Single inhalation exposure to polyamide micro and nanoplastic particles impairs vascular dilation without generating pulmonary inflammation in virgin female Sprague Dawley rats.

BACKGROUND: Exposure to micro- and nanoplastic particles (MNPs) in humans is being identified in both the indoor and outdoor environment. Detection of these materials in the air has made inhalation exposure to MNPs a major cause for concern. One type of plastic polymer found in indoor and outdoor settings is polyamide, often referred to as nylon. Inhalation of combustion-derived, metallic, and carbonaceous aerosols generate pulmonary inflammation, cardiovascular dysfunction, and systemic inflammation. Additionally, due to the additives present in plastics, MNPs may act as endocrine disruptors. Currently there is limited knowledge on potential health effects caused by polyamide or general MNP inhalation. OBJECTIVE: The purpose of this study is to assess the toxicological consequences of a single inhalation exposure of female rats to polyamide MNP during estrus by means of aerosolization of MNP. METHODS: Bulk polyamide powder (i.e., nylon) served as a representative MNP. Polyamide aerosolization was characterized using particle sizers, cascade impactors, and aerosol samplers. Multiple-Path Particle Dosimetry (MPPD) modeling was used to evaluate pulmonary deposition of MNPs. Pulmonary inflammation was assessed by bronchoalveolar lavage (BAL) cell content and H&E-stained tissue sections. Mean arterial pressure (MAP), wire myography of the aorta and uterine artery, and pressure myography of the radial artery was used to assess cardiovascular function. Systemic inflammation and endocrine disruption were quantified by measurement of proinflammatory cytokines and reproductive hormones. RESULTS: Our aerosolization exposure platform was found to generate particles within the micro- and nano-size ranges (thereby constituting MNPs). Inhaled particles were predicted to deposit in all regions of the lung; no overt pulmonary inflammation was observed. Conversely, increased blood pressure and impaired dilation in the uterine vasculature was noted while aortic vascular reactivity was unaffected. Inhalation of MNPs resulted in systemic inflammation as measured by increased plasma levels of IL-6. Decreased levels of 17ß-estradiol were also observed suggesting that MNPs have endocrine disrupting activity. CONCLUSIONS: These data demonstrate aerosolization of MNPs in our inhalation exposure platform. Inhaled MNP aerosols were found to alter inflammatory, cardiovascular, and endocrine activity. These novel findings will contribute to a better understanding of inhaled plastic particle toxicity.

Towards implementing artificial intelligence post-processing in weather and climate: proposed actions from the Oxford 2019 workshop.

The most mature aspect of applying artificial intelligence (AI)/machine learning (ML) to problems in the atmospheric sciences is likely post-processing of model output. This article provides some history and current state of the science of post-processing with AI for weather and climate models. Deriving from the discussion at the 2019 Oxford workshop on Machine Learning for Weather and Climate, this paper also presents thoughts on medium-term goals to advance such use of AI, which include assuring that algorithms are trustworthy and interpretable, adherence to FAIR data practices to promote usability, and development of techniques that leverage our physical knowledge of the atmosphere. The coauthors propose several actionable items and have initiated one of those: a repository for datasets from various real weather and climate problems that can be addressed using AI. Five such datasets are presented and permanently archived, together with Jupyter notebooks to process them and assess the results in comparison with a baseline technique. The coauthors invite the readers to test their own algorithms in comparison with the baseline and to archive their results. This article is part of the theme issue 'Machine learning for weather and climate modelling'.

Inhaled Nitric Oxide Is Associated with Improved Oxygenation in a Subpopulation of Infants with Congenital Diaphragmatic Hernia and Pulmonary Hypertension.

