Attention-deficit hyperactivity disorder and executive dysfunction in preschool children. A comparison of NEPSY and BRIEF-P assessments.

OBJECTIVE: The aim of the study was to explore prevalence, interrelations and accuracy of assessing psychopathology, intelligence, and executive functions (EF) in preschool children with ADHD (age 2.1-6.5 years). METHOD: We prospectively investigated 115 preschool outpatient children (91 boys, 24 girls, aged 4.3±1.0 years) with the clinical diagnosis of ADHD. Assessment included clinical history, background, psychosocial problems (CBCL, C-TRF), ADHD (DISYPS external ratings), cognitive performance (WPPSI-III, K-ABC), and executive functions (BRIEF-P, NEPSY). RESULTS: We found a high frequency of dysexecutive problems in up to 64 % in the parental BRIEF-P assessments, up to 62 % in the BRIEF-P teachers' assessments, and 62 % in the NEPSY functional assessments. Parental and teachers' BRIEF-P scores were only correlated in one subscale, inhibition, and NEPSY and BRIEF-P were not correlated at all. It was found that 42.5 % of the children with noticeable findings had agreeing results in all three, and another 45 % in two tests. CONCLUSIONS: About 2/3 of the ADHD preschool children had detectable EF dysfunctions. In order to assess dysexecutive problems, multi-method testing is mandatory.

[Advocacy for pediatric care]. / Politische Kindermedizin: Für eine bessere Zukunft aller Kinder.

Advocacy for pediatric care ("Politische Kindermedizin") is an Austrian association of engaged pediatricians, aiming at identifying, analyzing and evaluating pressing issues of pediatric care and to suggest improvements to the responsible politicians. The aim was and is to achieve an improvement of pediatric care for children and adolescents in the sense of patient advocacy. The history and concerns of the initiative "Politische Kindermedizin" from 1997 until the present are presented.

Psychopathology among parents of children and adolescents with separation anxiety disorder.

OBJECTIVE: To examine psychopathology among parents of children and adolescents with separation anxiety disorder (SAD). METHOD: A case-control design was applied: parents of children and adolescents suffering from SAD (n = 30; age: 10.7 ± 1.8 a) were compared with parents of youth without any psychiatric disease (n = 30; age: 11.2 ± 1.8 a). The SCID-I, a structured clinical interview to assess psychopathology, was applied among the parents group. RESULTS: Parents of children and adolescents suffering from SAD exhibited a significantly higher prevalence of psychopathology, mainly anxiety disorders and mood disorders, in comparison with the control group. Within anxiety disorders, mothers predominantly suffered from social phobia and specific phobia. Fathers most frequently suffered from obsessive-compulsive disorder and social phobia. Maternal anxiety disorder (current and lifetime) and maternal affective disorder (lifetime) proved to be significant predictors of SAD in youth. CONCLUSIONS: The associations between parents' psychopathology and the development of SAD in their children are discussed in the light of clinical implications, both in terms of psychotherapeutic care as well as treatment outcome.

Cognitive functions and glycemic control in children and adolescents with type 1 diabetes.

BACKGROUND: The relationship between metabolic control and cognitive function in adolescents with type 1 diabetes (DM type 1) is not clear. We compared the quality of glycemic control (GC) and cognitive measures in adolescents with DM type 1 to find out if the quality of diabetes management is related to cognitive impairment. METHOD: We assessed executive functions (EFs) and other neuropsychological and psychosocial variables in 70 adolescent patients with DM type 1 and 20 age-matched controls. Patients were divided into two groups according to their last hemoglobin A1c (HbA1c): acceptable (HbA1c 5.9-8.0%, mean 6.9%, 36 patients, mean age 14 years) and non-optimal (HbA1c 8.2-11.6%, mean 9.3%, 34 patients, mean age 15.6 years). RESULTS: We found impaired EFs, mainly problems of concept formation (p=0.038), cognitive flexibility (p=0.011) and anticipation (p=0.000), in the patients with DM type 1. Both groups did not differ in intelligence, most assessed EFs and adjustment to chronic illness (Youth Self-Report; YSR). Younger patients (<15 years) were cognitively less flexible. GC was worse in older patients and in patients with longer duration of the disease. We also found significant differences between patients with diabetes and controls concerning somatic complaints, internalizing problems (Child Behavior Checklist; CBCL) and social activity (CBCL and YSR). CONCLUSIONS: DM type 1 is associated with cognitive deficits in adolescents independent of the quality of metabolic control and the duration of the disease. These deficits are probably related to the disease, especially in patients with early-onset diabetes.

