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Oltman SP, Rogers EE, Baer RJ, Amsalu R, Bandoli G, Chambers CD, Cho H, Dagle JM, Karvonen KL, Kingsmore SF, McKenzie-Sampson S, Momany A, Ontiveros E, Protopsaltis LD, Rand L, Kobayashi ES, Steurer MA, Ryckman KK, Jelliffe-Pawlowski LL. Early Newborn Metabolic Patterning and Sudden Infant Death Syndrome. JAMA Pediatr 2024:2823155. [PMID: 39250160 PMCID: PMC11385317 DOI: 10.1001/jamapediatrics.2024.3033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
Importance Sudden infant death syndrome (SIDS) is a major cause of infant death in the US. Previous research suggests that inborn errors of metabolism may contribute to SIDS, yet the relationship between SIDS and biomarkers of metabolism remains unclear. Objective To evaluate and model the association between routinely measured newborn metabolic markers and SIDS in combination with established risk factors for SIDS. Design, Setting, and Participants This was a case-control study nested within a retrospective cohort using data from the California Office of Statewide Health Planning and Development and the California Department of Public Health. The study population included infants born in California between 2005 and 2011 with full metabolic data collected as part of routine newborn screening (NBS). SIDS cases were matched to controls at a ratio of 1:4 by gestational age and birth weight z score. Matched data were split into training (2/3) and testing (1/3) subsets. Data were analyzed from January 2005 to December 2011. Exposures Metabolites measured by NBS and established risk factors for SIDS. Main Outcomes and Measures The primary outcome was SIDS. Logistic regression was used to evaluate the association between metabolic markers combined with known risk factors and SIDS. Results Of 2 276 578 eligible infants, 354 SIDS (0.016%) cases (mean [SD] gestational age, 38.3 [2.3] weeks; 220 male [62.1%]) and 1416 controls (mean [SD] gestational age, 38.3 [2.3] weeks; 723 male [51.1%]) were identified. In multivariable analysis, 14 NBS metabolites were significantly associated with SIDS in a univariate analysis: 17-hydroxyprogesterone, alanine, methionine, proline, tyrosine, valine, free carnitine, acetyl-L-carnitine, malonyl carnitine, glutarylcarnitine, lauroyl-L-carnitine, dodecenoylcarnitine, 3-hydroxytetradecanoylcarnitine, and linoleoylcarnitine. The area under the receiver operating characteristic curve for a 14-marker SIDS model, which included 8 metabolites, was 0.75 (95% CI, 0.72-0.79) in the training set and was 0.70 (95% CI, 0.65-0.76) in the test set. Of 32 infants in the test set with model-predicted probability greater than 0.5, a total of 20 (62.5%) had SIDS. These infants had 14.4 times the odds (95% CI, 6.0-34.5) of having SIDS compared with those with a model-predicted probability less than 0.1. Conclusions and Relevance Results from this case-control study showed an association between aberrant metabolic analytes at birth and SIDS. These findings suggest that we may be able to identify infants at increased risk for SIDS soon after birth, which could inform further mechanistic research and clinical efforts focused on monitoring and prevention.
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Affiliation(s)
- Scott P Oltman
- California Preterm Birth Initiative, University of California San Francisco, San Francisco
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco
| | - Rebecca J Baer
- California Preterm Birth Initiative, University of California San Francisco, San Francisco
- Department of Pediatrics, University of California San Diego, La Jolla
| | - Ribka Amsalu
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, San Francisco
| | - Gretchen Bandoli
- Department of Pediatrics, University of California San Diego, La Jolla
| | | | - Hyunkeun Cho
- Department of Biostatistics, University of Iowa, Iowa City
| | - John M Dagle
- Department of Pediatrics, University of Iowa, Iowa City
| | - Kayla L Karvonen
- Department of Pediatrics, University of California San Francisco, San Francisco
| | | | | | - Allison Momany
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City
| | - Eric Ontiveros
- Rady Children's Institute for Genomic Medicine, San Diego, California
| | | | - Larry Rand
- California Preterm Birth Initiative, University of California San Francisco, San Francisco
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, San Francisco
| | | | - Martina A Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco
| | - Kelli K Ryckman
- Department of Epidemiology, University of Iowa, Iowa City
- Department of Epidemiology and Biostatistics, Indiana University, Bloomington
| | - Laura L Jelliffe-Pawlowski
- California Preterm Birth Initiative, University of California San Francisco, San Francisco
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco
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Blum L, Vincent D, Boettcher M, Knopf J. Immunological aspects of necrotizing enterocolitis models: a review. Front Immunol 2024; 15:1434281. [PMID: 39104529 PMCID: PMC11298363 DOI: 10.3389/fimmu.2024.1434281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 07/08/2024] [Indexed: 08/07/2024] Open
Abstract
Necrotizing enterocolitis (NEC) is one of the most devasting diseases affecting preterm neonates. However, despite a lot of research, NEC's pathogenesis remains unclear. It is known that the pathogenesis is a multifactorial process, including (1) a pathological microbiome with abnormal bacterial colonization, (2) an immature immune system, (3) enteral feeding, (3) an impairment of microcirculation, and (4) possibly ischemia-reperfusion damage to the intestine. Overall, the immaturity of the mucosal barrier and the increased expression of Toll-like receptor 4 (TLR4) within the intestinal epithelium result in an intestinal hyperinflammation reaction. Concurrently, a deficiency in counter-regulatory mediators can be seen. The sum of these processes can ultimately result in intestinal necrosis leading to very high mortality rates of the affected neonates. In the last decade no substantial advances in the treatment of NEC have been made. Thus, NEC animal models as well as in vitro models have been employed to better understand NEC's pathogenesis on a cellular and molecular level. This review will highlight the different models currently in use to study immunological aspects of NEC.
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Affiliation(s)
| | | | | | - Jasmin Knopf
- Department of Pediatric Surgery, University Medical Center Mannheim, University Heidelberg, Mannheim, Germany
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Bosco A, Piu C, Picciau ME, Pintus R, Fanos V, Dessì A. Metabolomics in NEC: An Updated Review. Metabolites 2023; 14:14. [PMID: 38248817 PMCID: PMC10821135 DOI: 10.3390/metabo14010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/13/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Necrotizing enterocolitis (NEC) represents the most common and lethal acute gastrointestinal emergency of newborns, mainly affecting those born prematurely. It can lead to severe long-term sequelae and the mortality rate is approximately 25%. Furthermore, the diagnosis is difficult, especially in the early stages, due to multifactorial pathogenesis and complex clinical pictures with mild and non-specific symptoms. In addition, the existing tests have poor diagnostic value. Thus, the scientific community has been focusing its attention on the identification of non-invasive biomarkers capable of prediction, early diagnosis and discriminating NEC from other intestinal diseases in order to intervene early and block the progression of the pathology. In this regard, the use of "omics" technologies, especially metabolomics and microbiomics, could be a fundamental synergistic strategy to study the pathophysiology of NEC. In addition, a deeper knowledge of the microbiota-host cross-talk can clarify the metabolic pathways potentially involved in the pathology, allowing for the identification of specific biomarkers. In this article, the authors analyze the state-of-the-art concerning the application of metabolomics and microbiota analysis to investigate this pathology and discuss the future possibility of the metabolomic fingerprint of patients for diagnostic purposes.
