Evaluating the feasibility of a multicenter teleneonatology clinical effectiveness trial.

BACKGROUND: Our research consortium is preparing for a prospective multicenter trial evaluating the impact of teleneonatology on the health outcomes of at-risk neonates born in community hospitals. We completed a 6-month pilot study to determine the feasibility of the trial protocol. METHODS: Four neonatal intensive care units ("hubs") and four community hospitals ("spokes") participated in the pilot-forming four hub-spoke dyads. Two hub-spoke dyads implemented synchronous, audio-video telemedicine consultations with a neonatologist ("teleneonatology"). The primary outcome was a composite feasibility score that included one point for each of the following: site retention, on-time screening log completion, no eligibility errors, on-time data submission, and sponsor site-dyad meeting attendance (score range 0-5). RESULTS: For the 20 hub-spoke dyad months, the mean (range) composite feasibility score was 4.6 (4, 5). All sites were retained during the pilot. Ninety percent (18/20) of screening logs were completed on time. The eligibility error rate was 0.2% (3/1809). On-time data submission rate was 88.4% (84/95 case report forms). Eighty-five percent (17/20) of sponsor site-dyad meetings were attended by both hub and spoke site staff. CONCLUSIONS: A multicenter teleneonatology clinical effectiveness trial is feasible. Learnings from the pilot study may improve the likelihood of success of the main trial. IMPACT: A prospective, multicenter clinical trial evaluating the impact of teleneonatology on the early health outcomes of at-risk neonates born in community hospitals is feasible. A multidimensional composite feasibility score, which includes processes and procedures fundamental to completing a clinical trial, is useful for quantitatively measuring pilot study success. A pilot study allows the investigative team to test trial methods and materials to identify what works well or requires modification. Learnings from a pilot study may improve the quality and efficiency of the main effectiveness trial.

Provider Perspectives on the Acceptability, Appropriateness, and Feasibility of Teleneonatology.

OBJECTIVE: We aimed to measure provider perspectives on the acceptability, appropriateness, and feasibility of teleneonatology in neonatal intensive care units (NICUs) and community hospitals. STUDY DESIGN: Providers from five academic tertiary NICUs and 27 community hospitals were surveyed using validated implementation measures to assess the acceptability, appropriateness, and feasibility of teleneonatology. For each of the 12 statements, scale values ranged from 1 to 5 (1 = strongly disagree; 5 = strongly agree), with higher scores indicating greater positive perceptions. Survey results were summarized, and differences across respondents assessed using generalized linear models. RESULTS: The survey response rate was 56% (203/365). Respondents found teleneonatology to be acceptable, appropriate, and feasible. The percent of respondents who agreed with each of the twelve statements ranged from 88.6 to 99.0%, with mean scores of 4.4 to 4.7 and median scores of 4.0 to 5.0. There was no difference in the acceptability, appropriateness, and feasibility of teleneonatology when analyzed by professional role, years of experience in neonatal care, or years of teleneonatology experience. Respondents from Level I well newborn nurseries had greater positive perceptions of teleneonatology than those from Level II special care nurseries. CONCLUSION: Providers in tertiary NICUs and community hospitals perceive teleneonatology to be highly acceptable, appropriate, and feasible for their practices. The wide acceptance by providers of all roles and levels of experience likely demonstrates a broad receptiveness to telemedicine as a tool to deliver neonatal care, particularly in rural communities where specialists are unavailable. KEY POINTS: · Neonatal care providers perceive teleneonatology to be highly acceptable, appropriate, and feasible.. · Perceptions of teleneonatology do not differ based on professional role or years of experience.. · Perceptions of teleneonatology are especially high in smaller hospitals with well newborn nurseries..

Introduction of Amplitude-Integrated Electroencephalography (aEEG) Monitoring in a Level 2 NICU: Improving the Quality of Care for Neurologically At-Risk Newborns.

