Functional Connectivity Network Disruption Underlies Domain-Specific Impairments in Attention for Children Born Very Preterm.

Attention problems are common in school-age children born very preterm (VPT; < 32 weeks gestational age), but the contribution of aberrant functional brain connectivity to these problems is not known. As part of a prospective longitudinal study, brain functional connectivity (fc) was assessed alongside behavioral measures of selective, sustained, and executive attention in 58 VPT and 65 full-term (FT) born children at corrected-age 12 years. VPT children had poorer sustained, shifting, and divided attention than FT children. Within the VPT group, poorer attention scores were associated with between-network connectivity in ventral attention, visual, and subcortical networks, whereas between-network connectivity in the frontoparietal, cingulo-opercular, dorsal attention, salience and motor networks was associated with attention functioning in FT children. Network-level differences were also evident between VPT and FT children in specific attention domains. Findings contribute to our understanding of fc networks that potentially underlie typical attention development and suggest an alternative network architecture may help support attention in VPT children.

Altered functional network connectivity relates to motor development in children born very preterm.

Individuals born very preterm (<32 weeks gestation) are at increased risk for neuromotor impairments. The ability to characterize the structural and functional mechanisms underlying these impairments remains limited using existing neuroimaging techniques. Resting state-functional magnetic resonance imaging (rs-fMRI) holds promise for defining the functional network architecture of the developing brain in relation to typical and aberrant neurodevelopment. In 58 very preterm and 65 term-born children studied from birth to age 12 years, we examined relations between functional connectivity measures from low-motion rs-fMRI data and motor skills assessed using the Movement Assessment Battery for Children, 2nd edition. Across all subscales, motor performance was better in term than very preterm children. Examination of relations between functional connectivity and motor measures using enrichment analysis revealed between-group differences within cerebellar, frontoparietal, and default mode networks, and between basal ganglia-motor, thalamus-motor, basal ganglia-auditory, and dorsal attention-default mode networks. Specifically, very preterm children exhibited weaker associations between motor scores and thalamus-motor and basal ganglia-motor network connectivity. These findings highlight key functional brain systems underlying motor development. They also demonstrate persisting developmental effects of preterm birth on functional connectivity and motor performance in childhood, providing evidence for an alternative network architecture supporting motor function in preterm children.

Very preterm birth: maternal experiences of the neonatal intensive care environment.

OBJECTIVE: Examine sources, predictors and child outcomes associated with neonatal intensive care unit (NICU)-related stress for mothers of infants born very preterm (VPT). STUDY DESIGN: Participants were 133 mothers of VPT infants admitted to a regional level-III NICU. At term equivalent, mothers completed the Parental Stressor Scale: NICU and were interviewed about their psychological well-being and family circumstances. Infant clinical data were also collected. At corrected age 4 years, 49 children were assessed for cognition, language and socio-emotional development. RESULT: Mothers reported moderate to low stress, with parental role alteration considered most stressful and parent-staff communications least stressful. Predictors of overall stress included maternal educational underachievement, stressful life events, postnatal depression and infant unsettled-irregular behavior. NICU-related stress was associated with child anxiety and poorer language development. CONCLUSION: Parental well-being is an important focus of care in the neonatal setting. Strategies are needed to optimize early engagement and reduce stress levels to assist improved child outcomes.

Factors associated with feeding difficulties in the very preterm infant.

