Abnormal heart rate characteristics are associated with abnormal neuroimaging and outcomes in extremely low birth weight infants.

OBJECTIVE: Brain injury in preterm infants may lead to an inflammatory response and central nervous system dysfunction reflected by abnormal heart rate characteristics (HRC). We hypothesized that a continuously monitored HRC index reflecting reduced HR variability and decelerations correlates with abnormal neuroimaging and outcomes in extremely low birth weight infants (ELBW). STUDY DESIGN: We analyzed the average HRC index within 28 days after birth (aHRC28) and head ultrasound (HUS) in 384 ELBW infants. In 50 infants with brain magnetic resonance imaging (MRI) and 70 infants with Bayley neurodevelopmental testing at 1 year of age, we analyzed the relationship between aHRC28, MRI abnormalities and low Bayley scores. RESULT: aHRC28 was higher in infants with severe HUS abnormalities (2.65±1.27 for Grade III-IV intraventricular hemorrhage (IVH) or cystic periventricular leukomalacia (cPVL) versus 1.72±0.95 for normal or Grade I-II IVH, P<0.001). Higher aHRC28 was also associated with white matter damage on MRI and death or Bayley motor or mental developmental index <70. Associations persisted after adjusting for gestational age, birth weight and septicemia. For every one point increase in aHRC28, the odds ratio of death or Bayley score <70 was 2.45 (95% CI 1.46, 4.05, P<0.001). CONCLUSION: A continuously monitored HRC index provides an objective, noninvasive measure associated with abnormal brain imaging and adverse neurologic outcomes in ELBW infants.

Interface exchange coupling in Co nanoparticles dispersed in a Mn matrix.

The structural and magnetic properties of 1.8 nm Co particles dispersed in a Mn matrix by co-depositing pre-formed mass-selected Co clusters with an atomic vapour of Mn onto a common substrate have been studied by using EXAFS (extended x-ray absorption fine structure), XMCD (x-ray magnetic circular dichroism), magnetometry, and theoretical modelling. At low Co volume fraction (5%) Co@Mn shows a significant degree of alloying and the well-defined particles originally deposited become centres of high Co concentration CoMn alloy that evolves from pure Co at the nanoparticle centre to the pure Mn matrix within a few nm. Each inhomogeneity is a core-shell particle with a Co-rich ferromagnetic core in contact with a Co-depleted antiferromagnetic shell. The XMCD reveals that the Co moment localized on the Co atoms within the Co-rich cores is much smaller than the ferromagnetic moment of the Co nanoparticles deposited at the same volume fraction in Ag. Electronic structure calculations indicate that the small magnitude of the core Co moment can be understood only if significant alloying occurs. Monte Carlo modelling replicates the exchange bias (EB) behaviour observed at low temperature from magnetometry measurements. We ascribe EB to the interaction between the ferromagnetic Co-rich cores and the antiferromagnetic Mn-rich shells.

A comparison of developmental versus functional assessment in the rehabilitation of young children.

