'Baby Liberation' - Developing and implementing an individualised, developmentally-supportive care bundle to critically unwell infants in an Australian Paediatric Intensive Care Unit.

BACKGROUND: Infants requiring high acuity care within a Paediatric Intensive Care Unit are at multifactorial risk of neurological injury to the immature brain, resulting in long-term developmental difficulties. In 2020, Queensland Children's Hospital implemented an individualised family-centred developmental care program, 'Baby Liberation', to address an identified service gap for critically unwell infants, aimed at optimising early neuroprotective strategies and minimising risk of suboptimal developmental outcomes. AIM: To implement Baby Liberation for infants admitted to a quaternary paediatric intensive care referral centre. Secondary aims were to describe environmental changes, enablers and limitations related to implementation. STUDY DESIGN: A single-centre, prospective implementation pilot study investigated the feasibility of implementing Baby Liberation. Subjects included infants less than six months of age admitted to Queensland Children's Hospital Paediatric Intensive Care Unit. OUTCOME MEASURES: Primary measures comprised data collected during the implementation period, including number of eligible patients and number of developmental care plans provided. Environmental audit data were collected pre and post implementation to inform secondary outcomes. RESULTS: Baby Liberation was feasibly implemented into the Queensland Children's Hospital Paediatric Intensive Care Unit. During implementation, 181 individualised care plans were provided to 313 eligible infants (57.8 %). Environmental audits showed improvements in all areas of developmental care, with greatest improvements noted in pain and stress management (+95 %) and staff support and development (+83.3 %). CONCLUSION: Implementation of Baby Liberation was feasible within a large quaternary paediatric intensive care unit and has potential to be expanded into other clinical areas providing acute infant care.

Congenital Heart Disease Long-term Improvement in Functional hEalth (CHD LIFE): A partnership programme to improve the long-term functional health of children with congenital heart disease in Queensland.

Children who undergo open-heart surgery in the first year of life for congenital heart disease (CHD) are at high-risk for impaired development across multiple domains. International recommendations include systematic periodic developmental surveillance into adolescence and the establishment of long-term follow-up programmes. This article describes the establishment and evolution of the Queensland Paediatric Cardiac Service neurodevelopmental follow-up programme - CHD LIFE (Long-term Improvement in Functional hEalth). Contextualising best practice recommendations to ensure a family-centred and sustainable approach to understand and support the long-term functional health needs of high-risk children with CHD as standard care was needed. We describe the transition from a centralised pilot Programme to the implementation of an integrated statewide approach aimed at delivering consistent high-level standards of care and a platform to evaluate therapeutic interventions.

The Young Canadians Roundtable on Health: promising practices for youth and adults working in partnership.

SETTING: Canadian youth (aged 15-29 years) are more diverse, educated, connected and socially engaged than ever before. However, many face health-related challenges, including mental health problems (10-20%), substance use concerns (14%) and obesity (45%). INTERVENTION: The Young Canadians Roundtable on Health (YCRH) was created in 2013 to be Canada's youth voice on health. Supported by the Sandbox Project, this youth-led advisory works primarily virtually, leading advocacy projects and wide-ranging health initiatives. OUTCOMES: Youth and adult allies engaged in a participatory research evaluation of the YCRH, which was identified as a living laboratory, where youth could experiment with ideas and provide new perspectives on health issues. Adult allies reported learning new skills from youth, and youth gained advocacy and leadership skills. Collaborative projects resulted in a sense of shared achievement. Further, youth increased their connections to health and youth-serving spaces across the country. Identified challenges included difficulties in coordinating a national roundtable and defining shared responsibilities. IMPLICATIONS: The researchers generated the following evidence-based promising practices for youth engagement in health systems and program planning: (1) provide a consistent platform for youth input; (2) appreciate different forms of knowledge, expertise and communication methods; (3) invest in relationships and build mutual understanding among youth and adults; (4) for adult allies, be patient and comfortable with the ambiguity and unpredictability of working with youth; and (5) continually revisit and renegotiate structure and flexibility.

Neuromotor performance in infants before and after early open-heart surgery and risk factors for delayed development at 6 months of age.

