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Johng S, Licht DJ, Hedrick HL, Rintoul N, Linn RL, Gebb JS, Xiao R, Massey SL. Prenatal Brain Maturation is Delayed in Neonates with Congenital Diaphragmatic Hernia. J Pediatr 2024; 264:113738. [PMID: 37722557 DOI: 10.1016/j.jpeds.2023.113738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE To assess brain development in fetuses with congenital diaphragmatic hernia (CDH) using a fetal Total Maturation Score (fTMS). STUDY DESIGN This is a retrospective cohort study using data from a single-center clinical registry. Neonates with an antenatal diagnosis of CDH between 2014 and 2020 and prenatal brain magnetic resonance imaging (MRI) (n = 48) were included. We compared our study sample with historical healthy controls (n = 48). The relationship between fTMS and gestational age (GA), as well as the association between fTMS and key prenatal variables and placental pathologic findings, were evaluated. RESULTS Compared with healthy controls, neonates with CDH had a significant delay in fTMS (P value <.001). Within the CDH cohort, there was no significant difference in fTMS based on CDH severity, intrathoracic liver position, right vs left CDH, sex, presence of abnormal echocardiogram findings, treatment with extracorporeal membrane oxygenation (ECMO), or in-hospital mortality. Placentas of neonates with CDH had a high proportion of fetal vascular malperfusion (56%) and chronic inflammation (67%), and relatively large placentas had a protective effect on prenatal brain maturation (P value = .025). CONCLUSIONS Prenatal brain maturation in neonates with CDH is delayed. Placental pathology may influence fetal brain development. The etiology and clinical impact of prenatal brain immaturity in neonates with CDH warrant further investigation.
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Affiliation(s)
- Sandy Johng
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Daniel J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Holly L Hedrick
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Natalie Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rebecca L Linn
- Division of Anatomic Pathology, Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Juliana S Gebb
- Richard D Wood, Jr Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Shavonne L Massey
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
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Wild KT, Hedrick HL, Ades AM, Fraga MV, Avitabile CM, Gebb JS, Oliver ER, Coletti K, Kesler EM, Van Hoose KT, Panitch HB, Johng S, Ebbert RP, Herkert LM, Hoffman C, Ruble D, Flohr S, Reynolds T, Duran M, Foster A, Isserman RS, Partridge EA, Rintoul NE. Update on Management and Outcomes of Congenital Diaphragmatic Hernia. J Intensive Care Med 2023:8850666231212874. [PMID: 37933125 DOI: 10.1177/08850666231212874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Infants with congenital diaphragmatic hernia (CDH) benefit from comprehensive multidisciplinary teams that have experience in caring for the unique and complex issues associated with CDH. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies and pulmonary hypertension management, and extracorporeal membrane oxygenation, mortality and morbidity remain high. These infants have unique and complex issues that begin in fetal and infant life, but persist through adulthood. Here we will review the literature and share our clinical care pathway for neonatal care and follow up. While many advances have occurred in the past few decades, our work is just beginning to continue to improve the mortality, but also importantly the morbidity of CDH.
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Affiliation(s)
- K Taylor Wild
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Holly L Hedrick
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Anne M Ades
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Maria V Fraga
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Catherine M Avitabile
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Juliana S Gebb
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen Coletti
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Erin M Kesler
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - K Taylor Van Hoose
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Howard B Panitch
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Sandy Johng
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Renee P Ebbert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa M Herkert
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Casey Hoffman
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Deanna Ruble
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sabrina Flohr
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tom Reynolds
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa Duran
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Audrey Foster
- Department of Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca S Isserman
- Division of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Emily A Partridge
- Richard D. Wood Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Pediatric General, Thoracic, and Fetal Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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Johng S, Fraga MV, Patel N, Kipfmueller F, Bhattacharya A, Bhombal S. Unique Cardiopulmonary Interactions in Congenital Diaphragmatic Hernia: Physiology and Therapeutic Implications. Neoreviews 2023; 24:e720-e732. [PMID: 37907403 DOI: 10.1542/neo.24-11-e720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Congenital diaphragmatic hernia (CDH) results in abdominal contents entering the thoracic cavity, affecting both cardiac and pulmonary development. Maldevelopment of the pulmonary vasculature occurs within both the ipsilateral lung and the contralateral lung. The resultant bilateral pulmonary hypoplasia and associated pulmonary hypertension are important components of the pathophysiology of this disease that affect outcomes. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies, pulmonary hypertension management, and the option of extracorporeal membrane oxygenation, overall CDH mortality remains between 25% and 30%. With increasing recognition that cardiac dysfunction plays a large role in morbidity and mortality in patients with CDH, it becomes imperative to understand the different clinical phenotypes, thus allowing for individual patient-directed therapies. Further research into therapeutic interventions that address the cardiopulmonary interactions in patients with CDH may lead to improved morbidity and mortality outcomes.
