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Rodolaki K, Pergialiotis V, Sapantzoglou I, Theodora M, Antsaklis P, Pappa K, Daskalakis G, Papapanagiotou A. N-Terminal Pro-B Type Natriuretic Peptide as a Predictive Biomarker of Bronchopulmonary Dysplasia or Death Due to Bronchopulmonary Dysplasia in Preterm Neonates: A Systematic Review and Meta-Analysis. J Pers Med 2023; 13:1287. [PMID: 37763055 PMCID: PMC10532602 DOI: 10.3390/jpm13091287] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Emerging evidence suggests the clinical utility of N terminal pro B type natriuretic peptide (NT-proBNP) in multiple cardiac and pulmonary abnormalities both in adult and pediatric populations. To date, however, there is no consensus regarding its efficacy for the prediction and severity of bronchopulmonary dysplasia in premature neonates. The objective of the present meta-analysis was to determine differences in NT-proBNP among neonates that develop BPD or die from BPD and to evaluate if there is relative information on the diagnostic accuracy of the method. METHODS We conducted a systematic search according to the PRISMA guidelines and looked into Medline (1966-2023), Scopus (2004-2023), Clinicaltrials.gov (2008-2023), EMBASE (1980-2023), Cochrane Central Register of Controlled Trials CENTRAL (1999-2022) and Google Scholar (2004-2023) together with the reference lists from included studies. The potential risk of bias encountered in our study was evaluated using the QUADAS -2 tool. Finally, a total of 9 studies met the eligibility criteria, comprising 1319 newborns, from which 397 developed BPD and 922 were unaffected controls. RESULTS The results retrieved from our meta-analysis showed that newborns suffering from BPD had notably elevated NT-proBNP levels after birth when compared with healthy neonates (SMD 2.57, 95% CI 0.41, 4.72). The summary effect of the AUC meta-analysis showed that NT-proBNP was very accurate in detecting neonates at risk of developing severe BPD or dying from the disease (AUC -0.16, 95% CI -0.23, -0.08). No studies reported data relevant to the sensitivity and/or specificity of the method in diagnosing BPD. CONCLUSION Serum NT-proBNP levels represent a potential future biomarker with great diagnostic validity for the prediction of BPD complicating preterm deliveries. The limited amount of studies included and the significant variations in cutoff values and timing of measurement still restrict the application of NT-proBNP as an established clinical biomarker for BPD. The design of larger prospective studies will provide a more representative number of participants and will address the discrepancies in existing literature.
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Affiliation(s)
- Kalliopi Rodolaki
- 1st Department of Pediatrics, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece;
| | - Vasilios Pergialiotis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (V.P.); (I.S.); (M.T.); (P.A.); (K.P.); (G.D.)
| | - Ioakeim Sapantzoglou
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (V.P.); (I.S.); (M.T.); (P.A.); (K.P.); (G.D.)
| | - Marianna Theodora
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (V.P.); (I.S.); (M.T.); (P.A.); (K.P.); (G.D.)
| | - Panagiotis Antsaklis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (V.P.); (I.S.); (M.T.); (P.A.); (K.P.); (G.D.)
| | - Kalliopi Pappa
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (V.P.); (I.S.); (M.T.); (P.A.); (K.P.); (G.D.)
| | - Georgios Daskalakis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (V.P.); (I.S.); (M.T.); (P.A.); (K.P.); (G.D.)
