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Yamamichi T, Imanishi Y, Sakai T, Yoshida M, Takayama K, Uga N, Umeda S, Usui N. Risk factors for and developmental relation of delayed oral nutrition in infants with congenital diaphragmatic hernia. Pediatr Surg Int 2023; 40:2. [PMID: 37991549 DOI: 10.1007/s00383-023-05595-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE To identify risk factors for delayed oral nutrition in infants with a congenital diaphragmatic hernia (CDH) and its impact on developmental delay at 18 months of age. METHODS This retrospective single-center cohort study compared the clinical parameters in patients with isolated CDH born and treated at our hospital between 2006 and 2020. We evaluated clinical features significantly related to delayed oral nutrition (defined as taking ≥ 30 days from weaning from mechanical ventilation to weaning from tube feeding). RESULTS Twenty-six of the 80 cases had delayed oral nutrition. Univariate analyses showed significant differences. Multivariate analyses were performed on the three items of preterm delivery, defect size (over 50% to nearly entire defect), and ventilation for ≥ 9 days. We identified the latter two items as independent risk factors. The adjusted odds ratios were 4.65 (95% confidence interval, 1.27-7.03) and 6.02 (1.65-21.90), respectively. Delayed oral nutrition was related to a significantly higher probability of developmental delay at 18 months (crude odds ratio 4.16, 1.19-14.5). CONCLUSION In patients with CDH, a large defect and ventilatory management over 9 days are independent risk factors for delayed oral nutrition, which is a potent predictor of developmental delay that requires active developmental care.
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Affiliation(s)
- Taku Yamamichi
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan.
| | - Yousuke Imanishi
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Takaaki Sakai
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Mina Yoshida
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Keita Takayama
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Naoko Uga
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Satoshi Umeda
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, Osaka, 594-1101, Japan
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Lum LCS, Ramanujam TM, Yik YI, Lee ML, Chuah SL, Breen E, Zainal-Abidin AS, Singaravel S, Thambidorai CR, de Bruyne JA, Nathan AM, Thavagnanam S, Eg KP, Chan L, Abdel-Latif ME, Gan CS. Outcomes of neonatal congenital diaphragmatic hernia in a non-ECMO center in a middle-income country: a retrospective cohort study. BMC Pediatr 2022; 22:396. [PMID: 35799173 PMCID: PMC9264560 DOI: 10.1186/s12887-022-03453-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most studies examining survival of neonates with congenital diaphragmatic hernia (CDH) are in high-income countries. We aimed to describe the management, survival to hospital discharge rate, and factors associated with survival of neonates with unilateral CDH in a middle-income country. METHODS We retrospectively reviewed the medical notes of neonates with unilateral CDH admitted to a pediatric intensive care unit (PICU) in a tertiary referral center over a 15-year period, from 2003-2017. We described the newborns' respiratory care pathways and then compared baseline demographic, hemodynamic, and respiratory indicators between survivors and non-survivors. The primary outcome measure was survival to hospital discharge. RESULTS Altogether, 120 neonates were included with 43.3% (52/120) diagnosed antenatally. Stabilization occurred in 38.3% (46/120) with conventional ventilation, 13.3% (16/120) with high-frequency intermittent positive-pressure ventilation, and 22.5% (27/120) with high frequency oscillatory ventilation. Surgical repair was possible in 75.0% (90/120). The overall 30-day survival was 70.8% (85/120) and survival to hospital discharge was 66.7% (80/120). Survival to hospital discharge tended to improve over time (p > 0.05), from 56.0% to 69.5% before and after, respectively, a service reorganization. For those neonates who could be stabilized and operated on, 90.9% (80/88) survived to hospital discharge. The commonest post-operative complication was infection, occurring in 43.3%. The median survivor length of stay was 32.5 (interquartile range 18.8-58.0) days. Multiple logistic regression modelling showed vaginal delivery (odds ratio [OR] = 4.8; 95% confidence interval [CI] [1.1-21.67]; p = 0.041), Apgar score [Formula: see text] 7 at 5 min (OR = 6.7; 95% CI [1.2-36.3]; p = 0.028), and fraction of inspired oxygen (FiO2) < 50% at 24 h (OR = 89.6; 95% CI [10.6-758.6]; p < 0.001) were significantly associated with improved survival to hospital discharge. CONCLUSIONS We report a survival to hospital discharge rate of 66.7%. Survival tended to improve over time, reflecting a greater critical volume of cases and multi-disciplinary care with early involvement of the respiratory team resulting in improved transitioning from PICU. Vaginal delivery, Apgar score [Formula: see text] 7 at 5 min, and FiO2 < 50% at 24 h increased the likelihood of survival to hospital discharge.
