Pablo J Sánchez

Brown University, Providence, Rhode Island, United States

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Publications (149)786.86 Total impact

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    ABSTRACT: Inhaled nitric oxide (INO), a selective pulmonary vasodilator, has revolutionized the treatment of neonatal hypoxemic respiratory failure (NHRF). However, there is lack of sustained improvement in 30 to 46% of infants. Aerosolized prostaglandins I2 (PGI2) and E1 (PGE1) have been reported to be effective selective pulmonary vasodilators. The objective of this study was to evaluate the feasibility of a randomized controlled trial (RCT) of inhaled PGE1 (IPGE1) in NHRF. Two pilot multicenter phase II RCTs are included in this report. In the first pilot, late preterm and term neonates with NHRF, who had an oxygenation index (OI) of >=15 and <25 on two arterial blood gases and had not previously received INO, were randomly assigned to receive two doses of IPGE1 (300 and 150 ng/kg/min) or placebo. The primary outcome was the enrollment of 50 infants in six to nine months at 10 sites. The first pilot was halted after four months for failure to enroll a single infant. The most common cause for non-enrollment was prior initiation of INO. In a re-designed second pilot, co-administration of IPGE1 and INO was permitted. Infants with suboptimal response to INO received either aerosolized saline or IPGE1 at a low (150 ng/kg/min) or high dose (300 ng/kg/min) for a maximum duration of 72 hours. The primary outcome was the recruitment of an adequate number of patients (n = 50) in a nine-month-period, with fewer than 20% protocol violations. No infants were enrolled in the first pilot. Seven patients were enrolled in the second pilot; three in the control, two in the low-dose IPGE1, and two in the high-dose IPGE1 groups. The study was halted for recruitment futility after approximately six months as enrollment targets were not met. No serious adverse events, one minor protocol deviation and one pharmacy protocol violation were reported. These two pilot RCTs failed to recruit adequate eligible newborns with NHRF. Complex management RCTs of novel therapies for persistent pulmonary hypertension of the newborn (PPHN) may require novel study designs and a longer period of time from study approval to commencement of enrollment.Trial registration: Pilot one: NCT number: 00598429 on 10 January 2008. Last updated: 3 February 2011.Pilot two: NCT number: 01467076 October 2011. Last updated: 13 February 2013.
    Trials. 12/2014; 15(1):486.
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    ABSTRACT: Prophylactic indomethacin reduces severe intraventricular hemorrhage but may increase spontaneous intestinal perforation (SIP) in extremely low birth weight (ELBW) infants. Early feedings improve nutritional outcomes but may increase the risk of SIP. Despite their benefits, use of these therapies varies largely by physician preferences in part because of the concern for SIP.
    Pediatrics 10/2014; · 5.30 Impact Factor
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    ABSTRACT: Background: Congenital CMV infection is a leading cause of sensorineural hearing loss (SNHL) and neurodevelopmental impairment in childhood. Information on CMV detection in cerebrospinal fluid (CSF) and its association with outcomes is limited. The objective of this study was to determine the significance of CMV detection in CSF of infants with congenital CMV infection. Methods: Retrospective review of cases of congenital CMV infection diagnosed at Nationwide Children’s Hospital, Parkland Memorial Hospital/Children’s Medical Center Dallas, and the University of Oklahoma Health Sciences Center from 1996-2014. Diagnosis of congenital CMV was made by culture or PCR from urine or saliva within the first 3 weeks of age. Detection of CMV in CSF was performed by culture or PCR. Clinical, laboratory, radiographic, and audiologic data was reviewed. Infants in whom CMV was detected in CSF were compared to those whose CSF was negative for CMV. Results: Twenty-two infants with congenital CMV infection who had a lumbar puncture performed and CSF tested for CMV were enrolled. All 22 infants had clinically apparent ("symptomatic") disease. 