AIM: To investigate early medical and family factors associated with later feeding risk in preterm infants. METHODS: For this longitudinal study, 136 infants born ≤30 weeks gestation were enrolled. Medical and social background factors were assessed at term equivalent age. Infants underwent magnetic resonance imaging, neurobehavioral evaluation and feeding assessment. Parent involvement in the neonatal intensive care unit was tracked, and maternal mental health was assessed at neonatal intensive care unit discharge. At age 2 years, feeding outcome was assessed using the Eating Subscale of the Infant-Toddler Social Emotional Assessment (n = 80). Associations between feeding problems at age 2 years and (i) early medical factors, (ii) neurobehavioral functioning and feeding at term equivalent age, (iii) cerebral structure and (iv) maternal mental health were investigated using regression. RESULTS: Eighteen (23%) children had feeding problems at age 2 years. Feeding problems were associated with early hypotonia (p = 0.03; ß = 0.29) and lower socio-economic status (p = 0.046; ß = -0.22). No associations were observed between early medical factors, early feeding performance, cerebral structure alterations or maternal well-being and feeding outcome. CONCLUSION: Early hypotonia may disrupt the development of oral-motor skills. Hypotonia and poor feeding also may share a common aetiology. Associations with lower socio-economic status highlight the potential influence of family background factors in feeding problems in the preterm infant.

Childhood exposure to sexual abuse and partnership outcomes at age 30.

BACKGROUND: In this study, 30-year longitudinal data from the Christchurch Health and Development Study (CHDS) were used to examine the associations between childhood exposure to sexual abuse and intimate relationship outcomes at age 30. In addition, a broad range of early childhood and family confounding factors were tested, and the role of intervening factors from adolescence was explored. METHOD: The investigation analyzed data from a birth cohort of over 900 New Zealand adults studied to the age of 30. At ages 18 and 21 cohort members reported on any exposure to sexual abuse prior to age 16. This information, along with prospective data gathered in childhood and adolescence, was used to predict partnership outcomes at age 30. RESULTS: After adjustment for early childhood and family factors, exposure to more severe forms of childhood sexual abuse (CSA) was associated with earlier and more frequent cohabitation, higher rates of perpetrated interpartner violence (IPV), and early parenthood, lower relationship satisfaction and investment. Several factors from adolescence partially or fully mediated these associations, notably a history of early consensual sexual intercourse, higher number of sexual partnerships, substance abuse problems, and self-esteem. After adjustment for intervening factors, exposure to CSA remained significantly associated with IPV. CONCLUSIONS: The findings support a causal chain process, whereby early childhood and family factors place some individuals at risk for CSA. The extent of CSA exposure is related to adolescent risk taking, which in turn leads to early and more frequent cohabitation, risk of IPV, and lower relationship satisfaction and investment.

Ankylosing spondylitis: recent developments and anaesthetic implications.

Ankylosing spondylitis can present significant challenges to the anaesthetist as a consequence of the potential difficult airway, cardiovascular and respiratory complications, and the medications used to reduce pain and control the disease. There is also an increased risk of neurological complications in the peri-operative period. Awake fibreoptic intubation is the safest option in those patients with a potentially difficult airway as it allows continuous neurological monitoring while achieving a definitive airway. Neurophysiological monitoring (somatosensory and motor evoked potentials) should be considered in patients undergoing surgery for cervical spine deformity. The medical management of the disease has improved with the use of anti-tumour necrosis factor-alpha agents. There is potential for increased wound infection in patients taking these drugs. This article reviews the anaesthetic issues in patients with ankylosing spondylitis. The challenge to the anaesthetist is in the understanding of these issues so that appropriate management can be planned and undertaken.

Very preterm children show impairments across multiple neurodevelopmental domains by age 4 years.