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Affiliation(s)
- Lucy Chai See Lum
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia.
| | | | - Yee Ian Yik
- Division of Pediatric Surgery, Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Mei Ling Lee
- Department of Pediatrics, Hospital Tengku Ampuan Afzan, Pahang, Malaysia
| | - Soo Lin Chuah
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Emer Breen
- Clinical Investigation Center, University of Malaya Medical Center, 5th Floor East Tower, Kuala Lumpur, Malaysia
| | | | - Srihari Singaravel
- Division of Pediatric Surgery, Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | | | - Jessie Anne de Bruyne
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Anna Marie Nathan
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Surendran Thavagnanam
- Queen Mary University of London, Barts Health NHS Trust, Royal London Children's Hospital, London, UK
| | - Kah Peng Eg
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Lucy Chan
- Department of Anesthesia, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Mohamed E Abdel-Latif
- Department of Neonatology, Centenary Hospital for Women and Children, The Canberra Hospital, Canberra, ACT, Australia.,Department of Public Health, La Trobe University, Bundoora, Melbourne, VIC, Australia
| | - Chin Seng Gan
- Department of Pediatrics, University Malaya Medical Center, 59100, Lembah Pantai, Kuala Lumpur, Malaysia
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Okolo F, Zhang G, Rhodes J, Gittes GK, Potoka DA. Intra-Amniotic Sildenafil Treatment Promotes Lung Growth and Attenuates Vascular Remodeling in an Experimental Model of Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2020; 47:787-799. [PMID: 32663823 DOI: 10.1159/000508986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Defective lung development resulting in lung hypoplasia and an attenuated and hypermuscularized pulmonary vasculature contributes to significant postnatal mortality in congenital diaphragmatic hernia (CDH). We hypothesize that deficient embryonic pulmonary blood flow contributes to defective lung development in CDH, which may therefore be ameliorated via enhancement of embryonic pulmonary blood flow. METHODS The mouse nitrofen model of CDH was utilized to measure embryonic pulmonary blood flow by in utero intracardiac injection of FITC-labeled tomato lectin and color-flow Doppler ultrasound. The effect of prenatal intra-amniotic treatment with sildenafil on survival, lung growth, and vascular morphology in the nitrofen model was determined. RESULTS Nitrofen-treated embryos exhibited decreased blood flow in the lung periphery compared to controls, and intra-amniotic sildenafil significantly improved embryonic pulmonary blood flow. Similar to nitrofen alone, pups delivered after nitrofen treatment and intra-amniotic injection of dextrose control exhibited respiratory distress and never survived beyond 6 h. Intra-amniotic sildenafil ameliorated respiratory distress in nitrofen-treated pups and improved postnatal survival to 82%. Following intra-amniotic sildenafil treatment at embryonic day (E)10.5, nitrofen-treated P0 lungs were larger with increased left lobe weight, reduced small pulmonary arterial wall muscularization, and increased airway branching complexity compared to controls. Intra-amniotic sildenafil treatment later at E15.5 also resulted in improved survival, lung growth, and attenuation of vascular remodeling in nitrofen-treated embryos. CONCLUSIONS Defective embryonic pulmonary blood flow may contribute to lung maldevelopment in CDH. Enhancement of embryonic pulmonary blood flow via intra-amniotic sildenafil results in lung growth and attenuation of pulmonary vascular remodeling and may have therapeutic potential for CDH.
