151 research outputs found
Paediatric cerebral sinovenous thrombosis: findings of the International Paediatric Stroke Study
No full textOBJECTIVES: We evaluated clinical features, treatment practices and early outcome in a multicentre cohort of children with cerebral sinovenous thrombosis (CSVT).METHODS: Children with CSVT from 10 countries were enrolled from January 2003 to July 2007 in the International Paediatric Stroke Study. We analysed clinical symptoms, underlying conditions, antithrombotic treatment and neurological outcome at hospital discharge in 170 children.RESULTS: Of 170 children enrolled, 60% were male; median age 7.2 years (IQR 2.9-12.4). Headache, altered consciousness, focal deficits and seizures were common presenting clinical features. Infarction affected 37% and intracranial haemorrhage 31%. Risk factors included chronic disease in 50%; acute systemic illness or head/neck disorders 41%; prothrombotic state 20% and other haematological abnormality 19%. Discharge neurological status was normal in 48%, abnormal in 43% and unknown in 5%. Antithrombotic therapy was common, most often low molecular weight heparin was common, with significant regional variation in treatment practices. Mortality was low (4%) and was associated with no anticoagulation but not underlying chronic disease, anatomic extent of thrombosis or intracranial haemorrhage. Abnormal neurological status at discharge or death was associated with decreased level of consciousness at presentation and the presence of an identified prothrombotic state.CONCLUSIONS: Our study extends the observations of previously published smaller studies in children with CSVT that this is a morbid disease with diverse underlying causes and risk factors. Divergent treatment practices among highly specialised centres as well as limited data on treatment efficacy and safety suggest that further study of this condition is warranted.</p
The feasibility of performing a randomised controlled trial of therapeutic hypothermia for neuroprotection after paediatric cardiac arrest in the UK
No full textCardiac arrest in paediatric patients often results in death or survival with severe brain injury.
Therapeutic hypothermia, lowering of core body temperature to 32 to 34⁰C may reduce
injury to the brain in the period after circulation has been restored. This thesis comprises
studies related to the feasibility of performing a randomised controlled trial (RCT) of
therapeutic hypothermia for neuroprotection after cardiac arrest in the UK.
A systematic Cochrane review of paediatric evidence finds no published RCTs supporting or
refuting the use of therapeutic hypothermia after cardiac arrest. Four on-going RCTs are
identified which will add to the future evidence base; however, a future UK RCT is
recommended.
Additional support for a RCT is demonstrated by two UK surveys of paediatric intensive care
and emergency care clinicians. Current UK practice is varied and clinical equipoise exists
regarding post cardiac arrest temperature management.
A national, retrospective study of all admissions to paediatric intensive care after out of
hospital (OHCA) and in hospital cardiac arrest (IHCA) shows an overall survival of 76 and
50% respectively. Important differences between IHCA and OHCA populations are
identified, recommending separation in a RCT. The incidence rate of cardiac arrest
admissions to PICU in the UK is too low to recruit to a UK only RCT, after consideration of
sample size requirements.
A large, multi-centre, retrospective, observational study of OHCA patients identified multiple
factors associated with survival. A survival prediction model, incorporating: pupillary
reaction, blood lactate level and duration of cardiac arrest, is described. The model could be
used as a tool for stratified randomisation within a RCT.
