Necesidades de cuidados en recién nacidos con encefalopatía hipóxico-isquémica tratados con hipotermia terapéutica / Care needs in newborns with hypoxic-ischemic encephalopathy treated with therapeutic hypothermia

Objetivo: describir las necesidades de cuidados de Enfermería derivadas de las principales secuelas en recién nacidos (RN) diagnosticados de encefalopatía hipóxico-isquémica (EHI) y tratados con hipotermia terapéutica en el Hospital Universitario Miguel Servet de Zaragoza (España).Método: estudio descriptivo transversal con datos retrospectivos sobre 32 pacientes, mediante revisión de historias clínicas. Variables de estudio: variables sociodemográficas, clínicas (para establecer la gravedad de la EHI se utilizó la escala de García-Alix) y necesidades de cuidados enfermeros.Resultados: se estudiaron 32 pacientes. El 68,8% fue diagnosticado de EHI moderada y el 31,2% de EHI severa, con resultado de fallecimiento tras el tratamiento del 21,9%. El 31,3% sufrió aspiración de líquido meconial en el momento del parto. Un 32% tuvo alteraciones visuales, un 20% alteraciones en la integridad de la piel, un 16% problemas de eliminación y crisis epilépticas, y un 12% microcefalia. El 100% estaba escolarizado, el 12% tenía apoyo en el colegio y solamente el 4% necesitó acudir a un centro de educación especial. El 68% de las familias recibió apoyo tras el alta hospitalaria. El 56% fue incluido en un programa de atención temprana.Conclusión: la población infantil con EHI tratados con hipotermia presentan secuelas a medio-largo plazo, siendo las más relevantes las alteraciones visuales, las de la integridad de la piel, problemas de eliminación, crisis epilépticas y microcefalia. Se han de potenciar los programas de seguimiento y apoyo tras el alta para poder detectar de forma precoz los signos de alarma, así como para el acompañamiento de sus familias. (AU)

Objective: to describe the Nursing care needs derived of the main consequences in newborns (NBs) diagnosed with hypoxic-ischemic encephalopathy (HIE) and treated with therapeutic hypothermia at the Hospital Universitario Miguel Servet in Zaragoza (Spain).Method: a descriptive cross-sectional study with retrospective data about 32 patients, through clinical record review. The study variables were sociodemographic, clinical (the scale by García-Alix was used to determine the severity of GIE), and Nursing care needs.Results: thirty-two (32) patients were studied; 68.8% were diagnosed with moderate HIE and 31.2% with severe HIE, with 21.9% of death outcomes after treatment. Out of these patients, 31.3% suffered meconium fluid aspiration at the time of delivery; 32% had visual alterations, 20% had alterations in their skin integrity, 16% had elimination problems and epileptic seizures, and 12% presented microcephalia. 100% of them were enrolled in school, 12% had support at school, and only 4% needed to attend a special education centre. Regarding their families, 68% received support after discharge from hospital, and 56% were included in an early care program.Conclusion: the paediatric population with HIE treated with hypothermia presented sequels at medium-long term; the most relevant were visual and skin integrity alterations, elimination problems, epileptic seizures and microcephalia. Programs for follow-up and support after discharge from hospital must be promoted, for an early detection of warning signs, as well as for accompanying their families. (AU)

Velamentous cord insertion, ischemic-hypoxic encephalopathy, and neurological rehabilitation: A case report / Inserción "velamentosa", encefalopatía hipóxico-isquémica y rehabilitación neurológica: reporte de caso.