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Affiliation(s)
- Frances Okolo
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - GuangFeng Zhang
- Department of Surgery, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | - Julie Rhodes
- Department of Surgery, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | - George K Gittes
- Department of Surgery, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA,
| | - Douglas A Potoka
- Department of Surgery, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
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Okolo FC, Zhang G, Rhodes J, Potoka DA. Intra-amniotic Sildenafil Treatment Modulates Vascular Smooth Muscle Cell Phenotype in the Nitrofen Model of Congenital Diaphragmatic Hernia. Sci Rep 2018; 8:17668. [PMID: 30518769 PMCID: PMC6281652 DOI: 10.1038/s41598-018-34948-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/11/2018] [Indexed: 01/10/2023] Open
Abstract
The etiology of pulmonary vascular abnormalities in CDH is incompletely understood. Studies have demonstrated improvement in pulmonary vasculature with prenatal therapy in animal models. We hypothesize that prenatal sildenafil may attenuate defective pulmonary vascular development via modulation of vSMC phenotype from undifferentiated, proliferative phenotype to differentiated, contractile phenotype. We utilized the nitrofen model of CDH to examine the effect of IA sildenafil on pulmonary vSMC phenotype during lung development. Timed-pregnant CD-1 mice were gavage fed 25 mg nitrofen or olive oil (control) at E8.5 of gestation. Single IA injections of Sildenafil (Revatio; 10 µL of 4 mg/4 ml solution) or dextrose control were performed at E12.5. Mice were sacrificed on various gestational days for embryonic lung harvest. Markers of vSMC development of undifferentiated and differentiated phenotypes were analyzed by immunostaining and western blot. Across all time points in gestation, nitrofen-treated embryonic lungs demonstrated increased vSMC expression of NOTCH3, Hes-5, PDGFR-β, desmin and α-SMA and decreased expression of calponin and SMMHC, compared to oil controls. IA dextrose treatment had no effect on expression levels. However, IA Sildenafil treatment resulted in down-regulation of NOTCH3, Hes-5, PDGFR-β, desmin and α-SMA and upregulation of calponin and SMMHC, comparable to oil controls. In the nitrofen model, vSMC express markers consistent with more undifferentiated proliferative phenotype, resulting in hypermuscularization of intrapulmonary arterioles in CDH. A single dose of IA Sildenafil treatment early in gestation, results in sustained normalization of vSMC phenotype. Pharmacologic modulation of the vSMC phenotype at key gestational points may have therapeutic potential.
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MESH Headings
- Amnion
- Animals
- Female
- Hernias, Diaphragmatic, Congenital/chemically induced
- Hernias, Diaphragmatic, Congenital/drug therapy
- Hernias, Diaphragmatic, Congenital/etiology
- Injections
- Lung/blood supply
- Lung/drug effects
- Lung/embryology
- Mice
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/embryology
- Phenotype
- Phenyl Ethers
- Pregnancy
- Sildenafil Citrate/administration & dosage
- Sildenafil Citrate/therapeutic use
- Vasodilator Agents/administration & dosage
- Vasodilator Agents/therapeutic use
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Affiliation(s)
- Frances C Okolo
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Guangfeng Zhang
- Department of Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Julie Rhodes
- Department of Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Douglas A Potoka
- Department of Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Morini F, Lally KP, Lally PA, Crisafulli RM, Capolupo I, Bagolan P. Treatment Strategies for Congenital Diaphragmatic Hernia: Change Sometimes Comes Bearing Gifts. Front Pediatr 2017; 5:195. [PMID: 28959686 PMCID: PMC5603669 DOI: 10.3389/fped.2017.00195] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/23/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report treatment strategies' evolution and its impact on congenital diaphragmatic hernia (CDH) outcome. DESIGN Registry-based cohort study using the CDH Study Group database, 1995-2013. SETTING International multicenter database. PATIENTS CDH patients entered into the registry. Late presenters or patients with very incomplete data were excluded. Patients were divided into three Eras (1995-2000; 2001-2006; 2007-2013). MAIN OUTCOME MEASURES Treatment strategies and outcomes. One-way ANOVA, X2 test, and X2 test for trend were used. A Sydak-adjusted p < 0.0027 was considered significant. Prevalence or mean (SE) are reported. RESULTS Patients: 8,603; included: 7,716; Era I: 2,146; Era II: 2,572; Era III: 2,998. From Era I to Era III, significant changes happened. Some severity indicators such as gestational age, prevalence of prenatal diagnosis, and inborn patients significantly worsened. Also, treatment strategies such as the use of prenatal steroids and inhaled nitric oxide, age at operation, prevalence of minimal access surgery, and the use of surfactant significantly changed. Finally, length of hospital stay became significantly longer and survival to discharge slightly but significantly improved, from 67.7 to 71.4% (p for trend 0.0019). CONCLUSION Treatment strategies for patients registered since 1995 in the CDH Study Group significantly changed. Survival to discharge slightly but significantly improved.