OBJECTIVES: To determine which patients with congenital diaphragmatic hernia (CDH) and pulmonary hypertension (PH) benefit from inhaled nitric oxide (iNO) treatment by comparing characteristics and outcomes of iNO responders to nonresponders. STUDY DESIGN: We performed a retrospective chart review of infants with CDH treated at our center between 2011 and 2016. In a subset of patients, iNO was initiated for hypoxemia or echocardiographic evidence of extrapulmonary right to left shunting. Initial post-treatment blood gases were reviewed, and patients were classified as responders (increased PaO2 >20 mm Hg) or nonresponders. Baseline characteristics, echocardiograms and outcomes were compared between groups with Fisher exact tests and Mann-Whitney t tests, as appropriate. RESULTS: During the study period, 95 of 131 patients with CDH (73%) were treated with iNO. All patients with pretreatment echocardiograms (n = 90) had echocardiographic evidence of PH. Thirty-eight (40%) patients met treatment response criteria. Responders had significant improvements in PaO2 (51 ± 3 vs 123 ± 7 mm Hg, P < .01), alveolar-arterial gradient (422 ± 30 vs 327 ± 27 mm Hg, P < .01), and PaO2 to FiO2 ratio (82 ± 10 vs 199 ± 15 mm Hg, P < .01). Nonresponders were more likely to have left ventricular systolic dysfunction (27% vs 8%, P = .03) on echocardiogram. Responders were less likely to require extracorporeal membrane support (50 vs 24%, P = .02). CONCLUSIONS: iNO treatment is associated with improved oxygenation and reduced need for ECMO in a subpopulation of patients with CDH with PH and normal left ventricular systolic function.

Congenital diaphragmatic hernia sacs: prenatal imaging and associated postnatal outcomes.

BACKGROUND: The presence of a hernia sac in congenital diaphragmatic hernia (CDH) has been reported to be associated with higher lung volumes and better postnatal outcomes. OBJECTIVE: To compare prenatal imaging (ultrasound and MRI) prognostic measurements and postnatal outcomes of CDH with and without hernia sac. MATERIALS AND METHODS: We performed database searches from January 2008 to March 2017 for surgically proven cases of CDH with and without hernia sac. All children had a detailed ultrasound (US) examination and most had an MRI examination. We reviewed the medical records of children enrolled in our Pulmonary Hypoplasia Program. RESULTS: Of 200 cases of unilateral CDH, 46 (23%) had hernia sacs. Cases of CDH with hernia sac had a higher mean lung-to-head ratio (LHR; 1.61 vs. 1.17; P<0.01), a higher mean observed/expected LHR (0.49 vs. 0.37; P<0.01), and on MRI a higher mean observed/expected total lung volume (0.53 vs. 0.41; P<0.01). Based on a smooth interface between lung and herniated contents, hernia sac or eventration was prospectively questioned by US and MRI in 45.7% and 38.6% of cases, respectively. Postnatally, hernia sac is associated with shorter median periods of admission to the neonatal intensive care unit (45.0 days vs. 61.5 days, P=0.03); mechanical ventilation (15.5 days vs. 23.5 days, P=0.04); extracorporeal membrane oxygenation (251 h vs. 434 h, P=0.04); decreased rates of patch repair (39.0% vs. 69.2%, P<0.01); and pulmonary hypertension (56.1% vs. 75.4%, P=0.03). CONCLUSION: Hernia sac is associated with statistically higher prenatal prognostic measurements and improved postnatal outcomes. Recognition of a sharp interface between lung and herniated contents may allow for improved prenatal diagnosis; however, delivery and management should still occur at experienced quaternary neonatal centers.

Fear of childbirth and elective caesarean section: a population-based study.

BACKGROUND: This population-based cohort study aimed to investigate the demographic and psychosocial characteristics associated with fear of childbirth and the relative importance of such fear as a predictor of elective caesarean section. METHODS: A sample of 1789 women from the Akershus Birth Cohort in Norway provided data collected by three self-administered questionnaires at 17 and 32 weeks of pregnancy and 8 weeks postpartum. Information about the participants' childbirths was obtained from the hospital records. RESULTS: Eight percent of the women reported fear of delivery, defined as a score of ≥85 on the Wijma Delivery Expectancy Questionnaire. Using multivariable logistic regression models, a previous negative overall birth experience exerted the strongest impact on fear of childbirth, followed by impaired mental health and poor social support. Fear of childbirth was strongly associated with a preference for elective caesarean section (aOR 4.6, 95% CI 2.9-7.3) whereas the association of fear with performance of caesarean delivery was weaker (aOR 2.4, 95% CI 1.2-4.9). The vast majority (87%) of women with fear of childbirth did not, however, receive a caesarean section. By contrast, a previous negative overall birth experience was highly predictive of elective caesarean section (aOR 8.1, 95% CI 3.9-16.7) and few women without such experiences did request caesarean section. CONCLUSIONS: Results suggest that women with fear of childbirth may have identifiable vulnerability characteristics, such as poor mental health and poor social support. Results also emphasize the need to focus on the subjective experience of the birth to prevent fear of childbirth and elective caesarean sections on maternal request. Regarding the relationship with social support, causality has to be interpreted cautiously, as social support was measured at 8 weeks postpartum only.