10 (45%) infants had CMV detected in CSF (CSF+) and were compared to the 12 infants whose CSF was CMV-negative (CSF-). The CSF+ infants did not differ from those whose CSF was CMV negative (CMV-) in age at diagnosis (median/range; 1.5 [1-8] vs.1 [1-17]; p>0.05), platelet count (p=0.47), alanine aminotransferase (p=0.11), direct bilirubin concentration (p=0.08), or CSF analyses including white blood cell count (p=0.98), protein content(p=0.39), or glucose concentration (p=0.31). Of the CSF+ infants, 6 (60%) had SNHL, while 10 (83%) CSF- infants had SNHL. Abnormalities on CNS imaging studies, either ultrasound/CT/MRI, were comparable between groups. Conclusion: CMV was frequently detected in CSF of infants with clinically apparent congenital CMV infection. However, its detection was not associated with increased rate of SNHL or neuroimaging abnormalities. Larger studies that incorporate neurodevelopmental assessments are needed to determine the potential role of CSF evaluation in the management of infants with congenital CMV infection.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Congenital CMV infection (cCMV) is a common congenital infection and a significant contributor to non-genetic sensorineural hearing loss (SNHL). Real-time PCR of newborn saliva specimens has been shown to be highly sensitive and specific compared to culture based methods for CMV screening. Although both saliva and urine samples are known to be acceptable for identifying infants with cCMV, it is thought that urine samples may contain more virus and thus, are optimal for cCMV screening. The objective is to compare viral load (VL) levels between saliva and urine samples from a large cohort of infants with cCMV infection identified through a newborn screening program. Methods: As part of the NIDCD CHIMES study, newborns at 7 U.S. medical centers were screened for CMV by saliva and dried blood spot PCR. Infants who screened positive were enrolled in a follow-up study to confirm congenital infection by testing saliva and urine samples using a previously described real-time PCR assay. CMV viral load in saliva samples obtained at screening and enrollment was compared to urine collected at enrollment in follow-up. Results: Of the 100,332 newborns screened for CMV from 2007 to 2011, viral load levels in both saliva and urine samples were available in 73% (336/462) of infants with confirmed cCMV. Of these, 36% (121/336) were enrolled within the first 3 weeks of life. The median viral load level in saliva at screening and enrollment (2.x106 IU/ml and 1.1x107 IU/ml, respectively) was significantly higher than in urine (8.3x105 IU/ml; p < 0.0001). There was no significant difference between VL in saliva and urine in infants with and without symptomatic disease and with and without congenital SNHL. In the smaller cohort of infants enrolled within 3 weeks of birth, median saliva VL at screening and enrollment (1.1x106 IU/ml vs. 9.3x106 IU/ml, respectively) was higher than urine VL (7.9x105IU/ml; p < 0.0001) . Conclusion: Infants with congenital CMV infection shed large amounts of virus in both saliva and urine. However, saliva samples contained higher viral load than urine, are easier to collect and do not require DNA extraction. Therefore, we propose that saliva should be considered the ideal specimen and real-time PCR of saliva is appropriate for both newborn screening and diagnosis of cCMV.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Prolonged antibiotic therapy among preterm infants in the NICU is associated with adverse outcomes including death and necrotizing enterocolitis. The optimal metric to measure antibiotic use in the NICU and thus guide stewardship efforts is unknown. The purpose of this study was to apply two different metrics of antibiotic use to a large cohort of NICU infants and compare the results. Methods: Prospective collection and analysis of all antibiotics provided to every infant admitted to the NICU at Parkland Memorial Hospital, Dallas during a 14 month period (SCOUT study). Pertinent clinical and outcome data were collected. Two different metrics for determining antibiotic use were calculated for all antibiotics: 1) days of therapy (DOT) and 2) number of calendar days (CD) that the antibiotics were administered. DOT was calculated by dividing the dosing interval by 24 hours, then multiplying by the number of doses, summed for each antibiotic. CD was determined by the number of days in which a dose of an antibiotic was administered. For example, a 6-dose course of q8 hour ampicillin begun Monday evening and completed Wednesday morning would equal 2 DOT (8 ÷ 24 x 6 = 2) and 3 CD (Mon, Tue, Wed = 3). Results: 1521 infants were admitted during the study period; 364 (24%) received no systemic antibiotics and were excluded. 