Predictive value of the test of infant motor performance and the Hammersmith infant neurological examination for cerebral palsy in infants.

BACKGROUND: Current recommendations for early detection tools for cerebral palsy (CP) include assessments that vary in feasibility and resource requirements. The predictive value of less resource-intensive tools has not been fully explored. AIMS: To determine the predictive value of the Test of Infant Motor Performance (TIMP) at 3-4 months corrected age (CA) for CP, and whether administration of both the TIMP and the Hammersmith Infant Neurological Exam (HINE) improves early CP detection. STUDY DESIGN: Five-year retrospective observational study of infants who received the TIMP and the HINE at 3-4 months CA in a high-risk follow-up clinic. TIMP and HINE cut-off scores (alone and in combination) were compared for CP discriminatory ability. SUBJECTS: Of patients with HINE scores (n = 1389; 676 [48.7 %] female; median gestational age at birth 31 weeks [interquartile range 29-34 weeks]), 1343 had concurrent TIMP scores available. OUTCOME MEASURES: Clinical diagnosis of CP. RESULTS: HINE total score <57 had optimal CP predictive value (AUC = 0.815; 77 % sensitivity; 91 % specificity) compared to optimal TIMP cut-off (1 SD below the mean, AUC = 0.71; 52 % sensitivity; 94 % specificity) and all tested TIMP and HINE combinations (all p < 0.001). CONCLUSIONS: HINE total score <57 at 3-4 months CA had the best CP predictive value, confirming its value absent first-line detection tools. Concurrent administration of TIMP did not improve predictive value.

Hammersmith Infant Neurological Examination Clinical Use to Recommend Therapist Assessment of Functional Hand Asymmetries.

PURPOSE: To determine whether asymmetry scores derived from the Hammersmith Infant Neurological Examination (HINE) can provide cutoff scores for recommending in-depth assessment of upper extremity functional deficits by therapists using the Hand Assessment for Infants (HAI). METHODS: Observational study in a clinical laboratory with the HINE and the HAI administered concurrently to 101 infants 3 to 12 months corrected age developing typically or atypically. Predictive value of HINE asymmetry scores for atypical HAI was determined. RESULTS: Total HINE asymmetry scores of 4 or greater had 100% sensitivity and 88% or greater specificity for identifying infants with an asymmetric HAI score of 3 or greater point difference between hands. CONCLUSIONS: For infants receiving a total HINE asymmetry score of 4 or greater, referral to therapists for HAI assessment may be beneficial to precisely evaluate function and determine the need for targeted upper extremity interventions.

Standardized Neurodevelopmental Surveillance of High-risk Infants Using Telehealth: Implementation Study during COVID-19.

INTRODUCTION: Neurodevelopmental surveillance is critical for high-risk infants following neonatal intensive care discharge and is traditionally performed in-person. COVID-19 interruption of regular surveillance necessitated a rapid development of telehealth models for effective and standardized care. METHODS: We used implementation science and lean methodologies to develop an effective telehealth neurodevelopmental surveillance program for high-risk infants. Interventions included reorganization of visit flow processes and a telehealth toolkit for standardized neurological and developmental assessments. We tested and improved our intervention through plan-do-study-act cycles, value-added analysis, and parent- and provider-satisfaction questionnaires. Process metrics (standard elements, subspecialty referrals, diagnostic tests, and prescriptions ordered) were compared in group-level analyses between telehealth patients (N = 97) March 16, 2020-July 1, 2020 and a matched in-person cohort at the same period the previous year. Run charts examined shifts in balancing measures (provider efficiency and missed visits) over 8 weeks before and after implementation. RESULTS: Primary outcomes were visit completion (100%), patient parent satisfaction (>90% strongly agreed or agreed telehealth procedures were valuable and easy to use) and ability to accurately diagnose cerebral palsy (no statistical difference with comparison visits). Providers (N = 6) rated telehealth experiences favorably. Process metrics indicated no differences between telehealth and in-person visits (all P > 0.05). Following telehealth implementation, provider efficiency increased to near baseline (median 88.9% versus 91.7%) and median missed visits decreased to 0% from 20% (in-person). CONCLUSIONS: Implementation of telehealth for neurodevelopmental surveillance in a tertiary high-risk infant follow-up clinic successfully provided standardized and timely care during stay-at-home orders; broader telehealth applications may overcome access barriers in this field.

