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Journal of Cardiovascular Development... Sep 2023Transcatheter device closure of patent ductus arteriosus (PDA) in preterm infants has been proven to be a feasible and safe technique with promising results when... (Review)
Review
Transcatheter device closure of patent ductus arteriosus (PDA) in preterm infants has been proven to be a feasible and safe technique with promising results when compared to surgical ligation. However, managing transport and anaesthesia in extremely premature infants with haemodynamically significant PDA and limited reserves presents unique challenges. This review article focuses on the key considerations throughout the clinical pathway for the PDA device closure, including referral hospital consultation, patient selection, intra- and inter-hospital transport, and anaesthesia management. The key elements encompass comprehensive patient assessment, meticulous airway management, optimised ventilation strategies, precise thermoregulation, patient-tailored sedation protocols, vigilant haemodynamic monitoring, and safe transport measures throughout the pre-operative, intra-operative, and post-operative phases. A multidisciplinary approach enhances the chances of procedure success, improves patient outcomes, and minimises the risk of complications.
PubMed: 37754806
DOI: 10.3390/jcdd10090377 -
Journal of Pediatric Orthopedics Mar 2022Premature radial physeal closure is a relatively rare occurrence in children. When isolated growth arrest of the radius with continued ulnar growth occurs, the resulting...
INTRODUCTION
Premature radial physeal closure is a relatively rare occurrence in children. When isolated growth arrest of the radius with continued ulnar growth occurs, the resulting ulnar positive deformity leads to altered wrist mechanics and pain. Timely epiphysiodesis of the distal ulna with and without ulnar shortening osteotomy can address these issues, but continued ulnar overgrowth is a possible complication. We seek to evaluate the success rate of the primary epiphysiodesis of the ulna and associated clinical outcomes.
METHODS
A chart review was conducted at 2 children's hospitals from 2008 to 2019. Patients between the ages of 6 and 18 years old, with premature distal radius physeal closure, with or without positive ulnar variance, and >2 months follow-up were included. We evaluated the following characteristics for each patient: demographics, initial cause of premature radial physeal closure, ulnar variance, additional procedures performed during epiphysiodesis, preoperative and postoperative pain, range of motion, instability. Summary statistics were conducted and expressed as proportions, medians and means. A paired t test evaluated change in ulnar variance for those who had an ulnar shortening osteotomy performed.
RESULTS
Thirty-one wrists among 30 patients were identified, and the median age at the time of surgery was 12.2 years (interquartile range: 3.4). Ulnar shortening osteotomies were performed in 53.1% of cases and distal radius osteotomy in 15.6%. Bone graft was utilized in 25.8% of the epiphysiodesis procedures. There were 2 failures of primary epiphysiodesis indicating an index success rate of 93.7%. The average ulnar variance correction was 3.1 mm (95% confidence interval: 1.9, 4.4). The mean physeal time to closure was 134 days. Preoperative symptoms were resolved for 90.6% cases at final follow-up.
CONCLUSION
Ulnar epiphysiodesis successfully terminates ulnar physeal growth in 93.7% of cases. Preoperative symptoms were completely resolved with a median physeal closure of just over 4 months. Ulnar variance was corrected on average by 4.1 mm when a radial or ulnar shortening osteotomy was performed at the time of epiphysiodesis.
LEVEL OF EVIDENCE
Level IV-case series.
Topics: Child; Humans; Infant; Radius; Radius Fractures; Range of Motion, Articular; Ulna; Wrist Joint
PubMed: 35138298
DOI: 10.1097/BPO.0000000000001993 -
Translational Pediatrics Dec 2020The role of oxygen, reactive oxygen species (ROS), and isoprostanes (IsoPs) in regulating patency and closure of patent ductus arteriosus (PDA) have been studied in... (Review)
Review
The role of oxygen, reactive oxygen species (ROS), and isoprostanes (IsoPs) in regulating patency and closure of patent ductus arteriosus (PDA) have been studied in preterm infants. Also the possible correlation between a hemodynamically significant PDA and its pharmacological treatment with oxidative stress has been investigated. The National Library of Medicine (MEDLINE) database was searched without time limits. Available data demonstrate that free radicals are not always harmful and that ROS and IsoPs play a relevant role in DA closure. On the other hand, a hemodynamically significant PDA can cause oxidative stress and this can partially explain its association with other complications of prematurity related to oxidative stress, such as bronchopulmonary dysplasia (BPD), intraventricular haemorrhage (IVH), and necrotizing enterocolitis (NEC). Some drugs used for pharmacological closure, such as ibuprofen, also have antioxidant effects, and the closure of PDA can restore a proper tissue oxygenation and the balance between pro-oxidant and antioxidant factors. These data support the importance of the relationship between PDA and oxidative stress whose understanding increase our awareness when we approach this prematurity complication in the clinical practice. Further studies might assess the reliability of ROS as possible biomarkers of the risk of developing a hsPDA.
