Fetal general movements and brain sonography in a population at risk for preterm birth

Striking Multiple Primary Tumors that underwent Whipple Procedure due to Periampullary Carcinoma: An Analysis of 21 Cases

Introduction

The term multiple primary tumor (MPT) is used to describe cases where two or more primary tumors show no histopathological similarities in between. Multiple primary tumor cases have begun to increase in recent years as a result of the increase in life expectancy because of the increase in life standards and progress in diagnostic methods. In this study, MPT cases with periampullary tumors that underwent Whipple procedure were discussed in the light of literature data.

Materials and methods

The patient files of 223 cases with periampullary tumors that underwent Whipple procedure in our hospital during the last 6 years were examined retrospectively. More than one primary tumor was detected in 21 patients.

Results

Periampullary carcinomas were detected as a second primary tumor in 18 patients. First primary tumor was periampullary carcinoma in 3 patients that underwent Whipple procedure. After the Whipple procedure, 5 patients died due to early complications in the first 30 days and 6 patients died due to metastases and additional problems that developed during follow-up.

Discussion

The incidence of MPT has been reported as 0.7 to 14.5% in the literature. Most of them are multiple primary case presentations. In patient management, it is recommended that each tumor should be evaluated independently of its own characteristics, and treatment and follow-up should be planned accordingly.

Conclusion

The MPT cases are increasing. The possibility of MPT as well as metastasis should be kept in mind during the evaluation of tumor foci seen during diagnosis and follow-up of patients. The characteristics of each tumor, survival, and prognosis should be evaluated separately and the most appropriate treatment should be offered to the patient. It is recommended that synchronic primary tumors which are considered to be surgically resectable without metastasis should be removed in the same session.How to cite this article: Dilek ON, Ozsay O, Karaisli S, Gür EÖ, Er A, Haciyanli SG, Kar H, Dilek FH. Striking Multiple Primary Tumors that underwent Whipple Procedure due to Periampullary Carcinoma: An Analysis of 21 Cases. Euroasian J Hepato-Gastroenterol 2018;8(1):1-5.

The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia

Introduction

Liver involvement is common in hematological malignancies, but the incidence and pattern of liver injury vary among the different types. The aims of our study were to determine the incidence and clinical course of acute hepatitis and the important factors for its development in patients with leukemia after chemotherapy.

Materials and methods

All patients with the diagnosis of leukemia who were treated at the Department of Hematology between January 2008 and January 2013 were included in the study. A detailed medical history, clinical and laboratory findings, treatment modalities, complications, and clinical course were recorded retrospectively.

Results

A total of 124 patients (64 females) with the diagnosis of leukemia were included in the study. The mean age was 45.2 years (16-89 years) and mean follow-up time was 29.7 months (0.25-192 months). A total of 43 (34.6%) patients had acute hepatitis after chemotherapy. Pattern of liver injury was hepatocellular in 31 patients, cholestasis in 2, and mix in 10 patients. Age (p = 0.001), hepatitis B surface antigen (HBsAg, p = 0.007), acute leukemia (p < 0.001), positive blood culture (p = 0.004), the amount of transfused red blood cell (p = 0.001), and amount of transfused platelets (p = 0.002) were significantly different under univariate analysis between the acute hepatitis group and the nonacute hepatitis group. Under multivariate analysis, only acute lymphoblastic leukemia (ALL) was identified as independent predictive factor for development of acute hepatitis after starting chemotherapy.

Conclusion

Acute and self-limited hepatitis develops in the substantial proportion of patients with leukemia. The most important factor for development of acute hepatitis is the type of leukemia.

How to cite this article: Kaya M, Akdogan R, Uçmak F, Ayyildiz MO, Karakus A, Kaplan MA. The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia. Euroasian J Hepato-Gastroenterol 2018;8(1):31-37.

Cross-validation Studies of a Novel Low-cost Hepatitis B Virus Quantitative Polymerase Chain Reaction System

Aim

This research focused on the results of the cross-validation program related with the performance of a Cuban novel low-cost real-time quantitative polymerase chain reaction (qPCR) assay for hepatitis B virus (HBV) quantification developed by the Therapeutic Vaccine against Hepatitis B Department, Vaccines Division, Center for Genetic Engineering and Biotechnology (CIGB), Havana, Cuba.

