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van Haren JS, Delbressine FLM, Schoberer M, te Pas AB, van Laar JOEH, Oei SG, van der Hout-van der Jagt MB. Transferring an extremely premature infant to an extra-uterine life support system: a prospective view on the obstetric procedure. Front Pediatr 2024; 12:1360111. [PMID: 38425664 PMCID: PMC10902175 DOI: 10.3389/fped.2024.1360111] [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: 12/22/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
To improve care for extremely premature infants, the development of an extrauterine environment for newborn development is being researched, known as Artificial Placenta and Artificial Womb (APAW) technology. APAW facilitates extended development in a liquid-filled incubator with oxygen and nutrient supply through an oxygenator connected to the umbilical vessels. This setup is intended to provide the optimal environment for further development, allowing further lung maturation by delaying gas exposure to oxygen. This innovative treatment necessitates interventions in obstetric procedures to transfer an infant from the native to an artificial womb, while preventing fetal-to-neonatal transition. In this narrative review we analyze relevant fetal physiology literature, provide an overview of insights from APAW studies, and identify considerations for the obstetric procedure from the native uterus to an APAW system. Lastly, this review provides suggestions to improve sterility, fetal and maternal well-being, and the prevention of neonatal transition.
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Affiliation(s)
- Juliette S. van Haren
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, Netherlands
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
| | | | - Mark Schoberer
- Institute for Applied Medical Engineering and Clinic for Neonatology, University Hospital Aachen, Aachen, Germany
| | - Arjan B. te Pas
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Judith O. E. H. van Laar
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - S. Guid Oei
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - M. Beatrijs van der Hout-van der Jagt
- Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
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Ghouse F, Idrobo Zapata C, Kasam Shiva PK, Aguilar A, Siripragada R, Nair N, Vera E, Suresh A. Closing the Gap: Investigation of Various Approaches in the Management of Patent Ductus Arteriosus. Cureus 2023; 15:e45009. [PMID: 37829984 PMCID: PMC10565609 DOI: 10.7759/cureus.45009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2023] [Indexed: 10/14/2023] Open
Abstract
In preterm newborns with extremely low birth weights, patent ductus arteriosus (PDA), which is defined as a remnant connection between the aorta and pulmonary artery after 72 hours of birth, is frequently linked to substantial morbidity and mortality. If left untreated, a hemodynamically significant PDA (hsPDA) increases the risk for bronchopulmonary dysplasia, necrotizing enterocolitis, and intraventricular hemorrhage among other morbidities, and can even lead to death. While instances of patent ductus arteriosus (PDA) resolving on their own are frequent, the primary approach for managing PDA closure in premature infants involves pharmacological interventions, commonly utilizing indomethacin, ibuprofen, or paracetamol. However, with these pharmacological treatment options, there is an increased risk of renal toxicity, gastrointestinal bleeding, and reopening of PDA among other complications. If pharmacological interventions are not successful or contraindicated, PDA can be closed via transcatheter closure or surgical ligation. As with any medically invasive procedure, it is not without risks and can lead to long-term complications. This review explores the different management options and the benefits and outcomes of conservative management vs. active management in order to get one step closer to standardizing the treatment for PDA. With so much controversy surrounding the best management option, there is a lack of evidence to support one treatment method superior to the other in reducing overall mortality, and this needs to be explored further.
