Does the Head Position Affect Neonatal Lateral Ventricular Volume?

OBJECTIVE: This study aimed to determine whether there are differences in the lateral ventricular volumes, measured by three-dimensional ultrasound (3D US) depending on the posture of the neonate (right and left lateral decubitus). STUDY DESIGN: This was a prospective analysis of the lateral ventricular volumes of preterm neonates recruited from Victoria Hospital, London, Ontario (June 2018-November 2019). A total of 24 premature neonates were recruited. The first cohort of 18 unstable premature neonates were imaged with 3D US in their current sides providing 15 right-sided and 16 left-sided 3D US images. The neonates in the second cohort of six relatively stable infants were imaged after positioning in each lateral decubitus position for 30 minutes, resulting in 40 3D US images obtained from 20 posture change sessions. The images were segmented and the ventricle volumes in each lateral posture were compared with determine whether the posture of the head influenced the volume of the upper and lower ventricle. RESULTS: For the first cohort who did not have their posture changed, the mean of the right and left ventricle volumes were 23.81 ± 15.51 and 21.61 ± 16.19 cm3, respectively, for the 15 images obtained in a right lateral posture and 13.96 ± 8.69 and 14.92 ± 8.77 cm3, respectively, for the 16 images obtained in the left lateral posture. Similarly, for the second cohort who had their posture changed, the mean of right and left ventricle volumes were 20.92 ± 17.3 and 32.74 ± 32.33 cm3, respectively, after 30 minutes in the right lateral posture, and 21.25 ± 18.4 and 32.65 ± 31.58 cm3, respectively, after 30 minutes in the left lateral posture. Our results failed to show a statistically significant difference in ventricular volumes dependence on posture. CONCLUSION: Head positioned to any lateral side for 30 minutes does not have any effect on the lateral ventricular volumes of neonates. KEY POINTS: · Three-dimensional cranial ultrasound can measure neonatal ventricle volume.. · Ventricle volume in each lateral ventricle may be affected by posture of the neonate.. · The 30 minutes in any lateral posture is not sufficient to create volume difference in lateral ventricles..

Interventions for increasing solid organ donor registration.

BACKGROUND: A solution for increasing the number of available organs for transplantation is to encourage more individuals to register a commitment for deceased organ donation. However, the percentage of the population registered for organ donation remains low in many countries. OBJECTIVES: To evaluate the benefits and harms of various interventions used to increase deceased organ donor registration. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 11 August 2020 through contact with an Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: We included all randomised controlled trials (RCTs), cluster RCTs and quasi-RCTs of interventions to promote deceased organ donor registration. We included studies if they measured self-reported or verified donor registration, intention to donate, intention to register a decision or number of individuals signing donor cards as outcomes. DATA COLLECTION AND ANALYSIS: Two authors independently assessed retrieved studies and extracted data from included studies. We assessed studies for risk of bias. We obtained summary estimates of effect using a random-effects model and expressed results as risk ratios (RR) (95% confidence intervals; CI) for dichotomous outcomes and mean difference (MD; 95% CI) or standardised mean difference (SMD; 95% CI) for continuous outcomes. In multi-arm trials, data were pooled to create single pair-wise comparisons. Analyses were stratified by specific intervention setting where available. MAIN RESULTS: Our search strategy identified 46 studies (47 primary articles, including one abstract) comprising 24 parallel RCTs, 19 cluster RCTs and 3 quasi-RCTs. Sample sizes ranged from 138 to 1,085,292 (median = 514). A total of 16 studies measured registration behaviour, 27 measured intention to register/donate and three studies measured both registration behaviour and intention to register. Interventions were delivered in a variety of different settings: schools (14 studies), driver's motor vehicle (DMV) centres (5), mail-outs (4), primary care centres (3), workplaces (1), community settings (7) and general public (12). Interventions were highly varied in terms of their content and included strategies such as educational sessions and videos, leveraging peer leaders, staff training, message framing, and priming. Most studies were rated as having high or unclear risk of bias for random sequence generation and allocation concealment and low risk for the remainder of the domains. Data from 34/46 studies (74%) were available for meta-analysis. Low certainty evidence showed organ donation registration interventions had a small overall effect on improving registration behaviour (16 studies, 1,294,065 participants: RR 1.30, 95% CI 1.19 to 1.43, I2 = 84%), intention to register/donate (dichotomous) (10 studies, 10,838 participants: RR 1.21, 95% CI 1.03 to 1.42, I2 = 91%) and intention to register/donate (continuous) (9 studies, 3572 participants: SMD 0.23, 95% CI 0.11 to 0.36, I2 = 67%). Classroom-based interventions delivered in a lecture format by individuals from the transplant community may be effective at increasing intention to register/donate (3 studies, 675 participants: RR 1.33, 95% CI 1.15 to 1.55, I² = 0%). Community interventions targeting specific ethnic groups were generally effective at increasing registration rates (k = 5, n = 4186; RR 2.14, 95% CI 1.35 to 3.40, I² = 85%), although heterogeneity was high. In particular, interventions delivered in the community by trained peer-leaders appear to be effective (3 studies, 3819 participant: RR 2.09, 95% CI 1.08 to 4.06, I² = 87%), although again, the data lacked robustness. There was some evidence that framing messages (e.g. anticipated regret) and priming individuals (e.g. reciprocity) in a certain way may increase intention to register/donate, however, few studies measured this effect on actual registration. Overall, the studies varied significantly in terms of design, setting, content and delivery. Selection bias was evident and a quarter of the studies could not be included in the meta-analysis due to incomplete outcome data reporting. No adverse events were reported. AUTHORS' CONCLUSIONS: In our review, we identified a variety of approaches used to increase organ donor registration including school-based educational sessions and videos, leveraging peer leaders in the community, DMV staff training, targeted messaging and priming. The variability in outcome measures used and incompleteness in reporting meant that most data could not be combined for analysis. When data were combined, overall effect sizes were small in favour of intervention groups over controls, however, there was significant variability in the data. There was some evidence that leveraging peer-leaders in the community to deliver organ donation education may improve registration rates and classroom-based education from credible individuals (i.e. members of the transplant community) may improve intention to register/donate, however, there is no clear evidence favouring any particular approach. There was mixed evidence for simple, low-intensity interventions utilising message framing and priming. However, it is likely that interest in these strategies will persist due to their reach and scalability. Further research is therefore required to adequately address the question of the most effective interventions for increasing deceased organ donor registration.