Self-injurious behavior in adolescent girls. Association with psychopathology and neuropsychological functions.

BACKGROUND: Self-injurious behavior (SIB) is increasingly popular in psychically ill adolescents, especially in girls with posttraumatic stress (PTSD) and personality disorders. Adolescents with SIB frequently exhibit neurofunctional and psychopathological deficits. We speculated that specific neuropsychological deficits and temperamental factors could predispose patients to SIB and prospectively explored adolescent psychiatric patients with and without SIB in order to find out differences in psychopathology, and neuropsychological or temperamental factors. SAMPLING AND METHODS: Ninety-nine psychically ill adolescent girls with SIB, aged 12-19 years and treated at our clinic, were prospectively recruited during a period of 5.5 years (1999-2005). The clinical (ICD-10) diagnoses were mainly substance abuse, eating disorders, depression, PTSD and personality disorders. The control group was also prospectively recruited during the same period and consisted of 77 girls with similar diagnoses and ages but no SIB. All patients were subjected to the same selection of clinical and neuropsychological tests, mainly self-rating questionnaires and tests evaluating executive functions. RESULTS: Adolescent girls with psychiatric disease and SIB were more severely traumatized and depressed. They reported severe emotional and behavioral problems and deficits of self-regulation. In addition, their parents more frequently had psychiatric problems. Temperament, intelligence, investigated executive functions and presence of dissociative symptoms were not different in patients with and without SIB. CONCLUSIONS: We could not verify our primary hypothesis that SIB is related to specific neuropsychological deficits or temperamental factors. SIB was associated with traumatic experience, depression, problems of self-regulation and parental psychiatric disease. The prevention of SIB should therefore focus on improving affect regulation, the management of emotional distress and problem-solving strategies.

Position dependent changes of cerebral blood flow velocities in premature infants.

UNLABELLED: The supine or prone positioning of infants has been a cause of much controversy. Recently it has been postulated that the position dependent hypoperfusion of the brainstem represents a possible cause of sudden infant death. To demonstrate position dependency and maturational changes of cerebral perfusion in premature newborn infants we investigated cerebral blood flow velocities (CBFV) in the main supratentorial and brainstem cerebral arteries. Measurements of CBFV were done with transfontanellar colour-coded Doppler sonography in the internal carotid artery (ICA), basilar artery (BA), and vertebral artery (VA) in the prone (head centered-baseline) and supine positions (maximal rotation to both sides) in 23 premature infants aged between 3-5 days of life. We performed follow-up measurements in 17 infants 7-10 days later and in 16 infants at the corrected age of 1 month. There was no difference in mean CBFVs between the prone and supine position at the first investigation. At the third investigation, CBFVs were significantly higher in the supine compared to the prone position. The CBFVs of the ICA were higher than in the BA and VA. This difference was not influenced by the body position but increased with post-natal age more in the VA (159%) than in the BA (129%) and ICA (128%). Position dependency was not seen in the ICA perfusion. In the prone position, five infants showed an incomplete steal effect in the contralateral VA. There was no significant side difference in the CBFVs of the ICA and VA, but in the resistance indices in the VA (left > right). CONCLUSION: in premature newborns, position dependent changes of cerebral blood flow velocity develop with maturation and are most pronounced in the vertebrobasilar system. These changes are possibly due to compression of the vertebral artery by neck movement and suggest an individual risk of brainstem perfusion deficits that may be aggravated with age and head rotation in a prone position.

Support for fast comprehension of ICU data: visualization using metaphor graphics.

