Clinical features of plastic bronchitis in children after congenital heart surgery.

BACKGROUND: Plastic bronchitis (PB) can occur in patients who have undergone congenital heart surgery (CHS). This study aimed to investigate the clinical features of PB in children after CHS. METHODS: We conducted a retrospective cohort study using the electronic medical record system. The study population consisted of children diagnosed with PB after bronchoscopy in the cardiac intensive care unit after CHS from May 2016 to October 2021. RESULTS: A total of 68 children after CHS were finally included in the study (32 in the airway abnormalities group and 36 in the right ventricular dysfunction group). All children were examined and treated with fiberoptic bronchoscopy. Pathogens were detected in the bronchoalveolar lavage fluid of 41 children, including 32 cases in the airway abnormalities group and 9 cases in the right ventricular dysfunction group. All patients were treated with antibiotics, corticosteroids (intravenous or oral), and budesonide inhalation suspension. Children with right ventricular dysfunction underwent pharmacological treatment such as reducing pulmonary arterial pressure. Clinical symptoms improved in 64 children, two of whom were treated with veno-arterial extracorporeal membrane oxygenation (ECMO) due to recurrent PB and disease progression. CONCLUSIONS: Children with airway abnormalities or right ventricular dysfunction after CHS should be alerted to the development of PB. Pharmacological treatment such as anti-infection, corticosteroids, or improvement of right ventricular function is the basis of PB treatment, while fiberoptic bronchoscopy is an essential tool for the diagnosis and treatment of PB. ECMO assistance is a vital salvage treatment for recurrent critically ill PB patients.

Comparison of the Ultrasound-Guided Supraclavicular and Infraclavicular Approaches for Subclavian Vein Cannulation in Children With Congenital Heart Disease.

OBJECTIVES: Central venous catheterization is used widely in critical pediatric patients. The authors sought to compare the success rate and safety of ultrasound-guided subclavian vein cannulation performed via infraclavicular and supraclavicular approaches. DESIGN: The authors compared the success rate of the first puncture and other information for cannulation in the children with congenital heart disease requiring central venous catheterization who were assigned randomly to the supraclavicular approach group (group A) or infraclavicular approach group (group B). SETTING: Medical university hospital pediatric cardiac intensive care units. PARTICIPANTS: Pediatric patients diagnosed with congenital heart disease in the preoperative period who were admitted to the cardiac intensive care unit and required subclavian vein catheterization. INTERVENTIONS: Ultrasound-guided subclavian vein cannulation. MEASUREMENTS AND MAIN RESULTS: Sixty-seven children were included in the study, with 32 in group A and 35 in group B. Notably, there was a significant difference in the success rate of the first puncture between groups A and B (90.6% v 71.4, %, p = 0.047). Furthermore, the access time in group A was 11.8 seconds (3.2-95), which was significantly shorter than that in group B (16.0 [6.5-227] seconds, p = 0.001). In addition, the catheter malposition rate in group A was significantly lower than that in group B (0% v 11.4%, p = 0.049). Conversely, there were no significant differences in the total access time, overall success rate, and complications (eg, pneumothorax, hemorrhage, puncture artery, and nerve injury) between the 2 groups. CONCLUSIONS: For children with congenital heart disease requiring central venous catheterization during the perioperative period, the subclavian vein is a feasible site for catheterization. The supraclavicular approach, especially the left side, has a higher first-puncture success rate, shorter access time, lower complications, and a trend of lower incidence of catheter malposition. However, a larger sample size of a randomized controlled study is expected to verify the advantages of ultrasound-guided subclavian catheterization in children.

Engineered Metallic Ion-Based Hydrogel for Tendon-Bone Reconstruction.

Rotator cuff regeneration is hindered by compromised vascular architecture, inflammation, and instability of the reconstructed tendon-bone interface. Herein, inspired by the phenomenon of magnetic clasps being connected together by a specific structure, an engineered metallic ion-based hydrogel scaffold was constructed through a bioorthogonal click reaction between (DOPA)4-PEG5-N3 and DBCO-BMP-2 peptides and a photopolymerization process in the hydrogel matrix, exhibiting the potential for angiogenesis, bone regeneration, and modulation of the inflammatory milieu, which aimed at facilitating rotator cuff regeneration. In vitro studies showed that the composite hydrogel scaffold stimulated the angiogenic activity of human umbilical vein endothelial cells and osteogenic differentiation of bone marrow mesenchymal stem cells, transforming macrophages from M1 to M2. Moreover, imaging and immunohistochemical analysis of a rat rotator cuff injury models demonstrated that the composite hydrogel could effectively promote regeneration and exhibit remarkable biocompatibility. In summary, this composite hydrogel material established an effective platform for the release of metal ions and clickable peptides, which accelerated the regeneration of rotator cuff injuries and had broad prospects for application in rotator cuff therapy.

