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Jackson SS, Lee JJ, Jackson WM, Price JC, Beers SR, Berkenbosch JW, Biagas KV, Dworkin RH, Houck CS, Li G, Smith HAB, Ward DS, Zimmerman KO, Curley MAQ, Horvat CM, Huang DT, Pinto NP, Salorio CF, Slater R, Slomine BS, West LL, Wypij D, Yeates KO, Sun LS. Sedation Research in Critically Ill Pediatric Patients: Proposals for Future Study Design From the Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research IV Workshop. Pediatr Crit Care Med 2024; 25:e193-e204. [PMID: 38059739 DOI: 10.1097/pcc.0000000000003426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES Sedation and analgesia for infants and children requiring mechanical ventilation in the PICU is uniquely challenging due to the wide spectrum of ages, developmental stages, and pathophysiological processes encountered. Studies evaluating the safety and efficacy of sedative and analgesic management in pediatric patients have used heterogeneous methodologies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) IV hosted a series of multidisciplinary meetings to establish consensus statements for future clinical study design and implementation as a guide for investigators studying PICU sedation and analgesia. DESIGN Twenty-five key elements framed as consensus statements were developed in five domains: study design, enrollment, protocol, outcomes and measurement instruments, and future directions. SETTING A virtual meeting was held on March 2-3, 2022, followed by an in-person meeting in Washington, DC, on June 15-16, 2022. Subsequent iterative online meetings were held to achieve consensus. SUBJECTS Fifty-one multidisciplinary, international participants from academia, industry, the U.S. Food and Drug Administration, and family members of PICU patients attended the virtual and in-person meetings. Participants were invited based on their background and experience. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Common themes throughout the SCEPTER IV consensus statements included using coordinated multidisciplinary and interprofessional teams to ensure culturally appropriate study design and diverse patient enrollment, obtaining input from PICU survivors and their families, engaging community members, and using developmentally appropriate and validated instruments for assessments of sedation, pain, iatrogenic withdrawal, and ICU delirium. CONCLUSIONS These SCEPTER IV consensus statements are comprehensive and may assist investigators in the design, enrollment, implementation, and dissemination of studies involving sedation and analgesia of PICU patients requiring mechanical ventilation. Implementation may strengthen the rigor and reproducibility of research studies on PICU sedation and analgesia and facilitate the synthesis of evidence across studies to improve the safety and quality of care for PICU patients.
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Affiliation(s)
- Shawn S Jackson
- Departments of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Jennifer J Lee
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - William M Jackson
- Department of Anesthesiology, Montefiore Medical Center, New York, NY
| | - Jerri C Price
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Sue R Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - John W Berkenbosch
- Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, KY
| | - Katherine V Biagas
- Department of Pediatrics, The Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Robert H Dworkin
- Departments of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY
| | - Constance S Houck
- Departments of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Heidi A B Smith
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Denham S Ward
- Departments of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - Martha A Q Curley
- School of Nursing, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher M Horvat
- Departments of Critical Care Medicine, Pediatrics and Biomedical Informatics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David T Huang
- Departments of Critical Care Medicine, Emergency Medicine, Clinical and Translational Science, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Neethi P Pinto
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cynthia F Salorio
- Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebeccah Slater
- Department of Paediatric Neuroscience, University of Oxford, Oxford, United Kingdom
| | - Beth S Slomine
- Center for Brain Injury Recovery, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Leanne L West
- International Children's Advisory Network, Atlanta, GA
| | - David Wypij
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Keith O Yeates
- Department of Psychology, University of Calgary, Calgary, AB, Canada
| | - Lena S Sun
- Departments of Pediatrics and Anesthesiology, Columbia University Irving Medical Center, New York, NY