BACKGROUND: The purpose of this study was to explore the differences in and potential uses of information derived from developmental vs. functional assessment during the acute rehabilitation of very young children with acquired brain injury. Both methods of assessment are typically used during hospitalization in order to assist in developing individualized goals and outcome measures. With the trend of shortened hospital stays, effective assessment for determining optimal treatment goals and outcomes becomes increasingly important. The results from a developmental and a functional assessment obtained on 23 inpatient children below 6 years of age who had experienced either an acquired brain injury or encephalitis were compared. The data was collected through a retrospective chart review spanning 4 years. METHODS AND OUTCOME MEASURES: Each child received a cognitive and a language test using either the Early Learning Accomplishment Profile (E-LAP) or the Learning Accomplishment Profile Diagnostic (LAP-D) for the developmental assessment measure. The Functional Independence Measure for Children (WeeFIM) was used as a functional assessment. Summary statistics and frequencies were calculated for variables including age and diagnosis. Partial Pearson correlations and 95% confidence intervals were calculated between the functional and developmental assessments, adjusting for the amount of time between administrations of the two exams. Pearson correlations were computed between length of hospital stay and performance on the developmental and functional quotients. RESULTS: Moderate, statistically significant Pearson partial correlations were found between the E-LAP/LAP-D cognitive quotient and the WeeFIM cognitive quotient (r = 0.42, 95% CI (0, 0.72)), the E-LAP/LAP-D language quotient and the WeeFIM cognitive quotient (r = 0.55, 95% CI (0.17, 0.79)) and the E-LAP/LAP-D cognitive quotient and the WeeFIM total quotient (r = 0.50, 95% CI (0.10, 0.76)). An inverse correlation was found between the length of stay and the E-LAP/ LAP-D cognitive quotient (r = -0.68, 95% CI (-0.86, -0.34)) as well as the E-LAP/LAP-D language quotient (r = -0.61, 95% CI (-0.83, -0.23)). CONCLUSIONS: The moderate but limited correlations between developmental and functional assessments may be attributed to differences in the two forms of assessment including the test items, their administration and scoring. While both forms of assessment were thought to be useful for developing individualized treatment goals and measuring outcomes, there were advantages and disadvantages to each.

The use of dopamine enhancing medications with children in low response states following brain injury.

PRIMARY OBJECTIVE: The study examines the possible relationship between dopamine-enhancing medications and improvement of arousal and awareness in children during persistent low response states (Rancho Los Amigos Levels I, II and III). RESEARCH DESIGN: A retrospective review was conducted of 10 children enrolled in an existing clinical protocol. The Kluge Children's Rehabilitation Center (KCRC) low response protocol provides a double baseline serial measure (A, A, B, B, B) design. Scores on the Western NeuroSensory Stimulation Profile (WNSSP) are the dependent variable. METHODS AND PROCEDURES: Ten children, mean age of 13.7 years low response state (30 days or more) who were treated with dopamine agonists. Co-morbid or iatrogenic influences were addressed or ruled out. Seven children had traumatic brain injury, one cerebral vascular accident, one anoxia and one encephalitis. EXPERIMENTAL INTERVENTION: On average, dopamine medications were started 52.9 days post-event. MAIN OUTCOMES AND RESULTS: Paired t-test of WNSSP scores before medications and on medications were significant at p = 0.03 (paired t-test). Also, the distributions of the slopes (rates of change of WNSSP scores over time) were significantly different in the pre-medication and medication phases (Paired T-test, p = 0.02). Random coefficient model comparison of individuals during pre- and medication phase response variability on WNSSP yielded F-test at p = 0.02. CONCLUSIONS: These results suggest a promising relationship between acceleration of recovery for some children in a low response state and administration of dopamine-enhancing medications.

Scaling laws in magneto-optical properties of aggregated ferrofluids.

Since statistically isotropic fractal aggregates of particles are a particular case of self-organized critical systems, we describe formally field-induced behaviors of aggregated ferrofluids as responses of regular at-equilibrium critical systems at the critical point to the small field conjugated to its order parameter. This leads us to expect some general scaling laws, which are checked numerically on two examples: the magnetic susceptibility and the magneto-optical linear dichroism of two-dimensional aggregated ferrofluids. This is performed by numerical simulations of such an aggregating system under weak magnetic field applied in the plane of the aggregates.

Attention-deficit/hyperactivity disorder in preschoolers. Does it exist and should we treat it?

