Augusto Frederico Schmidt

Evolution of critically ill patients with gastroschisis from three tertiary centers

OBJECTIVES AND INTRODUCTION: Gastroschisis is a congenital abdominal wall defect with increasing occurrence worldwide over the past 20–30 years. Our aim was to analyze the morbidity of newborns after gastroschisis closure, with emphasis on metabolic and hydroelectrolyte disturbances in patients at three tertiary university centers. METHODS: From January 2003 to June 2009, the following patient data were collected retrospectively: (A) Background maternal and neonatal data: maternal age, prenatal diagnosis, type of delivery, Apgar scores, birth weight, gestational age and sex; (B) Surgical modalities: primary or staged closure; and (C) Hospital course: levels of serum sodium and levels of serum albumin in the two first postoperative days, number of ventilation days, other postoperative variables and survival. Statistical analyses were used to examine the associations between some variables. RESULTS: 163 newborns were included in the study. Primary closure of the abdominal defect was performed in 111 cases (68.1%). The mean serum sodium level was 127.4±6.7 mEq/L, and the mean serum albumin level was 2.35±0.5 g/dL. Among the correlations between variables, it was verified that hyponatremia and hypoalbuminemia correlated with the number of days on the ventilator but not with the number of days on total parenteral nutrition (TPN); mortality rate correlated with infection. The final survival rate was 85.9%. CONCLUSION: In newborns with gastroschisis, more aggressive attention to hyponatremia and hypoalbuminemia would improve the outcome.

Inflammatory response in a rat model of gastroschisis is associated with an increase of NF-kappaB.

Babies with gastroschisis have high morbidity, which is associated with inflammatory bowel injury caused by exposure to amniotic fluid. The objective of this study was to identify components of the inflammatory response in the intestine and liver in an experimental model of gastroschisis in rats. The model was surgically created at 18.5 days of gestation. The fetuses were exposed through a hysterotomy and an incision at the right of the umbilicus was made, exposing the fetal bowel. Then, the fetus was placed back into the uterus until term. The bowel in this model had macro- and microscopic characteristics similar to those observed in gastroschisis. The study was conducted on three groups of 20 fetuses each: gastroschisis, control, and sham fetuses. Fetal body, intestine and liver weights and intestine length were measured. IL-1beta, IL-6, IL-10, TNF-alpha, IFN-gamma and NF-kappaB levels were assessed by ELISA. Data were analyzed statistically by ANOVA followed by the Tukey post-test. Gastroschisis fetuses had a decreased intestine length (means +/- SD, 125 +/- 25 vs 216 +/- 13.9; P < 0.005) and increased intestine weight (0.29 +/- 0.05 vs 0.24 +/- 0.04; P < 0.005). Intestine length correlated with liver weight only in gastroschisis fetuses (Pearsons correlation coefficient, r = 0.518, P = 0.019). There were no significant differences in the concentrations of IL-1beta, TNF-alpha or IFN-gamma in the intestine, whereas the concentration of NF-kappaB was increased in both the intestine and liver of fetuses with gastroschisis. These results show that the inflammatory response in the liver and intestine of the rat model of gastroschisis is accompanied by an increase in the amount of NF-kappaB in the intestine and liver.

Antenatal steroid and tracheal occlusion restore vascular endothelial growth factor receptors in congenital diaphragmatic hernia rat model

OBJECTIVEnInvestigate the effects of antenatal steroids and tracheal occlusion on pulmonary expression of vascular endothelial growth factor receptors in rats with nitrofen-induced congenital diaphragmatic hernia.nnnSTUDY DESIGNnFetuses were exposed to nitrofen at embryonic day 9.5. Subgroups received dexamethasone or were operated on for tracheal occlusion, or received combined treatment. Morphologic variables were recorded. To analyze vascular endothelial growth factor receptor 1 and vascular endothelial growth factor receptor 2 expression, we performed Western blotting and immunohistochemistry. Morphologic variables were analyzed by analysis of variance and immunohistochemistry by Kruskal-Wallis test.nnnRESULTSnCongenital diaphragmatic hernia decreased body weight, total lung weight, and lung-to-body weight ratio. Tracheal occlusion increased total lung weight and lung-to-body weight ratio (P < .05). Fetuses with congenital diaphragmatic hernia had reduced vascular endothelial growth factor receptor 1 and vascular endothelial growth factor receptor 2 expression, whereas steroids and tracheal occlusion increased their expression. Combined treatment increased expression of receptors, but had no additive effect.nnnCONCLUSIONnVascular endothelial growth factor signaling disruption may be associated with pulmonary hypertension in congenital diaphragmatic hernia. Tracheal occlusion and steroids provide a pathway for restoring expression of vascular endothelial growth factor receptors.