A Systematic Review of Assessments and Interventions for Chronic Pain in Young Children With or at High Risk for Cerebral Palsy.

BACKGROUND: Pain is common in children with cerebral palsy. The purpose of this systematic review was to evaluate the evidence regarding assessments and interventions for chronic pain in children aged ≤2 years with or at high risk for cerebral palsy. METHODS: A comprehensive literature search was performed. Included articles were screened using PRISMA guidelines and quality of evidence was reviewed using best-evidence tools by independent reviewers. Using social media channels, an online survey was conducted to elicit parent preferences. RESULTS: Six articles met criteria. Parent perception was an assessment option. Three pharmacologic interventions (gabapentin, medical cannabis, botulinum toxin type A) and 1 nonpharmacologic intervention were identified. Parent survey report parent-comfort and other nonpharmacologic interventions ranked as most preferable. CONCLUSION: A conditional GRADE recommendation was in favor of parent report for pain assessment. Clinical trials are sorely needed because of the lack of evidence for safety and efficacy of pharmacologic interventions.

Protocol and Feasibility-Randomized Trial of Telehealth Delivery for a Multicomponent Upper Extremity Intervention in Infants With Asymmetric Cerebral Palsy.

BACKGROUND: Past work showed that an in-person, therapist-guided, parent-implemented multicomponent intervention increased the motor functioning of the more affected upper extremity (UE) in infants with asymmetric cerebral palsy. The authors document treatment fidelity and provide initial testing of telehealth intervention delivery in a new subject sample. METHODS: The authors adapted the intervention manual used in the previous trial for telehealth. Infants (6-24 months) were randomly assigned to intervention (n = 7) or waitlist (n = 6). The intervention prescribed soft-constraint wear on the less affected UE for 6 hours, 5 d/wk, and exercises. After an initial in-person training session, three 15- to 45-minute telehealth sessions were performed. RESULTS: Median weekly constraint wear was 21 hours (interquartile range = 10.3-29.7); average parent-treatment fidelity was 95.7% (SD 11.2). A significant large (Cohen d = 0.92) between-group differences occurred on fine motor functioning of more affected UEs. CONCLUSION: The telehealth intervention was feasible and potentially effective, but a larger trial is needed to evaluate efficacy.

Caregiver perception of hand function in infants with cerebral palsy: psychometric properties of the Infant Motor Activity Log.

AIM: To evaluate the properties of the Infant Motor Activity Log (IMAL), a caregiver-report for frequency and quality of use of more affected upper extremity in infants with neurological and functional impairments. METHOD: This was a prospective cohort study of 66 children (34 females, 32 males) aged 6 to 24 months (mean age [SD] 13.7mo [5.3]) with neurological and functional impairments and a confirmed cerebral palsy diagnoses after 2 years, and 51 age-matched typically developing children. The IMAL was administered at baseline and 4 weeks later. Typically developing infants were tested with randomly assigned 'more affected' upper extremity. Psychometric properties were evaluated using Spearman's correlation coefficient, Cronbach's alpha, and Jonckheere-Terpstra tests. RESULTS: In the children with impairments, the IMAL showed internal consistency (alpha≥0.88) for the How Well Scale (HWS) and How Often Scale (HOS). Test-retest reliability was 0.64 (HOS) and 0.70 (HWS), demonstrating stability over time. Correlation with Bayley Scales of Infant and Toddler Development, Third Edition more affected arm raw scores were 0.70 (HOS) and 0.72 (HWS) (p<0.001) demonstrating construct validity. Both scale scores decreased with increasing Gross Motor Function Classification System and Mini-Manual Ability Classification System (p<0.001) levels, supporting discriminative validity. Discrimination between typically developing infants and infants with impairments was high (HWS: area under the receiver operating characteristic curve [AUC] 0.96, 95% confidence interval [CI] 0.94-0.99 and HOS AUC=0.95, CI 0.92-0.99). INTERPRETATION: The IMAL is a valid and reliable discriminative caregiver measure of upper limb performance and may complement measures of capacity in infants with neurological and functional impairments. WHAT THIS PAPER ADDS: The Infant Motor Activity Log (IMAL) is a valid and reliable measure of caregiver perception of upper limb function. The IMAL fills a measurement gap for infant motor performance in children with impairments. The IMAL discriminates among motor function levels.

