Advanced analyses of physiological signals and their role in Neonatal Intensive Care

Preterm infants admitted to the neonatal intensive care unit (NICU) face an array of life-threatening diseases requiring procedures such as resuscitation and invasive monitoring, and other risks related to exposure to the hospital environment, all of which may have lifelong implications. This thesis examined a range of applications for advanced signal analyses in the NICU, from identifying of physiological patterns associated with neonatal outcomes, to evaluating the impact of certain treatments on physiological variability. Firstly, the thesis examined the potential to identify infants at risk of developing intraventricular haemorrhage, often interrelated with factors leading to preterm birth, mechanical ventilation, hypoxia and prolonged apnoeas. This thesis then characterised the cardiovascular impact of caffeine therapy which is often administered to prevent and treat apnoea of prematurity, finding greater pulse pressure variability and enhanced responsiveness of the autonomic nervous system. Cerebral autoregulation maintains cerebral blood flow despite fluctuations in arterial blood pressure and is an important consideration for preterm infants who are especially vulnerable to brain injury. Using various time and frequency domain correlation techniques, the thesis found acute changes in cerebral autoregulation of preterm infants following caffeine therapy. Nutrition in early life may also affect neurodevelopment and morbidity in later life. This thesis developed models for identifying malnutrition risk using anthropometry and near-infrared interactance features. This thesis has presented a range of ways in which advanced analyses including time series analysis, feature selection and model development can be applied to neonatal intensive care. There is a clear role for such analyses in early detection of clinical outcomes, characterising the effects of relevant treatments or pathologies and identifying infants at risk of later morbidity

Development of machine learning schemes for use in non-invasive and continuous patient health monitoring

Stephanie Baker developed machine learning schemes for the non-invasive and continuous measurement of blood pressure and respiratory rate from heart activity waveforms. She also constructed machine learning models for mortality risk assessment from vital sign variations. This research contributes several tools that offer significant advancements in patient monitoring and wearable healthcare

Diffusion tensor imaging and resting state functional connectivity as advanced imaging biomarkers of outcome in infants with hypoxic-ischaemic encephalopathy treated with hypothermia

Therapeutic hypothermia confers significant benefit in term neonates with hypoxic-ischaemic encephalopathy (HIE). However, despite the treatment nearly half of the infants develop an unfavourable outcome. Intensive bench-based and early phase clinical research is focused on identifying treatments that augment hypothermic neuroprotection. Qualified biomarkers are required to test these promising therapies efficiently. This thesis aims to assess advanced magnetic resonance imaging (MRI) techniques, including diffusion tensor imaging (DTI) and resting state functional MRI (fMRI) as imaging biomarkers of outcome in infants with HIE who underwent hypothermic neuroprotection. FA values in the white matter (WM), obtained in the neonatal period and assessed by tract-based spatial statistics (TBSS), correlated with subsequent developmental quotient (DQ). However, TBSS is not suitable to study grey matter (GM), which is the primary site of injury following an acute hypoxic-ischaemic event. Therefore, a neonatal atlas-based automated tissue labelling approach was applied to segment central and cortical grey and whole brain WM. Mean diffusivity (MD) in GM structures, obtained in the neonatal period correlated with subsequent DQ. Although the central GM is the primary site of injury on conventional MRI following HIE; FA within WM tissue labels also correlated to neurodevelopmental performance scores. As DTI does not provide information on functional consequences of brain injury functional sequel of HIE was studied with resting state fMRI. Diminished functional connectivity was demonstrated in infants who suffered HIE, which associated with an unfavourable outcome. The results of this thesis suggest that MD in GM tissue labels and FA either determined within WM tissue labels or analysed with TBSS correlate to subsequent neurodevelopmental performance scores in infants who suffered HIE treated with hypothermia and may be applied as imaging biomarkers of outcome in this population. Although functional connectivity was diminished in infants with HIE, resting state fMRI needs further study to assess its utility as an imaging biomarker following a hypoxic-ischaemic brain injury.Open Acces