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Affiliation(s)
| | | | | | | | | | - Angelica Dessì
- Department of Surgical Sciences, University of Cagliari and Neonatal Intensive Care Unit, AOU Cagliari, 09124 Cagliari, Italy; (A.B.); (C.P.); (M.E.P.); (R.P.); (V.F.)
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Guardado M, Steurer M, Chapin C, Hernandez RD, Ballard PL, Torgerson D. The Urinary Metabolomic Fingerprint in Extremely Preterm Infants on Total Parenteral Nutrition vs. Enteral Feeds. Metabolites 2023; 13:971. [PMID: 37755251 PMCID: PMC10537655 DOI: 10.3390/metabo13090971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/28/2023] Open
Abstract
Total Parenteral Nutrition (TPN), which uses intravenous administration of nutrients, minerals and vitamins, is essential for sustaining premature infants until they transition to enteral feeds, but there is limited information on metabolomic differences between infants on TPN and enteral feeds. We performed untargeted global metabolomics on urine samples collected between 23-30 days of life from 314 infants born <29 weeks gestational age from the TOLSURF and PROP cohorts. Principal component analysis across all metabolites showed a separation of infants solely on TPN compared to infants who had transitioned to enteral feeds, indicating global metabolomic differences between infants based on feeding status. Among 913 metabolites that passed quality control filters, 609 varied in abundance between infants on TPN vs. enteral feeds at p < 0.05. Of these, 88% were in the direction of higher abundance in the urine of infants on enteral feeds. In a subset of infants in a longitudinal analysis, both concurrent and delayed changes in metabolite levels were observed with the initiation of enteral feeds. These infants had higher concentrations of essential amino acids, lipids, and vitamins, which are necessary for growth and development, suggesting the nutritional benefit of an enteral feeding regimen.
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Affiliation(s)
- Miguel Guardado
- Biological and Medical Informatics Graduate Program, School of Medicine, Mission Bay Campus, University of California, San Francisco, CA 94134, USA
- Department of Epidemiology and Biostatistics, School of Medicine, Mission Bay Campus, University of California, San Francisco, CA 94158, USA;
- Department of Bioengineering and Therapeutic Sciences, School of Medicine, Mission Bay Campus, University of California, San Francisco, CA 94134, USA;
| | - Martina Steurer
- Department of Pediatrics, School of Medicine, Mission Bay & Parnassus Campuses, University of California, San Francisco, CA 94158, USA; (M.S.); (C.C.); (P.L.B.)
| | - Cheryl Chapin
- Department of Pediatrics, School of Medicine, Mission Bay & Parnassus Campuses, University of California, San Francisco, CA 94158, USA; (M.S.); (C.C.); (P.L.B.)
| | - Ryan D. Hernandez
- Department of Bioengineering and Therapeutic Sciences, School of Medicine, Mission Bay Campus, University of California, San Francisco, CA 94134, USA;
| | - Philip L. Ballard
- Department of Pediatrics, School of Medicine, Mission Bay & Parnassus Campuses, University of California, San Francisco, CA 94158, USA; (M.S.); (C.C.); (P.L.B.)
| | - Dara Torgerson
- Department of Epidemiology and Biostatistics, School of Medicine, Mission Bay Campus, University of California, San Francisco, CA 94158, USA;
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Bautista GM, Cera AJ, Chaaban H, McElroy SJ. State-of-the-art review and update of in vivo models of necrotizing enterocolitis. Front Pediatr 2023; 11:1161342. [PMID: 37082706 PMCID: PMC10112335 DOI: 10.3389/fped.2023.1161342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/13/2023] [Indexed: 04/22/2023] Open
Abstract
NEC remains one of the most common causes of mortality and morbidity in preterm infants. Animal models of necrotizing enterocolitis (NEC) have been crucial in improving our understanding of this devastating disease and identifying biochemical pathways with therapeutic potential. The pathogenesis of NEC remains incompletely understood, with no specific entity that unifies all infants that develop NEC. Therefore, investigators rely on animal models to manipulate variables and provide a means to test interventions, making them valuable tools to enhance our understanding and prevent and treat NEC. The advancements in molecular analytic tools, genetic manipulation, and imaging modalities and the emergence of scientific collaborations have given rise to unique perspectives and disease correlates, creating novel pathways of investigation. A critical review and understanding of the current phenotypic considerations of the highly relevant animal models of NEC are crucial to developing novel therapeutic and preventative strategies for NEC.
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Affiliation(s)
- Geoanna M. Bautista
- Department of Pediatrics, Division of Neonatology, University of California, Davis, Sacramento, CA, United States
| | - Anjali J. Cera
- Department of Pediatrics, Division of Neonatology, University of California, Davis, Sacramento, CA, United States
| | - Hala Chaaban
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma, OK, United States
| | - Steven J. McElroy
- Department of Pediatrics, Division of Neonatology, University of California, Davis, Sacramento, CA, United States
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Wang K, Tao GZ, Salimi-Jazi F, Lin PY, Sun Z, Liu B, Sinclair T, Mostaghimi M, Dunn J, Sylvester KG. Butyrate induces development-dependent necrotizing enterocolitis-like intestinal epithelial injury via necroptosis. Pediatr Res 2023; 93:801-809. [PMID: 36202969 DOI: 10.1038/s41390-022-02333-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 09/12/2022] [Accepted: 09/18/2022] [Indexed: 03/05/2023]
Abstract
BACKGROUND The accumulation of short-chain fatty acids (SCFAs) from bacterial fermentation may adversely affect the under-developed gut as observed in premature newborns at risk for necrotizing enterocolitis (NEC). This study explores the mechanism by which specific SCFA fermentation products may injure the premature newborn intestine mucosa leading to NEC-like intestinal cell injury. METHODS Intraluminal injections of sodium butyrate were administered to 14- and 28-day-old mice, whose small intestine and stool were harvested for analysis. Human intestinal epithelial stem cells (hIESCs) and differentiated enterocytes from preterm and term infants were treated with sodium butyrate at varying concentrations. Necrosulfonamide (NSA) and necrostatin-1 (Nec-1) were used to determine the protective effects of necroptosis inhibitors on butyrate-induced cell injury. RESULTS The more severe intestinal epithelial injury was observed in younger mice upon exposure to butyrate (p = 0.02). Enterocytes from preterm newborns demonstrated a significant increase in sensitivity to butyrate-induced cell injury compared to term newborn enterocytes (p = 0.068, hIESCs; p = 0.038, differentiated cells). NSA and Nec-1 significantly inhibited the cell death induced by butyrate. CONCLUSIONS Butyrate induces developmental stage-dependent intestinal injury that resembles NEC. A primary mechanism of cell injury in NEC is necroptosis. Necroptosis inhibition may represent a potential preventive or therapeutic strategy for NEC. IMPACT Butyrate induces developmental stage-dependent intestinal injury that resembles NEC. A primary mechanism of cell injury caused by butyrate in NEC is necroptosis. Necroptosis inhibitors proved effective at significantly ameliorating the enteral toxicity of butyrate and thereby suggest a novel mechanism and approach to the prevention and treatment of NEC in premature newborns.