OBJECTIVES: Neurodevelopmental outcomes associated with preterm birth are of major health and educational concern. This study examined the neuromotor, cognitive, language and emotional/behavioural outcomes of a regional cohort of 4-year-old children born extremely preterm (EPT: 23-27 weeks' gestation), very preterm (VPT: 28-33 weeks) and full term (FT: 38-41 weeks). Of particular interest were children's risks of impairment across multiple neurodevelopmental domains. METHODS: Data were gathered as part of a prospective longitudinal study of 105 very preterm (< or = 33 weeks gestation) and 107 FT children born during 1998-2000. At 4 years corrected age, children underwent a comprehensive multidisciplinary assessment that included a paediatric neurological examination, cognitive and language testing, and an assessment of child emotional and behavioural adjustment. RESULTS: At age 4 years, compared to FT children, EPT and VPT children had increased risks of cerebral palsy (EPT 18%, VPT 15%, FT 1%), cognitive delay (EPT 33%, VPT 36%, FT 13%), language delay (EPT 29%, VPT 29%, FT 10%) and emotional/behavioural adjustment problems (EPT 37%, VPT 13%, FT 11%). EPT and VPT children were three times more likely to have multiple domain impairments than FT children (EPT 30%, VPT 29%, FT 10%). CONCLUSIONS: A substantial proportion of preschool children born very preterm show clinically significant problems in at least one neurodevelopmental domain, with impairment in multiple domains being common. There is a need to monitor preschool development across a range of functional domains and to consider the likely cascading effects of multiple impairments on later development.

Puerperal streptococcal toxic shock syndrome treated with recombinant human activated protein C and intravenous immunoglobulin.

Group A streptococcal sepsis is an uncommon management challenge and has a potentially fulminate course. We present the case of a 25-year-old woman who, within 24h of spontaneous vaginal delivery at 32 weeks of gestation, developed signs of systemic infection and multi-organ failure requiring admission to the intensive care unit. Recombinant human activated protein C and intravenous immunoglobulin were used; subsequently heparin-induced thrombocytopenia and pulmonary embolus also required treatment.

Management of acute procedural pain in the neonatal intensive care unit (NICU).

Neonates experience pain and may be more sensitive to it. Our objective was to assess pain management strategies in Irish neonatal units. We performed a cross-sectional telephone survey of all twenty neonatal units in the Republic of Ireland. Nurse managers or the on call registrar was questioned about their unit's analgesia practices. Four units (20%) had guidelines for neonatal procedural pain management Two units (10%) used the PIPP pain assessment tool. Non-nutritive sucking and swaddling were most popular for minor procedures, but use was infrequent. Eight units (40%) had access to sucrose but use was low in most units. Three units used breast-feeding (15%) for heal lancing, IM injections and venepuncture. Most units (60%) stated emergency situations as the main reason for not using analgesia. Despite growing evidence supporting neonatal pain experience and increased sensitivity, neonates are not often afforded the benefits of intervention in Irish NICUs.

Self-harm in young people: a perspective for mental health nursing care.

AIMS: This paper addresses the assessment and management of self-harm in young people by a nurse consultant-led self-harm service in the UK. The purpose of the paper is to present some of the theoretical perspectives of the service and how these have influenced current practice with this group of young people. BACKGROUND: Self-harm in young people continues to be a serious concern for health services globally. Rates of self-harm in teenagers in the UK are among the highest in Europe. The current literature offers information on the nature of self-harm and some evidence of specific interventions mainly from a 'psychiatric perspective'. This paper examines the development of a locally based nurse-led self-harm team involved in the care of this group of young people. A sociological view of children and young people is applied in examining the way society construes self-harm and the formation of the behaviour as a deviant act. Self-harm is considered in the context of transition through adolescence and the growth of self-identity. CONCLUSION: The locally based child and adolescent mental health service has drawn together the evolving nurse consultant role, mental health nursing and medical sociology. This integration of people and theory will enhance the services understanding of self-harm in young people. At an international level, there is a need to consider the sociological dimensions of self-harm in young people as a way forward for mental health nurses who are involved in working with this group of people.

Expression of HC subunits from Clostridium botulinum types C and D and their evaluation as candidate vaccine antigens in mice.

Two proteins representing the heavy-chain subunits of botulinum neurotoxin types C and D were expressed in Escherichia coli, and their vaccine potential was evaluated. Mice were vaccinated with doses ranging from 0.5 to 10 microg and were challenged with 10 to 10(5) 50% lethal doses of toxin. For the type C subunit protein, C50, two doses of 2 microg were required for full protection, while, for type D subunit protein, D50, two 1- microg doses were required. A bivalent vaccine consisting of a mixture of these two proteins also provided protection against both botulinum neurotoxin type C and type D challenge. Antibody levels in serum were determined by both enzyme-linked immunosorbent assays and serum neutralization assays

Association of atypical chest pain presentations by African Americans and the lack of utilization of reperfusion therapy.

