Emergent Prophylactic, Reparative and Restorative Brain Interventions for Infants Born Preterm With Cerebral Palsy

Worldwide, an estimated 15 million babies are born preterm (<37 weeks' gestation) every year. Despite significant improvements in survival rates, preterm infants often face a lifetime of neurodevelopmental disability including cognitive, behavioral, and motor impairments. Indeed, prematurity remains the largest risk factor for the development of cerebral palsy. The developing brain of the preterm infant is particularly fragile; preterm babies exhibit varying severities of cerebral palsy arising from reductions in both cerebral white and gray matter volumes, as well as altered brain microstructure and connectivity. Current intensive care therapies aim to optimize cardiovascular and respiratory function to protect the brain from injury by preserving oxygenation and blood flow. If a brain injury does occur, definitive diagnosis of cerebral palsy in the first few hours and weeks of life is difficult, especially when the lesions are subtle and not apparent on cranial ultrasound. However, early diagnosis of mildly affected infants is critical, because these are the patients most likely to respond to emergent treatments inducing neuroplasticity via high-intensity motor training programs and regenerative therapies involving stem cells. A current controversy is whether to test universal treatment in all infants at risk of brain injury, accepting that some patients never required treatment, because the perceived potential benefits outweigh the risk of harm. Versus, waiting for a diagnosis before commencing targeted treatment for infants with a brain injury, and potentially missing the therapeutic window. In this review, we discuss the emerging prophylactic, reparative, and restorative brain interventions for infants born preterm, who are at high risk of developing cerebral palsy. We examine the current evidence, considering the timing of the intervention with relation to the proposed mechanism/s of action. Finally, we consider the development of novel markers of preterm brain injury, which will undoubtedly lead to improved diagnostic and prognostic capability, and more accurate instruments to assess the efficacy of emerging interventions for this most vulnerable group of infants

Prospectus, November 9, 2011

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Modeling the Risk of Team Sport Injuries: A Narrative Review of Different Statistical Approaches

Injuries are a common occurrence in team sports and can have significant financial, physical and psychological consequences for athletes and their sporting organizations. As such, an abundance of research has attempted to identify factors associated with the risk of injury, which is important when developing injury prevention and risk mitigation strategies. There are a number of methods that can be used to identify injury risk factors. However, difficulty in understanding the nuances between different statistical approaches can lead to incorrect inferences and decisions being made from data. Accordingly, this narrative review aims to (1) outline commonly implemented methods for determining injury risk, (2) highlight the differences between association and prediction as it relates to injury and (3) describe advances in statistical modeling and the current evidence relating to predicting injuries in sport. Based on the points that are discussed throughout this narrative review, both researchers and practitioners alike need to carefully consider the different types of variables that are examined in relation to injury risk and how the analyses pertaining to these different variables are interpreted. There are a number of other important considerations when modeling the risk of injury, such as the method of data transformation, model validation and performance assessment. With these technical considerations in mind, researchers and practitioners should consider shifting their perspective of injury etiology from one of reductionism to one of complexity. Concurrently, research implementing reductionist approaches should be used to inform and implement complex approaches to identifying injury risk. However, the ability to capture large injury numbers is a current limitation of sports injury research and there has been a call to make data available to researchers, so that analyses and results can be replicated and verified. Collaborative efforts such as this will help prevent incorrect inferences being made from spurious data and will assist in developing interventions that are underpinned by sound scientific rationale. Such efforts will be a step in the right direction of improving the ability to identify injury risk, which in turn will help improve risk mitigation and ultimately the prevention of injuries

Prospectus, March 9, 2011

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Moderating Effect of the Neighborhood Physical Activity Environment on the Relation Between Psychosocial Factors and Physical Activity in Children: A Longitudinal Study

Background Few studies have examined the moderating role of neighbourhood environments on the relation between psychosocial factors and physical activity, and results of these studies are mixed. This study examined this relationship in 636 fifth to seventh graders from South Carolina, USA. Methods From 2010 to 2013, children and their parent/guardian completed annual self-reported surveys assessing psychosocial factors, and children wore accelerometers for 1 week each year. Neighbourhood environments were classified as supportive or non-supportive for physical activity (PA) based on in-person audits of facilities near children’s homes and windshield surveys of children’s streets. Growth curve analyses were completed to assess the moderating effect of the neighbourhood physical activity environment (NPAE) on the relation between psychosocial factors and total physical activity (TPA) over time. Results Significant interactions on TPA were found for (1) time, NPAE and parent-reported parent support for PA; (2) time, NPAE and child-reported equipment in the home; (3) child-reported parental support for PA and time; (4) child-reported parental support for PA and NPAE; (5) PA self-schema and time and (6) child-reported parental encouragement and time. Parental support and a supportive NPAE were important for TPA, especially as children transitioned to middle school, whereas home equipment and a supportive NPAE were important for fifth graders’ TPA. Conclusion Consistent with the socioecological model, PA behaviour was dependent on interacting effects across levels of influence. Generally, both a supportive NPAE and positive psychosocial factors were needed to support TPA. Factors influencing PA across multiple levels should be addressed in PA interventions

Prospectus, March 16, 2011

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The cause-specific morbidity and mortality, and referral patterns of all neonates admitted to a tertiary referral hospital in the northern provinces of Vietnam over a one year period.