The diagnosis of ADHD in preschool-aged children is difficult. High activity level, impulsivity, and short attention span--to a degree--are age-appropriate characteristics of normal preschool-aged children. However, excessive levels of these characteristics impede successful socialization, optimal learning, and positive parent-child interaction. Environmental stressors, inadequate parenting skills, and other diagnoses such as oppositional defiant, posttraumatic stress, or adjustment disorders can mimic ADHD. Although labeling may be necessary to obtain services, the emphasis should be placed on symptom resolution, given the uncertainties of diagnostic accuracy in this age group. Deferring a specific diagnosis of ADHD until confounding issues are clarified should be considered. The evaluation of serious behavior problems in young children must include a comprehensive consideration of environmental, health, cognitive, educational, and behavioral interactions. Both assessment and intervention should focus on the interactions between the child and his or her environment to determine how they facilitate or hinder adaptive integration as both the child and surroundings change and evolve. Treatment invariably necessitates involvement of a child and family psychotherapist or counselor to address behavior management strategies as well as family dynamics, parental psychopathology, or life stress. Parents must understand that counseling is an essential component of treatment and that they must be active participants. Psychopharmacologic intervention may be appropriate in some instances, although conventional wisdom suggests caution in young children, given the limited information about safety and efficacy of many agents, especially in children younger than 3 years old. Stimulants appear to be safe in older preschool-aged children. Children started on medication should be monitored closely for both positive and negative effects. A double-blinded, placebo-controlled trial of medication is warranted in equivocal situations.

Effect of short-term hormone replacement therapy on left ventricular mass and contractile function.

OBJECTIVE: To determine the effect of hormone replacement therapy (HRT) on cardiac structure and function and whether these changes are related to changes in blood volume. DESIGN: Open-label pilot study. SETTING: Academic medical center. PATIENT(S): Eighteen healthy postmenopausal women. INTERVENTION(S): We administered medroxyprogesterone acetate orally, 5 mg/d for 2 months followed by 2 months of oral sequential 17beta-estradiol, 1 mg/d plus medroxyprogesterone acetate, 10 mg/d for the last 12 days of each month. MAIN OUTCOME MEASURE(S): Cardiac output, stroke volume, heart rate, end diastolic volume, end systolic volume, ejection fraction, and left ventricular mass were measured by echocardiography; blood and plasma volumes were measured using 125I-albumin dilution. RESULT(S): Cardiac output, stroke volume, left ventricular mass, end diastolic volume, and ejection fraction increased by 12.8%, 11.7%, 9.4%, 7.2%, and 10.9%, respectively, by 16 weeks. End systolic volume decreased, whereas heart rate was unaffected. There was a significant increase in blood volume (5.2%) and plasma volume (4.8%) from baseline during treatment, which could explain the increased cardiac output but not the increased ejection fraction. CONCLUSION(S): Hormone replacement therapy causes modest but significant increases in cardiac output, ejection fraction, and left ventricular mass. These pilot data suggest a direct myocardial effect of HRT that is preload independent.

Transvaginal ultrasonographic assessment of Hyskon or lactated Ringer's solution instillation after laparoscopy: randomized, controlled study.

We sought to evaluate two common fluids placed in the pelvis after pelvic surgery for their ability to remain in the pelvis for a time thought adequate for prevention of adhesions. Thirteen patients undergoing operative laparoscopy were randomized to receive 250 ml 32% dextran 70 (Hyskon), 250 ml lactated Ringer's solution, or no fluid (control) at the end of surgery. Serial transvaginal ultrasonograms were obtained at 1 hr, 3 hr, 6 hr, 24 hr, 96 hr (4 days), and 168 hr (7 days) after surgery. Patients were asked about side effects of fluid instillation. The volume of lactated Ringer's solution declined rapidly after instillation, with no significant difference from control at 24 hr (12 ml versus 7 ml). The volume of Hyskon did not decline rapidly by 24 hr and remained higher than the volume in controls or those receiving lactated Ringer's solution (188 ml, P = 0.003). Although the volume of Hyskon remained higher than that of lactated Ringer's solution or fluid volume in control patients by days 4 and 7, this difference did not reach statistical significance (45 ml versus 7 ml and 14 ml respectively, P = 0.39, on day 4). Patients in all groups noted abdominal pain. One patient who received Hyskon developed severe vulvar edema and another developed dyspnea. We conclude that the volume of Hyskon in the peritoneal cavity after laparoscopy does not decline as rapidly as does that of lactated Ringer's solution; however, significant side effects may limit its usefulness. Transvaginal ultrasonography is useful in monitoring fluids placed in the pelvis for prevention of adhesions.

