Respiratory symptoms in preterm infants: burden of disease in the first year of life

OBJECTIVE: While respiratory symptoms in the first year of life are relatively well described for term infants, data for preterm infants are scarce. We aimed to describe the burden of respiratory disease in a group of preterm infants with and without bronchopulmonary dysplasia (BPD) and to assess the association of respiratory symptoms with perinatal, genetic and environmental risk factors. METHODS: Single centre birth cohort study: prospective recording of perinatal risk factors and retrospective assessment of respiratory symptoms during the first year of life by standardised questionnaires. MAIN OUTCOME MEASURES: Cough and wheeze (common symptoms), re-hospitalisation and need for inhalation therapy (severe outcomes). PATIENTS: 126 preterms (median gestational age 28.7 weeks; 78 with, 48 without BPD) hospitalised at the University Children's Hospital of Bern, Switzerland 1999-2006. RESULTS: Cough occurred in 80%, wheeze in 44%, re-hospitalisation in 25% and long term inhalation therapy in wheezers in 13% of the preterm infants. Using logistic regression, the main risk factor for common symptoms was frequent contact with other children. Severe outcomes were associated with maximal peak inspiratory pressure, arterial cord blood pH, APGAR- and CRIB-Score. CONCLUSIONS: Cough in preterm infants is as common as in term infants, whereas wheeze, inhalation therapy and re-hospitalisations occur more often. Severe outcomes are associated with perinatal risk factors. Preterm infants who did not qualify for BPD according to latest guidelines also showed a significant burden of respiratory disease in the first year of life

Effects of Changes in Colored Light on Brain and Calf Muscle Blood Concentration and Oxygenation

