Child bereavement-what matters to the families. Part 2: The long term.

The death of a child is a devastating event. Families experience profound grief and loss immediately following the death, and this remains and evolves as time progresses. In this, the second in a series, we discuss the importance of longer term bereavement care and how continuing contact with healthcare can be navigated. As bereaved parents who are also doctors, we again share our experiences. The complex nature of parenting, supporting siblings or managing a pregnancy after loss are explored, and we look at the involvement of bereaved parents in developing bereavement services.

Child bereavement-what matters to the families. Part 1: Immediate and short-term communication and care.

The death of a child is a complex and hugely significant time for a family and community. Sophisticated but sensitive management by clinicians can have both short-term and long-term impacts on how families process the death. There is a paucity of guidance for optimal child bereavement care. A description of the child death review process including key legalities is provided here, and other essential aspects such as memory making, cultural aspects and sibling involvement are explored. Useful agencies and resources are also detailed. We, as both clinicians and bereaved parents, can uniquely provide an overview of the logistics of managing such a challenging event and highlight important subtleties in communication. We attempt, using our own experiences, to provide a framework and best inform future practice.

Examining motor evoked potential amplitude and short-interval intracortical inhibition on the up-going and down-going phases of a transcranial alternating current stimulation (tacs) imposed alpha oscillation.

Many brain regions exhibit rhythmical activity thought to reflect the summed behaviour of large populations of neurons. The endogenous alpha rhythm has been associated with phase-dependent modulation of corticospinal excitability. However, whether exogenous alpha rhythm, induced using transcranial alternating current stimulation (tACS) also has a phase-dependent effect on corticospinal excitability remains unknown. Here, we triggered transcranial magnetic stimuli (TMS) on the up- or down-going phase of a tACS-imposed alpha oscillation and measured motor evoked potential (MEP) amplitude and short-interval intracortical inhibition (SICI). There was no significant difference in MEP amplitude or SICI when TMS was triggered on the up- or down-going phase of the tACS-imposed alpha oscillation. The current study provides no evidence of differences in corticospinal excitability or GABAergic inhibition when targeting the up-going (peak) and down-going (trough) phase of the tACS-imposed oscillation.

Physiological evidence consistent with reduced neuroplasticity in human adolescents born preterm.

Preterm-born children commonly experience motor, cognitive, and learning difficulties that may be accompanied by altered brain microstructure, connectivity, and neurochemistry. However, the mechanisms linking the altered neurophysiology with the behavioral outcomes are unknown. Here we provide the first physiological evidence that human adolescents born preterm at or before 37 weeks of completed gestation have a significantly reduced capacity for cortical neuroplasticity, the key overall mechanism underlying learning and memory. We examined motor cortex neuroplasticity in three groups of adolescents who were born after gestations of ≤32 completed weeks (early preterm), 33-37 weeks (late preterm), and 38-41 weeks (term) using a noninvasive transcranial magnetic brain stimulation technique to induce long-term depression (LTD)-like neuroplasticity. Compared with term-born adolescents, both early and late preterm adolescents had reduced LTD-like neuroplasticity in response to brain stimulation that was also associated with low salivary cortisol levels. We also compared neuroplasticity in term-born adolescents with that in term-born young adults, finding that the motor cortex retains a relatively enhanced neuroplastic capacity in adolescence. These findings provide a possible mechanistic link between the altered brain physiology of preterm birth and the subsequent associated behavioral deficits, particularly in learning and memory. They also suggest that altered hypothalamic-pituitary-adrenal axis function due to preterm birth may be a significant modulator of this altered neuroplasticity. This latter finding may offer options in the development of possible therapeutic interventions.

Simultaneous application of slow-oscillation transcranial direct current stimulation and theta burst stimulation prolongs continuous theta burst stimulation-induced suppression of corticomotor excitability in humans.

The objective of this study was to assess whether the simultaneous application of slow-oscillation transcranial direct current stimulation enhances the neuroplastic response to transcranial magnetic theta burst stimulation. Motor evoked potential amplitude was assessed at baseline and at regular intervals up to 60 min following continuous theta burst stimulation, slow-oscillation transcranial direct current stimulation, and the simultaneous application of these paradigms. In addition, the electroencephalographic power spectra of slow and fast delta, and theta frequency bands recorded over the motor cortex were analyzed prior to and up to 5 min following each intervention. There was longer-lasting motor evoked potential suppression following the simultaneous application of continuous theta burst stimulation and slow-oscillation transcranial direct current stimulation compared with when continuous theta burst stimulation was applied alone. Slow-oscillation transcranial direct current stimulation applied alone did not modulate the motor evoked potential amplitude. No significant changes in spectral power were observed following slow-oscillation transcranial direct current stimulation. Simultaneous application of continuous theta burst stimulation and slow-oscillation transcranial direct current stimulation may provide an approach to prolong the induction of neuroplastic changes in motor cortical circuits by repetitive transcranial magnetic brain stimulation.

Cortical oscillatory activity and the induction of plasticity in the human motor cortex.

Repetitive transcranial magnetic stimulation paradigms such as continuous theta burst stimulation (cTBS) induce long-term potentiation- and long-term depression-like plasticity in the human motor cortex. However, responses to cTBS are highly variable and may depend on the activity of the cortex at the time of stimulation. We investigated whether power in different electroencephalogram (EEG) frequency bands predicted the response to subsequent cTBS, and conversely whether cTBS had after-effects on the EEG. cTBS may utilize similar mechanisms of plasticity to motor learning; thus, we conducted a parallel set of experiments to test whether ongoing electroencephalography could predict performance of a visuomotor training task, and whether training itself had effects on the EEG. Motor evoked potentials (MEPs) provided an index of cortical excitability pre- and post-intervention. The EEG was recorded over the motor cortex pre- and post-intervention, and power spectra were computed. cTBS reduced MEP amplitudes; however, baseline power in the delta, theta, alpha or beta frequencies did not predict responses to cTBS or learning of the visuomotor training task. cTBS had no effect on delta, theta, alpha or beta power. In contrast, there was an increase in alpha power following visuomotor training that was positively correlated with changes in MEP amplitude post-training. The results suggest that the EEG is not a useful state-marker for predicting responses to plasticity-inducing paradigms. The correlation between alpha power and changes in corticospinal excitability following visuomotor training requires further investigation, but may be related to disengagement of the somatosensory system important for motor memory consolidation.