Bei kongenitalen Zwerchfelldefekten kommt es zu einer Herniation von abdominellen Organen in den Thorax. Es resultieren eine Lungenhypoplasie und eine pulmonale Hypertonie, die die hohe Mortalität und Morbidität bestimmen. In dieser Studie wurden prä-, peri- und postnatale Parameter von Patienten mit kongenitalen Zwerchfelldefekten retrospektiv betrachtet und auf eine mögliche Prädiktion für das Outcome sowie auf therapeutische Qualitätsänderungen überprüft. Im prospektiven Teil wurde die weitere Entwicklung der Kinder nach dem stationären Aufenthalt eruiert. Statistisch signifikante Unterschiede zeigten sich für einen höheren 1’ APGAR, eine seltenere Anwendung von NO und ein selteneres Vorkommen von assoziierten Anomalien bei den überlebenden verglichen mit den verstorbenen Patienten. Die Überlebenden hatten niedrigere Beatmungsfrequenzen, inspiratorische Spitzendrücke, Sauerstoffkonzentration sowie Mitteldrücke bei Beatmung und höhere arterieller Mitteldrücke. Als negativ für das Outcome erwiesen sich ein Polyhydramnion, eine Leberherniation oder die Notwendigkeit einer HFOV. Im zeitlichen Verlauf zeigten sich ein höherer 5’ APGAR, eine zeitigere Diagnosestellung in der Schwangerschaft, eine spätere Durchführung der Operationen und seltenere Rezidive. Die Kinder wurden mit niedrigeren Beatmungsdrücken und niedrigerem Sauerstoffgehalt beatmet, ohne dass sich das Outcome verschlechterte. Bezüglich der späteren Entwicklung gab es orthopädische und neurologische Folgen. Die Kinder hatten nur wenige Einschränkungen im Alltag. Dennoch zeigte sich das potentielle Auftreten einer Minderung der kognitiven Fähigkeiten.

Pulmonary vascular disease (PVD) and lung hypoplasia (LH) are the two main causes of mortality and morbidity in patients with congenital diaphragmatic hernia (CDH). Previous studies have shown that remodeling of the extracellular matrix (ECM) by elastase and matrix metalloproteinase (MMP) enzymes, concomitant with smooth muscle cell (SMC) proliferation and deposition of ECM proteins and growth factors, leads to primary pulmonary hypertension (PH) and that blockade of this pathway results in disease reversal. The aim of our study is to determine whether a similar pathway is induced in the PVD associated with CDH and to verify whether its inhibition will lead to reversal of PVD. Firstly, we confirmed various aspects of PVD in the nitrofen induced CDH rat model. These included: left lung hypoplasia, right ventricular hypertrophy, and increased arterial smooth muscle wall thickness alongside decreases in arterial lumen area and total number of distal pulmonary vessels. We also showed increases in elastase and matrix metalloproteinase (MMP) enzyme activities within distal pulmonary arteries (PAs), which, we were able to inhibit using serine elastase (sivelestat, elafin, and serpina1) and MMP (GM6001) inhibitors. Furthermore, we confirmed increased SMC proliferation and deposition of osteopontin (OPN) and epidermal growth factor (EGF) within the diseased vasculatures. We are now working on using sivelestat and GM6001 pharmaceuticals as well as endothelial progenitor cells (EPCs) and mesenchymal stem cells (MSCs) modified to express elafin and serpina1 to determine their abilities to reverse the PVD associated with CDH. This project is part of our translational research program with the ultimate goal of developing a novel strategy of targeting PVD in infants with CDH to improve patient survival and long-term outcome.

No description available.

