Predictors of cerebral palsy in very preterm infants: the EPIPAGE prospective population‐based cohort study

Aim The aim of this study was to assess the independent role of cerebral lesions on ultrasound scan, and several other neonatal and obstetric factors, as potential predictors of cerebral palsy (CP) in a large population‐based cohort of very preterm infants. Method As part of EPIPAGE, a population‐based prospective cohort study, perinatal data and outcome at 5 years of age were recorded for 1812 infants born before 33 weeks of gestation in nine regions of France in 1997. Results The study group comprised 942 males (52%) and 870 females with a mean gestational age of 30 weeks (SD 2wks; range 24–32wks) and a mean birthweight of 1367g (SD 393g; range 450–2645g). CP was diagnosed at 5 years of age in 159 infants (prevalence 9%; 95% confidence interval [CI] 7–10%), 97 males and 62 females, with a mean gestational age of 29 weeks (SD 2wks; range 24–32wks) and a mean birthweight of 1305g (SD 386g; range 500–2480g). Among this group, 67% walked without aid, 14% walked with aid, and 19% were unable to walk. Spastic, ataxic, and dyskinetic CP accounted for 89%, 7%, and 4% of cases respectively. The prevalence of CP was 61% among infants with cystic periventricular leukomalacia, 50% in infants with intraparenchymal haemorrhage, 8% in infants with grade I intraventricular haemorrhage, and 4% in infants without a detectable cerebral lesion. After controlling for cerebral lesions and obstetric and neonatal factors, only male sex (odds ratio [OR] 1.52; 95% CI 1.03–2.25) and preterm premature rupture of membranes or preterm labour (OR 1.72; 95% CI 0.95–3.14) were predictors of the development of CP in very preterm infants. Interpretation Cerebral lesions were the most important predictor of CP in very preterm infants. In addition, infant sex and preterm premature rupture of membranes or preterm labour were also independent predictors of CP.     

Sevoflurane for central catheter placement in neonatal intensive care: a randomized trial

Objective: To compare the efficacy and safety of sevoflurane deep sedation with glucose and nonnutritive sucking (GNNS) in reducing the duration of the procedure and in preventing pain‐related effects during peripherally inserted central catheter (PICC) placement. Background: PICC placement in neonatal intensive care is a delicate and stressful procedure that requires pain prevention. GNNS has been recommended in this situation but remain often inefficient. Methods: We designed a randomized controlled study in a sixteen‐bed pediatric and neonatal unit in a tertiary hospital. Fifty‐nine neonates at >28 weeks of gestation with continuous positive airway pressure or invasive mechanical ventilation and requiring PICC placement were included. Patients were randomized to receive inhaled sevoflurane (IS) or glucose and non‐nutritive sucking (GNNS). Procedural duration and conditions, hemodynamic and respiratory parameters, occurrence of movements and complications were compared ( http://clinicaltrials.gov trial register no. NCT00420693). Results: The two groups had similar demographics. There were no between‐group differences in procedural duration (P = 0.84) despite greater immobility in IS group (P = 0.017). IS was also associated with fewer episodes of hypertension (P = 0.003), tachycardia (P < 0.001), and bradycardia (P = 0.02). Occurrences of hypotension were not different between the groups (P = 0.06). The GNNS group showed more desaturation during the 4 h after the procedure (P = 0.03). Complications during intensive care stay did not differ between groups. Conclusion: Inhaled sevoflurane does not make easier catheters placement but prevent pain‐related symptoms. Because sevoflurane is responsible for hypotension, it requires careful monitoring and treatment adaptation.     

Electrocardiogram-Based Algorithm to Predict the Left Ventricular Lead Position in Recipients of Cardiac Resynchronization Systems

Introduction: Biventricular pacing is associated with various electrocardiographic patterns depending on the position of the left ventricular (LV) lead. We aimed to develop an electrocardiogram-based algorithm to predict the position of the LV lead.
Methods: The algorithm was developed in 100 consecutive recipients of cardiac resynchronization therapy (CRT) systems. QRS axis, morphology, and polarity were analyzed with a view to define the specific electrocardiographic characteristics associated with the various LV lead positions . The algorithm was prospectively validated in 50 consecutive CRT device recipients.
Results: The first analysis of the algorithm was the QRS morphology in V₁. A positive R wave in V₁ suggested LV lateral or posterior wall stimulation. A QS pattern was specific of anterior LV leads. In the presence of an R wave in V₁, V₆ was analyzed to distinguish between an inferior and anterior LV lead. Inferior leads were never associated with a positive V₆. To differentiate between lateral and posterior positions, we analyzed the pattern in V₂. Lateral leads were associated with an R morphology in V₁ and a negative V₂. Posterior leads were associated with an R morphology in V₁ and V₂. The algorithm allowed a reliable distinction between an inferior or anterior and a lateral or posterior lead position in 90% of patients. Inferior, anterior, lateral, and posterior positions were reliably distinguished in 80% of patients.
Conclusion: This algorithm predicted the position of the LV lead with a high sensitivity and predictive value.     