Including citizens in institutional reviews: expectations and experiences from the Dutch Healthcare Inspectorate.

BACKGROUND: Recent changes in the structure and policy context of Dutch health care have placed the issue of citizen participation high on the agenda of the Dutch Healthcare Inspectorate (IGZ), which conducts quality and safety reviews in medical practices and health-care institutions. With a few exceptions, the potential role that citizens can play in the regulation of health-care institutions is overlooked in research on patient/citizen participation in health care. OBJECTIVE: This research addressed the following question: What are the (political) expectations for increasing citizen participation in health-care regulation and how do these compare to regulators' expectations and experiences in practice? DESIGN: Because of the largely explorative nature of this study, we used qualitative methods (document and web analysis, focus groups and interviews) to answer this question. RESULTS: Our study shows that inspectors already have experience with participatory formats that lead to important information. There are three areas where the IGZ is currently increasing citizen participation: (i) providing individuals with information about inspectorate processes and activities, (ii) including patients as sources of information, and (iii) formally reviewing how citizen participation is ensured by health-care institutions. In situations where the patient has the clearest overview of the whole care trajectory, intensive methods of participation deliver valuable information. CONCLUSIONS: It is important to target participation activities and to capitalize on existing opportunities and activities, rather than creating participation activities for the sake of participation. In this regard, further research on the effectiveness and efficacy of different participatory strategies is necessary.

Developing a research agenda on ethical issues related to using social media in healthcare.

The consequences of using publicly available social media applications specifically for healthcare purposes are largely unaddressed in current research. Where they are addressed, the focus is primarily on issues of privacy and data protection. We therefore use a case study of the first live Twitter heart operation in the Netherlands, in combination with recent literature on social media from other academic fields, to identify a wide range of ethical issues related to using social media for health-related purposes. Although this case reflects an innovative approach to public education and patient centeredness, it also illustrates the need for institutions to weigh the various aspects of use and to develop a plan to deal with these on a per case basis. Given the continual development of technologies, researchers may not yet be able to oversee and anticipate all of the potential implications. Further development of a research agenda on this topic, the promotion of guidelines and policies, and the publication of case studies that reveal the granularity of individual situations will therefore help raise awareness and assist physicians and institutions in using social media to support existing care services.

Seasonally adjusted birth frequencies follow the Poisson distribution.

BACKGROUND: Variations in birth frequencies have an impact on activity planning in maternity wards. Previous studies of this phenomenon have commonly included elective births. A Danish study of spontaneous births found that birth frequencies were well modelled by a Poisson process. Somewhat unexpectedly, there were also weekly variations in the frequency of spontaneous births. Another study claimed that birth frequencies follow the Benford distribution. Our objective was to test these results. MATERIAL AND METHOD: We analysed 50,017 spontaneous births at Akershus University Hospital in the period 1999-2014. To investigate the Poisson distribution of these births, we plotted their variance over a sliding average. We specified various Poisson regression models, with the number of births on a given day as the outcome variable. The explanatory variables included various combinations of years, months, days of the week and the digit sum of the date. RESULTS: The relationship between the variance and the average fits well with an underlying Poisson process. A Benford distribution was disproved by a goodness-of-fit test (p < 0.01). The fundamental model with year and month as explanatory variables is significantly improved (p < 0.001) by adding day of the week as an explanatory variable. Altogether 7.5% more children are born on Tuesdays than on Sundays. The digit sum of the date is non-significant as an explanatory variable (p = 0.23), nor does it increase the explained variance. INERPRETATION: Spontaneous births are well modelled by a time-dependent Poisson process when monthly and day-of-the-week variation is included. The frequency is highest in summer towards June and July, Friday and Tuesday stand out as particularly busy days, and the activity level is at its lowest during weekends.

Release of surfactant cargo from interfacially-active halloysite clay nanotubes for oil spill remediation.