BACKGROUND: Early identification of infants with CHD at heightened risk of developmental delays can inform surveillance priorities. This study investigated pre-operative and post-operative neuromotor performance in infants undergoing open-heart surgery, and their developmental status at 6 months of age, to identify risk factors and inform care pathways. METHODS: Infants undergoing open-heart surgery before 4 months of age were recruited into a prospective cohort study. Neuromotor performance was assessed pre-operatively and post-operatively using the Test of Infant Motor Performance and Prechtl's Assessment of General Movements. Development was assessed at 6 months of age using the Ages and Stages Questionnaire third edition. Pre-operative and post-operative General Movements performance was compared using McNemar's test and test of infant motor performance z-scores using Wilcoxon's signed rank test. Risk factors for delayed development at 6 months were explored using logistic regression. RESULTS: Sixty infants were included in this study. In the 23 (38%) infants. A total of 60 infants were recruited. In the 23 (38%) infants assessed pre-operatively, there was no significant difference between pre- and post-operative performance on the GMs (p=0.63) or TIMP (p=0.28). At discharge, 15 (26%) infants presented with abnormal GMs, and the median TIMP z-score was -0.93 (IQR: -1.4 to -0.69). At 6 months, 28 (52.8%) infants presented with gross motor delay on the ASQ-3, significantly negatively associated with gestational age (p=0.03), length of hospital stay (p=0.04) and discharge TIMP score (p=0.01). CONCLUSIONS: Post-operative assessment using the GMs and TIMP may be useful to identify infants requiring individualised care and targeted developmental follow-up. Long-term developmental surveillance beyond 6 months of age is recommended.

Clinical feasibility of pre-operative neurodevelopmental assessment of infants undergoing open heart surgery.

AIM: Assessing the neurodevelopmental status of infants with congenital heart disease before surgery provides a means of identifying those at heightened risk of developmental delay. This study aimed to investigate factors impacting clinical feasibility of pre-operative neurodevelopmental assessment of infants undergoing early open heart surgery. METHODS: Infants who underwent open heart surgery prior to 4 months of age participated in this cross-sectional study. The Test of Infant Motor Performance and Prechtl's Assessment of General Movements were undertaken on infants pre-operatively. When assessments could not be undertaken, reasons were ascribed to either infant or environmental circumstances. Demographic data and Aristotle scores were compared between groups of infants who did or did not undergo assessment. Binary logistic regression was used to explore associations. RESULTS: A total of 60 infants participated in the study. Median gestational age was 38.78 weeks (interquartile range: 36.93-39.72). Of these infants, 37 (62%) were unable to undergo pre-operative assessment. Twenty-four (40%) could not complete assessment due to infant-related factors and 13 (22%) due to environmental-related factors. For every point increase in the Aristotle Patient-Adjusted Complexity score, the infants likelihood of being unable to undergo assessment increased by 35% (odds ratio: 0.35; 95% confidence interval: 1.03-1.77, P = 0.03). CONCLUSION: Over half of the infants undergoing open heart surgery were unable to complete pre-operative neurodevelopmental assessment. The primary reason for this was infant-related medical instability. Findings suggest further research is warranted to investigate whether the Aristotle Patient-Adjusted Complexity score might serve as an indicator to inform developmental surveillance with this medically fragile cohort.

Shared white matter alterations across emotional disorders: A voxel-based meta-analysis of fractional anisotropy.

BACKGROUND: White matter (WM) integrity may represent a shared biomarker for emotional disorders (ED). Aims: To identify transdiagnostic biomarkers of reduced WM by meta-analysis of findings across multiple EDs. METHOD: Web of Science was searched systematically for studies of whole brain analysis of fractional anisotropy (FA) in adults with major depressive disorder, bipolar disorder, social anxiety disorder, obsessive-compulsive disorder or posttraumatic stress disorder compared with a healthy control (HC) group. Peak MNI coordinates were extracted from 37 studies of voxel-based analysis (892 HC and 962 with ED) and meta-analyzed using seed-based d Mapping (SDM) Version 4.31. Separate meta-analyses were also conducted for each disorder. RESULTS: In the transdiagnostic meta-analysis, reduced FA was identified in ED studies compared to HCs in the left inferior fronto-occipital fasciculus, forceps minor, uncinate fasciculus, anterior thalamic radiation, superior corona radiata, bilateral superior longitudinal fasciculi, and cerebellum. Disorder-specific meta-analyses revealed the OCD group had the most similarities in reduced FA to other EDs, with every cluster of reduced FA overlapping with at least one other diagnosis. The PTSD group was the most distinct, with no clusters of reduced FA overlapping with any other diagnosis. The BD group were the only disorder to show increased FA in any region, and showed a more bilateral pattern of WM changes, compared to the other groups which tended to demonstrate a left lateralized pattern of FA reductions. CONCLUSIONS: Distinct diagnostic categories of ED show commonalities in WM tracts with reduced FA when compared to HC, which links brain networks involved in cognitive and affective processing. This meta-analysis facilitates an increased understanding of the biological markers that are shared by these ED.

