Routine Echocardiography is not Required in Neonates with Arterial Ischemic Stroke.

OBJECTIVE: Current guidelines suggest routine echocardiography (ECHO) in the acute phase to exclude a cardiac source for neonatal arterial ischemic stroke (NAIS). However, the commonly assumed embolic origin from a cardiac source for NAIS is challenged and the need for ECHO in NAIS remains questionable, especially during the era of standard fetal anomaly scanning. Our hypothesis is that any complex cardiac defects potentially causing NAIS would likely be detected during routine prenatal scans, thus possibly making routine postnatal ECHO redundant. This study aimed to determine the prevalence of significant cardiac risk factors and evaluate the necessity of routine postnatal ECHO in NAIS during the routine use of prenatal fetal sonography. STUDY DESIGN: Retrospective review of 54 infants diagnosed with NAIS via brain magnetic resonance imaging who underwent an ECHO evaluation during the acute period to exclude potential cardiac origins for NAIS. RESULTS: Postnatal ECHO revealed no intracardiac thrombus or vegetation, and only identified structural heart anomalies in three (5%) infants. Interestingly, these three cases had already been diagnosed with syndromic conditions or chromosomal malformations prenatally. In the remaining infants, postnatal ECHO was either normal or showed minor abnormalities unlikely to have contributed to the stroke. The detection rates of complex cardiac anomalies from prenatal scans and postnatal ECHO were statistically similar (p = 0.617). CONCLUSION: The probability of ECHO to exclude cardiac sources for NAIS is so low that in the era of standard fetal anomaly scanning, routine postnatal ECHO may not be necessary for all NAIS infants, except when chromosomal malformations are detected. KEY POINTS: · Guidelines recommend an acute phase ECHO to identify a cardiac source of NAIS.. · ECHO not effective at excluding NAIS's cardiac origin for infants with normal fetal scans.. · Routine postnatal ECHO is unnecessary in NAIS infants, except with genetic abnormalities..

Two-Dimensional MOF Modulated Fiber Nanogenerator for Effective Acoustoelectric Conversion and Human Motion Detection.

The real-time application of piezoelectric nanogenerators (PNGs) under a harsh environment remains a challenge due to lower output performance and poor durability. Thus, the development of flexible, sensitive, and stable PNGs became a topic of interest to capture different human motions including gesture monitoring to speech recognition. Herein, a scalable approach is adapted where naphthylamine bridging a [Cd(II)-µ-I4] two-dimensional (2D) metal-organic framework (MOF)-reinforced poly(vinylidene fluoride) (PVDF) composite nanofibers mat is prepared to fabricate a flexible and sensitive composite piezoelectric nanogenerator (C-PNG). The needle-shaped MOF was successfully synthesized by the layering and diffusion of two different solutions. The incorporation of single-crystalline 2D MOF ensures a large content of electroactive phases (98%) with a resultant high-magnitude piezoelectric coefficient of 41 pC/N in a composite nanofibers mat due to the interfacial specific interaction with -CH2-/-CF2- dipoles of PVDF. As an outcome, C-PNG generates high electrical output (open-circuit voltage of 22 V and maximum power density of 24 µW/cm2) with a very fast response time (tr ≈ 5 ms) under periodic pressure imparting stimuli. Benefiting from bending and twisting functionality, C-PNG is capable of scavenging biomechanical energy by mimicking complex musculoskeletal motions that broaden its application in wearable electronics and fabric integrated medical devices. In addition, C-PNG also demonstrates an efficient acoustic vibration to electric energy conversion capability with an improved power density and acoustic sensitivity of 6.25 µW and 0.95 V/Pa, respectively. The overall energy conversion efficiency is sufficient to operate several consumer electronics without any energy storage unit. This acoustic observation is further validated by the finite element method-based theoretical simulation. Overall, the 2D MOF-based device design strategy opens up a new possibility to develop a human-motion compatible energy generator and a self-powered acoustic sensor to power up electronic gadgets as well as low-frequency noise detection.