Dual-Targeted Metal Ion Network Hydrogel Scaffold for Promoting the Integrated Repair of Tendon-Bone Interfaces.

The tendon-bone interface has a complex gradient structure vital for stress transmission and pressure buffering during movement. However, injury to the gradient tissue, especially the tendon and cartilage components, often hinders the complete restoration of the original structure. Here, a metal ion network hydrogel scaffold, with the capability of targeting multitissue, was constructed through the photopolymerization of the LHERHLNNN peptide-modified zeolitic imidazolate framework-8 (LZIF-8) and the WYRGRL peptide-modified magnesium metal-organic framework (WMg-MOF) within the hydrogel scaffold, which could facilitate the directional migration of metal ions to form a dynamic gradient, thereby achieving integrated regeneration of gradient tissues. LZIF-8 selectively migrated to the tendon, releasing zinc ions to enhance collagen secretion and promoting tendon repair. Simultaneously, WMg-MOF migrated to cartilage, releasing magnesium ions to induce cell differentiation and facilitating cartilage regeneration. Infrared spectroscopy confirmed successful peptide modification of nano ZIF-8 and Mg-MOF. Fluorescence imaging validated that LZIF-8/WMg-MOF had a longer retention, indirectly confirming their successful targeting of the tendon-bone interface. In summary, this dual-targeted metal ion network hydrogel scaffold has the potential to facilitate synchronized multitissue regeneration at the compromised tendon-bone interface, offering favorable prospects for its application in the integrated reconstruction characterized by the gradient structure.

Does sacubitril/valsartan work in children with heart failure?-a pilot study.

Background: Sacubitril/valsartan is an angiotensin receptor neprilysin antagonist (ARNI) approved for adult heart failure (HF). Its safety and efficacy in pediatric HF patients with cardiomyopathy or congenital heart disease are poorly understood. A pilot study was conducted to assess the clinical response, efficacy and safety of sacubitril/valsartan in this population at a tertiary care hospital in China. Methods: Clinical parameters of patients who received sacubitril/valsartan from January 2019 to March 2023 were retrospectively collected and analyzed. Children over 1 month with a left ventricular ejection fraction (LVEF) <45% were included. Clinical efficacy was evaluated by echocardiographic LVEF, N-terminal pro-brain natriuretic peptide (NT-proBNP), New York Heart Association (NYHA) HF classification, HF re-admission, and death or transplantation. The initial dose was either 0.2 mg/kg bid or 0.4 mg/kg bid, with a target dose of 2.3 mg/kg bid or 3.1 mg/kg bid. Results: Forty-five patients (60% male) with a median age of 7.86 years were enrolled. Among them, 23 had congenital heart disease and 22 had cardiomyopathies. The median maintenance dose was 0.76 mg/kg. The primary endpoint of LVEF up to 45% was reached by 24 patients (53.3%). The median NT-proBNP was significantly decreased from 5,501.5 pg/ml to 2,241.5 pg/ml (P < 0.001), more in congenital heart disease than in cardiomyopathies (P = 0.032). The NYHA HF class was improved or remained stable in 42 cases (93.3%). During a median follow-up of 1.23 years, 13 patients (28.9%) were re-hospitalized due to HF, and 9 patients (20%) died or underwent transplantation. Hypotension was the main adverse event, occurring in 8 patients. Conclusions: Sacubitril/valsartan may be effective in children with HF, but its safety and outcomes may differ depending on the etiology and anatomy of HF. Early post-operative congenital heart disease patients had less tolerance, more hypotension but better recovery and outcomes, while mid- and late- post-operative congenital heart disease patients and cardiomyopathy patients had less side effects but poorer clinical outcomes.