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Affiliation(s)
- Sandy Johng
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - Maria V Fraga
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | | | - Shazia Bhombal
- Department of Pediatrics, Emory University/Children's Healthcare of Atlanta, Atlanta, GA
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Romer AJ, Johng S, Hsia J, Scott S, Reddy A, Gardner MM. Cyanosis in a Newborn Immediately after Birth. NEJM Evid 2022; 1:EVIDmr2100060. [PMID: 38319182 DOI: 10.1056/evidmr2100060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Cyanosis in a Newborn Immediately after BirthA male neonate, weighing 3.9 kg, was delivered via Cesarean section at 39 weeks of gestation. He cried immediately after birth, but his whole body appeared blue and he had low muscle tone that did not improve with suctioning and stimulation. Blow-by with 100% oxygen was initiated, and pulse oximetry on his left hand measured 40%. What is the diagnosis?
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Affiliation(s)
- Amy J Romer
- from the Critical Care, Cardiac Critical Care, Cardiology, and Neonatology Fellowship Programs at the Children's Hospital of Philadelphia
| | - Sandy Johng
- from the Critical Care, Cardiac Critical Care, Cardiology, and Neonatology Fellowship Programs at the Children's Hospital of Philadelphia
| | - Jill Hsia
- from the Critical Care, Cardiac Critical Care, Cardiology, and Neonatology Fellowship Programs at the Children's Hospital of Philadelphia
| | - Sarah Scott
- from the Critical Care, Cardiac Critical Care, Cardiology, and Neonatology Fellowship Programs at the Children's Hospital of Philadelphia
| | - Anireddy Reddy
- from the Critical Care, Cardiac Critical Care, Cardiology, and Neonatology Fellowship Programs at the Children's Hospital of Philadelphia
| | - Monique M Gardner
- from the Critical Care, Cardiac Critical Care, Cardiology, and Neonatology Fellowship Programs at the Children's Hospital of Philadelphia
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Clyman RI, Hills NK, Liebowitz M, Johng S. Relationship between Duration of Infant Exposure to a Moderate-to-Large Patent Ductus Arteriosus Shunt and the Risk of Developing Bronchopulmonary Dysplasia or Death Before 36 Weeks. Am J Perinatol 2020; 37:216-223. [PMID: 31600791 PMCID: PMC9940607 DOI: 10.1055/s-0039-1697672] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study was aimed to examine the relationship between duration of infant exposure to a moderate-to-large patent ductus arteriosus (PDA) shunt and the risk of developing bronchopulmonary dysplasia (BPD) or death before 36 weeks (BPD/death). STUDY DESIGN Infants <28 weeks' gestation who survived ≥7 days (n = 423) had echocardiograms performed on day 7 and at planned intervals. RESULTS In multivariable regression models, BPD/death did not appear to be increased until infants had been exposed to a moderate-to-large PDA for at least 7-13 days: OR (95%CI) (referent = closed or small PDA): moderate-to-large PDA exposure for <7 days: 0.38 (range, 0.10-1.46); for 7 to 13 days = 2.12 (range, 1.04-4.32); for ≥14 days = 3.86 (range, 2.15-6.96). Once the threshold of 7 to 13 days had been reached, additional exposure (≥14 days) did not significantly add to the increased incidence of BPD/death: (referent exposure = 7-13 days) exposure for 14 to 27 days = 1.34 (range, 0.52-3.45); for 28 to 48 days = 2.34 (range, 0.88-6.19); for ≥49 days = 1.80 (range. 0.59-5.47). A similar relationship was found for the outcome of BPD-alone. CONCLUSION Infants < 28 weeks' gestation required at least 7 to 13 days of exposure to a moderate-to-large PDA before a significant increase in the incidence of BPD/death was apparent. Once this threshold was reached additional exposure to a moderate-to-large PDA did not significantly add to the increased incidence of BPD/death.
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Affiliation(s)
- Ronald I. Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA,Department of Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Nancy K. Hills
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Melissa Liebowitz
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Sandy Johng
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
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Kim T, Hinton DJ, Johng S, Wang JB, Choi DS. Levo-tetrahydropalmatine decreases ethanol drinking and antagonizes dopamine D2 receptor-mediated signaling in the mouse dorsal striatum. Behav Brain Res 2013; 244:58-65. [PMID: 23376703 DOI: 10.1016/j.bbr.2013.01.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 01/18/2013] [Accepted: 01/24/2013] [Indexed: 12/20/2022]
Abstract
An herb derived compound, levo-tetrahydropalmatine (L-THP), attenuates self-administration of cocaine and opiates in rodents. Since L-THP mainly antagonizes dopamine D2 receptors (D2R) in the brain, it is likely to regulate other addictive behaviors as well. Here, we examined whether L-THP regulates ethanol drinking in C57BL/6J mice using a two-bottle choice drinking experiment. L-THP treated mice consumed less ethanol compared to vehicle-treated mice during the 15% ethanol drinking session while water consumption remained similar between each group. We then examined the molecular basis underlying the pharmacological effect of L-THP in mice. Our results indicated that a single injection of L-THP increased active phosphorylated forms of PKA, AKT and ERK in the caudate-putamen (CPu), but not in the nucleus accumbens (NAc), of alcohol naïve mice. Interestingly, we found that systematic treatment with L-THP for 4 consecutive days while mice were drinking 15% ethanol increased pPKA levels in the CPu, but not in the NAc. In contrast to the effect of acute L-THP treatment, no differences were detected for pAKT or pERK in either striatal regions. Together, our findings suggest that reduction of ethanol drinking by L-THP treatment is possibly correlated with D2R-mediated PKA signaling in the CPu.
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Affiliation(s)
- Taehyun Kim
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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