Amplitude-integrated electroencephalography (aEEG) is a bedside tool for continuous monitoring of brain activity with the possibility of real-time interpretation. Amplitude-integrated electroencephalography is routinely used in Canadian tertiary NICUs; however, its use in Level 2 NICUs has been limited. A bedside aEEG program was introduced in a Level 2 NICU in order to help facilitate the timely transfer of neurologically compromised infants and keep mother-infant dyads together where reassurance of appropriate neurological status could be attained. A monitoring guideline and educational program were developed. The introduction of aEEG monitoring enhanced the care provided to neurologically at-risk newborns. This experience can be used as a framework for other Level 2 NICUs who may wish to embark upon a similar initiative.

Accuracy of Simulated Research Tasks by Community Hospitals Participating in a Multicenter Telemedicine Trial.

Background/Aims: Clinical trials evaluating facility-to-facility telemedicine may include sites that have limited research experience. For the trial to be successful, these sites must correctly perform research-related tasks. This study aimed to determine whether health care professionals at community hospitals could accurately identify simulated study eligible patients and submit data to a research coordinating center. Methods: Twenty-seven community hospitals in the United States and Canada participated in this study. An electronic survey was sent to one designated health care professional at each site. The survey included a description of trial eligibility criteria and five written neonatal resuscitation scenarios. For each scenario, the participant determined whether the neonate was study eligible. One scenario required participants to submit 14 data elements to the coordinating center. Accuracy of study eligibility and data submission was summarized using standard descriptive statistics. Results: The survey response rate was 100% (27/27). Overall accuracy in determining study eligibility was 89% (120/135), and accuracy varied across the five scenarios (range 82-93%). Overall accuracy of data submission was 92% (310/336). Data were >95% accurate for 9 of the 14 data elements, with 100% accuracy achieved for 6 data elements. These results were used to clarify eligibility criteria, inform database design, and improve training materials for the subsequent clinical trial. Conclusions: Health care professionals at community hospitals accurately determined trial eligibility and submitted study data based on written clinical scenarios. Research teams conducting telemedicine trials with community hospitals should consider completing pre-trial simulation activities to identify opportunities for improving trial processes and materials.

Evaluation of transport-related outcomes for neonatal transport teams with and without physicians.

OBJECTIVE: The aim of this study was to evaluate if the presence of a physician in the neonatal transport team (NTT) affects transport-related outcomes and procedural success. DESIGN: Retrospective cohort study with propensity score matching. SETTING: Canadian national study. PATIENTS: Neonatal transports from nontertiary centres between January 2014 and December 2017. INTERVENTIONS: Comparison of transports conducted by NTTs with physicians (MD Group) and without physicians (noMD Group). MAIN OUTCOME MEASURES: The primary outcome was the change in patient acuity as measured by the transport risk index of physiologic severity (TRIPS) score. Secondary outcomes included mortality within 24 hours of NICU admission, clinical complications during transport, procedural success, and stabilization time. RESULTS: Among 9,703 eligible cases, 899 neonatal transports attended by NTTs with physicians were compared to 899 neonatal transports without physicians using propensity score matching. No differences were seen in the improvement of TRIPS score or mortality ≤24 hours of NICU admission. The MD Group had more clinical complications (7.7% versus 5.0%, P=0.02). No differences were seen in success rates of invasive procedures. The MD Group had shorter stabilization times. In multivariable analysis, the MD Group was not a significant predictor for the improvement in TRIPS score after adjustment for covariates. CONCLUSIONS: Neonatal transports conducted by teams including physicians compared to teams without physicians, did not have higher improvement in TRIPS scores and had similar success rates for procedures. These results provide insights for the planning of the structure and training of specialized interfacility neonatal transport programs.

Mapping the neuroanatomical impact of very preterm birth across childhood.

