Bottle-feeding and gastroesophageal reflux disease improvement after restrictive tethered oral tissues release.

Aim: This study aimed to determine the impact of laser surgical tongue-tie, lip-tie, buccal-tie release on bottle-feeding and gastroesophageal reflux disease (GERD) after functional assessment of tongue and lip movement in a prospective cohort study conducted from June 2019 to June 2020 in a private general dental practice. Methods: Preoperative, one-week and one-month postoperative surveys were completed, using the Revised Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R). All study participants were bottle-feeding dyads (0-12 weeks of age) with untreated ankyloglossia and/or tethered maxillary/buccal frena. Results: The study had 40 bottle feeding infants enrolled. Posterior :tongue-tie was noted in 67.5% of this cohort. Statistically significant improvement in I-GERQ-R scores was reported between preoperative (16.6, SD: 6.1; min-max: 8-28), 1 week (14.1, SD: 4.2; min-max: 6-24) and 1 month I-GERQ-R total scores (9.1, SD: 4.5; min-max:3-27) (ANOVA test - P <.001). Conclusion: This study confirms the need for functional assessment of tongue and lip movement for this significantly affected cohort when surgical release is proposed. Laser surgical release (frenotomy) of tongue-tie, lip-tie, buccal-tie resulted in significant improvement in I-GERQ-R outcomes were found for cohorts of the classically recognised anterior tongue-tie and the less obvious (without functional assessment) and less diagnosed posterior tongue tie were found.

Short lingual frenum in infants, children and adolescents. Part 2: Lingual frenum release. Functional surgical approach.

AIM: The aim of this study was to review the craniofacial growth impairment and different malfunctions associated with short lingual frenum and to assess the validity of lingual frenum surgery based on minimally invasive laser release with a myofunctional approach. MATERIALS AND METHODS: Thirty patients, children and adolescents whose ages ranged from 8 years to 18 years, diagnosed with a short lingual frenum and concomitant orthodontic problems and/or presence of associated muscular or postural problems, were treated in this study. Pre-operative tongue assessment was performed following morphological and functional criteria, consisting of measurement of the free tongue, and of visual assessment of tongue protrusion out of the mouth and elevation to the incisive palatal papilla. Postural evaluation was assessed in frontal and lateral view. Laser surgery was completed with local anaesthesia, using Erbium YAG laser (2940 nm, LightWalker, AT-Fotona, Ljubljana, Slovenia) equipped with sapphire conical tip (600 micron), with energy ranging from 120 to 160 mJ, at 15 Hz frequency, and varying the adjustable pulse duration from 300 µs to 600 µs. RESULTS: Significant improvement was noted in 29 of 30 patients comparing preoperative scores to both three-week and two-month post-op scores. Postural improvement was found in 18 of 30 patients, indicating the multifactorial involvement of different causes for correct body posture. CONCLUSION: This study confirmed the validity of Erbium:YAG laser surgery as an effective technique in children and adolescents to release a short lingual frenum. The functional approach of the procedure performed with the Erbium:YAG laser, and the concomitant myofunctional therapy demonstrated to be simple and safe in children, and adolescents. Because of the multifactorial causes involved in correct body posture, an adequate osteopathic therapy is important to successfully complete the full body rehabilitation.

Short lingual frenum in infants, children and adolescents. Part 1: Breastfeeding and gastroesophageal reflux disease improvement after tethered oral tissues release.

