Outcomes of congenital diaphragmatic hernia in the modern era of management.

OBJECTIVE: To identify clinical factors associated with pulmonary hypertension (PH) and mortality in patients with congenital diaphragmatic hernia (CDH). STUDY DESIGN: A prospective cohort of neonates with a diaphragm defect identified at 1 of 7 collaborating medical centers was studied. Echocardiograms were performed at 1 month and 3 months of age and analyzed at a central core by 2 cardiologists independently. Degree of PH and survival were tested for association with clinical variables using Fischer exact test, χ(2), and regression analysis. RESULTS: Two hundred twenty patients met inclusion criteria. Worse PH measured at 1 month of life was associated with higher mortality. Other factors associated with mortality were need for extracorporeal membrane oxygenation, patients inborn at the treating center, and patients with a prenatal diagnosis of CDH. Interestingly, patients with right sided CDH did not have worse outcomes. CONCLUSIONS: Severity of PH is associated with mortality in CDH. Other factors associated with mortality were birth weight, gestational age at birth, inborn status, and need for extracorporeal membrane oxygenation.

Prenatal MRI Findings of Fetuses with Congenital High Airway Obstruction Sequence

OBJECTIVE: To define the MRI findings of congenital high airway obstruction sequence (CHAOS) in a series of fetuses. MATERIALS AND METHODS: Prenatal fetal MR images were reviewed in seven fetuses with CHAOS at 21 to 27 weeks of gestation. The MRI findings were reviewed. The MRI parameters evaluated included the appearance of the lungs and diaphragm, presence or absence of hydrops, amount of amniotic fluid, airway appearance, predicted level of airway obstruction, and any additional findings or suspected genetic syndromes. RESULTS: All the fetuses viewed (7 of 7) demonstrated the following MRI findings: dilated airway below the level of obstruction, increased lung signal, markedly increased lung volumes with flattened or inverted hemidiaphragms, massive ascites, centrally positioned and compressed heart, as well as placentomegaly. Other frequent findings were anasarca (6 of 7) and polyhydramnios (3 of 7). MRI identified the level of obstruction as laryngeal in five cases and tracheal in two cases. In four of the patients, surgery or autopsy confirmed the MRI predicted level of obstruction. Associated abnormalities were found in 4 of 7 (genetic syndromes in 2). Postnatal radiography (n = 3) showed markedly hyperinflated lungs with inverted or flattened hemidiaphragms, strandy perihilar opacities, pneumothoraces and tracheotomy. Two fetuses were terminated and one fetus demised in utero. Four fetuses were delivered via ex utero intrapartum treatment procedure. CONCLUSION: MRI shows a consistent pattern of abnormalities in fetuses with CHAOS, accurately identifies the level of airway obstruction, and helps differentiate from other lung abnormalities such as bilateral congenital pulmonary airway malformation by demonstrating an abnormally dilated airway distal to the obstruction.

Pentobarbital prevents the development of C-fiber-induced hyperalgesia in the rat.

Noxious stimuli applied to the skin can produce long-lasting, C-fiber-dependent, secondary hyperalgesia that is mediated by central mechanisms. NMDA receptor antagonists and low doses of morphine can preferentially block the development of hyperalgesia without significantly altering unpotentiated responses to nociceptive stimuli. The aim of our study was to determine if low doses of pentobarbital can also preferentially alter either hyperalgesic or unpotentiated responses to nociceptive heat stimuli in spinalized and intact rats. Our results demonstrate the following. (1) Mustard oil applied above the ankle joint or electrical stimulation of the sciatic nerve at C-fiber intensity in spinalized, unanesthetized rats decreased the latency to withdrawal of the foot from water maintained at 47-49 degrees C. This secondary hyperalgesia to thermal stimulation persisted for at least 1 h and was most likely mediated by central mechanisms. (2) Pentobarbital in both spinalized and spinal cord-intact rats prevented the development of the late component (42-120 min) but only partially decreased the early (2-6 min) component of hyperalgesia. In contrast, pentobarbital had relatively minimal effects on unpotentiated withdrawal responses. Thus, pentobarbital is similar to morphine in its ability to prevent hyperalgesia, but may differ from the anesthetic isoflurane, which does not interfere with the development of hyperalgesia.