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Affiliation(s)
- Kewei Wang
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Department of Gastrointestinal Surgery, The First Hospital of China Medical University, 110001, Shenyang, Liaoning Province, China
| | - Guo-Zhong Tao
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | | | - Po-Yu Lin
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Zhen Sun
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Bo Liu
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Tiffany Sinclair
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Mirko Mostaghimi
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - James Dunn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Karl G Sylvester
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
- Stanford Metabolic Health Center, Stanford University School of Medicine and Stanford Healthcare, Stanford, CA, USA.
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Anand ST, Ryckman KK, Baer RJ, Charlton ME, Breheny PJ, Terry WW, Kober K, Oltman S, Rogers EE, Jelliffe-Pawlowski LL, Chrischilles EA. Metabolic differences among newborns born to mothers with a history of leukemia or lymphoma. J Matern Fetal Neonatal Med 2022; 35:6751-6758. [PMID: 33980115 PMCID: PMC8586052 DOI: 10.1080/14767058.2021.1922378] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 04/18/2021] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Leukemia and lymphoma are cancers affecting children, adolescents, and young adults and may affect reproductive outcomes and maternal metabolism. We evaluated for metabolic changes in newborns of mothers with a history of these cancers. METHODS A cross-sectional study was conducted on California births from 2007 to 2011 with linked maternal hospital discharge records, birth certificate, and newborn screening metabolites. History of leukemia or lymphoma was determined using ICD-9-CM codes from hospital discharge data and newborn metabolite data from the newborn screening program. RESULTS A total of 2,068,038 women without cancer history and 906 with history of leukemia or lymphoma were included. After adjusting for differences in maternal age, infant sex, age at metabolite collection, gestational age, and birthweight, among newborns born to women with history of leukemia/lymphoma, several acylcarnitines were significantly (p < .001 - based on Bonferroni correction for multiple testing) higher compared to newborns of mothers without cancer history: C3-DC (mean difference (MD) = 0.006), C5-DC (MD = 0.009), C8:1 (MD = 0.008), C14 (MD = 0.010), and C16:1 (MD = 0.011), whereas citrulline levels were significantly lower (MD = -0.581) among newborns born to mothers with history of leukemia or lymphoma compared to newborns of mothers without a history of cancer. CONCLUSION The varied metabolite levels suggest history of leukemia or lymphoma has metabolic impact on newborn offspring, which may have implications for future metabolic consequences such as necrotizing enterocolitis and urea cycle enzyme disorders in children born to mothers with a history of leukemia or lymphoma.
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Affiliation(s)
- Sonia T. Anand
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, United States of America
| | - Kelli K. Ryckman
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, United States of America
- Department of Pediatrics, University of Iowa, Iowa City, Iowa, United States of America
| | - Rebecca J. Baer
- Department of Pediatrics, University of California San Diego, La Jolla, California, United States of America
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California, United States of America
| | - Mary E. Charlton
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, United States of America
| | - Patrick J. Breheny
- Department of Biostatistics, University of Iowa, Iowa City, Iowa, United States of America
| | - William W. Terry
- Department of Pediatrics, University of Iowa, Iowa City, Iowa, United States of America
| | - Kord Kober
- Department of Physiological Nursing, University of California San Francisco, San Francisco, California, United States of America
| | - Scott Oltman
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Elizabeth E. Rogers
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California, United States of America
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California, United States of America
| | - Laura L. Jelliffe-Pawlowski
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
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Ye C, Wu J, Reiss JD, Sinclair TJ, Stevenson DK, Shaw GM, Chace DH, Clark RH, Prince LS, Ling XB, Sylvester KG. Progressive Metabolic Abnormalities Associated with the Development of Neonatal Bronchopulmonary Dysplasia. Nutrients 2022; 14:nu14173547. [PMID: 36079804 PMCID: PMC9459725 DOI: 10.3390/nu14173547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Objective: To assess the longitudinal metabolic patterns during the evolution of bronchopulmonary dysplasia (BPD) development. Methods: A case-control dataset of preterm infants (<32-week gestation) was obtained from a multicenter database, including 355 BPD cases and 395 controls. A total of 72 amino acid (AA) and acylcarnitine (AC) variables, along with infants’ calorie intake and growth outcomes, were measured on day of life 1, 7, 28, and 42. Logistic regression, clustering methods, and random forest statistical modeling were utilized to identify metabolic variables significantly associated with BPD development and to investigate their longitudinal patterns that are associated with BPD development. Results: A panel of 27 metabolic variables were observed to be longitudinally associated with BPD development. The involved metabolites increased from 1 predominant different AC by day 7 to 19 associated AA and AC compounds by day 28 and 16 metabolic features by day 42. Citrulline, alanine, glutamate, tyrosine, propionylcarnitine, free carnitine, acetylcarnitine, hydroxybutyrylcarnitine, and most median-chain ACs (C5:C10) were the most associated metabolites down-regulated in BPD babies over the early days of life, whereas phenylalanine, methionine, and hydroxypalmitoylcarnitine were observed to be up-regulated in BPD babies. Most calorie intake and growth outcomes revealed similar longitudinal patterns between BPD cases and controls over the first 6 weeks of life, after gestational adjustment. When combining with birth weight, the derived metabolic-based discriminative model observed some differences between those with and without BPD development, with c-statistics of 0.869 and 0.841 at day 7 and 28 of life on the test data. Conclusions: The metabolic panel we describe identified some metabolic differences in the blood associated with BPD pathogenesis. Further work is needed to determine whether these compounds could facilitate the monitoring and/or investigation of early-life metabolic status in the lung and other tissues for the prevention and management of BPD.