A hérnia diafragmática congênita (CDH) tem incidência de aproximadamente 1:2500 nascidos vivos e mortalidade de aproximadamente 70%. A hipertensão arteiral pulmonar é umas das principais complicações neonatais e pode levar à sobrecarga cardíaca. A principal estratégia de tratamento para os casos de grave hipoplasia pulmonar no período pré-natal é a traqueo-oclusão fetal (TO), no entanto, as consequências geradas ao tecido cardíaco são incertas, tanto na CDH quanto no tratamento com TO. Troponininas (cTnI e cTnT) são proteínas intracelulares miocárdicas utilizadas como indicativo de lesão cardiomiocítica. Portanto, nosso objetivo foi avaliar as alterações anatômicas, funcionais e bioquímicas dos ventrículos esquerdo (VE) e direito (VD) na CDH e CDHTO por meio das análises de ecocardiografia (ECO), histologia e bioquímica no modelo experimental de CDH. Para isso, foram utilizados neonatos de coelhos (n=10) divididos em três grupos: controle (C), hérnia diafragmática congênita (CDH), e hérnia diafragmática congênita + traqueo-oclusão (CDHTO). A cirurgia de CDH foi realizada no dia 25 da gestação (DG) da coelha (termo = 31 dias), e a TO no 27DG. A coleta foi realizada em 30DG, a ECO neonatal foi realizada imediatamente após retirada do útero e após o sacrifício os pulmões e coração foram coletados. A mortalidade da CDH fi de 20% e de CDHTO de 30%. Os resultados da ECO e da histologia mostraram hipoplasia de VE nos grupos CDH e CDHTO (*p<0,05), sendo que no VD, o grupo CDH apresentou dilatação e o grupo CDHTO apresentou hipoplasia. Na imunofluorescência (IF), western blotting (WB) e RT-qPCR houve aumento de cTnI no VD dos grupos CDH e CDHTO em relação à C (*p<0,05), sem alteração de expressão de cTnI no VE (NS); cTnT não apresentou alteração em ambos ventrículos (NS). Concluímos que as alterações cardíacas em CDH e CDHTO podem ser verificadas logo após o nascimento e há associação das alterações ecocardiográficas, histométricas e bioquímicas, como a hipoplasia de VE e dilatação de VD associada ao aumento tecidual de cTnI no VD no grupo CDH, indicando sofrimento cardíaco ainda no período fetal. Além disso, a realização do tratamento fetal pela TO no grupo CDH (CDHTO) não apresentou melhora das alterações do comprometimento do miocárdio. / Congenital diaphragmatic hernia (CDH) has an incidence of approximately 1: 2500 live births and a mortality rate of approximately 70%. Pulmonary hypertension is one of the major neonatal complications and can lead to cardiac overload. The main treatment strategy for cases of severe prenatal pulmonary hypoplasia is fetal tracheal occlusion (TO), however, the consequences in the cardiac tissue are uncertain, in both the CDH and the TO treatment. cTnI and cTnT are myocardial intracellular proteins used as an indicative of cardiomyocyte injury that could be measured in neonates with CDH. Therefore, our aim was to evaluate the anatomical, functional and biochemical alterations in the left ventricle (LV) and in the right ventricle (RV) of neonates with CDH and CDHTO through echocardiography (ECO), histology and biochemistry analysis in the experimental rabbit CDH model. Neonates of rabbits (n = 10) were divided into three groups: C (control), CDH (congenital diaphragmatic hernia) and CDHTO (congenital diaphragmatic hernia + tracheal occlusion). CDH surgery was performed on day 25 of gestation (GD) of the rabbit (term = 31 days), and TO treatment on 27GD. The harvest was performed in 30GD, followed by neonatal ECO immediately after birth, then after sacrifice the lungs and heart were harvested. The mortality in the surgical groups was 20% CDH and 30% CDHTO. The ECO and histology results showed LV hypoplasia in the CDH and CDHTO (* p <0.05) groups. In the RV, the CDH group presented dilation and the CDHTO group presented hypoplasia. In the immunofluorescence (IF), western blotting (WB) and RTqPCR analysis there was an increase of cTnI in the RV of CDH and CDHTO groups in comparison with C group (* p<0.05), with no alteration of cTnI expression in the LV (NS). There was no difference of cTnT expression in both ventricles (NS). We conclude that cardiac alterations in CDH and CDHTO can be verified soon after birth, also there is an association of echocardiographic, histometric and biochemical alterations, such as LV hypoplasia and RV dilation with increased cTnI tissue expression in the RV of CDH group, indicating cardiac distress still in the fetal period. In addition, the performance of CDH fetal treatment by TO, (CDHTO) group, did not improve the myocardial detriment.