Does ventricular volume affect the neurodevelopmental outcome in infants with intraventricular hemorrhage?

OBJECTIVE: The aim of this study is to investigate whether ventricular volume in posthemorrhagic ventricle dilatation impacts neurodevelopmental outcome. Infants were scanned with 3D cranial ultrasound in the first few months of life, and their neurodevelopmental outcome at 4, 8, 12, and 24 months corrected age (CA) was examined. METHODS: Forty-nine infants who suffered an intraventricular hemorrhage (IVH) were enrolled in the study. Subjects were scanned multiple times during their stay in the neonatal intensive care unit. Images were manually segmented to measure total volume of the lateral ventricles, and the highest volume was taken. Infants with a volume ≤ 20 cc were considered low-volume (n = 33), and infants with a volume ≥ 40 cc were considered high-volume (n = 12). Developmental outcome was assessed at 4, 8, and 12 months CA with the Alberta Infant Motor Scale (AIMS) and Infant Neurological International Battery (Infanib), and at 24 months CA with the Bayley Scales of Infant Development 3e (BSID III). RESULTS: Infants in the low-volume group had higher scores on the Infanib at 4 months CA, and on both the AIMS and Infanib at 8 and 12 months CA, even after controlling for gestational age, birth weight, and worst grade of IVH. We observed a trend where low-volume infants also scored higher on the cognitive and gross-motor subtests of the BSID III at 24 months CA. CONCLUSION: Our results show that ventricular volume affects neurodevelopmental outcome in infants with IVH. This finding could guide the timing of future interventions, as earlier intervention may decrease the likelihood of adverse neurodevelopmental outcome.

Three-dimensional cranial ultrasound and functional near-infrared spectroscopy for bedside monitoring of intraventricular hemorrhage in preterm neonates.

Germinal Matrix-Intraventricular Hemorrhage (GMH-IVH) remains a significant cause of adverse neurodevelopment in preterm infants. Current management relies on 2-dimensional cranial ultrasound (2D cUS) ventricular measurements. Reliable biomarkers are needed to aid in the early detection of posthemorrhagic ventricular dilatation (PHVD) and subsequent neurodevelopment. In a prospective cohort study, we incorporated 3-dimensional (3D) cUS and functional near-infrared spectroscopy (fNIRS) to monitor neonates with GMH-IVH. Preterm neonates (≤ 32 weeks' gestation) were enrolled following a GMH-IVH diagnosis. Neonates underwent sequential measurements: 3D cUS images were manually segmented using in-house software, and the ventricle volumes (VV) were extracted. Multichannel fNIRS data were acquired using a high-density system, and spontaneous functional connectivity (sFC) was calculated. Of the 30 neonates enrolled in the study, 19 (63.3%) had grade I-II and 11 (36.7%) grade III-IV GMH-IVH; of these, 7 neonates (23%) underwent surgical interventions to divert cerebrospinal fluid (CSF). In infants with severe GMH-IVH, larger VV were significantly associated with decreased |sFC|. Our findings of increased VV and reduced sFC suggest that regional disruptions of ventricular size may impact the development of the underlying white matter. Hence, 3D cUS and fNIRS are promising bedside tools for monitoring the progression of GMH-IVH in preterm neonates.