AIM: This study aimed to determine the impact of laser surgical tongue-tie, lip-tie, buccal tie release on breastfeeding and Gastroesophageal Reflux Disease (GERD) in a prospective cohort study conducted from June 2019 to June 2020 in a private general dental practice. MATERIALS AND METHODS: Preoperative, one-week and one-month postoperative surveys were completed, consisting of Visual Analogue Scale (VAS) for nipple pain severity, Breastfeeding Self-Efficacy Scale Short Form (BSES-SF), and the Revised Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R). All study participants were breastfeeding dyads (0-12 weeks of age) with untreated ankyloglossia and/or tethered maxillary/buccal frena. The laser surgery was completed using 2 different near- infrared diode lasers with 300µm diameter fibre: a 980 nm wavelength diode laser (Lasotronix Smart Pro, Piaseczno Poland) was used at 4.0 W, gated with 100 µs t/on and 100 µs t/off, and a 1470 nm wavelength diode laser (Pioon S1, Wuhan Pioon Tech Co Ltd., Wuhan, China), used at 3.5W, gated with 50 ms t/on and 50 ms t/off. RESULTS: Statistically significant improvement was noted in VAS, I-GERQ-R and BSES-SF comparing preoperative scores to both one-week and one-month scores. The study had 132 breastfeeding dyads enrolled. Posterior tongue-tie was noted in 71% of this cohort. CONCLUSION: This study confirms the need for functional assessment of tongue and lip movement for this significantly affected cohort. Laser surgical release (frenotomy) of tongue-tie, lip-tie, buccal-tie resulted in significant improvement in breastfeeding outcomes. These improvements (VAS, I-GERQ-R and BSES-SF) in breastfeeding outcomes were found for cohorts of the classically recognised anterior tongue-tie and the less obvious (without functional assessment) submucosal tongue-tie were found.

Does a 'code stroke' rapid access protocol decrease door-to-needle time for thrombolysis?

BACKGROUND: Timely administration of intravenous tissue plasminogen activator (IVtPA) for acute ischaemic stroke is associated with better clinical outcomes. Therefore, a coordinated hospital system of acute clinical assessment and neuroimaging will likely avoid delays in IV-tPA administration. AIM: In July 2007, we implemented a 'code stroke' rapid access protocol at the Royal Melbourne Hospital with the aim of achieving rapid stroke assessment and treatment. This study investigates the quality of our 'code stroke' protocol and its impact on door-to-needle time and IV-tPA usage. METHODS: We included patients thrombolysed with IV-tPA from January 2003 to June 2007 (pre-code stroke era) and patients thrombolysed from July 2007 to December 2010 (code stroke era). Data collected were demographics, time points (stroke symptom onset, presentation to emergency department, neuroimaging and thrombolysis) and clinical outcomes (modified Rankin Scale) at discharge, symptomatic, intracerebral haemorrhage and death during admission). We compared the door-to-needle time and usage of IV-tPA between the two eras. RESULTS: Patient data on 98 'pre-code stroke' thrombolysed patients and 189 'code stroke' thrombolysed patients were collected. The median age was 71 (60-79), 56% were males, and the median baseline National Institute of Health Stroke Scale score was 13 ± 6.3. There was an 18-min reduction in the median door-to-needle time (90 min in 'pre-code stroke era' vs 72 min in 'code stroke era', P < 0.001). The rate of IV-tPA usage increased from 3.9% in 2004 to 17.3% in 2010. CONCLUSION: Our study showed that 'code stroke' rapid access protocol decreased door-to-needle time and possibly contributed to the increased IV-tPA usage.

Age over 80 years is not associated with increased hemorrhagic transformation after stroke thrombolysis.