Finally, therapeutic hypothermia is retrospectively compared with standard, normothermic
temperature management after OHCA. In a limited population, no difference in survival is
found; however, important information on application, logistics and safety of the intervention
are evaluated
Evaluating the impact of Attention Process Training (APT) on attention deficit in the early stages of recovery from stroke
No full textAttention deficits are a prominent sequel of stroke and impact negatively on rehabilitation outcomes. However, rehabilitation efforts are almost entirely concerned with the remediation of physical impairments that result from the stroke despite the involvement of attention in physical functioning. Attention Process Training (APT) is a cognitive retraining programme originally designed for the remediation of attention deficit following traumatic brain injury. However, the efficacy of APT post-stroke is not yet known, as to date, few studies have been conducted with small sample sizes. This study evaluated the effectiveness of APT in improving attention in stroke survivors within the 5 to 8 week period post-stroke. Seventy eight patients admitted to hospital with first-ever-stroke were identified as having an attention deficit by obtaining a score of 1 standard deviation below the normative mean on any of the following widely-used neuropsychological measures of attention; the Auditory Attention Quotient (AAQ) or Visual Attention Quotient (VAQ) of the Integrated Visual and Auditory Continuous Performance Test, (IVA-CPT), either trial of the Trail Making Test (TMT), the Paced Auditory Serial Addition Test (PASAT), or by 3 or more errors made on the left or right side of the Bells Cancellation Test. These measures were re-administered on completion of treatment. Participants were randomised to either the experimental group who received standard care and up to 30 hours of APT or to a control group that received standard care only. The primary outcome measure was the Full Scale Attention Quotient (FSAQ) of the IVA-CPT which is a measure of attention derived from both auditory and visual attention quotients. The secondary outcome measure was a health-related quality of life measure, the SF-36, (Short-Form-36). Both measures were administered before treatment and again on the completion of treatment. The results showed that on the primary outcome, the APT group showed improvement from baseline to post-treatment whereas the SC group had not. Significant improvement by the APT group was also demonstrated on two other measures of the IVA-CPT including the Auditory Attention Quotient and the Full Scale Response Quotient (a measure of impulsivity). On the quality of life measure neither the APT group nor the SC group demonstrated a significant change in scores. The results of this study provide further support for the efficacy of cognitive rehabilitation and in particular that APT is an effective cognitive treatment option for the remediation of attention deficit in the early stages of stroke recovery. The characteristics of stroke survivors who might benefit most from APT are identified as well as those factors that possibly influence the subjective experience of this particular intervention. The appropriateness of some measures such as the PASAT, the TMT, cancellation tests as well as continuous performance tests that are often used in research of attention deficit, are also discussed in the context of a stroke population. It is hopeful that the optimistic outcomes of this study will encourage further needed research in this area in order to inform stroke rehabilitation specialists to incorporate cognitive rehabilitation into predominantly physically-focussed programmes
International paediatric stroke study: Stroke associated with cardiac disorders
No full textBackground and hypothesis: The aetiologies of arterial ischaemic stroke in children are diverse and often multifactorial. A large proportion occurs in children with cardiac disorders. We hypothesized that the clinical and radiographic features of children with arterial ischaemic stroke attributed to cardiac disorders would differ from those with other causes. Methods: Using the large population collected in the prospective International Paediatric Stroke Study, we analysed the characteristics, clinical presentations, imaging findings, and early outcomes of children with and without cardiac disorders. Results: Aetiological data were available for 667 children with arterial ischaemic stroke (ages 29 days to 19 years). Cardiac disorders were indentified in 204/667 (30·6%), congenital defects in 121/204 (59·3%), acquired in 40/204 (19·6%), and isolated patent foramen ovale in 31/204 (15·2%). Compared to other children with stroke, those with cardiac disorders were younger (median age 3·1 vs. 6·5 years; P<0·001) and less likely to present with headache (25·6% vs. 44·6%; P<0·001), but were similar in terms of gender and presentation with focal deficits, seizures, or recent infection. Analysis of imaging data identified significant differences (P=0·005) in the vascular distribution (anterior vs. posterior circulation or both) between groups. Bilateral strokes and haemorrhagic conversion were more prevalent in the cardiac disorders group. Conclusions: Cardiac disorders were identified in almost one-third of children with arterial ischaemic stroke. They had similar clinical presentations to those without cardiac disorders but differed in age and headache prevalence. Children with cardiac disorders more frequently had a 'cardioembolic stroke pattern' with a higher prevalence of bilateral strokes in both the anterior and posterior circulations, and a greater tendency to haemorrhagic transformation.</p
International Paediatric Stroke Study: stroke associated with cardiac disorders.
No full textBACKGROUND AND HYPOTHESIS: The aetiologies of arterial ischaemic stroke in children are diverse and often multifactorial. A large proportion occurs in children with cardiac disorders. We hypothesized that the clinical and radiographic features of children with arterial ischaemic stroke attributed to cardiac disorders would differ from those with other causes.
METHODS: Using the large population collected in the prospective International Paediatric Stroke Study, we analysed the characteristics, clinical presentations, imaging findings, and early outcomes of children with and without cardiac disorders.
