Arterial hypertension in infants with congenital diaphragmatic hernia following surgical repair

Pulmonary hypertension (PH) and cardiac dysfunction are established comorbidities of congenital diaphragmatic hernia (CDH). However, there is very little data focusing on arterial hypertension in CDH. This study aims to investigate the incidence of arterial hypertension in neonates with CDH at hospital discharge. Archived clinical data of 167 CDH infants who received surgical repair of the diaphragmatic defect and survived for > 60 days were retrospectively analyzed. Blood pressure (BP) values were averaged for the last 7 days before discharge and compared to standard BP values for sex, age, and height provided by the AHA in 2004. BP values reaching or extending the 95th percentile were defined as arterial hypertension. The use of antihypertensive medication was analyzed at discharge and during hospitalization. Arterial hypertension at discharge was observed in 19 of 167 infants (11.3%) of which 12 (63%) were not receiving antihypertensive medication. Eighty patients (47.9%) received antihypertensive medication at any point during hospitalization and 28.9% of 152 survivors (n = 44) received antihypertensive medication at discharge, although in 45.5% (n = 20) of patients receiving antihypertensive medication, the indication for antihypertensive medication was myocardial hypertrophy or frequency control. BP was significantly higher in ECMO compared to non-ECMO patients, despite a similar incidence of arterial hypertension in both groups (13.8% vs. 10.1%, p = 0.473). Non-isolated CDH, formula feeding, and minimal creatinine in the first week of life were significantly associated with arterial hypertension on univariate analysis. Following multivariate analysis, only minimal creatinine remained independently associated with arterial hypertension.   Conclusion: This study demonstrates a moderately high incidence of arterial hypertension in CDH infants at discharge and an independent association of creatinine values with arterial hypertension. Physicians should be aware of this risk and include regular BP measurements and test of renal function in CDH care and follow-up. What is Known: • Due to decreasing mortality, morbidity is increasing in surviving CDH patients. • Pulmonary hypertension and cardiac dysfunction are well-known cardiovascular comorbidities of CDH. What is New: • There is a moderately high incidence of arterial hypertension in CDH infants at discharge even in a population with frequent treatment with antihypertensive medication. • A more complicated hospital course (ECMO, higher degree of PH, larger defect size) was associated with a higher risk for arterial hypertension.

Spontaneous breathing in selected neonates with very mild congenital diaphragmatic hernia

AIMS

Current treatment guidelines recommend immediate postnatal intubation in all neonates with congenital diaphragmatic hernia (CDH). This study aimed to investigate the feasibility and outcomes of a spontaneous breathing approach (SBA) versus immediate intubation in neonates with prenatally diagnosed very mild CDH.

METHODS

A retrospective study was conducted comparing neonates with very mild CDH (left-sided, liver-down, observed-to-expected lung-to-head ratio ≥45%) undergoing SBA and matched controls receiving standard treatment. Data on early echocardiographic findings, respiratory support, length of hospital stay, and clinical outcomes were analyzed.

RESULTS

Of 151 CDH neonates, eight underwent SBA, while 31 received standard treatment. SBA was successful in six of eight patients. SBA patients had shorter length of stay (14 vs. 30 days, p = .005), mechanical ventilation (3.5 vs. 8.7 days, p = .011), and oxygen supplementation (3.2 vs. 9.3 days, p = .013) compared to matched controls. Echocardiographic evidence of pulmonary hypertension and cardiac dysfunction were significantly lower in SBA neonates after admission but similar before surgical repair. The SBA group tolerated enteral feeding earlier (day of life 7 vs. 16, p = .019).

CONCLUSIONS

SBA appears feasible and beneficial for prenatally diagnosed very mild CDH. It was associated with a shortened hospital stay supportive therapies. However, larger trials are needed to confirm these findings and determine optimal respiratory support.

Hemolysis during Venovenous Extracorporeal Membrane Oxygenation in Neonates with Congenital Diaphragmatic Hernia: A Prospective Observational Study

OBJECTIVE

To investigate the incidence of hemolysis and its association with outcome in neonates with congenital diaphragmatic hernia (CDH) requiring venovenous extracorporeal membrane oxygenation (ECMO) treatment using a Medos Deltastream circuit with a DP3 pump, a hilite 800 LT oxygenator system, and a ¼' tubing.