A numerical study of the hemodynamic behavior and gas transport in cardiovascular systems with severe cardiac or cardiopulmonary failure supported by venoarterial extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been extensively demonstrated as an effective means of bridge-to-destination in the treatment of patients with severe ventricular failure or cardiopulmonary failure. However, appropriate selection of candidates and management of patients during Extracorporeal membrane oxygenation (ECMO) support remain challenging in clinical practice, due partly to insufficient understanding of the complex influences of extracorporeal membrane oxygenation support on the native cardiovascular system. In addition, questions remain as to how central and peripheral venoarterial extracorporeal membrane oxygenation modalities differ with respect to their hemodynamic impact and effectiveness of compensatory oxygen supply to end-organs. In this work, we developed a computational model to quantitatively address the hemodynamic interaction between the extracorporeal membrane oxygenation and cardiovascular systems and associated gas transport. Model-based numerical simulations were performed for cardiovascular systems with severe cardiac or cardiopulmonary failure and supported by central or peripheral venoarterial extracorporeal membrane oxygenation. Obtained results revealed that: 1) central and peripheral venoarterial extracorporeal membrane oxygenation modalities had a comparable capacity for elevating arterial blood pressure and delivering oxygenated blood to important organs/tissues, but induced differential changes of blood flow waveforms in some arteries; 2) increasing the rotation speed of extracorporeal membrane oxygenation pump (ω) could effectively improve arterial blood oxygenation, with the efficiency being especially high when ω was low and cardiopulmonary failure was severe; 3) blood oxygen indices (i.e., oxygen saturation and partial pressure) monitored at the right radial artery could be taken as surrogates for diagnosing potential hypoxemia in other arteries irrespective of the modality of extracorporeal membrane oxygenation; and 4) Left ventricular (LV) overloading could occur when ω was high, but the threshold of ω for inducing clinically significant left ventricular overloading depended strongly on the residual cardiac function. In summary, the study demonstrated the differential hemodynamic influences while comparable oxygen delivery performance of the central and peripheral venoarterial extracorporeal membrane oxygenation modalities in the management of patients with severe cardiac or cardiopulmonary failure and elucidated how the status of arterial blood oxygenation and severity of left ventricular overloading change in response to variations in ω. These model-based findings may serve as theoretical references for guiding the application of venoarterial extracorporeal membrane oxygenation or interpreting in vivo measurements in clinical practice.

Perioperative extracorporeal membrane oxygenation in pediatric congenital heart disease: Chinese expert consensus.

BACKGROUND: Congenital heart disease (CHD) is one of the main supportive diseases of extracorporeal membrane oxygenation in children. The management of extracorporeal membrane oxygenation (ECMO) for pediatric CHD faces more severe challenges due to the complex anatomical structure of the heart, special pathophysiology, perioperative complications and various concomitant malformations. The survival rate of ECMO for CHD was significantly lower than other classifications of diseases according to the Extracorporeal Life Support Organization database. This expert consensus aims to improve the survival rate and reduce the morbidity of this patient population by standardizing the clinical strategy. METHODS: The editing group of this consensus gathered 11 well-known experts in pediatric cardiac surgery and ECMO field in China to develop clinical recommendations formulated on the basis of existing evidences and expert opinions. RESULTS: The primary concern of ECMO management in the perioperative period of CHD are patient selection, cannulation strategy, pump flow/ventilator parameters/vasoactive drug dosage setting, anticoagulation management, residual lesion screening, fluid and wound management and weaning or transition strategy. Prevention and treatment of complications of bleeding, thromboembolism and brain injury are emphatically discussed here. Special conditions of ECMO management related to the cardiovascular anatomy, haemodynamics and the surgical procedures of common complex CHD should be considered. CONCLUSIONS: The consensus could provide a reference for patient selection, management and risk identification of perioperative ECMO in children with CHD. Video abstract (MP4 104726 kb).

Effect of high-energy and/or high-protein feeding in children with congenital heart disease after cardiac surgery: a systematic review and meta-analysis.

High-energy or high-protein feeding offers a promising approach to improving malnutrition in children after congenital heart surgery. However, the effect of high-energy or high-protein feeding in this population has not yet been systematically reviewed. Therefore, we aimed to assess the safety and effectiveness of high-energy or high-protein feeding in children after congenital heart surgery. Five electronic databases (PubMed, Embase, CENTRAL, CINAHL, and Scopus) were searched from inception to April 23, 2022. After screening the literature according to inclusion and exclusion criteria, a risk of bias assessment was performed using version 2 of the Cochrane risk-of-bias tool for randomized trials, and the certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations system. Finally, the random effects model was used to perform a meta-analysis of all data. A total of 609 subjects from 9 studies were included for qualitative analysis, and meta-analyses were performed on data from 8 of these studies. The results showed that high-energy and/or high-protein feeding did not increase feeding intolerance (RR = 1.09, 95% CI: 0.80, 1.48) or fluid intake (MD = - 12.50 ml/kg/d, 95% CI: - 36.10, 11.10); however, the intervention was beneficial in increasing weight (MD = 0.5 kg, 95% CI: 0.23, 0.77) and reducing the duration of mechanical ventilation (MD = - 17.45 h, 95% CI: - 27.30, - 7.60), intensive care unit (ICU) stay (MD = - 1.45 days, 95% CI: - 2.36, - 0.54) and hospital stay (MD = - 2.82 days, 95% CI: - 5.22, - 0.43). However, high-energy and/or protein feeding did not reduce the infection rate (RR = 0.68, 95% CI: 0.25, 1.87) or mortality (RR = 1.50, 95% CI: 0.47, 4.82). CONCLUSION: The certainty of the evidence was graded as moderate to high, which suggests that high-energy and/or high-protein feeding may be safe in children after congenital heart surgery. Furthermore, this intervention improves nutrition and reduces the duration of mechanical ventilation, length of ICU stay, and length of hospital stay. However, the overall conclusion of this meta-analysis will need to be confirmed in a cohort of patients with different cardiac physiologies. WHAT IS KNOWN: • Malnutrition is highly prevalent in children with congenital heart disease (CHD) and can negatively affect the prognosis of these children. • High-energy and/or high-protein feeding can improve nutrition status and facilitate recovery; however, evidence on its safety and efficacy is lacking. WHAT IS NEW: • Pooled data suggest that high-energy and/or high-protein feeding does not increase fluid intake or feeding intolerance in children with CHD. • High-energy and/or high-protein feeding may reduce the duration of mechanical ventilation, length of intensive care unit stay, and length of hospital stay.