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Affiliation(s)
- Farhana Ghouse
- Medicine, Saint James School of Medicine, Park Ridge, USA
| | | | - Pavan K Kasam Shiva
- Internal Medicine, Bangalore Medical College and Research Institute, Bangalore, IND
| | - Anne Aguilar
- Internal Medicine, Universidad Popular Autónoma del Estado de Puebla, Puebla, MEX
| | - Rithika Siripragada
- Internal Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Nandini Nair
- Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, IND
| | - Emiliano Vera
- Internal Medicine, Universidad Autónoma de Guadalajara, Guadalajara, MEX
| | - Amrita Suresh
- Internal Medicine, Kasturba Medical College, Mangalore, IND
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Panchal NK, Prince Sabina E. Non-steroidal anti-inflammatory drugs (NSAIDs): A current insight into its molecular mechanism eliciting organ toxicities. Food Chem Toxicol 2023; 172:113598. [PMID: 36608735 DOI: 10.1016/j.fct.2022.113598] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/21/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of medications that are routinely been used across the world. Their analgesic, anti-inflammatory, and antipyretic effects have all been well-documented. Moreover, they are been deliberated to have a protective role against various critical diseases such as cancer and cardiovascular diseases. However, the data presented by numerous studies in past have signified the adverse effects of NSAIDs due to overdosing on various systems such as cardiovascular, gastrointestinal, hepatic, renal, neural, etc. Despite substantial studies representing the mechanism behind the clinical risk of NSAIDs, there are very few reviews that have collated comprehensive records of various toxicities caused by overdosing on NSAIDs. As a result, we have presented a comprehensive overview of existing information on NSAIDs in this review. In addition to that, we have concentrated on presenting our understanding of various organ-based toxicities caused due to NSAID's prolonged use/overdosage.
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Affiliation(s)
- Nagesh Kishan Panchal
- Department of Biotechnology, School of Biosciences and Technology Vellore Institute of Technology, Vellore, India
| | - Evan Prince Sabina
- Department of Biotechnology, School of Biosciences and Technology Vellore Institute of Technology, Vellore, India.
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Jeelan Basha N, Basavarajaiah SM, Shyamsunder K. Therapeutic potential of pyrrole and pyrrolidine analogs: an update. Mol Divers 2022; 26:2915-2937. [PMID: 35079946 PMCID: PMC8788913 DOI: 10.1007/s11030-022-10387-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/12/2022] [Indexed: 12/14/2022]
Abstract
The chemistry of nitrogen-containing heterocyclic compound pyrrole and pyrrolidine has been a versatile field of study for a long time for its diverse biological and medicinal importance. Biomolecules such as chlorophyll, hemoglobin, myoglobin, and cytochrome are naturally occurring metal complexes of pyrrole. These metal complexes play a vital role in a living system like photosynthesis, oxygen carrier, as well storage, and redox cycling reactions. Apart from this, many medicinal drugs are derived from either pyrrole, pyrrolidine, or by its fused analogs. This review mainly focuses on the therapeutic potential of pyrrole, pyrrolidine, and its fused analogs, more specifically anticancer, anti-inflammatory, antiviral, and antituberculosis. Further, this review summarizes more recent reports on the pyrrole, pyrrolidine analogs, and their biological potential.
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Affiliation(s)
- N Jeelan Basha
- Department of Chemistry, Indian Academy Degree College-Autonomous, Bengaluru, Karnataka, 560043, India.
| | - S M Basavarajaiah
- P.G. Department of Chemistry, Vijaya College, Bengaluru, Karnataka, 560004, India
| | - K Shyamsunder
- Department of Chemistry, Indian Academy Degree College-Autonomous, Bengaluru, Karnataka, 560043, India
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Ovalı F. Molecular and Mechanical Mechanisms Regulating Ductus Arteriosus Closure in Preterm Infants. Front Pediatr 2020; 8:516. [PMID: 32984222 PMCID: PMC7477801 DOI: 10.3389/fped.2020.00516] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022] Open
Abstract
Failure of ductus arteriosus closure after preterm birth is associated with significant morbidities. Ductal closure requires and is regulated by a complex interplay of molecular and mechanical mechanisms with underlying genetic factors. In utero patency of the ductus is maintained by low oxygen tension, high levels of prostaglandins, nitric oxide and carbon monoxide. After birth, ductal closure occurs first by functional closure, followed by anatomical remodeling. High oxygen tension and decreased prostaglandin levels mediated by numerous factors including potassium channels, endothelin-1, isoprostanes lead to the contraction of the ductus. Bradykinin and corticosteroids also induce ductal constriction by attenuating the sensitivity of the ductus to PGE2. Smooth muscle cells of the ductus can sense oxygen through a mitochondrial network by the role of Rho-kinase pathway which ends up with increased intracellular calcium levels and contraction of myosin light chains. Anatomical closure of the ductus is also complex with various mechanisms such as migration and proliferation of smooth muscle cells, extracellular matrix production, endothelial cell proliferation which mediate cushion formation with the interaction of blood cells. Regulation of vessel walls is affected by retinoic acid, TGF-β1, notch signaling, hyaluronan, fibronectin, chondroitin sulfate, elastin, and vascular endothelial cell growth factor (VEGF). Formation of the platelet plug facilitates luminal remodeling by the obstruction of the constricted ductal lumen. Vasa vasorum are more pronounced in the term ductus but are less active in the preterm ductus. More than 100 genes are effective in the prostaglandin pathway or in vascular smooth muscle development and structure may affect the patency of ductus. Hemodynamic changes after birth including fluid load and flow characteristics as well as shear forces within the ductus also stimulate closure. Current pharmacological treatment for the closure of a patent ductus is based on the blockage of the prostaglandin pathway mainly through COX or POX inhibition, albeit with some limitations and side effects. Further research for new agents aiming ductal closure should focus on a clear understanding of vascular biology of the ductus.
