Christopher Collura

Left cardiac sympathetic denervation for the treatment of long QT syndrome and catecholaminergic polymorphic ventricular tachycardia using video-assisted thoracic surgery

BACKGROUND Long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT) are two of the most common, potentially lethal, cardiac channelopathies. Treatment strategies for the primary and secondary prevention of life-threatening polymorphic ventricular tachycardia/fibrillation include pharmacotherapy with beta-blockers, implantable cardioverter defibrillators, and left cardiac sympathetic denervation (LCSD). OBJECTIVES This study sought to report our institutional experience with LCSD using video-assisted thoracic surgery (VATS). METHODS From November 2005 through November 2008, 20 patients (8 female, average age at surgery 9.1 +/- 9.7 years, range 2 months to 42 years) underwent LCSD via either a traditional approach (N = 2) or VATS (N = 18). A total of 12 patients had genotype-positive LQTS (7 LQT1, 2 LQT2, 1 LQT3, 2 LQT1/LQT2), 2 had JLNS, 4 had genotype-negative LQTS, and 2 had CPVT1. Electronic medical records were reviewed for patient selection, perioperative complications, and short-term outcomes. RESULTS LCSD was performed as a secondary prevention strategy in 11 patients (8 LQTS patients, average QTc 549 ms) and as primary prevention in 9 patients (average QTc 480 ms). There were no perioperative complications, including no intraoperative ectopy, no uncontrolled hemorrhage, and no VATS cases requiring conversion to a traditional approach. The average length of available follow-up was 16.6 +/- 9.5 months (range 4 to 40 months). Among the 18 patients who underwent VATS-LCSD, the average time from operation to dismissal was 2.6 days (range 1 day to 15 days), the majority being next-day dismissals. Among those receiving LCSD as secondary prevention, there has been a marked reduction in cardiac events. CONCLUSIONS We present a series of 20 patients with LQTS and CPVT who underwent LCSD, 18 using VATS. The minimally invasive VATS surgical approach was associated with minimal perioperative complications, including no intraoperative ectopy and excellent immediate and short-term outcomes. Videoscopic denervation surgery, in addition to traditional LCSD, offers a safe and effective treatment option for the personalized medicine required for patients with LQTS/CPVT.

MicroRNA-mRNA interactions in a murine model of hyperoxia-induced bronchopulmonary dysplasia

BackgroundBronchopulmonary dysplasia is a chronic lung disease of premature neonates characterized by arrested pulmonary alveolar development. There is increasing evidence that microRNAs (miRNAs) regulate translation of messenger RNAs (mRNAs) during lung organogenesis. The potential role of miRNAs in the pathogenesis of BPD is unclear.ResultsFollowing exposure of neonatal mice to 80% O2 or room air (RA) for either 14 or 29 days, lungs of hyperoxic mice displayed histological changes consistent with BPD. Comprehensive miRNA and mRNA profiling was performed using lung tissue from both O2 and RA treated mice, identifying a number of dynamically regulated miRNAs and associated mRNA target genes. Gene ontology enrichment and pathway analysis revealed that hyperoxia modulated genes involved in a variety of lung developmental processes, including cell cycle, cell adhesion, mobility and taxis, inflammation, and angiogenesis. MiR-29 was prominently increased in the lungs of hyperoxic mice, and several predicted mRNA targets of miR-29 were validated with real-time PCR, western blotting and immunohistochemistry. Direct miR-29 targets were further validated in vitro using bronchoalveolar stem cells.ConclusionIn newborn mice, prolonged hyperoxia induces an arrest of alveolar development similar to that seen in human neonates with BPD. This abnormal lung development is accompanied by significant increases in the levels of multiple miRNAs and corresponding decreases in the levels of predicted mRNA targets, many of which have known or suspected roles in pathways altered in BPD. These data support the hypothesis that dynamic regulation of miRNAs plays a prominent role in the pathophysiology of BPD.

Emergency Video Telemedicine Consultation for Newborn Resuscitations: The Mayo Clinic Experience