STUDY DESIGN

Plasma free hemoglobin (PFH) was prospectively measured once daily during ECMO using spectrophotometric testing. Patients (n = 62) were allocated into two groups according to presence or absence of hemolysis. Hemolysis was defined as PFH ≥ 50 mg/dL on at least 2 consecutive days during ECMO treatment. Hemolysis was classified as either moderate with a maximum PFH of 50-100 mg/dL or severe with a maximum PFH >100 mg/dL.

RESULTS

Hemolysis was detected in 14 patients (22.6%). Mortality was 100% in neonates with hemolysis compared with 31.1% in neonates without hemolysis (P < .001). In 21.4% hemolysis was moderate and in 78.6% severe. Using multivariable analysis, hemolysis (hazard ratio: 6.8; 95%CI: 1.86-24.86) and suprasystemic pulmonary hypertension (PH) (hazard ratio: 3.07; 95%CI: 1.01-9.32) were independently associated with mortality. Hemolysis occurred significantly more often using 8 French (Fr) cannulae than 13 Fr cannulae (43% vs 17%; P = .039). Cutoff for relative ECMO flow to predict hemolysis were 115 ml/kg/ minute for patients with 8 Fr cannulae (Area under the curve [AUC] 0.786, P = .042) and 100 ml/kg/ minute for patients with 13 Fr cannulae (AUC 0.840, P < .001).

CONCLUSIONS

Hemolysis in CDH neonates receiving venovenous ECMO is independently associated with mortality.

Percutaneous, ultrasound-guided single- and multisite cannulation for veno-venous extracorporeal membrane oxygenation in neonates

AIMS

Extracorporeal membrane oxygenation (ECMO) is a widely used technique to support neonates with severe respiratory failure. Data on percutaneous, ultrasound-guided veno-venous (VV) ECMO cannulation in neonates is still scarce. Aim of this study was to describe our institutional experience with ultrasound-guided percutaneous, VV ECMO cannulation in neonates with severe respiratory failure.

METHODS

Neonates receiving ECMO support at our department between January 2017 and January 2021 were retrospectively identified. Patients receiving VV ECMO cannulation performed by the percutaneous Seldinger technique by single- or multisite cannulation were analyzed.

RESULTS

A total of 54 neonates received ECMO cannulation performed by the percutaneous Seldinger technique. In 39 patients (72%) a 13 French bicaval dual-lumen cannula was inserted and in 15 patients (28%) two single-lumen cannulae were used. Cannulae positioning using the multisite approach was in all cases as desired. The tip of the 13 French cannula was located in the IVC in 35/39 patients, in four patients position was too proximal but did not dislocate during the ECMO run. One (2%) preterm neonate (weight 1.75 kg) developed a cardiac tamponade which was successfully managed with drainage. Median duration of ECMO was 7 days (interquartile range: 5-16 days). Forty-four patients (82%) were successfully weaned from ECMO and in 31/44 (71%) the ECMO cannulae were removed with a delay of 0.9-7.2 days (median 2.8 days) after weaning without noticing complications.

CONCLUSIONS

A correct cannula placement using the ultrasound-guided percutaneous Seldinger technique, for both single- and multisite cannulation, seems feasible in most neonatal patients receiving VV ECMO.

Dynamics of pulmonary hypertension severity in the first 48 h in neonates with prenatally diagnosed congenital diaphragmatic hernia

Introduction

Pulmonary hypertension (PH) is one of the major contributing factors to the high morbidity and mortality in neonates with congenital diaphragmatic hernia (CDH). The severity and duration of postnatal PH are an established risk factor for patient outcome; however, the early postnatal dynamics of PH have not been investigated. This study aims to describe the early course of PH in CDH infants, and its relation to established prognostic markers and outcome measures.

Methods

We performed a monocentric retrospective review of neonates with prenatally diagnosed CDH, who received three standardized echocardiographic examinations at 2-6 h, 24, and 48 h of life. The degree of PH was graded as one of three categories: mild/no, moderate, or severe PH. The characteristics of the three groups and their course of PH over 48 h were compared using univariate and correlational analyses.