Hysteroscopy versus hysterectomy for the treatment of abnormal uterine bleeding: a comparison of cost.

OBJECTIVE: To compare the costs of hysteroscopic treatment of abnormal uterine bleeding with the costs associated with abdominal and vaginal hysterectomy. DESIGN: Retrospective review. SETTING: Academic medical center and outpatient gynecology practice. PATIENTS: A list of all women undergoing an endometrial ablation (n = 60), hysteroscopic myomectomy (n = 14), abdominal (n = 192), or vaginal (n = 37) hysterectomy between June 1, 1987 and June 1, 1992 for the treatment of abnormal uterine bleeding was generated by a computer search of billing records using the appropriate ICD-9-CM codes. MAIN OUTCOME MEASURE: The direct cost per case for each patient were defined as the sum of the surgeon's fee, all related hospital and operating room charges, the anesthesiologist's fee, and the cost of preoperative medications. When the initial procedure failed, the cost associated with any additional surgery was accounted for in the determination of the direct cost per case. Indirect costs per case were calculated based on known demographic data, recovery time, and the cost in lost productivity during recuperation. Mean direct and indirect costs per case were determined for each procedure and compared. RESULTS: The mean direct cost per case for endometrial ablation was $5,159 and for myomectomy and ablation was $5,525. The direct cost per case was not different between the hysteroscopic procedures but both were significantly less expensive than either vaginal ($8,132) or abdominal ($8,833) hysterectomy. Total hospital cost also was significantly less for the hysteroscopic procedures than for hysterectomy by either technique. The indirect costs associated with the hysteroscopic procedures were significantly less than those incurred by abdominal and vaginal hysterectomy. CONCLUSIONS: The total direct and indirect cost per case of an hysteroscopic approach to the treatment of abnormal uterine bleeding is significantly less than that associated with vaginal or abdominal hysterectomy. This difference persists when the cost of failure of an hysteroscopic procedure is accounted for.

Prognostic significance of morphologic changes of the corpus luteum by transvaginal ultrasound in early pregnancy monitoring.

OBJECTIVE: To determine whether the ultrasound appearance, size, or change in size of the corpus luteum of early pregnancy correlated with serum progesterone, estradiol (E2), or 17-hydroxyprogesterone or were predictive of pregnancy outcome. METHODS: Transvaginal ultrasound assessment of the corpus luteum was performed prospectively on 55 women between 4-8 weeks' gestation. Forty-five (82%) subjects conceived in spontaneous cycles and ten (18%) conceived in cycles stimulated with clomiphene citrate. Fifty-three of 55 (96.4%) women had a second ultrasound assessment 5-8 days later (mean 6.7). Blood was drawn from each patient on the day of the ultrasound examination to measure hormone concentration. RESULTS: The appearance of the corpus luteum (macrocystic [more than 50% cystic], microcystic [less than 50% cystic], or noncystic) was not predictive of hormone concentration or pregnancy outcome. A nonviable pregnancy occurred in five of six (83%) women in whom a corpus luteum was undetectable by ultrasound and in 15 of 49 (31%) women in whom a corpus luteum was present (P = .01). There was no specific corpus luteum volume which could predict pregnancy failure. However, when a decreasing volume from first to second ultrasound examination was observed, 11 of 20 (55%) pregnancies resulted in nonviable outcomes compared to five of 27 (19%) when an increasing volume was observed (P < .01). There was no significant positive correlation between corpus luteum volume and plasma progesterone or 17-hydroxyprogesterone. A weak correlation was observed between corpus luteum volume and E2 (r = 0.38, P = .04). CONCLUSIONS: Our data reveal a lack of correlation between the size of the corpus luteum on ultrasound examination and known steroid products in pregnancies conceived during spontaneous cycles. Corpus luteum volume and steroid products were higher in those patients whose ovulation was induced with clomiphene citrate. Also, different morphologic appearances of the corpus luteum in early human pregnancy, based on the amount of cystic component, have no functional significance. However, a decreasing corpus luteum volume before 8 weeks' gestation is associated with a higher probability of early pregnancy loss.

