NIDCAP improves brain function and structure in preterm infants with severe intrauterine growth restriction.

OBJECTIVE: The effect of NIDCAP (Newborn Individualized Developmental Care and Assessment Program) was examined on the neurobehavioral, electrophysiological and neurostructural development of preterm infants with severe intrauterine growth restriction (IUGR). STUDY DESIGN: A total of 30 infants, 27-33 weeks gestation, were randomized to control (C; N=17) or NIDCAP/experimental (E; N=13) care. Baseline health and demographics were assessed at intake; electroencephalography (EEG) and magnetic resonance imaging (MRI) at 35 and 42 weeks postmenstrual age; and health, growth and neurobehavior at 42 weeks and 9 months corrected age (9 months). RESULTS: C and E infants were comparable in health and demographics at baseline. At follow-up, E infants were healthier, showed significantly improved brain development and better neurobehavior. Neurobehavior, EEG and MRI discriminated between C and E infants. Neurobehavior at 42 weeks correlated with EEG and MRI at 42 weeks and neurobehavior at 9 months. CONCLUSION: NIDCAP significantly improved IUGR preterm infants' neurobehavior, electrophysiology and brain structure. Longer-term outcome assessment and larger samples are recommended.

Is the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) effective for preterm infants with intrauterine growth restriction?

OBJECTIVE: This study investigates the effectiveness of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) on neurobehavioral and electrophysiological functioning of preterm infants with severe intrauterine growth restriction (IUGR). STUDY DESIGN: Thirty IUGR infants, 28 to 33 weeks gestational age, randomized to standard care (control/C=18), or NIDCAP (experimental/E=12), were assessed at 2 weeks corrected age (2wCA) and 9 months corrected age (9mCA) in regard to health, anthropometrics, and neurobehavior, and additionally at 2wCA in regard to electrophysiology (EEG). RESULT: The two groups were comparable in health and anthropometrics at 2wCA and 9mCA. The E-group at 2wCA showed significantly better autonomic, motor, and self-regulation functioning, improved motility, intensity and response thresholds, and reduced EEG connectivity among several adjacent brain regions. At 9mCA, the E-group showed significantly better mental performance. CONCLUSION: This is the first study to show NIDCAP effectiveness for IUGR preterm infants.

Individualized developmental care for a large sample of very preterm infants: health, neurobehaviour and neurophysiology.

AIM: To assess medical and neurodevelopmental effects of Newborn Individualized Developmental Care and Assessment Program (NIDCAP) for a large sample of very early-born infants. METHODS: One hundred and seven singleton inborn preterm infants, <29 weeks gestational age (GA), <1250 g birth weight, enrolled in three consecutive phases, were randomized within phase to NIDCAP (treatment, E) or standard care (C). Treatment extended from admission to the Newborn Intensive Care Unit to 2 weeks corrected age (wCA). Outcome included medical, neurobehavioural and neurophysiological status at 2 wCA, and growth and neurobehavioural status at 9 months (m) CA. RESULTS: The C- and E-group within each of the three consecutive phases and across the three phases were comparable in terms of all background measures; they therefore were treated as one sample. The results indicated for the E-group significant reduction in major medical morbidities of prematurity as well as significantly improved neurodevelopmental (behaviour and electrophysiology) functioning at 2 wCA; significantly better neurobehavioural functioning was also found at 9 mCA. CONCLUSION: The NIDCAP is an effective treatment for very early-born infants. It reduces health morbidities and enhances neurodevelopment, functional competence and life quality for preterm infants at 2 w and 9 mCA.

Prolonged T*2 values in newborn versus adult brain: Implications for fMRI studies of newborns.

The neonatal brain possesses higher water content, lower macromolecular concentration, and reduced synaptic density than is found in the brain of a 1-year-old child. Changes in MRI characteristics of brain such as relaxation times accompany rapid changes in brain during early postnatal development. It was hypothesized that T(*)(2) values found in newborns would be significantly higher than those found in 9-month-old children and adults as measured at 1.5 T. Spoiled gradient echo measurements of T(*)(2) within the brains of newborns, 9-month-olds, and adults confirmed this hypothesis. The results have implications with regard to functional MRI studies in newborns since, in general, BOLD signal optimization is achieved when echo times TE are set equal to the T(*)(2) values of the tissue of interest. Since significantly longer T(*)(2) values are found in newborns, it is suggested that the TE values employed for fMRI studies of newborns should be increased to maximize BOLD signal intensity changes and improve the overall reliability of fMRI results in newborns.