Network Implementation of Guideline for Early Detection Decreases Age at Cerebral Palsy Diagnosis.

BACKGROUND AND OBJECTIVES: Early diagnosis of cerebral palsy (CP) is critical in obtaining evidence-based interventions when plasticity is greatest. In 2017, international guidelines for early detection of CP were published on the basis of a systematic review of evidence. Our study aim was to reduce the age at CP diagnosis throughout a network of 5 diverse US high-risk infant follow-up programs through consistent implementation of these guidelines. METHODS: The study leveraged plan-do-study-act and Lean methodologies. The primary outcome was age at CP diagnosis. Data were acquired during the corresponding 9-month baseline and quarterly throughout study. Balancing measures were clinic no-show rates and parent perception of the diagnosis visit. Clinic teams conducted strengths, weaknesses, opportunities, and threats analyses, process flow evaluations, standardized assessments training, and parent questionnaires. Performance of a 3- to 4-month clinic visit was a critical process step because it included a Hammersmith Infant Neurologic Examination, a General Movements Assessment, and standardized assessments of motor function. RESULTS: The age at CP diagnosis decreased from a weighted average of 19.5 (95% confidence interval 16.2 to 22.8) to 9.5 months (95% confidence interval 4.5 to 14.6), with P = .008; 3- to 4-month visits per site increased from the median (interquartile range) 14 (5.2-73.7) to 54 (34.5-152.0), with P < .001; and no-show rates were not different. Parent questionnaires revealed positive provider perception with improvement opportunities for information content and understandability. CONCLUSIONS: Large-scale implementation of international guidelines for early detection of CP is feasible in diverse high-risk infant follow-up clinics. The initiative was received positively by families and without adversely affecting clinic operational flow. Additional parent support and education are necessary.

Early prediction of spontaneous Patent Ductus Arteriosus (PDA) closure and PDA-associated outcomes: a prospective cohort investigation.

BACKGROUND: Patent ductus arteriosus (PDA), the most commonly diagnosed cardiovascular condition in preterm infants, is associated with increased mortality and harmful long-term outcomes (chronic lung disease, neurodevelopmental delay). Although pharmacologic and/or interventional treatments to close PDA likely benefit some infants, widespread routine treatment of all preterm infants with PDA may not improve outcomes. Most PDAs close spontaneously by 44-weeks postmenstrual age; treatment is increasingly controversial, varying markedly between institutions and providers. Because treatment detriments may outweigh benefits, especially in infants destined for early, spontaneous PDA closure, the relevant unanswered clinical question is not whether to treat all preterm infants with PDA, but whom to treat (and when). Clinicians cannot currently predict in the first month which infants are at highest risk for persistent PDA, nor which combination of clinical risk factors, echocardiographic measurements, and biomarkers best predict PDA-associated harm. METHODS: Prospective cohort of untreated infants with PDA (n=450) will be used to predict spontaneous ductal closure timing. Clinical measures, serum (brain natriuretic peptide, N-terminal pro-brain natriuretic peptide) and urine (neutrophil gelatinase-associated lipocalin, heart-type fatty acid-binding protein) biomarkers, and echocardiographic variables collected during each of first 4 postnatal weeks will be analyzed to identify those associated with long-term impairment. Myocardial deformation imaging and tissue Doppler imaging, innovative echocardiographic techniques, will facilitate quantitative evaluation of myocardial performance. Aim1 will estimate probability of spontaneous PDA closure and predict timing of ductal closure using echocardiographic, biomarker, and clinical predictors. Aim2 will specify which echocardiographic predictors and biomarkers are associated with mortality and respiratory illness severity at 36-weeks postmenstrual age. Aim3 will identify which echocardiographic predictors and biomarkers are associated with 22 to 26-month neurodevelopmental delay. Models will be validated in a separate cohort of infants (n=225) enrolled subsequent to primary study cohort. DISCUSSION: The current study will make significant contributions to scientific knowledge and effective PDA management. Study results will reduce unnecessary and harmful overtreatment of infants with a high probability of early spontaneous PDA closure and facilitate development of outcomes-focused trials to examine effectiveness of PDA closure in "high-risk" infants most likely to receive benefit. TRIAL REGISTRATION: ClinicalTrials.gov NCT03782610. Registered 20 December 2018.