An electrochemical nitric oxide generator for in-home inhalation therapy in pulmonary artery hypertension.

BACKGROUND: Inhaled NO is a selective pulmonary vasodilator proven to be therapeutic for patients with pulmonary artery hypertension (PAH). The most common NO delivery system in clinical practice is cylinder-based, but unfortunately limited by its high costs, complicated delivery, and the requirement of an extensive supply chain, leaving vast unmet medical needs globally. METHODS: To address the need for rapid, affordable, and safe production of nitric oxide (NO) for in-home inhalation therapy in patients with PAH. We developed a novel portable device to derive NO from a nitrite complex solution with a copper(II)-ligand catalyst, and further examined its effectiveness in a porcine model of PAH. This model was established by using female Bama miniature pig and induced by monocrotaline (MCT) administration. RESULTS: This generator could rapidly and safely produce therapeutic NO at concentrations ranging from 0 to 100 parts per million (ppm) with the least disproportionated nitrogen dioxide (NO2) and byproducts. It could effectively alleviate pulmonary arterial pressure (PAP) and pulmonary vascular resistance (PVR) in piglets with PAH, without causing major physiologic disruptions. CONCLUSIONS: Our electrochemical NO generator is able to produce the desired NO doses for pulmonary vasodilation in a safe and sustainable way, with low costs, which paves the way for its subsequent clinical trials in the patient with PAH and other common cardiopulmonary conditions with a high disease burden around the world.

Prediction value of regional oxygen saturation in intestine and kidney for acute kidney injury in children with congenital heart disease after surgery.

OBJECTIVE: To study the prediction value of regional oxygen saturation (rSO 2) in brain, intestine and kidney for acute kidney injury (AKI) in children with congenital heart disease after surgery. METHODS: Fifty-seven children with congenital heart disease (CHD), whose weight >2.5 kg and age≤1 year were treated in Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine from January 2020 to December 2020. The rSO 2 of brain, intestine and kidney were monitored with near-infrared spectroscopy continuously for 48 h after surgery. The predictive values of cerebral, intestinal and renal rSO 2 for occurrence and severity of postoperative AKI were analyzed. RESULTS: Among 57 patients, postoperative AKI developed in 38 cases (66.7%), including 18 cases of AKI-1 (47.4%), 9 cases of AKI-2 (23.7%) and 11 cases of AKI-3 (28.9%). There was no significant difference in cerebral rSO 2 between AKI group and non-AKI group ( F=0.012, P>0.05), while the intestinal rSO 2 and renal rSO 2 in AKI group were significantly lower than those in non-AKI group ( F=5.017 and 5.003, both P<0.05). There was no significant difference in brain rSO 2 between children with or without AKI-2 and above ( F=0.311, P>0.05), but the intestinal rSO 2 and renal rSO 2 in children with AKI-2 and above were lower than other children ( F=6.431 and 14.139, both P<0.05). The area under ROC curve (AUC) of intestinal rSO 2 3 h after surgery for predicting AKI was 0.823, and with intestinal rSO 2 3 h after surgery <85%, the sensitivity and specificity were 66.7% and 89.5%, respectively. The AUC of renal rSO 2 for the diagnosis of AKI at 31 h after surgery was 0.918, and with intestinal rSO 2 31 h after surgery <84%, the sensitivity and specificity were 72.2% and 84.2%, respectively. The AUC of intestinal rSO 23 h after surgery for the diagnosis of AKI-2 and above was 0.829, and with intestinal rSO 2 3 h after surgery <84%, the sensitivity and specificity were 62.2% and 90.0%, respectively. The AUC of renal rSO 2 for the diagnosis of AKI-2 and above was 0.826 at 34 h postoperatively, and with intestinal rSO 2 34 h after surgery <71%, the sensitivity and specificity were 91.9% and 55.0%, respectively. CONCLUSION: The monitoring of intestinal and renal rSO 2 can predict the occurrence and severity of postoperative AKI in children with congenital heart disease after surgery.