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Aalten M, Tataranno ML, Dudink J, Lemmers PMA, Lindeboom MYA, Benders MJNL. Brain injury and long-term outcome after neonatal surgery for non-cardiac congenital anomalies. Pediatr Res 2023; 94:1265-1272. [PMID: 37217607 DOI: 10.1038/s41390-023-02629-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/31/2023] [Accepted: 04/06/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND There is growing evidence that neonatal surgery for non-cardiac congenital anomalies (NCCAs) in the neonatal period adversely affects long-term neurodevelopmental outcome. However, less is known about acquired brain injury after surgery for NCCA and abnormal brain maturation leading to these impairments. METHODS A systematic search was performed in PubMed, Embase, and The Cochrane Library on May 6, 2022 on brain injury and maturation abnormalities seen on magnetic resonance imaging (MRI) and its associations with neurodevelopment in neonates undergoing NCCA surgery the first month postpartum. Rayyan was used for article screening and ROBINS-I for risk of bias assessment. Data on the studies, infants, surgery, MRI, and outcome were extracted. RESULTS Three eligible studies were included, reporting 197 infants. Brain injury was found in n = 120 (50%) patients after NCCA surgery. Sixty (30%) were diagnosed with white matter injury. Cortical folding was delayed in the majority of cases. Brain injury and delayed brain maturation was associated with a decrease in neurodevelopmental outcome at 2 years of age. CONCLUSIONS Surgery for NCCA was associated with high risk of brain injury and delay in maturation leading to delay in neurocognitive and motor development. However, more research is recommended for strong conclusions in this group of patients. IMPACT Brain injury was found in 50% of neonates who underwent NCCA surgery. NCCA surgery is associated with a delay in cortical folding. There is an important research gap regarding perioperative brain injury and NCCA surgery.
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Affiliation(s)
- Mark Aalten
- Department of Neonatology, University Medical Center, Utrecht Brain Center and Wilhelmina Children's Hospital, University Utrecht, Utrecht, Netherlands
| | - Maria Luisa Tataranno
- Department of Neonatology, University Medical Center, Utrecht Brain Center and Wilhelmina Children's Hospital, University Utrecht, Utrecht, Netherlands
| | - Jeroen Dudink
- Department of Neonatology, University Medical Center, Utrecht Brain Center and Wilhelmina Children's Hospital, University Utrecht, Utrecht, Netherlands
| | - Petra M A Lemmers
- Department of Neonatology, University Medical Center, Utrecht Brain Center and Wilhelmina Children's Hospital, University Utrecht, Utrecht, Netherlands
| | - Maud Y A Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Manon J N L Benders
- Department of Neonatology, University Medical Center, Utrecht Brain Center and Wilhelmina Children's Hospital, University Utrecht, Utrecht, Netherlands.
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3
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Kagan MS, Wang JT, Pier DB, Zurakowski D, Jennings RW, Bajic D. Infant Perioperative Risk Factors and Adverse Brain Findings Following Long-Gap Esophageal Atresia Repair. J Clin Med 2023; 12:jcm12051807. [PMID: 36902591 PMCID: PMC10003188 DOI: 10.3390/jcm12051807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/06/2023] [Accepted: 02/14/2023] [Indexed: 02/26/2023] Open
Abstract
Recent findings implicate brain vulnerability following long-gap esophageal atresia (LGEA) repair. We explored the relationship between easily quantifiable clinical measures and previously reported brain findings in a pilot cohort of infants following LGEA repair. MRI measures (number of qualitative brain findings; normalized brain and corpus callosum volumes) were previously reported in term-born and early-to-late premature infants (n = 13/group) <1 year following LGEA repair with the Foker process. The severity of underlying disease was classified by an (1) American Society of Anesthesiologist (ASA) physical status and (2) Pediatric Risk Assessment (PRAm) scores. Additional clinical end-point measures included: anesthesia exposure (number of events; cumulative minimal alveolar concentration (MAC) exposure in hours), length (in days) of postoperative intubated sedation, paralysis, antibiotic, steroid, and total parenteral nutrition (TPN) treatment. Associations between clinical end-point measures and brain MRI data were tested using Spearman rho and multivariable linear regression. Premature infants were more critically ill per ASA scores, which showed a positive association with the number of cranial MRI findings. Clinical end-point measures together significantly predicted the number of cranial MRI findings for both term-born and premature infant groups, but none of the individual clinical measures did on their own. Listed easily quantifiable clinical end-point measures could be used together as indirect markers in assessing the risk of brain abnormalities following LGEA repair.