Color light therapy is a therapeutic method in complementary medicine. In color therapy, light of two contrasting colors is often applied in a sequential order. The aim of this study was to investigate possible physiological effects, i.e., changes in the blood volume and oxygenation in the brain and calf muscle of healthy subjects who were exposed to red and blue light in sequential order. The hypothesis was that if a subject is first exposed to blue and then red light, the effect of the red light will be enhanced due to the contrastingly different characteristics of the two colors. The same was expected for blue light, if first exposing a subject to red and then to blue light. Twelve healthy volunteers (six male, six female) were measured twice on two different days by near-infrared spectroscopy during exposure to colored light. Two sequences of colored light were applied in a controlled, randomized, crossover design: first blue, then red, and vice versa. For the brain and muscle, the results showed no significant differences in blood volume and oxygenation between the two sequences, and a high interindividual physiological variability. Thus, the hypothesis had to be rejected. Comparing these data to results from a previous study, where subjects were exposed to blue and red light without sequential color changes, shows that the results of the current study appear to be similar to those of red light exposure. This may indicate that the exposure to red light was preponderant and thus effects of blue light were outweighed. KEYWORDS: color, color light therapy, near-infrared spectroscopy, NIRS, physiology, brain, muscle, hemodynamics, oxygenation functional study INTRODUCTION Light is essential for humankind. Although man has become fairly independent of Nature's day-and-night cycle, man still relies on light. Light influences human beings in many ways, on the physical, emotional, or spiritual-mental level. Light affects various physiological processes in man Colored light is also used in complementary medicine; however, no uniform concept exists, and forms and applications are manifold. Since it would extend the scope of this study to report in much detail on the various forms of colored light therapy, only general information is given. Colored light therapy is either used as stand-alone or within complementary medicine systems, such as anthroposophic medicine. The application of colored light in complementary medicine mostly aims at improving patients' vitality and emotional and spiritual-mental well-being. Color light therapy is performed by either irradiating patients with colored light (direct application) or by facilitating patients to perceive colored light; for example, by projecting colored light onto a screen (indirect application). Although different concepts exist, it is common that the choice of the colors depends on the therapeutic goal; so-called warm colors (yellow, orange, and red) are applied to induce activating effects and so-called cool colors (cyan, blue, and violet) are applied to induce calm and relaxation. In practice, either single colors or combinations of colors are employed. When a combination is used, light of different colors is usually sequentially applied: green followed by red, or blue followed by red. While color light therapy has been used for many years, knowledge about possible effects of colored light and, in particular, its indirect application on physiological parameters is yet scarce. Therefore, the aim of our study was to investigate, using noninvasive near-infrared spectrophotometry (NIRS), the possible effects of blue and red light on blood volume and tissue oxygenation in the brain and calf muscle in healthy subjects. We focused on blue and red light as they are the two main colors used in medical treatment and hold opposite features as mentioned above. In a previous study, we investigated the effects of red and blue light severally Since colored light is often applied in sequential order, the aim of this study was to investigate the effects of red and blue light in a sequential order and, in particular, during the color changes. The hypothesis was that if a subject is first exposed to blue and then to red light, the effect of the red light will be enhanced due to the contrastingly different characteristics of the two colors. The same was expected for first exposing a subject to red and then to blue light. MATERIAL AND METHODS Study Design The study had a controlled, randomized (by computer), crossover design. Participants Thirteen healthy volunteers (seven male, six female) were measured during exposure to colored light. One male subject had to be excluded since he fell asleep during the measurement. The remaining twelve Weinzirl et al.: Colored Light and Brain Oxygenation TheScientificWorldJOURNAL (2011) 11, 1216-1225 1218 subjects had a mean age of 30 years, with a range of 18 to 44 years, mean height of 174 (159 to 190) cm, and mean weight of 65 (52 to 88) kg. Written informed consent was obtained prior to each measurement from all subjects. Material and Methods Light sources were white light bulbs (60W, OSRAM, Germany) incorporated in two arrays of 12 light bulbs each. Blue light filters were mounted in front of one-half of the light bulbs and red light filters (both filters, Lee, Germany) in front of the other half Measurement Protocol All subjects were measured twice on different days to avoid carryover effects. On the days of measurement, the subjects were exposed to the sequence of blue followed by red light or vice versa in a randomized, crossover protocol. Each subject was seated in a comfortable chair with armrests placed at a 1.5-m distance from a white wall One NIRS sensor was attached to the left forehead over the frontal lobe and at a location between Fp1 and F7 according to the international 10/20 system The protocol was approved by the Ethical Committee of the Canton of Basel, where the measurements were carried out due to logistic reasons and was in accordance with the Declaration of Helsinki. Measured Parameters Relative concentration changes of oxyhemoglobin (O 2 Hb in µM), deoxyhemoglobin (HHb in µM), total hemoglobin (tHb in µM), redox state of cytochrome oxidase aa3 (Cyt in µM), absolute values of total hemoglobin concentration (THI in µM, also called tissue hemoglobin index by the manufacturer), and tissue oxygen saturation (StO 2 in %, also named tissue oxygenation index [TOI] by the manufacturer) were measured in the frontal lobe of the brain and in the calf muscle throughout the entire experiment. While O 2 Hb, HHb, tHb, and Cyt were calculated using the modified Lambert-Beer law[27], the calculation of THI and StO 2 was based on spatially resolved spectroscopy StO 2 represents the regional tissue oxygenation, and