| | - Aggeliki Papapanagiotou
- Department of Biological Chemistry, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Martini S, Corsini I, Corvaglia L, Suryawanshi P, Chan B, Singh Y. A scoping review of echocardiographic and lung ultrasound biomarkers of bronchopulmonary dysplasia in preterm infants. Front Pediatr 2023; 11:1067323. [PMID: 36846161 PMCID: PMC9950276 DOI: 10.3389/fped.2023.1067323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/18/2023] [Indexed: 02/12/2023] Open
Abstract
Despite recent improvements in neonatal care, moderate to severe bronchopulmonary dysplasia (BPD) is still associated with high mortality and with an increased risk of developing pulmonary hypertension (PH). This scoping review provides an updated overview of echocardiographic and lung ultrasound biomarkers associated with BPD and PH, and the parameters that may prognosticate their development and severity, which could be clinically helpful to undertake preventive strategies. A literature search for published clinical studies was conducted in PubMed using MeSH terms, free-text words, and their combinations obtained through appropriate Boolean operators. It was found that the echocardiography biomarkers for BPD, and especially those assessing right ventricular function, are reflective of the high pulmonary vascular resistance and PH, indicating a strong interplay between heart and lung pathophysiology; however, early assessment (e.g., during the first 1-2 weeks of life) may not successfully predict later BPD development. Lung ultrasound indicating poor lung aeration at day 7 after birth has been reported to be highly predictive of later development of BPD at 36 weeks' postmenstrual age. Evidence of PH in BPD infants increases risk of mortality and long-term PH; hence, routine PH surveillance in all at risk preterm infants at 36 weeks, including an echocardiographic assessment, may provide useful information. Progress has been made in identifying the echocardiographic parameters on day 7 and 14 to predict later development of pulmonary hypertension. More studies on sonographic markers, and especially on echocardiographic parameters, are needed for the validation of the currently proposed parameters and the timing of assessment before recommendations can be made for the routine clinical practice.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOUBO, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, IRCCS AOUBO, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Pradeep Suryawanshi
- Department of Neonatology, Bharati Vidyapeeth University Medical College, Pune, India
| | - Belinda Chan
- Division of Neonatology, University of Utah, Salt Lake City, UT, United States
| | - Yogen Singh
- Department of Pediatrics - Division of Neonatology, Loma Linda University School of Medicine, Loma linda, CA, United States.,Neonatology/Pediatric Cardiology, Cambridge University Hospitals, Cambridge, United Kingdom
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3
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Khan SS, Bada HS, Torres M, Almodovar M, Hanna M. The Trend of Urinary N Terminal Probrain Natriuretic Peptide in Extremely Low Birth Weight Infants during the Neonatal Period. Am J Perinatol 2022; 39:1027-1032. [PMID: 34753181 DOI: 10.1055/a-1692-1039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE N-terminal probrain natriuretic peptide (NT-proBNP) is a biomarker of interest in many cardiopulmonary diseases in extremely low birth weight (ELBW) Infants. However, there is a gap in knowledge about the trend of ELBW infant's urinary NT-proBNP during the neonatal period. AIM To determine the trend of urinary NT-proBNP during the first 4 weeks of life of an ELBW infant. STUDY DESIGN We analyzed prospectively enrolled 87 ELBW infants. Urinary NT-proBNP to creatinine ratios were measured on days 1 to 7, 14, and 28 of life. We plotted each study point's means to determine the trend of urinary NT-proBNP over the entire neonatal period. Data were analyzed using the Friedman analysis of variance for comparative analysis of study points. RESULTS Urinary NT-proBNP/creatinine ratios were significantly elevated on days 1 to 7 (mean 2,452, ± 1,518) than day 14 (mean 747, ± 176), and day 28 (mean 149, ± 54), p = 0.001. Overall, urinary NT-proBNP levels were highest during days 1 to 3 (mean 3,232, ± 1,255) and lowest on day 28 (mean 149, ± 54). CONCLUSION Urinary NT-proBNP levels are higher during the first week in ELBW infants with a downward trend during the neonatal period, the lowest values at 4 weeks postnatal age. More studies are required to determine the clinical utility of this trend during and beyond the neonatal period. KEY POINTS · NT-proBNP is a biomarker for monitoring cardiac disease in premature infants.. · The trend of urinary NT-proBNP is unknown in premature infants.. · A trend of urinary NT-proBNP was determined during the first 4 weeks in premature infants..