1157 infants (76%) accounted for 19,788 hospital days and received 1439 separate antibiotic courses. The total volume of antibiotic administered was 9394 by DOT and 5915 by CD. Agent-specific antibiotic use by DOT and CD is shown (Table). Antibiotic No. of courses DOT CD % difference All 1439 9394 5915 -37% Gentamicin 1399 4468 4551 2% Ampicillin 1233 3579 4417 31% Oxacillin 181 676 874 23% Vancomycin 41 249 276 11% Piperacillin/tazobactam 36 171 195 14% 1st generation cephalosporins 18 10 23 130% Penicillin 12 69 77 12% 3rd generation cephalosporins 6 10 13 30% Meropenem 5 26 30 14% Metronidazole 4 38 42 11% Other 14 98 115 17% Conclusion: Antibiotic use in the NICU varies substantially by the metric used. When used to describe a course of antibiotics, CD does not account for the number of agents. When used for specific agents, CD overestimates therapy volume by 13% on average. Our ongoing evaluation of which metric best predicts adverse outcomes is important to guide antibiotic stewardship efforts.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Neonatal enterovirus (EV) infections have high morbidity & mortality. Antiviral therapy is not currently available. Pleconaril is an oral capsid binder with activity against EVs. Methods: Neonates with suspected EV sepsis (hepatitis, coagulopathy, or myocarditis) were randomized 2:1 to receive oral pleconaril or placebo x 7 days. Specimens (oropharynx, rectum, urine, serum) for viral culture & polymerase chain reaction (PCR), pharmacokinetic analysis, & safety evaluations were obtained over 14 days & clinical assessments were performed over 24 months. Results: 61 subjects were enrolled (43 treatment, 18 placebo), of whom 43 were confirmed EV-infected by culture or PCR (31 treatment, 12 placebo). Baseline characteristics were similar between EV-infected groups; median (range) age at illness onset was 4.5 (1-15) & 5.0 (1-10) days, respectively. Low culture yields precluded demonstrating a difference in the primary endpoint, day 5 oropharyngeal culture positivity (25% positive on Day 1 & 0% on Day 5 in the treatment group v. 30% on Day 1 & 0% on Day 5 in the placebo group). However, subjects in the treatment group became culture-negative from all anatomic sites combined faster than subjects in the placebo group (Fig 1; median 4.0 v. 7.0 days, p = 0.08) & fewer subjects in the treatment group remained PCR-positive from the oropharynx when last sampled (83% positive on Day 1 & 23% positive at a median of 14 days in the treatment group v. 100% positive on Day 1 & 58% positive at a median of 14 days in the placebo group, p = 0.02). By intent to treat, 10/43 (23%) of all subjects in the treatment group & 8/18 (44%) in the placebo group died (Fig 2; p = 0.02 for 2 month survival difference). Among EV-confirmed subjects, 7/31 (23%) in the treatment group died v. 5/12 (42%) in the placebo group (Fig 3; p = 0.26). Pleconaril concentrations exceeded the IC90 after the first treatment day, but 41% of subjects did not achieve this targetduring the 1st treatment day. 1 subject in the treatment group & 3 in the placebo group had treatment-related adverse events. Conclusion: Shorter times to culture & PCR negativity & suggestion of greater survival among pleconaril recipients support potential efficacy & warrant further evaluation. SEQ Figure * ARABIC 1. Culture positive SEQ Figure * ARABIC 2. Survival, all subjects SEQ Figure * ARABIC 3. Survival, EV-confirmed
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
  • Joseph B Cantey, Phillip S Wozniak, Pablo J Sánchez
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    ABSTRACT: Prolonged or unnecessary antibiotic use is associated with adverse outcomes in neonates. Our objectives were to quantify all antibiotic use in a Level III NICU and to identify scenarios where their use could be reduced.