Are individual differences in appetitive and defensive motivation related? A psychophysiological examination in two samples.

Appetitive and defensive motivation account for a good deal of variance in personality and mental health, but whether individual differences in these systems are correlated or orthogonal has not been conclusively established. Previous investigations have generally relied on self-report and have yielded conflicting results. We therefore assessed the relation between psychophysiological indices of appetitive and defensive motivation during elicitation of these motivational states: specifically, frontal electroencephalogram asymmetry during reward anticipation and startle response during anticipation of predictable or unpredictable threat of shock. Results in a sample of psychopathology-free community members (n=63), an independent sample of undergraduates with a range of internalising symptoms (n=64), and the combination of these samples (n=127) revealed that differences in responding to the two tasks were not significantly correlated. Average coefficients approached zero in all three samples (community: .04, undergraduate: -.01, combined: .06). Implications of these findings for research on normal and abnormal personality are discussed.

Does anxiety sensitivity correlate with startle habituation? An examination in two independent samples.

Individuals with anxiety disorders have previously demonstrated abnormal habituation to aversiveness over time. As anxiety sensitivity (AS), or an individuals' propensity to fear of anxiety-related sensations, has been shown to be a risk factor for anxiety disorders (particularly panic disorder), the present study examined whether AS was also associated with abnormal habituation. This association was examined in two independent samples of undergraduates (Ntotal=178). Habituation was operationalised as the reduction in startle response to multiple startle probes presented over 2.5 minutes and three definitions of this reduction were employed. Results indicated that individuals with higher levels of AS evidenced deficits in startle habituation, but the strength of this relationship was somewhat dependent on the definition of startle habituation, with the most robust definition being an analysis of participants' individual slopes across all nine blinks. The present findings suggest that startle habituation is a key mechanism underlying AS, and may help elucidate the role this risk factor plays in the pathogenesis of anxiety disorders.

The relation between symptoms of bulimia nervosa and obsessive-compulsive disorder: a startle investigation.

Bulimia nervosa (BN) and obsessive-compulsive disorder (OCD) co-occur at greater rates than chance and may have shared mechanisms of dysfunction. One of these proposed mechanisms is a hyper-responsive aversive system as indicated by heightened startle response to aversive stimuli. The present study examined this hypothesis using 2 types of aversive stimuli: disorder specific (e.g., high-caloric food pictures for BN, contamination pictures for OCD) and nondisorder specific (e.g., knife). Temporal parameters of aversive responding were also examined by assessing startle response in anticipation of and following picture presentation. The sample consisted of 114 undergraduate women selected to have a broad range of BN and/or OCD symptomatology. OCD symptoms were associated with increased startle potentiation during the anticipation and presentation of contamination pictures, and BN symptoms were associated with increased startle potentiation during disorder-related contamination pictures (e.g., sink, toilet). BN symptoms were also associated with increased startle potentiation during and following the presentation of food pictures (though the former effect was only a trend). Additionally, the interaction of BN and OCD symptoms was associated with elevated startle responding during the presentation of contamination and threat stimuli. Overall, the present study provides evidence that BN and OCD symptoms are associated with heightened aversive responding to disorder-specific stimuli, and comorbid BN and OCD symptoms are associated with heightened aversive responding across disorder-specific and nonspecific aversive stimuli. Clinical and theoretical implications are discussed.

Biomarkers of threat and reward sensitivity demonstrate unique associations with risk for psychopathology.