OBJECTIVES: The time-oriented analysis of electronic patient records on (neonatal) intensive care units is a tedious and time-consuming task. Graphic data visualization should make it easier for physicians to assess the overall situation of a patient and to recognize essential changes over time. METHODS: Metaphor graphics are used to sketch the most relevant parameters for characterizing a patient's situation. By repetition of the graphic object in 24 frames the situation of the ICU patient is presented in one display, usually summarizing the last 24 h. RESULTS: VIE-VISU is a data visualization system which uses multiples to present the change in the patient's status over time in graphic form. Each multiple is a highly structured metaphor graphic object. Each object visualizes important ICU parameters from circulation, ventilation, and fluid balance. CONCLUSION: The design using multiples promotes a focus on stability and change. A stable patient is recognizable at first sight, continuous improvement or worsening condition are easy to analyze, drastic changes in the patient's situation get the viewers attention immediately.

SIDS related anxiety--a risk factor analysis.

BACKGROUND: The growing public interest in the Sudden Infant Death Syndrome (SIDS) has led to a new psychological problem--SIDS related anxiety (SRA). General public awareness, unfavourable experience in the past, present problems with the infant or insufficient support from the family may lead or contribute to SRA. OBJECTIVE: The study was conducted to explore which of these factors contribute most to the development of SRA. PATIENTS AND METHODS: Families visiting our outpatient clinic during 18 months were interviewed by means of a structured questionnaire. We assessed demographic data, obstetric history, experience of child loss, pregnancy and delivery complications, infant morbidity, family-child interaction, family support and the relation of each of these single factors to SRA. RESULTS: Of 169 families, 58% (98/169) admitted to suffer from SRA and 21% (32/156) from severe SRA. We found a strong and significant relationship between previous experience of child loss and SRA (OR: 2.95, 95% CI: 1.43-6.09, P < 0.005) and between pregnancy complications and SRA (OR: 2.19, 95% CI: 1.18-4.08, P < 0.05). There were no significant relationships between SRA and either delivery complications, child morbidity, impaired family-child interaction or insufficient support from the family. CONCLUSIONS: SRA occurs in an unexpectedly large proportion of families visiting a SIDS counseling clinic. SRA must be taken seriously, and psychological or psychotherapeutic help should be offered. Prevention of SRA should include psychological care for families who experience loss of children or high-risk pregnancies.

[Evaluation of the cardiorespiratory monitor SpiroGuard C for infants. Improved registration of respiratory events by new sensors and intelligent alarm management system]. / Evaluierung des Herz-Atem-Uberwachungsgerätes SpiroGuard C für Säuglinge. Verbesserte Erfassung von respiratorischen Ereignissen durch neue Sensorik und intelligentes Alarmmanagement?

OBJECTIVES: The SpiroGuard C is a commercially available cardiorespiratory monitor working with field plethysmography, wireless signal transmission and a novel alarm management system. In order to determine the recognition rates for central, mixed and obstructive apneas, a prospective clinical trial was performed comparing frequency and kind of signals from the monitor with those simultaneously registered by polysomnographic studies. DESIGN: Normal respiratory and alarm signals of the monitor under investigation were integrated into a polysomnographic setting. All central, mixed and obstructive apneas lasting more than 10 seconds as well as all alarms obtained from the monitor were evaluated. RESULTS: 47 series of monitor recordings could be evaluated in parallel to polysomnographic studies: the detection rate for central apneas was 298/328 (90.85%), for mixed apneas 9/41 (21.95%) and for obstructive apneas 0/36 (0%). Out of the total of 708 registered alarms 359 (50.71%) were false alarms, 307 (43.36%) were apnea-related and 42/708 (5.93%) were alarms due to technical problems. 177 of the 359 false alarms (49.30%) occurred during apneas that were shorter than 10 seconds, 119 (33.15%) were related to bad signal quality, and 55 (15.32%) were caused by movement artifacts. CONCLUSION: The recognition rate for central apneas was high (> 90%), while sensitivity for mixed and obstructive apneas was not satisfactory. Approximately half of the alarms were false alarms. These could be reduced by setting the apnea detection time to > 15 seconds, by tighter fastening of the respiration belt (improving the signal transmission), and by turning off the instrument when the child is awake and physically active. The wireless system renders the SpiroGuard C an attractive alternative for home monitoring.