Three-Dimensional MOF-Assisted Self-Polarized Ferroelectret: An Effective Autopowered Remote Healthcare Monitoring Approach.

In recent years, flexible and sensitive pressure sensors are of extensive interest in healthcare monitoring, artificial intelligence, and national security. In this context, we report the synthetic procedure of a three-dimensional (3D) metal-organic framework (MOF) comprising cadmium (Cd) metals as nodes and isoniazid (INH) moieties as organic linkers (CdI2-INH═CMe2) for designing self-polarized ferroelectret-based highly mechano-sensitive skin sensors. The as-synthesized MOF preferentially nucleates the stable piezoelectric ß-phase in poly(vinylidene fluoride) (PVDF) and also gives rise to a porous ferroelectret composite film. Benefiting from the porous structure of 3D MOFs, composite ferroelectret film-based ultrasensitive pressure sensor (mechano-sensitivity of 8.52 V/kPa within 1 kPa pressure range) as well as high-throughput ( power density of 32 µW/cm2) mechanical energy harvester (MEH) has been designed. Simulation-based finite element method (FEM) analysis indicates that the geometrical stress confinement effect within the interpore region of the ferroelectret structure synergistically influences the mechano-electrical property of the MEH. In addition, 143 pC/N (∼4.5 times higher than commercial piezoelectric PVDF films) piezoelectric charge coefficient (d33) magnitude and superior response time (tr ∼ 8 ms) of this composite ferroelectret film enable the detection of different physiological signals such as coughing, pronunciation, and gulping behavior, making it a promising candidate for early intervention of healthcare, which may play a significant role in accurate alert of influenza and chronic obstructive pulmonary disease (COPD)-related symptoms. In addition, MEH enables the tracking of the subtle pressure change in the wrist pulse, indicating its usefulness in effective mechano-sensitivity. Since the cardiovascular signal is one of the vital parameters that can determine the on-going physiological conditions, the wireless transmission of the detected wrist pulse signal has been demonstrated. All of these features coupled with wireless data transmission indicate the promising application of MOF-assisted composite ferroelectret films in noninvasive real-time remote healthcare monitoring.

Late onset neonatal acute kidney injury: results from the AWAKEN Study.

BACKGROUND: Most studies of neonatal acute kidney injury (AKI) have focused on the first week following birth. Here, we determined the outcomes and risk factors for late AKI (>7d). METHODS: The international AWAKEN study examined AKI in neonates admitted to an intensive care unit. Late AKI was defined as occurring >7 days after birth according to the KDIGO criteria. Models were constructed to assess the association between late AKI and death or length of stay. Unadjusted and adjusted odds for late AKI were calculated for each perinatal factor. RESULTS: Late AKI occurred in 202/2152 (9%) of enrolled neonates. After adjustment, infants with late AKI had higher odds of death (aOR:2.1, p = 0.02) and longer length of stay (parameter estimate: 21.9, p < 0.001). Risk factors included intubation, oligo- and polyhydramnios, mild-moderate renal anomalies, admission diagnoses of congenital heart disease, necrotizing enterocolitis, surgical need, exposure to diuretics, vasopressors, and NSAIDs, discharge diagnoses of patent ductus arteriosus, necrotizing enterocolitis, sepsis, and urinary tract infection. CONCLUSIONS: Late AKI is common, independently associated with poor short-term outcomes and associated with unique risk factors. These should guide the development of protocols to screen for AKI and research to improve prevention strategies to mitigate the consequences of late AKI.

Rapid Evaluation of Integral Quality and Safety of Surface and Waste Waters by a Multisensor System (Electronic Tongue).