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Affiliation(s)
- Mackenzie Shea Kagan
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Bader 3, Boston, MA 02115, USA
| | - Jue Teresa Wang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Bader 3, Boston, MA 02115, USA
- Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Danielle Bennett Pier
- Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Department of Neurology, Division of Pediatric Neurology, Massachusetts General Hospital, 55 Fruit Street, Wang 708, Boston, MA 021114, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Bader 3, Boston, MA 02115, USA
- Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Russell William Jennings
- Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Department of Surgery, Esophageal and Airway Treatment Center, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Dusica Bajic
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Bader 3, Boston, MA 02115, USA
- Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-(617)-355-7737; Fax: +1-(618)-730-0894
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Keunen K, Sperna Weiland NH, de Bakker BS, de Vries LS, Stevens MF. Impact of surgery and anesthesia during early brain development: A perfect storm. Paediatr Anaesth 2022; 32:697-705. [PMID: 35266610 PMCID: PMC9311405 DOI: 10.1111/pan.14433] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/06/2022] [Accepted: 02/20/2022] [Indexed: 11/27/2022]
Abstract
Neonatal surgery and concomitant anesthesia coincide with a timeframe of rapid brain development. The speed and complexity of early brain development superimposed on immature regulatory mechanisms that include incomplete cerebral autoregulation, insufficient free radical scavenging and an immature immune response puts the brain at risk. Brain injury may have long-term consequences for multiple functional domains including cognition, learning skills, and behavior. Neurodevelopmental follow-up studies have noted mild-to-moderate deficits in children who underwent major neonatal surgery and related anesthesia. The present review evaluates neonatal surgery against the background of neurobiological processes that unfold at a pace unparalleled by any other period of human brain development. First, a structured summary of early brain development is provided in order to establish theoretical groundwork. Next, literature on brain injury and neurodevelopmental outcome after neonatal surgery is discussed. Special attention is given to recent findings of structural brain damage reported after neonatal surgery. Notably, high-quality imaging data acquired before surgery are currently lacking. Third, mechanisms of injury are interrogated taking the perspective of early brain development into account. We propose a novel disease model that constitutes a triad of inflammation, vascular immaturity, and neurotoxicity of prolonged exposure to anesthetic drugs. With each of these components exacerbating the other, this amalgam incites the perfect storm, resulting in brain injury. When examining the brain, it seems intuitive to distinguish between neonates (i.e., <60 postconceptional weeks) and more mature infants, multiple and/or prolonged anesthesia exposure and single, short surgery. This review culminates in an outline of anesthetic considerations and future directions that we believe will help move the field forward.
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Affiliation(s)
- Kristin Keunen
- Department of Anaesthesiology, Amsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
| | - Nicolaas H. Sperna Weiland
- Department of Anaesthesiology, Amsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
| | - Bernadette S. de Bakker
- Department of Medical Biology Section Clinical Anatomy & Embryology, Amsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
| | - Linda S. de Vries
- Department of NeonatologyUniversity Medical CenterUtrechtThe Netherlands
| | - Markus F. Stevens
- Department of Anaesthesiology, Amsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
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Kagan MS, Mongerson CRL, Zurakowski D, Bajic D. Impact of Infant Thoracic Non-cardiac Perioperative Critical Care on Homotopic-Like Corpus Callosum and Forebrain Sub-regional Volumes. FRONTIERS IN PAIN RESEARCH 2022; 3:788903. [PMID: 35465294 PMCID: PMC9021551 DOI: 10.3389/fpain.2022.788903] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 02/09/2022] [Indexed: 12/02/2022] Open
Abstract
Previously, we reported quantitatively smaller total corpus callosum (CC) and total forebrain size in critically ill term-born and premature patients following complex perioperative critical care for long-gap esophageal atresia (LGEA) that included Foker process repair. We extended our cross-sectional pilot study to determine sub-regional volumes of CC and forebrain using structural brain MRI. Our objective was to evaluate region-specific CC as an in-vivo marker for decreased myelination and/or cortical neural loss of homotopic-like sub-regions of the forebrain. Term-born (n = 13) and premature (n = 13) patients, and healthy naïve controls (n = 21) <1-year corrected age underwent non-sedated MRI using a 3T Siemens scanner, as per IRB approval at Boston Children's Hospital following completion of clinical treatment for Foker process. We used ITK-SNAP (v.3.6) to manually segment six sub-regions of CC and eight sub-regions of forebrain as per previously reported methodology. Group differences were assessed using a general linear model univariate analysis with corrected age at scan as a covariate. Our analysis implicates globally smaller CC and forebrain with sub-region II (viz. rostral body of CC known to connect to pre-motor cortex) to be least affected in comparison to other CC sub-regions in LGEA patients. Our report of smaller subgenual forebrain implicates (mal)adaptation in limbic circuits development in selected group of infant patients following LGEA repair. Future studies should include diffusion tractography studies of CC in further evaluation of what appears to represent global decrease in homotopic-like CC/forebrain size following complex perioperative critical care of infants born with LGEA.
