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Journal of Pediatric Surgery Dec 2023The objective of this study was to identify factors associated with prolonged birth admission length of stay (LOS) and to evaluate the association between these...
BACKGROUND
The objective of this study was to identify factors associated with prolonged birth admission length of stay (LOS) and to evaluate the association between these characteristics and readmission in the year following discharge for children with congenital diaphragmatic hernia (CDH).
METHODS
This was a single-center retrospective cohort study of children with isolated CDH born in the Special Delivery Unit and admitted to the Newborn/Infant Intensive Care Unit at Children's Hospital of Philadelphia from April 2008 to August 2019. Birth admission hospitalization was categorized into 3 groups (≤35, 36-75, and >76 days) based on the data distribution. Participant factors included gestational age (days), side of CDH (right/left), liver position (up/down), CDH repair technique (open/minimally invasive), exposure to extracorporeal membrane oxygenation, lung-to-head circumference ratio, and feeding tube at discharge. Chi-squared, t-tests and analysis of variance were used to examine bivariable associations between participant characteristics, birth admission LOS and readmission in the year following initial hospital discharge. Multivariable logistic regression was used to evaluate factors associated with readmission.
RESULTS
Children hospitalized ≥76 days at birth had 4.33 (95% CI: 1.2, 15.2) higher odds of readmission than those admitted for ≤35 days. Children with a non-operative feeding tube at discharge had 4.12 (895% CI: 1.6, 10.5) higher odds of readmission when compared to those with no feeding tube at discharge.
CONCLUSIONS
Longer birth hospitalization and non-operative feeding tube are associated with increased readmissions in the year after discharge.
LEVEL OF EVIDENCE
Level III.
Topics: Infant, Newborn; Infant; Humans; Child; Hernias, Diaphragmatic, Congenital; Patient Readmission; Retrospective Studies; Hospitalization; Length of Stay
PubMed: 37659921
DOI: 10.1016/j.jpedsurg.2023.08.002 -
Frontiers in Bioengineering and... 2023Pulmonary hypertension associated with congenital diaphragmatic hernia (CDH) is a critical factor in determining prognosis. We propose that intra-amniotic sildenafil...
Pulmonary hypertension associated with congenital diaphragmatic hernia (CDH) is a critical factor in determining prognosis. We propose that intra-amniotic sildenafil administration is an effective prenatal therapy for CDH-induced pulmonary hypertension. To assess the efficacy of this treatment, we administered sildenafil to nitrofen-induced congenital diaphragmatic hernia fetuses and control fetuses via an intra-amniotic injection after a laparotomy on the pregnant dam at either E13.5 or E15.5. Intra-amniotic sildenafil treatment attenuated peripheral vascular muscularization, enhanced pulmonary blood flow, and increased the ratio of pulmonary artery size to aortic size in congenital diaphragmatic hernia fetuses after both E13.5 and E15.5 treatments. E13.5-treated congenital diaphragmatic hernia fetuses showed a higher and more prolonged expression of cyclic guanosine monophosphate (cGMP)-dependent protein kinase and more production of vascular endothelial growth factor, resulting in a significant improvement in lung architecture. The E13.5-treated congenital diaphragmatic hernia fetuses also had an increase in lung weight-to-body weight ratio and an improved fetal survival. Intra-amniotic sildenafil treatment did not show any detectable negative effects in control fetuses. Intra-amniotic sildenafil treatment for rats attenuates CDH-induced pulmonary hypertension and enhanced peripheral pulmonary blood flow. Moreover, early intervention may be preferable to better accelerate lung development and improve prognosis. Direct sildenafil administration via an intra-amniotic injection may be a promising option in congenital diaphragmatic hernia prenatal therapy.