The paper describes a wide-range practical application of the potentiometric multisensor system (MS) (1) for integral safety evaluation of a variety of natural waters at multiple locations, under various climatic conditions and anthropogenic stress and (2) for close to real consistency evaluation of waste water purification processes at urban water treatment plants. In total, 25 natural surface water samples were collected around St. Petersburg (Russia), analyzed as is, and after ultrasonic treatment. Toxicity of the samples was evaluated using bioassay and MS. Relative errors of toxicity assessment with MS in these samples were below 20%. The system was also applied for fast determination of integral water quality using chemical oxygen demand (COD) values in 20 samples of water from river and ponds in Kolkata (India) and performed with an acceptable precision of 20% to 22% in this task. Furthermore, the MS was applied for fast simultaneous evaluation of COD, biochemical oxygen demand, inorganic phosphorous, ammonia, and nitrate nitrogen at two waste water treatment plants (over 320 samples). Reasonable precision (within 25%) of such analysis is acceptable for rapid water safety evaluation and enables fast control of the purification process. MS proved to be a practicable analytical instrument for various real-world tasks related to water safety monitoring.

Outcome of Preterm Infants with Transient Cystic Periventricular Leukomalacia on Serial Cranial Imaging Up to Term Equivalent Age.

OBJECTIVE: To determine the outcome of preterm infants whose cystic periventricular leukomalacia "disappeared" on serial screening cranial imaging studies. STUDY DESIGN: Infants ≤26 weeks of gestation born between 2002 and 2012 who had cranial imaging studies at least twice, the most abnormal study at <28 days of age and another closest to 36 weeks, were reviewed. The outcome of late death (after 36 weeks postmenstrual age) or neurodevelopmental impairment (NDI) in surviving infants at 18-26 months corrected age was compared between the infants with no cystic periventricular leukomalacia on both studies and cystic periventricular leukomalacia that disappeared (cystic periventricular leukomalacia at <28 days but not at 36 weeks), persisted (cystic periventricular leukomalacia on both studies), or appeared late (cystic periventricular leukomalacia only at 36 weeks). Predictors of NDI were evaluated by logistic regression. RESULTS: Of 7063 eligible infants, 433 (6.1%) had cystic periventricular leukomalacia. Among the 433 infants with cystic periventricular leukomalacia, cystic periventricular leukomalacia disappeared in 76 (18%), persisted in 87 (20%), and 270 (62%) had late cystic periventricular leukomalacia. Loss to follow-up ranged between 3% and 13%. Death or NDI was more common in infants with disappeared cystic periventricular leukomalacia compared with those with no cystic periventricular leukomalacia (38 of 72 [53%] vs 1776 of 6376 [28%]; OR [95% CI] 2.8 [1.8-4.6]). Disappeared, persistent, and late cystic periventricular leukomalacia were all also independently associated with NDI (OR 1.17, 1.21, and 1.16, respectively). CONCLUSIONS: Infants with "disappeared" cystic periventricular leukomalacia are at increased risk of adverse outcome similar to infants with persistent or late cystic periventricular leukomalacia.

Assessment of association between rapid fluctuations in serum sodium and intraventricular hemorrhage in hypernatremic preterm infants.

AIM: This study aims to determine the association between the rapid fluctuations in serum sodium and intraventricular hemorrhage (IVH) or death in hypernatremic preterm infants. STUDY DESIGN: Single center observational study including 216 infants < 1,000 g birth weight and <29 weeks gestational age, who had serum sodium levels monitored at least every 12 hours. Logistic regression analyses were used to identify which of the commonly cited risk factors for IVH, including the rapid (to the extent of ≥10 and ≥15 mmol/L/d) rise or fall in serum sodium, was associated with the primary outcome of any IVH, or the secondary composite outcome of severe IVH or death during the first 10 days of life in hypernatremic infants. RESULTS: Of 216 infants, 126 (58%) studied developed hypernatremia (serum sodium ≥ 150 mmol/L). IVH was more frequent in hypernatremic infants (p = 0.01). Presence of hypernatremia was an independent risk factor for IVH on logistic regression analysis (p = 0.022, odds ratio 2.0, 95% confidence interval: 1.1-3.8). Rapid (≥ 10 and ≥ 15 mmol/L/d) rise or fall in serum sodium in hypernatremic infants was not associated with the outcomes. CONCLUSION: Hypernatremia per se, but not the rapid fluctuations (not exceeding 10-15 mmol/L/d) in serum sodium was independently associated with IVH.