Analysis of clinical features of neonates with congenital heart disease who develop necrotizing enterocolitis: a retrospective case-control study.

Background: Infants with congenital heart disease (CHD) are known to have higher rates of necrotizing enterocolitis (NEC). Although the etiology is recognized as distinct from the premature neonatal population, there is not a universal consensus regarding etiology or specific risk factors. To analyze the clinical features of neonates with CHD who develop NEC. Methods: A retrospective study of neonates with CHD in the cardiac intensive care unit (ICU) between 2015 and 2018 was performed, and modified Bell's criteria were used to diagnose NEC. Patients were divided into 2 groups according to ductal-dependent (DD) lesions, and were further stratified by Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) score and Aristotle score, to compare the differences. Results: Among 412 patients with CHD, 69 (16%) developed NEC. The incidence of NEC was notably higher among DD patients than among non-DD (nDD) patients (18.7% vs. 11.1%; P=0.04). Patients with RACHS-1 >2 also had a higher rate of NEC than did those with RACHS-1 ≤2 (19.49% vs. 9.29%; P=0.01). nDD patients who developed NEC were younger, had a lower gestational age (36.25±1.88 vs. 38.10±1.28 weeks; P=0.00), a lower weight (2.86±0.85 vs. 3.33±0.55 kg; P=0.01), and a lower birth weight (2.79±0.79 vs. 3.26±0.55; P=0.01) compared to the DD group. All nDD patients developed NEC after congenital heart surgery, while only 38 cases (76%), NEC occurred after heart surgery in the DD group. Four patients needed surgery for NEC in the DD group and RACHS-1 >2 group. Presence of NEC was not associated with an increased risk of mortality in any group. Conclusions: NEC is a common complication in neonates with CHD and can occur both before and after CHD operations. Likely there are varying mechanism for NEC in different forms of CHD. While NEC is more common in patients with DD CHD and those with more complex forms of CHD, there was no significant difference observed in weight-for-age Z-score (WAZ) between the DD group during follow-up.

High-Energy Enteral Nutrition in Infants After Complex Congenital Heart Surgery.

Background: Malnutrition is common in complex congenital heart disease (CCHD). The purpose of this study was to compare the safety and efficacy of early initiation of high-energy enteral nutrition (EN) with regular energy EN in infants after surgery for CCHD. Methods: This is a subgroup analysis of a randomized controlled trial (RCT) which was conducted in the cardiac intensive care unit (CICU) of the largest pediatric heart center in China. Eighty children with CCHD after surgery were from two groups, the intervention group (n = 40) was given high-energy EN and the control group (n = 40) was given regular energy EN. We analyzed the effects of the two interventions on outcomes such as caloric attainment rate, gastrointestinal intolerance, duration of mechanical ventilation, and anthropometry at discharge. Results: There was no difference in the daily milk intake between the two groups, but the calorie intake (50.2 vs. 33.4, P < 0.001), protein intake (1.1 vs. 0.9, P < 0.001) and caloric attainment rate were higher in the intervention group (77.5 vs. 45.0%, P = 0.003). In addition, the incidence of pneumonia (P = 0.003) and duration of mechanical ventilation (P = 0.008) were less in the intervention group, and biceps circumference and triceps skinfold thickness at hospital discharge were greater than those in the control group (P < 0.001). We have not found statistical differences in gastrointestinal intolerance, glycemic fluctuations, incidence of pressure ulcers, length of CICU stay and postoperative hospital days between the two groups. Conclusions: Early initiation of high-energy EN may be safe and effective in infants after complex cardiac surgery. Low doses high-energy EN did not increase gastrointestinal intolerance or glycemic fluctuations and also improved post-operative nutrition by increasing caloric and protein intake without increasing fluid intake.

Predictive factors contributing to prolonged recovery in patients after Fontan operation.

