The effects of in utero exposure to teratogens on organ size: a prospective paediatric study

In low-income countries, prospective data on combined effects of in utero teratogen exposure are lacking and necessitates new research. The aim of the present study was to explore the effect of in utero teratogen exposure on the size of the kidneys and pancreas 5 years after birth in a low-income paediatric population. Data was collected from 500 mother-child pairs from a low-income setting. Anthropometric measurements included body weight, (BW) body height, mid-upper arm and waist circumference (WC). Clinical measurements included blood pressure (BP), mean arterial pressure and heart rate. Ultrasound measurements included pancreas, and kidney measurements at age 5 years. The main outcome of interest was the effect of maternal smoking and alcohol consumption on ultrasound measurements of organ size at age 5 years. Left and right kidney length measurements were significantly lower in smoking exposed children compared to controls (p = 0.04 and p = 0.03). Pancreas body measurements were significantly lower in smoking exposed children (p = 0.04). Multiple regression analyses were used to examine the associations between the independent variables (IDVs), maternal age, body mass index (BMI), mid-upper arm circumference (MUAC) and BW of the child, on the dependent variables (DVs) kidney lengths and kidney volumes. Also, the association between in utero exposure to alcohol and nicotine and pancreas size. WC was strongest (r = 0.28; p < 0.01) associated with pancreas head [F (4, 454) = 13.44; R2 = 0.11; p < 0.01] and tail (r = 0.30; p < 0.01) measurements at age 5 years, with in utero exposure, sex of the child and BMI as covariates. Kidney length and pancreas body measurements are affected by in utero exposure to nicotine at age 5 years and might contribute to cardiometabolic risk in later life. Also, findings from this study report on ultrasound reference values for kidney and pancreas measurements of children at age 5 years from a low-income setting.

When primary repair is not enough: a comparison of synthetic patch and muscle flap closure in congenital diaphragmatic hernia?

PURPOSE

Primary closure is often inadequate for large congenital diaphragmatic hernia (CDH) and necessitates repair by prosthetic patch or autologous muscle flap. Our aim was to evaluate outcomes of open patch versus flap repair, specifically diaphragmatic reherniation.

METHODS

A retrospective review (IRB #2017-6361) was performed on all CDH patients repaired from 2005 to 2016 at a single academic children's hospital. Patients were excluded from final analysis if they had primary or minimally invasive repair, expired, or were lost to follow-up.

RESULTS

Of 171 patients, 151 (88.3%) survived to discharge, 9 expired after discharge and 11 were lost to follow up, leaving 131 (86.8%) long-term survivors. Median follow-up was 5 years. Open repair was performed in 119 (90.8%) of which 28 (23.5%) underwent primary repair, 34 (28.6%) patch repair, and 57 (47.9%) flap repair. Overall, 6/119 (5%) patients reherniated, 1/28 (3.6%) in the primary group, 3/34 (8.8%) in the patch group, and 2/57 (3.5%) in the flap group. Comparing prosthetic patch to muscle flap repair, there was no significant difference in the number of patients who recurred nor time to reherniation (3 vs. 2, p = 0.295; 5.5 ± 0.00 months vs. 53.75 ± 71.06 months, p = 0.288). One patient in the patch group recurred twice.

CONCLUSIONS

Both muscle flap and patch repair of large CDH are feasible and durable with a relatively low risk of recurrence.

In utero teratogen exposure and cardiometabolic risk in 5-year-old children: a prospective pediatric study