Naturally occurring halloysite clay nanotubes are effective in stabilizing oil-in-water emulsions and can serve as interfacially-active vehicles for delivering oil spill treating agents. Halloysite nanotubes adsorb at the oil-water interface and stabilize oil-in-water emulsions that are stable for months. Cryo-scanning electron microscopy (Cryo-SEM) imaging of the oil-in-water emulsions shows that these nanotubes assemble in a side-on orientation at the oil-water interface and form networks on the interface through end-to-end linkages. For application in the treatment of marine oil spills, halloysite nanotubes were successfully loaded with surfactants and utilized as an interfacially-active vehicle for the delivery of surfactant cargo. The adsorption of surfactant molecules at the interface serves to lower the interfacial tension while the adsorption of particles provides a steric barrier to drop coalescence. Pendant drop tensiometry was used to characterize the dynamic reduction in interfacial tension resulting from the release of dioctyl sulfosuccinate sodium salt (DOSS) from halloysite nanotubes. At appropriate surfactant compositions and loadings in halloysite nanotubes, the crude oil-saline water interfacial tension is effectively lowered to levels appropriate for the dispersion of oil. This work indicates a novel concept of integrating particle stabilization of emulsions together with the release of chemical surfactants from the particles for the development of an alternative, cheaper, and environmentally-benign technology for oil spill remediation.

Identifying and explaining the variability in development and implementation costs of disease management programs in the Netherlands.

BACKGROUND: In the Netherlands, disease management programs (DMPs) are used to treat chronic diseases. Their aim is to improve care and to control the rising expenditures related to chronic diseases. A bundled payment was introduced to facilitate the implementation of DMPs. This payment is an all-inclusive price per patient per year for a pre-specified care package. However, it is unclear to which extent the costs of developing and implementing DMPs are included in this price. Consequently, the organizations providing DMPs bear financial risk because the development and implementation (D&I) costs may be substantial. The aim of this paper is to investigate the variability in and drivers of D&I costs among 22 DMPs and highlight characteristics that impact these. METHODS: The data was analyzed using a mixed methods approach. Descriptive statistical analysis explored the variability in D&I costs as measured by a self-developed costing instrument and investigated the drivers. In addition, qualitative research, including document analysis and interviews, was conducted to explain the possible underlying reasons of cost variability. RESULTS: The development costs varied from €5,891 to €274,783 and the implementation costs varied from €7,278 to €387,879 across DMPs. Personnel costs were the main component of development. Development costs were strongly correlated with the implementation costs (ρ = 0.55), development duration (ρ = 0.74), and number of FTEs dedicated DMP development. Organizations with large size and high level of care prior to the implementation of a DMP had relatively low development costs. These findings were in line with the cross-case qualitative comparison where programs with a longer history, more experienced project leadership, previously established ICT systems, and less complex patient populations had lower D&I costs. CONCLUSIONS: There is wide variation in D&I costs of DMPs, which is driven primarily by the duration of the development phase and the staff needed to develop and implement a DMP. These drivers are influenced by the attributes of the DMP, characteristics of the target population, project leadership, and ICT involved. There are indications of economies of scale and economies of scope, which may reduce D&I costs.

Engineered transcription-associated Cas9 targeting in eukaryotic cells.

DNA targeting Class 2 CRISPR-Cas effector nucleases, including the well-studied Cas9 proteins, evolved protospacer-adjacent motif (PAM) and guide RNA interactions that sequentially license their binding and cleavage activities at protospacer target sites. Both interactions are nucleic acid sequence specific but function constitutively; thus, they provide intrinsic spatial control over DNA targeting activities but naturally lack temporal control. Here we show that engineered Cas9 fusion proteins which bind to nascent RNAs near a protospacer can facilitate spatiotemporal coupling between transcription and DNA targeting at that protospacer: Transcription-associated Cas9 Targeting (TraCT). Engineered TraCT is enabled when suboptimal PAM interactions limit basal activity in vivo and when one or more nascent RNA substrates are still tethered to the actively transcribing target DNA in cis. We further show that this phenomenon can be exploited for selective editing at one of two identical targets in distinct gene loci, or, in diploid allelic loci that are differentially transcribed. Our work demonstrates that temporal control over Cas9's targeting activity at specific DNA sites may be engineered without modifying Cas9's core domains and guide RNA components or their expression levels. More broadly, it establishes RNA binding in cis as a mechanism that can conditionally stimulate CRISPR-Cas DNA targeting in eukaryotes.

A universal deep-learning model for zinc finger design enables transcription factor reprogramming.

Cys2His2 zinc finger (ZF) domains engineered to bind specific target sequences in the genome provide an effective strategy for programmable regulation of gene expression, with many potential therapeutic applications. However, the structurally intricate engagement of ZF domains with DNA has made their design challenging. Here we describe the screening of 49 billion protein-DNA interactions and the development of a deep-learning model, ZFDesign, that solves ZF design for any genomic target. ZFDesign is a modern machine learning method that models global and target-specific differences induced by a range of library environments and specifically takes into account compatibility of neighboring fingers using a novel hierarchical transformer architecture. We demonstrate the versatility of designed ZFs as nucleases as well as activators and repressors by seamless reprogramming of human transcription factors. These factors could be used to upregulate an allele of haploinsufficiency, downregulate a gain-of-function mutation or test the consequence of regulation of a single gene as opposed to the many genes that a transcription factor would normally influence.