The birth of a child diagnosed with congenital diaphragmatic hernia (CDH) involves significant intensive care at the beginning of life and the need for surgery. Parents’ experiences during the acute phase of hospitalization for a critically ill infant not born premature is currently limited in the literature; in particular, there is no literature describing parents’ experiences of nursing care for having a infant with CDH in the Neonatal Intensive Care Unit (NICU). Using narrative inquiry this study explores stories of parents’ early experiences of nursing care in the NICU for an infant born with CDH. A thematic analysis revealed a main overarching theme of “not knowing” with three interrelated subthemes related to parents’ need for information and open communication; participation, power and partnership; and nursing presence to transition from not knowing to knowing their infant. The findings from this study suggest that parents want to be recognized as key members within the multidisciplinary team and that the nurse has the ability to facilitate aspects of care to impact parents positively or negatively. Implications for practice focus on supporting parents through evolving empowerment and participation in the care of their infant. / Graduate / 0569

INTRODUCTION: Pulmonary hypoplasia causes high morbidity and mortality in congenital diaphragmatic hernia (CDH) patients. MiR-10a and miR-200b are overexpressed in human CDH lungs. We aimed to define their roles in lung development. METHODS: We profiled miR-10a expression with RT-qPCR and in situ hybridization using a nitrofen rat model for CDH. The effects of miR-10a on airway branching were evaluated in lung explants. MiR-200b’s role in airway branching was assessed in miR-200b knockout lung explants. Crossing miR-200b knockout mice with CFP-E-Cadherin was used to evaluate miR-200b’s effects on epithelial differentiation. RESULTS: Expression of miR-10a was altered in the nitrofen model and miR-10a mimics reversed lung hypoplasia in vitro. Heterozygous miR-200b lung explants displayed reduced airway branching. CFP-E-Cadherin/miR-200b knockout lung explants showed reduced epithelial expression. CONCLUSION: Both miR-10a and miR-200b are critical for lung development and CDH. Normalizing their expression may reverse lung hypoplasia and reduce the associated morbidity and mortality in CDH. / February 2016

Bei kongenitalen Zwerchfelldefekten kommt es zu einer Herniation von abdominellen Organen in den Thorax. Es resultieren eine Lungenhypoplasie und eine pulmonale Hypertonie, die die hohe Mortalität und Morbidität bestimmen. In dieser Studie wurden prä-, peri- und postnatale Parameter von Patienten mit kongenitalen Zwerchfelldefekten retrospektiv betrachtet und auf eine mögliche Prädiktion für das Outcome sowie auf therapeutische Qualitätsänderungen überprüft. Im prospektiven Teil wurde die weitere Entwicklung der Kinder nach dem stationären Aufenthalt eruiert. Statistisch signifikante Unterschiede zeigten sich für einen höheren 1’ APGAR, eine seltenere Anwendung von NO und ein selteneres Vorkommen von assoziierten Anomalien bei den überlebenden verglichen mit den verstorbenen Patienten. Die Überlebenden hatten niedrigere Beatmungsfrequenzen, inspiratorische Spitzendrücke, Sauerstoffkonzentration sowie Mitteldrücke bei Beatmung und höhere arterieller Mitteldrücke. Als negativ für das Outcome erwiesen sich ein Polyhydramnion, eine Leberherniation oder die Notwendigkeit einer HFOV. Im zeitlichen Verlauf zeigten sich ein höherer 5’ APGAR, eine zeitigere Diagnosestellung in der Schwangerschaft, eine spätere Durchführung der Operationen und seltenere Rezidive. Die Kinder wurden mit niedrigeren Beatmungsdrücken und niedrigerem Sauerstoffgehalt beatmet, ohne dass sich das Outcome verschlechterte. Bezüglich der späteren Entwicklung gab es orthopädische und neurologische Folgen. Die Kinder hatten nur wenige Einschränkungen im Alltag. Dennoch zeigte sich das potentielle Auftreten einer Minderung der kognitiven Fähigkeiten.