PubMed: 33457306
DOI: 10.21037/tp-20-121 -
Seminars in Perinatology Mar 2023While cyclooxygenase inhibitors have been the most common medications used to facilitate earlier closure of patent ductus arteriosus in preterm infants, adverse effects... (Review)
Review
While cyclooxygenase inhibitors have been the most common medications used to facilitate earlier closure of patent ductus arteriosus in preterm infants, adverse effects and low efficacy in extremely low gestational age neonates (ELGANs) have highlighted a need for alternative options. Combination therapy with acetaminophen and ibuprofen is a novel strategy for PDA treatment in ELGANs, as it may facilitate higher ductal closure rates via additive action on two separate pathways inhibiting prostaglandin production. Initial small observational studies and pilot randomized clinical trials indicate potentially higher efficacy of the combination regime to induce ductal closure in comparison to treatment with ibuprofen alone. In this review, we examine the potential clinical impact of treatment failure in ELGANs with significant PDA, highlight the biological rationale in support of studying combination therapy, and review the randomized and non-randomized studies to date. With the rising number of ELGANs receiving neonatal intensive care, who are vulnerable to PDA-related morbidities, there is an urgent need for adequately powered clinical trials to systematically investigate the efficacy and safety of combination therapy for PDA treatment.
Topics: Infant, Newborn; Humans; Ductus Arteriosus, Patent; Infant, Premature; Ibuprofen; Indomethacin; Infant, Low Birth Weight
PubMed: 36914507
DOI: 10.1016/j.semperi.2023.151720 -
Journal of Perinatology : Official... Oct 2023Patent ductus arteriosus (PDA) is the most common cardiovascular condition diagnosed in premature infants. Acetaminophen was first proposed as a potential treatment for... (Review)
Review
Patent ductus arteriosus (PDA) is the most common cardiovascular condition diagnosed in premature infants. Acetaminophen was first proposed as a potential treatment for PDA in 2011. Since that time acetaminophen use among extremely preterm neonates has increased substantially. The limited available data demonstrate that acetaminophen reduces PDA without evident hepatotoxicity. These findings have led some to suggest that acetaminophen is a safe and effective therapy for PDA closure. However, the lack of apparent hepatoxicity is predictable. Acetaminophen induced cellular injury is due to CYP2E1 derived metabolites; and hepatocyte CYP2E1 expression is low in the fetal and neonatal period. Here, we review preclinical and clinical data that support the hypothesis that the lung, which expresses high levels of CYP2E1 during fetal and early postnatal development, may be particularly susceptible to acetaminophen induced toxicity. Despite these emerging data, the true potential pulmonary risks and benefits of acetaminophen for PDA closure are largely unknown. The available clinical studies in are marked by significant weakness including low sample sizes and minimal evaluation of extremely preterm infants who are typically at highest risk of pulmonary morbidity. We propose that studies interrogating mechanisms linking developmentally regulated, cell-specific CYP2E1 expression and acetaminophen-induced toxicity as well as robust assessment of pulmonary outcomes in large trials that evaluate the safety and efficacy of acetaminophen in extremely preterm infants are needed.