is mainly related to changes in the arterial oxygen saturation and blood flow, and only weakly to changes in mean arterial blood pressure and cerebral blood volume Data Analysis The concentrations of O 2 Hb, HHb, tHb, Cyt, THI, and StO 2 were calculated by the software provided by the manufacturer (Hamamatsu Photonics, Hamamatsu, Japan). Data were manually screened for movement artifacts, which were removed. The first 3 min of the measurements were discarded because they may have contained initial transitions. The remaining 5 min of the baseline measurements were also tested for transition effects and since none were found, these 5 min constituted the initial baseline. Each measurement was divided into the following periods (5-min duration each): initial baseline, exposure to the first color, exposure to the second color, and three consecutive periods of recovery phase. For each of the periods, a median was calculated for each parameter and the values of the initial baseline were subtracted from the values of the other periods. Weinzirl et al.: Colored Light and Brain Oxygenation TheScientificWorldJOURNAL (2011) 11, 1216-1225 1220 Temporal changes: Using a paired t-test, the last 5-min period of the initial baseline was compared to the first and second period of the colored light exposure and to the three periods of recovery for each sequence (blue/red and red/blue) separately. In addition, the difference between the red and blue exposure for each sequence was analyzed by a t-test. Comparison of the two color sequences: Using a paired t-test, the values for the two sequences (blue/red and red/blue) were compared. Other parameters: By a linear mixed effects (LME) model (R statistical software), the influence of physiological parameters, such as age, weight, and height, on the measured parameters was tested. RESULTS Changes in Hemodynamics and Tissue Oxygenation in the Brain Temporal changes: The changes in the different parameters in the brain during and after exposure to blue/red and red/blue light are shown in Comparison of the two color sequences: Although the O 2 Hb and tHb traces appear different between the two sequences in Changes in Hemodynamics and Tissue Oxygenation Saturation of the Calf Muscle Temporal changes: In the calf muscle, O 2 Hb, tHb, THI, and, to a lesser extent, HHb concentration increased significantly during and after exposure for both sequences of blue/red and red/blue light DISCUSSION Changes in the Brain Although the O 2 Hb and tHb traces appear different between the two color sequences in To interpret the observed changes, they are best compared to the previous experiments, which focused on exposure to light of single colors without sequential color changes In the current study, there were no significant changes in any of the parameters (except Cyt) during and after the exposure, independent of the sequence (blue/red or red/blue). Thus, these changes are comparable to the changes in the previous study during red light exposure and different from the ones during blue light exposure. This could be interpreted as a preponderance of the effects excited by the red light over the effect of the blue light. This may be due to an outweighing effect of the red light or a too short exposure time (5 min) for the blue light to induce effects. Additionally, subjects were aware that after the blue light, the red light would appear. It is known from studies on the motor cortex that anticipating The significant decrease in the redox state of Cyt (red/blue sequence only) may be interpreted as a decrease in oxygenation, oxygen consumption, or blood flow. Despite its significance, the change was very small. It is noteworthy that tHb and THI seem to move in opposite directions even though the differences are not significant. This may indicate that the superficial tissue and the brain react in a differing way to the exposure to colored light. Consequently, our hypothesis that the contrast between the two colors will enhance the effect of one of the colors is rejected. Nonetheless, the results indicate a predominating effect of the red light. Weinzirl et al.: Colored Light and Brain Oxygenation TheScientificWorldJOURNAL (2011) 11, 1216-1225 1223 Changes in the Calf Muscle Again, for an easier understanding, we first summarize the findings of the previous publication In the current study, the tHb, O 2 Hb, and THI increased highly significantly for both sequences (blue/red and red/blue). Similar to the previous study, this can be explained by an accumulation of venous blood due to the sedentary position of the subjects during the measurement. The hypothesis of venous pooling is also supported by the slightly, although not significantly, decreased StO 2 . The results of the current study are similar to the exposure to solely red light in the previous study, while the significant increase in StO 2 during exposure to solely blue light is absent. Again this may be due to an outweighing effect of the red light or a too short exposure time (5 min) for the blue light to induce an effect. In summary, it appears that the effects excited by the red light exposure are dominant and outweigh the effects of the blue light. As for the brain, our hypothesis that the contrast between the two colors will enhance the effect of one of the colors is rejected. Nonetheless, the results suggest a preponderant effect of the red light. General Considerations, Limitations, and Outlook The statistical significance of p = 0.05 means per definition that one out of 20 tests will lead to statistical significance by pure chance, which holds true for any study with this significance level. Thus, if, as in this study, several statistical tests are carried out, it has to be considered that in 5% of the tests, significances may be obtained just by chance. The LME model (R statistical software) already takes into account multiple testing and therefore corrects for it. For the paired t-test, five tests were carried per parameter. As usual for exploratory studies, we did not correct for multiple testing. For example, for the time evolution, a Bonferroni correction could be applied, which means that the significance level should be set at p = 0.01 instead of p = 0.05. In this study, a correction for multiple testing has no relevant effect on the interpretation of the results because few, but mostly high, significances were found NIRS was used because it is completely noninvasive, does not use ionizing radiation or tracers, is compatible with other methods since it does not interfere electromagnetically (e.g., MRI, EEG) It would be worthwhile to include different aspects of exposure to colored light in future studies, e.g., different colors, intensities, durations, as well as other measurement locations and postures