Those born very preterm (VPT; <32 weeks gestational age) have an increased risk in developing a wide range of cognitive deficits. In early-to-late childhood, brain structure has been shown to be altered in VPT compared to full-term (FT) children; however, the results are inconsistent. The current study examined subcortical volumes, cortical thickness, and surface area in a large cohort of VPT and FT children aged 4-12 years. Structural magnetic resonance imaging (MRI) was obtained on 120 VPT and 146 FT children who returned up to three times, resulting in 176 VPT and 173 FT unique data points. For each participant, Corticometric Iterative Vertex-based Estimation of Thickness was used to obtain global measurements of total brain, cortical grey and cortical white matter volumes, along with surface-based measurements of cortical thickness and surface area, and Multiple Automatically Generated Templates (MAGeT) brain segmentation tool was used to segment the subcortical structures. To examine group differences and group-age interactions, mixed-effects models were used (controlling for whole-brain volume). We found few differences between the two groups in subcortical volumes. The VPT children showed increased cortical thickness in frontal, occipital and fusiform gyri and inferior pre-post-central areas, while thinning occurred in the midcingulate. Cortical thickness in occipital regions showed more rapid decreases with age in the VPT compared to the FT children. VPT children also showed both regional increases, particularly in the temporal lobe, and decreases in surface area. Our results indicate a delayed maturational trajectory in those born VPT.

Periventricular Hemorrhagic Infarction in Very Preterm Infants: Characteristic Sonographic Findings and Association with Neurodevelopmental Outcome at Age 2 Years.

OBJECTIVE: To describe the sonographic characteristics of periventricular hemorrhagic infarction (PVHI) and their association with mortality and neurodevelopmental disability in very preterm infants born in 2008-2013. STUDY DESIGN: Retrospective multicenter observational cohort study. Diagonal PVHI size was measured and severity score assessed. PVHI characteristics were scored and temporal trends were assessed. Neurodevelopmental outcome at 2 years of corrected age was assessed using either the Bayley Scales of Infant and Toddler Development, Third Edition or the Griffiths Mental Development Scales. Multigroup analyses were applied as appropriate. RESULTS: We enrolled 160 infants with median gestational age of 26.6 weeks. PVHI was mostly unilateral (90%), associated with an ipsilateral grade III intraventricular hemorrhage (84%), and located in the parietal lobe (51%). Sixty-four (40%) infants with PVHI died in the neonatal period. Of the survivors assessed at 2 years of corrected age, 65% had normal cognitive and 69% had normal motor outcomes. The cerebral palsy rate was 42%. The composite outcome of death or severe neurodevelopmental disability was observed in 58%, with no trends over the study period (P = .6). Increasing PVHI severity score was associated with death (P < .001). Increasing PVHI size and severity score were negatively associated with gross motor scores (P = .01 and .03, respectively). Trigone involvement was associated with cerebral palsy (41% vs 14%; P = .004). Associated posthemorrhagic ventricular dilation (36%) was an independent risk factor for poorer cognitive and motor outcomes (P < .001 for both). CONCLUSIONS: Increasing PVHI size and severity score were predictive of less optimal gross motor outcome and death in very preterm infants.

Impaired Right Ventricular Performance Is Associated with Adverse Outcome after Hypoxic Ischemic Encephalopathy.

Rationale: Asphyxiated neonates with hypoxic ischemic encephalopathy (HIE) are at risk of myocardial dysfunction; however, echocardiography studies are limited and little is known about the relationship between hemodynamics and brain injury.Objectives: To analyze the association between severity of myocardial dysfunction and adverse outcome as defined by the composite of death and/or abnormal magnetic resonance imaging.Methods: Neonates with HIE undergoing therapeutic hypothermia were enrolled. Participants underwent echocardiography at 24 hours, 72 hours (before rewarming), and 96 hours (after rewarming). Cerebral hemodynamics were monitored by near-infrared spectroscopy and middle cerebral artery Doppler.Measurements and Main Results: Fifty-three patients with a mean gestation and birthweight of 38.8 ± 2.0 weeks and 3.33 ± 0.6 kg, respectively, were recruited. Thirteen patients (25%) had mild encephalopathy, 27 (50%) had moderate encephalopathy, and 13 (25%) had severe encephalopathy. Eighteen patients (34%) had an adverse outcome. Severity of cardiovascular illness (P < 0.001) and severity of neurologic insult (P = 0.02) were higher in neonates with adverse outcome. Right ventricle (RV) systolic performance at 24 hours was substantially lower than published normative data in all groups. At 24 hours, lower tricuspid annular plane systolic excursion (P = 0.004) and RV fractional area change (P < 0.001), but not pulmonary hypertension, were independently associated with adverse outcome on logistic regression. High brain regional oxygen saturation (P = 0.007) and low middle cerebral artery resistive index (P = 0.04) were associated with RV dysfunction on post hoc analysis.Conclusions: RV dysfunction is associated with the risk of adverse outcome in asphyxiated patients with HIE undergoing hypothermia. Echocardiography may be a valuable diagnostic and prognostic tool in this vulnerable population.