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Affiliation(s)
- Mackenzie Shea Kagan
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Chandler R. L. Mongerson
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Dusica Bajic
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- *Correspondence: Dusica Bajic
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6
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Evanovich DM, Wang JT, Zendejas B, Jennings RW, Bajic D. From the Ground Up: Esophageal Atresia Types, Disease Severity Stratification and Survival Rates at a Single Institution. Front Surg 2022; 9:799052. [PMID: 35356503 PMCID: PMC8959439 DOI: 10.3389/fsurg.2022.799052] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Esophageal atresia (EA), although a rare congenital anomaly, represents one of the most common gastrointestinal birth defects. There is a gap in our knowledge regarding the impact of perioperative critical care in infants born with EA. This study addresses EA types, disease severity stratification, and mortality in a retrospective cohort at a single institution. Institutional Review Board approved our retrospective cross-sectional study of term-born (n = 53) and premature infants (28–37 weeks of gestation; n = 31) that underwent primary surgical repair of EA at a single institution from 2009–2020. Demographic and clinical data were obtained from the electronic medical record, Powerchart (Cerner, London, UK). Patients were categorized by (i) sex, (ii) gestational age at birth, (iii) types of EA (in relation to respiratory tract anomalies), (iv) co-occurring congenital anomalies, (v) severity of disease (viz. American Society of Anesthesiologists (ASA) and Pediatric Risk Assessment (PRAm) scores), (vi) type of surgical repair for EA (primary anastomosis vs. Foker process), and (vii) survival rate classification using Spitz and Waterston scores. Data were presented as numerical sums and percentages. The frequency of anatomical types of EA in our cohort parallels that of the literature: 9.5% (8/84) type A, 9.5% (8/84) type B, 80% (67/84) type C, and 1% (1/84) type D. Long-gap EA accounts for 88% (7/8) type A, 75% (6/8) type B, and 13% (9/67) type C in the cohort studied. Our novel results show a nearly equal distribution of sex per each EA type, and gestational age (term-born vs. premature) by anatomical EA type. PRAm scoring showed a wider range of disease severity (3–9) than ASA scores (III and IV). The survival rate in our EA cohort dramatically increased in comparison to the literature in previous decades. This retrospective analysis at a single institution shows incidence of EA per sex and gestational status for anatomical types (EA type A-D) and by surgical approach (primary anastomosis vs. Foker process for short-gap vs. long-gap EA, respectively). Despite its wider range, PRAm score was not more useful in predicting disease severity in comparison to ASA score. Increased survival rates over the last decade suggest a potential need to assess unique operative and perioperative risks in this unique population of patients. Presented findings also represent a foundation for future clinical studies of outcomes in infants born with EA.