Die Betreuung und Reanimation des Neugeborenen

Entstehung und Anwendung dieser Empfehlungen Eine Arbeitsgruppe der Schweizerischen Gesellschaft für Neonatologie (SGN) hat im Jahr 2000 Empfehlungen zur Betreuung und Reanimation von Neugeborenen für die Schweiz ausgearbeitet. Nach einer ersten Überarbeitung 2007 werden diese nun aufgrund neuerer Daten und Evidenzen1) sowie Revisionen internationaler Empfehlungen2)– 7) erneut revidiert. Diese Leitlinien sollen als Empfehlungen verstanden werden, die im individuellen Fall angepasst werden können und sollen

Perinatale Betreuung an der Grenze der Lebensfähigkeit zwischen 22 und 26 vollendeten Schwangerschaftswochen

Die ersten Empfehlungen zur Betreuung von Frühgeborenen an der Grenze der Lebensfähigkeit in der Schweiz wurden im Jahre 2002 veröffentlicht1). Als Grundlage dienten damals unter anderem Empfehlungen europäischer2), 3) und kanadischer Fachgruppen4), sowie die relevanten edizinischethischen Richtlinien der Schweizerischen Akademie der Medizinischen Wissenschaften (SAMW)5), 6). Revidierte Empfehlungen aus Nordamerika und Europa7)–11), neue Empfehlungen aus weiteren Ländern12)–17) und neue Daten zu Mortalität und Morbidität18)– 22), insbesondere auch aus der Schweiz23), 24), haben Anlass dazu gegeben, die Empfehlungen für die Schweiz zu überarbeiten

Lung Volume, Breathing Pattern and Ventilation Inhomogeneity in Preterm and Term Infants

BACKGROUND: Morphological changes in preterm infants with bronchopulmonary dysplasia (BPD) have functional consequences on lung volume, ventilation inhomogeneity and respiratory mechanics. Although some studies have shown lower lung volumes and increased ventilation inhomogeneity in BPD infants, conflicting results exist possibly due to differences in sedation and measurement techniques. METHODOLOGY/PRINCIPAL FINDINGS: We studied 127 infants with BPD, 58 preterm infants without BPD and 239 healthy term-born infants, at a matched post-conceptional age of 44 weeks during quiet natural sleep according to ATS/ERS standards. Lung function parameters measured were functional residual capacity (FRC) and ventilation inhomogeneity by multiple breath washout as well as tidal breathing parameters. Preterm infants with BPD had only marginally lower FRC (21.4 mL/kg) than preterm infants without BPD (23.4 mL/kg) and term-born infants (22.6 mL/kg), though there was no trend with disease severity. They also showed higher respiratory rates and lower ratios of time to peak expiratory flow and expiratory time (t(PTEF)/t(E)) than healthy preterm and term controls. These changes were related to disease severity. No differences were found for ventilation inhomogeneity. CONCLUSIONS: Our results suggest that preterm infants with BPD have a high capacity to maintain functional lung volume during natural sleep. The alterations in breathing pattern with disease severity may reflect presence of adaptive mechanisms to cope with the disease process

Preventable hospitalization and access to primary health care in an area of Southern Italy

<p>Abstract</p> <p>Background</p> <p>Ambulatory care-sensitive conditions (ACSC), such as hypertension, diabetes, chronic heart failure, chronic obstructive pulmonary disease and asthma, are conditions that can be managed with timely and effective outpatient care reducing the need of hospitalization. Avoidable hospitalizations for ACSC have been used to assess access, quality and performance of the primary care delivery system. The aims of this study were to quantify the proportion of avoidable hospital admissions for ACSCs, to identify the related patient's socio-demographic profile and health conditions, to assess the relationship between the primary care access characteristics and preventable hospitalizations, and the usefulness of avoidable hospitalizations for ACSCs to monitor the effectiveness of primary health care.</p> <p>Methods</p> <p>A random sample of 520 medical records of patients admitted to medical wards (Cardiology, Internal Medicine, Pneumology, Geriatrics) of a non-teaching acute care 717-bed hospital located in Catanzaro (Italy) were reviewed.</p> <p>Results</p> <p>A total of 31.5% of the hospitalizations in the sample were judged to be preventable. Of these, 40% were for congestive heart failure, 23.2% for chronic obstructive pulmonary disease, 13.5% for angina without procedure, 8.4% for hypertension, and 7.1% for bacterial pneumonia. Preventable hospitalizations were significantly associated to age and sex since they were higher in older patients and in males. The proportion of patients who had a preventable hospitalization significantly increased with regard to the number of hospital admissions in the previous year and to the number of patients for each primary care physician (PCP), with lower number of PCP accesses and PCP medical visits in the previous year, with less satisfaction about PCP health services, and, finally, with worse self-reported health status and shorter length of hospital stay.</p> <p>Conclusion</p> <p>The findings from this study add to the evidence and the urgency of developing and implementing effective interventions to improve delivery of health care at the community level and provided support to the usefulness of avoidable hospitalizations for ACSCs to monitor this process.</p

Genes Expressed in Specific Areas of the Human Fetal Cerebral Cortex Display Distinct Patterns of Evolution