Procedural Interventions and Stabilization Times During Interfacility Neonatal Transport.

OBJECTIVE: Transport teams perform multiple procedural interventions during the stabilization of critically ill neonates. The setting of this study was a national cohort of interfacility neonatal transports from nontertiary centers. METHODS: A retrospective cohort study of neonatal transports having interventional procedures using the Canadian Neonatal Transport Network database during 2014 to 2016. Demographics and procedures associated with stabilization times ≤ 120 versus > 120 minutes were analyzed. Predictors of stabilization time were evaluated using multivariable logistic regression analysis. RESULTS: Among 3,350 neonatal transports analyzed, the 3 most frequently performed procedures were peripheral intravenous insertion, arterial blood gas sampling, and endotracheal tube insertion, with success rates of 85.2%, 89.1%, and 95.3%, respectively. The frequency of procedures varied across gestational age subgroups, and success rates were lower for umbilical arterial catheter insertions. After adjustment for confounders, more invasive procedures and a higher number of interventions were associated with longer stabilization times. CONCLUSION: The type and frequency of procedures performed had a significant impact on stabilization time. Any procedures that are nonessential for stabilization at the nontertiary center, such as umbilical arterial catheter insertion, could be minimized to promote timely admission to tertiary centers. The demonstrated variations in procedural success among teams provide useful information for benchmarking and promote the sharing of training practices.

Longitudinal Study of White Matter Development and Outcomes in Children Born Very Preterm.

Identifying trajectories of early white matter development is important for understanding atypical brain development and impaired functional outcomes in children born very preterm (<32 weeks gestational age [GA]). In this study, 161 diffusion images were acquired in children born very preterm (median GA: 29 weeks) shortly following birth (75), term-equivalent (39), 2 years (18), and 4 years of age (29). Diffusion tensors were computed to obtain measures of fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD), which were aligned and averaged. A paediatric atlas was applied to obtain diffusion metrics within 12 white matter tracts. Developmental trajectories across time points demonstrated age-related changes which plateaued between term-equivalent and 2 years of age in the majority of posterior tracts and between 2 and 4 years of age in anterior tracts. Between preterm and term-equivalent scans, FA rates of change were slower in anterior than posterior tracts. Partial least squares analyses revealed associations between slower MD and RD rates of change within the external and internal capsule with lower intelligence quotients and language scores at 4 years of age. These results uniquely demonstrate early white matter development and its linkage to cognitive functions.

Evaluation of Situation, Background, Assessment, Recommendation Tool During Neonatal and Pediatric Interfacility Transport.

OBJECTIVE: We aimed to determine if the implementation of Situation, Background, Assessment, Recommendation (SBAR) training improved the quality of real-life telephone communication. We evaluated interfacility neonatal and pediatric transports performed by registered nurses, respiratory therapists, and physicians (MDs). METHODS: This was a quality improvement study performed to evaluate telephone communication before and after SBAR training. Training consisted of lectures, review of audio files, and simulated role-playing. Recorded audio files of real-life transports were evaluated for clarity and content by 3 raters using a standardized scoring tool. RESULTS: Ninety-four and ninety-three calls were evaluated before and after the intervention, respectively. The total item scores were higher posttraining (mean ± standard deviation [pre: 15.06 ± 2.60, post: 17.60 ± 2.61], P < .001). Global rating scores ≥ 4 were higher in the posttraining group (pre: 50.0% vs. post: 66.7%; P = .02; odds ratio = 1.43; 95% confidence interval, 1.04-1.97). There was no significant difference in the duration of calls (mean ± SD [pre: 9.29 ± 4.59 minutes, post: 9.70 ± 4.65 minutes). In subgroup analysis, the total item score was significantly improved posttraining for registered nurses and respiratory therapists but not MDs. CONCLUSION: Standardized SBAR training was effective in improving telephone communication by RNs and RTs. The inclusion of SBAR training routinely within the educational curriculum of transport programs can enhance communication.