    The Pediatric Infectious Disease Journal 09/2014; · 3.14 Impact Factor
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    ABSTRACT: Objective Obstetric antecedents were analyzed in births where the infant received whole-body cooling for neonatal encephalopathy. Methods This retrospective cohort study included all live-born singleton infants delivered at or beyond 36 weeks gestation from October 2005 through December 2011. Infants who had received whole-body cooling identified by review of a prospective neonatal registry were compared to a control group comprising the remaining obstetric population delivered at greater than 36 weeks but not cooled. Univariable analysis was followed by a staged, stepwise selection of variables with the intent to rank significant risk factors for cooling. Results A total of 86,371 women delivered during the study period and 98 infants received whole-body cooling (1.1/1,000 livebirths). Of these 98 infants, 80 (88%) newborns had moderate encephalopathy and 10 (12%) had severe encephalopathy prior to cooling. Maternal age less than or equal to 15 years, low parity, maternal body habitus (BMI > 40 kg/m2), diabetes, preeclampsia, induction, epidural analgesia, chorioamnionitis, length of labor, and mode of delivery were associated with significantly increased risk of infant cooling during univariable analysis. Catastrophic events to include umbilical cord prolapse (OR 14; 95%CI, 3-72), placental abruption (OR 17; 95%CI, 7-44), uterine rupture (OR 130; 95%CI, 11-1477) were the strongest factors associated with infant cooling after staged-stepwise logistic analysis. Conclusion A variety of intrapartum characteristics were associated with infant cooling for neonatal encephalopathy with the most powerful antecedents being umbilical cord prolapse, placental abruption, and uterine rupture.
    American journal of obstetrics and gynecology 08/2014; · 3.97 Impact Factor
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    ABSTRACT: Objective: Antenatal magnesium (anteMg) is used for various obstetric indications including fetal neuroprotection. Infants exposed to anteMg may be at risk for respiratory depression and delivery room (DR) resuscitation. The study objective was to compare the risk of acute cardio-respiratory (CR) events among preterm infants who were and were not exposed (noMg) to anteMg. Study Design: This was a retrospective analysis of prospective data collected in the NICHD Neonatal Research Network's Generic Database from 4/1/11 to 3/31/12. The primary outcome was DR intubation or respiratory support at birth or on day 1 of life. Secondary outcomes were invasive mechanical ventilation (MV), hypotension treatment, neonatal morbidities and mortality. Logistic regression analysis evaluated the risk of primary outcome after adjustment for covariates. Results: We evaluated 1,544 infants <29 weeks GA (1,091 in anteMg group and 453 in noMg group). Mothers in the anteMg group were more likely to have higher education, pregnancy-induced hypertension and antenatal corticosteroids; while their infants were younger in gestation and weighed less (P<0.05). The primary outcome (odds ratio [OR], 1.2, 95% confidence interval [CI], 0.88-1.65) was similar between groups. Hypotension treatment (OR, 0.70, 95% CI, 0.51-0.97) and invasive MV (OR, 0.54, 95% CI, 0.41-0.72) were significantly less in the anteMg group. Conclusion: Among preterm infants <29 weeks gestation, anteMg exposure was not associated with an increase in CR events in the early newborn period. The safety of anteMg as measured by the need for DR intubation or respiratory support on day 1 of life was comparable between groups.