Two emotional/motivational constructs that have been posited to underlie anxiety and depressive disorders are heightened sensitivity to threat and reduced sensitivity to reward, respectively. It is unclear, though, whether these constructs are only epiphenomena or also connote risk for these disorders (and relatedly, whether they connote risk for separate disorders). Using family history of psychopathology as an indicator of risk, the present study examined whether biomarkers of sensitivity to threat (startle potentiation) and reward (frontal EEG asymmetry) were associated with similar or different familial liabilities. In addition, the present study examined whether these biomarkers were associated with risk independent of proband DSM-IV diagnosis. One-hundred and seventy-three individuals diagnosed with panic disorder (PD), early onset major depressive disorder (MDD), both (comorbids), or controls completed two laboratory paradigms assessing sensitivity to predictable/unpredictable threat (measured via startle response) and reward (measured via frontal EEG asymmetry during a gambling task). Results indicated that across all participants: (a) startle potentiation to unpredictable threat was associated with family history of PD (but not MDD); and (b) frontal EEG asymmetry while anticipating reward was associated with family history of MDD (but not PD). Additionally, both measures continued to be associated with family history of psychopathology after controlling for proband DSM-IV diagnosis. Results suggest that the proposed biomarkers of sensitivity to unpredictable threat and reward exhibit discriminant validity and may add to the predictive validity of the DSM-IV defined constructs of PD and MDD, respectively.

Relation between Respiratory Sinus Arrythymia and Startle Response during Predictable and Unpredictable Threat.

Research suggests that lower respiratory sinus arrhythmia (RSA) is associated with greater aversive responding. One physiological indicator of aversive responding is startle potentiation. While a few studies have demonstrated an inverse association between RSA and startle potentiation, no study to date has distinguished whether this relation is similar for predictable versus unpredictable aversive stimuli. This is an important distinction, given that degree of predictability has been shown to be an important determinant of aversive responding. The present study examined whether resting RSA was associated with startle eye blink responding during predictable and unpredictable threat of electric shock. Resting RSA was collected during a 6-minute seated baseline phase at the beginning of the experimental session. Participants then completed a computerized startle task in which predictable and unpredictable shocks were administered. Results indicated that lower resting RSA was associated with greater startle potentiation during unpredictable threat, but not during predictable threat. These findings are consistent with a growing body of literature suggesting that individual differences in RSA are associated with aversive responding, and extend previous work by suggesting that RSA may be more robustly associated with a heightened sensitivity to unpredictable threat. This pattern of results may have implications for the understanding of pathological anxiety given that individuals with anxiety disorders typically exhibit low RSA and heightened responding during unpredictable threat.

Association between respiratory sinus arrhythmia and reductions in startle responding in three independent samples.

Evidence suggests that respiratory sinus arrhythmia (RSA) may be an important indicator of physiological flexibility. However, few studies have examined the relation between RSA and defensive habituation, a process contingent on physiological flexibility. In three independent samples, habituation was defined as the time course of 9 startle responses. In Sample one and two, startle was recorded (1) while shock electrodes were attached to participants' and (2) before a threat-of-shock task. In Sample three, startle was recorded without these two components. In the first two samples, startle magnitude significantly decreased over time but in Sample three, startle only decreased at a trend level. Further, low RSA was associated with less of a reduction in startle magnitude over time within the first two samples, but was unrelated to startle reduction in the third. This suggests that low RSA is associated with less habituation to contextual anxiety, which may reflect difficulties regulating anxiety.

A psychophysiological investigation of threat and reward sensitivity in individuals with panic disorder and/or major depressive disorder.

Heightened sensitivity to threat and reduced sensitivity to reward are potential mechanisms of dysfunction in anxiety and depressive disorders, respectively. However, few studies have simultaneously examined whether these mechanisms are unique or common to these disorders. In this study, sensitivity to predictable and unpredictable threat (measured by startle response during threat anticipation) and sensitivity to reward (measured by frontal electroencephalographic [EEG] asymmetry during reward anticipation) were assessed in 4 groups (N = 191): those with (1) panic disorder (PD) without a lifetime history of depression, (2) major depression (MDD) without a lifetime history of an anxiety disorder, (3) comorbid PD and MDD, and (4) controls. General distress/negative temperament (NT) was also assessed via self-report. Results indicated that PD (with or without comorbid MDD) was uniquely associated with heightened startle to predictable and unpredictable threat, and MDD (with or without comorbid PD) was uniquely associated with reduced frontal EEG asymmetry. Both psychophysiological measures of threat and reward sensitivity were stable on retest approximately 9 days later in a subsample of participants. Whereas the comorbid group did not respond differently on the tasks relative to the PD-only and MDD-only groups, they did report greater NT than these 2 groups (which did not differ from each other). Results suggest that heightened sensitivity to threat and reduced sensitivity to reward may be specific components of PD and MDD, respectively. In addition, relative to noncomorbid depression and PD, comorbid MDD and PD may be characterized by heightened NT, but not abnormal levels of these "specific" components.