Materials and methods

Dilution series with the plasmid standard at concentrations of 900,000 to 0.09 copies/reaction (c/r) were made for each PCR instrument. The mean cycles threshold (Ct) values and PCR efficiency were compared among the cyclers. Hepatitis B virus-positive serum samples were used for the calculation of reproducibility of the HBV assay. Biotecon Diagnostics (BCD) also ordered the oligo sequences from a second supplier and compared the PCR performance to those provided from the CIGB.

Results

All PCR cyclers were able to detect concentrations up to 0.09 c/r. However, below the concentration of 9 c/r, the variation of results increased within and between the cyclers. The PCR efficiency showed satisfying results. The overall coefficient of variation (CV) cycler values were 1.29 and 0.91% for M6 and M19 respectively. No significance was observed between the different primer suppliers.

Conclusion

The HBV assay was performed with a good concordance between the five real-time instruments from different suppliers. The HBV assay was also performed with a high reproducibility for samples with a high and a low viral load. The HBV assay is robust against different primer suppliers.

How to cite this article: Aguiar J, Silva JA, García G, Guillén G, Aguilar JC. Cross-validation Studies of a Novel Low-cost Hepatitis B Virus Quantitative Polymerase Chain Reaction System. Euroasian J Hepato-Gastroenterol 2018;8(1):38-41.

Neuroimaging perspectives on fetal motor behavior

We are entering a new era of understanding human development with the ability to perform studies at the earliest time points possible. There is a substantial body of evidence to support the concept that early motor behaviour originates from supraspinal motor centres, reflects neurological integrity, and that altered patterns of behaviour precede clinical manifestation of disease. Cine Magnetic Resonance Imaging (cineMRI) has established its value as a novel method to visualise motor behaviour in the human fetus, building on the wealth of knowledge gleaned from ultrasound based studies. This paper presents a state of the art review incorporating findings from human and preclinical models, the insights from which, we propose, can proceed a reconceptualisation of fetal motor behaviour using advanced imaging techniques. Foremost is the need to better understand the role of the intrauterine environment, and its inherent unique set of stimuli that activate sensorimotor pathways and shape early brain development. Finally, an improved model of early motor development, combined with multimodal imaging, will provide a novel source of in utero biomarkers predictive of neurodevelopmental disorders.

Neurodevelopmental Correlates of Fetal Motor Behavior Assessed Using Cine MR Imaging

BACKGROUND AND PURPOSE

Fetal motor behavior is widely used as a clinical indicator for healthy development; however, our understanding of its potential as a marker for neurologic integrity is underdeveloped. MR imaging allows complete views of the whole fetus, which, combined with brain imaging, may improve the characterization of this relationship. This study aimed to combine an analysis of fetal motor behavior, brain MR imaging, and postnatal outcome, to provide insight into neurodevelopmental correlates of motor behavior.

MATERIALS AND METHODS

Cine MR imaging was used to acquire sequences of fetal motor behavior in subjects with normal and abnormal findings on conventional brain MR imaging between 18 weeks' gestation and term. General movement sequences were analyzed using established criteria. Brain MR imaging was reported by an expert fetal neuroradiologist. Subjects were followed for up to 4 years postnatally with standard postnatal assessments.

RESULTS

Nineteen of 21 fetuses with normal brain MR imaging findings showed normal general movements, compared with 14 of 22 of the fetuses with abnormal brain MR imaging findings, which, when classified by severity of the malformation, showed a significant relationship with postnatal outcome (P = .021). There was a significant relationship among neurodevelopmental outcome, general movement quality, and MR imaging of the brain (P = .020).

CONCLUSIONS

The findings from this study demonstrate that a combined structural and functional imaging approach to the fetus will improve the characterization of early neurologic integrity, with the potential to inform postnatal outcome. This also lays the groundwork for further in vivo research as advanced imaging techniques are developed to study fetal neurologic development.