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Affiliation(s)
- Francesco Morini
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Pamela A Lally
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Rosa Maria Crisafulli
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Wessel LM, Fuchs J, Rolle U. The Surgical Correction of Congenital Deformities: The Treatment of Diaphragmatic Hernia, Esophageal Atresia and Small Bowel Atresia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:357-64. [PMID: 26051693 DOI: 10.3238/arztebl.2015.0357] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 03/03/2015] [Accepted: 03/03/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND More than half of all congenital deformities can be detected in utero. The initial surgical correction is of paramount importance for the achievement of good long-term results with low surgical morbidity and mortality. METHODS Selective literature review and expert opinion. RESULTS Congenital deformities are rare, and no controlled trials have been performed to determine their optimal treatment. In this article, we present the prenatal assessment, treatment, and long-term results of selected types of congenital deformity. Congenital diaphragmatic hernia (CDH) affects one in 3500 live-born infants, while esophageal atresia affects one in 3000 and small-bowel atresia one in 5000 to 10,000. If a congenital deformity is detected and its prognosis can be reliably inferred from a prenatal assessment, the child should be delivered at a specialized center (level 1 perinatal center). The associated survival rates are 60-80% after treatment for CDH and well over 90% after treatment for esophageal or small-bowel atresia. Despite improvements in surgical correction over the years, complications and comorbidities still affect 20-40% of the treated children. These are not limited to surgical complications in the narrow sense, such as recurrence, postoperative adhesions and obstruction, stenoses, strictures, and recurrent fistulae, but also include pulmonary problems (chronic lung disease, obstructive and restrictive pulmonary dysfunction), gastrointestinal problems (dysphagia, gastro-esophageal reflux, impaired intestinal motility), and failure to thrive. Moreover, the affected children can develop emotional and behavioral disturbances. Minimally invasive surgery in experienced hands yields results as good as those of conventional surgery, as long as proper selection criteria are observed. CONCLUSION Congenital deformities should be treated in recognized centers with highly experienced interdisciplinary teams. As no randomized trials of surgery for congenital deformities are available, longitudinal studies and registries will be very important in the future.
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Affiliation(s)
- Lucas M Wessel
- Department of Pediatric Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Department of Pediatric Surgery and Pediatric Urology, University Hospital Frankfurt, Campus Niederrad,Frankfurt am Main
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Shetty S, Kennea N, Desai P, Giuliani S, Richards J. Length of stay and cost analysis of neonates undergoing surgery at a tertiary neonatal unit in England. Ann R Coll Surg Engl 2016; 98:56-60. [PMID: 26688402 DOI: 10.1308/rcsann.2016.0034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction There is a lack of knowledge on the average length of stay (LOS) in neonatal units after surgical repair of common congenital anomalies. There are few if any publications reporting the activity performed by units undertaking neonatal surgery. Such activity is important for contracting arrangements, commissioning specialist services and counselling parents. The aim of this study was to describe postnatal LOS for infants admitted to a single tertiary referral neonatal unit with congenital malformations requiring surgery. Methods Data on nine conditions were collected prospectively for babies on the neonatal unit over a five-year period (2006-2011). For those transferred back to their local unit following surgery, the local unit was contacted to determine the total LOS. Only those babies who had surgery during their first admission to our unit and who survived to discharge were included in the study. Cost estimates were based on the tariffs agreed for neonatal care between our trust and the London specialised commissioning group in 2011-2012. Results The median LOS for the conditions studied was: gastroschisis 35 days (range: 19-154 days), oesophageal atresia 33 days (range: 9-133 days), congenital diaphragmatic hernia 28 days (range: 7-99 days), intestinal atresia 24 days (range: 6-168 days), Hirschsprung's disease 21 days (range: 15-36 days), sacrococcygeal teratoma 17 days (range: 12-55 days), myelomeningocoele 15.5 days (range: 8-24 days), anorectal malformation 15 days (range: 6-90 days) and exomphalos 12 days (range: 3-228 days). The total neonatal bed day costs for the median LOS ranged from £8,701 (myelomeningocoele) to £23,874 (gastroschisis). The cost of surgery was not included. Conclusions There is wide variation in LOS for the same conditions in a single neonatal unit. This can be explained by different types and severity within the same congenital anomalies, different surgeons and other clinical confounders (eg sepsis, surgical complications, associated anomalies). These data will enable us to give more detailed information to families following prenatal or postnatal diagnosis. They also allow more detailed planning of resource allocation for neonatal admissions.