Thrombolysis trials have recruited few patients aged ≥80 years, which has led to uncertainty about the likely risk-to-benefit profile in the elderly. Leukoaraiosis (LA) has been associated with hemorrhagic transformation (HT) and increases with advanced age. We tested whether there were any independent associations between age, LA and HT. Consecutive patients treated with intravenous (IV) tissue plasminogen activator (tPA) were identified from a prospective database. LA on baseline CT scans was assessed by two independent raters using the modified Van Swieten Score (mVSS) (maximum score 8, severe >4). HT was assessed on routine 24 hour to 48 hour CT /MRI scans using the European Cooperative Acute Stroke Study criteria for hemorrhagic infarct (HI) or parenchymal hematoma (PH) and judged symptomatic by the treating neurologist as per Safe Implementation of Thrombolysis in Stroke criteria. There were 206 patients treated with IV tPA (mean age: 71.0 years; range: 24-92 years), of whom 65/206 (32%) were aged ≥80 years. Overall, HT occurred in 41/206 patients (20%), HI in 31, PH1 in four (one symptomatic) and PH2 in six (three symptomatic). Age was not associated with HT (any HT: odds ratio [OR]=1.01; 95% confidence interval [CI]=0.5-2.08; p=0.99; PH: OR=0.53; 95% CI=0.12-2.3; p=0.51). There was one patient with PH1 and one patient with PH2 in 65 patients ≥80 years, both asymptomatic. LA was present in 112/208 (54%), and severe in 16.5%. LA increased with age (p<0.001) but was not associated with PH (any LA: OR=0.83; 95% CI=0.25-2.8; p=0.99; severe LA: OR=0.54, 95% CI=0.09-3.5; p=0.99). Age ≥80 years or LA did not increase the risk of HT (including PH) after thrombolysis, although LA increased with age. Neither factor should exclude otherwise eligible patients from tPA treatment.

A practical assessment of magnetic resonance diffusion-perfusion mismatch in acute stroke: observer variation and outcome.

MR diffusion/perfusion mismatch may help identify patients for acute stroke treatment, but mixed results from clinical trials suggest that further evaluation of the mismatch concept is required. To work effectively, mismatch should predict prognosis on arrival at hospital. We assessed mismatch duration and associations with functional outcome in acute stroke. We recruited consecutive patients with acute stroke, recorded baseline clinical variables, performed MR diffusion and perfusion imaging and assessed 3-month functional outcome. We assessed practicalities, agreement between mismatch on mean transit time (MTT) or cerebral blood flow (CBF) maps, visually and with lesion volume, and the relationship of each to functional outcome. Of 82 patients starting imaging, 14 (17%) failed perfusion imaging. Overall, 42% had mismatch (56% at <6 h; 41% at 12-24 h; 23% at 24-48 h). Agreement for mismatch by visual versus volume assessment was fair using MTT (kappa 0.59, 95% CI 0.34-0.84) but poor using CBF (kappa 0.24, 95% CI 0.01-0.48). Mismatch by either definition was not associated with functional outcome, even when the analysis was restricted to just those with mismatch. Visual estimation is a reasonable proxy for mismatch volume on MTT but not CBF. Perfusion is more difficult for acute stroke patients than diffusion imaging. Mismatch is present in many patients beyond 12 h after stroke. Mismatch alone does not distinguish patients with good and poor prognosis; both can do well or poorly. Other factors, e.g. reperfusion, may influence outcome more strongly, even in patients without mismatch.

Phyllosphere microbiology with special reference to diversity and plant genotype.

The phyllosphere represents the habitat provided by the aboveground parts of plants, and on a global scale supports a large and complex microbial community. Microbial interactions in the phyllosphere can affect the fitness of plants in natural communities, the productivity of agricultural crops, and the safety of horticultural produce for human consumption. The structure of phyllosphere communities reflects immigration, survival and growth of microbial colonists, which is influenced by numerous environmental factors in addition to leaf physico-chemical properties. The recent use of culture-independent techniques has demonstrated considerable previously unrecognized diversity in phyllosphere bacterial communities. Furthermore, there is significant recent evidence that plant genotype can play a major role in determining the structure of phyllosphere microbial communities. The main aims of this review are: (i) to discuss the diversity of phyllosphere microbial populations; (ii) to consider the processes by which microbes colonize the phyllosphere; (iii) to address the leaf characteristics and environmental factors that determine the survival and growth of colonists; (iv) to discuss microbial adaptations that allow establishment in the phyllosphere habitat and (v) to evaluate evidence for plant genotypic control of phyllosphere communities. Finally, we suggest approaches and priority areas for future research on phyllosphere microbiology.

