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Rafat N, Schaible T. Extracorporeal Membrane Oxygenation in Congenital Diaphragmatic Hernia. Front Pediatr 2019; 7:336. [PMID: 31440491 PMCID: PMC6694279 DOI: 10.3389/fped.2019.00336] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/24/2019] [Indexed: 01/04/2023] Open
Abstract
Congenital diaphragmatic hernia (CDH) is characterized by failure of diaphragmatic development with lung hypoplasia and persistent pulmonary hypertension of the newborn (PPHN). If conventional treatment with gentle ventilation and optimized vasoactive medication fails, extracorporeal membrane oxygenation (ECMO) may be considered. The benefits of ECMO in CDH are still controversial, since there are only few randomized trials demonstrating the advantages of this therapeutic option. At present, there is no precise prenatal and/or early postnatal prognostication parameter to predict reversibility of PPHN in CDH patients. Indications for initiating ECMO include either respiratory or circulatory parameters, which are also undergoing continuous refinement. Centers with higher case numbers and the availability of ECMO published promising survival rates, but data on long-term results, including morbidity and quality of life, are rare. Survival might be influenced by the timing of ECMO initiation and the timing of surgical repair. In this regard a trend toward early initiation of ECMO and early surgery on ECMO exists. The results concerning the cannulation modes are similar and a consensus on time limit for ECMO runs does not exist. The use of ECMO in CDH will continue to be evaluated, and prospective randomized trials and registry network are necessary to help answering the addressed questions of patient selection and management.
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Affiliation(s)
- Neysan Rafat
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
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McHoney M, Hammond P. Role of ECMO in congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2018; 103:F178-F181. [PMID: 29138242 DOI: 10.1136/archdischild-2016-311707] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 10/20/2017] [Accepted: 10/28/2017] [Indexed: 01/06/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is typified morphologically by failure of diaphragmatic development with accompanying lung hypoplasia and persistent pulmonary hypertension of the newborn (PPHN). Patients who have labile physiology and low preductal saturations despite optimal ventilatory and inotropic support may be considered for extracorporeal membrane oxygenation (ECMO). Systematic reviews into the benefits of ECMO in CDH concluded that any benefit is unclear. Few randomised trials exist to demonstrate clear benefit and guide management. However, ECMO may have its uses in those that have reversibility of their respiratory disease. A few centres and networks have demonstrated an increase in survival rate by post hoc analysis (based on a difference in referral patterns with the availability of ECMO) in their series. One issue may be that of careful patient selection with regard to reversibility of pathophysiology. At present, there is no single test or prognostication that predicts reversibility of PPHN and criteria for referral for ECMO is undergoing continued refinement. Overall survival is similar between cannulation modes. There is no consensus on the time limit for ECMO runs. The optimal timing of surgery for patients on ECMO is difficult to definitively establish, but it seems that repair at an early stage (with careful perioperative management) is becoming less of a taboo, and may improve outcome and help with either coming off ECMO or decisions on withdrawal later. The provision of ECMO will continue to be evaluated, and prospective randomised trial are needed to help answer question of patient selection and management.
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Affiliation(s)
- Merrill McHoney
- Paediatric Surgery, Royal Hospital for Sick Children Edinburgh, Edinburgh, UK
| | - Philip Hammond
- Paediatric Surgery, Royal Hospital for Sick Children Edinburgh, Edinburgh, UK
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Barreto Ortiz S, Hori D, Nomura Y, Yun X, Jiang H, Yong H, Chen J, Paek S, Pandey D, Sikka G, Bhatta A, Gillard A, Steppan J, Kim JH, Adachi H, Barodka VM, Romer L, An SS, Shimoda LA, Santhanam L, Berkowitz DE. Opsin 3 and 4 mediate light-induced pulmonary vasorelaxation that is potentiated by G protein-coupled receptor kinase 2 inhibition. Am J Physiol Lung Cell Mol Physiol 2017; 314:L93-L106. [PMID: 28882814 DOI: 10.1152/ajplung.00091.2017] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We recently demonstrated that blue light induces vasorelaxation in the systemic mouse circulation, a phenomenon mediated by the nonvisual G protein-coupled receptor melanopsin (Opsin 4; Opn4). Here we tested the hypothesis that nonvisual opsins mediate photorelaxation in the pulmonary circulation. We discovered Opsin 3 (Opn3), Opn4, and G protein-coupled receptor kinase 2 (GRK2) in rat pulmonary arteries (PAs) and in pulmonary arterial smooth muscle cells (PASMCs), where the opsins interact directly with GRK2, as demonstrated with a proximity ligation assay. Light elicited an intensity-dependent relaxation of PAs preconstricted with phenylephrine (PE), with a maximum response between 400 and 460 nm (blue light). Wavelength-specific photorelaxation was attenuated in PAs from Opn4-/- mice and further reduced following shRNA-mediated knockdown of Opn3. Inhibition of GRK2 amplified the response and prevented physiological desensitization to repeated light exposure. Blue light also prevented PE-induced constriction in isolated PAs, decreased basal tone, ablated PE-induced single-cell contraction of PASMCs, and reversed PE-induced depolarization in PASMCs when GRK2 was inhibited. The photorelaxation response was modulated by soluble guanylyl cyclase but not by protein kinase G or nitric oxide. Most importantly, blue light induced significant vasorelaxation of PAs from rats with chronic pulmonary hypertension and effectively lowered pulmonary arterial pressure in isolated intact perfused rat lungs subjected to acute hypoxia. These findings show that functional Opn3 and Opn4 in PAs represent an endogenous "optogenetic system" that mediates photorelaxation in the pulmonary vasculature. Phototherapy in conjunction with GRK2 inhibition could therefore provide an alternative treatment strategy for pulmonary vasoconstrictive disorders.