OBJECTIVE To describe the Mayo Clinic experience with emergency video telemedicine consultations for high-risk newborn deliveries. PATIENTS AND METHODS From March 26, 2013, through December 31, 2015, the Division of Neonatal Medicine offered newborn telemedicine consultations to 6 health system sites. A wireless tablet running secure video conferencing software was used by the local care teams. Descriptive data were collected on all consultations. After each telemedicine consult, a survey was sent to the neonatologist and referring provider to assess the technology, teamwork, and user satisfaction. RESULTS During the study, neonatologists conducted 84 telemedicine consultations, and 64 surveys were completed. Prematurity was the most frequent indication for consultation (n=32), followed by respiratory distress (n=15) and need for advanced resuscitation (n=14). After the consult, nearly one-third of the infants were able to remain in the local hospital. User assessment of the technology revealed that audio and video quality were poor or unusable in 16 (25%) and 12 (18.8%) of cases, respectively. Providers failed to establish a video connection in 8 consults (9.5%). Despite technical issues, providers responded positively to multiple questions assessing teamwork (86.0% [n=37 of 43] to 100.0% [n=17 of 17] positive responses per question). In 93.3% (n=14 of 15) of surveyed cases, the local provider agreed that the telemedicine consult improved patient safety, quality of care, or both. CONCLUSION Telemedicine consultation for neonatal resuscitation improves patient access to neonatology expertise and prevents unnecessary transfers to a higher level of care. A highly reliable technology infrastructure that provides high-quality audio and video should be considered for any emergency telemedicine service.

Two Infants, Same Prognosis, Different Parental Preferences

A central principle of justice is that similar cases should be decided in similar ways. In pediatrics, however, there are cases in which 2 infants have similar diagnoses and prognoses, but their parents request different treatments. In this Ethics Rounds, we present such a situation that occurred in a single NICU. Three physician-ethicists analyze the issues.

Pediatric Palliative Care in the Intensive Care Unit

The chronicity of illness that afflicts children in Pediatric Palliative Care and the medical technology that has improved their lifespan and quality of life make prognostication extremely difficult. The uncertainty of prognostication and the available medical technologies make both the neonatal intensive care unit and the pediatric intensive care unit locations where many children will receive Pediatric Palliative Care. Health care providers in the neonatal intensive care unit and pediatric intensive care unit should integrate fundamental Pediatric Palliative Care principles into their everyday practice.

Physician views regarding the benefits and burdens of prenatal surgery for myelomeningocele

Objective:Examine how pediatric and obstetrical subspecialists view benefits and burdens of prenatal myelomeningocele (MMC) closure.Study design:Mail survey of 1200 neonatologists, pediatric surgeons and maternal–fetal medicine specialists (MFMs).Results:Of 1176 eligible physicians, 670 (57%) responded. Most respondents disagreed (68%, 11% strongly) that open fetal surgery places an unacceptable burden on women and their families. Most agreed (65%, 10% strongly) that denying the benefits of open maternal–fetal surgery is unfair to the future child. Most (94%) would recommend prenatal fetoscopic over open or postnatal MMC closure for a hypothetical fetoscopic technique that had similar shunt rates (40%) but decreased maternal morbidity. When the hypothetical shunt rate for fetoscopy was increased to 60%, physicians were split (49% fetoscopy versus 45% open). Views about burdens and fairness correlated with the likelihood of recommending postnatal or fetoscopic over open closure.Conclusion:Individual and specialty-specific values may influence recommendations about prenatal surgery.

From Goals of Care to Improved Family Outcomes in the Neonatal Intensive Care Unit: Determining the Intervention