Dysfunctional attitudes as a moderator of pharmacotherapy and psychotherapy for chronic depression.

OBJECTIVE: Individuals with chronic depression exhibit heterogeneous responses to treatment. Important individual differences may therefore exist within this particularly difficult to treat population that act as moderators of treatment response. METHOD: The present study examined whether pretreatment levels of dysfunctional attitudes (DA) moderated treatment response in a large sample of chronically depressed individuals. Data were taken from the Research Evaluating the Value of Augmenting Medication with Psychotherapy (REVAMP) treatment study--a multi-site treatment and augmentation study of 808 chronically depressed individuals. REVAMP comprised two phases: 1) a 12-week open-label antidepressant trial and 2), a subsequent phase, in which phase 1 non-remitters (N = 491) were randomized to either receive an ongoing medication algorithm alone, medication plus cognitive behavioral analysis system of psychotherapy, or medication plus brief supportive psychotherapy. RESULT: In phase 1, compared to the pharmacotherapy response of patients with lower DA scores, the response for patients with higher DA scores was steeper, but leveled off toward the end of the phase. In phase 2, DA predicted a differential response in the medication only arm, but not in the two psychotherapy + medication conditions. Specifically, in the phase 2 medication only condition, patients with higher DA improved while those with lower DA scores did not. CONCLUSION: These results indicate that the relation between DA and treatment response in chronic depression is complex, but suggest that greater DA may be associated with a steeper reduction and/or better response to pharmacotherapy.

Frontal brain asymmetry in depression with comorbid anxiety: a neuropsychological investigation.

The approach-withdrawal model posits that depression and anxiety are associated with a relative right asymmetry in frontal brain activity. Most studies have tested this model using measures of cortical brain activity such as electroencephalography. However, neuropsychological tasks that differentially use left versus right frontal cortical regions can also be used to test hypotheses from the model. In two independent samples (Study 1 and 2), the present study investigated the performance of currently depressed individuals with or without a comorbid anxiety disorder and healthy controls on neuropsychological tasks tapping primarily left (verbal fluency) or right (design fluency) frontal brain regions. Across both samples, results indicated that comorbid participants performed more poorly than depressed only and control participants on design fluency, while all groups showed equivalent performance on verbal fluency. Moreover, comorbid participants showed "asymmetrical" performance on these two tasks (i.e., poorer design [right frontal] relative to verbal [left frontal] fluency), whereas depressed only and control participants showed approximately symmetrical profiles of performance. Results from these two samples suggest an abnormal frontal asymmetry in neurocognitive performance driven primarily by right frontal dysfunction among anxious-depressed individuals and highlight the importance of considering comorbid anxiety when examining frontal brain functioning in depression.

Differentiation of traumatic and heat-induced dental tissue fractures via SEM analysis.

Previous studies have examined the effects of heating on teeth; however, none have identified characteristics that allow analysts to differentiate traumatic from heat-induced fractures. This study examined our ability to discern notable differences in preincineration traumatic fractures and heat-induced fractures in postincineration dentition. Twelve anterior dental specimens were subjected to blunt force trauma while a second set were not. All 24 samples were then incinerated in a muffle furnace at a peak temperature (900°C) consistent with house fires. The specimens were subsequently examined with a scanning electron microscope to identify and compare heat-induced and traumatic fractures. The results obtained during examination yielded no differences between the features displayed by specimens that had been inflicted with preincineration trauma and those that did not. Unlike bone, distinguishing features for the differentiation of traumatic and heat-induced fractures could not be compiled.

Effects of predictability of shock timing and intensity on aversive responses.

An important characteristic of aversive stimuli that determines emotional responses is whether the stimuli are predictable. Human laboratory studies in this area have typically operationalized predictability as being able to predict the occurrence of aversive events, but animal studies suggest that being able to predict other characteristics of the stimuli may also play a role in aversive responding. To examine this, the present study examined two characteristics: the timing and intensity of aversive stimuli. Specifically, participants were randomly assigned to receive shocks that were either predictable or unpredictable in terms of when they would occur (timing) and/or their intensity. Indicators of aversive emotional responses were EMG startle responses and subjective anxiety ratings. Results revealed that aversive responding was elevated for unpredictable timing and intensity suggesting that the predictability of both characteristics play a role in aversive responding (though the effects for timing were stronger). In sum, the anxiogenic effects of unpredictability may generalize to situations beyond unpredictable timing.