No description available.

Largely as a consequence of the ongoing obesity epidemic, research into adipose tissue biology has increased substantially in recent years. Worldwide, the number of people classed as overweight or obese is growing, and this represents a major public health concern. Adipose tissue is broadly divided into two types; white and brown. Whilst white adipose tissue (WAT) functions to store and mobilise triglycerides, brown adipose tissue burns chemical energy to generate heat. WAT is further divided into visceral “bad” fat and subcutaneous “good” fat depots, and it is an increase in the former that is linked to obesity-associated diseases. As well as adipocytes, several other cell types including haematopoietic and endothelial are found within adipose tissue, and comprise the stromal vascular fraction (SVF). Adipocyte precursor cells (APCs) also reside within the SVF and are essential for the maintenance and expansion of adipose tissue. The protein encoded by the Wilms’ tumour 1 (Wt1) gene is predominantly known to function as a transcription factor, but also has a role in post-transcriptional processing. Deletion of Wt1 in adult mice results in a considerable loss of fat tissue. Moreover, recent work has revealed that a proportion of the APCs from all visceral WAT depots express Wt1, therefore revealing heterogeneity within the APC population. Additionally, visceral WAT depots are encapsulated by a WT1 expressing mesothelial layer, which has its origins in the lateral plate mesoderm (LPM), and can give rise to mature adipocytes. Lineage tracing has demonstrated that a significant proportion of the mature adipocytes in all adult visceral WAT depots (but not subcutaneous) are derived from cells that express Wt1 in late gestation. These findings uncovered key ontogenetic differences between visceral and subcutaneous WAT and led us to ask whether Wt1 functions in visceral adipose tissue biology. Preliminary work has shown that adipocytes derived from Wt1 expressing (Wt1+) precursor cells have fewer, larger lipid droplets than those derived from non-Wt1 expressing (Wt1-) precursors. In this thesis, this heterogeneity is explored further using a Wt1GFP/+ knock-in mouse. When Wt1+ and Wt1- APCs are cultured separately, the Wt1+ population differentiate into adipocytes more readily. Moreover, the Wt1+ APCs are more proliferative than the Wt1-. Preliminary results also suggest that the Wt1+ APCs may secrete a factor(s) that causes the Wt1- APCs to exhibit improved adipogenic differentiation, a result that is supported by data from comparative transcriptomic analysis. Finally, the percentage of APCs decreases when mice are fed a high fat diet. Interestingly, this decrease is more pronounced for the Wt1+ population. Therefore, it appears that as well as exhibiting differing behaviours in vitro, the Wt1+ and Wt1- populations respond differently to physiologically relevant conditions in vivo. Whilst the LPM is a major source of visceral WAT, the origin of subcutaneous WAT is currently unknown. Here, the Prx1-Cre and Prx1-CreERT2 mouse lines are used to investigate this. It is shown that the majority of subcutaneous WAT adipocytes and APCs are labelled by Prx1-Cre, however this is not the case for most of the visceral WAT depots. The exception to this is the pericardial (heart fat) depot, in which approximately 70% of the adipocytes and 40% of the APCs are labelled. Moreover, a proportion of the Prx1-Cre labelled pericardial APCs also express Wt1, therefore suggesting additional heterogeneity. Preliminary results show that this heterogeneity may have functional consequences, at least in vitro. Additionally, lineage tracing studies suggest that the somatic LPM may be one source of subcutaneous WAT and pericardial visceral WAT Finally, it is shown that the conditional deletion of Wt1 in the Prx1-Cre lineage results in abnormal diaphragm development. Congenital diaphragmatic hernia (CDH) is severe birth defect, the etiology of which is not well understood. Here, a new model of CDH has been developed, and the cellular and molecular mechanisms responsible for the defect in this model are investigated.