BACKGROUND: Prolonged recovery is a severe issue in patients after Fontan operation. However, predictive factors related to this issue are not adequately evaluated. The present study aimed to investigate potential predictive factors which can predict Fontan postoperative recovery. METHODS: We retrospectively reviewed the perioperative medical records of patients with Fontan surgery between January 2015 and December 2018, and divided patients with > 75%ile cardiac intensive care unit stay into prolonged recovery group. The others were assigned to standard recovery group. Patients that died or underwent a Fontan takedown were excluded. Statistical analysis was performed to compare data difference of the two groups. RESULTS: 282/307 cases fulfilled the inclusion criteria. Seventy patients were considered in prolonged recovery and 212 patients were defined as standard recovery. Pre- and intra-operative data showed a higher incidence of heterotaxy syndrome, longer cardiopulmonary bypass and aortic cross-clamp time in the prolonged recovery group. Postoperative information analysis displayed that ventilation time, oxygen index after extubation, hemodynamic data, inotropic score (IS), drainage volume, volume resuscitation, pulmonary hypertension (PH) treatment, and surgical reintervention were significantly different between the two groups. Higher IS postoperatively, and PH treatment and higher fluid resuscitation within two days were independent predictive factors for prolonged recovery in our multivariate model. C-statistic model showed a high predictive ability in prolonged recovery by using the three factors. CONCLUSIONS: Ventilation time, higher IS in postoperative day, and PH treatment and higher fluid resuscitation within two days were independent risk factors and have a high predictability for Fontan prolonged recovery.

What is the postoperative nutrition intake in children with congenital heart disease? A single-center analysis in China.

BACKGROUND: It is common that inadequate nutritional intake happens in patients with congenital heart disease (CHD), which can adversely affect the prognosis of patients. However, the details and reasons are not clear enough so far. Therefore, the primary aim of this study was to investigate the current nutritional requirements and energy intake on days 1-7 in the cardiac intensive care unit after surgery. Our secondary aim was to investigate potential factors that hinder nutritional supply and to compare the resting energy expenditure (REE) based on two methods, the Fick method and the Schofield equation. METHODS: Using retrospective analysis, we collected data from postoperative children with CHD at a children's hospital in Shanghai, China. We used the Fick method to calculate the REE, and compare the results with the actual enteral nutrition intake. Meanwhile, we recorded the initiation time of enteral nutrition, feeding intolerance, unfinished milk volume, etc. Then the correlation between the results of the Fick method and the equation method was calculated. RESULTS: A total of 49 patients were included, with a median age of 22 months (IQR 4.9, 57.3), and a median Aristotle basic complexity score of 8 (IQR 6.0, 9.8). The time interval for surgical intervention within 7 days after operation was 4 (IQR 2.5, 6). No statistical difference in REE on postoperative days 1-7. The average enteral nutrition energy provided 64.6 (33.6, 79.6)% of the REE, which showed a significant decrease on postoperative day 4, and then reached its lowest on postoperative day 5. The protein supply was 0.7 ± 0.3 kcal/kg/d. In addition, the REE calculated by the Fick method was moderately correlated with that estimated by the equation (r = 0.467, P = 0.001). CONCLUSIONS: The energy and protein supply in the acute postoperative period in children with CHD is inadequate. Fluid restriction and fasting may be the main causes. In addition, there is a moderate correlation between the REE calculated by the Fick method and that estimated by the equation.

Diagnostic Performance of Metagenomic Next-Generation Sequencing in Pediatric Patients: A Retrospective Study in a Large Children's Medical Center.

BACKGROUND: Metagenomic next-generation sequencing (mNGS) has the potential to become a complementary, if not essential, test in some clinical settings. However, the clinical application of mNGS in a large population of children with various types of infectious diseases (IDs) has not been previously evaluated. METHODS: From April 2019 to April 2021, 640 samples were collected at a single pediatric hospital and classified as ID [479 (74.8%)], non-ID [NID; 156 (24.4%)], and unknown cases [5 (0.8%)], according to the final clinical diagnosis. We compared the diagnostic performance in pathogen detection between mNGS and standard reference tests. RESULTS: According to final clinical diagnosis, the sensitivity and specificity of mNGS were 75.0% (95% CI: 70.8%-79.2%) and 59.0% (95% CI: 51.3%-66.7%), respectively. For distinguishing ID from NID, the sensitivity of mNGS was approximately 45.0% higher than that of standard tests (75.0% vs 30.0%; P < 0.001). For fungal detection, mNGS showed positive results in 93.0% of cases, compared to 43.7% for standard tests (P < 0.001). Diagnostic information was increased in respiratory system samples through the addition of meta-transcriptomic sequencing. Further analysis also showed that the read counts in sequencing data were highly correlated with clinical diagnosis, regardless of whether infection was by single or multiple pathogens (Kendall's tau b = 0.484, P < 0.001). CONCLUSIONS: For pediatric patients in critical condition with suspected infection, mNGS tests can provide valuable diagnostic information to resolve negative or inconclusive routine test results, differentiate ID from NID cases, and facilitate accurate and effective clinical therapeutic decision-making.

Exposure to traffic-related fine particulate matter 2.5 causes respiratory damage via peroxisome proliferator-activated receptor gamma-regulated inflammation.