Initiation of passive cooling at referring centre is most predictive of achieving early therapeutic hypothermia in asphyxiated newborns.

OBJECTIVE: To identify factors associated with early initiation and achievement of therapeutic hypothermia (TH) in newborns with hypoxic-ischemic encephalopathy (HIE). METHODS: Retrospective cohort study of newborns who received TH according to National Institute of Child Health and Human Development (NICHD) criteria in two academic level 3 Neonatal Intensive Care Units (NICU) between 2009 and 2013. All infants were transported by a neonatal transport team (NNTT). Multivariate linear regression including who initiated cooling and degree of resuscitation in the model was performed. RESULTS: Two hundred and seven infants were included. Waiting for advice from a tertiary care NICU was independently associated with a 50 minute delay in the median time of initiation of TH. The need for extensive resuscitation (cardiopulmonary resuscitation [CPR] or epinephrine) was independently associated with a reduction of 43 minutes in the median time to reach target core temperature. Log-transformed time to initiation of TH was associated with time to reach target core temperature (P<0.001). A doubling of time to initiation of TH corresponds to a 24% (95% CI 18% to 30%) increase in median time to reach target core temperature. CONCLUSIONS: Initiating passive cooling at the referring centre, before transfer, is critical to faster achievement of target core temperature in asphyxiated infants. Greater outreach education and development of clinical care pathways are needed to improve optimal delivery of TH to enhance outcome.

Associations of Perinatal Clinical and Magnetic Resonance Imaging Measures with Developmental Outcomes in Children Born Very Preterm.

OBJECTIVE: To identify perinatal risk factors associated with long-term neurocognitive and behavioral impairments in children born very preterm using a multivariate, partial least squares approach. STUDY DESIGN: Twenty-seven perinatal clinical and magnetic resonance imaging measures were collected at birth and during the neonatal intensive care stay for 105 neonates born very preterm (≤ 32 weeks gestational age). One-half of the children returned for neuropsychological assessments at 2 and 4 years of age. Parent-reported behavioral measures were also obtained at 4 years of age. Three partial least squares analyses were performed to determine associations between clinical and radiologic measures with cognitive outcomes at 2 and 4 years of age, as well as with behavioral measures at 4 years of age. RESULTS: Within the first components of each analysis, only intrauterine growth restriction, male sex, and absence of antenatal corticosteroid use were associated with poorer cognitive and language ability at 2 and 4 years of age, accounting for 79.6% and 71.4% of the total variance, respectively. In addition, white matter injury at term-equivalent age contributed to more problematic internalizing behaviors, behavioral symptoms, and impaired executive function at 4 years of age, accounting for 67.9% of the total variance. CONCLUSIONS: Using this data-driven multivariate approach, specific measures in prenatal and early postnatal life are shown to be selectively and significantly associated with cognitive and behavioral outcomes in children born very preterm. Early detection of risk factors can help inform prognoses of children at greatest risk of long-term impairments.

Longitudinal cerebellar growth following very preterm birth.