Neurology of Fabry disease.

BACKGROUND: Fabry disease has diverse neurological manifestations, many of which influence morbidity and quality of life. AIMS: The aim of the study was to document the clinical and subclinical neurological manifestations in a cohort of Australian patients with Fabry disease, using multiple clinical tools and a multidisciplinary approach. METHODS: Participants completed focused questionnaires and underwent clinical neurological examination, Neurocognitive testing using Mini Mental State Examination and Neuropsychiatry Unit Cognitive Screen, Quantitative Sensory Testing (QST), autonomic assessment using RR interval variation, intracranial magnetic resonance imaging (MRI) and audiology. In subsets of patients who had previously undergone QST and/or prospective serial quality-of-life assessments over the previous 5 years, results before and after enzyme replacement therapy were compared. RESULTS: Twenty hemizygotes and two heterozygotes were recruited. The age (mean +/- standard deviation (SD)) of male participants was 40.4 +/- 11.9 years (range 20-62 years); the women were aged between 20 and 56 years. Increasing age was strongly associated with increasing neurological disability. Clinical peripheral neuropathy predominantly affected thermal sensation in all patients, with variable involvement of pinprick and light touch. QST confirmed these findings. Clinical cerebellar tests were commonly abnormal: this has not been previously reported in the absence of symptomatic cerebrovascular disease. There was hearing loss was in 90% of patients and no patient older than 44 years had normal hearing. MRI lesion prevalence increased with age. Despite neurological complications being common, formal cognitive testing was basically normal. QST thresholds for pain showed a significant change after enzyme replacement therapy. CONCLUSIONS: Neurological complications in Fabry disease are common, complex and may be devastating. All patients studied had neurological involvement, with protean and diverse manifestations.

Infection after acute stroke is associated with poor short-term outcome.

BACKGROUND: We sought to explore the frequency, risk factors, and clinical consequences of post-stroke infections (PSI). METHODS: We assessed consecutive patients admitted with suspected stroke. On day 1, we recorded the patients' baseline characteristics, stroke subtype and severity, physiological parameters, and laboratory results. On day 5, we recorded the occurrence of complications including infections, and functional outcome. RESULTS: We recruited 439 patients [398 with stroke and 41 with transient ischaemic attack (TIA)], of whom 73 (17%) had PSI (67 with stroke and 6 with TIA) by day 5. Compared to patients without PSI, those with PSI were significantly more likely to: (i) be older (mean age 78 vs 73 years, P=0.001); (ii) be dependent before admission (47% vs 24%, P<0.001); (iii) have total anterior circulation strokes (40% vs 20%, P<0.001); (iv) be hypoxic on arrival (35% vs 17%, P=0.001); (v) have urinary catheters (43% vs 16%, P<0.001), and (vi) develop pressure sores (7% vs 2%, P=0.022) and seizures (12% vs 2%, P<0.001). After adjusting for case mix, PSI was significantly associated with in-hospital death (OR 2.50, 95% CI 1.27-4.90, P=0.008) and institutionalization on discharge (OR 1.86, 95% CI 1.00-3.43, P=0.049). CONCLUSIONS: Post-stroke infection can affect patients admitted with TIA as well as acute stroke, and it may be associated with poor short-term outcomes.

Identification of quantitative trait loci for resistance to Xanthomonas campestris pv. campestris in Brassica rapa.