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Affiliation(s)
- Safdar S Khan
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Maritza Torres
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Melvin Almodovar
- Division of Pediatric Cardiology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Mina Hanna
- Division of Neonatology, Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky
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Wu N, Li J, Luo H, Wang D, Bai X. Hydroxysafflor yellow A promotes apoptosis via blocking autophagic flux in liver cancer. Biomed Pharmacother 2021; 136:111227. [PMID: 33485070 DOI: 10.1016/j.biopha.2021.111227] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/20/2020] [Accepted: 12/31/2020] [Indexed: 01/27/2023] Open
Abstract
Hydroxysafflor yellow A (HSYA) extracted from the herb Cathartics tinctorius L. negatively regulates liver cancer growth. However, the exact mechanism of HSYA action in liver cancer remains largely unknown. In this study, HSYA inhibited liver cancer cell growth in vivo and in vitro, evidenced by cell proliferation inhibition detected by CCK8, numerous apoptotic cells shown by flow cytometry assay, and expression of apoptosis-related proteins determined by western blot. Importantly, our data revealed that HSYA triggered autophagic response and autophagosome accumulation considering the increased levels of LC3II-conversion examined by western blot, LC3 puncta visualized by immunofluorescence, and expression of autophagy-related genes shown by quantitative real-time PCR. Furthermore, HSYA blocked the late-phase of autophagic flux via impairing the lysosomal acidification and downregulating LAMP1 expression, thereby likely inducing apoptosis. In addition, HSYA inhibited PI3K/AKT/mTOR signaling pathway. Taken together, as HSYA might inhibit cell proliferation and promote apoptosis via blocking autophagic flux in liver cancer, it may be considered a promising candidate for liver cancer therapy.
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Affiliation(s)
- Na Wu
- School of Basic Medical Sciences, Binzhou Medical University, Yantai, 264003, China.
| | - Jingmin Li
- School of Basic Medical Sciences, Binzhou Medical University, Yantai, 264003, China.
| | - Hanlin Luo
- School of Basic Medical Sciences, Binzhou Medical University, Yantai, 264003, China.
| | - Dong Wang
- School of Basic Medical Sciences, Binzhou Medical University, Yantai, 264003, China.
| | - Xianyong Bai
- School of Basic Medical Sciences, Binzhou Medical University, Yantai, 264003, China.
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Iliodromiti Z, Christou E, Vrachnis N, Sokou R, Vrachnis D, Mihopoulou G, Boutsikou T, Iacovidou N. Serum and Urinary N-Terminal Pro-brain Natriuretic Peptides as Biomarkers for Bronchopulmonary Dysplasia of Preterm Neonates. Front Pediatr 2020; 8:588738. [PMID: 33194922 PMCID: PMC7655774 DOI: 10.3389/fped.2020.588738] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/14/2020] [Indexed: 11/13/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a common cause of respiratory illness in preterm newborns with high morbidity and mortality rates. At present, there are no early prognostic biomarkers that can be used in clinical practice to predict the development of BPD. In this review, we critically appraise evidence regarding the use of serum N-terminal pro-brain natriuretic peptide (NTproBNP) levels as a biomarker for BPD in neonates. Furthermore, we summarize studies assessing the feasibility of urinary NTproBNP levels as a non-invasive method to predict BPD in preterm infants. Multiple studies reported a strong association between NTproBNP serum levels and the onset of BPD. For urinary NTproBNP there is scarce evidence showing an association with BPD. Given the promising data obtained by preliminary studies, further assessment of this biomarker in both serum and urine is needed. Standardized reference values should be defined before conducting any further clinical studies.