Exposure to particulate matter 2.5 (PM2.5) potentially triggers airway inflammation. Peroxisome proliferator-activated receptor gamma (PPARγ) has been reported to regulate inflammatory responses in diverse cell types. Therefore, this work investigated the mechanisms of PPARγ in regulating traffic-related PM2.5-induced airway inflammation. Using the diffusion flame burner soot generation, traffic-related PM2.5 was generated and adsorbed. BALB/c male mice and human bronchial epithelial cells (16-HBE) were exposed to PM2.5 alone or co-treatment with rosiglitazone (RSG), an agonist of PPARγ. To the end of exposure, bronchoalveolar lavage fluid (BALF), venous blood and arterial blood, trachea, bronchus and lung tissues were collected. The levels of IL-1ß, IL-6, and IL-17 were detected by ELISA, and the cell types in BALF were counted. Hematoxylin-eosin (H&E) assay were used to analyze the pathological conditions of lung, bronchus, and pulmonary artery. Apoptosis was detected by TUNEL, and PPARγ expression in lung and bronchus was detected by immunohistochemical (IHC) staining. Western Blot was used to detect PPARγ, NF-kB, AP-1 and STAT3 expression in lung and bronchus. The viability was detected by MTT method. PM2.5 exposure caused pathological damage to the lung, bronchus and pulmonary artery tissue, which induced apoptosis of bronchial epithelial cells. PM2.5 exposure caused local inflammation of the whole body and airway. PPARγ expression increased after PM2.5 exposure. PM2.5 exposure regulated the downstream signaling pathways to affect the inflammatory response through PPARγ. Exposure to traffic-related PM2.5 caused respiratory damage via PPARγ-regulated inflammation.

Objective evaluation of wearable thermoelectric generator: From platform building to performance verification.

Wearable thermoelectric generators can harvest heat from the human body to power an intelligent electronic device, which plays an important role in wearable electronics. However, due to the complexity of human skin, there is still no unified standard for performance testing of wearable thermoelectric generators under wearable conditions. Herein, a test platform suitable for a wearable thermoelectric generator was designed and built by simulating the structure of the arm. Based on the biological body temperature regulation function, water flow and water temperature substitute blood flow and blood temperature, the silicone gel with some thickness simulates the skin layer of the human arm, thus achieving the goal of adjusting the thermal resistance of human skin. Meanwhile, the weight is used as the contact pressure to further ensure the reliability and accuracy of the test data. In addition, the environment regulatory system is set up to simulate the outdoor day. Actually, the maximum deviation of the performance of the thermoelectric generator worn on the test platform and human arm is ∼5.2%, indicating the accuracy of objective evaluation.

Evaluation of acute kidney injury by urinary tissue inhibitor metalloproteinases-2 and insulin-like growth factor-binding protein 7 after pediatric cardiac surgery.

BACKGROUND: With adult patients, the measurement of [TIMP-2]*[IGFBP7] can predict the risk of moderate to severe AKI within 12 h of testing. In pediatrics, however, the performance of [TIMP-2]*[IGFBP7] as a predictor of AKI was less studied and yet to be widely utilized in clinical practice. This study was conducted to validate the utility of [TIMP-2]*[IGFBP7] as an earlier biomarker for AKI prediction in Chinese infants and small children. METHODS: We measured urinary [TIMP-2]*[IGFBP7] using NEPHROCHECK® at eight perioperative time points in 230 patients undergoing complex cardiac surgery and evaluated the performance of [TIMP-2]*[IGFBP7] for predicting severe AKI within 72 h of surgery. RESULTS: A total of 50 (22%) of 230 developed AKI stages 2-3 within 72 h after CPB initiation. In the AKI stage 2-3 patients, two patterns of serum creatinine (SCr) elevations were observed. The patients with only a transient increase in SCr within 24 h (< 24 h, early AKI 2-3) did not experience a worse outcome than patients in AKI stage 0-1. AKI stage 2-3 patients with SCr elevation after 24 h (24-72 h, late AKI 2-3), as well as AKI dialysis patients (together designated severe AKI), did experience worse outcomes. Compared to AKI stages 0-1, significant elevations of [TIMP-2]*[IGFBP7] values were observed in severe AKI patients at hours T2, T4, T12, and T24 following CPB initiation. The AUC for predicting severe AKI with [TIMP-2]*[IGFBP7] at T2 (AUC = 0.76) and maximum T2/T24 (AUC = 0.80) are higher than other time points. The addition of the NEPHROCHECK® test to the postoperative parameters improved the risk assessment of severe AKI. CONCLUSIONS: Multiple AKI phenotypes (early versus late AKI) were identified after pediatric complex cardiac surgery according to SCr-based AKI definition. Urinary [TIMP-2]*[IGFBP7] predicts late severe AKI (but not early AKI) as early as 2 h following CPB initiation. A higher resolution version of the Graphical abstract is available as Supplementary information.

