Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy: Reducing Variability in Practice through a Collaborative Telemedicine Initiative.

OBJECTIVE: This study aimed to assess the viability of implementing a tele-educational training program in neurocritical care for newborns diagnosed with hypoxic-ischemic encephalopathy (HIE) and treated with therapeutic hypothermia (TH), with the goal of reducing practice variation. STUDY DESIGN: Prospective study including newborns with HIE treated with TH from 12 neonatal intensive care units in Brazil conducted from February 2021 to February 2022. An educational intervention consisting of 12 biweekly, 1-hour, live videoconferences was implemented during a 6-month period in all centers. Half of the centers had the assistance of a remote neuromonitoring team. The primary outcome was the rate of deviations from TH protocol, and it was evaluated during a 3-month period before and after the intervention. Logistic regression via generalized estimating equations was performed to compare the primary and secondary outcomes. Protocol deviations were defined as practices not in compliance with the TH protocol provided. A subanalysis evaluated the differences in protocol deviations and clinical variables between centers with and without neuromonitoring. RESULTS: Sixty-six (39.5%) newborns with HIE were treated with TH during the preintervention period, 69 (41.3%) during the intervention period and 32 (19.1%) after intervention. There was not a significant reduction in protocol deviations between the pre- and postintervention periods (37.8 vs. 25%, p = 0.23); however, a decrease in the rates of missing Sarnat examinations within 6 hours after birth was seen between the preintervention (n = 5, 7.6%) and postintervention (n = 2, 6.3%) periods (adjusted odds ratio [aOR]: 0.36 [0.25-0.52], p < 0.001). Centers with remote neuromonitoring support had significantly lower rates of seizures (27.6 vs. 57.5%; aOR: 0.26 [0.12-0.55], p < 0.001) and significant less seizure medication (27.6 vs. 68.7%; aOR: 0.17 [0.07-0.4], p < 0.001). CONCLUSION: This study shows that implementing a tele-educational program in neonatal neurocritical care is feasible and may decrease variability in the delivery of care to patients with HIE treated with TH. KEY POINTS: · Neurocritical care strategies vary widely in low- and middle-income countries.. · Heterogeneity of care may lead to suboptimal efficacy of neuroprotective strategies.. · Tele-education and international collaboration can decrease the variability of neurocritical care provided to infants with HIE..

Measurement properties of the Spinal Appearance Questionnaire in adolescents with idiopathic scoliosis: a systematic review.

BACKGROUND: Scoliosis is defined as a three-dimensional deformity of the spine characterized by lateral tilt and axial rotation of the vertebrae. Its magnitude in the frontal plane is identified by a Cobb angle greater than 10o. The aim of the study was to systematically examine the clinimetric properties of the Spinal Appearance Questionnaire (SAQ) in its cross-cultural adaptations in different languages. METHODS: Medline (PubMed), CINAHL, EMBASE, Science Direct, PsycINFO and WorldWideScience.org databases were used for screening studies until July 16, 2022. In this study, records on the development, evaluation and translation of the SAQ instrument in adolescents with idiopathic scoliosis were included. In addition, two independent reviewers defined whether the studies were eligible and analyzed their psychometric properties of internal consistency, reliability, content validity, cross-cultural validity, construct validity and structural validity, according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). The modified GRADE was applied for evidence synthesis. RESULTS: A total of 95 articles were selected by title and abstract. After removing duplicates and reading and searching the references, a total of 13 studies were included in this review. The original version of the SAQ was described in English, and the instrument was translated into Polish, Canadian French, Simplified Chinese, Spanish (Europe), Danish, Traditional Chinese, Portuguese (Brazil), Korean, German, Turkish and Persian. The evidence was moderate for construct validity, low for internal consistency, and very low for reliability and cross-cultural validity; the content and structural validity properties did not present minimum data for classification. CONCLUSION: The quality of the evidence regarding the clinimetric properties of the SAQ instrument in adolescents with idiopathic scoliosis was low due to the absence of clinimetric properties or dubious methodological quality. However, for clinical practice and research, we recommend the use of the instrument to assess the self-perception of the spine in adolescents. For future translations and adaptations, we recommend the use of the COSMIN guidelines.