Background: Aorta and carotid intima-media thickness (IMT) is a measure of subclinical atherosclerosis and useful to assess cardiometabolic risk in the young. The in utero milieu may involve cardiometabolic programing and the development of cardiometabolic risk factors in children. Maternal smoking, alcohol consumption, and micronutrient deficiencies during pregnancy influence the development of the cardiovascular system through a process of DNA methylation.Aim: To explore an association between maternal smoking and alcohol consumption during pregnancy and intima media thickness in 5-year-old children for a low-income setting.Methods: Data were collected from 500 mother-child pairs at antenatal clinic visit, at birth, and at age 5 years. Anthropometric measurements were collected at birth and again at age 5 years. As well as clinical and ultrasound measurements at age 5 years. Clinical measurements, at age 5 years, included blood pressure, mean arterial pressure, and heart rate. Ultrasound measurements of the aorta and carotid arteries IMT were performed at age 5 years. Main outcome of interest was effect of dual teratogen exposure on the ultrasound measures IMT as indication of cardiometabolic risk.Results: cIMT was significantly higher in children exposed to both alcohol and nicotine during pregnancy compared to those not exposed (p = .008). In separate linear models, dual in utero exposure (beta = 0.12; p = .01) and male sex (beta = 0.14; p = .01) were associated with higher right cIMT values (F(6,445) = 5.20; R² = 0.07, p < .01); male sex (beta = 0.13; p = .01) and low birth weight (beta = 0.07; p = .01) with higher left cIMT value (F(4,491) = 4.49; R² = 0.04; p = .01); and males sex (beta = 0.11; p = .02) with higher aorta IMT (F(6,459) = 5.63; R² = 0.07; p < .01). Significant positive correlations between maternal measures of adiposity, maternal MUAC (r = 0.10; p = .03), and maternal BMI (r = 0.12; p < .01) and right cIMT measurements adjusted for the BMI of the child at age 5 years as covariate. Blood pressure measurements at age 5 years were not significantly associated with IMT but, instead, correlated significantly and positively with the BMI of the child at age 5 years (p < .01).Conclusion: Children exposed to both maternal smoking and alcohol consumption during pregnancy presented with cardiometabolic risk factors 5 years after birth. In addition, maternal adiposity, male sex, and low birth weight were associated with higher IMT at age 5 years.

Hemorrhage after on-ECMO repair of CDH is equivalent for muscle flap and prosthetic patch

BACKGROUND/PURPOSE

Prosthetic patch (patch) and muscle flap (flap) techniques are utilized for severe congenital diaphragmatic hernia (CDH) repair; however, when performed on extracorporeal membrane oxygenation (ECMO), the risk of hemorrhage increases. We sought to compare bleeding complications between repair types.

METHODS

We retrospectively reviewed 2010-2016 on-ECMO CDH repairs.

RESULTS

Twenty-nine patients met criteria: 13 patch (44.8%) and 16 flap (55.2%). Eight patch (61.5%) and 13 flap (81.2%) patients had left-sided defects (p = 0.223). All defects were Type C or D (Type C: patch 53.8%, flap 56.2%, p = 0.596). There was no difference in gestational age at delivery (patch 37.5 ± 0.9 weeks, flap 37.2 ± 1.3 weeks, p = 0.390) or age at repair (patch 7.46 ± 6.6 days, flap 6.00 ± 4.3 days, p = 0.476). Seven patch (53.8%) and 9 flap (56.2%) patients survived to discharge (p = 0.596). Estimated intraoperative blood loss was equivalent (patch 35.3 ± 53.9 mL, flap 24.2 ± 18.4 mL, p = 0.443). One patch patient (7.6%) and two (12.5%) flap patients required reoperation in the first 48 h for bleeding (p = 0.580). 48-h postoperative transfusions were the same for those that required reoperation (patch 282.0 mL/kg, flap 208.5 ± 21.9 mL/kg, p = 0.054) and those that did not (patch 120.7 ± 111.7 mL/kg, flap 118.4 ± 89.9 mL/kg, p = 0.561).

CONCLUSIONS

On-ECMO bleeding complications are equivalent for both flap and patch CDH repair.

LEVEL OF EVIDENCE

Type III (retrospective comparative study).

Minimally Invasive Pediatric Cholecystectomy: A Comparison of Robotic and Laparoscopic Single and Multiport Techniques

BACKGROUND

Pediatric laparoscopic cholecystectomy is the current standard of care for gallbladder pathology. Single-incision and multiport procedures, as well as robotic and minimally invasive platforms, have been described; however, there is no head-to-head assessment of these interventions in the existing literature. The purpose of our study was to directly compare the minimally invasive cholecystectomy techniques of laparoscopic multiport (LMP), laparoscopic single incision (LSI), robotic multiport (RMP), and robotic single incision (RSI).

MATERIALS AND METHODS

All cholecystectomies performed by a single surgeon at a tertiary-care center from 2010 to 2014 were retrospectively reviewed. Seventy-one subjects were included as follows: 30 LMP, 20 LSI, 11 RMP, and 10 RSI. Data were collected on patient characteristics, operative technique, operative times, medications, and postoperative course and analyzed using a Kruskal-Wallis test with a significance of P < .05.

RESULTS

Operative times for LMP and RSI were similar and shortest of all groups, while LSI was the most time consuming (P = .04). Pain medication use, both narcotic and non-narcotic, was not statistically different with any operation type (P = .37 and .98, respectively). Postoperative length of stay was similar across all groups except for the RSI group which was significantly shorter (P = .04).

CONCLUSIONS

RSI cholecystectomy has significantly shorter postoperative length of stay compared to other minimally invasive techniques. In addition, operative times for RSI are equivalent to the current standard LMP technique.