PURPOSE: To measure cerebellar growth in a longitudinal cohort of very preterm infants to identify early predictors of subsequent brain growth. Although the cerebellum grows rapidly during late gestation, the rate and variability of growth following premature birth, and the effects of associated injury, are largely unknown. MATERIALS AND METHODS: In all, 105 very-preterm born infants (24-32 weeks GA) were imaged using magnetic resonance imaging (MRI) at birth, term-equivalent, 2, and 4 years of age. Cerebellar and total cerebral volumes were estimated from 1 mm isotropic T1 -weighted scans acquired at 1.5T and 3T, using an atlas-based approach. Linear models were used to analyze cerebellar volume as cross-sectional and longitudinal functions of age, clinical, and radiological correlates. Linear models were also used to test for associations between volume and cognitive outcome. RESULTS: Cerebellar volume increased rapidly with age-at-scan during both the preterm (0.7 mL/wk, P < 0.001) and term periods (1.8 mL/wk, P < 0.001). Infants with grade 3 or 4 germinal matrix hemorrhage (GMH) had smaller cerebellar volumes as a percentage of total brain volume starting at birth and continuing to 4 years of age (-0.43%, -0.57%, -1.09% at preterm, term, and 4 years, respectively, P < 0.01). Irrespective of age-at-scan, early cerebellar volume was predictive of volume at 4 years of age (slope = 1.3, P < 0.001). Cerebellar volumes were not found to predict cognitive outcome at 4 years of age; P < 0.2. CONCLUSION: High-grade GMH and small perinatal cerebellar size is predictive of cerebellar development up to 4 years of age. These findings suggest that it is possible to identify individuals at high risk of reduced cerebellar volumes at an early age. J. Magn. Reson. Imaging 2016;43:1462-1473.

The interfacility transport of critically ill newborns.

The practice of paediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile intensive care units capable of delivering state-of-the-art critical care during paediatric and neonatal transport. While outcomes are best for high-risk infants born in a tertiary care setting, high-risk mothers often cannot be safely transferred. Their newborns may then have to be transported to a higher level of care following birth. The present statement reviews issues relating to transport of the critically ill newborn population, including personnel, team competencies, skills, equipment, systems and processes. Six recommendations for improving interfacility transport of critically ill newborns are highlighted, emphasizing the importance of regionalized care for newborns.

Le transport interhospitalier des nouveau-nés et des enfants continue de prendre de l'expansion. Les équipes de transport se sont transformées en unités de soins intensifs mobiles en mesure de prodiguer des soins intensifs de pointe à ces populations pendant le transport. L'évolution des nouveau-nés à haut risque est plus favorable dans un établissement de soins tertiaires, mais bien souvent, les mères à haut risque ne peuvent pas être transférées en toute sécurité. Leur nouveau-né devra peut-être être transporté vers un établissement offrant un niveau de soins plus avancé après la naissance. Le présent document de principes traite des enjeux liés au transport des nouveau-nés gravement malades, y compris le personnel, les compétences et les habiletés de l'équipe, l'équipement, les systèmes et les processus. Sont présentées six recommandations pour améliorer le transport interhospitalier des nouveau-nés gravement malades, qui font ressortir l'importance des soins régionaux pour les nouveau-nés.

Pediatric Esophageal Button Battery Protocol Reduces Time From Presentation to Removal.

OBJECTIVE: Evaluate implementation of an institutional protocol to reduce the time to removal of esophageal button battery (BB) and increase use of mitigation strategies. METHODS: We developed a protocol for esophageal BB management [Zakai's Protocol (ZP)]. All cases of esophageal BB impaction managed at a tertiary care center before and after implementation from 2011 to 2023 were reviewed. Time to BB removal, adherence to critical steps, and use of mitigation strategies (honey/sucralfate, acetic acid) were evaluated. RESULTS: Fifty-one patients (38 pre-ZP, 13 post-ZP) were included. Median age was 2.3 years (IQR 1.3-3.4). After implementation, the time from arrival at the institution to arrival in the operating room (OR) reduced by 4.2 h [4.6 h (IQR 3.9-6.5) to 0.4 h (IQR 0.3-0.6), p < 0.001] and there was improvement in all management steps. The number of referrals direct to otolaryngology increased from 51% to 92%, arrival notification increased from 86% to 100%, avoidance of second x-ray increased from 63% to 100%, and direct transfer to OR increased from 92% to 100%. Adherence to mitigation strategies such as preoperative administration of honey or sucralfate increased from 0% to 38%, intraoperative use of acetic acid from 3% to 77%, and nasogastric tube insertion from 53% to 92%. CONCLUSION: Implementation of ZP substantially reduced the time to BB removal and the use of mitigation strategies in our tertiary care institution. Additional strategies focused on prevention of BB ingestion, and shortening the transfer time to the tertiary care hospital are required to prevent erosive complications. LEVEL OF EVIDENCE: Level 3 Case-series Laryngoscope, 2024.