Biological and molecular characterization of a U.S. isolate of Hosta virus X.

Hosta virus X (HVX) is rapidly becoming a serious pathogen of commercially important hosta plants worldwide. We report here biological and molecular characterization of a U.S. isolate of HVX, HVX-37. HVX-37 infectivity was tested in 21 hosta cultivars over three growth seasons, and three types of responses were defined based upon the ability of the virus to cause local and/or systemic infections. Four cultivars resistant to systemic HVX infection were identified. The full-length sequence of the HVX-37 genome was determined, the first complete sequence of a U.S. HVX isolate. Comparison with the previously sequenced HVX-Korea (Kr) genome revealed a high level of sequence similarity, as well as some differences. Notably, a 105-nucleotide long, near-perfect direct repeat in the Kr isolate is absent in HVX-37. The accuracy of the HVX-37 genome sequence was confirmed by infectivity of in vitro transcripts synthesized from a full-length HVX-37 cDNA on Nicotiana benthamiana and hosta plants.

Surprising Results from a Search for Effective Disinfectants for Tobacco mosaic virus-Contaminated Tools.

Over 100 years after its discovery, Tobacco mosaic virus (TMV) remains an economically important pathogen for producers of many vegetatively propagated crops including petunias (Petunia × hybrida). To directly address this concern, we have developed a robust system to determine efficacy of disinfectants for treating TMV-contaminated cutting tools using a combination of preliminary screens and replicated trials. Contrary to widely held beliefs, wild-type (wt) TMV and four additional tobamovirus species infected four petunia cultivars without producing obvious viral symptoms. In contrast, a petunia isolate of TMV with 99.0% (nucleotide) and 99.4% (amino acid) coat protein sequence identity to wt TMV produced symptoms on all but one tested cultivar. We also show that TMV transmission can occur up to the twentieth petunia plant cut following a single cutting event on a TMV-infected plant. Although many new products are now available, treatment of TMV-contaminated tools with a 20% (wt/vol) solution of nonfat dry milk (NFDM) plus 0.1% Tween 20 or a 1:10 dilution of household bleach (0.6% sodium hypochlorite), two "old standbys", completely eliminated TMV transmission to petunias. Treatment of contaminated tools with 1% (wt/vol) Virkon S or 20% NFDM also significantly reduced the incidence of infected petunias. Other treatments identified in the preliminary screens are candidates for the second phase of screening that simulates contamination during the process of taking cuttings.

Identification of domains of the Tomato spotted wilt virus NSm protein involved in tubule formation, movement and symptomatology.