Does maternal intrapartum antibiotic treatment prolong the incubation time required for blood cultures to become positive for infants with early-onset sepsis?

BACKGROUND: We hypothesized that maternal intrapartum antibiotic treatment delays the growth of the organism in the blood culture obtained during the work-up for infants with suspected early-onset sepsis (EOS). METHODS: Single center, retrospective review of infants with blood culture-proven EOS over 13.5 years period. EOS was defined by isolation of a pathogen from blood culture obtained within 72 hours of birth and antibiotic treatment for ≥ 5 days. RESULTS: Among 81 infants with positive blood cultures, 38 were deemed to have EOS and 43 were deemed contaminants. The organisms grown were as follows: Escherichia coli in 17 infants, Group B streptococcus in 10 infants, and others in 11 infants. Overall, 17 infants with EOS did not receive intrapartum antibiotics and had blood cultures drawn for being symptomatic after birth. The other 21 infants who received intrapartum antibiotics had blood culture drawn primarily for maternal chorioamnionitis. The median (interquartile range [IQR]) incubation time to blood culture positivity was not different in infants who received intrapartum antibiotics compared with infants who did not (19.6 hours, IQR 16-28 hours vs. 19.5 hours, IQR 17.2-21.6 hours, p = 0.7489). CONCLUSION: Maternal intrapartum antibiotic treatment did not delay the time to blood culture positivity in infants with EOS.

Screening Cranial Imaging at Multiple Time Points Improves Cystic Periventricular Leukomalacia Detection.

OBJECTIVE: The aim of this study is to determine whether the cystic periventricular leukomalacia (cPVL) detection rate differs between imaging studies performed at different time points. DESIGN: We retrospectively reviewed the prospectively collected data of 31,708 infants from the NICHD Neonatal Research Network. Inclusion criteria were infants < 1,000 g birth weight or < 29 weeks' gestational age who had cranial imaging performed using both early criterion (cranial ultrasound [CUS] < 28 days chronological age) and late criterion (CUS, magnetic resonance imaging, or computed tomography closest to 36 weeks postmenstrual age [PMA]). We compared the frequency of cPVL diagnosed by early and late criteria. RESULTS: About 664 (5.2%) of the 12,739 infants who met inclusion criteria had cPVL using either early or late criteria; 569 using the late criterion, 250 using the early criterion, and 155 patients at both times. About 95 (14.3%) of 664 cPVL cases seen on early imaging were no longer visible on repeat screening closest to 36 weeks PMA. Such disappearance of cPVL was more common in infants < 26 weeks' gestation versus infants of 26 to 28 weeks' gestation (18.5 vs. 11.5%; p = 0.013). CONCLUSIONS: Cranial imaging at both < 28 days chronological age and closest to 36 weeks PMA improves cPVL detection, especially for more premature infants.

Relationship between acute kidney injury and brain MRI findings in asphyxiated newborns after therapeutic hypothermia.

BACKGROUND: We hypothesized that acute kidney injury (AKI) in asphyxiated neonates treated with therapeutic hypothermia would be associated with hypoxic-ischemic lesions on brain magnetic resonance imaging (MRI). METHODS: Medical records of 88 cooled neonates who had had brain MRI were reviewed. All neonates had serum creatinine assessed before the start of cooling; at 24, 48, and 72 h through cooling; and then on day 5 or 7 of life. A neonatal modification of the Kidney Disease: Improving Global Outcomes guidelines was used to classify AKI. MRI images were evaluated by a neuroradiologist masked to outcomes. Outcome of interest was abnormal brain MRI at 7-10 d of life. RESULTS: AKI was found in 34 (39%) of 88 neonates, with 15, 7, and 12 fulfilling criteria for stages 1, 2, and 3, respectively. Brain MRI abnormalities related to hypoxia-ischemia were present in 50 (59%) newborns. Abnormal MRI was more frequent in infants from the AKI group (AKI: 25 of 34, 73% vs. no AKI: 25 of 54, 46%; P = 0.012; odds ratio (OR) = 3.2; 95% confidence interval (CI) = 1.3-8.2). Multivariate analysis identified AKI (OR = 2.9; 95% CI = 1.1-7.6) to be independently associated with the primary outcome. CONCLUSION: AKI is independently associated with the presence of hypoxic-ischemic lesions on postcooling brain MRI.