OBJECTIVE: One possible factor resulting in delays in using reperfusion therapy in patients with acute myocardial infarction (AMI) is the failure to recognize cardiac symptomatology early in certain subgroups of patients. These patients may undergo extensive evaluation for gastrointestinal or musculoskeletal complaints before it is recognized that they are suffering from an AMI. METHODS: The records of patients (52% Black and 48% White; 49% male and 51% female) presenting to an urban teaching hospital with enzyme documented myocardial infarctions were retrospectively examined for traditional elements of atypia in their initial chest pain descriptions to the emergency department (ED). The rate of reperfusion therapy utilization was also determined for this group. RESULTS: Of the patients meeting the study criteria (166 total), 43% were found to have atypical elements in the character of their pain description. This high prevalence of atypia also coincided with a low reperfusion intervention rate of 38%. In examining the subgroups, it appears that African Americans and women had the highest rates of atypical pain (56% and 46%, respectively) while also having the lowest utilization rates for reperfusion therapies (31% and 33%, respectively). This compares to rates of 48% for Whites and 60% for White males who had more typical chest pain. CONCLUSIONS: While no direct correlation can be drawn from the data, it has been suggested that atypical presentations may result in early failure to recognize myocardial infarction and cause delay in or prevent appropriate therapy. It is thought that chest pain should be de-emphasized as a part of the indication criteria for thrombolytics and emergent angioplasty.

Teenage pregnancy: cause for concern.

AIMS: To describe the lifetime prevalence of teenage pregnancy and parenthood, in addition to the psychosocial backgrounds and current circumstances of young parents in a sample of 533 young women studied from bith to 21 years. METHODS: The data were gathered as part of the Christchurch Health and Development Study. This study consists of a cohort of 1265 young people born in the Christchurch urban area during mid 1977 and who have been regularly assessed up to the age of 21 years. Information was collected on all pregnancies and births from ages 14-21 years. RESULTS: By age 21 years, 26% of the sample had been pregnant and 14% had become parents. Most pregnancies occurred between ages 17-21 years. Young women who became pregnant were characterised by higher rates of educational under-achievement, conduct problems, sexual risk taking, family adversity, and were more likely to identify themselves as Maori. Amongst those who became pregnant, there was a tendency for young women with a personal history of family adversity to proceed with their pregnancy and become young mothers. CONCLUSIONS: By age 21 years, at least a quarter of all young women studied had been pregnant at least once. The wide range of personal and social factors associated with teenage pregnancy and parenthood suggests that teenage pregnancy does not solely reflect the effects of problematic adolescent sexual practices. Implications for teen pregnancy prevention and the health and development of children born to younger mothers are discussed.

Life course outcomes of young people with anxiety disorders in adolescence.

OBJECTIVE: This study examined associations between the extent of anxiety disorder in adolescence (14-16 years) and young people's later risks of a range of mental health, educational, and social role outcomes (16-21 years). METHOD: Data were gathered over the course of a 21-year longitudinal study of a birth cohort of 1,265 New Zealand children. Measures collected included (1) an assessment of DSM-III-R anxiety disorders between the ages of 14 and 16 years; (2) assessments of mental health, educational achievement, and social functioning between the ages of 16 and 21 years; and (3) measures of potentially confounding social, family, and individual factors. RESULTS: Significant linear associations were found between the number of anxiety disorders reported in adolescence and later risks of anxiety disorder; major depression; nicotine, alcohol, and illicit drug dependence; suicidal behavior; educational underachievement; and early parenthood. Associations between the extent of adolescent anxiety disorder and later risks of anxiety disorder, depression, illicit drug dependence, and failure to attend university were shown to persist after statistical control for the confounding effects of sociofamilial and individual factors. CONCLUSIONS: Findings suggest that adolescents with anxiety disorders are at an increased risk of subsequent anxiety, depression, illicit drug dependence, and educational underachievement as young adults. Clinical and research implications are considered.