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Affiliation(s)
- Chengyin Ye
- Department of Health Management, School of Public Health, Hangzhou Normal University, Hangzhou 311100, China
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Jinghua Wu
- Department of Health Management, School of Public Health, Hangzhou Normal University, Hangzhou 311100, China
| | - Jonathan D. Reiss
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94304, USA
- Stanford Metabolic Health Center, Stanford Children’s Hospital, Stanford, CA 94304, USA
| | - Tiffany J. Sinclair
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - David K. Stevenson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94304, USA
- Stanford Metabolic Health Center, Stanford Children’s Hospital, Stanford, CA 94304, USA
| | - Gary M. Shaw
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94304, USA
| | | | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research, Education and Quality, Sunrise, FL 33323, USA
| | - Lawrence S. Prince
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94304, USA
| | - Xuefeng Bruce Ling
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94304, USA
- Clinical and Translational Research Program, Betty Irene Moore Children’s Heart Center, Lucile Packard Children’s Hospital, Palo Alto, CA 94304, USA
- Correspondence: (X.B.L.); (K.G.S.); Tel.: +1-650-723-6439 (K.G.S.); Fax: +1-650-725-5577 (K.G.S.)
| | - Karl G. Sylvester
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94304, USA
- Stanford Metabolic Health Center, Stanford Children’s Hospital, Stanford, CA 94304, USA
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94304, USA
- Correspondence: (X.B.L.); (K.G.S.); Tel.: +1-650-723-6439 (K.G.S.); Fax: +1-650-725-5577 (K.G.S.)
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Newborn screen metabolic panels reflect the impact of common disorders of pregnancy. Pediatr Res 2022; 92:490-497. [PMID: 34671094 PMCID: PMC10265936 DOI: 10.1038/s41390-021-01753-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/08/2021] [Accepted: 09/14/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hypertensive disorders of pregnancy and maternal diabetes profoundly affect fetal and newborn growth, yet disturbances in intermediate metabolism and relevant mediators of fetal growth alterations remain poorly defined. We sought to determine whether there are distinct newborn screen metabolic patterns among newborns affected by maternal hypertensive disorders or diabetes in utero. METHODS A retrospective observational study investigating distinct newborn screen metabolites in conjunction with data linked to birth and hospitalization records in the state of California between 2005 and 2010. RESULTS A total of 41,333 maternal-infant dyads were included. Infants of diabetic mothers demonstrated associations with short-chain acylcarnitines and free carnitine. Infants born to mothers with preeclampsia with severe features and chronic hypertension with superimposed preeclampsia had alterations in acetylcarnitine, free carnitine, and ornithine levels. These results were further accentuated by size for gestational age designations. CONCLUSIONS Infants of diabetic mothers demonstrate metabolic signs of incomplete beta oxidation and altered lipid metabolism. Infants of mothers with hypertensive disorders of pregnancy carry analyte signals that may reflect oxidative stress via altered nitric oxide signaling. The newborn screen analyte composition is influenced by the presence of these maternal conditions and is further associated with the newborn size designation at birth. IMPACT Substantial differences in newborn screen analyte profiles were present based on the presence or absence of maternal diabetes or hypertensive disorder of pregnancy and this finding was further influenced by the newborn size designation at birth. The metabolic health of the newborn can be examined using the newborn screen and is heavily impacted by the condition of the mother during pregnancy. Utilizing the newborn screen to identify newborns affected by common conditions of pregnancy may help relate an infant's underlying biological disposition with their clinical phenotype allowing for greater risk stratification and intervention.
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Gunasekaran A, Devette C, Levin S, Chaaban H. Biomarkers of Necrotizing Enterocolitis: The Search Continues. Clin Perinatol 2022; 49:181-194. [PMID: 35210000 DOI: 10.1016/j.clp.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Necrotizing enterocolitis (NEC) is the most common gastrointestinal (GI) emergency in the neonatal intensive care unit. Despite advances in medical care, mortality and morbidity from NEC have not changed. This is likely due to the lack of a clear understanding of this multifactorial disease, and reliable biomarkers for accurate diagnosis of NEC. Currently, the diagnosis of NEC is made by a combination of nonspecific clinical signs, symptoms, and radiological findings. Though biomarkers have been studied extensively, none offer an acceptable sensitivity or specificity to be used. This review will focus on the available literature on biomarkers for preterm NEC, acknowledging the limitations in studies including the variability of inclusion criteria, and most importantly, the lack of gold standard case definition for NEC.
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Affiliation(s)
- Aarthi Gunasekaran
- Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA
| | - Christa Devette
- Department of Pediatrics, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA.
| | - Samuel Levin
- Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA.
| | - Hala Chaaban
- Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA.
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Reiss JD, Peterson LS, Nesamoney SN, Chang AL, Pasca AM, Marić I, Shaw GM, Gaudilliere B, Wong RJ, Sylvester KG, Bonifacio SL, Aghaeepour N, Gibbs RS, Stevenson DK. Perinatal infection, inflammation, preterm birth, and brain injury: A review with proposals for future investigations. Exp Neurol 2022; 351:113988. [DOI: 10.1016/j.expneurol.2022.113988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 01/06/2022] [Accepted: 01/13/2022] [Indexed: 11/26/2022]
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12
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Immunoreactive Trypsinogen and Free Carnitine Changes on Newborn Screening after Birth in Patients Who Develop Type 1 Diabetes. Nutrients 2021; 13:nu13103669. [PMID: 34684667 PMCID: PMC8538382 DOI: 10.3390/nu13103669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
Are free carnitine concentrations on newborn screening (NBS) 48–72 h after birth lower in patients who develop type 1 diabetes than in controls? A retrospective case-control study of patients with type 1 diabetes was conducted. NBS results of patients from a Sydney hospital were compared against matched controls from the same hospital (1:5). Multiple imputation was performed for estimating missing data (gestational age) using gender and birthweight. Conditional logistic regression was used to control for confounding and to generate parameter estimates (α = 0.05). The Hommel approach was used for post-hoc analyses. Results are reported as medians and interquartile ranges. A total of 159 patients were eligible (80 females). Antibodies were detectable in 86. Median age at diagnosis was 8 years. Free carnitine concentrations were lower in patients than controls (25.50 µmol/L;18.98–33.61 vs. 27.26; 21.22–34.86 respectively) (p = 0.018). Immunoreactive trypsinogen was higher in this group (20.24 µg/L;16.15–29–52 vs. 18.71; 13.96–26.92) (p = 0.045), which did not persist in the post-hoc analysis. Carnitine levels are lower and immunoreactive trypsinogen might be higher, within 2–3 days of birth and years before development of type 1 diabetes as compared to controls, although the differences were well within reference ranges and provide insight into the pathogenesis into neonatal onset of type 1 diabetes development rather than use as a diagnostic tool. Given trypsinogen’s use for evaluation of new-onset type 1 diabetes, larger studies are warranted.