    American Journal of Obstetrics and Gynecology 07/2014; · 3.97 Impact Factor
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    ABSTRACT: Objective To determine the frequency of respiratory viral infections among infants who were evaluated for late-onset sepsis in the neonatal intensive care units (NICUs) of Parkland Memorial Hospital, Dallas, Texas; and Women & Infants Hospital, Providence, Rhode Island. Study design Prospective cohort study conducted from January 15, 2012 to January 31, 2013. Infants in the NICU were enrolled if they were inborn, had never been discharged home, and were evaluated for sepsis (at >72 hours of age) and antibiotic therapy was initiated. Infants had a nasopharyngeal specimen collected for detection of respiratory viruses by multiplex polymerase chain reaction within 72 hours of the initiation of antibiotic therapy. Their medical records were reviewed for demographic, clinical, radiographic, and laboratory data until NICU discharge. Results During the 13-month study, 8 of 100 infants, or 8 (6%) of the 135 sepsis evaluations, had a respiratory virus detected by polymerase chain reaction (2, enterovirus/rhinovirus; 2, rhinovirus; 2, coronaviruses; and 2, parainfluenza-3 virus). By bivariate analysis, the infants with viral detection were older (41 vs 11 days; P = .007), exposed to individuals with respiratory tract viral symptoms (37% vs 2%; P = .003), tested for respiratory viruses by provider (75% vs 11%; P < .001), and had lower total neutrophil counts (P = .02). In multivariate regression analysis, the best predictor of viral infection was the caregivers' clinical suspicion of viral infection (P = .006). Conclusions A total of 8% of infants, or 6% of all NICU sepsis evaluations, had a respiratory virus detected when evaluated for bacterial sepsis. These findings argue for more respiratory viral testing of infants with suspected sepsis using optimal molecular assays to establish accurate diagnoses, prevent transmission, and inform antibiotic stewardship efforts.
    Journal of Pediatrics 07/2014; · 3.74 Impact Factor
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    ABSTRACT: IMPORTANCE Reduced death and neurodevelopmental impairment among infants is a goal of perinatal medicine. OBJECTIVE To assess the association between surgery during the initial hospitalization and death or neurodevelopmental impairment of very low-birth-weight infants. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort analysis was conducted of patients enrolled in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database from 1998 through 2009 and evaluated at 18 to 22 months' corrected age. Twenty-two academic neonatal intensive care units participated. Inclusion criteria were birth weight 401 to 1500 g, survival to 12 hours, and availability for follow-up. A total of 12 111 infants were included in analyses. EXPOSURES Surgical procedures; surgery also was classified by expected anesthesia type as major (general anesthesia) or minor (nongeneral anesthesia). MAIN OUTCOMES AND MEASURES Multivariable logistic regression analyses planned a priori were performed for the primary outcome of death or neurodevelopmental impairment and for the secondary outcome of neurodevelopmental impairment among survivors. Multivariable linear regression analyses were performed as planned for the adjusted mean scores of the Mental Developmental Index and Psychomotor Developmental Index of the Bayley Scales of Infant Development, Second Edition, for patients born before 2006. RESULTS A total of 2186 infants underwent major surgery, 784 had minor surgery, and 9141 infants did not undergo surgery. The risk-adjusted odds ratio of death or neurodevelopmental impairment for all surgery patients compared with those who had no surgery was 1.29 (95% CI, 1.08-1.55). For patients who had major surgery compared with those who had no surgery, the risk-adjusted odds ratio of death or neurodevelopmental impairment was 1.52 (95% CI, 1.24-1.87). Patients classified as having minor surgery had no increased adjusted risk. Among survivors who had major surgery compared with those who had no surgery, the adjusted risk of neurodevelopmental impairment was greater and the adjusted mean Bayley scores were lower. CONCLUSIONS AND RELEVANCE Major surgery in very low-birth-weight infants is independently associated with a greater than 50% increased risk of death or neurodevelopmental impairment and of neurodevelopmental impairment at 18 to 22 months' corrected age. The role of general anesthesia is implicated but remains unproven.