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Affiliation(s)
- Devon Michael Evanovich
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
- Tufts School of Medicine, Tufts University, Boston, MA, United States
| | - Jue Teresa Wang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Harvard University, Boston, MA, United States
| | - Benjamin Zendejas
- Harvard Medical School, Harvard University, Boston, MA, United States
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States
- Esophageal and Airway Treatment Center, Boston Children's Hospital, Boston, MA, United States
| | - Russell William Jennings
- Harvard Medical School, Harvard University, Boston, MA, United States
- Department of Surgery, Boston Children's Hospital, Boston, MA, United States
- Esophageal and Airway Treatment Center, Boston Children's Hospital, Boston, MA, United States
| | - Dusica Bajic
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Harvard University, Boston, MA, United States
- *Correspondence: Dusica Bajic
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Walker SM. Developmental Mechanisms of CPSP: Clinical Observations and Translational Laboratory Evaluations. Can J Pain 2021; 6:49-60. [PMID: 35910395 PMCID: PMC9331197 DOI: 10.1080/24740527.2021.1999796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Understanding mechanisms that underly the transition from acute to chronic pain and identifying potential targets for preventing or minimizing this progression have specific relevance for chronic postsurgical pain (CPSP). Though it is clear that multiple psychosocial, family, and environmental factors may influence CPSP, this review will focus on parallels between clinical observations and translational laboratory studies investigating the acute and long-term effects of surgical injury on nociceptive pathways. This includes data related to alterations in sensitivity at different points along nociceptive pathways from the periphery to the brain; age- and sex-dependent mechanisms underlying the transition from acute to persistent pain; potential targets for preventive interventions; and the impact of prior surgical injury. Ongoing preclinical studies evaluating age- and sex-dependent mechanisms will also inform comparative efficacy and preclinical safety assessments of potential preventive pharmacological interventions aimed at reducing the risk of CPSP. In future clinical studies, more detailed and longitudinal peri-operative phenotyping with patient- and parent-reported chronic pain core outcomes, alongside more specialized evaluations of somatosensory function, modulation, and circuitry, may enhance understanding of individual variability in postsurgical pain trajectories and improve recognition and management of CPSP.
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Affiliation(s)
- Suellen M. Walker
- Clinical Neurosciences (Pain Research), Developmental Neurosciences, UCL GOS Institute of Child Health, London, UK; Department of Paediatric Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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8
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Kagan MS, Mongerson CRL, Zurakowski D, Jennings RW, Bajic D. Infant study of hemispheric asymmetry after long-gap esophageal atresia repair. Ann Clin Transl Neurol 2021; 8:2132-2145. [PMID: 34662511 PMCID: PMC8607454 DOI: 10.1002/acn3.51465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/14/2021] [Accepted: 09/29/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Previous studies have demonstrated that infants are typically born with a left-greater-than-right forebrain asymmetry that reverses throughout the first year of life. We hypothesized that critically ill term-born and premature patients following surgical and critical care for long-gap esophageal atresia (LGEA) would exhibit alteration in expected forebrain asymmetry. METHODS Term-born (n = 13) and premature (n = 13) patients, and term-born controls (n = 23) <1 year corrected age underwent non-sedated research MRI following completion of LGEA treatment via Foker process. Structural T1- and T2-weighted images were collected, and ITK-SNAP was used for forebrain tissue segmentation and volume acquisition. Data were presented as absolute (cm3 ) and normalized (% total forebrain) volumes of the hemispheres. All measures were checked for normality, and group status was assessed using a general linear model with age at scan as a covariate. RESULTS Absolute volumes of both forebrain hemispheres were smaller in term-born and premature patients in comparison to controls (p < 0.001). Normalized hemispheric volume group differences were detected by T1-weighted analysis, with premature patients demonstrating right-greater-than-left hemisphere volumes in comparison to term-born patients and controls (p < 0.01). While normalized group differences were very subtle (a right hemispheric predominance of roughly 2% of forebrain volume), they represent a deviation from the expected pattern of hemispheric brain asymmetry. INTERPRETATION Our pilot quantitative MRI study of hemispheric volumes suggests that premature patients might be at risk of altered expected left-greater-than-right forebrain asymmetry following repair of LGEA. Future neurobehavioral studies in infants born with LGEA are needed to elucidate the functional significance of presented anatomical findings.