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The microbiome, guard or threat to infant health. Trends Mol Med 2021; 27:1175-1186. [PMID: 34518093 DOI: 10.1016/j.molmed.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/29/2021] [Accepted: 08/11/2021] [Indexed: 11/23/2022]
Abstract
Despite improvements in survival for very low birthweight (VLBW) premature infants, there continues to be significant morbidity for these infants at remarkable cost to the healthcare system. Concurrent development of the preterm infant intestine alongside the gut microbiome in the clinical setting rather than in the protected in utero environment where it would usually occur creates significant vulnerabilities for the infant's immature intestine and immune system, resulting in devastating illness and neurological injury. However, the microbiome also has the capacity to promote healthy development. Studies of parallel gut microbiome and preterm infant development have given key insight into the impact of the microbiome on intestinal as well as neural development and may provide potential therapeutic targets to prevent preterm infant morbidities.
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Oltman SP, Rogers EE, Baer RJ, Jasper EA, Anderson JG, Steurer MA, Pantell MS, Petersen MA, Partridge JC, Karasek D, Ross KM, Feuer SK, Franck LS, Rand L, Dagle JM, Ryckman KK, Jelliffe-Pawlowski LL. Newborn metabolic vulnerability profile identifies preterm infants at risk for mortality and morbidity. Pediatr Res 2021; 89:1405-1413. [PMID: 33003189 PMCID: PMC8061535 DOI: 10.1038/s41390-020-01148-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Identifying preterm infants at risk for mortality or major morbidity traditionally relies on gestational age, birth weight, and other clinical characteristics that offer underwhelming utility. We sought to determine whether a newborn metabolic vulnerability profile at birth can be used to evaluate risk for neonatal mortality and major morbidity in preterm infants. METHODS This was a population-based retrospective cohort study of preterm infants born between 2005 and 2011 in California. We created a newborn metabolic vulnerability profile wherein maternal/infant characteristics along with routine newborn screening metabolites were evaluated for their association with neonatal mortality or major morbidity. RESULTS Nine thousand six hundred and thirty-nine (9.2%) preterm infants experienced mortality or at least one complication. Six characteristics and 19 metabolites were included in the final metabolic vulnerability model. The model demonstrated exceptional performance for the composite outcome of mortality or any major morbidity (AUC 0.923 (95% CI: 0.917-0.929). Performance was maintained across mortality and morbidity subgroups (AUCs 0.893-0.979). CONCLUSIONS Metabolites measured as part of routine newborn screening can be used to create a metabolic vulnerability profile. These findings lay the foundation for targeted clinical monitoring and further investigation of biological pathways that may increase the risk of neonatal death or major complications in infants born preterm. IMPACT We built a newborn metabolic vulnerability profile that could identify preterm infants at risk for major morbidity and mortality. Identifying high-risk infants by this method is novel to the field and outperforms models currently in use that rely primarily on infant characteristics. Utilizing the newborn metabolic vulnerability profile for precision clinical monitoring and targeted investigation of etiologic pathways could lead to reductions in the incidence and severity of major morbidities associated with preterm birth.
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Affiliation(s)
- Scott P. Oltman
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California,Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
| | - Elizabeth E. Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Rebecca J. Baer
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California,Department of Pediatrics, University of California San Diego, La Jolla, CA
| | | | - James G. Anderson
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Martina A. Steurer
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California,Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Matthew S. Pantell
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Mark A. Petersen
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - J. Colin Partridge
- Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Deborah Karasek
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California,Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Kharah M. Ross
- Owerko Centre, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta
| | - Sky K. Feuer
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California,Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Linda S. Franck
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California,School of Nursing, University of California San Francisco, San Francisco California
| | - Larry Rand
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California,Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - John M. Dagle
- Department of Pediatric, University of Iowa, Iowa City, IA
| | - Kelli K. Ryckman
- Department of Epidemiology, University of Iowa, Iowa City, IA,Department of Pediatric, University of Iowa, Iowa City, IA
| | - Laura L. Jelliffe-Pawlowski
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, California,Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
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15
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Jiang YN, Ye YX, Sangild PT, Thymann T, Engelsen SB, Khakimov B, Jiang PP. Plasma Metabolomics to Evaluate Progression of Necrotising Enterocolitis in Preterm Pigs. Metabolites 2021; 11:metabo11050283. [PMID: 33946896 PMCID: PMC8146597 DOI: 10.3390/metabo11050283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 02/04/2023] Open
Abstract
Necrotising enterocolitis (NEC) is a microbiome-dependent gut disease in preterm infants in early life. Antibiotic treatment is a common intervention for NEC. How NEC lesions, with or without antibiotics, affect plasma metabolome was explored in this study. Formula-fed preterm pigs were used as a model for human NEC and treated with saline, parenteral or oral antibiotics (n = 15-17) for four days after delivery. Gut tissues were collected for evaluation of NEC-like lesions and plasma for metabolomic analysis by proton nuclear magnetic resonance spectroscopy (1H-NMR). Metabolites were annotated, quantified and subjected to statistical modelling to delineate the effects of NEC and antibiotic treatment. Presence of severe NEC lesions, not antibiotic treatment, was the main drive for plasma metabolite changes. Relative to other pigs, pigs with severe NEC lesions had higher levels of alanine, histidine and myo-inositol, and lower levels of 3-hydroxybutyric acid and isobutyric acid. Across NEC lesion states (healthy, mild, severe), antibiotics directly affected only a few metabolites (tryptophan, 3-phenyllactic acid). Together and independently, NEC and antibiotic treatment affected circulating metabolites in preterm pigs. Amino acids and plasma metabolites, partly related to the gut microbiome, may be helpful to monitor progression of NEC lesions after proper validation.
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Affiliation(s)
- Yan-Nan Jiang
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China; (Y.-N.J.); (Y.-X.Y.)
| | - Yong-Xin Ye
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China; (Y.-N.J.); (Y.-X.Y.)
| | - Per Torp Sangild
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, DK-1870 Frederiksberg, Denmark; (P.T.S.); (T.T.)
- Department of Neonatology, Rigshospitalet, DK-2100 Copenhagen, Denmark
- Department of Paediatrics, Odense University Hospital, DK-5000 Odense, Denmark
| | - Thomas Thymann
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, DK-1870 Frederiksberg, Denmark; (P.T.S.); (T.T.)
| | - Søren Balling Engelsen
- Department of Food Science, University of Copenhagen, DK-1958 Frederiksberg, Denmark; (S.B.E.); (B.K.)
| | - Bekzod Khakimov
- Department of Food Science, University of Copenhagen, DK-1958 Frederiksberg, Denmark; (S.B.E.); (B.K.)
| | - Ping-Ping Jiang
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China; (Y.-N.J.); (Y.-X.Y.)
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, DK-1870 Frederiksberg, Denmark; (P.T.S.); (T.T.)