Protective measures feasibility for infants of low income SARS-CoV-2 positive breastfeeding mothers: a prospective multicenter cohort study.

AIM: The aim was to evaluate the feasibility of protective measures for infants of low-income SARS-CoV-2 positive breastfeeding mothers. BACKGROUND: Breastfeeding mothers with SARS-CoV-2 positive should avoid exposing the infant through protective measures (PM), but it could be challenging in a low-income population. METHODS: A prospective, multicenter study was conducted between July and October 2020 (BRACOVID). The participants were recruited at birth and interviewed through a structured questionnaire at seven and 14 days in the home environment. The feasibility of PM during breastfeeding at home was defined by guidelines recommendations (mask using, handwashing, and distancing from newborn when not breastfeeding). Three groups according to the feasibility of guidelines: complete guidelines feasibility (CG): all PM; partial guidelines feasibility (PG): at least one PM feasible; no guidelines (NG): infeasibility to all of PM. Flu-like neonatal symptoms, mothers' breastfeeding practices. We evaluated the association between PM feasibility and socioeconomic factors. RESULTS: 117 infected mothers from 17 Brazilian hospitals were enrolled. 47 (40%) mothers followed all recommendations, 14 (11.9%) could not practice at least one recommendation, and 50 (42.7%) did not execute any of them. The breastfeeding rate was 98%. Factors associated with infeasibility were monthly family income < 92.7 dollars/person, high housing density (>1 inhabitant/room), teenage mothers, responsive feeding, and poor schooling. Regarding infants' flu-like symptoms, 5% presented symptoms at fourteen days (NG group). CONCLUSION: The guidelines were not applied to infants of SARs-CoV-positive mothers in 54.6% of the dyads since the recommendations were unviable in their environments. During pandemics, we should look for feasible and effective guidelines to protect neonates from low-income populations. IMPLICATIONS FOR NURSING MANAGEMENT: Poor socioeconomic conditions lead to the unfeasibility of protective measures for infants of low-income SARS-CoV-2 positive breastfeeding mothers during the isolation period in the pandemics. The orientations and the support provided to dyad should consider the socioeconomic factors to guide feasible measures in the home environment and promote adequate protections; only an individual approach will allow a safe environment for low-income infants.

Therapeutic Hypothermia in Brazil: A MultiProfessional National Survey.

OBJECTIVE: To determine the rate of therapeutic hypothermia (TH) use, current practices, and long-term follow-up. STUDY DESIGN: Prospective cross-sectional national survey with 19 questions related to the assessment of hypoxic-ischemic encephalopathy (HIE) and TH practices. An online questionnaire was made available to health care professionals working in neonatal care in Brazil. RESULTS: A total of 1,092 professionals replied, of which 681 (62%) reported using TH in their units. Of these, 624 (92%) provided TH practices details: 136 (20%) did not use any neurologic score or amplitude-integrated electroencephalogram (aEEG) to assess encephalopathy and 81(13%) did not answer this question. Any specific training for encephalopathy assessment was provided to only 81/407 (19%) professionals. Infants with mild HIE are cooled according to 184 (29%) of the respondents. Significant variations in practice were noticed concerning time of initiation and cooling methods, site of temperature measurements and monitoring, and access to aEEG, electroencephalogram (EEG), and neurology consultation. Only 19% could perform a brain magnetic resonance imaging (MRI), and 31% reported having a well-established follow-up program for these infants. CONCLUSION: TH has been implemented in Brazil but with significant heterogeneity for most aspects of hypothermia practices, which may affect safety or efficacy of the therapy. A step forward toward quality improvement is important.

Comparison Between Transcutaneous Electrical Nerve Stimulation and Stabilization Exercises in Fatigue and Transversus Abdominis Activation in Patients With Lumbar Disk Herniation: A Randomized Study.