Resistance to six known races of black rot in crucifers caused by Xanthomonas campestris pv. campestris (Pammel) Dowson is absent or very rare in Brassica oleracea (C genome). However, race specific and broad-spectrum resistance (to type strains of all six races) does appear to occur frequently in other brassica genomes including B. rapa (A genome). Here, we report the genetics of broad spectrum resistance in the B. rapa Chinese cabbage accession B162, using QTL analysis of resistance to races 1 and 4 of the pathogen. A B. rapa linkage map comprising ten linkage groups (A01-A10) with a total map distance of 664 cM was produced, based on 223 AFLP bands and 23 microsatellites from a F(2) population of 114 plants derived from a cross between the B. rapa susceptible inbred line R-o-18 and B162. Interaction phenotypes of 125 F(2) plants were assessed using two criteria: the percentage of inoculation sites in which symptoms developed, and the severity of symptoms per plant. Resistance to both races was correlated and a cluster of highly significant QTL that explained 24-64% of the phenotypic variance was located on A06. Two additional QTLs for resistance to race 4 were found on A02 and A09. Markers closely linked to these QTL could assist in the transference of the resistance into different B. rapa cultivars or into B. oleracea.

Early neurological deterioration in acute stroke: clinical characteristics and impact on outcome.

BACKGROUND: A significant proportion of acute stroke patients suffer neurological deterioration during the first few days of recovery. AIM: To explore the frequency, clinical characteristics, and consequences of early neurological deterioration during the acute recovery period. METHODS: We assessed all consecutive patients admitted to a University hospital with suspected stroke. We recorded the following on admission: baseline characteristics, physiological parameters and laboratory results. On day 5 we recorded occurrence of complications, and functional outcome. Early neurological deterioration was defined as an increase in National Institute of Health Stroke Score (NIHSS) by two or more points (or stroke-related death) between admission and day 5. RESULTS: We recruited 188 stroke patients, of whom 36 (19%) suffered early neurological deterioration. Patients with early neurological deterioration were significantly more likely to: (i) arrive at the hospital earlier (median 2.25 vs. 7.2 h, p = 0.015); (ii) have a history of atrial fibrillation (33% vs. 16%, p = 0.039); (iii) be current non-smokers (24% vs. 11%, p = 0.041); (iv) have a severe stroke-more total anterior circulation strokes (67% vs. 26%, p < 0.001) and worse NIHSS and GCS scores; (v) have intracerebral haemorrhage (22% vs. 7%, p = 0.011); (vi) have higher serum urea (mean 7.8 vs. 6.5 mmol/l, p = 0.035) and leukocyte count (mean 12.6 vs. 9.7 x 10(9)/l, p = 0.044); and (vi) die in hospital (44% vs. 10%, OR 12.8, 95%CI 3.8-43.1, p < 0.001). DISCUSSION: Early neurological deterioration is a frequent and important complication in acute stroke, with a poor short-term prognosis. Effective treatment strategies are urgently needed to reduce its occurrence and impact on recovery.

MR diffusion-weighted imaging and outcome prediction after ischemic stroke.

BACKGROUND: MR diffusion-weighted imaging (DWI) shows acute ischemic lesions early after stroke so it might improve outcome prediction and reduce sample sizes in stroke treatment trials. Previous studies of DWI and outcome produced conflicting results. OBJECTIVE: To determine whether DWI lesion characteristics independently predict outcome in a broad range of patients with acute stroke. METHODS: The authors recruited hospital-admitted patients with all severities of suspected stroke, assessed stroke severity on the NIH Stroke Scale (NIHSS), performed early brain DWI, and assessed outcome at 3 months (modified Rankin Scale). Clinical data and DWI lesion parameters were evaluated in a logistic regression model to identify independent predictors of outcome at 3 months and a previously described "Three-Item Scale" (including DWI) was tested for outcome prediction. RESULTS: Among 82 patients (mean NIHSS 7.1 [+/-6.3 SD]), the only independent outcome predictors were age and stroke severity. Neither DWI lesion volume nor apparent diffusion coefficient nor the previously described Three-Item Scale predicted outcome independently. Comparison with previous studies suggested that DWI may predict outcome only in patients with more severe cortical ischemic strokes. CONCLUSIONS: Across a broad range of stroke severities, diffusion-weighted imaging (DWI) did not predict outcome beyond that of key clinical variables. Thus, DWI is unlikely to reduce sample sizes in acute stroke trials assessing functional outcome, especially where estimated treatment effects are modest.

