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author:("Das, abik")
1.  Brain injury following trial of hypothermia for neonatal hypoxic–ischaemic encephalopathy 
Objective
The objective of our study was to examine the relationship between brain injury and outcome following neonatal hypoxic–ischaemic encephalopathy treated with hypothermia.
Design and patients
Neonatal MRI scans were evaluated in the National Institute of Child Health and Human Development (NICHD) randomised controlled trial of whole-body hypothermia and each infant was categorised based upon the pattern of brain injury on the MRI findings. Brain injury patterns were assessed as a marker of death or disability at 18–22 months of age.
Results
Scans were obtained on 136 of 208 trial participants (65%); 73 in the hypothermia and 63 in the control group. Normal scans were noted in 38 of 73 infants (52%) in the hypothermia group and 22 of 63 infants (35%) in the control group. Infants in the hypothermia group had fewer areas of infarction (12%) compared to infants in the control group (22%). Fifty-one of the 136 infants died or had moderate or severe disability at 18 months. The brain injury pattern correlated with outcome of death or disability and with disability among survivors. Each point increase in the severity of the pattern of brain injury was independently associated with a twofold increase in the odds of death or disability.
Conclusions
Fewer areas of infarction and a trend towards more normal scans were noted in brain MRI following whole-body hypothermia. Presence of the NICHD pattern of brain injury is a marker of death or moderate or severe disability at 18–22 months following hypothermia for neonatal encephalopathy.
doi:10.1136/archdischild-2011-301524
PMCID: PMC3722585  PMID: 23080477
2.  Childhood Outcomes after Hypothermia for Neonatal Encephalopathy 
The New England journal of medicine  2012;366(22):2085-2092.
BACKGROUND
We previously reported early results of a randomized trial of whole-body hypothermia for neonatal hypoxic–ischemic encephalopathy showing a significant reduction in the rate of death or moderate or severe disability at 18 to 22 months of age. Long-term outcomes are now available.
METHODS
In the original trial, we assigned infants with moderate or severe encephalopathy to usual care (the control group) or whole-body cooling to an esophageal temperature of 33.5°C for 72 hours, followed by slow rewarming (the hypothermia group). We evaluated cognitive, attention and executive, and visuospatial function; neurologic outcomes; and physical and psychosocial health among participants at 6 to 7 years of age. The primary outcome of the present analyses was death or an IQ score below 70.
RESULTS
Of the 208 trial participants, primary outcome data were available for 190. Of the 97 children in the hypothermia group and the 93 children in the control group, death or an IQ score below 70 occurred in 46 (47%) and 58 (62%), respectively (P = 0.06); death occurred in 27 (28%) and 41 (44%) (P = 0.04); and death or severe disability occurred in 38 (41%) and 53 (60%) (P = 0.03). Other outcome data were available for the 122 surviving children, 70 in the hypothermia group and 52 in the control group. Moderate or severe disability occurred in 24 of 69 children (35%) and 19 of 50 children (38%), respectively (P = 0.87). Attention–executive dysfunction occurred in 4% and 13%, respectively, of children receiving hypothermia and those receiving usual care (P = 0.19), and visuospatial dysfunction occurred in 4% and 3% (P = 0.80).
CONCLUSIONS
The rate of the combined end point of death or an IQ score of less than 70 at 6 to 7 years of age was lower among children undergoing whole-body hypothermia than among those undergoing usual care, but the differences were not significant. However, hypothermia resulted in lower death rates and did not increase rates of severe disability among survivors. (Funded by the National Institutes of Health and the Eunice Kennedy Shriver NICHD Neonatal Research Network; ClinicalTrials.gov number, NCT00005772.)
doi:10.1056/NEJMoa1112066
PMCID: PMC3459579  PMID: 22646631
3.  Predictive Value of an Early Amplitude Integrated Electroencephalogram and Neurologic Examination 
Pediatrics  2011;128(1):e112-e120.
OBJECTIVE:
To examine the predictive validity of the amplitude integrated electroencephalogram (aEEG) and stage of encephalopathy among infants with hypoxic-ischemic encephalopathy (HIE) eligible for therapeutic whole-body hypothermia.
DESIGN:
Neonates were eligible for this prospective study if moderate or severe HIE occurred at <6 hours and an aEEG was obtained at <9 hours of age. The primary outcome was death or moderate/severe disability at 18 months.
RESULTS:
There were 108 infants (71 with moderate HIE and 37 with severe HIE) enrolled in the study. aEEG findings were categorized as normal, with continuous normal voltage (n = 12) or discontinuous normal voltage (n = 12), or abnormal, with burst suppression (n = 22), continuous low voltage (n = 26), or flat tracing (n = 36). At 18 months, 53 infants (49%) experienced death or disability. Severe HIE and an abnormal aEEG were related to the primary outcome with univariate analysis, whereas severe HIE alone was predictive of outcome with multivariate analysis. Addition of aEEG pattern to HIE stage did not add to the predictive value of the model; the area under the curve changed from 0.72 to 0.75 (P = .19).