Topics: Infant, Newborn; Humans; Ductus Arteriosus, Patent; Acetaminophen; Indomethacin; Infant, Low Birth Weight; Ibuprofen; Cytochrome P-450 CYP2E1; Infant, Extremely Premature
PubMed: 37169914
DOI: 10.1038/s41372-023-01697-2 -
Plastic and Reconstructive Surgery Mar 2022Facial sutures contribute significantly to postnatal facial development, but their potential role in craniofacial disease is understudied. Since interest in their... (Review)
Review
Facial sutures contribute significantly to postnatal facial development, but their potential role in craniofacial disease is understudied. Since interest in their development and physiology peaked in the mid-twentieth century, facial sutures have not garnered nearly the same clinical research interest as calvarial sutures or cranial base endochondral articulations. In addition to reinforcing the complex structure of the facial skeleton, facial sutures absorb mechanical stress and generally remain patent into and beyond adolescence, as they mediate growth and refine the shape of facial bones. However, premature closure of these sites of postnatal osteogenesis leads to disrupted growth vectors and consequent dysmorphologies. Although abnormality in individual sutures results in isolated facial deformities, we posit that generalized abnormality across multiple sutures may be involved in complex craniofacial conditions such as syndromic craniosynostosis. In this work, the authors comprehensively review 27 key facial sutures, including physiologic maturation and closure, contributions to postnatal facial development, and clinical consequences of premature closure.
Topics: Cranial Sutures; Craniosynostoses; Facial Bones; Humans
PubMed: 35196691
DOI: 10.1097/PRS.0000000000008816 -
Cureus Sep 2023In preterm newborns with extremely low birth weights, patent ductus arteriosus (PDA), which is defined as a remnant connection between the aorta and pulmonary artery... (Review)
Review
In preterm newborns with extremely low birth weights, patent ductus arteriosus (PDA), which is defined as a remnant connection between the aorta and pulmonary artery after 72 hours of birth, is frequently linked to substantial morbidity and mortality. If left untreated, a hemodynamically significant PDA (hsPDA) increases the risk for bronchopulmonary dysplasia, necrotizing enterocolitis, and intraventricular hemorrhage among other morbidities, and can even lead to death. While instances of patent ductus arteriosus (PDA) resolving on their own are frequent, the primary approach for managing PDA closure in premature infants involves pharmacological interventions, commonly utilizing indomethacin, ibuprofen, or paracetamol. However, with these pharmacological treatment options, there is an increased risk of renal toxicity, gastrointestinal bleeding, and reopening of PDA among other complications. If pharmacological interventions are not successful or contraindicated, PDA can be closed via transcatheter closure or surgical ligation. As with any medically invasive procedure, it is not without risks and can lead to long-term complications. This review explores the different management options and the benefits and outcomes of conservative management vs. active management in order to get one step closer to standardizing the treatment for PDA. With so much controversy surrounding the best management option, there is a lack of evidence to support one treatment method superior to the other in reducing overall mortality, and this needs to be explored further.
PubMed: 37829984
DOI: 10.7759/cureus.45009 -
Tropical Animal Health and Production Dec 2022In this work, we investigated cases of birth of calves with congenital defects in a farm in Southern Brazil. Only calves born from heifers were affected, and the disease...
In this work, we investigated cases of birth of calves with congenital defects in a farm in Southern Brazil. Only calves born from heifers were affected, and the disease occurred in both crossbred and purebred calves. Three necropsies were performed, tissues were collected for histopathology, and samples of liver of calves, blood serum, and food provided for cows and heifers were collected to quantify the levels of the minerals: manganese, copper, and zinc. The calves were born weak, with disproportionate dwarfism, limb deformities, and enlarged joints. Heads were shortened and domed. Long bones had a shortened diaphysis and a normal-sized epiphysis, when compared to the control. In one of the cases, there were white-yellowish lines on the metaphyseal surface of the epiphyseal plate. Histopathology of growth plates revealed premature closure, disarrangement of chondrocyte columns, and collapse of primary spongiosa. These findings supported a diagnosis of chondrodysplasia. Liver manganese levels were under the reference values in the three calves. Food analysis revealed insufficient levels of manganese in the diet of heifers, especially in sorghum silage, which was provided as the main source of food for the category in some periods. Approximately 6 months after the diet was changed, the problem ceased and only normal calves continued to be born. Our findings allowed to conclude the diagnosis of chondrodysplasia of nutritional origin and reinforce the thesis that manganese is the mineral deficient in these cases.