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Affiliation(s)
- Zoi Iliodromiti
- Neonatal Department, Aretaieio Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Christou
- Neonatal Department, Aretaieio Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Vrachnis
- Third Obstetrics and Gynecology Department, Attikon Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece.,Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
| | - Rozeta Sokou
- NICU, "Agios Panteleimon" General Hospital of Nikaia, Piraeus, Greece
| | - Dionysios Vrachnis
- Endocrinology Unit, Second Obstetrics and Gynecology Department, Aretaieio Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece
| | - Georgia Mihopoulou
- Second Obstetrics and Gynecology Department, Aretaieio Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, Aretaieio Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, Aretaieio Hospital, Medical School of National and Kapodistrian University of Athens, Athens, Greece
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Méndez-Abad P, Zafra-Rodríguez P, Lubián-López S, Benavente-Fernández I. Myocardial Function Maturation in Very-Low-Birth-Weight Infants and Development of Bronchopulmonary Dysplasia. Front Pediatr 2019; 7:556. [PMID: 32010652 PMCID: PMC6978685 DOI: 10.3389/fped.2019.00556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/19/2019] [Indexed: 01/07/2023] Open
Abstract
Background: Myocardial function in very-low-birth-weight infants (VLBWIs) develops during early postnatal life, but different patterns of temporal evolution that might be related to the development of bronchopulmonary dysplasia (BPD) are not completely understood. Methods: A prospective cohort study including VLBWIs admitted to our NICU from January 2015 to 2017 was conducted. Plasma N-terminal pro B type natriuretic peptide (NTproBNP) levels were measured, and echocardiograms were performed at 24 and 72 h of life and weekly thereafter until 36 weeks of postmenstrual age (PMA). We measured the tricuspid annular plane systolic excursion (TAPSE) by M-mode; the lateral tricuspid E', A', and S' waves; and the myocardial performance index (MPI) by tissue doppler imaging (TDI). The subjects were divided into non-BPD and BPD groups. Results: We included 101 VLBWIs. The TAPSE and E', A', and S' waves increased while MPI-TDI decreased over time. Birth gestational age (GA) and postnatal PMA impacted these parameters, which evolved differently in those who developed BPD compared to those in the non-BPD group. The NTproBNP levels at 14 days of life and different echocardiographic parameters were associated with the development of BPD in different multivariate models. Conclusion: TAPSE and TDI values depend on GA and PMA and follow a different temporal evolution that is related to the later development of BPD. Combined biochemical and echocardiographic biomarkers can help identify which VLBWIs are at higher risk of developing BDP.
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Affiliation(s)
- Paula Méndez-Abad
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
| | - Pamela Zafra-Rodríguez
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
| | - Simón Lubián-López
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
| | - Isabel Benavente-Fernández
- Department of Neonatology, Puerta del Mar University Hospital, Cádiz, Spain.,Department of Pediatrics, Institute for Research and Innovation in Biomedical Sciences (INiBICA), Cádiz, Spain
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Sehgal A, Malikiwi A, Paul E, Tan K, Menahem S. Right Ventricular Function in Infants with Bronchopulmonary Dysplasia: Association with Respiratory Sequelae. Neonatology 2016; 109:289-96. [PMID: 26886137 DOI: 10.1159/000442967] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 12/02/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND While cor pulmonale has been noted in infants with bronchopulmonary dysplasia (BPD), information on right ventricular (RV) function is limited. OBJECTIVE To assess RV function in infants with severe BPD and ascertain correlation with respiratory outcomes. METHODS We prospectively assessed RV function using tissue Doppler imaging (TDI), 2D fractional area change (FAC), M-mode tricuspid annular