    JAMA Pediatrics 06/2014; · 4.25 Impact Factor
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    ABSTRACT: Objective:The use of inhaled nitric oxide (iNO) in preterm infants remains controversial. In October 2010, a National Institutes of Health consensus development conference cautioned against use of iNO in preterm infants. This study aims (1) to determine the prevalence and variability in use of iNO in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NICHD NRN) before and after the consensus conference and (2) separately, to examine associations between iNO use and severe bronchopulmonary dysplasia (BPD) or death.Study design:The NICHD NRN Generic Database collects data including iNO use on very preterm infants. A total of 13 centers contributed data across the time period 2008 to 2011. Infants exposed or not to iNO were compared using logistic regression, which included factors related to risk as well as their likelihood of being exposed to iNO.Result:A total of 4885 infants were assessed between 2008 and 2011; 128 (2.6%) received iNO before day 7, 140 (2.9%) between day 7 and 28, and 47 (1.0%) at >28 days. Center-specific iNO use during 2008 to 2010 ranged from 21.9 to 0.4%; 12 of 13 sites reduced usage and overall NRN iNO usage decreased from 4.6 to 1.6% (P<0.001) in 2011. The use of iNO started between day 7 and day 14 was more prevalent among younger infants with more severe courses in week 1 and associated with increased risk of severe BPD or death (odds ratio 2.24; 95% confidence interval 1.23 to 4.07).Conclusion:The variability and total use of iNO decreased in 2011 compared with 2008 to 2010. iNO administration started at ⩾day 7 was associated with more severe outcomes compared with infants without iNO exposure.Journal of Perinatology advance online publication, 5 June 2014; doi:10.1038/jp.2014.105.
    Journal of perinatology: official journal of the California Perinatal Association 06/2014; · 1.59 Impact Factor
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    ABSTRACT: To test the hypothesis that the proportion of endotracheal intubation (ETI) in the delivery room (DR) decreased in Neonatal Research Network (NRN) centres after the National Institute of Child Health and Human Development NRN Surfactant, Positive Pressure, and Oxygenation Randomised Trial (SUPPORT).
    Archives of Disease in Childhood - Fetal and Neonatal Edition 05/2014; · 3.86 Impact Factor
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    ABSTRACT: Viral culture of urine or saliva has been the gold standard for the diagnosis of congenital CMV infection. Results of rapid culture and PCR of urine and saliva from 80 children were compared to determine the utility of a real-time PCR assay for congenital CMV diagnosis. Urine PCR was positive in 98.8% of specimens. Three PCR-positive urine samples were culture-negative. Saliva PCR and culture were concordant in 78 specimens (97.5%). Two PCR-positive saliva samples were culture-negative. PCR of urine or saliva is equivalent to rapid culture for congenital CMV diagnosis. Additionally, saliva samples are easier to collect than urine.
    The Journal of Infectious Diseases 05/2014; · 5.85 Impact Factor
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    ABSTRACT: Background MRI is a surrogate biomarker for major neurodevelopmental disabilities in survivors of perinatal hypoxic-ischemic encephalopathy as injury to the basal ganglia/thalami is highly predictive of major neuromotor and cognitive problems. Major disabilities and the appearance of neonatal (R2-2) MRI are improved with therapeutic hypothermia. We evaluated neurodevelopmental outcomes when conventional MRI showed minimal or no brain injury. Methods IRB-approved series of 62 infants (≥36 weeks; ≥1800 g; 34 male/28 female) cooled for hypoxic-ischemic encephalopathy from 2005-11 who underwent neonatal (R2-2) MRI and Bayley Scales of Infant and Toddler Development -III 22 +/- 7 (R2-9) months of age. MRI at 5-14 (mean 8) days was scored as normal (score=0), showing focal grey or white matter injury only (score =1), or basal ganglia/thalamic and/or watershed lesions with or without more extensive hemispheric injury (score =2). Sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) for MR scores 0 and 1 and statistical interaction between MRI score and age at MRI were determined. Results MR score=0 was seen in 35/62 patients; 26/35 (74%) were typically developing, 7 (20%) had moderate and 2 (6%) had severe delay. MR score=1 was seen in 17/62 (27%) patients; 5/17 (29%) were normal, 11/17 (65%) had moderate delay, and 1/17 (6%) had severe neurodevelopmental delay. Of the 52 patients with MR scores 0 and 1, 40% were abnormal. The NPV of a normal MRI was 74%. For score 1, sensitivity was 95% [CI 63%-83%], specificity 84% [CI 70%-90%], PPV 84% [CI 71%-93%], and NPV 74% [CI 62%-82%]. Conclusions Caution is warranted when prognosticating about neurodevelopmental status in early childhood after HIE with cooling and longer follow-up studies are needed to determine the prognostic significanceof a neonatal MRI (R2-4) showing no or minor degrees of brain injury.