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Affiliation(s)
- Fahri Ovalı
- Division of Neonatology, Department of Pediatrics, Istanbul Medeniyet University, Istanbul, Turkey
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Caterpillar Venom: A Health Hazard of the 21st Century. Biomedicines 2020; 8:biomedicines8060143. [PMID: 32486237 PMCID: PMC7345192 DOI: 10.3390/biomedicines8060143] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/22/2020] [Accepted: 05/24/2020] [Indexed: 12/24/2022] Open
Abstract
Caterpillar envenomation is a global health threat in the 21st century. Every direct or indirect contact with the urticating hairs of a caterpillar results in clinical manifestations ranging from local dermatitis symptoms to potentially life-threatening systemic effects. This is mainly due to the action of bioactive components in the venom that interfere with targets in the human body. The problem is that doctors are limited to relieve symptoms, since an effective treatment is still lacking. Only for Lonomia species an effective antivenom does exist. The health and economical damage are an underestimated problem and will be even more of a concern in the future. For some caterpillar species, the venom composition has been the subject of investigation, while for many others it remains unknown. Moreover, the targets involved in the pathophysiology are poorly understood. This review aims to give an overview of the knowledge we have today on the venom composition of different caterpillar species along with their pharmacological targets. Epidemiology, mode of action, clinical time course and treatments are also addressed. Finally, we briefly discuss the future perspectives that may open the doors for future research in the world of caterpillar toxins to find an adequate treatment.
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A single-dose indomethacin prophylaxis for reducing perinatal brain injury in extremely low birth weight infants: a non-inferiority analysis. J Perinatol 2019; 39:1462-1471. [PMID: 31570798 DOI: 10.1038/s41372-019-0509-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 08/01/2019] [Accepted: 08/15/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate whether rates of perinatal brain injury among extremely low birth weight infants are comparable between two treatments: single-dose indomethacin prophylaxis (SGL-IP) (0.2 mg/kg, given once) vs. standard-dose indomethacin prophylaxis (STD-IP) (0.1 mg/kg/day, 3 days). METHODS In this retrospective study, the primary outcome was perinatal brain injury (neuro-imaging evidence of intraventricular hemorrhage or periventricular leukomalacia) or death before discharge. A non-inferior efficacy of an SGL-IP regimen compared with a STD-IP regimen was determined by calculating the adjusted difference in the risk of the primary outcome using a multivariable logistic regression model. A 10-percentage point non-inferiority margin was favored. RESULTS Prevalence rates of primary outcome were 41.7% in the SGL-IP group (n = 403) and 42.5% in the STD-IP group (n = 509) (adjusted risk difference: -1.2, 95% CI: -7.6 to +5.2, p = 0.71). CONCLUSION Use of a single prophylactic indomethacin dose was as effective as a standard regimen in preventing perinatal brain injury.