Cr-Detector: A simple chemosensing system for onsite Cr (VI) detection in water.

Due to the increase in urbanization and industrialization, the load of toxicants in the environment is alarming. The most common toxicants, including heavy metals and metalloids such as hexavalent Chromium, have severe pathophysiological impacts on humans and other aquatic biotas. Therefore, developing a portable rapid detection device for such toxicants in the aquatic environment is necessary. This work portrays the development of a field-portable image analysis device coupled with 3,3',5,5'-tetramethylbenzidine (TMB) as a sensing probe for chromium (VI) detection in the aquatic ecosystem. Sensor parameters, such as reagent concentration, reaction time, etc., were optimized for the sensor development and validation using a commercial UV-Vis spectrophotometer. The chemoreceptor integrated with a uniform illumination imaging system (UIIS) revealed the system's applicability toward Cr(VI) detection. The calibration curve using the R-value of image parameters allows Cr(VI) detection in the linear range of 25 to 600 ppb, which covers the prescribed permissible limit by various regulatory authorities. Furthermore, the adjusted R2 = 0.992 of the linear fit and correlation coefficients of 0.99018 against the spectrophotometric method signifies the suitability of the developed system. This TMB-coupled field-portable sensing system is the first-ever reported image analysis-based technology for detecting a wide range of Cr(VI) in aquatic ecosystems to our knowledge.

Esophageal and rectal temperatures as estimates of core temperature during therapeutic whole-body hypothermia.

We monitored whole-body cooling concurrently by both esophageal and rectal probes. Esophageal temperature was significantly higher compared with simultaneous rectal temperature during cooling, with a temperature gradient ranging from 0.46 to 1.03°C (median, 0.8°C; IQR, 0.6-0.8°C). During rewarming, this temperature difference disappeared.

Acute kidney injury in asphyxiated newborns treated with therapeutic hypothermia.

OBJECTIVE: To test the hypothesis that acute kidney injury (AKI) would be independently associated with increased morbidity and mortality. STUDY DESIGN: A total of 96 consecutively cooled infants were reviewed retrospectively. Modified Acute Kidney Injury Network criteria were used to classify AKI based on absolute rise in serum creatinine (SCr) level from a previous trough (stage I, rise in SCr of 0.3 mg/dL or SCr 150-<200%; stage II, rise in SCr of 200-<300%; stage III, rise in SCr of ≥300%, SCr 2.5 mg/dL, or dialysis). Outcomes were mortality, duration of neonatal intensive care unit (NICU) stay, and duration of mechanical ventilation. RESULTS: AKI occurred in 36 of 96 infants (38%). Overall mortality was 7% and was higher for those with AKI, with the difference approaching statistical significance (14% vs 3% in those without AKI; P = .099). Patients with AKI stayed longer in the NICU (mean, 15.4 ± 9.3 days vs 11 ± 5.9 days; P = .014) and required prolonged mechanical ventilation (mean, 9.7 ± 5.9 days vs 4.8 ± 3.7 days; P < .001). On multivariate analysis, AKI remained predictive of prolonged duration of mechanical ventilation and prolonged NICU stay. CONCLUSION: We used the Acute Kidney Injury Network definition for AKI in asphyxiated newborns undergoing therapeutic hypothermia to demonstrate that the incidence of AKI remains high, but lower than rates published before the advent of therapeutic hypothermia. We highlight the importance of recognizing AKI in asphyxiated newborns undergoing therapeutic hypothermia, along with the potential benefits of early recognition.

Salt stress resilience in plants mediated through osmolyte accumulation and its crosstalk mechanism with phytohormones.