OBJECTIVE: To describe the cause-specific morbidity and mortality, and referral patterns of all neonates admitted to a tertiary referral hospital in the northern provinces of Vietnam. DESIGN: A prospective hospital based observational study. SETTING: The Neonatal Department, National Hospital of Pediatrics, Hanoi, Vietnam. PATIENTS: All admissions to the Neonatal Department over a 12 month period. MAIN OUTCOME MEASURES: Cause-specific morbidity and mortality; deaths. RESULTS: There were 5064 admissions with the commonest discharge diagnoses being infection (32%) and prematurity (29%). The case fatality ratio (CFR) was 13.9% (n = 703). Infection (38%), cardio/respiratory disorders (27%), congenital abnormalities (20%) and neurological conditions (10%) were the main causes of death. Of all the deaths, 38% had an admission weight ≥2500g. Higher CFR were associated with lower admission weights. Very few deaths (3%) occurred in the first 24 hours of life. Most referrals and deaths came from Hanoi and neighbouring provincial hospitals, with few from the most distant provinces. Two distant referral provinces had the highest CFR. CONCLUSIONS: The CFR was high and few deaths occurred in neonates <24 hours old. The high rates of infection call for an improvement in infection control practices and peripartum antibiotic use at provincial and tertiary level. Understanding provincial hospital capacity and referral pathways is crucial to improving the outcomes at tertiary centres. A quality of care audit tool would enable more targeted interventions and monitoring of health outcomes

A comparison of a structured home-based rehabilitation programme with conventional supervised pulmonary rehabilitation:A randomised non-inferiority trial

Background: Standardised home-based pulmonary rehabilitation (PR) programmes offer an alternative model to centre-based supervised PR for which uptake is currently poor. We determined if a structured home-based unsupervised PR programme was non-inferior to supervised centre-based PR for participants with COPD. Methods: A total of 287 participants with COPD who were referred to PR (187 male, mean (SD) age 68 (8.86) years, FEV1% predicted 48.34 (17.92)) were recruited. They were randomised to either centre-based PR or a structured unsupervised home-based PR programme including a hospital visit with a healthcare professional trained in motivational interviewing, a self-management manual and two telephone calls. Fifty-eight (20%) withdrew from the centre-based group and 51 (18%) from the home group. The primary outcome was dyspnoea domain in the chronic respiratory disease questionnaire (Chronic Respiratory Questionnaire Self-Report; CRQ-SR) at 7 weeks. Measures were taken blinded. We undertook a modified intention-to-treat (mITT) complete case analysis, comparing groups according to original random allocation and with complete data at follow-up. The non-inferiority margin was 0.5 units. Results: There was evidence of significant gains in CRQ-dyspnoea at 7 weeks in both home and centre-based groups. There was inconclusive evidence that home-based PR was non-inferior to PR in dyspnoea (mean group difference, mITT: −0.24, 95% CI −0.61 to 0.12, p=0.18), favouring the centre group at 7 weeks. Conclusions: The standardised home-based programme provides benefits in dyspnoea. Further evidence is needed to definitively determine if the health benefits of the standardised home-based programme are non-inferior or equivalent to supervised centre-based rehabilitation

Engaging stakeholders in realist programme theory building: insights from the prospective phase of a primary care dementia support study

‘Dementia - Personalised Care Team’ (D-PACT) is a five-year NIHR funded programme, using realist methods to develop and evaluate a complex, person-centred intervention for people with dementia and their carers. During the early project stages, we engaged with multiple stakeholders, including people with dementia and their carers, to develop an initial programme theory (IPT) – into an elaborated programme theory (EPT), by helping to uncover intervention mechanisms leading to outcomes in specific contexts. Realist research methods for developing programme theories are under-reported. In addition, there is a paucity of practical guidance on how to engage underserved and vulnerable populations in complex interventions programme theory development. We attend to these gaps, providing a worked example of how we meaningfully engaged people living with dementia and carers, alongside field experts, as stakeholders in this process. Our IPT theory building included multi-stakeholder primary research exercises and meetings with PPI contributors and an Expert Reference Group. We adapted interview schedules, and used visual resources and scenario-based activities, to support stakeholders to think in a ‘realist’ way. Using realist and thematic analyses led to hypothesis-building of causal mechanisms. Sharing findings with stakeholders led to further refinement of the intervention design, ready for testing in a subsequent feasibility study. We found that, despite the cognitive challenges associated with dementia, innovative methods of engagement can enable this stakeholder group to understand the realist approach and provide a platform through which to share their experiences. Taking a highly flexible and unhurried approach, led to novel insights into the complexities of person-centred dementia support. We argue for more detailed methodological guidance, based on realist principles, on how to collaborate with underrepresented populations to rigorously gain insights as to what is likely to make a difference and refine initial programme theory

Exploring the dynamics of compliance with community penalties

In this paper, we examine how compliance with community penalties has been theorized hitherto and seek to develop a new dynamic model of compliance with community penalties. This new model is developed by exploring some of the interfaces between existing criminological and socio-legal work on compliance. The first part of the paper examines the possible definitions and dimensions of compliance with community supervision. Secondly, we examine existing work on explanations of compliance with community penalties, supplementing this by drawing on recent socio-legal scholarship on private individuals’ compliance with tax regimes. In the third part of the paper, we propose a dynamic model of compliance, based on the integration of these two related analyses. Finally, we consider some of the implications of our model for policy and practice concerning community penalties, suggesting the need to move beyond approaches which, we argue, suffer from compliance myopia; that is, a short-sighted and narrowly focused view of the issues