- Correspondence:
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16
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McCarthy ME, Oltman SP, Rogers EE, Ryckman K, Jelliffe-Pawlowski LL, Danilack VA. The independent and combined influences of small for gestational age and socioeconomic status on newborn metabolite levels. J Matern Fetal Neonatal Med 2021; 35:6192-6198. [PMID: 33882790 DOI: 10.1080/14767058.2021.1909562] [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: 10/21/2022]
Abstract
OBJECTIVES To determine whether socioeconomic status (SES) and small birthweight for gestational age (SGA) exhibit independent or joint effects on infant levels of 42 metabolites. STUDY DESIGN Population-based retrospective cohort of metabolic newborn screening information linked to hospital discharge data. SGA infants defined by birthweight <10th percentile for gestational age by sex. SES was determined by a combined metric including education level, participation in the WIC nutritional assistance program, and receiving California MediCal insurance. We performed linear regression to determine the effects of SES independently, SGA independently, and the interaction of SGA and SES on 42 newborn metabolite levels. RESULTS 736,435 California infants born in 2005-2011 were included in the analysis. SGA was significantly associated with 36 metabolites. SES was significantly associated with 41 of 42 metabolites. Thirty-eight metabolites exhibited a dose-response relationship between SGA and metabolite levels as SES worsened. Fourteen metabolites showed significant interaction between SES and SGA. Eight metabolites showed significant individual and joint effects of SES and SGA: alanine, glycine, free carnitine, C-3DC, C-5DC, C-16:1, C-18:1, and C-18:2. CONCLUSIONS SES and SGA exhibited independent effects on a majority of metabolites and joint effects on select metabolites. A better understanding of how SES and SGA status are related to infant metabolites may help identify maternal and newborn interventions that can lead to better outcomes for infants born SGA.
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Affiliation(s)
- Molly E McCarthy
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, CA, USA.,UCSF California Preterm Birth Initiative, University of California San Francisco School of Medicine, San Francisco, CA, USA.,Brown University School of Public Health, Providence, RI, USA
| | - Scott P Oltman
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, CA, USA.,UCSF California Preterm Birth Initiative, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Elizabeth E Rogers
- UCSF California Preterm Birth Initiative, University of California San Francisco School of Medicine, San Francisco, CA, USA.,Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Kelli Ryckman
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Laura L Jelliffe-Pawlowski
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, CA, USA.,UCSF California Preterm Birth Initiative, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Valery A Danilack
- Brown University School of Public Health, Providence, RI, USA.,Department of Obstetrics and Gynecology, Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
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17
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Ng TKS, Kovalik JP, Ching J, Chan AW, Matchar DB. Novel metabolomics markers are associated with pre-clinical decline in hand grip strength in community-dwelling older adults. Mech Ageing Dev 2020; 193:111405. [PMID: 33217429 DOI: 10.1016/j.mad.2020.111405] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/26/2020] [Accepted: 11/11/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hand grip strength (HGS) has been proposed as a robust predictor for frailty and sarcopenia. Hence, identifying biomarkers for declining HGS accompanying aging could deepen our understanding of the biological underpinnings, informing pre-emptive intervention. Acylcarnitines (ACs) are metabolites generated by fatty acid metabolism in the mitochondria and are dysregulated in multiple disorders affecting the musculature. However, they have not been comprehensively profiled and examined regarding their utility in predicting variability in declining HGS, longitudinally. Thus, we aimed to: 1) validate previous findings on insignificant cross-sectional association between ACs and HGS, and 2) examine whether baseline ACs were associated with both decline and variability in HGS over 18 months, in community-dwelling older adults. METHODS We included participants who had HGS measured with dynamometer longitudinally (N = 121). We quantified ACs by targeted plasma metabolomics profiling. Multivariable linear regressions were then performed. RESULTS Cross-sectionally, ACs were not significantly associated with HGS. Longitudinally, baseline short-chain dicarboxylic and hydroxylated acylcarnitines (AC-DC/-OH) levels were inversely associated with and significantly explained the variability in 18-month decline in HGS. A specific AC species, the C4-OH, accounted for most of the variance explained. CONCLUSIONS We showed novel biomarkers for declining HGS, furthering molecular understanding and informing nutritional pre-emptive programs.
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Affiliation(s)
- Ted Kheng Siang Ng
- Duke-National University of Singapore Medical School, Center for Aging, Research and Education Singapore.
| | - Jean-Paul Kovalik
- Duke-National University of Singapore Medical School, Cardiovascular and Metabolic Disorders Programme, Singapore
| | - Jianhong Ching
- Duke-National University of Singapore Medical School, Cardiovascular and Metabolic Disorders Programme, Singapore
| | - Angelique W Chan
- Duke-National University of Singapore Medical School, Center for Aging, Research and Education Singapore; Duke-National University of Singapore Medical School, Program in Health Services and Systems Research, Singapore; National University of Singapore, Department of Sociology, Faculty of Arts and Social Sciences, Singapore
| | - David Bruce Matchar
- Duke-National University of Singapore Medical School, Center for Aging, Research and Education Singapore; Duke-National University of Singapore Medical School, Program in Health Services and Systems Research, Singapore; Duke University School of Medicine, Department of Medicine (General Internal Medicine), United States.
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18
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Newborn Screening Samples for Diabetes Research: An Underused Resource. Cells 2020; 9:cells9102299. [PMID: 33076340 PMCID: PMC7602529 DOI: 10.3390/cells9102299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 02/08/2023] Open
Abstract
Inborn errors of metabolism and diabetes share common derangements in analytes of metabolic networks that are tested for in newborn screening, usually performed 48-72 h after birth. There is limited research examining the metabolic imprint of diabetes on newborn screening results. This paper aims to demonstrate the links between diabetes, biochemical genetics and newborn screening in investigating disease pathophysiology in diabetes, provide possible reasons for the lack of research in diabetes in newborn screening and offer recommendations on potential research areas. We performed a systematic search of the available literature from 1 April 1998 to 31 December 2018 involving newborn screening and diabetes using OVID, MEDLINE, Cochrane and the PROSPERO register, utilizing a modified extraction tool adapted from Cochrane. Eight studies were included after screening 1312 records. Five studies reanalyzed dried blood spots (DBS) on filter paper cards, and three studies utilized pre-existing results. The results of these studies and how they relate to cord blood studies, the use of cord blood versus newborn screening dried blood spots as a sample and considerations on newborn screening and diabetes research is further discussed. The timing of sampling of newborn screening allows insight into neonatal physiology in a catabolic state with minimal maternal and placental influence. This, combined with the wide coverage of newborn screening worldwide, may aid in our understanding of the origins of diabetes.