Antenatal ultrasound value in risk calculation for Autism Spectrum Disorder: A systematic review to support future research

There is a growing research interest on the antenatal features of children with neurodevelopmental disorders. Indeed, it has been proved that the neurodevelopment is, at least partly, affected by processes occurring in fetal life and that the early neurodevelopmental disorders identification is essential to optimize long-term outcomes. This systematic review aims to summarize findings on antenatal ultrasound data, which are or might be considered early risk indexes of postnatal social impairments. We conducted systematic searches in Pubmed and PsychINFO databases to identify studies including fetal ultrasound measurements and postnatal neurodevelopmental outcome assessment. The bibliographic search included 3203 articles but after the assessment of the eligibility conducted by two independent researchers, only 26 studies were selected. Some alterations in ultrasound antenatal measurements (such as biophysical data, nuchal thickness and enlargement of cerebral ventricles) have been associated to autism spectrum disorder. However, data are still limited, controversial and not specific. Reported data are here discussed to strongly support studies on fetuses at high risk for autism spectrum disorder.

Primary Gastric Lymphoma: Clinicopathological Profile

Introduction

Gastrointestinal tract (GIT) is the most common site of involvement of extranodal non-Hodgkin’s lymphoma (NHL). There is regional variation in anatomical distribution of extranodal NHL, stomach being the most common site followed by small intestine. Primary gastric lymphoma (PGL) predominantly involves the antrum and corpus of the stomach. It arises from mucosa-associated lymphoid tissue (MALT) and is of B-cell lineage and often associated with Helicobacter pylori infection. Primary gastric lymphoma often presents with nonspecific symptoms. The present study was undertaken to ascertain the clinicopathological characteristics of PGL at a tertiary care center in South India.

Materials and methods

It is a retrospective study from 2006 to 2016. Patient’s data were obtained from institutional medical records. The histopathology slides were reviewed. The relevant immunohistochemistry (IHC) markers done were leukocyte common antigen (LCA), CD3, CD20, CD79a, CD10, Bcl-2, Bcl-6, CD5, Cyclin D1, CD138, and Ki-67. Correlating with the immunoprofile, further subtyping was done.

Results

A total of 405 patients of NHL were seen during the study period, out of which 43 patients were PGL. There were 32 males and 11 females, with M:F of 2.9:1. The mean age at diagnosis was 58 years. Abdominal pain and new-onset dyspepsia were the commonly observed presenting symptoms. The common site of involvement was antrum (20). Diffuse large B-cell lymphoma (DLBCL) was the most common histological subtype. Helicobacter pylori infection was seen in 18 (41%) patients. Majority of the patients were in stages II and III.

Conclusion

In our study, the initial presentation of PGL was with nonspecific symptoms like abdominal pain and new-onset dyspepsia. High degree of suspicion of such symptoms and biopsy of all suspicious lesions is essential for early detection. Diffuse large B-cell lymphoma was the most common histological subtype seen in our study.

How to cite this article: Malipatel R, Patil M, Rout P, Correa M, Devarbhavi H. Primary Gastric Lymphoma: Clinicopathological Profile. Euroasian J Hepato-Gastroenterol 2018;8(1):6-10.

Nature of Host Immunity during Hepatitis B Virus Infection and designing Immune Therapy

Hepatitis B virus (HBV) infections represent one of the major public health problems in global context. More than 2 billion people in the world have been infected with this virus at some point of time in their life and millions are chronically infected, indicating that chronic HBV-infected subjects remain as a living source of HBV transmission. The public health impact of this is tremendous. Considerable numbers of chronic HBV-infected individuals would eventually develop progressive liver diseases and their complications like hepatic failure, liver cirrhosis (LC), and hepatocellular carcinoma (HCC). Epidemiological studies have suggested that about 0.6 to 1.2 million people die annually from HBV-related liver diseases. These figures about death due to HBV and sufferings from HBV-related diseases indicate a notion of medical emergencies about HBV. In addition to these, the impact of HBV on health care delivery system moves beyond these numbers of HBV-related patients and HB-related deaths. This is because significant insights have already been developed about epidemiology, virology, and pathogenesis of HBV. Also, an effective and widely used preventive vaccine is available against HBV. In addition to these, antiviral drugs against HBV have been developed from early 1980s and several such drugs are now available commercially in the open market around the worldwide. Unfortunately, the ongoing therapeutic regimens could not stand the test of time and new insights about HBV pathogenesis are required for the development of new, novel, and evidence-based therapies for chronic HBV infections.

How to cite this article: Akbar SMF, Al-Mahtab M, Khan SI. Nature of Host Immunity during Hepatitis B Virus Infection and designing Immune Therapy. Euroasian J Hepato-Gastroenterol 2018;8(1):42-46.