Topics: Animals; Cattle; Female; Manganese; Brazil; Minerals; Copper; Zinc; Cattle Diseases
PubMed: 36565391
DOI: 10.1007/s11250-022-03438-7 -
The American Journal of Medicine Sep 2020Facial paralysis is the most common cranial nerve paralysis and the majority of these are idiopathic. Idiopathic facial nerve paralysis, or Bell palsy, typically... (Review)
Review
Facial paralysis is the most common cranial nerve paralysis and the majority of these are idiopathic. Idiopathic facial nerve paralysis, or Bell palsy, typically presents acutely, affects the entire face, may be associated with hyperacusis, a decrease in lacrimation, salivation, or dysgeusia, and typically resolves spontaneously. The diagnosis of idiopathic facial paralysis is made after a thorough history and physical examination to exclude alternative etiologies and follow-up to ensure recovery of facial function. Atypical presentation, recurrent paralysis, additional neurologic deficits, lack of facial recovery in 2-3 months, or a history of head and neck or cutaneous malignancy are concerning for alternative causes of facial paralysis requiring workup. The erroneous use of the eponym Bell palsy to refer to all causes of facial paralysis, regardless of the history and presentation, may result in cognitive errors, including premature closure, anchoring bias, and diagnosis momentum. Hence, we recommend replacing the eponym Bell palsy with idiopathic facial nerve paralysis.
Topics: Bell Palsy; Facial Nerve; Facial Paralysis; Humans
PubMed: 32445717
DOI: 10.1016/j.amjmed.2020.04.023 -
Paediatric Drugs Mar 2022The hemodynamic impact of persistent patent ductus arteriosus (PDA) is associated with neonatal morbidities and mortality in preterm newborns. While there has been... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The hemodynamic impact of persistent patent ductus arteriosus (PDA) is associated with neonatal morbidities and mortality in preterm newborns. While there has been considerable debate about optimal management of PDA and its impact on clinical outcomes, there is widespread variation in practice, such as using different pharmacotherapies to achieve closure of hemodynamically significant PDA during the first week of life in very low birth weight infants.
AIMS
The objective was to estimate the efficacy of acetaminophen, ibuprofen, and indomethacin with regard to ductal closure and to compare the costs of these three commonly used medications to treat PDA in preterm infants.
METHODS
PubMed, Embase, and Cochrane Registry were searched for trials from the years 2010-2020. We identified 17 randomized clinical trials (RCTs) and 14 case series that enrolled preterm infants < 37 weeks gestational age for inclusion. Pooled estimates of closure rates for acetaminophen (n = 630), ibuprofen (n = 694), and indomethacin (n = 312) were analyzed using the weighted proportion ratio using a Mantel‑Haenszel random effects model. The chi-squared test of proportions was used to determine significance between groups. We accessed cost estimates of pharmacotherapy from the Lexi-Comp average wholesale price database and utilized a decision tree model to appraise cost benefits for the outcome measure of successful PDA closure.
RESULTS
The pooled proportional point estimates of closure rates from RCTs for acetaminophen, ibuprofen, and indomethacin were 70.1% (95% confidence interval [CI] 60-80), 63.4% (95% CI 52.8-74.1), and 71.5% (95% CI 62.3-80.7), respectively. There was no significant statistical difference in closure rates when RCTs and uncontrolled case series were combined. Pairwise comparisons showed both acetaminophen and indomethacin were each more effective in closing PDA than ibuprofen (acetaminophen vs indomethacin: p = 0.01; ibuprofen vs indomethacin: p = 0.02; acetaminophen vs indomethacin: p = 0.93). Comparing costs for successful closure of PDA, at the average wholesale price of different medications, suggested that treatment with acetaminophen costs significantly less, with a mean of $1487 (95% CI 1300-1737), compared to ibuprofen, with a mean of $2585 (95% CI 2214-3104), and indomethacin, with a mean of $2661 (95% CI 2358-3052), per course of treatment.
CONCLUSIONS
Our meta-analysis suggests acetaminophen is non-inferior to both indomethacin and ibuprofen, and costs relatively less for successful PDA constriction in premature infants. Further clinical trials are warranted to compare acetaminophen's safety, along with short- and long-term effects, to help resolve the clinical conundrum of the necessity of early treatment in the management of PDA, and the optimal pharmacological course, if indicated.
Topics: Ductus Arteriosus, Patent; Humans; Ibuprofen; Indomethacin; Infant, Newborn; Infant, Premature; Infant, Very Low Birth Weight
PubMed: 35229248
DOI: 10.1007/s40272-022-00495-1