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8
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Rathi P, Messina C, Mintzer JP. Indomethacin dosing strategy and neonatal patent ductus arteriosus closure. J Neonatal Perinatal Med 2019; 12:411-417. [PMID: 31561393 DOI: 10.3233/npm-180148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Few studies exist that have evaluated the effects of indomethacin dosing frequency as a factor associated with successful patent ductus arteriosus closure in very low birth weight neonates. The objective of this study is to determine if indomethacin dosing strategy is associated with efficacy for initial patent ductus arteriosus management in very low birth weight neonates. METHODS This retrospective review compared every 12 hour and every 24 hour indomethacin regimens primarily for efficacy in initial patent ductus arteriosus management, defined as an absence of repeat medical and/or surgical treatment, and secondarily for safety in both univariate and multivariate models. RESULTS One hundred three very low birth weight neonates were included: 56 (54%) received every 12 hour and 47 (46%) underwent every 24 hour indomethacin dosing. Repeat medical and/or surgical patent ductus arteriosus treatment rates were similar between groups. Less ligation of the patent ductus arteriosus occurred with every 12 hour versus every 24 hour dosing (11% vs. 26%, p = 0.05), though this effect was mitigated controlling for birth weight and gestational age. Renal function, respiratory outcomes, feeding outcomes, length of stay, and mortality were similar between groups. CONCLUSIONS Neither the every 12 hour nor the every 24 hour indomethacin regimen demonstrated inferior efficacy or safety for initial management of patent ductus arteriosus. Further prospective analysis of indomethacin dosing strategy is warranted.
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Affiliation(s)
- P Rathi
- Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, NY, USA
| | - C Messina
- Department of Preventive Medicine, Division of Community and Behavioral Health, Stony Brook Children's Hospital, Stony Brook, NY, USA
| | - J P Mintzer
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Stony Brook Children's Hospital, Stony Brook, NY, USA
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Rooney SR, Shelton EL, Aka I, Shaffer CM, Clyman RI, Dagle JM, Ryckman K, Lewis TR, Reese J, Van Driest SL, Kannankeril PJ. CYP2C9*2 is associated with indomethacin treatment failure for patent ductus arteriosus. Pharmacogenomics 2019; 20:939-946. [PMID: 31486736 PMCID: PMC6817966 DOI: 10.2217/pgs-2019-0079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/15/2019] [Indexed: 12/12/2022] Open
Abstract
Aims: To identify clinical andgenetic factors associated with indomethacin treatment failure in preterm neonates with patent ductus arteriosus (PDA). Patients & Methods: This is a multicenter cohort study of 144 preterm infants (22-32 weeks gestational age) at three centers who received at least one treatment course of indomethacin for PDA. Indomethacin failure was defined as requiring subsequent surgical intervention. Results: In multivariate analysis, gestational age (AOR 0.76, 95% CI 0.60-0.96), surfactant use (AOR 9.77, 95% CI 1.15-83.26), and CYP2C9*2 (AOR 3.74; 95% CI 1.34-10.44) were each associated with indomethacin failure. Conclusion: Age, surfactant use, and CYP2C9*2 influence indomethacin treatment outcome in preterm infants with PDA. This combination of clinical and genetic factors may facilitate targeted indomethacin use for PDA.