Hypoxic-ischemic encephalopathy is a frequent and important cause of neurological problems in term and preterm newborns. A sentinel event of this entity is the vasa previa, specifically when there is an abnormality of the placenta such as a velamentous cord insertion. Some reports have shown the association between these two entities, but those regarding the recovery process and the neurological prognosis of children with both conditions are scarce. We present the case of a patient with a history of velamentous cord insertion and hypoxicischemic encephalopathy who received therapeutic hypothermia (cool cap). We describe his neurological rehabilitation process and we calculated the percentage of probability of presenting this condition compared to the population without these factors. The patient was a five-year-old boy with an Apgar index at birth equal to zero at one minute and equal to two at fifteen minutes who developed severe hypoxic-ischemic encephalopathy secondary to a velamentous cord insertion without prenatal diagnosis and a marked initial neurological and multisystemic compromise. The recovery process included early multidisciplinary management in the neonatal intensive care unit and a focus on early neurological habilitation. The patient is currently in school and he undergoes comprehensive therapies; on physical examination, he presents no motor or sensory deficiencies. His neuropsychological test suggests the risk of attention deficit hyperactivity disorder. Children with severe hypoxicischemic encephalopathy usually have disabilities due to motor, cognitive, and/or behavioral deficiencies.

La encefalopatía hipóxico-isquémica es una causa frecuente e importante de daño neurológico en recién nacidos a término y prematuros. Un evento centinela de esta condición es la vasa previa, específicamente cuando existe anormalidad de la placenta como la inserción "velamentosa" del cordón umbilical. Algunos reportes evidencian la asociación entre estas dos condiciones, pero son escasos los que dan cuenta del proceso de recuperación y del pronóstico neurológico de los niños afectados por ellas. Se presenta el caso de un paciente, con antecedentes de inserción "velamentosa" del cordón umbilical y encefalopatía hipóxico-isquémica, que recibió hipotermia terapéutica (cool cap). Se describe su proceso de rehabilitación neurológica y se calculó el porcentaje de probabilidad de presentar esta condición frente a la población sin estos factores. El niño tenía cinco años y el puntaje en su prueba de Apgar fue de 0 al minuto y de 2 a los 15 minutos. Desarrolló encefalopatía hipóxico-isquémica grave secundaria a una inserción "velamentosa" del cordón umbilical sin diagnóstico prenatal, con gran compromiso neurológico y multisistémico inicial. El proceso de recuperación incluyó el manejo inicial multidisciplinario en la unidad de cuidados intensivos neonatales y el inicio temprano de habilitación neurológica. Hoy el niño está escolarizado y en terapia integral, no presenta deficiencias motoras ni sensoriales en el examen físico, aunque la prueba neuropsicológica sugiere un riesgo de trastorno por déficit de atención e hiperactividad. Habitualmente, los niños con encefalopatía hipóxico-isquémica grave presentan discapacidad por deficiencias motoras, cognitivas o conductuales.

Determinants of Discharge Disposition From Acute Care for Survivors of Hypoxic-Ischemic Brain Injury: Results From a Large Population-Based Cohort Data Set.

OBJECTIVE: To identify determinants of discharge disposition from acute care among survivors of hypoxic-ischemic brain injury (HIBI), stratified by sex. DESIGN: Population-based retrospective cohort study using provincial data in Ontario, Canada. The determinants were grouped into predisposing, need, and enabling factors using the Anderson Behavioral Model. SETTING: Acute care. PARTICIPANTS: Survivors of HIBI aged ≥20 years at the time of hospitalization and discharged alive from acute care between April 1, 2002, and March 31, 2017. There were 7492 patients with HIBI, of whom 28% (N=2077) survived their acute care episode. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge disposition from acute care, categorized as complex continuing care (CCC), long-term care (LTC), inpatient rehabilitation (IR), home with support, home without support, and transferred to another acute care. RESULTS: The discharge dispositions for the 2077 survivors were IR 23.4% (n=487), CCC 19.5% (n=404), LTC 6.2% (n=128), home without support 31.2% (n=647), home with support 15.1% (n=314), and other 4.6%. Multinomial multivariable logistic regression analysis using home without support as the reference category revealed that female patients were significantly more likely than male patients to be discharged to LTC/CCC. Those who were older, were frail, and had longer stay in acute care or special care unit (SCU) were more likely to be discharged to LTC/CCC. The only significant determinant for IR was longer stay in acute care. Survivors with cardiac-related injury were less likely to be discharged to LTC/CCC. Income was a significant factor for male patients but not for female patients in the sex-stratified analysis. The following variables were investigated but were not significant determinants in this study: need factors (comorbidity score, prior psychiatric disorders, health care utilization) and enabling factors (income quintile, rural area of residence). CONCLUSIONS: Predisposing (age, sex) and need factors (frailty, acute care days, SCU days, type of injury) were significant determinants of discharge disposition from acute care after HIBI. In spite of a system with universal coverage, sex differences were found, with more female patients being discharged to CCC/LTC rather than IR, controlling for age and other confounders. These findings should be considered in appropriate discharge planning from acute care for survivors of HIBI.