Salinity stress is one of the significant abiotic stresses that influence critical metabolic processes in the plant. Salinity stress limits plant growth and development by adversely affecting various physiological and biochemical processes. Enhanced generation of reactive oxygen species (ROS) induced via salinity stress subsequently alters macromolecules such as lipids, proteins, and nucleic acids, and thus constrains crop productivity. Due to which, a decreasing trend in cultivable land and a rising world population raises a question of global food security. In response to salt stress signals, plants adapt defensive mechanisms by orchestrating the synthesis, signaling, and regulation of various osmolytes and phytohormones. Under salinity stress, osmolytes have been investigated to stabilize the osmotic differences between the surrounding of cells and cytosol. They also help in the regulation of protein folding to facilitate protein functioning and stress signaling. Phytohormones play critical roles in eliciting a salinity stress adaptation response in plants. These responses enable the plants to acclimatize to adverse soil conditions. Phytohormones and osmolytes are helpful in minimizing salinity stress-related detrimental effects on plants. These phytohormones modulate the level of osmolytes through alteration in the gene expression pattern of key biosynthetic enzymes and antioxidative enzymes along with their role as signaling molecules. Thus, it becomes vital to understand the roles of these phytohormones on osmolyte accumulation and regulation to conclude the adaptive roles played by plants to avoid salinity stress.

The relationship between clinically identifiable intrapartum sentinel events and short-term outcome after therapeutic hypothermia.

OBJECTIVE: To determine the impact of intrapartum sentinel events on short-term outcome post-hypothermia. STUDY DESIGN: Records of 77 infants of 36 weeks' gestation or more, who received therapeutic hypothermia, were reviewed. Some were delivered after a clinically identifiable intrapartum sentinel event (IISE). All survivors had brain magnetic resonance imaging (MRI) at 7 to 10 days of life. The primary outcome of neonatal death related to hypoxic-ischemic encephalopathy was compared in infants born with (n = 39) or without an IISE (n = 38). MRI abnormalities were also compared. Logistic regression analysis was used to determine the variables predicting the primary outcome. RESULTS: The two groups had similar Apgar scores, initial blood pHs, and early neurologic examinations. Base deficit was more severe in the IISE group. Neonatal death and hypoxic-ischemic injury was shown on brain MRI with basal nuclei, cortical, and subcortical white matter lesions extending beyond the watershed areas in infants surviving beyond the neonatal period were more common in the IISE group (P = .014; OR 11.1; 95% CI 1.3-92.6; and P = .034; OR 4.1; 95% CI 1.1-14.9, respectively). Multivariate analysis identified IISE (P = .023; OR 12.2; 95% CI 1.4-105.8) to be independently associated with neonatal death. CONCLUSIONS: IISEs are associated with neonatal death and severe injury as shown in brain MRI, even after hypothermia.

Clinical course of symptomatic spontaneous pneumothorax in term and late preterm newborns: report from a large cohort.

The purpose of this observational study was to characterize the clinical course of newborn infants with spontaneous pneumothorax and to identify those infants who eventually required further interventions. We performed a retrospective review of newborns with symptomatic spontaneous pneumothorax, born between January 2002 and December 2007. Seventy-six infants ≥36 weeks' gestation were identified with symptomatic spontaneous pneumothorax. Twenty-two (29%) of the 76 infants with spontaneous pneumothorax required either thoracentesis or/and thoracostomy drainage, and 54 (71%) were managed without such intervention. In all, 18 (24%) infants received mechanical ventilation and 12 (16%) infants developed persistent pulmonary hypertension (PPHN) during the course of illness. Ten of the 22 infants requiring thoracentesis and/or thoracostomy for progressively worsening respiratory distress developed PPHN. Seven of these 10 infants with PPHN received inhaled nitric oxide, and four infants subsequently required extracorporeal membrane oxygenation. In contrast, the majority of the infants (50 of 54, 93%) not requiring thoracentesis or/and thoracostomy could be managed simply with supplemental oxygen or close observation. Progressively worsening respiratory distress prompting intervention in infants with spontaneous pneumothorax may indicate presence of PPHN that needs prompt recognition and referral to tertiary-level neonatal units for escalating respiratory support.