plane systolic excursion (TAPSE) and myocardial performance index (MPI) using echocardiography. Additionally, we compared RV function with preterm infants with no BPD. RESULTS Eighteen preterm infants with severe BPD were enrolled at 36 weeks' gestation. Higher E/E' (r = 0.78, p < 0.0001) and lower FAC (r = 0.8, p < 0.0001) showed strong correlations with the subsequent duration of respiratory support. Correlations with TDI isovolumic velocity and Tei index were significant (-0.69, p = 0.002 and 0.58, p = 0.011, respectively). On comparison with infants with no BPD, TDI peak systolic velocities (0.06 ± 0.01 vs. 0.09 ± 0.01 m/s, p < 0.0001), peak isovolumic systolic velocities (0.05 ± 0.009 vs. 0.07 ± 0.008 m/s, p < 0.0001) and RV FAC (31 ± 4.7 vs. 36 ± 3.6%, p = 0.019) were significantly lower. Cardiac relaxation was impaired [higher TDI E/E' ratio (9.6 ± 1.8 vs. 5.2 ± 0.5, p < 0.0001) and higher RV MPI (0.33 ± 0.03 vs. 0.25 ± 0.03, p < 0.0001)]. CONCLUSIONS Impaired RV performance in the infants with severe BPD at 36 weeks' corrected gestation correlated with a longer duration of subsequent respiratory support.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Monash Health, Melbourne, Vic., Australia
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Kalra VK, Aggarwal S, Arora P, Natarajan G. B-type natriuretic peptide levels in preterm neonates with bronchopulmonary dysplasia: a marker of severity? Pediatr Pulmonol 2014; 49:1106-11. [PMID: 24214578 DOI: 10.1002/ppul.22942] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 08/23/2013] [Indexed: 12/16/2022]
Abstract
RATIONALE FOR THE STUDY B type natriuretic peptide (BNP) is a hormone released in response to stretching of the ventricular wall. The role of BNP as a biomarker of bronchopulmonary dysplasia (BPD) has not been clarified. OBJECTIVE To determine if plasma BNP concentrations correlate with the severity of BPD. METHODS This prospective observational case control study included 60 preterm infants (≤32 weeks); 27 infants had no/mild BPD, 19 had moderate and 14 had severe BPD. BNP levels were measured at 36 ± 2 weeks PMA or within a week of discharge home. Groups were compared using Mann-Whitney's U-test, Kruskal-Wallis, and bivariate regression. RESULTS Median (IQR) plasma levels of BNP in infants with moderate/severe BPD infants (n = 33) were higher as compared to those with no/mild BPD (n = 27); 27.1 (12.1-43.5) pg/ml versus 9.3 (6-18.5) pg/ml; P < 0.05 (Mann Whitney U). Median (IQR) BNP levels in infants with severe BPD (n = 14), 43.5 (28.4-189) pg/ml differed significantly from levels in those with moderate (n = 19), 22.8 (10.3-27.7) pg/ml; mild (n = 16), 11.5 (6.6-44.5 pg/ml); or no (n = 11), 8.1 (5-12.6 pg/ml) BPD (P < 0.001 Kruskal-Wallis). Based on receiver operating characteristic curves, BNP > 24.4 pg/ml at 36 ± 2 weeks PMA or discharge home was 85.7% sensitive and 76.1% specific for severe BPD. CONCLUSIONS An elevation in plasma BNP was significantly associated with severe BPD. We speculate that plasma BNP measurement in infants with BPD may aid in risk-stratification and further targeted therapies.
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Affiliation(s)
- Vaneet Kumar Kalra
- Division of Neonatology, The Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan and Hutzel Women's Hospital, Detroit, Michigan
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Nagiub M, Lee S, Guglani L. Echocardiographic Assessment of Pulmonary Hypertension in Infants with Bronchopulmonary Dysplasia: Systematic Review of Literature and a Proposed Algorithm for Assessment. Echocardiography 2014; 32:819-33. [DOI: 10.1111/echo.12738] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Mohamed Nagiub
- Division of Pediatric Cardiology; Department of Pediatrics; Children Hospital of Richmond; Virginia Commonwealth University; Richmond Virginia
| | - Sam Lee
- Division of Pediatric Cardiology; Department of Pediatrics; Children Hospital of Richmond; Virginia Commonwealth University; Richmond Virginia
| | - Lokesh Guglani
- Division of Pediatric Pulmonary Medicine; The Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Wayne State University School of Medicine; Detroit Michigan
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