OBJECTIVE: The purpose of this study was to compare transcutaneous electrical nerve stimulation (TENS) and stabilization exercises in an attempt to prevent fatigue and improve muscle activation in patients with lumbar disk herniation associated with low back pain. METHODS: This study involved 29 patients (age range 25-58 years) randomized into 2 groups: the segmental stabilization group (n = 15), who received stabilization exercises on the transversus abdominis (TrA) and lumbar multifidus muscles; and the TENS group (n = 14), who received electrotherapy. Groups underwent 16 sessions, for 60 minutes, twice per week, and they were evaluated before and after intervention. Pain was measured using a visual analog scale, functional disability using the Oswestry Disability Index, muscle activation and fatigue with electromyography, and patients' ability to contract the TrA with a pressure biofeedback unit. Analyses within and between groups were performed. RESULTS: The stabilization group improved lumbar multifidus fatigue (median frequency [MF] initial [P = .002], MF final [P < .001], MF slope [P = .001], and resistance time [P < .001]), ability to contract the TrA (P < .001), pain (P < .001), and functional disability (P < .001). TENS only was effective for pain (P = .012). CONCLUSION: Although it relieved pain, TENS was not effective as a single treatment to prevent fatigue, increase TrA contraction, and reduce functional disability in herniated disk patients. Stabilization exercises alone improved all measured outcomes.

Are lumbar multifidus fatigue and transversus abdominis activation similar in patients with lumbar disc herniation and healthy controls? A case control study.

PURPOSE: The aims of this study were to assess lumbar multifidus fatigue (LM) and transversus abdominis activation (TrA) in individuals with lumbar disc herniation associated with low back pain. METHODS: Sixty individuals were divided into the lumbar herniation (LHG, n = 30) and control groups (CG, n = 30). Fatigue of the LM was assessed using surface electromyography during the Sorensen effort test, and activation of the TrA with a pressure biofeedback unit. Pain intensity was determined using a visual analog scale and the McGill pain questionnaire. The Oswestry disability questionnaire and the Borg scale for self-evaluating exertion were used to assess functional disability. RESULTS: Fatigue was significantly more intense and the TrA activation was insufficient (p < 0.01) in individuals with disc herniation relative to the control group. The LHG had mild functional disability and moderate pain. There were differences in the initial exertion self-evaluation between groups, which were not observed in the final exertion evaluation. CONCLUSION: Individuals with lumbar disc herniation associated with low back pain have increased fatigue of the LM and decreased activation of the TrA, when compared to the control group.

Postural control in individuals with and without non-specific chronic low back pain: a preliminary case-control study.

STUDY DESIGN: A preliminary case-control study. OBJECTIVE: To assess postural control in individuals with and without non-specific chronic low back pain (cLBP) during quiet standing. cLBP affects 12-33 % of the adult population. Reasons for pain chronicity are yet poorly known. Change in postural control may be a risk factor for cLBP, although available studies are not conclusive. METHODS: Sample consisted of 21 individuals with cLBP and 23 controls without cLBP. Balance was assessed using a force plate (Balance Master, NeuroCom) by the modified clinical test of sensory interaction and balance, pain severity by the visual analogue scale, quality of life with the SF-36 Questionnaire, and functional disability with the Roland-Morris Questionnaire. RESULTS: Groups were homogeneous for age, weight, height and body mass index. Relative to controls, participants in the cLBP group had deficits in the postural control, with greater postural sway in the quiet standing condition with closed eyes closed on unstable surfaces (p < 0.05) for the following parameters: total COP oscillation [cLBP 1,432.82 (73.27) vs CG 1,187.77 (60.30)], root mean square sagittal plane [cLBP 1.21 (0.06) vs CG 1.04 (0.04)], COP area [cLBP 24.27 (2.47) vs CG 16.45 (1.79)] and mean speed of oscillation [cLBP 12.97 (0.84) vs CG 10.55 (0.70)]. CONCLUSION: Postural control, as evidenced by increased oscillation of COP, is impaired in individuals with cLBP relative to controls. Differences are magnified by visual deprivation and unstable surface conditions.

Translation, cross-cultural adaptation and clinimetric properties of the Brazilian Portuguese version of the Brace Questionnaire.