Early Spontaneous Movements of Infants With Hypoxic-Ischemic Encephalopathy.

OBJECTIVE: The aim of this study was to determine motor repertoire at 3 to 5 months of age in infants with hypoxic-ischemic encephalopathy (HIE) and to examine changes according to HIE severity. METHODS: Participants were 38 infants aged 3 to 5 months with HIE and 38 infants in the comparison group. The general movement assessment and the Motor Optimality Score (MOS) were used. RESULTS: Infants in the HIE group had a significantly lower total MOS and scores for fidgety movements, age adequacy of motor repertoire, and quality of movement patterns compared with the comparison group. Infants with grade III HIE compared with grade I had a significantly lower MOS. CONCLUSIONS: Infants with HIE had poorer motor repertoire at age 3 to 5 months when compared with peers. Motor repertoire deteriorated as HIE severity increased. Detecting potential developmental delays as early as possible allows for early intervention and rehabilitation in this population.

Acrobatic exercise recovers object recognition memory impairment in hypoxic-ischemic rats.

Neonatal hypoxia-ischemia (HI) can lead to cognitive impairments and motor dysfunction. Acrobatic exercises (AE) were proposing as therapeutic option to manage HI motor deficits, however, the cognitive effects after this treatment are still poorly understood. Therefore, we evaluated the effects of AE protocol on memory impairments and brain plasticity markers after Rice-Vannucci HI rodent model. Wistar rats on the 7th postnatal day (PND) were submitted to HI model and after weaning (PND22) were trained for 5 weeks with AE protocol, then subsequently submitted to cognitive tests. Our results showed recovery in novel object recognition (NOR) memory, but not, spatial Morris Water Maze (WM) memory after AE treatment in HI rats. BDNF and synaptophysin neuroplasticity markers indicate plastic alterations in the hippocampus and striatum, with maintenance of synaptophysin despite the reduction of total volume tissue, besides, hippocampal HI-induced ipsilateral BDNF increased, and striatum contralateral BDNF decreased were noted. Nevertheless, the exercise promoted functional recovery and seems to be a promising strategy for HI treatment, however, future studies identifying neuroplastic pathway for this improvement are needed.

A Total Sarnat Score in Mild Hypoxic-ischemic Encephalopathy Can Detect Infants at Higher Risk of Disability.

To define mild hypoxic-ischemic encephalopathy and distinguish infants at risk of disability in the first 6 hours, this study stratified risk of disability by using early neurologic examination findings of infants enrolled in the Prospective Research for Infants with Mild Encephalopathy cohort. A total Sarnat score of ≥5 when performed at <6 hours of age detected future disability. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01747863.

Pediatric Post-Cardiac Arrest Care: A Scientific Statement From the American Heart Association.

Successful resuscitation from cardiac arrest results in a post-cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post-cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post-cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post-cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post-cardiac arrest care.

Change in Function Over Inpatient Rehabilitation After Hypoxic Ischemic Brain Injury: A Population-Wide Cohort Study.