Clinical correlates of linear growth in children with cerebral palsy.

The purpose of this cross-sectional study was to determine correlates of linear growth in children with cerebral palsy (CP). 171 children with CP were measured and their charts reviewed. z scores were calculated for weight (Wz) and height (Hz). Hz correlated positively with Wz and head circumference, and negatively with age, the presence of spastic quadriplegia, non-ambulation and seizures. The correlation between Hz and age was stronger when non-ambulatory children were analysed separately. Multiple linear regression resulted in only Wz and age contributing significantly to the variance in stature as measured by Hz. These results provide preliminary evidence that nutritional status is a major correlate of growth in CP. The finding that linear growth worsens with age independent of nutrition suggests that other factors also influence growth in CP.

The general medical record. Concepts and suggestions for implementation.

Our view of a general medical record consists of a combination of distinct departmental- and specialty-specific medical records and an organizing kernel that contains arguably critical information. Because this system allows each clinical entity to evolve its own system, clinical priorities do not have to be negotiated or compromised. Additionally, subsystem or departmental medical records can be easily revised without disturbing the general medical record because of the modular design. Although the system seems robust with respect to design considerations, only implementation can provide adequate tests.

Long-term neuropsychological outcome of high risk infants with intracranial hemorrhage.

Evaluated long-term neuropsychological outcome of 20 high risk infants with intracranial hemorrhage (ICH) during the neonatal period who appeared free of significant impairment through 30 months of age. This group was compared with a matched sample of 20 high risk infants without intracranial hemorrhage and a group of 70 children with no history of perinatal or chronic health problems. A comprehensive neuropsychological evaluation at age 5 revealed that the two high risk groups tended to perform at a lower level than the control group across most measures. However, the ICH group performed at a significantly lower level than the control group on measures of perceptual-motor skills and intermodal memory abilities while the high risk group without ICH did not. The implications of differences in level and pattern of performance are discussed along with the implications of the current findings for long-term functioning of high risk infants with ICH.

Predictive validity of a preschool neurodevelopmental instrument.

The Pediatric Examination of Educational Readiness (PEER) is a combined neurodevelopmental, behavioral, and health assessment for children ages 4 to 6 years old. The purpose of this study was to examine its predictive validity. One hundred seven five-year-olds received the PEER at age five. At age eight, all took the Iowa Tests of Basic Skills (ITBS), a nationally normed achievement battery. Mean ITBS scores were significantly different between those passing and failing the PEER Developmental Attainment section (t = 4.5, df = 105, p less than .001). Of six developmental areas sampled, preacademic skills emerged as the most potent predictor of achievement (R = .43, Re = .18, p less than .001). Neuromaturation scores did not correlate with ITBS results. Sensitivity of the PEER was 45%, specificity was 87% and test accuracy was 79%. We conclude that the PEER is useful in describing current developmental strengths and weaknesses but has limited ability in predicting future learning problems for individual children.

Participation by pediatricians in early intervention: impetus from Public Law 99-457.