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Affiliation(s)
- Sydney R Rooney
- Vanderbilt University School of Medicine, UCSF, Nashville, TN 37232, USA
| | - Elaine L Shelton
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Ida Aka
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Christian M Shaffer
- Department of Medicine, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Ronald I Clyman
- Department of Pediatrics & Cardiovascular Research Center, University of California San Francisco, San Francisco, CA 94143, USA
| | - John M Dagle
- Department of Pediatrics, University of Iowa, Iowa City, UMKC, IA 52242, USA
| | - Kelli Ryckman
- Department of Epidemiology, University of Iowa, Iowa City, UMKC, IA 52242, USA
| | - Tamorah R Lewis
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO 64110, USA
| | - Jeff Reese
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
- Department of Medicine, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Prince J Kannankeril
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
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Escobar HA, Meneses-Gaviria G, Revelo-Jurado N, Villa-Rosero JF, Ijají Piamba JE, Burbano-Imbachí A, Cedeño-Burbano AA. Tratamiento farmacológico del conducto arterioso permeable en recién nacidos prematuros. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n2.64146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. Por lo general, el manejo farmacológico del conducto arterioso permeable (CAP) comprende inhibidores no selectivos de la enzima ciclooxigenasa, en especial indometacina e ibuprofeno. En años recientes también se ha sugerido al acetaminofén como alternativa terapéutica.Objetivo. Realizar una revisión narrativa de la literatura acerca del manejo farmacológico del CAP.Materiales y métodos. Se realizó una búsqueda estructurada de la literatura en las bases de datos ProQuest, EBSCO, ScienceDirect, PubMed, LILACS, Embase, Trip Database, SciELO y Cochrane Library con los términos “Ductus Arteriosus, patent AND therapeutics”; “Ductus Arteriosus, patent AND indometacin”; “Ductus Arteriosus, Patent AND ibuprofen”, y “Ductus Arteriosus, patent AND acetaminophen”. La búsqueda se hizo en inglés con sus equivalentes en español.Resultados. Se encontraron 69 artículos con información relevante para llevar a cabo la presente revisión.Conclusiones. En neonatos prematuros, la base del tratamiento farmacológico del CAP continúa siendo los inhibidores no selectivos de la ciclooxigenasa, indometacina e ibuprofeno, ambos con perfiles similares de seguridad y eficacia. La evidencia disponible sugiere que el acetaminofén podría constituir una alternativa útil para el manejo, pero resulta insuficiente para realizar recomendaciones definitivas respecto a la eficacia y seguridad de este medicamento.
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Ding Y, Wang X, Wu Y, Li H, Xu J, Wang X. Effects of prophylactic oral ibuprofen on the closure rate of patent ductus arteriosus in premature infants. Medicine (Baltimore) 2018; 97:e12206. [PMID: 30212951 PMCID: PMC6155941 DOI: 10.1097/md.0000000000012206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The aim of this study was to investigate the effects of prophylactic oral ibuprofen on the closure rate of patent ductus arteriosus (PDA).This was a retrospective study and data on infants born before 36 weeks were collected. The prophylactic group was treated with ibuprofen (10, 5, and 5 mg/kg) from days 1 to 3 after birth, respectively. The conventional group was treated with the same dose of ibuprofen from days 4 to 6 once they were echocardiographically confirmed with PDA on day 3 after birth. The placebo group was treated with 5% glucose.The closure rate of PDA in the prophylactic group significantly increased on day 7 compared with the placebo group (P = .02), but showed no difference compared with the conventional group (P = .12). Serum NT-proBNP in the prophylactic and conventional groups decreased compared with the placebo group (P = .03 vs P = .07).Prophylactic oral ibuprofen can increase the closure rate of PDA in premature infants; however, it showed no significant advantages compared with conventional treatment. Serum NT-proBNP can be used to observe PDA treatment responses in premature infants.
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de Albuquerque Botura C, da Rocha BA, Balensiefer T, Ames FQ, Bersani-Amado CA, Nakamura Cuman RK. Oral pharmacological treatment for patent ductus arteriosus in premature neonates with hemodynamic repercussions. ASIAN PAC J TROP MED 2017; 10:1080-1083. [PMID: 29203106 DOI: 10.1016/j.apjtm.2017.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 08/29/2017] [Accepted: 09/16/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of oral indomethacin, ibuprofen, and paracetamol in oral dosage form on patent ductus arteriosus (PDA) in premature neonates with significant clinical and hemodynamic repercussions (CHRs) and to determine the effect of these respective treatments on renal function. METHODS A retrospective study of cases of PDA in premature neonates in the Neonatal Intensive Care Unit was conducted. The treatments consisted of indomethacin [0.2 mg/(kg·d), 3-day cycle], ibuprofen [10 mg/(kg·d) followed by 5 mg/(kg·d), 3-day cycle], and paracetamol (15 mg/kg every 6 h, 5-day cycle). The drugs were administered as an oral solution. The following variables were considered: gestational age, newborn weight at birth, Apgar score, diuresis, serum creatinine and urea levels, and serum electrolyte levels (sodium and potassium). RESULTS Treatment with indomethacin presented efficacy of 87.5% in closure of the ductus with a mean outcome period of 3.5 d. In premature neonates with CHRs and contraindications for indomethacin, the initial treatment with either ibuprofen or paracetamol failed to close the ductus. However, when this treatment was followed by indomethacin, closure occurred in 66.7% of the neonates, with an outcome period of 9.66 d. The initial treatment with one cycle of ibuprofen followed by one or two cycles of paracetamol failed to close the ductus. CONCLUSIONS Oral indomethacin was effective for closure of the PDA in premature neonates with severe CHRs. Oral paracetamol or ibuprofen for PDA closure in premature neonates with severe CHRs and contraindications for indomethacin was ineffective. However, results in clinical improvements of neonates allowed the subsequent use of indomethacin and successful closure of the ductus. A significant reduction of diuresis occurred in neonates who were treated with indomethacin, either as a first-line treatment or after the failure of ibuprofen or paracetamol.