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Affiliation(s)
- Mackenzie S Kagan
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave., Boston, Massachusetts, 02115, USA
| | - Chandler R L Mongerson
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave., Boston, Massachusetts, 02115, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave., Boston, Massachusetts, 02115, USA.,Harvard Medical School, Harvard University, 25 Shattuck St., Boston, Massachusetts, 02115, USA
| | - Russell W Jennings
- Harvard Medical School, Harvard University, 25 Shattuck St., Boston, Massachusetts, 02115, USA.,Department of Surgery, Boston Children's Hospital, 300 Longwood Ave., Boston, Massachusetts, 02115, USA.,Esophageal and Airway Treatment Center, Boston Children's Hospital, 300 Longwood Ave., Boston, Massachusetts, 02115, USA
| | - Dusica Bajic
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave., Boston, Massachusetts, 02115, USA.,Harvard Medical School, Harvard University, 25 Shattuck St., Boston, Massachusetts, 02115, USA
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9
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Bajic D, Rudisill SS, Jennings RW. Head circumference in infants undergoing Foker process for long-gap esophageal atresia repair: Call for attention. J Pediatr Surg 2021; 56:1564-1569. [PMID: 33722370 PMCID: PMC8362829 DOI: 10.1016/j.jpedsurg.2021.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION We extended our pilot study in infants following long-gap esophageal atresia (LGEA) repair to report head circumference, an easily obtainable indirect measure of brain size. Data are presented in the context of previously reported body weight and T2-weighted MRI measures of intracranial and brain volumes. METHODS Clinical information and head circumference were obtained for term-born (n = 13) and premature (n = 13) infants following LGEA repair with Foker process, as well as healthy term-born controls (n = 20) <1-year corrected age who underwent non-sedated research MRI. General Linear Model univariate analysis with corrected age at scan as a covariate and Bonferroni adjusted p values assessed group differences. RESULTS We report no difference in head circumference between the three groups. Such findings paralleled trends in body weight and total intracranial volume but not in brain volume as previously reported for the same pilot cohort. DISCUSSION Results suggest uncompromised somatic and head growth after repair of LGEA. In contrast, a novel finding of discrepancy between head circumference (novel data) and brain size (previously published data) in the same cohort suggests that head circumference might not be the best indirect measure of brain size in selected group of patients.
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Affiliation(s)
- Dusica Bajic
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Bader 3, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Samuel S. Rudisill
- Department of Anesthesiology, Critical Care, and Pain
Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Bader 3, Boston,
MA 02115, USA,Rush Medical College at Rush University, 600 S. Paulina
Street, Chicago, IL 60612, USA
| | - Russell W. Jennings
- Harvard Medical School, 25 Shattuck Street, Boston, MA
02115, USA,Department of Surgery, Esophageal and Airway Treatment
Center, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA, 02115,
USA
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Alata M, González-Vega A, Piazza V, Kleinert-Altamirano A, Cortes C, Ahumada-Juárez JC, Eguibar JR, López-Juárez A, Hernandez VH. Longitudinal Evaluation of Cerebellar Signs of H-ABC Tubulinopathy in a Patient and in the taiep Model. Front Neurol 2021; 12:702039. [PMID: 34335454 PMCID: PMC8317997 DOI: 10.3389/fneur.2021.702039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/08/2021] [Indexed: 01/20/2023] Open
Abstract
Hypomyelination with atrophy of the basal ganglia and cerebellum (H-ABC) is a central neurodegenerative disease due to mutations in the tubulin beta-4A (TUBB4A) gene, characterized by motor development delay, abnormal movements, ataxia, spasticity, dysarthria, and cognitive deficits. Diagnosis is made by integrating clinical data and radiological signs. Differences in MRIs have been reported in patients that carry the same mutation; however, a quantitative study has not been performed so far. Our study aimed to provide a longitudinal analysis of the changes in the cerebellum (Cb), corpus callosum (CC), ventricular system, and striatum in a patient suffering from H-ABC and in the taiep rat. We correlated the MRI signs of the patient with the results of immunofluorescence, gait analysis, segmentation of cerebellum, CC, and ventricular system, performed in the taiep rat. We found that cerebellar and callosal changes, suggesting a potential hypomyelination, worsened with age, in concomitance with the emergence of ataxic gait. We also observed a progressive lateral ventriculomegaly in both patient and taiep, possibly secondary to the atrophy of the white matter. These white matter changes are progressive and can be involved in the clinical deterioration. Hypomyelination with atrophy of the basal ganglia and cerebellum (H-ABC) gives rise to a spectrum of clinical signs whose pathophysiology still needs to be understood.
