Introduction: ECMO is a critical rescue therapy for patients with refractory cardiopulmonary failure. Historically, ECMO patients have remained intubated and sedated. To minimize complications of prolonged mechanical ventilation, adults are increasingly extubated on ECMO to improve mobility and facilitate rehabilitation. This approach is not well described in pediatrics. We hypothesize that extubating pediatric ECMO patients is safe without increased incidence of complications. Methods: This multi-center retrospective cohort study included ECMO centers contributing to the Extracorporeal Life Support Organization (ELSO) registry between 2018 and 2022. Patient were 30 days to 18 years old with a primary ECMO indication of respiratory failure and primary cardiac diagnoses were excluded. Patients were grouped as extubated or non-extubated on ECMO. P-PREP scores were calculated to compare predicted in-hospital mortality between groups. A multivariate logistic regression model was developed to identify factors independently associated with ECMO in-hospital mortality. Results: Of 2416 patients meeting inclusion criteria, 112 were extubated (4.6%). There was no significant difference in P-PREP scores between groups. Extubated patients were older (median 6.1 vs. 2.4 years, p = 0.005), weighed more (median 32.5 vs. 13.3 kg, p < 0.001), more often cannulated to VV versus VA ECMO (p = 0.0005), and had a longer duration of ECMO support (median 275 vs. 167 hours, p < 0.0001). Extubated patients were better mobilized, defined as sitting in a bed or greater (29.5% vs. 4.8%, p < 0.0001). There was no significant increase in complications for extubated patients and no patients required re-intubation prior to decannulation. In-hospital mortality was higher in the extubated group (69.8% vs. 57.1% p = 0.0003) however in multivariate analysis, extubation was not a significant independent risk factor (p = 0.23). Independent predictors of mortality were weight (p = 0.006) and ECMO duration (p < 0.0001) whereas mobilization was protective (OR 0.34, p < 0.0001). Conclusions: Extubating pediatric patients on ECMO remains an uncommon practice, and is seen primarily in older patients requiring a longer duration of ECMO support. Potential benefits of this strategy are improved mobility without an increase in ECMO-related complications.
The microbial production, isolation, and structure elucidation of four new napyradiomycin congeners (1–4) is reported. The structures of these compounds, which are new additions to the marine-derived meroterpenoids, were defined by comprehensive spectroscopic analysis and by X-ray crystallography. Using fluorescence-activated cell sorting (FACS) analysis, napyradiomycins 1–4 were observed to induce apoptosis in the colon adenocarcinoma cell line HCT-116, indicating the possibility of a specific biochemical target for this class of cytotoxins.
Neonatal diabetes mellitus (NDM) is a rare condition that presents with diabetes in the first few months of life. The treatment of NDM may differ depending on the genetic etiology, with numerous studies showing the benefit of sulfonylurea therapy in cases caused by mutations in KCNJ11 or ABCC8 . Mutations in the insulin gene ( INS ) have also been identified as causes of NDM; these cases are generally best treated with insulin alone. We report a case of a female infant born small for gestational age (SGA) at late preterm diagnosed with NDM at 7 wk of life who was found by rapid whole-genome sequencing to harbor a novel de novo c.26C>G (p.Pro9Arg) variant in the INS gene. She presented with diabetic ketoacidosis, which responded to insulin therapy. She did not respond to empiric trial of sulfonylurea therapy early in her hospital course, and it was discontinued once a genetic diagnosis was made. Early genetic evaluation in patients presenting with NDM is essential to optimize therapeutic decision-making.
Increased inflammation has been well defined in coronavirus disease 2019 (COVID-19), while definitive pathways driving severe forms of this disease remain uncertain. Neutrophils are known to contribute to immunopathology in infections, inflammatory diseases, and acute respiratory distress syndrome, a primary cause of morbidity and mortality in COVID-19. Changes in neutrophil function in COVID-19 may give insight into disease pathogenesis and identify therapeutic targets.
This retrospective study evaluates the clinical utility of CFPNGS in the diagnosis and management of pediatric meningitis. CFPNGS identified a causative pathogen in 36% of 28 subjects, compared to 50% for diverse conventional testing (57% combined). CFPNGS may be considered as an adjunct to standard testing.