CONCLUSIONS:
The aEEG background pattern did not significantly enhance the value of the stage of encephalopathy at study entry in predicting death and disability among infants with HIE.
doi:10.1542/peds.2010-2036
PMCID: PMC3124102  PMID: 21669899
neonatal hypoxic-ischemic encephalopathy; amplitude integrated EEG
4.  Impact of Postnatal Corticosteroid (PNS) Use on Neurodevelopment at 18-22 Months Adjusted Age: Effects of Dose, Timing and Risk of Bronchopulmonary Dysplasia in Extremely Low Birthweight Infants (ELBW) 
Pediatrics  2009;123(3):e430-e437.
Objective:
Postnatal steroid use in bronchopulmonary dysplasia (BPD) decreases lung inflammation but increases impairment (NDI). We hypothesized that increased dose is associated with increased NDI, lower postmenstrual age (PMA) at exposure increases NDI and risk of BPD modifies the effect of PNS.
Methods:
Steroid dose and timing of exposure beyond 7 days was assessed among 2358 ELBW nested in a prospective trial, with 1667 (84%) survivors examined at 18-22 months PMA. Logistic regression tested the relationship between NDI (Bayley MDI/PDI < 70, disabling cerebral palsy (CP) or sensory impairment), total dose (tertiles < 0.9, 0.9-1.9, ≥ 1.9 mg/kg) and PMA at first dose. Separate logistic regression tested effect modification by BPD severity (Romagnoli Risk > 0.5 as high risk, n=2336 (99%) for days of life 4-7).
Results:
366 neonates (16%) were steroid treated (94% dexamethasone). Treated neonates were smaller and less mature. 72% of those treated were high risk for BPD. PNS exposure was associated with NDI/death (61 vs. 44%, p < 0.001). NDI increased with higher dose; 71% dead or impaired at highest dose tertile. Each 1 mg/kg was associated with a 2.0 point reduction in MDI and a 40% risk increase in disabling CP. (OR 1.4, 95% CI: 1.2-1.6). Older PMA did not mitigate the harm. Treatment after 33 weeks PMA was associated with greatest harm (NDI/death OR 2.5, 95% CI: 1.1-5.5) despite not receiving highest dose. The relationship of PNS to NDI was modified by BPD risk, (High risk OR 1.9, 95% CI: 1.4-2.6; Low risk OR 2.9, 95% CI: 1.8-4.8) with those at highest risk experiencing less harm.
Conclusion:
Higher PNS dose was associated with increased NDI. There is no “safe” window for PNS use in ELBWs. Neonates with low BPD risk should not be exposed. A randomized trial of PNS for infants at highest risk is warranted.
doi:10.1542/peds.2008-1928
PMCID: PMC2846831  PMID: 19204058
postnatal corticosteroids; neurodevelopmental impairment; extremely low birth weight infants
5.  Aggressive vs. Conservative Phototherapy for Infants with Extremely Low Birth Weight 
Background
It is unclear whether aggressive phototherapy to prevent neurotoxic effects of bilirubin benefits or harms infants with extremely low birth weight (1000 g or less).
Methods
We randomly assigned 1974 infants with extremely low birth weight at 12 to 36 hours of age to undergo either aggressive or conservative phototherapy. The primary outcome was a composite of death or neurodevelopmental impairment determined for 91% of the infants by investigators who were unaware of the treatment assignments.
Results
Aggressive phototherapy, as compared with conservative phototherapy, significantly reduced the mean peak serum bilirubin level (7.0 vs. 9.8 mg per deciliter [120 vs. 168 μmol per liter], P<0.01) but not the rate of the primary outcome (52% vs. 55%; relative risk, 0.94; 95% confidence interval [CI], 0.87 to 1.02; P = 0.15). Aggressive phototherapy did reduce rates of neurodevelopmental impairment (26%, vs. 30% for conservative phototherapy; relative risk, 0.86; 95% CI, 0.74 to 0.99). Rates of death in the aggressive-phototherapy and conservative-phototherapy groups were 24% and 23%, respectively (relative risk, 1.05; 95% CI, 0.90 to 1.22). In preplanned subgroup analyses, the rates of death were 13% with aggressive phototherapy and 14% with conservative phototherapy for infants with a birth weight of 751 to 1000 g and 39% and 34%, respectively (relative risk, 1.13; 95% CI, 0.96 to 1.34), for infants with a birth weight of 501 to 750 g.
Conclusions
Aggressive phototherapy did not significantly reduce the rate of death or neurodevelopmental impairment. The rate of neurodevelopmental impairment alone was significantly reduced with aggressive phototherapy. This reduction may be offset by an increase in mortality among infants weighing 501 to 750 g at birth. (ClinicalTrials. gov number, NCT00114543.)
doi:10.1056/NEJMoa0803024
PMCID: PMC2821221  PMID: 18971491

Results 1-5 (5)