Diagnostic and Prognostic Role of Serum Interleukin-6 in Malignant Transformation of Liver Cirrhosis

Aim

Alpha-fetoprotein (AFP) is still the most commonly used and the single most recommended marker in the diagnosis of hepatocellular carcinoma (HCC). Interleukin (IL)-6 is a circular cytokine and its role on carcinogenesis in various hematological and solid tumors is clearly documented. A combination of serum IL-6 and AFP may provide beneficial information regarding early diagnosis of HCC. In this study, the effect of plasma IL-6 level in the diagnosis of HCC was investigated.

Materials and methods

A total of 130 patients with liver cirrhosis, together with 30 control cases were enrolled in the trial. A diagnosis of HCC was present in 75 patients (57.6%) in the liver cirrhosis group. Blood samples were obtained from the enrolled study and control cases. Alpha-fetoprotein was quantified by chemiluminescent method. Plasma IL-6 levels of samples obtained at -80°C were quantified by human IL-6 BMS213/2 BMS213/2TEN kit.

Results

The HCC patients were older than the patients in the cirrhosis group (p = 0.016). On comparison of the HCC patients with the control group, AFP (p < 0.001) and IL-6 (p < 0.001) were significantly higher among the HCC patients. Comparison of HCC patients with liver cirrhosis cases with no diagnosis of HCC revealed significantly high AFP (p < 0.001) and IL-6 levels (p < 0.001) in HCC group. Cutoff value for IL-6 was calculated as 5.73 (pg/mL). No difference was detected in AFP (p = 0.600) and IL-6 (0.344) in all three subgroups. A total of 17 patients died during a mean follow-up period of 32.9 months. No correlation was found between mean AFP values and IL-6 values and survival rates.

Conclusion

Plasma IL-6 level was found to be significant in the diagnosis of HCC. Alpha-fetoprotein and IL-6 provided no advantage in terms of early diagnosis of HCC and no correlation was observed between these markers and survival.

How to cite this article: Yakut M, Özkan H, Karakaya MF, Erdal H. Diagnostic and Prognostic Role of Serum Interleukin-6 in Malignant Transformation of Liver Cirrhosis. Euroasian J Hepato-Gastroenterol 2018;8(1):23-30.

Intake of Bifidobacterium longum and Fructo-oligosaccharides prevents Colorectal Carcinogenesis

INTRODUCTION

We aimed to investigate the effects of intake of yogurt containing Bifidobacterium longum (BB536-y) and fructo-oligosaccharides (FOS) in preventing colorectal carcinogenesis in healthy subjects, and the preventive effects of short-chain fatty acids (SCFA), whose production was enhanced by the intake of BB536-y and FOS, in human colon cancer cell lines.

MATERIALS AND METHODS

The subjects were 27 healthy persons who were divided into a group taking yogurt containing BB536 (BB536-y group; n = 14) and a group taking yogurt containing BB536 and FOS (BB536-y with FOS group; n = 13) once a day for 5 weeks. The feces were sampled before and after the intake to analyze the amount of SCFA in the feces and the profile of intestinal flora, such as putrefactive bacteria and Bacteroides fragilis enterotoxin (ETBF). Subsequently, human colon cancer cell lines (DLD-1 cells, WirDr cells) were cultured in the presence of SCFA (butyric acid, isobutyric acid, acetic acid) in order to evaluate the cell growth-inhibitory activity of SCFA (WST-8 assay) by calculating the IC50 value from the dose-response curve.

RESULTS

Intake of BB536-y increased the total amount of SCFA in the feces and significantly suppressed the detection rate of ETBF and growth of putrefactive bacteria. Intake of BB536-y with FOS was associated with a higher Bifidobacterium detection rate than that of BB536-y alone. The contents of butyric acid, isobutyric acid, and acetic acid, namely, of SCFA, were also decreased. Analysis of the results of culture of DLD-1 cells and WirDr cells in the presence of butyric acid, isobutyric acid, and acetic acid revealed that each of the substances showed significant cell growth-inhibitory activity, with the activity being the highest for butyric acid, followed by that for isobutyric acid and acetic acid.