Results

Of 165 eligible CDH cases, initial PH classification was mild/no in 28%, moderate in 35%, and severe PH in 37%. The course of PH varied markedly based on the initial staging. No patient with initial no/mild PH developed severe PH, required extracorporeal membrane oxygenation (ECMO)-therapy, or died. Of cases with initial severe PH, 63% had persistent PH at 48 h, 69% required ECMO, and 54% died. Risk factors for any PH included younger gestational age, intrathoracic liver herniation, prenatal fetoscopic endoluminal tracheal occlusion (FETO)-intervention, lower lung to head ratio (LHR), and total fetal lung volume (TFLV). Patients with moderate and severe PH showed similar characteristics, except liver position at 24- (p = 0.042) and 48 h (p = 0.001), mortality (p = 0.001), and ECMO-rate (p = 0.035).

Discussion

To our knowledge, this is the first study to systematically assess the dynamics of PH in the first postnatal 48 h at three defined time points. CDH infants with initial moderate and severe PH have a high variation in postnatal PH severity over the first 48 h of life. Patients with mild/no PH have less change in PH severity, and an excellent prognosis. Patients with severe PH at any point have a significantly higher risk for ECMO and mortality. Assessing PH within 2-6 h should be a primary goal in the care for CDH neonates.

Ductus arteriosus flow predicts outcome in neonates with congenital diaphragmatic hernia

OBJECTIVE

To investigate whether the pattern of flow through the ductus arteriosus (DA) is associated with the need for extracorporeal membrane oxygenation support (ECMO) or death in neonates with congenital diaphragmatic hernia (CDH).

DESIGN

Retrospective observational study.

SETTING

German level III Neonatal Intensive Care Unit.

PARTICIPANTS

One hundred and nine CDH neonates were born between March 2009 and May 2021.

METHODS

DA flow pattern was assessed in echocardiograms obtained within 24 h of life by measuring flow time and velocity time integral (VTI) for both left-to-right (LR) and right-to-left (RL) components of the ductal shunt. A VTI ratio (VTILR/VTIRL) < 1.0 and an RL relative flow time (flow timeRL/(Flow timeLR+Flow timeRL)) >33% were defined as markers of abnormal flow patterns. The primary outcome was the need for ECMO. The secondary outcome was death.

RESULTS

Seventy-two patients (51.8%) had a VTI ratio <1.0, 73 (52.5%) an RL relative flow time >33%. Fifty-nine patients (42.4%) had an alteration of both values. Need for ECMO was present in 37.4% (n = 52), while 19.4% (n = 27) died. A VTI ratio <1.0 had the highest diagnostic accuracy for the need for ECMO, (sensitivity 82.7%, specificity 66.7%, negative predictive value [NPV] 86.6%, and positive predictive value [PPV] 59.7%) as well as for death (sensitivity 77.8%, specificity 54.5%, NPV 91.0%, and PPV 29.2%). Patients with VTI ratio <1.0 were 4.7 times more likely to need ECMO and 3.3 times more likely to die. VTI ratio values correlated significantly with pulmonary hypertension (PH) severity (r = -0.516, p < 0.001).

CONCLUSIONS

A VTI ratio <1.0 is a valuable threshold to identify high-risk CDH neonates. For improved risk stratification, other parameters-for example, left ventricular cardiac dysfunction-should be combined with DA flow assessment.

Increased N-terminal Pro-B-Type Natriuretic Peptide during Extracorporeal Life Support Is Associated with Poor Outcome in Neonates with Congenital Diaphragmatic Hernia

OBJECTIVES

To evaluate the prognostic information derived from the daily measurements of N-terminal pro-B-type natriuretic peptide (proBNP) in neonates with congenital diaphragmatic hernia undergoing extracorporeal life support (ECLS).

STUDY DESIGN

Plasma proBNP was prospectively measured daily during the first week of ECLS using an electrochemiluminescence immunoassay. Patients (n = 63) were allocated according to outcome: survivors (group 1, n = 35); nonsurvivors with successful weaning (defined as survival for >12 hours after ECLS discontinuation) (group 2, n = 16); nonsurvivors with unsuccessful weaning (group 3, n = 12). ProBNP kinetics were compared using Kruskal-Wallis testing and correlated with pulmonary hypertension and cardiac dysfunction on echocardiography using the Spearman correlation coefficient.