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Affiliation(s)
- S Shetty
- St George's University Hospitals NHS Foundation Trust , UK
| | - N Kennea
- St George's University Hospitals NHS Foundation Trust , UK
| | - P Desai
- St George's University Hospitals NHS Foundation Trust , UK
| | - S Giuliani
- St George's University Hospitals NHS Foundation Trust , UK
| | - J Richards
- St George's University Hospitals NHS Foundation Trust , UK
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Self-assessed physical health among children with congenital diaphragmatic hernia. Pediatr Surg Int 2016; 32:493-503. [PMID: 26909750 DOI: 10.1007/s00383-016-3879-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2016] [Indexed: 01/23/2023]
Abstract
PURPOSE The aim of this long-term follow-up study was to investigate the current self assessed physical health in a CDH birth cohort at a single center. METHODS Between 1990 and 2009, 195 children born with CDH were treated at Astrid Lindgren Children's Hospital. The primary survival rate was 85 %, and in 2010, 78 % were still alive. Data from medical records were supplemented by a questionnaire consisting of questions about perceived physical function. Patients were divided into groups according to time for intubation and need for extracorporeal membrane oxygenation. RESULTS Children born with CDH reported themselves to be having greater problems with asthma, developmental delay, seizure disorder, poor vision, and scoliosis in comparison with normal Swedish children. They also described a sense of having less strength and becoming breathless more often than healthy friends. Symptoms of gastroesophageal reflux and abdominal pain were also reported. CONCLUSIONS The majority of the children perceived their physical health as being overall good, but there was an increase of reported symptoms correlating with the severity of the malformation.
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Tiryaki S, Ozcan C, Erdener A. Initial oxygenation response to inhaled nitric oxide predicts improved outcome in congenital diaphragmatic hernia. Drugs R D 2014; 14:215-9. [PMID: 25239432 PMCID: PMC4269815 DOI: 10.1007/s40268-014-0063-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is the most important complication of congenital diaphragmatic hernia (CDH) and still has a high mortality rate. The aim of this study was to evaluate the effectiveness of inhaled nitric oxide therapy in PH due to CDH. METHODS Hospital records of children who had undergone inhaled nitric oxide therapy for PH due to CDH between June 2009 and December 2011 were reviewed. RESULTS Twenty-nine patients had a diagnosis of CDH at the time of study, and eight of these patients underwent nitric oxide therapy because of failure of conventional ventilation techniques, which was successful in five of these patients. Patients who had a good overall outcome of nitric oxide therapy experienced rapid improvement (pretreatment, mean PaO2 = 44.8 mmHg; after the first hour of therapy, mean PaO2 = 96.8 mmHg), whereas patients with no response did not have a similar course (pretreatment, PaO2 = 37 mmHg; after the first hour, PaO2 = 54.6 mmHg). CONCLUSION Inhaled nitric oxide therapy seems to increase survival in PH due to CDH. No predictive parameters to orient patient selection could be identified; however, the early response seemed to predict the overall outcome. Good results in our series were attributed to routine use of sildenafil and dopamine, along with the nitric oxide inhalation.
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10
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Cauley RP, Stoffan A, Potanos K, Fullington N, Graham DA, Finkelstein JA, Kim HB, Wilson JM. Pulmonary support on day 30 as a predictor of morbidity and mortality in congenital diaphragmatic hernia. J Pediatr Surg 2013; 48:1183-9. [PMID: 23845605 PMCID: PMC4877188 DOI: 10.1016/j.jpedsurg.2013.03.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 03/08/2013] [Indexed: 11/17/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) is associated with significant in-hospital mortality, morbidity and length-of-stay (LOS). We hypothesized that the degree of pulmonary support on hospital day-30 may predict in-hospital mortality, LOS, and discharge oxygen needs and could be useful for risk prediction and counseling. METHODS 862 patients in the CDH Study Group registry with a LOS ≥ 30 days were analyzed (2007-2010). Pulmonary support was defined as (1) room-air (n=320) (2) noninvasive supplementation (n=244) (3) mechanical ventilation (n=279) and (4) extracorporeal membrane oxygenation (ECMO, n=19). Cox Proportional hazards and logistic regression models were used to determine the case-mix adjusted association of oxygen requirements on day-30 with mortality and oxygen requirements at discharge. RESULTS On multivariate analysis, use of ventilator (HR 5.1, p=.003) or ECMO (HR 19.6, p<.001) was a significant predictor of in-patient mortality. Need for non-invasive supplementation or ventilator on day-30 was associated with a respective 22-fold (p<.001) and 43-fold (p<.001) increased odds of oxygen use at discharge compared to those on room-air. CONCLUSIONS Pulmonary support on Day-30 is a strong predictor of length of stay, oxygen requirements at discharge and in-patient mortality and may be used as a simple prognostic indicator for family counseling, discharge planning, and identification of high-risk infants.