Deletion and alanine-substitution mutants of the Tomato spotted wilt virus NSm protein were generated to identify domains involved in tubule formation, movement and symptomatology using a heterologous Tobacco mosaic virus expression system. Two regions of NSm, G(19)-S(159) and G(209)-V(283), were required for both tubule formation in protoplasts and cell-to-cell movement in plants, indicating a correlation between these activities. Three amino acid groups, D(154), EYKK(205-208) and EEEEE(284-288) were linked with long-distance movement in Nicotiana benthamiana. EEEEE(284-288) was essential for NSm-mediated long-distance movement, whereas D(154) was essential for tubule formation and cell-to-cell movement; indicating separate genetic controls for cell-to-cell and long-distance movement. The region I(57)-N(100) was identified as the determinant of foliar necrosis in Nicotiana benthamiana, and mutagenesis of HH(93-94) greatly reduced necrosis. These findings are likely applicable to other tospovirus species, especially those within the 'New World' group as NSm sequences are highly conserved.

Tobacco mosaic virus defective RNAs expressing C-terminal methyltransferase domain sequences are severely impaired in long-distance movement in Nicotiana benthamiana.

Tobamovirus replicase proteins, which function in replication and gene expression, are also implicated in viral cell-to-cell and long-distance movement. The role(s) of Tobacco mosaic virus (TMV) 126-/183-kDa replicase protein in the complex movement process are not understood due to lack of systems that can separate the multiple steps involved. We previously developed a bipartite TMV-defective RNA (dRNA) system to dissect the role of the N-terminal methyltransferase (MT) domain in accumulation and cell-to-cell movement of dRNAs [Knapp, E., Danyluk, G.M., Achor, D., Lewandowski, D.J., 2005. A bipartite Tobacco mosaic virus-defective RNA (dRNA) system to study the role of the N-terminal methyltransferase domain in cell-to-cell movement of dRNAs. Virology 341, 47-58]. In the current study we analyzed long-distance movement of dRNAs in the presence of helper virus in Nicotiana benthamiana. dRNAs expressing approximately 50% of the MT domain (DeltaHinc151) moved long-distances in more than half of the plants. dRNAs expressing approximately 90% of the MT domain sequences (DeltaCla151) predominantly failed to accumulate in upper leaves. The helper virus moved systemically when inoculated alone or with a dRNA. In inoculated leaves, more DeltaHinc151-induced infection foci spread adjacent to class V veins compared to those of DeltaCla151. Consequently, DeltaHinc151 infected more class V veins than DeltaCla151. DeltaCla151 was only detected in bundle sheath cells, whereas DeltaHinc151 could accumulate in bundle sheath and phloem parenchyma cells of class V veins. However, the latter accumulation pattern did not always result in systemic accumulation of DeltaHinc151, suggesting that factors in addition to those affecting cell-to-cell movement played a role in long-distance movement.

Identification and Characterization of a Novel Tobamovirus from Tropical Soda Apple in Florida.

Foliar symptoms suggestive of virus infection were recently observed on the noxious weed tropical soda apple (Solanum viarum) in Florida. An agent was mechanically transmitted to Nicotiana benthamiana, and virions were isolated from systemically infected leaves. Rod-shaped particles ~300 nm in length were observed in the partially purified preparations by electron microscopy. The host range determined by mechanical inoculation with purified virions included all tested plants in the Solanaceae (16 species including the important vegetable crops, pepper and tomato) and Chenopodiaceae (2 species) but excluded all tested plants in the Ama-ranthaceae, Apocynaceae, Brassicaceae, Caryophyllaceae, Cucurbitaceae, Fabaceae, Lamiaceae, Malvaceae, and Tropaeolaceae, including several common virus indicator hosts. Comparisons of the coat and movement protein nucleotide and deduced amino acid sequences of this putative tobamovirus with recognized members of this genus, indicate that it is a novel tobamovirus that shares the highest level of sequence identity with Pepper mild mottle virus followed by other members of the Solanaceae-infecting subgroup of tobamoviruses. The virus, for which the name Tropical soda apple mosaic virus (TSAMV) is proposed, was found to be widespread in tropical soda apple in peninsular Florida during an initial survey. TSAMV contamination of seed from infected tropical soda apple plants was found, suggesting that seed transmission may be important for TSAMV dissemination and epidemiology.