RESULTS

Infants in group 3 presented significantly higher proBNP values from day 3 to day 6 compared with group 1 and 2. Overall mortality among patients with the highest proBNP values on day 1 was 30.6% compared with 63% in those patients with at least 1 higher value on day 2 to day 7. In patients with a late increase (day 4 to day 7) in proBNP the mortality was 70%, compared with 32.6% in those with proBNP below the value on day 1. Weaning failure was 35% in patients with a late increase and 11.6% in those without a late increase. ProBNP correlated significantly with pulmonary hypertension and cardiac dysfunction before and during ECLS.

CONCLUSIONS

Absolute proBNP values are associated with weaning failure but not overall mortality in neonates with congenital diaphragmatic hernia undergoing ECLS. Echocardiographic findings correlate well with proBNP values.

The effect of a consortium of Penicillium sp. and Bacillus spp. in suppressing banana fungal diseases caused by Fusarium sp. and Alternaria sp

AIMS

This study sought to utilize indigenous soil micro-organisms to suppress wilt-causing fungal pathogens of the banana.

METHODS AND RESULTS

Fungal pathogens were isolated from wilt-affected rhizospheric soil, and potential antagonistic bacterial strains were isolated from healthy rhizospheric soil in the same area from which fungal pathogens were isolated. The antifungal activity of isolated micro-organisms against fungal pathogens was studied both in vitro and in vivo against fungal pathogens. It was found that Fusarium oxysporum and Alternaria sp. were pathogenic, while Penicillium sp., Bacillus velezensis and Bacillus subtilis were antagonistic. Moreover, it was seen that B. velezensis, B. subtilis and Penicillium sp. inhibited the growth of the two fungal pathogens in both in vitro and in vivo experiments. Further investigation indicated that B. velezensis, B. subtilis and Penicillium sp. were able to produce enzymatic antifungal compounds (chitinase and β-1,3-glucanase). The spray application around rhizome revealed that a combination of Bacillus spp. and Penicillium sp. in greenhouse conditions gave the highest reduction in disease severity by up to 60% to both fungal pathogens among the treatments.

CONCLUSIONS

Banana disease is seen to be induced not only by F. oxysporum but also by Alternaria sp. The isolated indigenous micro-organisms can effectively control both the pathogens. The combination of isolated antagonistic micro-organisms has thus demonstrated substantial potential for suppressing banana disease.

SIGNIFICANCE AND IMPACT OF THE STUDY

An antagonistic consortium isolated in this study has demonstrated remarkable potential for controlling fungal diseases caused by Fusarium sp. and Alternaria sp. Therefore, the use of indigenous microflora to improve disease suppression of banana plants against soil-borne pathogens is a preferable approach.

Hemodynamic response to optogenetic stimulation varied under different stimulus parameters

The coupling between neuronal activity and cerebral blood flow(CBF), known as neurovascular coupling, serves as the basis of functional brain imaging. Optogenetics provides a precise and selective approach to manipulate the activity in cell-specific neurons. It has been used in neuroscience research for comprehensive understanding about the light-evoked neurovascular coupling in rodent neuronal circuits. However, the spatiotemporal CBF response characteristics under different stimulus parameters such as pulse width and frequency remains unclear due to the lack of efficient CBF imaging technology. In this work, we used laser speckle contrast imaging(LSCI) to study the spatiotemporal hemodynamic response to optogenetic stimulation with different pulse widths (5ms, 10ms, 20ms) and frequencies (5Hz, 10Hz, 20Hz) in Channelrhodopsin-2(ChR2) expressing rats. The results showed that the averaged CBF response generally increased along with higher pulse width or frequency. The CBF peak response was significantly higher at 20ms and it took significantly shorter time to reach response peak at 5Hz. Our work adds additional insights in understanding the cell-specific neurovascular coupling mechanism and provides informative reference when applying ChR2 optogenetics in neurological disease research.

[Epidemiologic survey on mental health of maxillofacial traumatic inpatients]

OBJECTIVE

To Analyze the mental health level of maxillofacial traumatic inpatients.

METHODS

The mental test was carried out in 126 maxillofacial traumatic inpatients of Department of Oral and Maxillofacial Surgery of the Fourth Military Medical University from 10/1998 to 09/1999 with the SCL-90 (symptom check list-90).