Transient neonatal myasthenia gravis: refining risk estimate for infants born to women with myasthenia gravis.

OBJECTIVE: Transient neonatal myasthenia gravis (TNMG) can render a neonate vulnerable to catastrophic respiratory depression. Our aim was to describe the clinical manifestations of TNMG, and to determine when the myasthenic signs become apparent in TNMG. METHODS: We reviewed our own experience of infants who underwent routine inpatient monitoring for TNMG and combined our local data with observations from previous studies. RESULTS: Only three case series (n = 110) reported both the type and timing of onset of myasthenic signs. Adding local data (n = 37) yielded 147 infants born to women with MG. Fifteen infants (10%) developed signs of TNMG with onset being 1.5 ± 2.6 days (mean ± 3SD) after birth. Feeding difficulties and low tone were the commonest presenting signs, and only 1 of the 147 infants needed intubation for hypoventilation. CONCLUSIONS: TNMG signs were mostly not life-threatening. We suggest only 4 days of routine postnatal observation for infants born to women with MG.

Brainstem hypoxic-ischemic lesions on MRI in infants treated with therapeutic cooling: effects on the length of stay and mortality.

OBJECTIVE: To test the hypothesis that brainstem hypoxic-ischemic injury on magnetic resonance imaging (MRI) would be independently associated with short-term outcomes in cooled asphyxiated infants. METHODS: A total of 90 consecutively cooled asphyxiated infants who survived to have brain MRI were reviewed. A neuroradiologist who was masked to outcomes evaluated MRI images for brainstem involvement. Outcomes were mortality and length of stay. RESULTS: Brainstem lesions were present on post-cooling brain MRI in 20 of the 90 infants (22%). Overall, four infants died before discharge, and all four had brainstem involvement. The infants with brainstem involvement had longer hospital stay (29 days, IQR 20-47 versus 16 days, IQR 10-26; P = 0.0001), compared to infants without brainstem lesions (n = 70); and upon multivariate analysis, brainstem involvement remained independently associated with prolonged hospital stay (ß = 12.4, P = 0.001). CONCLUSION: This study demonstrates the importance of recognizing brainstem injury for the prediction of short-term outcomes in cooled asphyxiated infants.

Severe intraventricular hemorrhage in preterm infants: comparison of risk factors and short-term neonatal morbidities between grade 3 and grade 4 intraventricular hemorrhage.