Die vorliegende Arbeit beschäftigt sich mit der Anwendung der sonographischen Lungenbiometrie in der Pränataldiagnostik zur Erkennung einer Lungenhypoplasie. Im ersten Abschnitt wurden anhand definierter Messebenen Normwerte für verschiedene biometrische Parameter (Durchmesser, Länge) der fetalen Lunge erstellt. Im zweiten Abschnitt wurde diese Meßmethode mit Hilfe eines Hochrisikokollektivs (N=29) für die intrauterine Entwicklung einer Lungenhypoplasie hinsichtlich ihrer prognostischen Aussagekraft untersucht. Es konnte nur eine sehr geringe Sensitivität und Spezifität der verschiedenen Messebenen festgestellt werden. Die Vierkammerblickebene wies mit Werten für die Sensitivität von 57% und 44 % sowie für die Spezifität von 42 % und 50 % noch die höchste Validität auf. Eine Fehlbildung, die typischerweise mit der Ausbildung einer Lungenhypoplasie einhergeht, ist die kongenitale Zwerchfellhernie. Da die beschriebenen Messebenen bei dieser Fehlbildung nur schwer zu verwenden sind, wurde in der Literatur ein neuer Parameter, die Lung-to-Head-Ratio, in die pränatale Diagnostik eingeführt. In einem dritten Abschnitt wurde die Lung-to-Head-Ratio (LHR) prospektiv in ihrer prognostischen Aussagekraft bei 18 Feten mit isolierter Zwerchfellhernie untersucht. Neben dem Outcome (Überleben) wurden auch neonatale Ventilationsparameter sowie das Risiko der Entwicklung einer pulmonalen Hypertonie untersucht. Für die LHR konnte kein signifikanter Einfluß auf das Outcome gefunden werden. Es konnte kein signifikanter Zusammenhang zwischen der pränatal bestimmten Lungengröße und dem postnatalen Verlauf der Beatmungsparameter bzw. dem Risiko der Entwicklung einer pulmonalen Hypertonie gefunden werden. Die sonographische Erkennung einer Lungenhypoplasie ist möglich. Mit den derzeit vorhandenen Messebenen ist jedoch eine Einschätzung der Prognose einer Lungenhypoplasie pränatal nicht möglich. Die Ergebnisse unterstützen die Überlegungen, dass die kongenitale Zwerchfellhernie ein sehr komplexes Krankheitsbild ist, welches in seinem Schweregrad nicht nur durch einen Parameter (Lungengröße) eingeschätzt werden kann. / This study analysed the application of the sonographic lung biometry on the prenatal detection of pulmonary hypoplasia. The first chapter defined sonographic levels for the measurement of different biometric parameter (diameter, length) of the fetal lung. The second chapter analysed the application of this method regarding its predictive value in a group with high risk for developing pulmonary hypoplasia (N=29). The sensitivity and specificity of the various measurement levels was low. The level of the four chamber view had the highest validity with a sensitivity of 57 % and 44 % and with a specificity of 42 % and 50 %. The congenital diaphragmatic hernia is a malformation which typically develope pulmonary hypoplasia. The above described measurement levels are difficult to reproduce in congenital diaphragmatic hernia. Therefor a new biometric parameter has been introduced in the literature, the lung-to-Head-Ratio (LHR). In the third chapter the LHR was analysed concerning the evaluation of the prognosis in 18 fetuses with isolated diaphragmatic hernia. The following parameters were examined: outcome of the fetuses; neonatal ventilation parameters; occurance of pulmonary hypertension. There was no significant correlation between the LHR at time of diagnosis of the diaphragmatic hernia and these parameters. The prenatal detection of a pulmonary hypoplasia using the method of sonographic lung biometry is possible. But it is not possible to predict the severity of pulmonary hypoplasia in these cases. It would seem that the lung is a too complex organ for it to be prognostically judged only by measuring a single biometric parameter.