OBJECTIVE: To estimate change in motor, cognitive, and overall functional performance during inpatient rehabilitation (IR) and to identify potential determinants of these outcomes among patients with hypoxic-ischemic brain injury (HIBI). DESIGN: Population-based retrospective cohort study using Ontario's health administrative data. SETTING: Inpatient rehabilitation. PARTICIPANTS: Survivors of HIBI 20 years and older discharged from acute care between fiscal years 2002-2003 and 2010-2011 and admitted to IR within 1 year of acute care discharge (N=159). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Functional status as measured by FIM, total, and scores on motor and cognitive subscales. RESULTS: A higher proportion (77%) of HIBI patients in the study were male and 28% were older than 65 years. We observed material improvements in FIM total, motor, and cognitive scores from across the IR episode. Potential determinants of total FIM gain were living in rural location (ß, 10.4; 95% CI, 0.21-21), having shorter preceding acute care length of stay (15-30 vs >60 days ß, 10.4; 95% CI, 1.4-19.5), and failing to proceed directly to IR following acute care discharge (ß, 8.7; 95% CI, 1.8-15.5). Motor FIM gain had similar identified potential determinants. Identified potential determinants of cognitive FIM gain were shorter (ie, 31-60 vs >60 days) preceding acute care, longer IR and length of stay, and proceeding directly to IR. There were no sex differences in functional gain. CONCLUSIONS: Inpatient rehabilitation is beneficial to HIBI survivors. Timely access to these services may be crucial in achieving optimal outcomes for these patients.

Physical exercise enhances adult cortical plasticity in a neonatal rat model of hypoxic-ischemic injury: Evidence from BOLD-fMRI and electrophysiological recordings.

Neuroplasticity is considered essential for recovery from brain injury in developing brains. Recent studies indicate that it is especially effective during early postnatal development and during the critical period. The current study used functional magnetic resonance imaging (fMRI) and local field potential (LFP) electrophysiological recordings in rats that experienced neonatal hypoxic-ischemic (HI) injury during the critical period to demonstrate that physical exercise (PE) can improve cortical plasticity even when performed during adulthood, after the critical period. We investigated to what extent the blood oxygen level-dependent (BOLD)-fMRI responses were increased in the contralesional spared cortex, and how these increases were related to the LFP electrophysiological measurements and the functional outcome. The balance of excitation and inhibition was assessed by measuring excitatory and inhibitory postsynaptic currents in stellate cells in the primary somatosensory (S1) cortex, which was compared with the BOLD-fMRI responses in the contralesional S1 cortex. The ratio of inhibitory postsynaptic current (IPSC) to excitatory postsynaptic current (EPSC) at the thalamocortical (TC) input to the spared S1 cortex was significantly increased by PE, which is consistent with the increased BOLD-fMRI responses and improved functional outcome. Our data clearly demonstrate in an experimental rat model of HI injury during the critical period that PE in adulthood enhances neuroplasticity and suggest that enhanced feed-forward inhibition at the TC input to the S1 cortex might underlie the PE-induced amelioration of the somatosensory deficits caused by the HI injury. In summary, the results of the current study indicate that PE, even if performed beyond the critical period or during adulthood, can be an effective therapy to treat neonatal brain injuries, providing a potential mechanism for the development of a potent rehabilitation strategy to alleviate HI-induced neurological impairments.

Are rehabilitation outcomes after severe anoxic brain injury different from severe traumatic brain injury? A matched case-control study.

Many reports have investigated rehabilitation outcomes after a traumatic brain injury (TBI); however, comparably less is known about whether they differ from outcomes of an anoxic brain injury (ABI). Thus, we aimed to compare the rehabilitation outcomes of patients with ABI with control patients who have TBI. Forty participants with ABI and 40 participants with TBI were included in this retrospective study. Participants with ABI were matched with participants with TBI who had similar clinical characteristics such as age, initial Functional Independence Measurement (FIM) score, and duration of coma. FIM and Functional Ambulation Classification (FAC) scores on rehabilitation admission and on rehabilitation discharge were recorded. The FIM score in the ABI group was 41.7±28.5 on rehabilitation admission and increased to 57.1±31.4 on rehabilitation discharge. The FIM score in the TBI group was 40.8±24.0 on rehabilitation admission and increased to 65.9±35.3 on rehabilitation discharge. There was no statistically significant difference in the FIM scores on rehabilitation discharge between groups. Initial FAC was similar in both groups and there was no statistically significant difference in the FAC scores on rehabilitation discharge. The multiple linear regression analysis showed that intensive care unit length of stay had an inverse relationship with the FAC change. We did not find significant differences in the rehabilitation outcomes of participants with ABI compared with participants with TBI. Considering the lack of information in the literature on ABI rehabilitation, this study may be important to guide rehabilitation teams.