Effects of endotracheal suctioning in high-frequency oscillatory and conventionally ventilated low birth weight neonates on cerebral hemodynamics observed by near infrared spectroscopy (NIRS).

Adverse changes in cerebral hemodynamics during endotracheal suctioning have been reported in conventionally ventilated newborns, whereas observations on the effect of endotracheal suctioning during high-frequency ventilation have not been reported to date. The present study was designed to investigate the effect of endotracheal suctioning on cerebral hemodynamics in high-frequency and conventionally ventilated infants. Changes in cerebral concentration of oxygenated (cO(2)Hb) and deoxygenated hemoglobin (cHHb) and oxidized cytochrome aa3 (cCyt.aa3) were measured by noninvasive near-infrared spectroscopy. In an open prospective study, 26 suctioning periods in 9 high-frequency and in 6 conventionally ventilated newborn infants were investigated. Heart rate, arterial oxygen saturation (SaO(2)), mean blood pressure (MABP), and transcutaneous carbon dioxide tension (TcpCO(2)) were monitored continuously. In both groups, a marked decrease in heart rate, SaO(2) and in cO(2)Hb, an increase in cHHb, and a variable pattern in the concentration of total hemoglobin were noted during endotracheal suctioning. During suctioning, no statistically significant differences between the two methods of mechanical ventilation could be observed. We conclude that the mode of ventilation had no significant effect on changes in cerebral hemodynamics during endotracheal suctioning.

Evaluation of an interdisciplinary data set for national intensive care unit assessment.

OBJECTIVES: To evaluate the ability of an interdisciplinary data set (recently defined by the Austrian Working Group for the Standardization of a Documentation System for Intensive Care [ASDI]) to assess intensive care units (ICUs) by means of the Simplified Acute Physiology Score II (SAPS II) for the severity of illness and the simplified Therapeutic Intervention Scoring System (TISS-28) for the level of provided care. DESIGN: A prospective, multicentric study. SETTING: Nine adult medical, surgical, and mixed ICUs in Austria. PATIENTS: A total of 1234 patients consecutively admitted to the ICUs. INTERVENTIONS: Collection of data for the ASDI data set. MEASUREMENTS AND MAIN RESULTS: The overall mean SAPS II score was 33.1+/-2.1 points. SAPS II overestimated hospital mortality by predicting mortality of 22.2%+/-2.9%, whereas observed mortality was only 16.8%+/-2.2%. The Hosmer-Lemeshow goodness-of-fit test for SAPS II scores showed lacking uniformity of fit (H = 53.78, 8 degrees of freedom; p < .0001). TISS-28 scores were recorded on 8616 days (30.6+/-1.5 points). TISS-28 scores were higher in nonsurvivors than in survivors (30.4+/-0.9 vs. 25.7+/-0.4, respectively; p < .05). No significant correlation between mean TISS-28 per patient per unit on the day of admission and mean predicted hospital mortality (r2 = .23; p < .54) or standardized mortality ratio per unit (r2 = -.22; p < .56) was found. CONCLUSIONS: Implementation of an interdisciplinary data set for ICUs provided data with which to evaluate performance in terms of severity of illness and provided care. The SAPS II did not accurately predict outcomes in Austrian ICUs and must, therefore, be customized for this population. A combination of indicators for both severity of illness and amount of provided care is necessary to evaluate ICU performance. Further data acquisition is needed to customize the SAPS II and to validate the TISS-28.

Three years experience with a patient data management system at a neonatal intensive care unit.