Unemployment and psychosocial adjustment in young adults: causation or selection?

This study investigates the relationships between unemployment following school leaving and psychosocial adjustment problems (mental health, substance use, crime, suicidal behaviours and teenage pregnancy) in a birth cohort of over 1000 New Zealand born young people. The data were gathered during the course of the Christchurch Health and Development Study (CHDS). The CHDS is a longitudinal study of a birth cohort of 1265 children born in the Christchurch (NZ) urban region who have been studied from birth to age 21. Data were gathered by personal interview on: (a) exposure to unemployment and (b) personal adjustment over the period from age 16 to age 21. Measures of personal adjustment included mental health (depression, anxiety), substance use, crime, suicidal behaviours and (for females) teenage pregnancy. Data were analysed using a fixed effects regression model that took into account both observed and non-observed sources of confounding and the possibility of reverse causal associations between personal adjustment and unemployment. Before adjustment for confounding and reverse causality there were significant (p < 0.001) associations between exposure to unemployment and measures of mental health, substance use, crime, suicidal behaviours and teenage pregnancy. Adjustment for confounding factors and reverse causality reduced these associations quite substantially and after control for sources of confounding a number of associations became nonsignificant. Nonetheless, after such control, exposure to unemployment remained significantly (p < 0.05) associated with suicidal ideation, substance abuse and criminal behaviours. It is concluded that, in part, the associations between unemployment and personal adjustment are spurious and reflect the presence of confounding factors that are related to both unemployment and adjustment. Nonetheless, the findings suggest that exposure to unemployment may be associated with increased risks of suicidal thoughts, crime and substance use.

Evaluation of study patients with Lyme disease, 10-20-year follow-up.

To determine the long-term impact of Lyme disease, we evaluated 84 randomly selected, original study patients from the Lyme, Connecticut, region who had erythema migrans, facial palsy, or Lyme arthritis 10-20 years ago and 30 uninfected control subjects. The patients in the 3 study groups and the control group did not differ significantly in current symptoms or neuropsychological test results. However, patients with facial palsy, who frequently had more widespread nervous system involvement, more often had residual facial or peripheral nerve deficits. Moreover, patients with facial palsy who did not receive antibiotics for acute neuroborreliosis more often now had joint pain and sleep difficulty and lower scores on the body pain index and standardized physical component sections of the Short-Form 36 Health Assessment Questionnaire than did antibiotic-treated patients with facial palsy. Thus, the overall current health status of each patient group was good, but sequelae were apparent primarily among patients with facial palsy who did not receive antibiotics for acute neuroborreliosis.

Comparative concentrations of metals in marine species from French Frigate Shoals, North Pacific Ocean.

Concentrations of arsenic, cadmium, chromium, copper, lead, mercury, selenium, and zinc were measured in coral, crab, eel, fish, lobster, and sediment samples collected from French Frigate Shoals, North Pacific Ocean. The sediments contained relatively high concentrations of selenium; moderate concentrations of arsenic, cadmium, copper and lead; and low concentrations of chromium and zinc. Metal concentrations were also determined in coral and crabs collected from the island of Oahu. Notably, a crab (Grapsus tenuicrustatus) and the undulated moray eel (Gymnothorax undulatus) exhibited high levels of copper and arsenic, respectively, relative to the other species studied. The concentrations of arsenic in the eel averaged 225 microg g(-1) dry wt, which was 3-12 times higher than that in all of the other species tested. The average concentration of copper in the crab was 343 microg g(-1) dry wt, 3-86 times greater than that in the other species studied. These data indicate background and comparative levels of the metals among the studied species. Lead levels in the coral (9-10 microg g(-1) dry wt) and crab (42-57 microg g(-1) dry wt) from Tern and Disappearing Islands were 23-283-fold greater than those from Oahu (0.4 and 0.2 microg g(-1) dry wt, respectively).