Efficient Decision Support Systems

This series is directed to diverse managerial professionals who are leading the transformation of individual domains by using expert information and domain knowledge to drive decision support systems (DSSs). The series offers a broad range of subjects addressed in specific areas such as health care, business management, banking, agriculture, environmental improvement, natural resource and spatial management, aviation administration, and hybrid applications of information technology aimed to interdisciplinary issues. This book series is composed of three volumes: Volume 1 consists of general concepts and methodology of DSSs; Volume 2 consists of applications of DSSs in the biomedical domain; Volume 3 consists of hybrid applications of DSSs in multidisciplinary domains. The book is shaped decision support strategies in the new infrastructure that assists the readers in full use of the creative technology to manipulate input data and to transform information into useful decisions for decision makers

Väga väikese gestatsioonivanusega enneaegsed lapsed Eestis: ravitulem ja prognostilised tegurid

Väitekirja elektrooniline versioon ei sisalda publikatsioone.Meditsiini arenguga on suurenenud VVGV (sünd <32. täisrasedusnädalat) vastsündinute elulemus, kuid lapsed on ohustatud erinevatest arenguhäiretest. VVGV laste tervisetulemit 2 aasta vanuses peetakse perinataalabi kvaliteedi oluliseks indikaatoriks. Uurimistöö eesmärkideks oli kirjeldada VVGV laste ravitulemit ja ägedat respiratoorset haigestumist Eestis, leida ebasoodsa tulemi riskitegurid ning hinnata riigi peri- ja neonataalabi kvaliteeti. Rahvastikupõhine edasivaatav kohortuuring hõlmas aastatel 2007-2008 sündinud 360 VVGV last. Perinataalsed andmed saadi neonataalsest uuringuregistrist. Varast tulemit esmase haiglaravi lõpul võrreldi 264 VVGV lapse võrdluskohordiga aastatest 2002-2003. Hilist tulemit enneaegsusele korrigeeritud 2 aasta vanuses hinnati 2007. aastal sündinud 155-l VVGV lapsel ja võrreldi ajalisena sündinud laste tulemiga. Järelkontrollil hinnati laste somaatilist, neurosensoorset ja arengulist tulemit. Äge respiratoorne haigestumus selgitati vanemate küsitluse teel. Uuringuperioodidel suurenes oluliselt VVGV laste elulemus (78 vs 85%), kusjuures perinataalabi oli hilisemal perioodil proaktiivsem ja neonataalne ravi vähem invasiivne. Elulemuse paranemisega püsis neonataalsete haigustega elulejate osakaal muutumatuna, kuid võrreldes kõrge sissetulekuga riikidega suhteliselt suurena. Järelkontrollil esines mõõdukas/raske arenguhäire 12%-l VVGV lastest: tserebraalparalüüs 8%-l, kognitiivse arengu mahajäämus 5%-l ja kõne arengu mahajäämus 10%-l. Kognitiivse, kõne ja motoorse arengu keskmine koondskoor Bayley testil oli VVGV lastel 0,5 SD võrra madalam kui ajalisena sündinutel. Samuti olid oluliselt väiksemad VVGV laste keskmine kaal, pikkus ja peaümbermõõt ning ägeda respiratoorse haigestumise korral esines neil oluliselt enam vilistavat hingamist ning haiglaravi vajadust. Ebasoodsa tervisetulemi peamiseks riskiteguriks oli hiliseid puudeid ennustavate neonataalsete haiguste põdemine esmasel haiglaravil. VVGV laste elulemus Eestis on võrdväärne arenenud meditsiiniabiga riikidega, kuid laste varane haigestumus ja tervisehäirete esinemine 2 aasta vanuses jääb osaliselt suuremaks. Tervishoiu peamiseks väljakutseks on vähendada VVGV enneaegsete neonataalset haigestumist, säilitades suure elulejate osakaalu.Advances in perinatal care have improved the survival of VLGA (born <32 weeks' gestation) infants dramatically, but these infants remain at substantial risk for a wide spectrum of long-term morbidities. Therefore, it is mandatory that any assessment of quality of care for VLGA infants includes the long-term outcome. The aims of the studies were to describe outcome and acute respiratory morbidity of VLGA infants in Estonia, to identify risk factors for adverse outcome, and to benchmark the quality of perinatal services in the country. A nationwide prospective cohort study comprised 360 live-born VLGA infants born in Estonia in 2007–2008. Perinatal data were collected to the neonatal research register. A historical cohort of 264 VLGA infants born in 2002–2003 was selected for analysis of changes in the short-term outcome. A sub-cohort of 155 surviving VLGA infants born in 2007 was compared with a matched full-term control group at 2 years of corrected age. The infants underwent physical, neurological, and developmental assessment. Acute respiratory morbidity was identified by parental interviews. The survival until discharge increased significantly (78% in 2002-2003 vs 85% in 2007-2008) with proactive perinatal management and less invasive neonatal care and without concomitant increases in neonatal morbidity. However, the morbidity rates were higher when compared with comparable data from high income countries. At follow-up, neurodevelopmental impairment was noted in 12% of VLGA infants, with 8% affected by cerebral palsy, 5% with cognitive delay, and 10% with language delay. The mean Cognitive, Language, and Motor Composite Scores assessed using the Bayley-III scales were in VLGA group in excess of 0.5 SD lower than in full-term infants. Wheezing during respiratory infections and somatic growth failure were significant problems among VLGA infants. Major neonatal morbidities, predictive of poor long-term outcome, were the main risk factors for adverse outcomes. The results showed that for VLGA infants in Estonia, the survival is comparable and the rates of early morbidities and impairments at 2 years are partly higher when compared to similar studies from high income countries. The challenge for perinatal services in Estonia is to reduce neonatal morbidity of VLGA infants without compromising their survival