PURPOSE: To perform a cross-cultural adaptation and validation of the Brazilian-Portuguese versions of the Brace Questionnaire in adolescent idiopathic scoliosis. METHODS: A forward-backward translation process was employed to produce a Brazilian Portuguese version of the Brace Questionnaire, followed by comprehensive cross-cultural adaptation stages. The measurements of internal consistency and test-retest reliability were assessed by Cronbach's a and intraclass correlation coefficient (ICC), respectively. The Pearson's correlation coefficient was used to analyze the concurrent validity by comparison with the Scoliosis Research Society-22r questionnaire. RESULTS: A total of 84 scoliosis patients (age 13.4 ± 2.0 years, thoracic Cobb angle 33.3° ± 13.8°, and lumbar Cobb angle 29.8° ± 14.3°) were included. The Brace Questionnaire showed excellent internal consistency (Cronbach α = 0.93) and moderate reliability (ICC = 0.86). The correlations between the Brace Questionnaire and Scoliosis Research Society-22 were r = 0.66; p = 0.011. In addition, it was found that the Brazilian version of the Brace Questionnaire does not have ceiling and floor effects. CONCLUSIONS: The Brazilian-Portuguese adaptation of the brace questionnaire shows excellent reliability and can be a valid tool for psychometric assessment in adolescent idiopathic scoliosis.

Efficacy of graded activity versus supervised exercises in patients with chronic non-specific low back pain: protocol of a randomised controlled trial.

BACKGROUND: Low back pain is a relevant public health problem, being an important cause of work absenteeism worldwide, as well as affecting the quality of life of sufferers and their individual functional performances. Supervised active physical routines and of cognitive-behavioral therapies are recommended for the treatment of chronic Low back pain, although evidence to support the effectiveness of different techniques is missing. Accordingly, the aim of this study is to contrast the effectiveness of two types of exercises, graded activity or supervised, in decreasing symptoms of chronic low back pain. METHODS/DESIGN: Sample will consist of 66 patients, blindly allocated into one of two groups: 1) Graded activity which, based on an operant approach, will use time-contingent methods aiming to increase participants' activity levels; 2) Supervised exercise, where participants will be trained for strengthening, stretching, and motor control targeting different muscle groups. Interventions will last one hour, and will happen twice a week for 6 weeks. Outcomes (pain, disability, quality of life, global perceived effect, return to work, physical activity, physical capacity, and kinesiophobia) will be assessed at baseline, at treatment end, and three and six months after treatment end. Data collection will be conducted by an investigator blinded to treatment allocation. DISCUSSION: This project describes the randomisation method that will be used to compare the effectiveness of two different treatments for chronic low back pain: graded activity and supervised exercises. Since optimal approach for patients with chronic back pain have yet not been defined based on evidence, good quality studies on the subject are necessary. TRIAL REGISTRATION: NCT01719276.

Effect of a telerehabilitation exercise program versus a digital booklet with self-care for patients with chronic non-specific neck pain: a protocol of a randomized controlled trial assessor-blinded, 3 months follow-up.

BACKGROUND: Neck pain is the fourth worldwide leading cause of disability and represents 22% of musculoskeletal disorders. Conservative intervention has been strongly recommended to treat chronic neck pain and Telerehabilitation is the alternative for the treatment of musculoskeletal conditions. There is a lack of high-quality research on the effects of telerehabilitation in patients with neck pain and functional disability. Therefore, this study aims to evaluate the effect of a telerehabilitation exercise program versus a digital booklet only with self-care information in individuals with non-specific chronic neck pain. METHODS: This is a prospectively registered, assessor-blinded, two-arm randomized controlled trial comparing a telerehabilitation exercise program versus a digital booklet with self-care information. Seventy patients will be recruited with non-specific chronic neck pain. Follow-ups will be conducted post-treatment, 6 weeks, and 3 months after randomization. The primary outcome will be disability at post-treatment (6 weeks) measured using neck pain disability. Secondary outcomes will be pain intensity levels, global perceived effect, self-efficacy, quality of life, kinesiophobia, and adherence to treatment. In our hypothesis, patients allocated to the intervention group experience outcomes that are similar to those of those assigned to the self-care digital booklet. Our hypothesis can then be approved or disapproved based on the results of the study. DISCUSSION: This randomized clinical trial will provide reliable information on the use of telerehabilitation to treat patients with chronic non-specific neck pain. TRIAL REGISTRATION: The study was prospectively registered at the Brazilian Registry of Clinical Trials (number: RBR-10h7khvk). Registered on 16 September 2022.