Part H of the Individuals with Disabilities Education Act (originally enacted as Public Law 99-457) requires that participating states phase in a system of early intervention services by 1993. By recognizing the importance of good health in the development of infants and toddlers, Congress acknowledged the key role of medical care providers in a comprehensive program for young children with or at risk for developmental delay or dysfunction. National and state surveys of pediatricians suggest limited but growing awareness of this legislation and uncertainty about how they might participate effectively. A chief concern relates to mechanisms of payment for developmental screening and assessment as well as time-demands for participation in interdisciplinary team activities. The American Academy of Pediatrics and its state chapters are responding to requests for information with educational seminars and print materials. Pediatricians can enhance the quality of community support services for children with special needs by participating in planning efforts and by coordinating health care with other aspects of early intervention. Other professionals and parents are looking to pediatricians for leadership and willing participation in the implementation of PL 99-457.

The validity of continuing developmental follow-up of high-risk infants to age 5 years.

We conducted a study to determine whether performance on developmental tests at age 5 years could predict academic achievement at age 8 years. As part of a longitudinal developmental surveillance project, 179 children at risk due to perinatal complications who had passed developmental screening through age 2 1/2 years and 50 comparison children underwent an extensive prekindergarten psychoeducational test battery at age 5 years and took the Iowa Tests of Basic Skills at age 8 years, if they had reached the third grade. The mean Iowa Tests of Basic Skills score was significantly lower for those children who were "flagged" on the prekindergarten psychoeducational test battery (t = 5.39). Preacademic, rather than developmental, items appeared to be the best predictors. However, the prekindergarten psychoeducational test battery correctly predicted low achievement or grade retention in only 58% of cases. Its sensitivity was 0.45 and its specificity was 0.85. No significant difference was noted between group Iowa Tests of Basic Skills mean scores for the high-risk or comparison group. When low achievement and failure to reach the third grade were combined, prevalence of "failure" was higher for the high-risk group (31% vs 24%). The only perinatal variable predictive of low achievement was neonatal seizures. In summary, because the ability to predict future academic achievement at age 5 years is limited, routine developmental testing for symptom-free preschool children is not warranted. High-risk infant follow-up programs should focus on the first several years of life.

Neonatal intensive care: is it worth it? Developmental sequelae of very low birthweight.

A significant portion of the health care dollar has been spent on neonatal intensive care since the early 1970s when technologic developments permitted salvage of very small premature infants. The wisdom of allocating so much for so few has been challenged, especially if the result is an increase in the number of severely mentally and motorically disabled children. Studies from around the world of the secular trends in mortality and morbidity for very and extremely low-birthweight babies uniformly indicate that there have been dramatic decreases in mortality and morbidity in the past 20 years. The relative proportion of moderate to severe disability has remained stable during this period of increasing survival potential. Thus, although the absolute numbers of children with disabilities caused by complications of very low birthweight may have increased slightly, they constitute a small minority of the overall number of children with disabilities requiring special educational and other services. Most surviving children with birthweights less than 1500 g remain free of significant functional impairments. It is often difficult for the clinician to identify early or even midway through the neonatal course which infants will have severe, life-long disabilities. By the time identification is feasible, heroic decisions about life supports are no longer called for. Thus, the ethical issues discussed earlier regarding decision-making based on anticipated quality of life become less relevant as the child's condition stabilizes. Given the generally favorable prognosis for even the smallest premature infant, the clinician is probably best advised to give the individual patient the benefit of the doubt. Undoubtedly, there will be exceptions. The more subtle effects of very low birthweight on learning and behavior are just becoming clear as long-term follow-up studies appear in the literature. Very low-birthweight infants who do not manifest severe disability do seem to be at risk for learning problems, although overall cognitive function is in the normal range. There are other effects of preterm birth. On average, stature appears to remain lower, although there may be catch-up growth later in childhood. Having a very low-birthweight infant places considerable stress on the family, but it is unclear whether this has a long-term impact. Studies have failed to show a consistent influence of preterm birth on long-term behavior. Behavior is likely affected more by the social-emotional milieu in which the child is reared than prematurity itself. The environment seems to take over in importance in affecting cognitive functioning after the first several years of life.(ABSTRACT TRUNCATED AT 400 WORDS)