Quantitative MRI in the very preterm brain: assessing tissue organization and myelination using magnetization transfer, diffusion tensor and T1 imaging.

Magnetization transfer ratio (MTR), diffusion tensor imaging (DTI) parameters and T(1) relaxometry values were used to create parametric maps characterizing the tissue microstructure of the neonatal brain in infants born very premature (24-32 gestational weeks) and scanned at preterm and term equivalent age. Group-wise image registration was used to determine anatomical correspondence between individual scans and the pooled parametric data at the preterm and term ages. These parametric maps showed distinct contrasts whose interrelations varied across brain regions and between the preterm and term period. Discrete patterns of regional variation were observed for the different quantitative parameters, providing evidence that MRI is sensitive to multiple independent aspects of brain maturation. MTR values showed a marked change in the pattern of regional variation at term equivalent age compared to the preterm period such that the ordinal ranking of regions by signal contrast changed. This was unlike all other parameters where the regional ranking was preserved at the two time points. Interpreting the data in terms of myelination and structural organization, we report on the concordance with available histological data and demonstrate the value of quantitative MRI for tracking brain maturation over the neonatal period.

Limitations of routine neuroimaging in predicting outcomes of preterm infants.

INTRODUCTION: Preterm births are increasing in number and while the rates of cerebral palsy have declined, there are increasing numbers of infants who survive with handicaps. In some studies, up to 50 % of children will have morbidity when followed up to school age. METHODS: A review of current literature was conducted to determine the validity of routine cranial ultrasound scans (CUS) to predict neurodevelopmental outcomes, including motor and cognitive deficits. We also reviewed the additional benefit offered by including MRI scans in scanning protocols to enhance the reliability in predicting the neurodevelopmental sequelae of prematurity. RESULTS: CUS is valuable as a screening tool to determine significant brain injury when conducted regularly over the first weeks of life in preterm infants. Subtle changes on CUS are difficult to interpret and more precise information is offered by performing MRI scans. These are most often carried out at term equivalent age but earlier scans may be just as useful in predicting neurocognitive outcomes. When MRI scans are either normal or seriously abnormal, there is a very clear correlation with outcome to 2 years of age. Mild and moderate degrees of injury defined on MRI need more sophisticated scanning sequences to determine the likelihood of associated sequelae. Follow-up to school age is essential to diagnose more subtle cognitive delays. CONCLUSION: CUS provides a good screening tool to detect serious brain injury resulting in motor handicaps but MRI scans are complementary and necessary to accurately predict the outcomes of preterm infants, especially cognitive delays.

Variations in transport outcomes of outborn infants among Canadian neonatal intensive care units.

BACKGROUND: Outborn infants born at community hospitals and transported to tertiary neonatal intensive care units (NICUs) for treatment account for 20% of all tertiary NICU admissions in Canada. Little is known about variations in their outcomes. The Transport Risk Index of Physiologic Stability (TRIPS) is a validated score of neonatal physiological status that can identify differences between transport teams' outcomes. OBJECTIVE: To examine regional variations in outcomes among outborn infants transported to Canadian tertiary NICUs using TRIPS. DESIGN AND METHODS: Transport teams prospectively collected data for all outborn infants admitted to 25 Canadian NICUs during 2006 to 2007. Singleton outborn infants ≥ 32 weeks' gestation admitted to NICUs for at least 24 hours who died or who were transferred to another NICU within 24 hours were examined for overall incidence of mortality, major morbidity, and change in TRIPS score. RESULTS: Complete transport data were available for 2313 (72.9%) of 3193 eligible infants. There were significant variations in interhospital and interprovincial outcomes. Factors significantly affecting change in TRIPS score were gender, pretransport TRIPS score, composition of transport team and distance traveled. CONCLUSION: Significant variation exists in transport outcomes in Canada. Further investigation is required to optimize infant transport systems, processes, and clinical care.