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Affiliation(s)
| | - Bruno Ambrósio da Rocha
- Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Paraná, Brazil
| | | | - Franciele Queiroz Ames
- Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Paraná, Brazil
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Abstract
BACKGROUND The incidence of hemodynamically significant patent ductus arteriosus (hsPDA) increases with decreasing gestational age and is associated with many common morbidities of extreme prematurity. Controversies remain surrounding the definition of hsPDA, the population of infants requiring treatment, the appropriate timing and method of treatment, and the outcomes associated with PDA and its therapies. PURPOSE This integrative literature review focuses on diagnostic and treatment recommendations derived from the highest levels of evidence. SEARCH STRATEGY PubMed and CINAHL were searched using key words "neonatal" and "patent ductus arteriosus" to discover the highest levels of evidence surrounding diagnosis, treatment methods, and outcomes. FINDINGS/RESULTS The lack of consensus surrounding the diagnosis and clinical significance of PDA hinders meta-analysis across studies and confounds understanding of appropriate management strategies. Novel biomarkers, pharmaceutical choices, and transcatheter closure methods are expanding diagnostic and treatment options. IMPLICATIONS FOR PRACTICE Infants weighing less than 1000 g are at highest risk. Prophylactic closure is no longer recommended, although early asymptomatic therapy is still preferred by some to avoid prolonged pulmonary overcirculation or decreased renal and gut perfusion. Conservative treatment measures such as fluid restriction and diuretic administration have not consistently proven effective and are in some instances detrimental. Cyclooxygenase inhibitors are effective but have adverse renal and mesenteric effects. Oral ibuprofen is associated with lower instance of necrotizing enterocolitis. IMPLICATIONS FOR RESEARCH Well-defined staging criteria would aid in comparison and meta-analysis. Trials that include a control group that receives no therapy may help separate the outcomes associated with prematurity from those associated with PDA.
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Yang B, Gao X, Ren Y, Wang Y, Zhang Q. Oral paracetamol vs. oral ibuprofen in the treatment of symptomatic patent ductus arteriosus in premature infants: A randomized controlled trial. Exp Ther Med 2016; 12:2531-2536. [PMID: 27698754 PMCID: PMC5038853 DOI: 10.3892/etm.2016.3676] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 08/23/2016] [Indexed: 01/12/2023] Open
Abstract
The aim of the present study was to analyze the changes of plasma and urinary prostaglandin E2 (PGE2) levels in preterm infants with symptomatic patent ductus arteriosus (sPDA) treated with oral ibuprofen and acetaminophen. A total of 87 preterm infants with sPDA admitted to the Neonatal Ward of the Affiliated Xuzhou Hospital of Medical College of Southeast University from October, 2012 to June, 2015 were selected and randomly divided into the ibuprofen group (n=43, 10 mg/kg ibuprofen administered orally as initial dose, followed by 5 mg/kg during the first 24 and 48 h later) and acetaminophen group (n=44, 15 mg/kg acetaminophen administered orally once every 6 h for three days). The levels of plasma and urinary PGE2 in the two groups were estimated before and after treatment. The treatment of sPDA infants with ibuprofen (ibuprofen group) or acetaminophen (acetaminophen group) caused a significant decrease in the plasma and urinary PGE2 levels in comparison with plasma and urinary PGE2 levels before treatment (P<0.05). Furthermore, plasma and urinary PGE2 levels in the acetaminophen group (45.0±36.9 ng/l) were significantly lower than those in the ibuprofen group (73.5±44.8 ng/l, P=0.002). The arterial duct closure rate was similar between the acetaminophen [31 (70.5%)] and ibuprofen groups [33 (76.7%), P=0.506]. The incidence of oliguria was less among sPDA infants of the acetaminophen group [1 (2.3%)] than observed among the sPDA infants of the ibuprofen