Introduction: Pediatric pneumonia can be severe and result in complications, including empyema and lung abscess formation. Conventional blood and pleural cultures often have limited sensitivity. Next-generation sequencing (NGS) may broadly detect pathogens from multiple body fluids despite antibiotic pre-exposure; however, the optimal timing and impact of sample type on diagnostic yield is unknown. The goal of this study is to understand how the detection of bacterial DNA changes over time in samples with varying proximity to the lungs. Methods: This is a prospective, single-center descriptive pilot study conducted at a tertiary children's hospital from July 2022 to June 2023. Children aged 3 months through 17 years admitted to the pediatric ICU with a primary diagnosis of complicated pneumonia, who were endotracheally intubated and/or had a tube thoracostomy were eligible. Plasma, endotracheal, nasopharyngeal, and pleural fluid samples were collected at three time points during hospitalization. After separate DNA and RNA extraction, combined libraries were prepared, enriched with RPIP (Illumina), sequenced and quantitative organism detections were analyzed after discharge. Results: Conventional microbiological culture identified a putative organism in 9 of 10 patients. Pathogens included: S. pneumoniae (2), H. influenzae (1), S. aureus (2), Streptococcus spp. (3), P. aeruginosa (1). The yield of pleural cultures was highest (8), followed by respiratory culture (5) and blood culture (2). NGS identified the same bacterial pathogen as traditional testing in all samples evaluated to date. The treated organism was detected by NGS in upper respiratory samples (NP swabs and/or sputum), plasma, and pleural fluid at the earliest timepoint. NGS detected more bacterial diversity than culture in nearly all samples, but bacterial diversity was greatest in the NP swabs. NGS made additional viral detections not detected by standard PCR panels. Conclusions: NGS detected a putative pathogen in all samples regardless of pre-treatment or time collected. Conventional culture methods only identified the pathogen reliably in invasively obtained pleural fluid or endotracheal aspirates. Future application of NGS may allow for non-invasive pathogen detection at a broader range of time points and more targeted antibiotic coverage.
SUMMARY Extrachromosomal circular DNA (ecDNA) is an important driver of aggressive tumor growth, promoting high oncogene copy number, intratumoral heterogeneity, accelerated evolution of drug resistance, enhancer rewiring, and poor outcome. ecDNA has been reported in medulloblastoma (MB), the most common malignant pediatric brain tumor, but the ecDNA landscape and its association with specific MB subgroups, its impact on enhancer rewiring, and its potential clinical implications, are not known. We assembled a retrospective cohort of 468 MB patient samples with available whole genome sequencing (WGS) data covering the four major MB subgroups WNT, SHH, Group 3 and Group 4. Using computational methods for the detection and reconstruction of ecDNA 1 , we find ecDNA in 82 patients (18%) and observe that ecDNA+ MB patients are more than twice as likely to relapse and three times as likely to die of disease. In addition, we find that individual medulloblastoma tumors often harbor multiple ecDNAs, each containing different amplified oncogenes along with co-amplified non-coding regulatory enhancers. ecDNA was substantially more prevalent among 31 analyzed patient-derived xenograft (PDX) models and cell lines than in our patient cohort. By mapping the accessible chromatin and 3D conformation landscapes of MB tumors that harbor ecDNA, we observe frequent candidate “enhancer rewiring” events that spatially link oncogenes with co-amplified enhancers. Our study reveals the frequency and diversity of ecDNA in a subset of highly aggressive tumors and suggests enhancer rewiring as a frequent oncogenic mechanism of ecDNAs in MB. Further, these results demonstrate that ecDNA is a frequent and potent driver of poor outcome in MB patients.
Ependymoma is a tumor of the brain or spinal cord. The two most common and aggressive molecular groups of ependymoma are the supratentorial ZFTA-fusion associated and the posterior fossa ependymoma group A. In both groups, tumors occur mainly in young children and frequently recur after treatment. Although molecular mechanisms underlying these diseases have recently been uncovered, they remain difficult to target and innovative therapeutic approaches are urgently needed. Here, we use genome-wide chromosome conformation capture (Hi-C), complemented with CTCF and H3K27ac ChIP-seq, as well as gene expression and DNA methylation analysis in primary and relapsed ependymoma tumors, to identify chromosomal conformations and regulatory mechanisms associated with aberrant gene expression. In particular, we observe the formation of new topologically associating domains ('neo-TADs') caused by structural variants, group-specific 3D chromatin loops, and the replacement of CTCF insulators by DNA hyper-methylation. Through inhibition experiments, we validate that genes implicated by these 3D genome conformations are essential for the survival of patient-derived ependymoma models in a group-specific manner. Thus, this study extends our ability to reveal tumor-dependency genes by 3D genome conformations even in tumors that lack targetable genetic alterations.