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19
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Shelby RD, Raab R, Besner GE, McElroy SJ. Hope on the horizon: promising novel therapies for necrotizing enterocolitis. Pediatr Res 2020; 88:30-34. [PMID: 32855510 DOI: 10.1038/s41390-020-1077-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Necrotizing enterocolitis (NEC) remains among the most common and devastating diseases in neonates. Despite advances in neonatal clinical care, specific treatment strategies and diagnostic modalities remain lacking. As a result, morbidity and mortality remain high. Improved understanding of the pathogenesis of NEC has the potential for improved therapeutics. Some of the areas of research leading to promising discoveries include inhibition of Toll-like receptor signaling, modulation of vascular endothelial growth factor signal pathways, defining metabolomic alterations in NEC to discover potential biomarkers, probing for genetic predispositions to NEC susceptibility, determining mechanistic relations between anemia and NEC, and microflora modulation through the use of probiotics. All of these areas may represent novel promising approaches to the prevention and treatment of NEC. This review will focus on these current and possible therapeutic perspectives.
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Affiliation(s)
- Rita D Shelby
- Department of Pediatric Surgery, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Gail E Besner
- Department of Pediatric Surgery, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Steven J McElroy
- Stead Family Department of Pediatrics and Department of Microbiology and Immunology, University of Iowa, Iowa City, IA, USA.
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20
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Progressive Metabolic Dysfunction and Nutritional Variability Precedes Necrotizing Enterocolitis. Nutrients 2020; 12:nu12051275. [PMID: 32365850 PMCID: PMC7281969 DOI: 10.3390/nu12051275] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/16/2022] Open
Abstract
Necrotizing Enterocolitis (NEC) is associated with prematurity, enteral feedings, and enteral dysbiosis. Accordingly, we hypothesized that along with nutritional variability, metabolic dysfunction would be associated with NEC onset. Methods: We queried a multicenter longitudinal database that included 995 preterm infants (<32 weeks gestation) and included 73 cases of NEC. Dried blood spot samples were obtained on day of life 1, 7, 28, and 42. Metabolite data from each time point included 72 amino acid (AA) and acylcarnitine (AC) measures. Nutrition data were averaged at each of the same time points. Odds ratios and 95% confidence intervals were calculated using samples obtained prior to NEC diagnosis and adjusted for potential confounding variables. Nutritional and metabolic data were plotted longitudinally to determine relationship to NEC onset. Results: Day 1 analyte levels of alanine, phenylalanine, free carnitine, C16, arginine, C14:1/C16, and citrulline/phenylalanine were associated with the subsequent development of NEC. Over time, differences in individual analyte levels associated with NEC onset shifted from predominantly AAs at birth to predominantly ACs by day 42. Subjects who developed NEC received significantly lower weight-adjusted total calories (p < 0.001) overall, a trend that emerged by day of life 7 (p = 0.020), and persisted until day of life 28 (p < 0.001) and 42 (p < 0.001). Conclusion: Premature infants demonstrate metabolic differences at birth. Metabolite abnormalities progress in parallel to significant differences in nutritional delivery signifying metabolic dysfunction in premature newborns prior to NEC onset. These observations provide new insights to potential contributing pathophysiology of NEC and opportunity for clinical care-based prevention.
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Necrotizing Enterocolitis: Using Regulatory Science and Drug Development to Improve Outcomes. J Pediatr 2019; 212:208-215.e1. [PMID: 31235383 DOI: 10.1016/j.jpeds.2019.05.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/02/2019] [Accepted: 05/13/2019] [Indexed: 01/24/2023]
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22
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Fell DB, Wilson LA, Hawken S, Spruin S, Murphy M, Potter BK, Little J, Chakraborty P, Lacaze-Masmonteil T, Wilson K. Association between newborn screening analyte profiles and infant mortality. J Matern Fetal Neonatal Med 2019; 34:835-838. [PMID: 31046492 PMCID: PMC7722351 DOI: 10.1080/14767058.2019.1615048] [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] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective To assess whether newborn screening analytes could be utilized beyond their traditional application to identify infants at high risk of mortality within the first 6 months of life. Methods We linked a province-wide newborn screening registry with health administrative databases to identify infant deaths within 6 months in a source population of live-born infants between 2010 and 2014. We used a nested case-control study design, in which all infant deaths between 7 days and 6 months of age were included as cases, and a random sample of infants from the source population were selected as controls and were matched to cases at a ratio of 10:1. We examined the association between mortality and screening analytes (acylcarnitines, amino acids, fetal-to-adult hemoglobin ratio, endocrine markers, and enzymes) using lasso regression to fit multivariable models. Results Among 350 infant deaths between 7 days and 6 months of age, and 3498 matched controls with complete data, our multivariable model demonstrated only modest ability to identify infant deaths (optimism-corrected c-statistic: 0.61, 95% confidence interval: 0.50–0.71). Conclusions We did not find newborn screening analytes to be strongly predictive of infant mortality between 7 days and 6 months of age in the general population of newborns. Future studies should investigate whether predictive modeling within more homogeneous cause-of-death categories could lead to improved predictive ability for infant mortality.
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Affiliation(s)
- Deshayne B Fell
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Lindsay A Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Steven Hawken
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sarah Spruin
- Institute for Clinical Evaluative Sciences, Ottawa, Canada
| | - Malia Murphy
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Beth K Potter
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Julian Little
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | | | | | - Kumanan Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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23
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Recent Potential Noninvasive Biomarkers in Necrotizing Enterocolitis. Gastroenterol Res Pract 2019; 2019:8413698. [PMID: 31178908 PMCID: PMC6501130 DOI: 10.1155/2019/8413698] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/31/2018] [Accepted: 02/12/2019] [Indexed: 12/27/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a rare but devastating gastrointestinal disease that predominately affects preterm neonates. Numerous studies have revealed that NEC is strongly associated with very low birth weight, degree of prematurity, formula feeding, infection, hypoxic/ischemic injury, and enteric dysbiosis. Given these clinical associations, the search for a deeper understanding of disease pathogenesis has led to an intense interest in the discovery and development of noninvasive biomarkers of NEC from stool, urine, and serum. Biomarkers for NEC may serve at least two general purposes of urgent unmet need: to improve diagnostic accuracy and disease prediction and to reveal the mechanism of the disease. This review will provide an overview of recent research focused on clinical NEC and highlight the advances that were made within the past five years towards the development of noninvasive diagnostic biomarkers.