Attitudes and beliefs of Brazilian physical therapists about chronic nonspecific low back pain and its impact on clinical decision-making: An Online Survey Study.

INTRODUCTION: Recent clinical practice guidelines recognize the importance of the biopsychosocial model in the management of patients with chronic nonspecific low back pain, and the attitudes and beliefs of physical therapists are believed to directly influence clinical decision-making. OBJECTIVE: To investigate factors associated to biomedical and biopsychosocial approaches and its impact on attitudes and beliefs to treat patients with chronic nonspecific low back pain. METHOD: This was a cross-sectional study conducted online with 302 Brazilian physiotherapists who treat patients with nonspecific chronic low back pain. The HC-PAIRS and PABS-PT were used to investigate attitudes and beliefs low back pain. Descriptive statistics and bivariate analyses were performed for association tests, comparing the scores on the scales between groups. In addition, multiple linear regression analyses were also used. RESULTS: The overall mean score of HC-PAIRS was 54.0 (9.0), and the biomedical and biopsychosocial factors of PABS-PT were 29.7 (9.0) and 36.2 (5.3), respectively. Significant associations were identified between gender (p = 0.04) and level of academic training (p < 0.00) and both scales, HC-PAIRS and PABSPT, respectively. CONCLUSION: Sociodemographic characteristics were associated with the beliefs of physical therapists; a higher score for treatment options for chronic low back pain based on the biomedical mode, was observed in female physiotherapist and in physios with higher education level. Variables such as age and length of professional experience indicated that the lower the age and/or length of professional experience of Brazilian physical therapists, the stronger the belief in the relationship between low back pain and tissue damage.

Remote Monitoring for Seizures During Therapeutic Hypothermia in Neonates With Hypoxic-Ischemic Encephalopathy.

Importance: Neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH) frequently experience seizures, which are associated with adverse outcomes. Efforts to rapidly identify seizures and reduce seizure burden may positively change neurologic and neurodevelopmental outcomes. Objective: To describe the onset, treatment, and evolution of seizures in a large cohort of newborns with HIE during TH assisted by a telehealth model and remote neuromonitoring approach. Design, Setting, and Participants: This was a prospective, observational, multicenter cohort study performed between July 2017 and December 2021 in 32 hospitals in Brazil. Participants were newborns with HIE meeting eligibility criteria and receiving TH. Data were analyzed from November 2022 to April 2023. Exposure: Infants with HIE receiving TH were remotely monitored with 3-channel amplitude-integrated electroencephalography (aEEG) including raw tracing and video imaging, and bedside clinicians received assistance from trained neonatologists and neurologists. Main Outcomes and Measures: Data on modified Sarnat examination, presence, timing and seizure type, aEEG background activity, sleep-wake cycling, and antiepileptic drugs used were collected. Descriptive statistical analysis was used with independent t test, χ2, Mann-Whitney test, and post hoc analyses applied for associations. Results: A total of 872 cooled newborns were enrolled; the median (IQR) gestational age was 39 (38-40) weeks, 518 (59.4%) were male, and 59 (6.8%) were classified as having mild encephalopathy by modified Sarnat examination, 504 (57.8%) as moderate, and 180 (20.6%) as severe. Electrographic seizures were identified in 296 newborns (33.9%), being only electrographic in 213 (71.9%) and clinical followed by electroclinical uncoupling in 50 (16.9%). Early abnormal background activity had a significant association with seizures. Infants with flat trace had the highest rate of seizures (58 infants [68.2%]) and the greatest association with the incidence of seizures (odds ratio [OR], 12.90; 95% CI, 7.57-22.22) compared with continuous normal voltage. The absence of sleep-wake cycling was also associated with a higher occurrence of seizures (OR, 2.22; 95% CI, 1.67-2.96). Seizure onset was most frequent between 6 and 24 hours of life (181 infants [61.1%]); however, seizure occurred in 34 infants (11.5%) during rewarming. A single antiepileptic drug controlled seizures in 192 infants (64.9%). The first line antiepileptic drug was phenobarbital in 294 (99.3%). Conclusions and Relevance: In this cohort study of newborns with HIE treated with TH, electrographic seizure activity occurred in 296 infants (33.9%) and was predominantly electrographic. Seizure control was obtained with a single antiepileptic drug in 192 infants (64.9%). These findings suggest neonatal neurocritical care can be delivered at remote limited resource hospitals due to innovations in technology and telehealth.