RESULTS: Aetiological data were available for 667 children with arterial ischaemic stroke (ages 29 days to 19 years). Cardiac disorders were indentified in 204/667 (30.6%), congenital defects in 121/204 (59.3%), acquired in 40/204 (19.6%), and isolated patent foramen ovale in 31/204 (15.2%). Compared to other children with stroke, those with cardiac disorders were younger (median age 3.1 vs. 6.5 years; P \u3c 0.001) and less likely to present with headache (25.6% vs. 44.6%; P \u3c 0.001), but were similar in terms of gender and presentation with focal deficits, seizures, or recent infection. Analysis of imaging data identified significant differences (P = 0.005) in the vascular distribution (anterior vs. posterior circulation or both) between groups. Bilateral strokes and haemorrhagic conversion were more prevalent in the cardiac disorders group.
CONCLUSIONS: Cardiac disorders were identified in almost one-third of children with arterial ischaemic stroke. They had similar clinical presentations to those without cardiac disorders but differed in age and headache prevalence. Children with cardiac disorders more frequently had a \u27cardioembolic stroke pattern\u27 with a higher prevalence of bilateral strokes in both the anterior and posterior circulations, and a greater tendency to haemorrhagic transformation
Neuromechanical measurement of motor impairments in relation to upper limb activity limitations after stroke
No full textLoss of upper-limb function is a problem following stroke. Recent research has led to the emergence of new treatments but progress is hampered by lack of reliable objective measures of impairment, and understanding of the underlying impairment mechanisms associated with loss and recovery of functional activity. The aim of this research was to identify, using neuromechanical measurement methods, inter-relationships between motor impairments, and correlates of motor impairments with functional activity limitation in the upper limb of acute and chronic stroke survivors.An instrumented rig has been developed to measure impairments: muscle weakness, active range of movement, motor control accuracy in rhythmic and discrete tracking tasks, spasticity, coactivation, contracture and non-neural stiffness. In pilot studies, signal processing and data analysis techniques have been used to generate novel, clinically and physiologically relevant indices to quantify impairments. In a Main Study, 13 older impaired participants in the acute phase post-stroke, 13 in the chronic phase 14 age-matched unimpaired participants underwent rig assessments and performed a test of upper limb activity. A sub-group of impaired participants were tested on two days for test-retest reliability evaluation.Statistical tests have confirmed the validity of the impairments to distinguish between acute and chronic patients and unimpaired individuals, except coactivation during discrete movements and non-neural stiffness. Repeatability coefficients for the active test indices have been presented as benchmark values for use in future trials. The muscle activation indices showed lower repeatability which highlights the challenge of using these to measure change over time. The impairments that contributed to lower motor control accuracy were reduced extensor weakness, delayed extensor onset timing, coactivation and smaller extension AROM and PROM; coactivation was more strongly associated with motor control accuracy than with spasticity or stiffness.The most important contributors to functional activity in the acute group was extensor weakness, and in the chronic group was motor control accuracy and coactivation (rhythmic task). Contracture was important contributor in both groups, and was associated with weakness and loss of active range of movement rather than spasticity. The findings support the notion that rehabilitation strategies should focus on increasing muscle strength and prevention of contracture. However, assessment of more complex impairments like motor control accuracy and coactivation may be crucial to better target therapy, especially in the later phases post-stroke
A profile of a paediatric population with feeding and swallowing difficulties at a tertiary hospital in the Western Cape
No full textIncludes abstract.Includes bibliographical resources.Feeding and/or swallowing difficulties (FSD) have been associated with some of the leading causes of infant and child mortality in South Africa. Preventable conditions such as lower respiratory tract infections (LRTI) and under-nutrition may be caused by FSD. FSD are frequently reported in paediatric populations and may occur with various medical co-morbidities. The nature of FSD is however under described and information specific to developing countries is scarce. Furthermore, limited information regarding the service delivery requirements of the paediatric population with FSD is available. To describe in a paediatric population: the nature and frequency of FSD, the nature of FSD in different medical conditions or participant characteristics, and the nature of the services and interventions received