Recording of Peak Endocardial Acceleration in the Atrium

Background: The important role played by peak endocardial acceleration (PEA or sonR) in hemodynamic monitoring of cardiac resynchronization therapy (CRT) was recently highlighted in several studies with the sensor embedded in a right ventricular (RV) lead tip. This study examined the short- and long-term reliability of a right atrial (RA) sonR sensor.
Methods: RA and RV sonR signals were measured from RA and RV leads respectively, at implant and up to 12 months of follow-up, in 19 recipients of either single chamber pacemakers or CRT systems. At 1 month of follow up, RA sonR signals and heart rate were simultaneously recorded during exercise.
Results: A reliable RA sonR signal amplitude was measured at implant, proportional to the RV amplitude. We observed in both the right atrium and right ventricle (1) a similar signal noise ratio at implant, (2) a similar evolution of the sonR signal amplitude up to 12 months of follow-up, and (3) a high correlation between heart rate and RA sonR signal amplitude during exercise.
Conclusions: The RA sonR signal was reliable and proportional to the RV signal on the short and long term, and reflected changes in activity. These observations suggest that the sonR sensor could be placed in the atrium for the hemodynamic monitoring of CRT system recipients.     

Complete Atrioventricular Block during Ablation of Atrial Flutter

We report the case of a 51‐year‐old patient who developed a complete atrioventricular (AV) block during the isthmic radiofrequency catheter ablation of a typical atrial flutter. The cause was an acute occlusion of the segment three of the right coronary artery. His recanalization was associated with the immediate restoration of a normal AV conduction. The complication is exceptional (one of 740 consecutive atrial flutter ablations). (PACE 2010; 516–519)     

An in vivo investigation of salivary properties,enamel hypomineralisation,and carious lesion severity in a group of Iraqi schoolchildren

International Journal of Paediatric Dentistry 2013; 23: 2–12 Background. Hypomineralised enamel is a prevalent, congenital defect vulnerable to deteriorate post‐eruptively particularly in the presence of an unfavourable oral environment. Aims. To assess the influence of salivary characteristics on the clinical presentation of hypomineralisation lesions diagnosed in first permanent and second primary molars and to evaluate caries severity in relation to the defect’s clinical presentation. Design. Recruitment consisted of 445 seven‐ to nine‐year‐old participants, of whom 152 were diagnosed as having molar hypomineralisation (MH); the remaining unaffected subjects (N = 293) were considered their controls for saliva analysis. Dental caries status was assessed in 300 subjects of saliva sub‐sample, equally divided as MH‐affected and non‐affected children. The International Caries Detection and Assessment System was used for caries detection. Salivary flow rates, viscosity, pH, and buffering capacity were determined. Results. Molar hypomineralisation‐affected children have significantly higher mean caries scores compared to the non‐affected group. Dentinal carious lesions were ten times more frequent in teeth with post‐eruptive breakdown (PEB) than with teeth with opacities only. Low salivary flow rates (LSFR), moderately viscous saliva, and low pH were significantly more common in the affected group. LSFR and moderate and highly acidic saliva were more likely associated with PEB. Conclusion. Demarcated hypomineralised enamel is a dynamic defect highly influenced by individual characteristics of the oral environment.     

Neuroimaging in childhood arterial ischaemic stroke: evaluation of imaging modalities and aetiologies

Aim The aim of this study was to describe neuroimaging patterns associated with arterial ischaemic stroke (AIS) in childhood and to differentiate them according to stroke aetiology. Method Clinical and neuroimaging (acute and follow‐up) findings were analysed prospectively in 79 children (48 males, 31 females) aged 2 months to 15 years 8 months (median 5y 3mo) at the time of stroke by the Swiss Neuropaediatric Stroke Registry from 2000 to 2006. Results Stroke was confirmed in the acute period in 36 out of 41 children who underwent computed tomography, in 53 of 57 who underwent T2‐weighted magnetic resonance imaging (MRI) and in all 48 children who underwent diffusion‐weighted MRI. AIS occurred in the anterior cerebral artery (ACA) in 63 participants and in all cases was associated with lesions of the middle cerebral artery (MCA). The lesion was cortical–subcortical in 30 out of 63 children, cortical in 25 out of 63, and subcortical in 8 of 63 children. Among participants with AIS in the posterior circulation territory, the stroke was cortical–subcortical in 8 out of 16, cortical in 5 of 16, and thalamic in 3 out of 16 children. Interpretation AIS mainly involves the anterior circulation territory, with both the ACA and the MCA being affected. The classification of Ganesan is an appropriate population‐based classification for our Swiss cohort, but the neuroimaging pattern alone is insufficient to determine the aetiology of stroke in a paediatric population. The results show a poor correlation between lesion pattern and aetiology.     

Developments in abortion policy in a context of illegality: The Belgian case from 1971 until 1990

On 3 April 1990, a new abortion law was passed in Belgium, replacingthe one from 1867. This change took approximately 20 years andresulted from a strong political debate, a number of proposalsfor legal reforms and from prosecutions of physicians, socialworkers and women having performed terminations of pregnancies(TOP). During this period, health professionals set up a sortof ‘illegal reform programme’. They were not onlysuccessful in organizing decentralized, accessible and non-profitTOP facilities, but also effective in producing the first datasets to monitor TOP requests in the country. In this way, theymodified TOP medical activity and practice and participatedgreatly in changing abortion from a situation characterizedby secrecy and danger before 1970, to a medical activity legalizedafter 1990. Legal TOP statistics published since 1990 cannotbe explained without taking into account this period of transitionwhere spedflc features of the following situation were prepared.