Can ventricular 3D ultrasound of neonates with posthemorrhagic hydrocephalus inform on the need for a ventriculoperitoneal shunt?

OBJECTIVE: Some neonates born prematurely with intraventricular hemorrhage develop posthemorrhagic hydrocephalus and require lifelong treatment to divert the flow of CSF. Early prediction of the eventual need for a ventriculoperitoneal shunt (VPS) is difficult, and early discussions with families are based on statistics and the grade of hemorrhage. The authors hypothesize that change in ventricular volume during ventricular taps that is measured with repeated 3D ultrasound (3D US) imaging of the lateral ventricles could be used to assess the risk of the future requirement of a VPS. METHODS: A total of 92 neonates with intraventricular hemorrhage who were treated in the NICU were recruited between April 2012 and November 2019. Only patients who required ventricular taps (VTs) were included in this study, resulting in the analysis of 19 patients with a total of 61 VTs. Among them, 14 patients were treated with a VPS, and in 5 patients the hydrocephalus resolved spontaneously. Parameters studied were total ventricular volume measured with 3D US, ventricular volume change after VT, the ratio between volume reduction and tap amount, the difference between tap amount and volume reduction after tap, the average tap amount, the average number of days between taps, pre-tap head circumference, and reduction in head circumference after tap. RESULTS: Statistically significant differences were found in ventricular volume reduction after tap (p = 0.007), the ratio between volume reduction and tap amount (p = 0.03), the difference between tap amount and volume reduction after tap (p = 0.05), and the interval of days between taps (p = 0.0115). CONCLUSIONS: Measuring with 3D US before and after VT can be a useful tool for quantifying ventricular volume. The findings in this study showed that neonates who experience a large reduction of ventricular volume after VT are more likely to be treated with a shunt than are neonates who experience a small reduction.

Influence of a patient navigation program on timeliness of care in patients with esophageal cancer.

BACKGROUND: Patient navigation (P.N.) is designed to eliminate barriers to care. The objective of this study was to evaluate the impact of a novel P.N. program on timeliness of care in patients with esophageal cancer. METHODS: This retrospective study compared the timeliness of care for esophageal cancer patients before (January 2014-March 2018) and after the implementation of a novel P.N. program (April 2018-March 2020), called EDAP, at a tertiary care center. The primary outcome was time from biopsy to first treatment; secondary outcomes included time from biopsy to complete staging, biopsy to complete preoperative workup, and referral to the first point of contact. The outcomes were evaluated in the entire cohort and then in a subgroup of patients undergoing curative multimodality therapy. RESULTS: There were 96 patients in the pre-EDAP group and 98 patients in the post-EDAP group. There was no significant difference between pre- and post-EDAP in the time from biopsy to first treatment and time from biopsy to staging in the overall cohort. In the subgroup of patients undergoing curative multimodality therapy, there was a significant decrease in time from biopsy to first treatment postnavigation (60-51 days, p = 0.02), in addition to a significant decrease in time from biopsy to preoperative workup and time from biopsy to staging. CONCLUSIONS: This is the first study demonstrating that a novel P.N. program for patients with esophageal cancer improved timeliness of care. The group of patients who benefited most were those undergoing curative multimodality therapy, likely given the extensive coordination of services required by this group.

Presurgical brain mapping of the language network in pediatric patients with epilepsy using resting-state fMRI.