Parents of critically ill infants often face intense psychosocial challenges in the neonatal intensive care unit (NICU) that can lead to strong emotional responses. The NICU experience can have untoward effects on mothers and fathers rooted in a marginalized role in protecting their babies. Many parents report feelings of helplessness and separation from their child during this critical course. Perceiving their infant in pain or observing their child’s fear and weakness have been described as key stressors. The events in the NICU, and especially experiencing the death of an infant in the hospital, can lead to posttraumatic stress disorder (PTSD) and poor health outcomes for parents. Unsatisfactory communication has been associated with increased rates of PTSD in family members of patients in the intensive care unit (ICU). Research has found that impaired communication can lead to increased stress for parents of infants in the NICU as well. Neonatal providers espouse a professional duty to provide open and honest information to facilitate parental decision making. In addition, they must be skilled in recognizing a family’s sociocultural and religious perspectives. This family-centered imperative directs relationship building and should prompt providers to partner with parents in establishing goals of care that represent the baby’s best interests and reflect the values of the family. In this issue of the Journal of Palliative Medicine, ClarkePounder, et al. describe important methods in capturing the content of provider communication with families in the NICU. Their research provides a vital proof of concept that neonatal providers and parents are willing to record bedside communication for the purpose of improvement. The work impressively captured the diminutive time parents’ voices are active in bedside rounds as well as the paucity of attention paid to psychosocial concerns. Albeit a single-center, small pilot study, these results alone may prove invaluable in contributing to a root-cause analysis for poor communication in the NICU. These data should inspire broader investigation to inform how unsatisfactory communication may influence stress, anxiety, and long-term mental and physical outcomes for parents. The lack of attention to psychosocial concerns and limiting a parent’s contributions to daily rounds runs counter to research describing predictors of family satisfaction. ICU care is more valued if spiritual needs of the family are optimized. Parents value religion and hope over medical talk in decisions regarding neonatal resuscitation. Families express significantly increased satisfaction with provider communication as well as decreased physician conflict when they participate in a greater amount of the medical decision making conversation in the ICU. Clarke-Pounder, et al. report findings that fail to prove the hypothesis that sharing family values and preferences with providers would increase dialogue about family concerns in the NICU. However, interpretation of this work should not go as far as to accept the null hypothesis. The authors discuss that by involving the family in a decision making tool, expectations may be recalibrated. Families in the intervention group expressed lower measures of satisfaction. The recalibration may have raised expectations, but the question remains whether bedside rounds are suitable for meaningful conversations meant to explore parental values. Establishing daily care plans for critically ill neonates involves reviewing clinical input and titrating intensive measures of treatment through multidisciplinary coordination. Medical speak and compromised parental input may be unavoidable during daily work rounds in the demanding NICU setting. Perhaps the family-centered objective of bedside rounds needs to be recalibrated. It could be unrealistic to expect effective parent-centered integration in this granular data-driven process. Measuring family-centered communication during rounds may not be the outcome of interest. This research incites further questions like whether satisfaction trends among families in the NICU would improve if they were provided a physical space separate from the cognitive and visceral bedside experience to personally explore goals of care with their baby’s providers? Would additional beside visits by neonatologists or interdisciplinary providers to review care plans and integrate goals improve the psychosocial care of families? Translating a decision making tool into improved family satisfaction may also be disproportionate to provider training. Physicians regularly dominate interactions with families, but maybe more concerning are the missed opportunities to identify, listen, and recognize emotional cues that inform value-driven preferences. Skills in advanced communication can modulate dissatisfaction and, more importantly, lessen psychological distress in the ICU. It remains unclear whether current simulation models of advanced communication training transfer to the bedside and impact quality of communication. Further unclear is whether physicians’ ability to build family-centered partnerships JOURNAL OF PALLIATIVE MEDICINE Volume 18, Number 2, 2015 a Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2015.1009

Outcomes of early inhaled nitric oxide use in premature African American neonates

ObjectiveMeta-analysis of individual-patient clinical trial data suggests that inhaled nitric oxide (iNO) improves respiratory outcomes in premature African American neonates. We hypothesized that early iNO therapy would be associated with lower mortality and less chronic lung disease (CLD) in extremely premature African American neonates.Study designWe conducted a retrospective cohort study of propensity score- and race-matched neonates 22–29 weeks gestation who were mechanically ventilated for treatment of respiratory distress and associated pulmonary hypertension (RDS + PPHN). We evaluated the association of iNO within 7 days of life with in-hospital mortality and CLD, using Cox proportional hazards regression and logistic regression, respectively.ResultAmong 178 matched pairs of African American patients, iNO was not associated with lower mortality (HR = 0.94, 95% CI 0.69–1.30) or less CLD (OR = 0.94, 95% CI 0.47–1.87).ConclusionsEarly, off-label iNO use is not associated with improved outcomes in premature African American neonates with RDS + PPHN.

Weighing the Social and Ethical Considerations of Maternal-Fetal Surgery

In this study, we describe how physicians weigh the importance of social and ethical considerations relevant to maternal-fetal surgery. OBJECTIVES: The ethics of maternal-fetal surgery involves weighing the importance of potential benefits, risks, and other consequences involving the pregnant woman, fetus, and other family members. We assessed clinicians’ ratings of the importance of 9 considerations relevant to maternal-fetal surgery. METHODS: This study was a discrete choice experiment contained within a 2015 national mail-based survey of 1200 neonatologists, pediatric surgeons, and maternal-fetal medicine physicians, with latent class analysis subsequently used to identify groups of physicians with similar ratings. RESULTS: Of 1176 eligible participants, 660 (56%) completed the discrete choice experiment. The highest-ranked consideration was of neonatal benefits, which was followed by consideration of the risk of maternal complications. By using latent class analysis, we identified 4 attitudinal groups with similar patterns of prioritization: “fetocentric” (n = 232), risk-sensitive (n = 197), maternal autonomy (n = 167), and family impact and social support (n = 64). Neonatologists were more likely to be in the fetocentric group, whereas surgeons were more likely to be in the risk-sensitive group, and maternal-fetal medicine physicians made up the largest percentage of the family impact and social support group. CONCLUSIONS: Physicians vary in how they weigh the importance of social and ethical considerations regarding maternal-fetal surgery. Understanding these differences may help prevent or mitigate disagreements or tensions that may arise in the management of these patients.