group [6 (14.0%)]; however, this difference was not statistically significant (P=0.108). Additionally, the incidences of fecal occult blood positive rate, intraventricular hemorrhage, neonatal necrotizing enterocolitis and bronchopulmonary dysplasia were distributed similarly in the ibuprofen and acetaminophen groups (P>0.05). The levels of platelet, serum creatinine and alanine transaminase showed no significant changes between the ibuprofen and acetaminophen groups (P>0.05). Following treatment with ibuprofen or acetaminophen, the extent of decrease of plasma and urinary PGE2 was significantly higher among sPDA infants with oliguria (135.0±38.0 ng/l) than that observed in sPDA infants without oliguria (52.5±37.0 ng/l) (P=0.01). The study also found a significant correlation between plasma and urinary PGE2 levels (r=0.648, P=0.01) and the coefficient of variation of urinary PGE2 (0.427) was less than that of plasma PGE2 (0.539). The clinical efficacy of oral ibuprofen and acetaminophen in the treatment of preterm infants with sPDA was similar with low adverse events, whereas acetaminophen-induced PGE2 levels were less than the levels observed in the ibuprofen-treated group. The incidence of oliguria was also lower in the acetaminophen group compared to the ibuprofen group. In addition, monitoring urinary PGE2 levels was more suitable because of its non-invasiveness in the clinical setting than monitoring of plasma PGE2 in preterm infants with sPDA.
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Affiliation(s)
- Bo Yang
- Department of Pediatrics, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
| | - Xiangyu Gao
- Department of Pediatrics, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
| | - Yi Ren
- Department of Pediatrics, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
| | - Yun Wang
- Department of Pediatrics, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
| | - Qinglin Zhang
- Department of Pediatrics, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China
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Gulack BC, Laughon MM, Clark RH, Sankar MN, Hornik CP, Smith PB. Comparative effectiveness and safety of indomethacin versus ibuprofen for the treatment of patent ductus arteriosus. Early Hum Dev 2015; 91:725-9. [PMID: 26386610 PMCID: PMC4662898 DOI: 10.1016/j.earlhumdev.2015.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 08/08/2015] [Accepted: 08/24/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is common in extremely premature infants and associated with increased morbidity and mortality. Medical management of PDA uses either indomethacin or ibuprofen. Despite numerous studies, uncertainty exists as to which drug is safer or more effective; we sought to fill this knowledge gap. METHODS We identified infants <28weeks gestational age discharged from neonatal intensive care units included in the Pediatrix Medical Group Clinical Data Warehouse between 2006 and 2012 who were treated with indomethacin or ibuprofen between postnatal days 2 and 14. Infants treated with both drugs or infants with a congenital malformation were excluded. We used multivariable logistic regression to determine the association of indomethacin versus ibuprofen on clinical outcomes. RESULTS Of 6349 patients who met study criteria, 1177 (19%) received ibuprofen and 5172 (81%) received indomethacin. The median gestational age was 25weeks (interquartile range 24-26), and 2894 (46%) infants were <750g at birth. On unadjusted analysis, infants who received ibuprofen had significantly higher incidences of death prior to discharge, surgical ligation of the PDA prior to discharge, death or spontaneous intestinal perforation within 7days of therapy, death or surgical ligation of the PDA prior to discharge, and an elevated creatinine within 7days of treatment. However, on multivariable analysis, no significant differences in outcomes were observed (odds ratio for death/PDA ligation for ibuprofen vs. indomethacin=1.12 [95% CI 0.91-1.39]). CONCLUSIONS We observed similar effectiveness and safety profiles for indomethacin and ibuprofen in the medical management of PDA in premature infants.