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Affiliation(s)
- Ryan P. Cauley
- Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
| | | | - Kristina Potanos
- Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Nora Fullington
- Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Dionne A. Graham
- Clinical Research Center, Boston Children’s Hospital, Boston, MA, USA
| | | | - Heung Bae Kim
- Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Jay M. Wilson
- Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
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Lath NR, Galambos C, Rocha AB, Malek M, Gittes GK, Potoka DA. Defective pulmonary innervation and autonomic imbalance in congenital diaphragmatic hernia. Am J Physiol Lung Cell Mol Physiol 2011; 302:L390-8. [PMID: 22114150 DOI: 10.1152/ajplung.00275.2011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is associated with significant mortality due to lung hypoplasia and pulmonary hypertension. The role of embryonic pulmonary innervation in normal lung development and lung maldevelopment in CDH has not been defined. We hypothesize that developmental defects of intrapulmonary innervation, in particular autonomic innervation, occur in CDH. This abnormal embryonic pulmonary innervation may contribute to lung developmental defects and postnatal physiological derangement in CDH. To define patterns of pulmonary innervation in CDH, human CDH and control lung autopsy specimens were stained with the pan-neural marker S-100. To further characterize patterns of overall and autonomic pulmonary innervation during lung development in CDH, the murine nitrofen model of CDH was utilized. Immunostaining for protein gene product 9.5 (a pan-neuronal marker), tyrosine hydroxylase (a sympathetic marker), vesicular acetylcholine transporter (a parasympathetic marker), or VIP (a parasympathetic marker) was performed on lung whole mounts and analyzed via confocal microscopy and three-dimensional reconstruction. Peribronchial and perivascular neuronal staining pattern is less complex in human CDH than control lung. In mice, protein gene product 9.5 staining reveals less complex neuronal branching and decreased neural tissue in nitrofen-treated lungs from embryonic day 12.5 to 16.5 compared with controls. Furthermore, nitrofen-treated embryonic lungs exhibited altered autonomic innervation, with a relative increase in sympathetic nerve staining and a decrease in parasympathetic nerve staining compared with controls. These results suggest a primary defect in pulmonary neural developmental in CDH, resulting in less complex neural innervation and autonomic imbalance. Defective embryonic pulmonary innervation may contribute to lung developmental defects and postnatal physiological derangement in CDH.
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Affiliation(s)
- Nikesh R Lath
- Department of Surgery, University of Pittsburgh, PA, USA
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Takahashi T, Koga H, Tanaka T, Shoji H, Takeda S, Shimizu T, Lane GJ, Yamataka A, Okazaki T. Pulmonary artery size has prognostic value in low birth weight infants with congenital diaphragmatic hernia. Pediatr Surg Int 2011; 27:847-50. [PMID: 21499880 DOI: 10.1007/s00383-011-2899-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2011] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to examine the relationship between birth weight, pulmonary artery (PA) size, and outcome in congenital diaphragmatic hernia (CDH) to establish if PA size has prognostic value. METHODS The subjects for this study were 39 consecutive left-sided CDH patients treated at our institution according to the same protocol from 2002 to 2009. Other CDH patients with concurrent anomalies that eventually caused death or who became symptomatic more than 6 h after birth were excluded. Birth weight was used to create two groups; low birth weight (LBW; birth weight ≤ 2,500 g; n = 15) and normal birth weight (NBW; birth weight >2,500 g; n = 24). Right PA (RPA) and left PA (LPA) were measured by echocardiography (EC) during late pregnancy (fetal; gestational age (GA): 32-34 weeks), and on days 0, and 2 of life and compared. RESULTS Mean birth weights were significantly different between the two groups; however, gender, mean GA, and outcome were similar. In LBW survivors, RPA was significantly larger than in non-survivors. PA size was not related to outcome in NBW. CONCLUSION We are the first to show that RPA size has prognostic value in low birth weight infants with left-sided CDH.