Does staged closure have a worse prognosis in gastroschisis

INTRODUCTION: Correction of gastroschisis can be accomplished by primary or staged closure. There is, however, no consensus regarding the best approach or criteria to favor one method over the other has been established. OBJECTIVE: To compare the outcome of primary and staged closure in newborns with gastroschisis using intravesical pressure (IVP) as the decision criterion. PATIENTS & METHODS: We prospectively analyzed 45 newborns with gastroschisis. An IVP with a threshold of 20 cm H2O was used to indicate primary or staged closure, and the outcomes between the two methods were compared. RESULTS AND DISCUSSION: Newborns in whom primary closure was feasible were born at a lower gestational age. There was no significant difference in the frequency of complications, time to begin oral feeding, length of parenteral nutrition or length of hospital stay. Compared with previous reports, our data showed higher rates of prenatal diagnosis and cesarean delivery, a lower average birth weight, a higher rate of small gestational age babies and a more frequent association with intestinal atresia. Conversely, our data showed a lower rate of postoperative necrotizing enterocolitis and a lower average length of hospital stay. CONCLUSION: No significant difference was observed in the outcome of newborns who underwent primary closure or staged closure of gastroschisis when using an IVP below 20 cm H2O as the criterion for primary closure.

Hydrogel protection: a novel approach to reduce bowel inflammation in experimental gastroschisis §

OBJECTIVEnIn gastroschisis there is herniation of the fetal bowel into the amniotic cavity that results in severe intestinal dysfunction. In order to reduce bowel exposure to amniotic fluid we used a hydrogel of N-isopropylacrylamide copolymerized with acrylic acid (P(NIPAAm-co-AAc)) to coat the herniated bowel through the use of a fibrin adhesive (Beriplast).nnnSTUDY DESIGNnGastroschisis was created in fetuses of 31 pregnant Sprague-Dawley rats by evisceration of the bowel through a right paramedian incision in the abdominal wall on day 18.5 of pregnancy. The fetuses were separated in four groups of 12 fetuses: control (C), gastroschisis (G), gastroschisis+fibrin adhesive (GA) and gastroschisis+fibrin adhesive+dry hydrogel (GAH). Animals were harvested at day 21.5 of pregnancy and the hydrogel was removed. Fetuses and bowels were weighed and morphometric analysis was performed. Isoelectric focusing of the amniotic fluid determined its electrical charge. We evaluated the hydrogel swelling ratio (Q) in the amniotic fluid. Histological analysis and scanning electronic microscopy (SEM) of the bowel and hydrogel were performed. Our primary outcome was bowel intactness after hydrogel removal and our secondary outcome was the effectiveness of the hydrogel in protecting the bowel against amniotic fluid and its components. Differences among the groups were tested by the ANOVA and Tukey-Kramer post-test method and the statistical significance accepted was for p values <0.05.nnnRESULTSnThe mass of swollen hydrogel was 34 times the mass of dry hydrogel. Isoelectric focusing of the amniotic fluid showed that most of its proteins are negatively charged as the hydrogel. SEM showed that removal of the hydrogel did not damage bowel serosa. Bowel weight, diameter and wall thickness were similar between groups C and GAH but bowel diameter and wall thickness was significantly reduced in C and GAH compared to G and GA (p<0.001).nnnCONCLUSIONnThe P(NIPAAm-co-AAc) hydrogel does not harm the bowel and provides a safe effective protection with reduction of bowel damage in gastroschisis.

Monitoring intravesical pressure during gastroschisis closure. Does it help to decide between delayed primary or staged closure

Introduction and objective: Correction of gastroschisis may be accomplished by either primary or staged closure or even delayed primary closure after the use of a preformed silo. However, there is neither a consensus on the best approach nor established criteria to favor one method over the other. The aim of this paper was to investigate the role of intravesical pressure (IVP) as a tool to prevent abdominal compartment syndrome in newborns undergoing correction of abdominal wall defects. Methods: We retrospectively analyzed 45 newborns with gastroschisis in whom trans-operative intravesical pressure was used to choose between primary or staged closure. A threshold of 20u2009cm H2O was used and the outcomes between the two methods were compared. Results: In 24 children delayed primary closure was achieved while the remaining 21 underwent staged reduction and closure. There was no difference in the frequency of complications, time to begin oral feeding, length of parenteral nutrition or length of hospital stay between the children of the two groups. The incidence of temporary oliguria or anuria, averaged 33% and it was similar in both groups of children. Conclusion: The data here presented suggests that monitoring intraoperative IVP during correction of gastroschisis may help to select children in whom staged closure is necessary, keeping their complication rate and overall outcome similar to that of children undergoing delayed primary closure. Further prospective studies should investigate more deeply the correlation between type of closure and the development of a compartment syndrome.

The female condom as a temporary silo: a simple and inexpensive tool in the initial management of the newborn with gastroschisis.