We report about our experience with the patient data management system (PDMS) Hewlett Packard CareVue 9000 at two neonatal ICUs. We describe our PDMS configuration (hard- and software), local adjustments and enhancements such as knowledge based systems for calculating the parenteral nutrition of newborn infants (VIE-PNN), for advising medication (VIE-Nmed), and for managing mechanical ventilation (VIE-VENT), and the results of a structured interview with our staff members about the acceptance of the system. Despite some criticism nearly all collaborators liked the system, especially because of its time saving automated documentation of vital data and mechanical ventilation parameters. More than 2/3 preferred the computer assisted documentation to charting by hand, only 1/41 would have liked to return to paper documentation. All staff members possessed excellent (15/39) or good (24/39) knowledge of the system. Main points of critique were the system's therapy planning facilities (medication administration records), the restrictive facilities for documenting patient care and the yet unsolved problems of data evaluation and export. PDM systems have to be constantly adapted to the user's needs and to the changing clinical environment. Living with the system asks for an intensive dialog with the system and its functionalities, for creativity and well defined ideas about the future system development.

New-born infants with severe hyaline membrane disease: radiological evaluation during high frequency oscillatory versus conventional ventilation.

OBJECTIVE: The aim of our study was to determine the impact of treatment with exogenous surfactant (ES) and high frequency oscillatory ventilation (HFOV) on the radiological appearance and clinical course of hyaline membrane disease (HMD) in new-born infants. MATERIALS AND METHODS: New-born infants (18) (median weight, 1010 g) with severe HMD (stages 3.5 and 4) who were treated with ES and HFOV were matched by birth weight and severity of disease with 18 new-born infants treated with ES and conventional mechanical ventilation (CV). Chest radiograms taken on days 1, 2/3, 4/5, 7, 14 and 28 were analyzed to check for the severity of generalized parenchymal opacities (GPO), local opacifications, pulmonary interstitial emphysema (PIE), gross air leak, general and localized overinflation, bronchopulmonary dysplasia (BPD) and clinical variables such as survival rates, duration of mechanical ventilation, mean airway pressure and inspired oxygen concentration. RESULTS: At 4 weeks of age, new-born infants treated by HFOV had less severe GPO (median degree 1.5 vs. 3), less PIE (1 vs. 7 patients) and fewer signs of BPD (median BPD degree 1.5 vs. 2.6). The incidence of pneumothorax and of local opacifications were similar in both groups. New-born infants on HFOV had a lower mortality rate (5 vs. 13), needed fewer days of mechanical ventilation (median 15 vs. 23 days) and lower inspiratory oxygen concentrations (median FiO2 0.38 vs. 0.64). CONCLUSION: In new-born infants with HMD, treatment with ES and HFOV resulted in a favourable radiological and clinical outcome as compared to treatment with ES and CV.

Effective data validation of high-frequency data: time-point-, time-interval-, and trend-based methods.

Real-time systems for monitoring and therapy planning, which receive their data from on-line monitoring equipment and computer-based patient records, require reliable data. Data validation has to utilize and combine a set of fast methods to detect, eliminate, and repair faulty data, which may lead to life-threatening conclusions. The strength of data validation results from the combination of numerical and knowledge-based methods applied to both continuously-assessed high-frequency data and discontinuously-assessed data. Dealing with high-frequency data, examining single measurements is not sufficient. It is essential to take into account the behavior of parameters over time. We present time-point-, time-interval-, and trend-based methods for validation and repair. These are complemented by time-independent methods for determining an overall reliability of measurements. The data validation benefits from the temporal data-abstraction process, which provides automatically derived qualitative values and patterns. The temporal abstraction is oriented on a context-sensitive and expectation-guided principle. Additional knowledge derived from domain experts forms an essential part for all of these methods. The methods are applied in the field of artificial ventilation of newborn infants. Examples from the real-time monitoring and therapy-planning system VIE-VENT illustrate the usefulness and effectiveness of the methods.

[Definition and evaluation of a documentation standard for intensive care medicine: the ASDI(Working Group for Standardization of a documentation system for Intensive care medicine) pilot project]. / Definition und Evaluation eines Dokumentationsstandards für Intensivmedizin: Das ASDI-Pilotprojekt.