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Affiliation(s)
- Sebastian Barreto Ortiz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Daijiro Hori
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.,Division of Cardiac Surgery, Johns Hopkins University , Baltimore, Maryland
| | - Yohei Nomura
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.,Division of Cardiac Surgery, Johns Hopkins University , Baltimore, Maryland
| | - Xin Yun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Asthma and Allergy Center, Johns Hopkins University , Baltimore, Maryland
| | - Haiyang Jiang
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Asthma and Allergy Center, Johns Hopkins University , Baltimore, Maryland
| | - Hwanmee Yong
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - James Chen
- Department of Biomedical Engineering, Johns Hopkins University , Baltimore, Maryland
| | - Sam Paek
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Deepesh Pandey
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Gautam Sikka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Anil Bhatta
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Andrew Gillard
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Jae Hyung Kim
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Viachaslau M Barodka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Lewis Romer
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.,Department of Biomedical Engineering, Johns Hopkins University , Baltimore, Maryland.,Departments of Cell Biology, Pediatrics, and the Center for Cell Dynamics, Johns Hopkins University , Baltimore, Maryland
| | - Steven S An
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Larissa A Shimoda
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Asthma and Allergy Center, Johns Hopkins University , Baltimore, Maryland
| | - Lakshmi Santhanam
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.,Department of Biomedical Engineering, Johns Hopkins University , Baltimore, Maryland
| | - Dan E Berkowitz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.,Department of Biomedical Engineering, Johns Hopkins University , Baltimore, Maryland
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Geva A, Gronsbell JL, Cai T, Cai T, Murphy SN, Lyons JC, Heinz MM, Natter MD, Patibandla N, Bickel J, Mullen MP, Mandl KD. A Computable Phenotype Improves Cohort Ascertainment in a Pediatric Pulmonary Hypertension Registry. J Pediatr 2017; 188. [PMID: 28625502 PMCID: PMC5572538 DOI: 10.1016/j.jpeds.2017.05.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To compare registry and electronic health record (EHR) data mining approaches for cohort ascertainment in patients with pediatric pulmonary hypertension (PH) in an effort to overcome some of the limitations of registry enrollment alone in identifying patients with particular disease phenotypes. STUDY DESIGN This study was a single-center retrospective analysis of EHR and registry data at Boston Children's Hospital. The local Informatics for Integrating Biology and the Bedside (i2b2) data warehouse was queried for billing codes, prescriptions, and narrative data related to pediatric PH. Computable phenotype algorithms were developed by fitting penalized logistic regression models to a physician-annotated training set. Algorithms were applied to a candidate patient cohort, and performance was evaluated using a separate set of 136 records and 179 registry patients. We compared clinical and demographic characteristics of patients identified by computable phenotype and the registry. RESULTS The computable phenotype had an area under the receiver operating characteristics curve of 90% (95% CI, 85%-95%), a positive predictive value of 85% (95% CI, 77%-93%), and identified 413 patients (an additional 231%) with pediatric PH who were not enrolled in the registry. Patients identified by the computable phenotype were clinically distinct from registry patients, with a greater prevalence of diagnoses related to perinatal distress and left heart disease. CONCLUSIONS Mining of EHRs using computable phenotypes identified a large cohort of patients not recruited using a classic registry. Fusion of EHR and registry data can improve cohort ascertainment for the study of rare diseases. TRIAL REGISTRATION ClinicalTrials.gov: NCT02249923.
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Affiliation(s)
- Alon Geva
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, MA,Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Boston, MA,Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Jessica L. Gronsbell
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Tianxi Cai
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Tianrun Cai
- Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, MA
| | - Shawn N. Murphy
- Department of Research Information Services and Computing, Partners Healthcare, Boston, MA,Department of Neurology, Massachusetts General Hospital, Boston, MA,Department of Biomedical Informatics, Harvard Medical School, Boston, MA
| | - Jessica C. Lyons
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA
| | - Michelle M. Heinz
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, MA
| | - Marc D. Natter
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Nandan Patibandla
- Information Services Department, Boston Children’s Hospital, Boston, MA
| | - Jonathan Bickel
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, MA,Information Services Department, Boston Children’s Hospital, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Mary P. Mullen
- Department of Cardiology, Boston Children’s Hospital, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kenneth D. Mandl
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, MA,Department of Biomedical Informatics, Harvard Medical School, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
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