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Affiliation(s)
- Toshiaki Takahashi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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13
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Single payer health insurance in pediatric surgery: US impressions and Canadian experience. Pediatr Surg Int 2011; 27:329-34. [PMID: 21085973 DOI: 10.1007/s00383-010-2590-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2010] [Indexed: 10/18/2022]
Abstract
CONTEXT Some advocate single payer national health insurance, present in Canada, as a solution to problems in US health care. METHOD Pediatric surgeons in the US and Canada were surveyed regarding their attitudes (US) and experience (Canada) under a single payer by electronic mail regarding features of a single payer using a Likert scale (1-strongly disagree to 5-strongly agree) on quality, administration, organization, and economics. RESULTS Overall response rate of 22% (175/835), 153 US, 22 Canadian. US and Canadian respondents predicted a higher quality of care for both emergency (66 and 36%, respectively) and elective conditions (47 and 9%) under a single payer. Both groups recognized delays for elective surgery. Better access to surgical care under a single payer, seen by most Canadians (81%), was not predicted among Americans (44%, p = 0.00012). Americans (68%) did not believe a single payer would address workforce shortages, while Canadians (68%) disagreed (p = 0.00001). Both groups agree (p = 0.7) that personal income is decreased. CONCLUSIONS US surgeons anticipate benefits and problems that Canadian surgeons with direct experience with a single payer do not experience. This discrepancy must be recognized during the ongoing debate over the future of US health care.
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Esumi G, Masumoto K, Teshiba R, Nagata K, Kinoshita Y, Yamaza H, Nonaka K, Taguchi T. Effect of insulin-like growth factors on lung development in a nitrofen-induced CDH rat model. Pediatr Surg Int 2011; 27:187-92. [PMID: 21046115 DOI: 10.1007/s00383-010-2791-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE Both the mortality and morbidity associated with congenital diaphragmatic hernia (CDH) are mainly caused by pulmonary hypoplasia and persistent pulmonary hypertension. A previous study revealed that insulin-like growth factors (IGFs) play important roles in fetal lung development. The aim of this study was to investigate the effect of IGF-1 and IGF-2 on tissue cultures of fetal hypoplastic lungs obtained from nitrofen-induced CDH model rats. METHODS Pregnant rats were exposed to nitrofen on day 9 of gestation (D9). Fetuses were harvested on D18 by caesarian section. Lung specimens of the CDH (+) fetus were divided into three groups; control, IGF-1, and IGF-2. The specimens from the control group were cultured in culture medium without IGFs. The IGF-1 group specimens were cultured with IGF-1 (500 ng/ml), and those in the IGF-2 group were cultured with IGF-2 (500 ng/ml). The mRNA expression of TTF-1, T1α and α-SMA were analyzed in each group using real-time RT-PCR after 24 and 48 h of incubation. Immunohistochemical staining of these markers was also assessed for each of the cultured specimens. RESULTS There was a significant increase in the expression of both TTF-1 and T1α mRNA in the IGF-2 group, in comparison to the control group after 48 h of culture. Immunohistochemical staining revealed that the cell morphology was changed from cuboidal to squamous type in the IGF-2 group. CONCLUSIONS An increased mRNA expression of the markers related to type 1 and 2 alveolar epithelial cells, and morphological changes in the epithelial cells were observed in the IGF-2 group. The administration of IGF-2 to nitrofen-induced hypoplastic lungs might lead to alveolar maturation, which thus results in their improved development.
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Affiliation(s)
- Genshiro Esumi
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
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Abdullah F, Zhang Y, Sciortino C, Camp M, Gabre-Kidan A, Price MR, Chang DC. Congenital diaphragmatic hernia: outcome review of 2,173 surgical repairs in US infants. Pediatr Surg Int 2009; 25:1059-64. [PMID: 19727769 DOI: 10.1007/s00383-009-2473-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2009] [Indexed: 11/29/2022]
Abstract
Congenital diaphragmatic hernia (CDH) remains one of the most challenging conditions to treat within the pediatric surgical and medical communities. In spite of modern treatment modalities, including extracorporeal membrane oxygenation (ECMO) and improved ventilatory support, mortality remains high. The present study analyzes a US database containing information from nearly 93 million discharges in the US. Infants with congenital diaphragmatic hernia who underwent surgical repair were identified by ICD-9 procedure code and inclusion criteria including an age at admission of less than 1 year. Variables of gender, race, age, geographic region, co-existing diagnoses and procedures, hospital type, hospital charges adjusted to 2006 dollars, length of stay, and inpatient mortality were collected. A total of 89% of patients were either treated initially or rapidly transferred to urban teaching hospitals for definitive treatment of CDH. The inpatient mortality rate was 10.4% with a median length of stay of 20 days (interquartile range of 9-40 days). The median inflation-adjusted total hospital charge was $116,210. Respiratory distress was the most common co-existing condition (68.8%) followed by esophageal reflux (27.8%). The most common concomitant procedures performed were ECMO (17.8%) and fundoplication (17.6%). This study, which represents the largest characterization of US infants who have undergone CDH repair using data from a nationally representative non-voluntary database, demonstrates that surgical repair is associated with significant mortality and morbidity.