Objective. The aim of this study is to report the use of a female condom as a non-surgical silon pouch in the early management of newborns with gastroschisis with large visceroabdominal disproportion. Methods. Pre-washed, sterile female condoms without spermicide were used as an early approach to treat gastroschisis in 20 newborns with large defects and in whom staged correction was anticipated. The condom was placed in the neonatal intensive care unit using sterile technique, with no anesthesia, and it was removed only at the time of the surgical procedure for gastroschisis correction. Results. There were no complications associated with the use of a female condom as a temporary silo for gastroschisis. It protected the exposed organs and also allowed a careful evaluation of the bowel and a better pre-operative planning without the need for emergency procedures. Conclusion. The use of a female condom as a silon pouch is a low-cost and simple alternative in the initial management of newborns with gastroschisis in whom primary correction is considered non-feasible.

Evaluation of nitric oxide (NO) and nitric oxide synthases (NOS) in the amniotic fluid in an experimental gastroschisis rat model.

UNLABELLEDnIntestinal damage due to gastroschisis (G), an anomaly found with increasing incidence by pediatric surgeons, is intimately associated with endogenous nitric oxide (NO) production and NO synthase (NOS) expression.nnnAIMnAim of the study was to evaluate NO production and NOS isoforms in the intestine and amniotic fluid (AF) using a rat model of gastroschisis.nnnMETHODSnA gastroschisis rat model was surgically created at 18.5 days of gestation (term=22 days). 3 groups of 12 fetuses each were studied: control (C), sham (S) and (G). Morphometric data of body weight (BW), intestinal weight (IW) and the IW/BW ratio were evaluated and compared. Indirect quantification of NO (nitrite and nitrate - NOx) was analyzed by chemiluminescence, and the expression of the 3 isoforms was analyzed by Western blotting.nnnRESULTSnGroup G showed an increase in IW and IW/BW compared with groups C and S. IW: G=0.27 ± 0.06, C=0.20 ± 0.02, S=0.20 ± 0.02 (p<0.01); IW/BW: G=4.11 ± 0.57, C=5.21 ± 1.04, S=5.18 ± 1.23 (p<0.05). NO in the G group was lower in the intestine and higher in AF, as opposed to C and S, where it had increased in the intestine and decreased in AF. Intestinal NOx: G=0.85 ± 0.28, C=1.86 ± 0.82, S=1.80 ± 0.69 (p<0.05); NOx in AF: G=161.87 ± 52.11, C=6.99 ± 5.45, S=48.73 ± 13.183 (p<0.001).nnnCONCLUSIONnThe intestinal inflammation in gastroschisis promotes the release of nitric oxide to the environment (AF). Perhaps NO in the AF may be an inflammatory marker for G.

The cholinergic response is increased in isolated ileum from gastroschisis rat model.

IntroductionBabies with gastroschisis (G) have high morbidity rate and long hospital stay due to bowel hypomotility caused by chronic exposure of the bowel to the amniotic fluid. Our aim was to evaluate the reactivity of isolated ileum in fetal rats selected for experimental gastroschisis.MethodG was surgically created at 18.5xa0days of gestation (termxa0=xa022xa0days). Concentration-dependent curve to the muscarinic agonist methacholine (1–30xa0μM) and contractions induced by electrical field stimulation (EFS, 1–16xa0Hz, 50xa0V, 1xa0ms) were carried out in isolated ileum of groups control (C), sham (S) and gastroschisis (G) (nxa0=xa030). Protein expression for M3 was assessed by western blot analysis.ResultsThe frequency and amplitude of spontaneous contractions were decreased in G (pxa0<xa00.001). Methacholine produced concentration-dependent contractions being the maximal response values higher in G (pxa0<xa00.01). EFS-induced frequency-dependent contractions showed 1.8 times higher in G as well as an increase of M3 expression.ConclusionThe frequency and the amplitude of rhythmic contractions were reduced along with an increase in the contraction induced by mucarinic agonist and by EFS in G. These results suggest the occurrence of an adaptative supersensitivity to cholinergic response via increases in the protein expression for M3 receptor.

Torcicolo congênito: avaliação de dois tratamentos fisioterapêuticos

ABSTRACT Objective: To evaluate the clinical course and to compare the effectiveness of physiotherapeutic treatment performed daily or once a week in newborns and infants with congenital torticollis. Methods: 47 patients with congenital torticollis were assisted at the Physiotherapy and Pediatric Surgery Services of the Clinical Hospital of Campinas University. The fol-lowing data were retrospectively collected: maternal and neonatal history, clinical presentation and physiothera-peutic treatment classified according to the frequency of the exercises. Intensive treatment was defined as sessions performed at the daycare clinic by the physiotherapist plus daily sessions performed by parents at home. Mini-mal treatment was defined as weekly sessions performed only by the physiotherapist at the daycare clinic, without participation of the parents. Results: The demographic characteristics of the stud-ied patients were: mean maternal age=26 years; first gestation=35 (75%); vaginal delivery=40 (85%); mean age at diagnosis =50 days. A sternomastoid nodule was felt seen