Novel approach to management of a posterior tracheal tear complicating percutaneous tracheostomy.

We treated a patient who developed a posterior tracheal wall perforation and severe respiratory compromise following percutaneous tracheostomy, using a covered expandable metallic stent. The stent was deployed under direct vision using rigid and fibreoptic bronchoscopy. The defect was sealed and the right lung, which had been collapsed, was re-expanded. The patient was subsequently weaned from mechanical ventilation. Late complications included halitosis, which was treated with nebulized colistin sulphate, and the development of intratracheal granulation tissue, which was cleared using low power (10 W) Nd:YAG laser.

Tracheal granulation tissue after percutaneous tracheostomy treated with Nd:Yag laser: three cases.

Three adult patients who received percutaneous serial dilatational tracheostomy post-cardiac surgery developed histologically confirmed tracheal granulation tissue superior to the point of entry of the tracheostomy tube into the trachea. This tissue significantly occluded the trachea in all patients and, in two, led to serious haemorrhage. Each patient had serial dilatational percutaneous tracheostomy using the Cook/Ciaglia technique. On each patient fibre-optic bronchoscopy confirmed satisfactory position of the guidewire and tracheostomy tube. Nd:Yag laser therapy was applied to areas of tracheal granulation tissue and was also employed to secure haemostasis. In each patient endobronchial Nd:YAG laser therapy successfully cleared the granulation tissue and secured haemostasis. Follow-up bronchoscopy showed no recurrence. Fibre-optic bronchoscopy at the time of tracheal decannulation may identify granulation tissue requiring appropriate referral and intervention.

Auditory evoked response data reduction by PCA: development of variables sensitive to reading disability.

Long latency auditory evoked responses (AER) were formed on 232 healthy normal and learning impaired subjects to tone pairs of 50 msec inter-stimulus interval (TALAER) and also to the words "tight" and "tyke" (TTAER). Both evoked potential (EP) type have been used to demonstrate differences between good readers (WIAT Basic Reading score > 115, N = 42) and poor readers (Reading score < 85, N = 42). A largely automated, hands off approach was used to reduce artifact contamination, to develop canonical measures for discriminating good from poor readers, and to predict reading scores across the entire population including intermediate (average) readers. Eye and muscle artifact were diminished by multiple regression. Substantial EP data reduction was enabled by an unrestricted use of Principal Components Analysis (PCA). For each EP type, 40 factors encompassed 70-80% of initial variance, a meaningful data reduction of about 90:1. Factor interpretation was enhanced by mapping of the factor loadings. By discriminant analysis, resulting factors predicted reading group membership with over 80% jackknifed and also split--half replication accuracy. By multiple regression, they produced a canonical variate correlating significantly (p < 0.001) with the Basic Reading score (r = 0.39). The TTAER factors were more useful than the TALAER factors. The relevance of rapid auditory processing and phonemic discrimination measurements to dyslexia is discussed.

Auditory evoked responses to similar words with phonemic difference: comparison between children with good and poor reading scores.

Our previous study demonstrated a physiologic deficit in two-tone discrimination in poor readers. This was specific to the left parietal area suggesting that poor readers handled rapid tones differently. The current paper extends this finding in the same population, demonstrating that poor readers also have difficulty with phonemic discrimination. Long latency auditory evoked potentials (AEP) were formed using a phonemic discrimination task in a group of children with reading disabilities and controls. Measuring peak-to-peak amplitude of the waveforms, we found reduced N1-P2 amplitude in the Poor Reader group. Using the t-statistic significance probability map (SPM) technique, we also found a group difference, maximal over the mid-parietal area, from 584 msec to 626 msec after the stimulus onset. This difference was due to a lower amplitude on the Poor Reader group. We hypothesized that this late difference constitutes a P3 response and that the Poor Reader group generated smaller P3 waves. These auditory evoked response (AER) data support a discrimination deficit for close phonemes in the Poor Reader group as they had smaller N1-P2 absolute amplitude and developed smaller P3 waves. Based on these data we should be able to differentiate between Good and Poor readers based on long latency potentials created from phonemic stimuli.

Tracheal stenting for rupture of the posterior wall of the trachea following percutaneous tracheostomy.

Perforation of the posterior wall of the trachea during percutaneous tracheostomy is a recognised complication. Treatment by either conservative or surgical management has been described. We report two patients who developed posterior tracheal wall perforation following percutaneous tracheostomy who were successfully treated by insertion of covered, expandable metallic stents. This is a well tolerated procedure that has minimal complications and can be performed at the bedside. We recommend that tracheal stenting should be considered for the management of posterior tracheal wall perforation following percutaneous tracheostomy in those patients unsuitable for surgical intervention.