PubMed: 37545896
DOI: 10.3389/fbioe.2023.1195623 -
Scientific Reports Sep 2023Outcomes of conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation (HFOV) in patients with congenital diaphragmatic hernia (CDH) were... (Meta-Analysis)
Meta-Analysis
Outcomes of conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation (HFOV) in patients with congenital diaphragmatic hernia (CDH) were compared through a systematic review and meta-analysis. Outcome measures included mortality and incidence of chronic lung disease (CLD). Odds ratio (OR) and 95% confidence interval (95%CI) were evaluated. Subgroup analyses were performed according to the strategy for applying HFOV in CDH patients. Group A: CMV was initially applied in all CDH patients, and HFOV was applied in unstable patients. Group B: chronologically analyzed. (CMV and HFOV era) Group C: CMV or HFOV was used as the initial MV. Of the 2199 abstracts screened, 15 full-text articles were analyzed. Regarding mortality, 16.7% (365/2180) and 32.8% (456/1389) patients died in CMV and HFOV, respectively (OR, 2.53; 95%CI 2.12-3.01). Subgroup analyses showed significantly worse, better, and equivalent mortality for HFOV than that for CMV in group A, B, and C, respectively. CLD occurred in 32.4% (399/1230) and 49.3% (369/749) patients in CMV and HFOV, respectively (OR, 2.37; 95%CI 1.93-2.90). The evidence from the literature is poor. Mortality and the incidence of CLD appear worse after HFOV in children with CDH. Cautious interpretation is needed due to the heterogeneity of each study.
Topics: Child; Humans; Respiration, Artificial; Hernias, Diaphragmatic, Congenital; High-Frequency Ventilation; Death; Cytomegalovirus Infections
PubMed: 37752154
DOI: 10.1038/s41598-023-42344-2 -
Cureus Sep 2023Traumatic diaphragmatic hernias (TDHs) can occur after both blunt and penetrating injury. Laparotomy and thoracotomy are commonly done for the management of TDHs....
Traumatic diaphragmatic hernias (TDHs) can occur after both blunt and penetrating injury. Laparotomy and thoracotomy are commonly done for the management of TDHs. Minimally invasive surgery, especially laparoscopic surgery, is being accepted as an effective and safe alternative to open surgical repair even in trauma cases. Laparoscopy also allows for the detection and management of clinically occult TDHs, thereby preventing the complications of missed or delayed diagnosis. Our case highlights the importance of timely intervention with a minimally invasive approach. A 39-year-old male presented to the emergency room after a road traffic accident. Computed tomography scan confirmed left-sided diaphragmatic rupture with gastric herniation. Laparoscopic repair of the hernia was done. He had an uneventful post-operative period. At the one-year follow-up, he was asymptomatic and was doing well. TDHs have a variable clinical presentation and radiological findings are not always diagnostic. Such cases can progress to potentially life-threatening complications such as strangulation and perforation of the herniated viscera. Timely diagnosis and management are therefore essential. A minimally invasive approach such as laparoscopy should be used for the management of TDHs in the acute setting where the patient is stable, and resources are available. In this case, once the gastric contents were aspirated via a nasogastric tube in the middle of the night, the immediate need for surgery was converted to an urgent nature, and the patient underwent surgery the next morning in a more controlled setting. In addition, timely intervention can prevent future complications that may occur if the condition is left untreated during the initial admission.
PubMed: 37900497
DOI: 10.7759/cureus.46017 -
Cureus Dec 2023Representing less than 1% of all traumatic injuries, diaphragmatic injuries are uncommon and are usually associated with injuries in other thoracic and abdominal...
Representing less than 1% of all traumatic injuries, diaphragmatic injuries are uncommon and are usually associated with injuries in other thoracic and abdominal organs. We report a case of a diaphragmatic injury in a 38-year-old man who presented to the Emergency Department due to a pedestrian-vehicle accident. He had a massive hemothorax on the left due to a ruptured spleen. An exploratory laparotomy was done to manage the bleeding, restore the diaphragmatic hernia contents in their right anatomical position, conduct a splenectomy, and repair the diaphragmatic defect. Although the majority of diaphragmatic ruptures are diagnosed acutely, late presentations are usually reported in blunt trauma; therefore, a high clinical suspicion with imaging is essential for the diagnosis.
PubMed: 38259404
DOI: 10.7759/cureus.51001 -
The Journal of Pediatrics Oct 2023To evaluate associations between cardiac catheterization (cath) hemodynamics, quantitative measures of right ventricular (RV) function by echocardiogram, and survival in...
OBJECTIVE
To evaluate associations between cardiac catheterization (cath) hemodynamics, quantitative measures of right ventricular (RV) function by echocardiogram, and survival in patients with congenital diaphragmatic hernia (CDH).