Comparison of SMART and WHIM as measurement tools in routine assessment of PDOC patients.

BACKGROUND: Royal College of Physicians guidelines on PDOC recommended repeated assessments of patients in PDOC are undertaken by skilled clinicians. The Wessex Head Injury Matrix (WHIM) and the Sensory Modality Assessment and Rehabilitation Technique (SMART) are the most commonly used measures within UK. OBJECTIVE: To evaluate the use of WHIM and SMART to identify potential changes in PDOC patients. METHODS: Twelve PDOC patients admitted to a post-acute regional neuro-rehabilitation unit were assessed using WHIM and SMART. Eight of 12 patients were diagnosed with a primary hypoxic ischemic brain injury (HIBI). RESULTS: Overall for the total group there was no significant correlation between patient's highest ranked behaviour and any SMART domain. Initial WHIM total observed behaviour was significantly correlated with SMART tactile domain. Patient's final WHIM and SMART domains were not significantly correlated. Among HIBI subgroup, initial WHIM highest ranked behaviour and WHIM total observed behaviour were significantly correlated with the SMART communication domain. Final WHIM highest ranked behaviour was positively correlated with SMART visual and tactile domains. Final WHIM total observed behaviour was significantly correlated with the SMART visual domain. CONCLUSIONS: Both measures show sensitivity to change in PDOC patients. Larger long-term follow-up of HIBI patients is highlighted.

Long-Term Functional and Psychosocial Outcomes After Hypoxic-Ischemic Brain Injury: A Case-Controlled Comparison to Traumatic Brain Injury.

BACKGROUND: Despite the increasing rate of survival from hypoxic-ischemic brain injury (HIBI), there is a paucity of evidence on the long-term functional outcomes after inpatient rehabilitation among these nontrauma patients compared to patients with traumatic brain injury (TBI). OBJECTIVES: To compare functional and psychosocial outcomes of patients with HIBI to those of case-matched patients with TBI 4-11 years after brain insult. DESIGN: Retrospective, matched case-controlled study. METHODS: Data at the time of rehabilitation admission and discharge were collected as part of a larger acquired brain injury (ABI) database at Toronto Rehabilitation Institute (TRI) between 1999 and 2009. This study consisted of 11 patients with HIBI and 11 patients with TBI that attended the neuro-rehabilitation day program at TRI during a similar time frame and were matched on age, admission Functional Independence Measure (FIM) scores, and acute care length of stay (ALOS). At 4-11 years following brain insult, patients were reassessed using the FIM, Disability Rating Scale (DRS), Personal Health Questionnaire Depression Scale (PHQ-9), and the Mayo-Portland Adaptability Inventory 4 (MPAI-4). RESULTS: At follow-up, patients with HIBI had significantly lower FIM motor and cognitive scores than patients with TBI (75.3 ± 20.6 versus 88.1 ± 4.78, P < .05, and 25.5 ± 5.80 versus 32.7 ± 2.54, P <.05, respectively) despite having a similar time frame postinsult (ie, 4-11 years). In addition, there were significant differences in motor and total FIM change from admission to follow-up between HIBI and TBI patients (P < .05). Patients with HIBI also had significantly lower scores on the DRS, PHQ-9, and total MPAI-4 at follow-up (P < .05). CONCLUSIONS: The study results suggest that patients with HIBI achieve less long-term functional improvements compared to patients with TBI. Further research is warranted to compare the components of inpatient rehabilitation while adjusting for demographics and clinical characteristics between these 2 groups of patients. LEVEL OF EVIDENCE: III.