Do acute diffusion- and perfusion-weighted MRI lesions identify final infarct volume in ischemic stroke?

BACKGROUND AND PURPOSE: An acute mismatch on diffusion-weighted MRI (DWI) and perfusion-weighted MRI (PWI) may represent the "tissue-at-risk." It is unclear which "semiquantitative" perfusion parameter most closely identifies final infarct volume. METHODS: Acute stroke patients underwent DWI and PWI (dynamic-susceptibility contrast imaging) on admission (baseline), and T2-weighted imaging (T2WI) at 1 or 3 months after stroke. "Semiquantitative" mean transit time (MTTsq=first moment of concentration/time curve), cerebral blood volume (CBVsq=area under concentration/time curve), and cerebral blood flow (CBFsq=CBVsq/MTTsq) were calculated. DWI and PWI lesions were measured at baseline and final infarct volume on T2WI acquired > or =1 month after stroke. Baseline DWI, CBFsq, and MTTsq lesion volumes were compared with final T2WI lesion volume. RESULTS: Among 46 patients, baseline DWI and CBFsq lesions were not significantly different from final T2WI lesion volume, but baseline MTTsq lesions were significantly larger. The correlation with final T2WI lesion volume was strongest for DWI (Spearman rank correlation coefficient rho=0.68), intermediate for CBFsq (rho=0.55), and weakest for MTTsq (rho=0.49) baseline lesion volumes. Neither DWI/CBFsq nor DWI/MTTsq mismatch predicted lesion growth; lesion growth was equally common in those with and without mismatch. CONCLUSIONS: Of the 2 PWI parameters, CBFsq lesions most closely identifies, and MTTsq overestimates, final T2WI lesion volume. "DWI/PWI mismatch" does not identify lesion growth. Patients without "DWI/PWI mismatch" are equally likely to have lesion growth as those with mismatch and should not be excluded from acute stroke treatment.

Magnetic resonance brain imaging in patients with acute stroke: feasibility and patient related difficulties.

OBJECTIVES: To assess organisational and patient specific limitations and safety of magnetic resonance imaging (MRI) as the first line investigation for hospital admitted stroke patients. METHODS: Consecutive patients admitted with acute stroke were assessed and an attempt was made to perform MRI in all patients. Oxygen saturation and interventions required during scanning were recorded. RESULTS: Among 136 patients recruited over 34 weeks, 85 (62%) underwent MRI. The patients' medical instability (15 of the 53 not scanned), contraindications to MRI (six of the 53 not scanned), and rapid symptom resolution (10 of the 53 not scanned) were the main reasons for not performing MRI. Of the 85 patients who underwent MRI, 26 required physical intervention, 17 did not complete scanning, and 11 of the 61 who had successful oxygen saturation monitoring were hypoxic during MRI. Organisational limitations accounted for only 13% of failures to scan. CONCLUSIONS: Up to 85% of hospital admitted acute stroke patients could have MRI as first line imaging investigation, but medical instability is the major limitation. Hypoxia is frequent in MRI. Patients should be monitored carefully, possibly by an experienced clinician, during scanning.

Temporal evolution of water diffusion parameters is different in grey and white matter in human ischaemic stroke.