Disease management projects and the Chronic Care Model in action: baseline qualitative research.

BACKGROUND: Disease management programs, especially those based on the Chronic Care Model (CCM), are increasingly common in The Netherlands. While disease management programs have been well-researched quantitatively and economically, less qualitative research has been done. The overall aim of the study is to explore how disease management programs are implemented within primary care settings in The Netherlands; this paper focuses on the early development and implementation stages of five disease management programs in the primary care setting, based on interviews with project leadership teams. METHODS: Eleven semi-structured interviews were conducted at the five selected sites with sixteen professionals interviewed; all project directors and managers were interviewed. The interviews focused on each project's chosen chronic illness (diabetes, eating disorders, COPD, multi-morbidity, CVRM) and project plan, barriers to development and implementation, the project leaders' action and reactions, as well as their roles and responsibilities, and disease management strategies. Analysis was inductive and interpretive, based on the content of the interviews. After analysis, the results of this research on disease management programs and the Chronic Care Model are viewed from a traveling technology framework. RESULTS: This analysis uncovered four themes that can be mapped to disease management and the Chronic Care Model: (1) changing the health care system, (2) patient-centered care, (3) technological systems and barriers, and (4) integrating projects into the larger system. Project leaders discussed the paths, both direct and indirect, for transforming the health care system to one that addresses chronic illness. Patient-centered care was highlighted as needed and a paradigm shift for many. Challenges with technological systems were pervasive. Project leaders managed the expenses of a traveling technology, including the social, financial, and administration involved. CONCLUSIONS: At the sites, project leaders served as travel guides, assisting and overseeing the programs as they traveled from the global plans to local actions. Project leaders, while hypothetically in control of the programs, in fact shared control of the traveling of the programs with patients, clinicians, and outside consultants. From this work, we can learn what roadblocks and expenses occur while a technology travels, from a project leader's point of view.

Maternal emotional distress in pregnancy and delivery of a small-for-gestational age infant.

OBJECTIVE: To assess the association between maternal emotional distress in pregnancy and delivery of a small-for-gestational age offspring. DESIGN: A cohort study in pregnancy. SETTING: Fifty hospitals with a maternity ward in Norway during 1998-2008. POPULATION: Seventy-one thousand eight hundred and ninety-eight women with a singleton pregnancy in the Norwegian Mother and Child Cohort Study were followed from early pregnancy to delivery. METHODS: Information on presence of emotional distress was obtained through self-administered questionnaires in pregnancy weeks 17 and 30 and on birthweight, gestational length at delivery and sex by linkage to the Medical Birth Registry of Norway. Emotional distress was measured by short forms of the Hopkins Symptom Checklist-25. MAIN OUTCOME MEASURE: Small-for-gestational age offspring (birthweight <2.5th percentile). RESULTS: Being emotionally distressed at gestational weeks 17 and 30 was not significantly associated with subsequent delivery of a small-for-gestational age infant (adjusted odds ratio 1.16; 95% confidence interval 0.87-1.54). This estimate was adjusted for smoking in pregnancy, parity, diabetes, pre-eclampsia, body mass index, education and maternal age. CONCLUSIONS: Emotional distress during pregnancy was not associated with subsequent delivery of a small-for-gestational age infant.

Reporting qualitative research in health informatics: REQ-HI recommendations.

To develop a set of recommendations for authors of qualitative studies in the field of health informatics, we conducted an extensive literature search and also manually checked major journals in the field of biomedical informatics and qualitative research looking for papers, checklists, and guidelines pertaining to assessing and reporting of qualitative studies. We synthesized the found criteria to develop an initial set of reporting recommendations that are particularly relevant to qualitative studies of health information technology systems. This paper presents a preliminary version of these recommendations. We are planning to refine and revise this version using comments and suggestions of experts in evaluation of health informatics applications and publish a detailed set of recommendations.

Dynamic 3-D Visualization of Climate Model Development and Results.