The Impact of Training Time on Understanding the Treatment of Adolescent Idiopathic Scoliosis According to SOSORT International Guidelines: An Online Survey Study.

The lack of knowledge by health professionals in the management of scoliosis can lead to an erroneous diagnosis. The aim of the current study was to understand the influence of length of professional experience on the knowledge of Brazilian physical therapists regarding international guidelines for the treatment of adolescent idiopathic scoliosis. The study was conducted using an online questionnaire consisting of 23 questions, divided into 8 questions on sociodemographic data and 15 questions based on information provided by the guidelines in the SOSORT 2016. In total, 506 physiotherapists were interviewed, and they comprised the study sample. The results showed that professionals who have been working for more than 6 years in the field have greater knowledge of AIS, seek to become more professional, and with that, have an understanding of AIS that is more aligned with the SOSORT. Length of experience made a difference when considering knowledge of the treatment of idiopathic scoliosis. The present study showed that a time since graduation of 6 years or more was satisfactory.

Protecting brains and saving futures guidelines: A prospective, multicenter, and observational study on the use of telemedicine for neonatal neurocritical care in Brazil.

BACKGROUND: Management of high-risk newborns should involve the use of standardized protocols and training, continuous and specialized brain monitoring with electroencephalography (EEG), amplitude integrated EEG, Near Infrared Spectroscopy, and neuroimaging. Brazil is a large country with disparities in health care assessment and some neonatal intensive care units (NICUs) are not well structured with trained personnel able to provide adequate neurocritical care. To reduce this existing gap, an advanced telemedicine model of neurocritical care called Protecting Brains and Saving Futures (PBSF) Guidelines was developed and implemented in a group of Brazilian NICUs. METHODS: A prospective, multicenter, and observational study will be conducted in all 20 Brazilian NICUs using the PBSF Guidelines as standard-of-care. All infants treated accordingly to the guidelines during Dec 2021 to Nov 2024 will be eligible. Ethical approval was obtained from participating centers. The primary objective is to describe adherence to the PBSF Guidelines and clinical outcomes, by center and over a 3-year period. Adherence will be measured by quantification of neuromonitoring, neuroimaging exams, sub-specialties consultation, and clinical case discussions and videoconference meetings. Clinical outcomes of interest are detection of seizures during hospitalization, use of anticonvulsants, inotropes, and fluid resuscitation, death before hospital discharge, length of hospital stay, and referral of patients to specialized follow-up. DISCUSSION: The study will provide evaluation of PBSF Guidelines adherence and its impact on clinical outcomes. Thus, data from this large prospective, multicenter, and observational study will help determine whether neonatal neurocritical care via telemedicine can be effective. Ultimately, it may offer the necessary framework for larger scale implementation and development of research projects using remote neuromonitoring. TRIAL REGISTRATION: NCT03786497, Registered 26 December 2018, https://www.clinicaltrials.gov/ct2/show/NCT03786497?term=protecting+brains+and+saving+futures&draw=2&rank=1.

Newborns at high risk for brain injury: the role of the amplitude-integrated electroencephalography.

OBJECTIVE: Amplitude-integrated electroencephalography (aEEG) is a simplified bedside neurophysiology tool that has been implemented in the neonatal intensive care unit and studied in an extensive range of clinical applications in the past decade. This critical review aimed to evaluate a variety of clinical applications of aEEG monitoring in diagnosis, clinical management, and prognosis assessment in critically ill neonates. SOURCES: The databases of Pubmed, SciELO, Lilacs, and Cochrane, books, and other online resources were consulted, as well as sources of professional experiences. SUMMARY OF FINDINGS: The clinical use of aEEG to access real-time brain function, background activity, and utility in seizures detection has been described. A critical review was realized considering the authors' professional experience. Newborns with hypoxic-ischemic encephalopathy and seizures screening represent the most common studied population. However, several studies have shown interesting applications on preterm infants, newborns with congenital heart disease, and other clinical situations of high risk of injury to the developing brain. CONCLUSION: The aEEG has shown to be a useful non-invasive bedside monitor that aids in evaluating brain function, background activity, and cyclicity. aEEG findings have also demonstrated good prognostic value in a group of critically ill neonates. The aEEG seizure diagnosis capability has limitations, which have been already well established. The use of neonatal brain monitoring such as aEEG was shown to give valuable information in several high-risk clinical situations.