    Pediatric Neurology 05/2014; · 1.50 Impact Factor
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    ABSTRACT: Objective:Bayley-III scales are currently used to evaluate outcomes of term infants following hypothermia therapy, while all before reported outcomes in this population have used Bayley-II. Our objectives were to determine the incidence of abnormal neurodevelopmental outcomes using Bayley III and the predictive value of Magnetic resonance imaging (MRI) in infants who received systemic hypothermia.Study Design:We conducted a prospective cohort study of inborn infants who underwent hypothermia for moderate/severe neonatal encephalopathy from October 2005-November 2011.Result:Eighty newborns underwent hypothermia (incidence of 1/1000). Of the survivors, 89% had Bayley-III performed around 24 months of age. An abnormal outcome using Bayley-III <85 occurred in 50%, while Bayley III <70 occurred in 13%. MRI predicted Bayley III<85 with sensitivity of 73%, specificity of 84%, positive-predictive value of 84% and negative-predictive value of 74%.Conclusion:A Bayley-III 85 cutoff identifies a disability rate of 50%, and MRI was predictive of abnormal outcomes. Findings can be useful for counseling of families and planning of future studies using Bayley III.Journal of Perinatology advance online publication, 17 April 2014; doi:10.1038/jp.2014.67.
    Journal of perinatology: official journal of the California Perinatal Association 04/2014; · 1.59 Impact Factor
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    ABSTRACT: To describe the results of brain magnetic resonance imaging (MRI) of infants with bacterial meningitis and how the findings affected clinical management. This retrospective study included all infants <12 months of age who were hospitalized at Children's Medical Center, Dallas and had culture-confirmed bacterial meningitis and a brain MRI from January 1, 2001 to December 1, 2011. Infants were identified by review of all positive bacterial cultures of cerebrospinal fluid (CSF) from the Children's Medical Center Microbiology Laboratory. Demographic, clinical, laboratory, and neuroimaging data were reviewed. Infants with ventriculoperitoneal shunt or whose CSF culture yielded skin commensals were excluded. A neuroradiologist blinded to clinical information reviewed all MRI studies. Of the 440 infants who had a positive CSF culture result, 111 (25%) had a pathogen isolated from CSF and were enrolled in the study. Of these, 68% (75/111) had a brain MRI performed during the hospitalization; abnormalities included leptomeningeal enhancement (57%), cerebral infarct (43%), subdural empyema (52%), cerebritis (26%), hydrocephalus (20%), and abscess (11%). By multiple logistic regression analysis, infants with late seizures and an abnormal neurologic examination were more likely to have an abnormal MRI (P < .05). MRI results led to neurosurgical intervention in 23% of infants; a positive bacterial culture of CSF obtained >48 hours after initiation of antibiotic therapy was associated with neurosurgical intervention (P = .01). Fourteen (19%) infants with bacterial meningitis had a normal brain MRI. Brain MRIs were performed frequently and often were abnormal in infants with bacterial meningitis, leading to changes in clinical management.
    The Journal of pediatrics 04/2014; · 4.02 Impact Factor
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    ABSTRACT: In 2012, pertussis outbreak in a Dallas county resulted in the deaths of 4 children (3, unvaccinated; 2, <60 days of age). Despite recommendations that include immunization of women preferably during the third trimester of pregnancy or postpartum, household contacts ("cocooning"), and infants as early as 42 days of age, challenges in pertussis prevention remain.