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Affiliation(s)
- Fizan Abdullah
- Division of Pediatric Surgery, Center for Pediatric Surgical Clinical Trials and Outcomes Research, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Harvey 319, Baltimore, MD 21287-0005, USA.
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Management of pulmonary hypertension in congenital diaphragmatic hernia: nitric oxide with prostaglandin-E1 versus nitric oxide alone. Pediatr Surg Int 2008; 24:1101-4. [PMID: 18726605 DOI: 10.1007/s00383-008-2225-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM Prostaglandin-E1 (PGE1) is used at most centers for treating pulmonary hypertension (PH) in congenital diaphragmatic hernia (CDH) because it has been regarded as effective. The aim of this study was to investigate the role of PGE1 for treating PH in CDH. METHODS We reviewed 49 CDH cases with echocardiography-proven PH. PH was treated with PGE1 and nitric oxide (NO) and high frequency oscillatory ventilation (HFOV) from 1997 to 2001 (PG + NO; n = 19) and with NO and HFOV from 2002 to 2007 (NO; n = 30). RESULTS Subject demographics, severity of PH, and presence of other anomalies were not significantly different between the two groups. In the PG + NO group, 12/19 (63.2%) survived (PG + NO-s) and 7/19 (36.8%) died (PG + NO-d). In the NO group, 21/30 (70.0%) survived (NO-s) and 9/30 (30.0%) died (NO-d). Survival rates were not significantly different. In the NO-s group, spontaneous closure of the ductus arteriosus (DA) was significantly earlier compared with the PG + NO-s group (P < 0.01; 4.0 +/- 0.9 vs. 9.5 +/- 2.2 days after birth). DA diameters were significantly larger in groups that died compared with groups that survived (P < 0.01), and PH persisted in groups that died. In the NO-s group, surgery was possible significantly earlier compared with the PG + NO-s group (P < 0.01; 3.75 +/- 0.67 vs. 6.12 +/- 0.78 days after birth). No NO-s case developed a PH crisis even though PGE1 was not used. Hospital stay was significantly shorter in the NO-s group compared with the PG + NO-s group (P < 0.05; 39.9 +/- 19 vs. 53.2 +/- 23 days). CONCLUSION Nitric oxide alone would appear to simplify the management of CDH with PH and provide better outcome.
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Clugston RD, Klattig J, Englert C, Clagett-Dame M, Martinovic J, Benachi A, Greer JJ. Teratogen-induced, dietary and genetic models of congenital diaphragmatic hernia share a common mechanism of pathogenesis. THE AMERICAN JOURNAL OF PATHOLOGY 2006; 169:1541-9. [PMID: 17071579 PMCID: PMC1780206 DOI: 10.2353/ajpath.2006.060445] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/20/2006] [Indexed: 11/20/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a frequently occurring, major congenital abnormality that has high mortality and significant morbidity in survivors. Currently, the pathogenesis of CDH is poorly understood. In this study, we have compared the anatomical characteristics of diaphragm defects in the well-described nitrofen model with the pathogenesis of CDH in vitamin A-deficient rats and wt1 null-mutant mice, representing teratogen-induced, dietary and genetic models of CDH, respectively. Our histological investigations, aided by three-dimensional reconstruction of the developing diaphragm, revealed a common pathogenic mechanism with regards to the location of the diaphragm defect in the foramen of Bochdalek (posterolateral diaphragm) and specific abnormalities within the primordial diaphragm. Furthermore, our analysis of postmortem specimens highlighted similarities in human cases of CDH and these animal models, supporting our hypothesis that CDH in humans arises from a defect in the primordial diaphragm. Immunohistochemical data were consistent with the defect in the primordial diaphragm being in the nonmuscular component. Importantly, these data show that very distinct models of CDH all share a common pathogenic mechanism and, together with supporting evidence from pathological specimens, highlight our proposed pathogenic model for CDH.
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Affiliation(s)
- Robin D Clugston
- Department of Physiology, University of Alberta, 513 HMRC, Edmonton, AB, Canada, T6G 2S2
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