OBJECTIVES: Our purpose was to investigate whether differences exist in the values and temporal evolution of mean diffusivity () and fractional anisotropy (FA) of grey and white matter after human ischaemic stroke. METHODS: Thirty two patients with lesions affecting both grey and white matter underwent serial diffusion tensor magnetic resonance imaging (DT-MRI) within 24 hours, and at 4-7 days, 10-14 days, 1 month, and 3 months after stroke. Multiple small circular regions of interest (ROI) were placed in the grey and white matter within the lesion and in the contralateral hemisphere. Values of [grey], [white], FA[grey] and FA[white] were measured in these ROI at each time point and the ratios of ischaemic to normal contralateral values (R and FAR) calculated. RESULTS: and FA showed different patterns of evolution after stroke. After an initial decline, the rate of increase of [grey] was faster than [white] from 4-7 to 10-14 days. FA[white] decreased more rapidly than FA[grey] during the first week, thereafter for both tissue types the FA decreased gradually. However, FA[white] was still higher than FA[grey] at three months indicating that some organised axonal structure remained. This effect was more marked in some patients than in others. R[grey] was significantly higher than R[white] within 24 hours and at 10-14 days (p<0.05), and FAR[white] was significantly more reduced than FAR[grey] at all time points (p<0.001). CONCLUSIONS: The values and temporal evolution of and FA are different for grey and white matter after human ischaemic stroke. The observation that there is patient-to-patient variability in the degree of white matter structure remaining within the infarct at three months may have implications for predicting patient outcome.

Improving the efficiency of delivery of thrombolysis for acute stroke: a systematic review.

BACKGROUND: Thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) is licensed for use within 3 h of acute ischaemic stroke. The less the delay to treatment, the more likely it is to be effective. AIMS: To assess the effectiveness of interventions designed to overcome barriers to rapid administration of thrombolytic therapy. DESIGN: Systematic review of previous clinical studies. METHODS: We searched for studies that evaluated the effect of an intervention to reduce delays to administration of rt-PA. We searched MEDLINE, EMBASE, the trials register of the Cochrane Stroke Group, and the Cochrane Controlled Trials Register. We sought randomized and non-randomized controlled trials, before-and-after studies, interrupted time series, and observational studies. RESULTS: We identified 10 non-randomized studies that evaluated interventions that could speed up admission to hospital and administration of rt-PA. The types of interventions included: (a) education programmes for the public to improve their knowledge about symptoms of acute stroke; (b) training programmes for paramedical staff to improve their accuracy of stroke diagnosis and hasten transport of the patient to hospital; (c) helicopter transfer of patients to hospital; (d) training programmes in acute stroke therapy for emergency department staff; and (e) re-organization of in-hospital systems to streamline acute stroke care. Several programmes were multifaceted interventions. DISCUSSION: We identified important areas that could be targets for interventions to improve the efficiency of delivering thrombolysis for acute stroke. Multifaceted programmes might be more likely to be successful in reducing delays to therapy.

Educational outcome at 8 years for children who were born extremely prematurely: a controlled study.

OBJECTIVE: To assess the educational outcome and utilization of special education resources at age 8 years in children who were born extremely prematurely, and to compare this outcome with a matched cohort of children born full-term. METHODS: All children with gestational age less than 28 weeks or birthweight of less than 1000 g, born at Royal North Shore Hospital from July 1985 through June 1990 were enrolled in a study of long-term outcome. A cohort of full-term children matched for age, sex and school with non-disabled extremely premature children was enrolled at age 8 years. Children were assessed using standardized measures of cognitive and academic achievement. Information was obtained from teachers regarding educational support and academic progress. RESULTS: Of 82 extremely premature children assessed at age 8 years, 8 (10%) had a severe disability, 13 (16%) had a mild or moderate disability and 61 (74%) were non-disabled (IQ > or = 85, no neurosensory disability). Thirty-five (43%) required special education support, 22 (27%) were below grade level in reading or mathematics and 25 (30%) were performing at grade level without support. Compared with controls, non-disabled extremely premature children had lower scores on standardized measures of academic achievement and were more likely to be reported by teachers as falling below grade level in reading (48% vs 13%; P < 0.001), mathematics (48% vs 10%; P < 0.001) and spelling (48% vs 17%; P < 0.002), and to require special education support (25% vs 4%; P = 0.004). CONCLUSION: Parents and professionals caring for extremely premature children need to be alert to the additional support that these children may require at school.