OBJECTIVES: A comparison of data from different intensive care units (ICUs) needs standardized documentation. In this study the ASDI documentation standard for intensive care was tested in clinical practice. Goal of the study was to evaluate parameters and functionality required for a national, interdisciplinary documentation system for intensive care. DESIGN: 13 ICUs participated in a 4-week trial using the provided program for documentation of all admitted patients during the observation period. In addition, a questionnaire was distributed to the unit coordinators. RESULTS: 376 patients were documented in 1591 patient days. Valid SAPS II scores were found in only 29% of the discharged patients (39.1 +/- 15.5 points). Time needed for data entry exceeded preset limits (ten minutes per patient and day) in 38% of the cases. All participants affirmed the necessity of a documentation standard for intensive care, giving quality control and cost analysis as the most important reasons. CONCLUSION: The ASDI data set fitted existing needs very closely. Only 7 out of 122 parameters (5.7%) were found to be superfluous and thus removed. Measures to reduce documentation effort to the default limits were a) a new, date orientated concept for manual recording, b) rede-sign of the user interface with new, user friendly data entry possibilities, and c) the integration of statistical analysis and reports in the documentation system. The revised data set represents a broad-based consensus, which seems to be well-suited as foundation for the national quality assurance program.

Utilizing temporal data abstraction for data validation and therapy planning for artificially ventilated newborn infants.

Medical diagnosis and therapy planning at modern intensive care units (ICUs) have been refined by the technical improvement of their equipment. However, the bulk of continuous data arising from complex monitoring systems in combination with discontinuously assessed numerical and qualitative data creates a rising information management problem at neonatal ICUs (NICUs). We developed methods for data validation and therapy planning which incorporate knowledge about point and interval data, as well as expected qualitative trend descriptions to arrive at unified qualitative descriptions of parameters (temporal data abstraction). Our methods are based on schemata for data-point transformation and curve fitting which express the dynamics of and the reactions to different degrees of parameters' abnormalities as well as on smoothing and adjustment mechanisms to keep the qualitative descriptions stable. We show their applicability in detecting anomalous system behavior early, in recommending therapeutic actions, and in assessing the effectiveness of these actions within a certain period. We implemented our methods in VIE-VENT, an open-loop knowledge-based monitoring and therapy planning system for artificially ventilated newborn infants. The applicability and usefulness of our approach are illustrated by examples of VIE-VENT. Finally, we present our first experiences with using VIE-VENT in a real clinical setting.

Effects of umbilical arterial catheterization on mesenteric hemodynamics.

Impairment of mesenteric blood flow due to the use of umbilical artery catheters (UAC) may increase the risk of necrotizing enterocolitis (NEC) in newborn infants. We used Duplex Doppler sonography to investigate the degree of vessel obstruction due to UAC and their effect on visceral hemodynamics in 12 newborn infants. Ultrasonography was performed before and immediately after removal of the UAC, which was positioned above the ostia of the celiac and superior mesenteric arteries (SMA). Vessel diameter, peak systolic blood flow velocity (PSFV), end diastolic blood flow velocity (EDFV), and Pourcelot's resistance index (RI) were measured in the celiac trunk and the SMA within 1 cm of their origins. Removal of the UAC led to a significant increase in mean PSFV (celiac trunk: 50 cm/s +/- 15 vs 62 cm/s +/- 0.22, P < 0.05; SMA: 52 cm/s +/- 0.17 vs 72 cm/s +/- 0.21, P < 0.05). RI increased from 0.7 +/- 0.14 to 0.74 +/- 0.13 and from 0.73 +/- 0.1 to 0.76 +/- 0.13 for the celiac trunk and SMA, respectively. The EDFV and vessel diameters did not change significantly after UAC removal. Our results suggest that UAC cause a decrease in mesenteric blood flow. Therefore, their use in hemodynamically unstable neonates or in those with gastrointestinal disease should be very carefully considered.

Magnetic resonance imaging of absent pulmonary valve syndrome.

A neonate with absent pulmonary valve syndrome was examined by means of echocardiography and magnetic resonance imaging (MRI). MRI provided an excellent evaluation of the intracardial morphology, vessel anatomy, mediastinal structures, and shunt flow; and it was superior to echocardiography for detection of aortopulmonary collaterals and vessel abnormalities. This case report of an uncommon cardiac abnormality confirms that MRI is a useful complementary modality to echocardiography in neonates and is recommended for problems with central pulmonary vessels and their relation to tracheobronchial structures.