the underlying prenatal mechanisms, and possible treatments that may reduce the prevalence of CP and alter the course of the disease.