Current Status and Future Directions of Neuromonitoring With Emerging Technologies in Neonatal Care.

Neonatology has experienced a significant reduction in mortality rates of the preterm population and critically ill infants over the last few decades. Now, the emphasis is directed toward improving long-term neurodevelopmental outcomes and quality of life. Brain-focused care has emerged as a necessity. The creation of neonatal neurocritical care units, or Neuro-NICUs, provides strategies to reduce brain injury using standardized clinical protocols, methodologies, and provider education and training. Bedside neuromonitoring has dramatically improved our ability to provide assessment of newborns at high risk. Non-invasive tools, such as continuous electroencephalography (cEEG), amplitude-integrated electroencephalography (aEEG), and near-infrared spectroscopy (NIRS), allow screening for seizures and continuous evaluation of brain function and cerebral oxygenation at the bedside. Extended and combined uses of these techniques, also described as multimodal monitoring, may allow practitioners to better understand the physiology of critically ill neonates. Furthermore, the rapid growth of technology in the Neuro-NICU, along with the increasing use of telemedicine and artificial intelligence with improved data mining techniques and machine learning (ML), has the potential to vastly improve decision-making processes and positively impact outcomes. This article will cover the current applications of neuromonitoring in the Neuro-NICU, recent advances, potential pitfalls, and future perspectives in this field.

Effectiveness of reaching and maintaining therapeutic hypothermia target temperature using low-cost devices in newborns with hypoxic-ischemic encephalopathy.

Therapeutic hypothermia (TH) using servo-controlled cooling devices has proved to be a safe and effective method to reduce mortality and sequelae in neonates with hypoxic-ischemic encephalopathy (HIE). However, such cooling devices can be expensive and have limited availability in low- and middle-income countries. To evaluate the feasibility and effectiveness of low-cost cooling devices (ice packs) to reach and maintain the target temperature in newborns with moderate or severe HIE. Descriptive retrospective cross-sectional study, including newborns with gestational age ≥35 weeks, weight ≥1800 g, with diagnosis of moderate or severe HIE, submitted to whole body hypothermia using ice packs for 72 hr. Data was obtained from medical records and databases. The thermal curves of each patient, time spent at the target temperature and rewarming time were evaluated. Complications directly related to therapeutic hypothermia, evolution, and early outcomes before hospital discharge were analyzed. Seventy-one newborns met the criteria for TH, and 61 completed the entire cooling period and were included in the final analysis. The average time to reach the target temperature was 1.50 ± 1.3 hr. The mean temperature during the cooling period was 33.5°C (±0.62). 82.32% of the measurements were within the target temperature range (from 33 to 34°C). The following adverse events were observed during TH: pulmonary hypertension 11.3%, arrhythmia 4.2%, and coagulopathy 26.7%. Whole body hypothermia using low-cost devices proved to be an effective method in the absence of availability of servo-controlled devices, representing a plausible option in restricted resource settings.

Low Back Pain in Elderly from Belém-Pa, Brazil: Prevalence and Association with Functional Disability.

BACKGROUND: This cross-sectional study aimed to determine the prevalence of low back pain (LBP) in the elderly population living in Belém-Pará and to assess the spectrum of problems related to these diseases including the demographic, socioeconomic, occupational characteristics and disability in this population. METHODS: Three structured questionnaires were applied in a randomly selected representative sample of 512 elderly people aged ≥60 years. RESULTS: LBP prevalence in the elderly population was 55.7%. Among then, 56.1% had pain at the time of the interview (punctual prevalence), 91.7% had LBP in the last 365 days (prevalence in the last year), and 85.3% at some point in life (prevalence at some point in life). Overall, most studies are above average. LBP was positively associated with hypertension and the influence of the physical and mental health on their social activities ranged from slightly to extreme. LBP was negatively associated with characteristics, such as education (over 11 years), class A or B income, physical activity, high satisfaction with previous work, and excellent self-perceived health, corroborating to the literature. CONCLUSIONS: Greater intensity of pain and functional disability were associated with the presence of comorbidities, smoking habits, and low physical activity. LBP prevalence was high, above the national average, mainly affecting the underprivileged classes related to several modifiable factors, highlighting the importance of preventive and interventionist actions for healthy aging.