CONCLUSION

These findings suggest that intake of both BB536-y and BB536-y with FOS prevents colorectal carcinogenesis.How to cite this article: Ohara T, Suzutani T. Intake of Bifidobacterium longum and Fructo-oligosaccharides prevents Colorectal Carcinogenesis. Euroasian J Hepato-Gastroenterol 2018;8(1):11-17.

Screening of Esophageal Varices by Noninvasive Means in Chronic Liver Disease

Introduction

Noninvasive assessment of esophageal varices (EV) decreases the medical and financial burden related to screening and helps in the management of patients with chronic liver diseases (CLDs). In this study, our aim was to assess the utility of the platelet count/spleen diameter index for the noninvasive evaluation of EV.

Materials and methods

In this cross-sectional observational study, a total of 100 CLD patients underwent screening endoscopy for EV in Medicine and Gastroenterology Department, Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh. Platelet count/spleen diameter ratio was assessed in all patients and its diagnostic implication was calculated.

Results

Upper gastrointestinal endoscopy revealed that 45 (45.0%) patients had medium EV followed by 27 (27.0%) that had small EV and 19 (19.0%) patients had large EV. Receiver operator characteristic (ROC) curve was constructed using platelet count/spleen index, which gave a cut-off value of >905. The validity of platelet count/spleen index evaluation of CLD was: Sensitivity 92.3%, specificity 66.7%, accuracy 90.0%, positive predictive value (PPV) and negative predictive value (NPV) were 96.6 and 46.2% respectively. True positive was 84 cases, false positive 3 cases, false negative 7 cases, and true negative 6 cases. If we consider cut-off value as 909 in the evaluation of EV in CLD, then true positive was 85 cases, false positive 3 cases, false negative 6 cases, and true negative 6 cases. From this, by calculation, sensitivity was 93.4%, specificity 66.7%, accuracy 91%, PPV 96.6%, and NPV 50%.

Conclusion

The platelet count/spleen index may be proposed to be a safe and reliable mean of screening of EV in CLD patients; however, case-control study would be required to validate this.

How to cite this article: Hossain E, Ahammed F, Saha SK, Foez SA, Rahim MA, Noor-e-Alam SM, Abdullah AS. Screening of Esophageal Varices by Noninvasive Means in Chronic Liver Disease. Euroasian J Hepato-Gastroenterol 2018;8(1):18-22.

Effect of (minor or major) maternal trauma on fetal motility: A prospective study

BACKGROUND

Fetal motility represents the spontaneous activity of the central nervous system and as such can be used to evaluate its functional integrity. Maternal mechanical trauma in pregnancy is a risk factor for hypoxic ischemic brain injury and can potentially affect the CNS and fetal motility.

AIM

To study motility in fetuses after maternal trauma.

STUDY DESIGN

Prospective study; 1-h sonographic observations at 2-8h (T1), 24-72h (T2) and >72h (T3) after trauma.

SUBJECTS

Fetuses exposed to trauma after 20weeks gestational age.

OUTCOME MEASURES

Motor aspects; differentiation into specific movement patterns, quality and quantity of general movements were compared to a normal population. Obstetrical outcome; neurological outcome at term and 1year of age.

RESULTS

Sixteen fetuses were examined between 2012 and 2014. Median gestational age at time of trauma was 25+6 (range 20-38) weeks. Most traumas were traffic accidents or falls, injuries were mainly minor. Motility assessment showed abnormal differentiation in 2/16; 2/14 and 0/16; abnormal quality in 2/16; 3/14 and 6/16; and abnormal quantity in 6/16, 9/14 and 9/16 at T1, T2 and T3 respectively. Preterm delivery occurred once. Neurological development was normal in 13/14 infants at term and 14/14 at one year.

CONCLUSIONS

This study shows that maternal trauma affected fetal motility in the majority of the fetuses. The changes in motility support the concern that even minor mechanical trauma may have influence on the functional integrity of the central nervous system, although no neurological sequelae were present at 1year.

Wavelet principal component analysis of fetal movement counting data preceding hospital examinations due to decreased fetal movement: a prospective cohort study

Background

Fetal movement (FM) counting is a simple and widely used method of assessing fetal well-being. However, little is known about what women perceive as decreased fetal movement (DFM) and how maternally perceived DFM is reflected in FM charts.