OBJECTIVE: Epilepsy affects neural processing and often causes intra- or interhemispheric language reorganization, rendering localization solely based on anatomical landmarks (e.g., Broca's area) unreliable. Preoperative brain mapping is necessary to weigh the risk of resection with the risk of postoperative deficit. However, the use of conventional mapping methods (e.g., somatosensory stimulation, task-based functional MRI [fMRI]) in pediatric patients is technically difficult due to low compliance and their unique neurophysiology. Resting-state fMRI (rs-fMRI), a "task-free" technique based on the neural activity of the brain at rest, has the potential to overcome these limitations. The authors hypothesized that language networks can be identified from rs-fMRI by applying functional connectivity analyses. METHODS: Cases in which both task-based fMRI and rs-fMRI were acquired as part of the preoperative clinical protocol for epilepsy surgery were reviewed. Task-based fMRI consisted of 2 language tasks and 1 motor task. Resting-state fMRI data were acquired while the patients watched an animated movie and were analyzed using independent component analysis (i.e., data-driven method). The authors extracted language networks from rs-fMRI data by performing a similarity analysis with functionally defined language network templates via a template-matching procedure. The Dice coefficient was used to quantify the overlap. RESULTS: Thirteen children underwent conventional task-based fMRI (e.g., verb generation, object naming), rs-fMRI, and structural imaging at 1.5T. The language components with the highest overlap with the language templates were identified for each patient. Language lateralization results from task-based fMRI and rs-fMRI mapping were comparable, with good concordance in most cases. Resting-state fMRI-derived language maps indicated that language was on the left in 4 patients (31%), on the right in 5 patients (38%), and bilateral in 4 patients (31%). In some cases, rs-fMRI indicated a more extensive language representation. CONCLUSIONS: Resting-state fMRI-derived language network data were identified at the patient level using a template-matching method. More than half of the patients in this study presented with atypical language lateralization, emphasizing the need for mapping. Overall, these data suggest that this technique may be used to preoperatively identify language networks in pediatric patients. It may also optimize presurgical planning of electrode placement and thereby guide the surgeon's approach to the epileptogenic zone.

Perfusion and Metabolic Neuromonitoring during Ventricular Taps in Infants with Post-Hemorrhagic Ventricular Dilatation.

Post-hemorrhagic ventricular dilatation (PHVD) is characterized by a build-up of cerebral spinal fluid (CSF) in the ventricles, which increases intracranial pressure and compresses brain tissue. Clinical interventions (i.e., ventricular taps, VT) work to mitigate these complications through CSF drainage; however, the timing of these procedures remains imprecise. This study presents Neonatal NeuroMonitor (NNeMo), a portable optical device that combines broadband near-infrared spectroscopy (B-NIRS) and diffuse correlation spectroscopy (DCS) to provide simultaneous assessments of cerebral blood flow (CBF), tissue saturation (StO2), and the oxidation state of cytochrome c oxidase (oxCCO). In this study, NNeMo was used to monitor cerebral hemodynamics and metabolism in PHVD patients selected for a VT. Across multiple VTs in four patients, no significant changes were found in any of the three parameters: CBF increased by 14.6 ± 37.6% (p = 0.09), StO2 by 1.9 ± 4.9% (p = 0.2), and oxCCO by 0.4 ± 0.6 µM (p = 0.09). However, removing outliers resulted in significant, but small, increases in CBF (6.0 ± 7.7%) and oxCCO (0.1 ± 0.1 µM). The results of this study demonstrate NNeMo's ability to provide safe, non-invasive measurements of cerebral perfusion and metabolism for neuromonitoring applications in the neonatal intensive care unit.

Brainstem shape is affected by clinical course in the neonatal intensive care unit.

The brainstem, critical for motor function, autonomic regulation, and many neurocognitive functions, undergoes rapid development from the third trimester. Accordingly, we hypothesized it would be vulnerable to insult during this period, and that a difficult clinical course in the neonatal intensive care unit (NICU) would affect development, and be reflected through atypical shape. Our study population consisted of 66 neonates - all inpatients from the NICU at Victoria Hospital, London Health Sciences Centre, ON, Canada, of which 45 entered the final analysis. The cohort varied in gestational age (GA) and ranged from neurologically healthy to severely brain-injured. Structural MRI was used to quantify brainstem shape at term-equivalent age. From these images, brainstems were semi-automatically segmented and co-registered across subjects. The anterior-posterior dimensions on a sagittal maximum intensity projection were used as the basis for shape comparison. Factor analysis was used to summarize variation in shape and in clinical course to determine three shape factors and three clinical factors, and their relationship assessed using correlation. A factor driven by low GA and associated complications correlated with alterations in the posterior medulla, while a factor driven by complications independent of GA correlated with alterations in the midbrain. Additionally, single clinical measures most representative of their respective clinical factor (days in NICU; days on ventilation) predicted the changes. Thus, different clinical courses in the NICU may have different effects on the shape of the brainstem, and may mediate some of the distinct neurodevelopmental profiles observed in premature and brain-injured neonates.