The impact of coronavirus outbreak on breastfeeding guidelines among Brazilian hospitals and maternity services: a cross-sectional study.

BACKGROUND: The World Health Organization recognizes exclusive breastfeeding a safe source of nutrition available for children in most humanitarian emergencies, as in the current pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Despite the Brazilian national guideline protecting breastfeeding practices, there are many concerns about protecting infants from their infected mothers. This study aimed to analyze how the Brazilian hospitals and maternity services promote and support mothers suspected or diagnosed with coronavirus disease (COVID-19). METHODS: This is a descriptive cross-sectional and multicenter study which collected data from 24 Brazilian hospitals and maternity services between March and July 2020. Representatives of the institutions completed a questionnaire based on acts to promote and support breastfeeding, the Baby-Friendly Hospital Initiative, and Brazil's federal law recommendations. RESULTS: The results showed that in delivery rooms, 98.5% of the services prohibited immediate and uninterrupted skin-to-skin contact between mothers and their infants and did not support mothers to initiate breastfeeding in the first hour. On the postnatal ward, 98.5% of the services allowed breastfeeding while implementing respiratory hygiene practices to prevent transmission of COVID-19. Companions for mothers were forbidden in 83.3% of the hospitals. Hospital discharge was mostly between 24 and 28 h (79.1%); discharge guidelines were not individualized. Additionally, a lack of support was noticed from the home environment's health community network (83.3%). Hospital and home breast pumping were allowed (87.5%), but breast milk donation was not accepted (95.8%). There was a lack of guidance regarding the use of infant comforting strategies. Guidelines specific for vulnerable populations were not covered in the material evaluated. CONCLUSIONS: In Brazil, hospitals have not followed recommendations to protect, promote, and support breastfeeding during the COVID-19 outbreak. The disagreement between international guidelines has been a major issue. The absence of recommendations on breastfeeding support during the pandemic led to difficulties in developing standards among hospitals in different regions of Brazil and other countries worldwide. The scientific community needs to discuss how to improve maternal and infant care services to protect breastfeeding in the current pandemic.

Effectiveness of Manual and Electrical Acupuncture for Chronic Non-specific Low Back Pain: A Randomized Controlled Trial.

BACKGROUND: Low back pain is a common condition that can be effectively treated by acupuncture. However, several treatment point prescriptions and further electrical needle stimulation (i.e., local acupoints, distal acupoints, and sensitized acupoints) may be used. There is an implicit yet unexplored assumption about the evidence on manual and electrical stimulation techniques. OBJECTIVE: The present study aims to identify effectiveness of electroacupuncture (EA) and manual acupuncture (MA) on pain and disability in patients with chronic nonspecific low back. METHODS: This study is a randomized controlled clinical trial. Sixty-six patients between 20 and 60 years of age with non-specific chronic low back pain experiencing low back pain lasting for at least the previous three months and ≥3 points on a 10 numerical analogic scale. Patients diagnosed with chronic LBP were assigned to receive either 12 sessions of MA or EA. The primary outcomes measurements were pain intensity on Numeric Rating Scale and disability by Roland Morris Disability Questionnaire. RESULTS: The participants reported improvements post-treatment to pain intensity and disability respectively; however, no differences between groups were observed. Regarding the secondary outcomes, we observed a between-group difference only for kinesiophobia in favor of the manual acupuncture group (difference = -4.1 points, 95% CI = -7.0 to -1.1). The results were maintained after 3 months of follow-up. CONCLUSION: The study provides evidence that EA is not superior to MA treatment. Both therapies had similar efficacy in reducing pain and disability for chronic nonspecific low back pain.