Application of Near-Infrared Spectroscopy to Monitor Perfusion During Extracorporeal Membrane Oxygenation After Pediatric Heart Surgery.

Objective: Venoarterial extracorporeal membrane oxygenation is an effective mechanical circulatory support that is used to rescue critically ill patients after congenital heart surgery. As there was still no recommended guideline for monitoring parameters during extracorporeal membrane oxygenation (ECMO), this study aimed to investigate the role of near-infrared spectroscopy (NIRS) in the early period of venoarterial (VA)-ECMO. Method: This study enrolled patients with NIRS monitoring during ECMO after pediatric cardiac surgery at Shanghai Children's Medical Center (2018-2020). The information obtained from the retrospective, the observational dataset included the demographic information, diagnoses, baseline characteristics, procedural details, ECMO data, monitoring data, in-hospital mortality, and complications of the patients. Results: The overall mortality rate was 43.6%. Lactate was significantly higher in non-survivors compared to survivors at 12 h (11.25 ± 7.26 vs. 6.96 ± 5.95 mmol/l, p = 0.022) and 48 h [2.2 (0.7, 20) vs. 1.4 (0.7, 5.8) mmol/l, p = 0.008] after initiation of ECMO. The cranial regional oxygen saturation (CrSO2) was significantly higher in survivors compared to non-survivors at 24 h (62.5 ± 14.61 vs. 52.05 ± 13.98%, p = 0.028), 36 h (64.04 ± 14.12 vs. 51.27 ± 15.65%, p = 0.005), and 48 h (65.32 ± 11.51 vs. 55.00 ± 14.18%, p = 0.008). Multivariate logistics regression analysis of the hemodynamic and laboratory parameters revealed that the CrSO2 at 36 h (OR = 0.945, p = 0.049) and 48 h (OR = 0.919, p = 0.032) was related to mortality. The use of continuous renal replacement therapy (OR = 14.940, p = 0.039) was also related to mortality. The optimal cutoff values for CrSO2 for predicting mortality after weaning off ECMO at 36 and 48 h were 57% (sensitivity: 61.5%, specificity: 80%) and 56% (sensitivity: 76.9%, specificity: 70%), respectively. The risk of mortality was higher among patients with a CrSO2(36h) < 57% (p = 0.028) by Kaplan-Meier analysis. Conclusion: Near-infrared spectroscopy may be a useful tool for monitoring the hemodynamic stability during the early period of ECMO, while CrSO2 can predict the in-hospital mortality after ECMO.

Early high-energy feeding in infants following cardiac surgery: a randomized controlled trial.

BACKGROUND: Effective nutrition programs are beneficial for nutritional recovery in infants. Few studies have focused on the effect of early high-energy feeding after open heart surgery. This study sought to assess the effects of early high-energy feeding in infants after congenital heart surgery. METHODS: Patients at a tertiary pediatric cardiology center who underwent open heart surgery between July 2016 and July 2018 were recruited and randomly allocated to 1 of the following 2 groups: (I) the intervention group (postoperative early high-energy feeding; n=124); and (II) the control group (no intervention; n=120).The primary endpoints of average energy delivery and growth Z-scores [i.e., weight-for-height Z-score (WHZ), weight-for-age Z-score (WAZ), and height-for-age Z-score (HAZ)] were recorded preoperatively, during the intensive care unit (ICU) stay, at discharge, and at 1 and 3 months postoperatively. The secondary endpoints of malnutrition recovery, ventilator support time, infection rate, and cardiac ICU (CICU) stay were also recorded. RESULTS: A total of 244 infants were included in the study. There were no significant differences in the baseline features between the 2 groups. The intervention group received higher calories on average than the control group (44.5 vs. 34.7; P<0.001). At discharge from the ICU, the WHZ (-2.29 vs. -2.76; P<0.001) and WAZ (-3.08 vs. -3.43; P=0.005) of patients in the intervention group were higher than those of patients in the control group. Ventilator support time (P=0.004), CICU stay (P=0.045), and infection rate (P=0.001) were significantly lower in the intervention group than the control group. At 3 months post-surgery, the intervention group exhibited a higher malnutrition recovery rate than the control group (19.4% vs. 6.5%; P=0.002). CONCLUSIONS: The administration of early high-energy feeding to infants after congenital heart surgery is associated with improved growth, reduced CICU stay, decreased ventilator support time, and reduced postoperative infection rates. TRIAL REGISTRATION: ClinicalTrials NCT04609358.