by infants and children with FSD. A descriptive, retrospective survey design was used to examine the medical records of 446 infantsand children aged less than 13 years who accessed services for FSD at a paediatric tertiary hospital from January 2007 to December 2009. Seventy percent of participants were under the age of 2 years at the time of first assessment. The nature of participants’ FSD, the medical conditions present, and services/interventions received were recorded. The data were described and associations were analysed statistically. Infants and children with FSD often presented with various medical co-morbidities affecting multiple organ systems with neurologic and gastro-intestinal tract conditions occurring most frequently. A third (34%) of the participants had confirmed aspiration on instrumental assessment. Participants with confirmed aspiration presented with statistically significantly more aspiration pneumonia (x2 = 26.4314, p <; .001) and unspecified LRTI (x2 = 21.2757, p <; .001) than those without aspiration. Participants required a range of services for FSD from Speech-Language Therapists (SLT) as well as medical intervention, and surgical procedures. Most participants (91%) received intervention for FSD for an average of 6 months with a mean of 6 SLT consultations. Forty-three percent of participants completed intervention while 20% continued to receive intervention. The present study profiled paediatric FSD in the Western Cape, South Africa. Infants and children with FSD presented with varied and multiple underlying medical conditions. The safety of swallowing was often (34%) compromised in this population which may have affected respiratory health negatively. Infants and children with FSD frequently presented with LRTI and growth faltering/under-nutrition, two of the leading causes of death in children under the age of 5 years. There is a need for dysphagia services at primary and district levels of health care in the Western Cape to detect and prevent paediatric FSD. While the management of FSD requires the collaboration of many health care professionals, the inclusion of SLTs and dieticians into primary and district level teams may assist with the identification of FSD for early intervention and may prevent FSD-related LRTI and undernutrition in infants and children with FS
A randomized trial of hyperglycemic control in pediatric intensive care.
No full textBACKGROUND: Whether an insulin infusion should be used for tight control of hyperglycemia in critically ill children remains unclear. METHODS: We randomly assigned children (≤16 years of age) who were admitted to the pediatric intensive care unit (ICU) and were expected to require mechanical ventilation and vasoactive drugs for at least 12 hours to either tight glycemic control, with a target blood glucose range of 72 to 126 mg per deciliter (4.0 to 7.0 mmol per liter), or conventional glycemic control, with a target level below 216 mg per deciliter (12.0 mmol per liter). The primary outcome was the number of days alive and free from mechanical ventilation at 30 days after randomization. The main prespecified subgroup analysis compared children who had undergone cardiac surgery with those who had not. We also assessed costs of hospital and community health services. RESULTS: A total of 1369 patients at 13 centers in England underwent randomization: 694 to tight glycemic control and 675 to conventional glycemic control; 60% had undergone cardiac surgery. The mean between-group difference in the number of days alive and free from mechanical ventilation at 30 days was 0.36 days (95% confidence interval [CI], -0.42 to 1.14); the effects did not differ according to subgroup. Severe hypoglycemia (blood glucose, <36 mg per deciliter [2.0 mmol per liter]) occurred in a higher proportion of children in the tight-glycemic-control group than in the conventional-glycemic-control group (7.3% vs. 1.5%, P<0.001). Overall, the mean 12-month costs were lower in the tight-glycemic-control group than in the conventional-glycemic-control group. The mean 12-month costs were similar in the two groups in the cardiac-surgery subgroup, but in the subgroup that had not undergone cardiac surgery, the mean cost was significantly lower in the tight-glycemic-control group than in the conventional-glycemic-control group: -24,682 to -$1,559). CONCLUSIONS: This multicenter, randomized trial showed that tight glycemic control in critically ill children had no significant effect on major clinical outcomes, although the incidence of hypoglycemia was higher with tight glucose control than with conventional glucose control. (Funded by the National Institute for Health Research, Health Technology Assessment Program, U.K. National Health Service; CHiP Current Controlled Trials number, ISRCTN61735247.)
Antithrombotic treatment in neonatal cerebral sinovenous thrombosis:results of the International Pediatric Stroke Study
No full textAntithrombotic treatments, outcomes, and prognostic factors in acute childhood-onset arterial ischaemic stroke: a multicentre, observational, cohort study
No full text- …