STUDY DESIGN
This single-center retrospective cohort study enrolled patients with CDH who underwent index cath from 2003 to 2022. Tricuspid annular plane systolic excursion z score, RV fractional area change, RV free wall and global longitudinal strain, left ventricular (LV) eccentricity index, RV/LV ratio, and pulmonary artery acceleration time were measured from preprocedure echocardiograms. Associations between hemodynamic values, echocardiographic measures, and survival were evaluated by Spearman correlation and Wilcoxon rank sum test, respectively.
RESULTS
Fifty-three patients (68% left-sided, 74% liver herniation, 57% extracorporeal membrane oxygenation, 93% survival) underwent cath (39 during index hospitalization, 14 later) including device closure of a patent ductus arteriosus in 5. Most patients (n = 31, 58%) were on pulmonary hypertension treatment at cath, most commonly sildenafil (n = 24, 45%) and/or intravenous treprostinil (n = 16, 30%). Overall, hemodynamics were consistent with precapillary pulmonary hypertension. Pulmonary capillary wedge pressure was >15 mm Hg in 2 patients (4%). Lower fractional area change and worse ventricular strain were associated with higher pulmonary artery pressure while higher LV eccentricity index and higher RV/LV ratio were associated with both higher pulmonary artery pressure and higher pulmonary vascular resistance. Hemodynamics did not differ based on survival status.
CONCLUSIONS
Worse RV dilation and dysfunction by echocardiogram correlate with higher pulmonary artery pressure and pulmonary vascular resistance on cath in this CDH cohort. These measures may represent novel, noninvasive clinical trial targets in this population.
Topics: Humans; Hernias, Diaphragmatic, Congenital; Retrospective Studies; Hypertension, Pulmonary; Ventricular Dysfunction, Right; Echocardiography; Cardiac Catheterization; Hemodynamics; Ventricular Function, Right
PubMed: 37329980
DOI: 10.1016/j.jpeds.2023.113564 -
Thoracic Surgery Clinics May 2024Bochdalek hernias are a rare occurrence in adults and usually asymptomatic, resulting in incidental discovery. However, surgical intervention is recommended for both... (Review)
Review
Bochdalek hernias are a rare occurrence in adults and usually asymptomatic, resulting in incidental discovery. However, surgical intervention is recommended for both symptomatic and asymptomatic Bochdalek hernias due to the risk of acute morbidity and mortality. There are various possible surgical approaches that may be appropriate depending on the circumstance, with robotic repair becoming increasingly popular. To date, the rarity of the condition has limited the available data on postoperative outcomes.
Topics: Humans; Hernias, Diaphragmatic, Congenital; Adult; Herniorrhaphy
PubMed: 38705663
DOI: 10.1016/j.thorsurg.2024.01.007 -
Pediatric Surgery International Nov 2023Patch repair of congenital diaphragmatic hernia (CDH) using Gore-Tex is associated with infection, adhesions, hernia recurrence, long-term musculoskeletal sequels and...
BACKGROUND
Patch repair of congenital diaphragmatic hernia (CDH) using Gore-Tex is associated with infection, adhesions, hernia recurrence, long-term musculoskeletal sequels and poor tissue regeneration. To overcome these limitations, the performance of two novel biodegradable membranes was tested to repair CDH in a growing pig model.
METHODS
Twelve male pigs were randomly assigned to 3 different groups of 4 animals each, determined by the type of patch used during thoracoscopic diaphragmatic hernia repair (Gore-Tex, polycaprolactone electrospun membrane-PCLem, and decellularized human chorion membrane-dHCM). After 7 weeks, all animals were euthanized, followed by necropsy for diaphragmatic evaluation and histological analysis.
RESULTS
Thoracoscopic defect creation and diaphragmatic repair were performed without any technical difficulty in all groups. However, hernia recurrence rate was 0% in Gore-Tex, 50% in PCLem and 100% in dHCM groups. At euthanasia, Gore-Tex patches appeared virtually unchanged and covered with a fibrotic capsule, while PCLem and dHCM patches were replaced by either floppy connective tissue or vascularized and floppy regenerated membranous tissue, respectively.
CONCLUSION
Gore-Tex was associated with a higher survival rate and lower recurrence. Nevertheless, the proposed biodegradable membranes were associated with better tissue integration when compared with Gore-Tex.