The tubule-forming NSm protein from Tomato spotted wilt virus complements cell-to-cell and long-distance movement of Tobacco mosaic virus hybrids.

A Florida isolate of Tomato spotted wilt virus (TSWV) was able to complement cell-to-cell movement of a movement-defective Tobacco mosaic virus (TMV) vector expressing the jellyfish green fluorescent protein (GFP). To test for complementation of movement in the absence of other TSWV proteins, the open reading frame for the NSm protein was expressed from TMV constructs encoding only the TMV replicase proteins. NSm was expressed from either the coat protein or movement protein subgenomic promoter, creating virus hybrids that moved cell to cell in inoculated leaves of tobacco, providing the first functional demonstration that NSm is the TSWV movement protein. Furthermore, these CP-deficient hybrids moved into upper leaves of Nicotiana benthamiana, demonstrating that NSm can support long-distance movement of viral RNAs. Tubules, characteristic of the NSm protein, were also formed in tobacco protoplasts infected with the TMV-TSWV hybrids. The C-terminus of the NSm protein was shown to be required for movement. TMV-TSWV hybrids expressing NSm and GFP moved within inoculated leaves. Our combination of single-cell and intact plant experiments to examine multiple functions of a heterologous viral protein provides a generalized strategy with wider application to other viruses also lacking a reverse genetic system.

A bipartite Tobacco mosaic virus-defective RNA (dRNA) system to study the role of the N-terminal methyl transferase domain in cell-to-cell movement of dRNAs.

Plant viruses, in particular Tobacco mosaic virus (TMV), are model systems to study RNA and protein trafficking in plants. Although TMV cell-to-cell transport controlled by the 30-kDa movement protein (MP) has been intensively studied, it was only recently demonstrated that the 126/183-kDa replicase proteins are also involved in cell-to-cell movement. Elucidating the role(s) of 126/183-kDa proteins in movement is complicated because these proteins have multiple functions associated with replication and gene expression. To overcome these difficulties we developed a TMV helper virus-defective RNA (dRNA) system to study the role of replicase protein sequences in dRNA cell-to-cell movement. Artificially constructed dRNAs lacking sequences encoding the helicase and polymerase domains of the replicase proteins and portions of the MP were viable in protoplasts and plants in the presence of helper virus. Expression of at least approximately 50% of the methyl transferase (MT) domain was required for efficient dRNA movement in Nicotiana benthamiana. dRNAs that encoded the N-terminal 64 replicase amino acids or lacked a translatable MT domain failed to move or moved poorly. TMV dRNAs expressing 258 amino acids of the replicase protein moved into all specialized non-vascular tissues, whereas dRNAs expressing replicase sequences beyond amino acid 258 were restricted to the epidermis and palisade mesophyll tissues. Furthermore, second-site mutations within the dRNA-encoded truncated replicase protein altered efficiency in dRNA cell-to-cell movement.

Biological and Molecular Characterization of a Novel Tobamovirus with a Unique Host Range.

Tobamoviruses are among the best characterized and most studied plant viruses. Three subgroups of tobamoviruses correspond to viral genome sequence and host range to include those viruses infecting (i) solanaceous plants, (ii) brassicas, or (iii) cucurbits or legumes. We isolated a virus from Florida landscape plantings of the malvaceous plant hibiscus (Hibiscus rosasinensis) that appears to be a tobamovirus based upon its virion morphology, genome organization, and coat protein sequence. The experimental host range of this virus included five malvaceous species but excluded all tested brassica, cucurbit, and legume species and 12 of the 19 solanaceous species tested. The unique host range and comparison of coat protein gene and protein sequences with those of recognized tobamoviruses indicate that this is a novel to-bamovirus. A limited survey revealed that this virus is widespread in hibiscus and related species in the Florida landscape.