Grade 3 intraventricular hemorrhage (IVH) (without parenchymal involvement) and grade 4 IVH (with parenchymal involvement) are often combined into description of a single entity, usually "severe" IVH, despite different long-term neurodevelopmental outcome. Although risk factors for severe IVH have already been well described, it is not known if these risk factors and associated short-term neonatal morbidities are different for grade 3 and grade 4 IVH, and indeed, this clustering of grade 3 and grade 4 IVH into severe IVH precludes further delineation of the potential risk and protective factors that can be altered to reduce the incidence of grade 4 IVH, which is presumably associated with worse outcome compared with grade 3 IVH. We sought to characterize and compare commonly cited risk factors and associated short-term neonatal morbidities between grade 3 and grade 4 IVH in very low-birth-weight (VLBW) infants. We performed a retrospective review of VLBW (birth weight < 1500 g) infants with severe IVH born between January 2001 and March 2007. Fifty-nine (10.5%) of 562 infants surviving beyond 3 days of age had severe IVH as recorded on routine cranial sonography during the first 7 to 10 days of life, 28 had grade 3, and 31 had grade 4 IVH. Infants with grade 4 IVH were younger [gestational age (weeks), grade 4 IVH versus grade 3 IVH: 25.5 +/- 1.7 versus 26.7 +/- 1.7, p = 0.02) and weighed less at birth [birth weight (g), grade 4 IVH versus grade 3 IVH: 860 +/- 214 versus 1007 +/- 253, p = 0.03) compared with infants with grade 3 IVH. Other commonly cited clinical factors that alter the risk for severe IVH, including mode of delivery, pregnancy-induced hypertension, premature and/or prolonged rupture of membranes, maternal fever, maternal bleeding, prenatal steroid administration, maternal magnesium sulfate therapy, 1-minute and 5-minute Apgar scores, need for delivery room resuscitation (epinephrine and chest compressions), surfactant therapy, presence of refractory hypotension, evidence of early onset culture-proven sepsis, use of high-frequency ventilation, presence of pneumothorax, and hemodynamically significant patent ductus arteriosus, were similar between infants with grade 3 and grade 4 IVH. Carbon dioxide tensions (minimum PaC (2), maximum PaCO(2), mean PaCO(2), standard deviation of PaCO(2), and coefficient of variation of PaCO (2)) in infants receiving mechanical ventilation during first 3 postnatal days were also not statistically dissimilar. To determine the variables differentiating grade 3 from grade 4 IVH in the study population, logistic regression analysis confirmed only the independent association of gestational age (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.5 to 0.9, P = 0.012) and maternal magnesium sulfate therapy (OR 0.3, 95% CI 0.07 to 0.9, P = 0.04) with the development of grade 4 IVH. Short-term neonatal morbidities were also similar between infants with grade 3 and grade 4 IVH. Among VLBW infants, the risk of a grade 4 versus grade 3 IVH increases with declining gestational age, but does not appear to be related to other commonly cited clinical factors. This information may be useful for prognostication and may improve the quality of parental counseling.

Pulmonary dysfunction and therapeutic hypothermia in asphyxiated newborns: whole body versus selective head cooling.

Compared with whole body cooling (WBC), selective head cooling (SHC) of asphyxiated newborns presumably allows effective brain cooling with less systemic hypothermia and potentially fewer systemic adverse effects. It is not known if pulmonary dysfunction, one of the potential adverse systemic effects of therapeutic hypothermic neuroprotection, differs with the method of cooling. We sought to investigate if pulmonary mechanics and gas exchange during therapeutic hypothermia differ between WBC and SHC. The severity of pulmonary dysfunction was determined in 59 asphyxiated newborns receiving therapeutic hypothermic neuroprotection by either SHC ( N = 31) or WBC ( N = 28). Ventilatory parameters and simultaneous alveolar-arterial oxygen gradient (A-a DO (2)) and partial pressure of carbon dioxide, arterial (PaCO (2)) were measured before the start of cooling (baseline), and at 4, 8, 12, 24, 48, and 72 hours of cooling. The diagnosis of persistent pulmonary hypertension of the newborn (PPHN) was established by echocardiography. Clinical monitoring and treatment during cooling, whether SHC or WBC, were similar. All (96%) but two infants (from the SHC group) required mechanical ventilation of varying duration during cooling, and nine infants (15%) developed PPHN. The baseline ventilator pressures requirement, and A-a DO (2) were similar among the 48 ventilated infants without PPHN (WBC 23, SHC 25) at the start of cooling. Ventilatory requirements remained modest and did not differ with the method of cooling. Similar numbers of infants without PPHN were able to be extubated after improvement in respiratory status while being cooled (WBC 42.8% versus SHC 37.9%, P = 0.79, odds ratio [OR] 1.2, 95% confidence interval [CI] 0.4 to 3.5). Nine infants (WBC 5, SHC 4) developed PPHN. Six of the nine (WBC 4, SHC 2) required inhaled nitric oxide therapy, and one infant from the WBC group subsequently required extracorporeal membrane oxygenation. The incidence of PPHN was similar in both the WBC and SHC groups (17.8% versus 12.9%, P = 0.72, OR 1.5, 95% CI 0.3 to 6.1). Pulmonary dysfunction is common but not severe in asphyxiated infants during therapeutic hypothermia. Pulmonary mechanics and gas exchange do not differ with the method of achieving hypothermia.