Noninvasive beat-to-beat finger arterial pressure monitoring during orthostasis: a comprehensive review of normal and abnormal responses at different ages

Over the past 30 years, noninvasive beat-to-beat blood pressure (BP) monitoring has provided great insight into cardiovascular autonomic regulation during standing. Although traditional sphygmomanometric measurement of BP may be sufficient for detection of sustained orthostatic hypotension, it fails to capture the complexity of the underlying dynamic BP and heart rate responses. With the emerging use of noninvasive beat-to-beat BP monitoring for the assessment of orthostatic BP control in clinical and population studies, various definitions for abnormal orthostatic BP patterns have been used. Here, age-related changes in cardiovascular control in healthy subjects will be reviewed to define the spectrum of the most important abnormal orthostatic BP patterns within the first 180 s of standing. Abnormal orthostatic BP responses can be defined as initial orthostatic hypotension (a transient systolic BP fall of >40 mmHg within 15 s of standing), delayed BP recovery (an inability of systolic BP to recover to a value of >20 mmHg below baseline at 30 s after standing) and sustained orthostatic hypotension (a sustained decline in systolic BP of ≥20 mmHg occurring 60-180 s after standing). In the evaluation of patients with light-headedness, pre(syncope), (unexplained) falls or suspected autonomic dysfunction, it is essential to distinguish between normal cardiovascular autonomic regulation and these abnormal orthostatic BP responses. The prevalence, clinical relevance and underlying pathophysiological mechanisms of these patterns differ significantly across the lifespan. Initial orthostatic hypotension is important for identifying causes of syncope in younger adults, whereas delayed BP recovery and sustained orthostatic hypotension are essential for evaluating the risk of falls in older adults.

Abstract P2-05-08: Impact of treatment history on prognostic ability of breast cancer index (BCI): Subset analysis from a validation study of patients with hormone receptor-positive (HR+) breast cancer with 1-3 positive nodes

Background: A new BCI model integrating tumor size and grade (BCIN+) was specifically developed and validated for prediction of risk of overall (0-15y) and late (5-15y) distant recurrence (DR) in HR+ women with 1-3 positive nodes (N1). The objective of this study was to evaluate the impact of treatment history on the prognostic performance of BCIN+ in a large clinical validation cohort of pre- and post-menopausal HR+, N1 patients.

Methods: The validation cohort was comprised of 402 HR+, N1 patients diagnosed at Massachusetts General Hospital between 1993-2007 with at least 5y of follow-up. BCIN+ risk scores were determined and patients stratified into low or high risk categories using a pre-specified cut-point blinded to clinical outcome. Kaplan-Meier estimates of overall (0-15y) and late (5-15y) DR were estimated and the difference was evaluated by log-rank test. Treatment-specific subsets were analyzed based on adjuvant endocrine (tamoxifen [TAM] only vs any history of aromatase inhibitors [AI]), and adjuvant chemotherapy treatment history.

Results: Mean age of patients was 53y. 99% were ER+, 91% PR+, and 13% HER2+. The majority of tumors were T1 (62%) or T2 (35%). Adjuvant endocrine treatment included TAM only for 191 (48%) patients and either AI only or a sequence of TAM and an AI in 211 (52%) patients. Most patients received chemotherapy (n=324; 81%). BCIN+ classified 20% and 80% as low and high risk, respectively.

In patients treated with TAM only, BCIN+ low and high risk had significantly different 15y rates of DR (95% CI) of 4.0% (0.0-11.4%) vs 41.7% (33.0-49.3%), respectively (p=0.0005). For patients disease-free at year 5, rates of late DR (5-15y) were 4.0% (0.0-11.5%) vs 20.0% (11.4-27.8%), respectively (p=0.04). In patients treated with an AI, BCIN+ low and high risk had significantly different 15y rates of DR of 0% (0.0-0.0%) vs 15.0% (8.1-21.5%), respectively (p=0.006). For patients disease-free at year 5, rates of late DR were 0.0% (0.0-0.0%) vs 12.2% (5.6-18.3%), respectively (p=0.02). There was no statistically significant difference in the prognostic performance of BCIN+ between patients treated with TAM only versus those with treatment including any history of AI (interaction p=0.99).

In the subset of patients treated with chemotherapy, BCIN+ classified 19% and 81% of patients as low and high risk with significantly different 15y rates of DR of 1.7% (0.0-4.9%) vs 30.9% (24.4-36.8%), respectively (p&lt;0.0001). For patients disease-free at year 5, rates of late DR were 1.7% (0.0-4.9%) and 16.3% (10.2-21.9%), respectively (p=0.006).