    The Journal of pediatrics 02/2014; · 4.02 Impact Factor
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    ABSTRACT: Objective The objective of this study was to characterize the incidence, management, and short-term outcomes of cardiovascular insufficiency (CVI) in mechanically ventilated newborns, evaluating four separate prespecified definitions. Study Design Multicenter, prospective cohort study of infants ≥34 weeks gestational age (GA) and on mechanical ventilation during the first 72 hours. CVI was prospectively defined as either (1) mean arterial pressure (MAP) < GA; (2) MAP < GA + signs of inadequate perfusion; (3) any therapy for CVI; or (4) inotropic therapy. Short-term outcomes included death, days on ventilation, oxygen, and to full feedings and discharge. Results Of 647 who met inclusion criteria, 419 (65%) met ≥1 definition of CVI. Of these, 98% received fluid boluses, 36% inotropes, and 17% corticosteroids. Of treated infants, 46% did not have CVI as defined by a MAP < GA ± signs of inadequate perfusion. Inotropic therapy was associated with increased mortality (11.1 vs. 1.3%; p < 0.05). Conclusion More than half of the infants met at least one definition of CVI. However, almost half of the treated infants met none of the definitions. Inotropic therapy was associated with increased mortality. These findings can help guide the design of future studies of CVI in newborns.
    American Journal of Perinatology 02/2014; · 1.57 Impact Factor
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    ABSTRACT: To evaluate the neurodevelopmental outcomes of very preterm (<30 weeks) infants who underwent tracheostomy. Retrospective cohort study from 16 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network over 10 years (2001-2011). Infants who survived to at least 36 weeks (N = 8683), including 304 infants with tracheostomies, were studied. Primary outcome was death or neurodevelopmental impairment (NDI; a composite of ≥1 of developmental delay, neurologic impairment, profound hearing loss, severe visual impairment) at a corrected age of 18-22 months. Outcomes were compared using multiple logistic regression. We assessed the impact of timing by comparing outcomes of infants who underwent tracheostomy before and after 120 days of life. Tracheostomies were associated with all neonatal morbidities examined and with most adverse neurodevelopmental outcomes. Death or NDI occurred in 83% of infants with tracheostomies and 40% of those without (OR adjusted for center 7.0, 95% CI 5.2-9.5). After adjustment for potential confounders, odds of death or NDI remained higher (OR 3.3, 95% CI 2.4-4.6), but odds of death alone were lower (OR 0.4, 95% CI 0.3-0.7) among infants with tracheostomies. Death or NDI was lower in infants who received their tracheostomies before, rather than after, 120 days of life (aOR 0.5, 95% CI 0.3-0.9). Tracheostomy in preterm infants is associated with adverse developmental outcomes and cannot mitigate the significant risk associated with many complications of prematurity. These data may inform counseling about tracheostomy in this vulnerable population.
    The Journal of pediatrics 01/2014; · 4.02 Impact Factor

Publication Stats

3k Citations
786.86 Total Impact Points


  • 2014
    • Brown University
      • Department of Pediatrics
      Providence, Rhode Island, United States
    • Nationwide Children's Hospital
      Columbus, Ohio, United States
  • 1990–2014
    • University of Texas Southwestern Medical Center
      • • Department of Pediatrics
      • • Department of Obstetrics and Gynecology
      Dallas, Texas, United States
  • 2011–2013
    • Emory University
      • Department of Pediatrics
      Atlanta, Georgia, United States
  • 2010–2013
    • University of Rochester
      • School of Medicine and Dentistry
      Rochester, NY, United States
    • King Abdulaziz Medical City in Jeddah
      Djidda, Makkah, Saudi Arabia
    • Children's Healthcare of Atlanta
      Atlanta, Georgia, United States
  • 2003–2012
    • University of Alabama at Birmingham
      • Department of Pediatrics
      Birmingham, AL, United States
    • Boston Children's Hospital
      • Department of Pediatrics
      Boston, Massachusetts, United States
  • 2009–2011
    • Duke University Medical Center
      • Department of Pediatrics
      Durham, NC, United States
  • 2008
    • Childrens Hospital of Pittsburgh
      Pittsburgh, Pennsylvania, United States
  • 1998
    • Riley Hospital for Children
      Indianapolis, Indiana, United States
  • 1989
    • University of Texas at Dallas
      Richardson, Texas, United States