Front Lines of Thoracic Surgery

Front Lines of Thoracic Surgery collects up-to-date contributions on some of the most debated topics in today's clinical practice of cardiac, aortic, and general thoracic surgery,and anesthesia as viewed by authors personally involved in their evolution. The strong and genuine enthusiasm of the authors was clearly perceptible in all their contributions and I'm sure that will further stimulate the reader to understand their messages. Moreover, the strict adhesion of the authors' original observations and findings to the evidence base proves that facts are the best guarantee of scientific value. This is not a standard textbook where the whole discipline is organically presented, but authors' contributions are simply listed in their pertaining subclasses of Thoracic Surgery. I'm sure that this original and very promising editorial format which has and free availability at its core further increases this book's value and it will be of interest to healthcare professionals and scientists dedicated to this field

Mechanical Ventilation

The therapeutic alliance has been found to predict psychotherapy outcome in numerous studies. However, critics maintain that the therapeutic alliance is a by-product of prior symptomatic improvements. Moreover, almost all alliance research to date has used differences between patients in alliance as predictor of outcome, and results of such analyses do not necessarily mean that improving the alliance with a given patient will improve outcome (i.e., a within-patient effect). In a sample of 646 patients (76% women, 24% men) in primary care psychotherapy, the effect of working alliance on next session symptom level was analyzed using multilevel models. The Clinical Outcomes in Routine Evaluation–Outcome Measure was used to measure symptom level, and the patient version of the Working Alliance Inventory–Short form revised (Hatcher &amp; Gillaspy, 2006) was used to measure alliance. There was evidence for a reciprocal causal model, in which the alliance predicted subsequent change in symptoms while prior symptom change also affected the alliance. The alliance effect varied considerably between patients. This variation was partially explained by patients with personality problems showing stronger alliance effect. These results indicate that the alliance is not just a by-product of prior symptomatic improvements, even though improvement in symptoms is likely to enhance the alliance. Results also point to the importance of therapists paying attention to ruptures and repair of the therapy alliance. Generalization of results may be limited to relatively brief primary care psychotherapy