Conclusions: In this subset analysis from a validation study of N1 patients, BCIN+ identified a significant proportion with a significantly low risk of late DR. This study confirms the ability of BCIN+ to identify a subset of patients with significantly low risk of recurrence across adjuvant endocrine and chemotherapy treatment backgrounds. BCIN+ may provide additional prognostic information to facilitate selection of N+ patients for extended endocrine treatment, wherein patients identified as BCIN+ low may be considered adequately treated with adjuvant therapy alone.

Citation Format: Zhang Y, Jerevall P-L, Schroeder BE, Ly A, Nolan H, Schnabel CA, Sgroi DC. Impact of treatment history on prognostic ability of breast cancer index (BCI): Subset analysis from a validation study of patients with hormone receptor-positive (HR+) breast cancer with 1-3 positive nodes [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-08.

Neural correlates of oddball detection in self-motion heading: a high-density event-related potential study of vestibular integration

The perception of self-motion is a product of the integration of information from both visual and non-visual cues, to which the vestibular system is a central contributor. It is well documented that vestibular dysfunction leads to impaired movement and balance, dizziness and falls, and yet our knowledge of the neuronal processing of vestibular signals remains relatively sparse. In this study, high-density electroencephalographic recordings were deployed to investigate the neural processes associated with vestibular detection of changes in heading. To this end, a self-motion oddball paradigm was designed. Participants were translated linearly 7.8 cm on a motion platform using a one second motion profile, at a 45° angle leftward or rightward of straight ahead. These headings were presented with a stimulus probability of 80-20 %. Participants responded when they detected the infrequent direction change via button-press. Event-related potentials (ERPs) were calculated in response to the standard (80 %) and target (20 %) movement directions. Statistical parametric mapping showed that ERPs to standard and target movements differed significantly from 490 to 950 ms post-stimulus. Topographic analysis showed that this difference had a typical P3 topography. Individual participant bootstrap analysis revealed that 93.3 % of participants exhibited a clear P3 component. These results indicate that a perceived change in vestibular heading can readily elicit a P3 response, wholly similar to that evoked by oddball stimuli presented in other sensory modalities. This vestibular-evoked P3 response may provide a readily and robustly detectable objective measure for the evaluation of vestibular integrity in various disease models.

Artificial lung basics: fundamental challenges, alternative designs and future innovations

There exists a growing demand for new technology that can take over the function of the human lung, from assisting an injured or recently transplanted lung to completely replacing the native organ. Many obstacles must be overcome to achieve the lofty goals and expectations of such a device. An artificial lung must be able to sustain the gas exchange requirements of a normal functioning lung. Pursuant to this purpose, the device must maintain appropriate blood pressure, decrease injury to blood cells and minimize clotting and immunologic response. Attachment methods vary, and ideally researchers want to find a way that minimizes bodily trauma, maximizes gas exchange and utilizes the inherent properties of the native lung. The currently proposed methods include the parallel, in-series and venous double-lumen cannula configurations. For the time being, current research focuses on the extracorporeal (i.e., outside the body) placement, but ultimate long-term goals look toward total implantation.

Impaired information processing speed and attention allocation in multiple sclerosis patients versus controls: a high-density EEG study

BACKGROUND

The no-go P3a is a variant of the P300 event-related potential (ERP) that indexes speed of information processing and attention allocation. The aim of this study was to compare ERP findings with results from the paced auditory serial addition test (PASAT) and to quantify latency, amplitude and topographical differences in P3a ERP components between multiple sclerosis (MS) patients and controls.

PATIENTS AND METHODS

Seventy-four subjects (20 relapsing remitting (RRMS) patients, 20 secondary progressive (SPMS) patients and 34 controls) completed a three-stimulus oddball paradigm (target, standard, and non-target). Subjects participated in separate visual and auditory tasks while data were recorded from 134 EEG channels. Latency differences were tested using an ANCOVA. Topographical differences were tested using statistical parametric mapping.

RESULTS

Visual P3a amplitude correlated with PASAT score in all MS patients over frontal and parietal areas. There were significant differences in latency, amplitude, and topography between MS patients and controls in the visual condition. RRMS and SPMS patients differed in visual P3a latency and amplitude at frontal and parietal scalp regions. In the auditory condition, there were latency differences between MS patients and controls only over the parietal region.

CONCLUSION

The present results demonstrate that information processing speed and attention allocation are impaired in MS.