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Affiliation(s)
| | - Arturo González-Vega
- Department of Chemical, Electronic and Biomedical Engineering, Division of Sciences and Engineering, University of Guanajuato, Guanajuato, Mexico
| | | | | | - Carmen Cortes
- Behavioral Neurophysiology Lab, Institute of Physiology, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Juan C Ahumada-Juárez
- Behavioral Neurophysiology Lab, Institute of Physiology, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Jose R Eguibar
- Behavioral Neurophysiology Lab, Institute of Physiology, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico.,Research Office, Vicerrectory of Research and Postgraduate Studies, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Alejandra López-Juárez
- Department of Chemical, Electronic and Biomedical Engineering, Division of Sciences and Engineering, University of Guanajuato, Guanajuato, Mexico
| | - Victor H Hernandez
- Department of Chemical, Electronic and Biomedical Engineering, Division of Sciences and Engineering, University of Guanajuato, Guanajuato, Mexico
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Bisson B, Gottrand L, Aumar M, Nicolas A, Sfeir R, Labreuche J, Thevenon A, Gottrand F. Prevalence of and Risk Factors for Sagittal Posture Abnormalities in Children Born With Esophageal Atresia: A Prospective Cohort Study. Front Pediatr 2021; 9:762078. [PMID: 34900868 PMCID: PMC8656431 DOI: 10.3389/fped.2021.762078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction: Scoliosis is a well-described complication of esophageal atresia (EA) caused by the associated spine malformations and/or thoracotomy. However, the sagittal posture abnormalities in patients with EA have not been described. The aim of this study was to evaluate the prevalence of and risk factors for sagittal posture abnormalities at the age of 6 years in patients operated on for EA. Methods: A prospective cohort of 123 patients with EA was examined by the same rehabilitation doctor at the time of a multidisciplinary visit scheduled at the age of 6 years. Children presenting with scoliosis (n = 4) or who missed the consultation (n = 33) were excluded. Univariate and multivariate logistic regression models with Firth's penalized-likelihood approach were used to identify risk factors associated with sagittal posture anomalies. Candidate risk factors included neonatal characteristics, associated malformations, atresia type, postoperative complications, psychomotor development retardation, orthopedic abnormalities, and neurological hypotonia. Results: The prevalence rates of sagittal posture abnormalities were 25.6% (n = 22; 95% CI, 16.7-36.1%). Multivariate analysis showed that minor orthopedic abnormalities (OR: 4.02, 95% CI: 1.29-13.43, P = 0.021), and VACTERL (OR: 3.35, 95% CI: 1.09-10.71, P = 0.042) were significant risk factors for sagittal posture abnormalities. Conclusion: This study shows that sagittal posture anomalies occur frequently in children operated on at birth for EA and are not directly linked to the surgical repair. These children should be screened and treated using postural physiotherapy, especially those with VACTERL and minor orthopedic abnormalities.
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Affiliation(s)
| | - Laurence Gottrand
- IEM Dabbadie, APF France Handicap, Villeneuve d'Ascq, France.,Univ. Lille, CHU Lille, Reference Centre for Chronic and Malformative Esophageal Diseases (CRACMO), Inserm U1286, Lille, France
| | - Madeleine Aumar
- Univ. Lille, CHU Lille, Reference Centre for Chronic and Malformative Esophageal Diseases (CRACMO), Inserm U1286, Lille, France
| | - Audrey Nicolas
- Univ. Lille, CHU Lille, Reference Centre for Chronic and Malformative Esophageal Diseases (CRACMO), Inserm U1286, Lille, France
| | - Rony Sfeir
- Univ. Lille, CHU Lille, Reference Centre for Chronic and Malformative Esophageal Diseases (CRACMO), Inserm U1286, Lille, France
| | - Julien Labreuche
- Univ. Lille, CHU Lille, ULR 2694-METRICS, Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | | | - Frederic Gottrand
- Univ. Lille, CHU Lille, Reference Centre for Chronic and Malformative Esophageal Diseases (CRACMO), Inserm U1286, Lille, France
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