Enriched rehabilitation promotes motor recovery in rats exposed to neonatal hypoxia-ischemia.

Despite continuous improvement in neonatology there is no clinically effective treatment for perinatal hypoxia ischemia (HI). Therefore, development of a new therapeutic intervention to minimize the resulting neurological consequences is urgently needed. The immature brain is highly responsive to environmental stimuli, such as environmental enrichment but a more effective paradigm is enriched rehabilitation (ER), which combines environmental enrichment with daily reach training. Another neurorestorative strategy to promote tissue repair and functional recovery is cyclosporine A (CsA). However, potential benefits of CsA after neonatal HI have yet to be investigated. The aim of this study was to investigate the effects of a combinational therapy of CsA and ER in attempts to promote cognitive and motor recovery in a rat model of perinatal hypoxic-ischemic injury. Seven-day old rats were submitted to the HI procedure and divided into 4 groups: CsA+Rehabilitation; CsA+NoRehabilitation; Vehicle+Rehabilitation; Vehicle+NoRehabilitation. Behavioural parameters were evaluated pre (experiment 1) and post 4 weeks of combinational therapy (experiment 2). Results of experiment 1 demonstrated reduced open field activity of HI animals and increased foot faults relative to shams in the ladder rung walking test. In experiment 2, we showed that ER facilitated acquisition of a staircase skilled-reaching task, increased number of zone crosses in open-field exploration and enhanced coordinated limb use during locomotion on the ladder rung task. There were no evident deficits in novel object recognition testing. Delayed administration of CsA, had no effect on functional recovery after neonatal HI. There was a significant reduction of cortical and hemispherical volume and hippocampal area, ipsilateral to arterial occlusion in HI animals; combinational therapy had no effect on these morphological measurements. In conclusion, the present study demonstrated that ER, but not CsA was the main contributor to enhanced recovery of motor ability after neonatal HI.

Early environmental enrichment affects neurobehavioral development and prevents brain damage in rats submitted to neonatal hypoxia-ischemia.

Our previous results demonstrated improved cognition in adolescent rats housed in environmental enrichment (EE) that underwent neonatal hypoxia-ischemia (HI). The aim of this study was to investigate the effects of early EE on neurobehavioral development and brain damage in rats submitted to neonatal HI. Wistar rats were submitted to the HI procedure on the 7th postnatal day (PND) and housed in an enriched environment (8th-20th PND). The maturation of physical characteristics and the neurological reflexes were evaluated and the volume of striatum, corpus callosum and neocortex was measured. Data analysis demonstrated a clear effect of EE on neurobehavioral development; also, daily performance was improved in enriched rats on righting, negative geotaxis and cliff aversion reflex. HI caused a transient motor deficit on gait latency. Brain atrophy was found in HI animals and this damage was partially prevented by the EE. In conclusion, early EE stimulated neurobehavioral development in neonate rats and also protects the neocortex and the corpus callosum from atrophy following HI. These findings reinforce the potential of EE as a strategy for rehabilitation following neonatal HI and provide scientific support to the use of this therapeutic strategy in the treatment of neonatal brain injuries in humans.

Determinants of Admission to Inpatient Rehabilitation Among Acute Care Survivors of Hypoxic-Ischemic Brain Injury: A Prospective Population-Wide Cohort Study.