Climate models play a significant role in the understanding of climate change, and the effective presentation and interpretation of their results is important for both the scientific community and the general public. In the case of the latter audience-which has become increasingly concerned with the implications of climate change for society-there is a requirement for visualizations which are compelling and engaging. We describe the use of ParaView, a well-established visualization application, to produce images and animations of results from a large set of modeling experiments, and their use in the promulgation of climate research results. Visualization can also make useful contributions to development, particularly for complex large-scale applications such as climate models. We present early results from the construction of a next-generation climate model which has been designed for use on exascale compute platforms, and show how visualization has helped in the development process, particularly with regard to higher model resolutions and novel data representations.

Use of "serious health games" in health care: a review.

This inter-disciplinary literature review examines current and potential uses of so-called "Serious Games" in health care. Based on a core body of 51 articles about Serious Games (12 pertaining specifically to health care), it briefly examines examples of use for training professionals, but focuses mostly on how games are used for patient treatment or education and how they can be used for disease prevention and health promotion. This article highlights considerations that must be made when designing and implementing Serious Games for these purposes.

Sex- and age-dependent effects of maternal organophosphate flame-retardant exposure on neonatal hypothalamic and hepatic gene expression.

After the phase-out of polybrominated diphenyl ethers, their replacement compounds, organophosphate flame retardants (OPFRs) became ubiquitous in home and work environments. OPFRs, which may act as endocrine disruptors, are detectable in human urine, breast milk, and blood samples collected from pregnant women. However, the effects of perinatal OPFR exposure on offspring homeostasis and gene expression remain largely underexplored. To address this knowledge gap, virgin female mice were mated and dosed with either a sesame oil vehicle or an OPFR mixture (tris(1,3-dichloro-2-propyl)phosphate, tricresyl phosphate, and triphenyl phosphate, 1 mg/kg each) from gestational day (GD) 7 to postnatal day (PND) 14. Hypothalamic and hepatic tissues were collected from one female and one male pup per litter on PND 0 and PND 14. Expression of genes involved in energy homeostasis, reproduction, glucose metabolism, and xenobiotic metabolism were analyzed using quantitative real-time PCR. In the mediobasal hypothalamus, OPFR increased Pdyn, Tac2, Esr1, and Pparg in PND 14 females. In the liver, OPFR increased Pparg and suppressed Insr, G6pc, and Fasn in PND 14 males and increased Esr1, Foxo1, Dgat2, Fasn, and Cyb2b10 in PND 14 females. We also observed striking sex differences in gene expression that were dependent on the age of the pup. Collectively, these data suggest that maternal OPFR exposure alters hypothalamic and hepatic development by influencing neonatal gene expression in a sex-dependent manner. The long-lasting consequences of these changes in expression may disrupt puberty, hormone sensitivity, and metabolism of glucose, fatty acids, and triglycerides in the maturing juvenile.

Right Ventricular Strain, Brain Natriuretic Peptide, and Mortality in Congenital Diaphragmatic Hernia.

Rationale: Brain-type natriuretic peptide (BNP) correlates with pulmonary hypertension as demonstrated by echocardiogram in congenital diaphragmatic hernia (CDH); however, its association with right ventricular (RV) function and mortality is unknown.Objectives: To characterize the relationships between echocardiogram-derived RV strain, BNP, and mortality in diaphragmatic hernia.Methods: We performed a single-center retrospective cohort study of infants with CDH and at least one BNP-echocardiogram pair within a 24-hour period. RV global longitudinal strain (GLS) and free-wall strain (FWS) were measured on existing echocardiograms. Associations among strain, BNP, and mortality were tested using mixed-effect linear and logistic regression models. Survival analysis was stratified by BNP and strain abnormalities.Results: There were 220 infants with 460 BNP-echocardiogram pairs obtained preoperatively (n = 237), ≤1 week postoperatively (n = 35), and >1 week postoperatively ("recovery"; n = 188). Strain improved after repair (P < 0.0001 for all periods). Higher BNP level was associated with worse strain in recovery but not before or immediately after operation (estimate [95% confidence interval] for recovery: GLS, 1.03 [0.50-1.57]; P = 0.0003; FWS, 0.62 [0.01-1.22]; P = 0.047). BNP and strain abnormalities were associated with an extracorporeal-membrane oxygenation requirement. Higher BNP level in recovery was associated with greater mortality (odds ratio, 11.2 [1.2-571.3]; P = 0.02). Abnormal strain in recovery had high sensitivity for detection of mortality (100% for GLS; 100% for FWS) but had low specificity for detection of mortality (28% for GLS; 48% for FWS).Conclusions: Persistent RV dysfunction after CDH repair may be detected by a high BNP level and abnormal RV strain.