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Affiliation(s)
- Brian C. Gulack
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Matthew M. Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Reese H. Clark
- Pediatrix Medical Group, Inc., Sunrise, FL, United States
| | | | - Christoph P. Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
| | - P. Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
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Indomethacin-Responsive Patent Ductus Arteriosus in an Extremely Preterm Infant at 8 Weeks Postnatal Age. Indian J Pediatr 2015; 82:655-6. [PMID: 25640067 DOI: 10.1007/s12098-015-1693-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 01/07/2015] [Indexed: 10/24/2022]
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Pacifici GM. Differential renal adverse effects of ibuprofen and indomethacin in preterm infants: a review. Clin Pharmacol 2014; 6:111-6. [PMID: 25114597 PMCID: PMC4124049 DOI: 10.2147/cpaa.s59376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the extent of renal adverse effects caused by ibuprofen or indomethacin in order to choose the safer drug to administer to preterm infants. METHODS THE FOLLOWING THREE PARAMETERS OF RENAL FUNCTION WERE TAKEN INTO CONSIDERATION: 1) the urine output; 2) the serum creatinine concentration; and 3) the frequency of oliguria. The bibliographic search was performed using PubMed and Embase databases as search engines. RESULTS Urine output ranged from 3.5±1.2 to 4.0±1.4 mL/kg/h after ibuprofen treatment, and from 2.8±1.1 to 3.6±1.4 mL/kg/h after indomethacin treatment. The values for ibuprofen are significantly (P<0.05) higher than those for indomethacin. The serum creatinine concentrations ranged from 0.98±0.24 to 1.48±0.2 mg/dL after ibuprofen treatment, and from 1.06±0.24 and 2.03±2.10 mg/dL after indomethacin treatment. The values for ibuprofen are significantly (P<0.05) lower than those for indomethacin. The frequency of oliguria ranged from 1.0% to 9.6% (ibuprofen) and from 14.8% to 40.0% (indomethacin), and was significantly lower following ibuprofen than indomethacin administration. In infants with body weight lower than 1,000 g, oliguria appeared in 5% (ibuprofen) and 40% (indomethacin; P=0.02). CONCLUSION Indomethacin is associated with more severe renal adverse effects than ibuprofen. Ibuprofen is less nephrotoxic than indomethacin and should be used to treat patent ductus arteriosus in preterm infants. Immaturity increases the frequency of adverse effects of indomethacin.
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Affiliation(s)
- Gian Maria Pacifici
- Medical School, Department of Translational Research and New Technologies in Medicine and Surgery, Section of Pharmacology, University of Pisa, Pisa, Italy
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Patent ductus arteriosus in preterm infants: do we have the right answers? BIOMED RESEARCH INTERNATIONAL 2013; 2013:676192. [PMID: 24455715 PMCID: PMC3885207 DOI: 10.1155/2013/676192] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 09/13/2013] [Accepted: 10/04/2013] [Indexed: 12/20/2022]
Abstract
Patent ductus arteriosus (PDA) is a common clinical condition in preterm infants. Preterm newborns with PDA are at greater risk for several morbidities, including higher rates of bronchopulmonary dysplasia (BPD), decreased perfusion of vital organs, and mortality. Therefore, cyclooxygenase (COX) inhibitors and surgical interventions for ligation of PDA are widely used. However, these interventions were reported to be associated with side effects. In the absence of clear restricted rules for application of these interventions, different strategies are adopted by neonatologists. Three different approaches have been investigated including prophylactic treatment shortly after birth irrespective of the state of PDA, presymptomatic treatment using echocardiography at variable postnatal ages to select infants for treatment prior to the duct becoming clinically significant, and symptomatic treatment once PDA becomes clinically apparent or hemodynamically significant. Future appropriately designed randomized controlled trials (RCTs) to refine selection of patients for medical and surgical treatments should be conducted. Waiting for new evidence, it seems wise to employ available clinical and echocardiographic parameters of a hemodynamically significant (HS) PDA to select patients who are candidates for medical treatment. Surgical ligation of PDA could be used as a back-up tool for those patients who failed medical treatment and continued to have hemodynamic compromise.
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