OBJECTIVE: To investigate demographic and acute care clinical determinants of admission to inpatient rehabilitation (IR) among patients with hypoxic-ischemic brain injury (HIBI) who survive the initial acute care episode. DESIGN: Population-wide prospective cohort study using Canadian Institutes for Health Information administrative health data from Ontario, Canada. All patients who survived their HIBI acute care episode during the study period remained eligible for the outcome, admission to IR, for 1 year postacute care discharge. SETTING: Inpatient rehabilitation. PARTICIPANTS: We included all patients with HIBI using International Classification of Diseases, Tenth Revision, Canadian Enhancement codes recorded at acute care admission who were ≥20 years old (N=599) and discharged from acute care between the 2002 and 2010 fiscal years, inclusive. Six patients were excluded from analyses because of missing data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Admission to IR. RESULTS: Of HIBI survivors admitted to IR within 1 year of acute care discharge (n=169), most (56.2%) had an IR admitting diagnosis indicating anoxic brain damage. Younger age, being a man, lower comorbidity burden, longer length of stay of preceding acute care episode, and shorter duration in special care were most predictive of admission to IR in multivariable regression models. Women had an almost 2-fold lower incidence of admission to IR (risk ratio, .62; 95% confidence interval, .46-.84). CONCLUSIONS: Older age, higher comorbidity burden, and shorter lengths of stay and delayed discharge from acute care are associated with lower incidence of IR admission for patients with HIBI. That women are almost 2-fold less likely to receive rehabilitation requires further investigation.

[Long-term outcome of childhood hypoxic-ischemic encephalopathy].

OBJECTIVE: To propose an adequate rehabilitation program for children suffering from hypoxic-ischemic encephalopathy (HIE) based on estimated outcomes. METHODS: Participants were 42 children, 28 boys and 14 girls, who suffered from HIE after neonatal period. We divided them into three groups; favorable (GMFCS level 1 or 2), moderate (level 3 or 4), and unfavorable (level 5), and compared the extent of brain lesions on MRI, age of onset, and complications among the groups. RESULTS: The number of children in favorable, moderate, and unfavorable groups was 10, 10 and 22, respectively. All children in favorable and moderate groups showed focal cerebral lesions on MRI. In contrast, most children in unfavorable group (19/22) had diffuse brain damage and the rest were infantile onset with focal cerebral lesions. The etiology and situation of HIE did not differ among three groups. Three children in moderate group whose onsets were earlier than 5 months showed lesions similar to those in neonatal HIE; in bilateral basal ganglia, thalamus, and perirolandic cortex. In favorable group, 7 children were able to walk independently within 5 months after the insult, but 9 had moderate or severe mental retardation and 3 showed severe visual impairment. A majority of unfavorable group developed scoliosis or hip dislocation, and underwent tracheostomy or gastrostomy. Five children who had stayed acute hospitals for longer than 6 months developed irreversible complications such as joint contractures before discharge. CONCLUSIONS: Children with focal cerebral lesions need continual rehabilitation and education for mental retardation and visual impairment, even if they can walk within several months after HIE. Those with diffuse brain damage need sufficient rehabilitation as early as possible to avoid developing secondary complications. MR image, age of onset, and clinical course were of great prognostic value to make appropriate long-term rehabilitation and education programs.

Rehabilitation outcome of anoxic-ischaemic encephalopathy survivors with prolonged disorders of consciousness.

OBJECTIVES: To examine the natural clinical course of patients admitted to inpatient neurorehabilitation in a coma, vegetative state (VS), or minimally conscious state (MCS) after anoxic-ischaemic encephalopathy (AIE). METHODS: This is a retrospective cohort study of 113 consecutive patients admitted to a German inpatient neurorehabilitation centre with severe disorders of consciousness (DOC) following AIE due to cardiac arrest over a 6-year period. Functional independence was measured with the Glasgow Outcome Scale (GOS) and recovery of consciousness with the Coma Remission Scale (CRS). Separate binary logistic regression models were used to identify independent predictors for functional and behavioural outcomes. RESULTS: Seven patients (6.2%) achieved a good functional outcome (GOS 4-5). Five of these showed significant functional improvement within the first 8 weeks. 22 patients (19.5%) recovered consciousness; the last patient began to make significant improvement between weeks 10 and 12. Logistic regression showed that both increasing age and lower admission CRS predicted unfavourable functional outcome and persistent DOC. A longer stay in the ICU also predicted persistent DOC at the end of neurorehabilitation. However, neither malignant somatosensory evoked potential (SEP) test results nor hypothermia treatment on the ICU were outcome predictors in either outcome category. CONCLUSION: Even among severely affected AIE patients arriving at a neurological rehabilitation centre in a DOC, there remains potential for functional and behavioural improvement. However, significant improvements may not begin for up to 3 months post-injury. This study suggests that recovery of consciousness and even a good neurological outcome are possible despite malignant SEP test results.