Topics: Animals; Male; Diaphragm; Hernias, Diaphragmatic, Congenital; Herniorrhaphy; Polytetrafluoroethylene; Swine
PubMed: 37999778
DOI: 10.1007/s00383-023-05584-x -
Endothelial-to-Mesenchymal Transition in Human and Murine Models of Congenital Diaphragmatic Hernia.Neonatology Apr 2024Congenital diaphragmatic hernia (CDH) is a complex congenital disorder, characterized by pulmonary hypertension (PH) and hypoplasia. PH secondary to CDH (CDH-PH)...
INTRODUCTION
Congenital diaphragmatic hernia (CDH) is a complex congenital disorder, characterized by pulmonary hypertension (PH) and hypoplasia. PH secondary to CDH (CDH-PH) features devastating morbidity and mortality (25-30%) among neonates. An unmet need is determining mechanisms triggering CDH-PH to save infants. Prior data suggest abnormal remodeling of the pulmonary vascular extracellular matrix (ECM), presumed to be driven by endothelial-to-mesenchymal transition (EndoMT), hinders postnatal vasodilation and limits anti-PH therapy in CDH. There are limited data on the role of EndoMT in CDH-PH.
METHODS
The purpose of the study was to investigate how EndoMT contributes to CDH-PH by identifying cells undergoing EndoMT noted by alpha smooth muscle actin (α-SMA) expression in human umbilical vein endothelial cells (HUVECs) and lung tissue obtained from murine pups using the nitrofen model. N = 8 CDH, N = 8 control HUVECs were stained for α-SMA and CD31 after being exposed for 24 h to TGFB, a known EndoMT promoter. N = 8 nitrofen, N = 8 control murine pup lungs were also stained for α-SMA and CD31. α-SMA and CD31 expression was quantified in HUVECs and murine tissue using Fiji imaging software and normalized to the total number of cells per slide noted by DAPI staining.
RESULTS
CDH HUVECs demonstrated a 1.1-fold increase in α-SMA expression (p = 0.02). The murine model did not show statistical significance between nitrofen and control pup lungs; however, there was a 0.4-fold increase in α-SMA expression with a 0.8-fold decrease in CD31 expression in the nitrofen pup lungs when compared to controls.
CONCLUSION
These results suggest that EndoMT could potentially play a role in the ECM remodeling seen in CDH-PH.
PubMed: 38588643
DOI: 10.1159/000537802 -
Scientific Reports Sep 2023Congenital diaphragmatic hernia (CDH) is a severe birth defect frequently associated with pulmonary hypoplasia, pulmonary hypertension, and heart failure. Since amniotic...
Congenital diaphragmatic hernia (CDH) is a severe birth defect frequently associated with pulmonary hypoplasia, pulmonary hypertension, and heart failure. Since amniotic fluid comprises proteins of both fetal and maternal origin, its analysis could provide insights on mechanisms underlying CDH and provide biomarkers for early diagnosis, severity of pulmonary changes and treatment response. The study objective was to identify proteomic changes in amniotic fluid consistently associated with CDH. Amniotic fluid was obtained at term (37-39 weeks) from women with normal pregnancies (n = 5) or carrying fetuses with CDH (n = 5). After immuno-depletion of the highest abundance proteins, off-line fractionation and high-resolution tandem mass spectrometry were performed and quantitative differences between the proteomes of the groups were determined. Of 1036 proteins identified, 218 were differentially abundant. Bioinformatics analysis showed significant changes in GP6 signaling, in the MSP-RON signaling in macrophages pathway and in networks associated with cardiovascular system development and function, connective tissue disorders and dermatological conditions. Differences in selected proteins, namely pulmonary surfactant protein B, osteopontin, kallikrein 5 and galectin-3 were validated by orthogonal testing using ELISA in larger cohorts and showed statistically significant differences aiding in the diagnosis and prediction of CDH. The findings provide potential tools for clinical management of CDH.
Topics: Pregnancy; Humans; Female; Hernias, Diaphragmatic, Congenital; Amniotic Fluid; Proteomics; Proteome; Biomarkers
PubMed: 37726509
DOI: 10.1038/s41598-023-42576-2