Auditory evoked responses to single tones and closely spaced tone pairs in children grouped by reading or matrices abilities.

Long latency auditory evoked responses (AER) were formed to single tones and rapid tone pairs. Using the t-statistic SPM technique, children with poorer WIAT reading scores demonstrated group difference overlying the left parietal and frontal language regions but just for AER to tone pair stimuli. Variables derived from these regions were not significantly different when the same subjects were grouped by K-BIT Matrices scores. When the same children were regrouped by Matrices scores and compared using the SPM technique, differences were now seen over the right hemisphere, especially in the parietal and frontotemporal regions, for both single and two-tone derived AERs. Variables derived from these regions were not significantly different for children when grouped by reading score. AER data support a specific deficit in two-tone stimulation for poorer reading children over the left hemisphere and also a deficit to both single and two-tone stimulation over the right hemisphere for children with poorer Matrices scores.

Ambient oxygen concentrations during simulated cardiopulmonary resuscitation.

Oxygen concentrations were measured at 12 points around a cardiopulmonary resuscitation practice mannequin following simulated ventilation with a self-inflating bag, a 'Waters' bag and a ventilator to determine whether increased oxygen concentrations may contribute to the risk of combustion from arcing defibrillator paddles. Ventilation was simulated using either a mask or via a tracheal tube fitted to the airway. The head of the mannequin rested upon a 10-cm-high pillow. Gas sampling took place after 5 min of ventilation with subsequent removal of the ventilatory device and placement on the pillow to the left of the mouth, with the tubing of the device removed to a point 1 m behind the mouth and with the device left connected to the tracheal tube. Gas was sampled after using all devices at oxygen flows of 10l.min-1 and 15l.min-1. Slightly increased oxygen concentrations were noted over the anterior chest after placement of all devices on the pillow at the higher flow. Concentrations of greater than 30% were measured in the left axilla after placement of all devices on the pillow at both flows. No increase in oxygen concentration was seen when the devices were either left connected to the tracheal tube or removed to a distance of 1 m. It would appear that leaving a patient connected to a ventilator poses no increase in risk of fire from ignition of combustible material in an oxygen-enriched atmosphere during defibrillation. Disconnecting any device which continues to discharge oxygen and leaving it on the pillow before defibrillation is dangerous.

Effectiveness of individualized neurodevelopmental care in the newborn intensive care unit (NICU).

The individual infant's neurodevelopmental process provides an integrative framework for the delivery of medical care needed to assure the infant's survival and quality of outcome. The infant's neurobehavioral functioning and expression provides an opportunity for caregivers to estimate the individual infant's current strengths, vulnerabilities and threshold to disorganization, as well as to identify the infant's strategies in collaborating in his or her best progression. This perspective supports caregivers in seeing themselves in a relationship with the infant, and in considering opportunities to enhance the infant's strengths and reduce apparent stressors in collaboration with the infant and the family. The results of several randomized studies supporting the effectiveness of such a neurodevelopment approach to NICU care will be presented, and suggest implications for staff education and nursery-wide implementation.

Effects of age upon interhemispheric EEG coherence in normal adults.

Age-related differences in quantified electrophysiological measures of interhemispheric EEG coherence were studied in 371 subjects (171 males and 200 females), ages 20-80, all of whom were judged to be optimally healthy. Principal components analysis (PCA) was performed on interhemispheric coherence of Laplacian referenced data from eight homologous left-right electrode pairs, from 0.5 to 32 Hz. Regression procedures, using signals from artifact monitoring channels, were used to minimize effects of eye movement and muscle artifact. Forty-six factors described 80% of the total variance, with electrode location the primary source of communality in factor formation. Within 350 right-handed subjects, results indicated a broad trend for decreased interhemispheric coherence with advancing age. Using canonical correlation, the coherence-based factors also successfully predicted spectral variables, previously found to maximally illustrate age-related EEG desynchronization. We speculate that age-related reduction of interhemispheric coherence may in part explain age-related EEG desynchrony and stems from age-related reduction of cortical connectivity. Gender differences of interhemispheric coherence were also evident. Females demonstrated higher interhemispheric coherence than males. Within a smaller subpopulation of 63 subjects (21 left and 42 right handed), there was a gender-by-handedness interaction, with higher interhemispheric coherence in right-handed females than right-handed males and the reverse in left-handed male and female subjects.