Subventricular zone-derived oligodendrogenesis in injured neonatal white matter in mice enhanced by a nonerythropoietic erythropoietin derivative.

Perinatal hypoxia-ischemia (HI) frequently causes white-matter injury, leading to severe neurological deficits and mortality, and only limited therapeutic options exist. The white matter of animal models and human patients with HI-induced brain injury contains increased numbers of oligodendrocyte progenitor cells (OPCs). However, the origin and fates of these OPCs and their potential to repair injured white matter remain unclear. Here, using cell-type- and region-specific genetic labeling methods in a mouse HI model, we characterized the Olig2-expressing OPCs. We found that after HI, Olig2+ cells increased in the posterior part of the subventricular zone (pSVZ) and migrated into the injured white matter. However, their oligodendrocytic differentiation efficiency was severely compromised compared with the OPCs in normal tissue, indicating the need for an intervention to promote their differentiation. Erythropoietin (EPO) treatment is a promising candidate, but it has detrimental effects that preclude its clinical use for brain injury. We found that long-term postinjury treatment with a nonerythropoietic derivative of EPO, asialo-erythropoietin, promoted the maturation of pSVZ-derived OPCs and the recovery of neurological function, without affecting hematopoiesis. These results demonstrate the limitation and potential of endogenous OPCs in the pSVZ as a therapeutic target for treating neonatal white-matter injury.

[The role of phototherapy in the rehabilitation of newborn babies and infants].

This review is devoted to the problems pertaining to the rational application of phototherapy in the rehabilitation of newborn babies and infants. The analysis of the classical and present-day literature sources provided materials for the development of the rationale for the use of colour-puncture therapy. The data included in this review indicate that phototherapy has positive effect on the immune and rehabilitative processes in the newborns following surgical interventions and in the breast-fed infants suffering hypoxic ischemic encephalopathy. Phototherapy is equally beneficial when the newborn babies need to be treated for cutaneous and nervous disorders or undergo a surgical operation. Moreover, it can be applied to manage endocrine disorders and diseases of the vegetative nervous system. The photo-induced changes in the skin influence the concentration of biologically active compounds in the systemic circulation. It is believed that colour-puncture therapy makes it possible to selectively affect biologically active points in the channel-meridian system of the newborn babies and infants.

Cannabidiol reduces brain damage and improves functional recovery after acute hypoxia-ischemia in newborn pigs.

Newborn piglets exposed to acute hypoxia-ischemia (HI) received i.v. cannabidiol (HI + CBD) or vehicle (HI + VEH). In HI + VEH, 72 h post-HI brain activity as assessed by amplitude-integrated EEG (aEEG) had only recovered to 42 ± 9% of baseline, near-infrared spectroscopy (NIRS) parameters remained lower than normal, and neurobehavioral performance was abnormal (27.8 ± 2.3 points, normal 36). In the brain, there were fewer normal and more pyknotic neurons, while astrocytes were less numerous and swollen. Cerebrospinal fluid concentration of neuronal-specific enolase (NSE) and S100ß protein and brain tissue percentage of TNFα(+) cells were all higher. In contrast, in HI + CBD, aEEG had recovered to 86 ± 5%, NIRS parameters increased, and the neurobehavioral score normalized (34.3 ± 1.4 points). HI induced histological changes, and NSE and S100ß concentration and TNFα(+) cell increases were suppressed by CBD. In conclusion, post-HI administration of CBD protects neurons and astrocytes, leading to histological, functional, biochemical, and neurobehavioral improvements.