Methods

We analyzed FM counting data from 148 DFM events occurring in 137 pregnancies. The women counted FM daily from pregnancy week 24 until birth using a modified count-to-ten procedure. Common temporal patterns for the two weeks preceding hospital examination due to DFM were extracted from the FM charts using wavelet principal component analysis; a statistical methodology particularly developed for modeling temporal data with sudden changes, i.e. spikes that are frequently found in FM data. The association of the extracted temporal patterns with fetal complications was assessed by including the individuals’ scores on the wavelet principal components as explanatory variables in multivariable logistic regression analyses for two outcome measures: (i) complications identified during DFM-related consultations (n = 148) and (ii) fetal compromise at the time of consultation (including relevant information about birth outcome and placental pathology). The latter outcome variable was restricted to the DFM events occurring within 21 days before birth (n = 76).

Results

Analyzing the 148 and 76 DFM events, the first three main temporal FM counting patterns explained 87.2% and 87.4%, respectively, of all temporal variation in the FM charts. These three temporal patterns represented overall counting times, sudden spikes around the time of DFM events, and an inverted U-shaped pattern, explaining 75.3%, 8.6%, and 3.3% and 72.5%, 9.6%, and 5.3% of variation in the total cohort and subsample, respectively. Neither of the temporal patterns was significantly associated with the two outcome measures.

Conclusions

Acknowledging that sudden, large changes in fetal activity may be underreported in FM charts, our study showed that the temporal FM counting patterns in the two weeks preceding DFM-related consultation contributed little to identify clinically important changes in perceived FM. It thus provides insufficient information for giving detailed advice to women on when to contact health care providers. The importance of qualitative features of maternally perceived DFM should be further explored.

An Attempt to Standardize Kurjak's Antenatal Neurodevelopmental Test: Osaka Consensus Statement

Analysis of the dynamics of fetal behavior in comparison with morphological studies has led to the conclusion that fetal behavioral patterns are directly reflecting developmental and maturational processes of fetal central nervous system (CNS). Four-dimensional ultrasound (4D US) offers a practical means for assessment of both the brain function and structure. The visualization of fetal activity in utero by 4D US could allow distinction between normal and abnormal behavioral patterns which might make possible the early recognition of fetal brain impairment. That new technology enabled introduction of Kurjak's antenatal neurodevelopmental test (KANET) in low- and high-risk pregnancies. In order to make the test reproducible, the standardization of the test was proposed in Osaka, Japan, during the International Symposium on Fetal Neurology of International Academy of Perinatal Medicine.

The KANET should be performed in the 3rd trimester from 28th to 38th week of gestation. The assessment should last from 15 to 20 minutes, and the fetuses should be examined when awake. If the fetus is sleeping, the assessment should be postponed for 30 minutes or for the next day between 14 and 16 hours. In cases of definitely abnormal or borderline score, the test should be repeated every two weeks till delivery. New modified KANET test should be used with eight instead of 10 parameters: Facial and mouth movements are combined in one category, isolated hand movements and hand to face movements are combined in one category. The score should be the same for abnormal fetuses 0 to 5, borderline score is from 6 to 13 and normal score is 14 or above.

After 4D US assessment of behavioral patterns in the fetuses from high-risk pregnancies, it is very important to continue with follow-up after delivery in infants who were borderline or abnormal as fetuses. Postnatal assessment of neonates includes initial neurological assessment according to Amiel-Tison's methodology (Amiel-Tison Neurological Assessment at Term, ATNAT) in the early neonatal period and every two weeks in preterm infants till discharge and at the postmenstrual age (PMA) between 37 and 40 weeks. If ATNAT is borderline or abnormal, initial assessment of general movements at the age of 36 to 38 weeks of PMA should be performed, than at writhing age (between 46 and 52 weeks), and at the fidgety age after 54 weeks of PMA. If the finding of fidgety movements is mildly abnormal or definitely abnormal, then one more assessment should be done in 2 to 4 weeks till PMA of 58 weeks. Brain ultrasonography should be performed in the first week of life and every 2 weeks afterward till discharge. In severely affected infants with grade 3 and above intraventricular hemorrhage, and those highly suspicious of hypoxic ischemic brain damage, magnetic resonance (MR) should be done if available. Infants should be followed until the age of at least 24 months when diagnosis of disabling or nondisabling cerebral palsy can be ultimately made. Infants with CP should be reassessed at the age of 6 years.