The developmental mechanisms through which the cerebral cortex increased in size and complexity during primate evolution are essentially unknown. To uncover genetic networks active in the developing cerebral cortex, we combined three-dimensional reconstruction of human fetal brains at midgestation and whole genome expression profiling. This novel approach enabled transcriptional characterization of neurons from accurately defined cortical regions containing presumptive Broca and Wernicke language areas, as well as surrounding associative areas. We identified hundreds of genes displaying differential expression between the two regions, but no significant difference in gene expression between left and right hemispheres. Validation by qRTPCR and in situ hybridization confirmed the robustness of our approach and revealed novel patterns of area- and layer-specific expression throughout the developing cortex. Genes differentially expressed between cortical areas were significantly associated with fast-evolving non-coding sequences harboring human-specific substitutions that could lead to divergence in their repertoires of transcription factor binding sites. Strikingly, while some of these sequences were accelerated in the human lineage only, many others were accelerated in chimpanzee and/or mouse lineages, indicating that genes important for cortical development may be particularly prone to changes in transcriptional regulation across mammals. Genes differentially expressed between cortical regions were also enriched for transcriptional targets of FoxP2, a key gene for the acquisition of language abilities in humans. Our findings point to a subset of genes with a unique combination of cortical areal expression and evolutionary patterns, suggesting that they play important roles in the transcriptional network underlying human-specific neural traits

Patterns of paediatric end-of-life care: a chart review across different care settings in Switzerland.

Paediatric end-of-life care is challenging and requires a high level of professional expertise. It is important that healthcare teams have a thorough understanding of paediatric subspecialties and related knowledge of disease-specific aspects of paediatric end-of-life care. The aim of this study was to comprehensively describe, explore and compare current practices in paediatric end-of-life care in four distinct diagnostic groups across healthcare settings including all relevant levels of healthcare providers in Switzerland. In this nationwide retrospective chart review study, data from paediatric patients who died in the years 2011 or 2012 due to a cardiac, neurological or oncological condition, or during the neonatal period were collected in 13 hospitals, two long-term institutions and 10 community-based healthcare service providers throughout Switzerland. Ninety-three (62%) of the 149 reviewed patients died in intensive care units, 78 (84%) of them following withdrawal of life-sustaining treatment. Reliance on invasive medical interventions was prevalent, and the use of medication was high, with a median count of 12 different drugs during the last week of life. Patients experienced an average number of 6.42 symptoms. The prevalence of various types of symptoms differed significantly among the four diagnostic groups. Overall, our study patients stayed in the hospital for a median of six days during their last four weeks of life. Seventy-two patients (48%) stayed at home for at least one day and only half of those received community-based healthcare. The study provides a wide-ranging overview of current end-of-life care practices in a real-life setting of different healthcare providers. The inclusion of patients with all major diagnoses leading to disease- and prematurity-related childhood deaths, as well as comparisons across the diagnostic groups, provides additional insight and understanding for healthcare professionals. The provision of specialised palliative and end-of-life care services in Switzerland, including the capacity of community healthcare services, need to be expanded to meet the specific needs of seriously ill children and their families

Changes in hemodynamics and tissue oxygenation saturation in the brain and skeletal muscle induced by speech therapy - a near-infrared spectroscopy study

Arts speech therapy (AST) is a therapeutic method within complementary medicine and has been practiced for decades for various medical conditions. It comprises listening and the recitation of different forms of speech exercises under the guidance of a licensed speech therapist. The aim of our study was to noninvasively investigate whether different types of recitation influence hemodynamics and oxygenation in the brain and skeletal leg muscle using near-infrared spectroscopy (NIRS). Seventeen healthy volunteers (eight men and nine women, mean age ± standard deviation 35.6 ± 12.7 years) were enrolled in the study. Each subject was measured three times on different days with the different types of recitation: hexameter, alliteration, and prose verse. Before, during, and after recitation, relative concentration changes of oxyhemoglobin (Δ[O2Hb]), deoxyhemoglobin (Δ[HHb]), total hemoglobin (Δ[tHb]), and tissue oxygenation saturation (StO2) were measured in the brain and skeletal leg muscle using a NIRS device. The study was performed with a randomized crossover design. Significant concentration changes were found during recitation of all verses, with mainly a decrease in Δ[O2Hb] and ΔStO2 in the brain, and an increase in Δ[O2Hb] and Δ[tHb] in the leg muscle during recitation. After the recitations, significant changes were mainly increases of Δ[HHb] and Δ[tHb] in the calf muscle. The Mayer wave spectral power (MWP) was also significantly affected, i.e., mainly the MWP of the Δ[O2Hb] and Δ[tHb] increased in the brain during recitation of hexameter and prose verse. The changes in MWP were also significantly different between hexameter and alliteration, and hexameter and prose. Possible physiological explanations for these changes are discussed. A probable reason is a different effect of recitations on the sympathetic nervous system. In conclusion, these changes show that AST has relevant effects on the hemodynamics and oxygenation of the brain and muscle