RESULTS

The total mark of SCL-90 was 153.76 +/- 62.44. The number of symptomatic items was 31.52 +/- 24.55, which was higher than that of domestic norm (P < 0.01). The inpatient constitutes at different level of SCL-90 total mark showed normal distribution. The every factor mark of SCL-90 was also higher than that of domestic norm (P < 0.01). The former four factors were melancholy, anxiety, horror and psychosis. The SCL-90 factors mark had an increased trend along with injury severity score (RISS). The age and sex had not notable influence on the mental health level (P > 0.05), but the educational level had notable influence on the mental hralth level (P < 0.05).

CONCLUSIONS

The mental health level of maxillofacial traumatic inpatients is lower than normal people and has a decreasing trend along with the RISS. The inpatient that has lower educational level also has lower mental health level. The mental handicap is caused by traumatic event and nosocomial stress.

[Study on maxillofacial impact injury associated with brain injury]

OBJECTIVE

The purpose was to study the mechanism and the characteristics of brain damage associated with maxillofacial injury under the impacting load of middle face.

METHODS

Eighteen rabbits were subjected to impacting on left middle face with pneumatic impact device, which were horizontally located on the ground. The impact velocities respectively were 4.77 m/s +/- 0.53 m/s (group A), 9.16 m/s +/- 0.65 m/s (group B) and 13.95 m/s +/- 0.67 m/s (group C). The acceleration of head and stress of encephalic was monitored during the impact period. The pathological characteristics of correlative tissues were examined in detail 6 hours after impacting. The contents of LPO, SOD and NO in blood and water in brain were measured at the same time.

RESULTS

The contents of LPO and SOD in blood significantly increased along with the increasing of impact velocity (P < 0.05). The same pattern was observed in the changing of water content of brain (P < 0.05). But the contents of NO in blood reduced when the impact velocity increased (P < 0.05). The animals of group A showed single fracture of middle face bone, while Group B showed multiple fractures of middle face bone. Group C represented severe maxillofacial injury associated with brain damage. The pathological damage of brain became more serious along with the increase of impact velocity. The peak value of head acceleration and encephalic stress of group C were higher than that of group A and group B (P < 0.05).

CONCLUSION

The responses of head acceleration and encephalic stress resulting from middle face impacting might play a key role in brain injury associated with maxillofacial injury.

[Relations of mechanical properties of human mandible to strain rate and density under tension load]

OBJECTIVE

To study the biomechanical properties of human mandible under tension load and deduce the constitutive equation.

METHODS

100 specimens taken from five mandible of fresh human cadavers were examined on INSTRON by a group of tensile tests at different strain rates (0.0003/s, 0.0030/s, 0.0300/s, 0.3000/s). Bone mineral density of every individual mandible was measured. The effect of strain rate (epsilon), bone mineral density (rho) on young modulus (E), strength (sigma u) and ultimate strain (epsilon u) was studied and the constitutive equation was deduced using the following model: Y = a rho b epsilon c.

RESULTS

(1) sigma u = 126.36 rho 1.88 x epsilon 0.044 (P < 0.01), (2) E = 25,170.97 rho 0.44 x epsilon 0.052 (P < 0.01), (3) epsilon u = 0.0088 rho 1.89 x epsilon -0.028 (P < 0.01), (4) sigma u = 6,309.57 rho 0.96 epsilon 0.056 x epsilon 0.80 (P < 0.01).

CONCLUSIONS

Strain rate and bone mineral density are important factors for the biomechanical properties of human mandible under tension load. The results above may modelize and characterize the constitutive relation within small strain rates. From the constitutive equation, we could estimate the stress level of the mandible and assess the possibility and degree of mandible injury.

[An epidemiologic retrospective study of 1693 maxillofacial injuries]

A 10-year review of 1693 maxillofacial injuries was presented with respect to age, sex, cause of injury, pattern of fracture, and associated systemic injuries. The majority of fractures in maxillofacial region were found in males, the most prevalent age ranged from 21 to 40 years. The leading cause of facial trauma was traffic accidents. Mandible fracture outranked zygomatic and maxillary fracture. Multiple fractures were more common than single fracture. The average number of fractures for each patient was 1.7. Accompanied injuries to brain and skull happened in almost half patients, which were more often than other part of the body. There was a higher incidence that midfacial fractures coincided with brain and skull damage.