Educational, psychosocial, and sexual outcomes of girls with conduct problems in early adolescence.

This paper examines the extent to which conduct problems at age 13 are associated with a range of educational, psychosocial, and sexual outcomes at age 18 in a birth cohort of 488 young women. Significant associations were found between early adolescent conduct problems and later risks of educational failure, juvenile crime, substance abuse, mental health problems, and adverse sexual outcomes by late adolescence. These elevated risks were explained, in part, by social, family, and personal disadvantages associated with adjustment at age 13. In addition, there was evidence of a causal chain process in which early adolescent conduct problems were associated with a series of adolescent risk-taking behaviours, including delinquent peer affiliations, early-onset sexual behaviour, substance use, and school problems that were, in turn, associated with increased risks of later adverse outcomes.

The natural history of cervical cryosurgical healing. The minimal effect of debridement of the cervical eschar [see comment].

BACKGROUND: Cryosurgery is a favored treatment method for cervical intraepithelial neoplasia (CIN) among family physicians, in part because it is inexpensive and requires the least technical training and skill. Although cervical cryosurgery has been used for more than 30 years, the natural history of the postprocedure process has never been described. The primary purpose of our study was to describe the natural history of the healing process after cervical cryosurgery. A secondary purpose was to determine the effect of mechanical debridement of the cervical eschar on the symptoms of healing. METHODS: We conducted a prospective multicentered trial in which women who had a histologic ally documented CIN lesion underwent cervical cryosurgery. Forty-six women were randomized to undergo eschar debridement at 48 hours after cryosurgey, and 38 women received standard care. All women were followed up and given preweighed sanitary pads for hydrorrhea (watery discharge) collection and a diary to record the severity and number of days of odor, pain, cramping, and hydrorrhea that were experienced. RESULTS: The average total amount of hydrorrhea or discharge was 288 g, which required using an average of 41 sanitary pads during a period of 12.4 days. The duration of odor was 8.9 days, and the pain and cramping experienced after cryosurgery lasted 4.7 days. Women who were obese had greater hydrorrhea and pad usage than nonobese women. Debridement of the cervical eschar did not significantly change the signs and symptoms of healing after cryosurgery. CONCLUSIONS: There are significant symptoms patients experience after cryosurgery that are not ameliorated by debridement. The expectations of the cryosurgical healing process should be disclosed to women before the procedure.

Distribution of polychlorinated biphenyls in marine species from French Frigate Shoals, North Pacific Ocean.

Polychlorinated biphenyls (PCBs) were analyzed in: sediment; coral (Porites evermanni); fish (Stegastes fasciolatus, Neoniphon sammara, Acanthurus triostegus and Mulloidichthys vanicolensis); crab (Grapsus tenuicrustatus); lobster (Panulirus marginatus); and eel (Conger cinereus, Gymnothoraxflavimarginatus, G. undulatus and G. meleagris) samples collected from Tern Island and the corresponding reference samples from Disappearing Island. The two islands are part of French Frigate Shoals, a national wildlife refuge in the North Pacific Ocean. The dominant congeners 118, 138 and 153 represent 22-25, 32-34, 12-39, 37-46 and 30-55% of the sum of PCBs in the coral, sediment, fish, crab and eel, respectively. In general, high trophic species such as eels were found to highly bioaccumulate PCBs. The total average PCB concentrations were as high as 96 and 29 microg/g dry wt. in eels and damselfish, respectively, from Tern Island. The localized behavior and high bioaccumulation potential for PCBs suggest that damselfish are an excellent species for monitoring PCBs in small areas in the ocean. The high average concentrations of the sum of PCBs in different food chain levels suggest that pollution source(s) are around Tern Island and possibly around Disappearing Island. Aroclor 1254 and its analogs are suspected sources responsible for PCBs in the samples.