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López-Suárez O, Concheiro-Guisán A, Sánchez-Pintos P, Cocho JA, Fernández Lorenzo JR, Couce ML. Acylcarnitine profile in neonatal hypoxic-ischemic encephalopathy: The value of butyrylcarnitine as a prognostic marker. Medicine (Baltimore) 2019; 98:e15221. [PMID: 30985723 PMCID: PMC6485840 DOI: 10.1097/md.0000000000015221] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 03/01/2019] [Accepted: 03/20/2019] [Indexed: 11/26/2022] Open
Abstract
Optimal prognostic markers evaluating early neuroprotective interventions in neonatal hypoxic-ischemic encephalopathy (HIE) are lacking. This study was designed to assess the prognostic value of acylcarnitines in neonatal HIE.An observational cohort study was conducted over 10 years in 67 HIE. Variables analyzed included sex, blood cord pH, Apgar score, hypothermia treatment (yes/no), neuron-specific enolase (NSE) levels, and clinical outcome (neurological examination, brain magnetic resonance imaging [MRI], and electroencephalogram) before discharge and at 6 months. Acylcarnitine profiles were analyzed by tandem-mass spectrometry on dried-blood spots collected on day 3 for newborn screening. A cohort of healthy newborns was used as control group.HIE patients had significantly increased C4, C5, C5:1, C6, C6-OH, C8 levels (all P < .01) and decreased long-chain acylcarnitine levels (P < .03). Hypothermia treatment was associated with a decrease in C4 levels (p = 0.005) and an increase in most long-chain acylcarnitine levels (P < .01). A significant association was found between C4 levels and NSE on day 1 of hypothermia treatment (P = .002) and abnormal brain magnetic resonance imaging (MRI) at discharge (P = .037). In the hypothermia group, C4 levels decreased in patients with favorable outcomes but remained high in those who progressed unfavorably.C4 appears to be a good prognostic marker in HIE, as blood levels correlated with NSE levels and abnormal MRI findings. Furthermore, hypothermia did not lead to decreased levels in patients with adverse outcomes.
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Affiliation(s)
- Olalla López-Suárez
- Neonatal Unit, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela
| | - Ana Concheiro-Guisán
- Neonatal Unit, Pediatric Service, Hospital Alvaro Cunqueiro, Health Research Institute of Vigo (IVI), Vigo
| | - Paula Sánchez-Pintos
- Diagnosis and Treatment of Congenital Metabolic Diseases Unit (UDyTEMC), Department of Pediatrics, Health Research Institute of Santiago (IDIS), CIBERER, Hospital Clínico Universitario de Santiago de Compostela, Spain
| | - Jose A. Cocho
- Diagnosis and Treatment of Congenital Metabolic Diseases Unit (UDyTEMC), Department of Pediatrics, Health Research Institute of Santiago (IDIS), CIBERER, Hospital Clínico Universitario de Santiago de Compostela, Spain
| | - José R. Fernández Lorenzo
- Neonatal Unit, Pediatric Service, Hospital Alvaro Cunqueiro, Health Research Institute of Vigo (IVI), Vigo
| | - María L. Couce
- Neonatal Unit, Department of Pediatrics, Hospital Clínico Universitario de Santiago de Compostela
- Diagnosis and Treatment of Congenital Metabolic Diseases Unit (UDyTEMC), Department of Pediatrics, Health Research Institute of Santiago (IDIS), CIBERER, Hospital Clínico Universitario de Santiago de Compostela, Spain
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New insights into necrotizing enterocolitis: From laboratory observation to personalized prevention and treatment. J Pediatr Surg 2019; 54:398-404. [PMID: 29980346 PMCID: PMC6344311 DOI: 10.1016/j.jpedsurg.2018.06.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/21/2018] [Accepted: 06/03/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND/PURPOSE Necrotizing enterocolitis (NEC) is a devastating disease of prematurity that develops after feeding, often without warning, and results in diffuse intestinal necrosis leading to sepsis and death in many cases. The lack of improvement in overall survival is influenced by nonspecific diagnostic modalities as well as inexact and nonpersonalized treatment strategies. METHODS/RESULTS Recently, we and others have shown that NEC develops in response to exaggerated bacterial signaling in the premature intestine, as a consequence of elevated expression and activity of the bacterial receptor toll-like receptor 4 (TLR4), which is important for normal gut development. Breast milk is a powerful TLR4 inhibitor, while mutations in TLR4 genes lead to increased NEC risk in humans, providing proof-of-concept for its role in NEC. Recently, a drug discovery approach has revealed a novel class of TLR4 inhibitors which are being developed for personalized approaches to NEC treatment. CONCLUSION This review will highlight the current understanding of the role of bacterial signaling in NEC pathogenesis, and will describe advances in diagnosis, prevention and treatment of NEC that may hopefully improve survival for these most fragile patients. SYSTEMATIC REVIEW Level of Evidence: Level II.
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Abstract
Necrotizing enterocolitis (NEC) is a devastating disease of prematurity, with no current method for early diagnosis. Diagnosis is particularly challenging, frequently occurring after the disease has progressed to the point of significant and often irreversible intestinal damage. Biomarker research has tremendous potential to advance clinical management of NEC and our understanding of its pathogenesis. This review discusses the need for novel biomarkers in NEC management, evaluates studies investigating such biomarkers, and explains the difficulties associated with translating biomarker discovery into clinical use.
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Affiliation(s)
- Gregory P Goldstein
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304
| | - Karl G Sylvester
- Department of Surgery, Division of Pediatric Surgery, 300 Pasteur Drive, Alway Building M116, MC 5733, Stanford, CA 94305.
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Abstract
Necrotizing enterocolitis (NEC) remains a devastating surgical emergency with high morbidity and mortality in preterm infants. Slow but steady progress has been made in past years searching for novel biomarkers of NEC, for both surveillance and diagnostic purposes. This review primarily focuses on recent discoveries: clinical applications of different categories of biomarkers for surveillance, early diagnosis, and predicting severity and prognosis; and understanding of pathophysiological mechanisms as a basis to rationalize the search for 'gut-associated specific biomarkers' of NEC. An important next step is to collaborate with our industrial partners to develop point-of-care tests, and to discover novel and gut-associated specific biomarkers that can be used for surveillance and early diagnosis of NEC in routine clinical settings.
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Rusconi B, Jiang X, Sidhu R, Ory DS, Warner BB, Tarr PI. Gut Sphingolipid Composition as a Prelude to Necrotizing Enterocolitis. Sci Rep 2018; 8:10984. [PMID: 30030452 PMCID: PMC6054655 DOI: 10.1038/s41598-018-28862-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 06/22/2018] [Indexed: 12/21/2022] Open
Abstract
Necrotizing enterocolitis (NEC) remains a major challenge in neonatology. Little is known about NEC pathophysiology apart from the presence of pre-event gut dysbiosis. Here, we applied broad range metabolomics to stools obtained 1-5 days before NEC developed from 9 cases (9 samples) and 19 (32 samples) controls matched for gestational age at birth and birth weight. The 764 identified metabolites identified six pathways that differ between cases and controls. We pursued sphingolipid metabolism because cases had decreased ceramides and increased sphingomyelins compared to controls, and because of the relevance of sphingolipids to human inflammatory disorders. Targeted analysis of samples from 23 cases and 46 controls confirmed the initial broad range observations. While metabolites provided only 73% accuracy of classification by machine learning, hierarchical clustering defined a sphingolipid associated grouping that contained 60% of the cases but only 13% of the controls, possibly identifying a pathophysiologically distinct subset of NEC. The clustering did not associate with any of the analyzed clinical and sample variables. We conclude that there are significant changes in sphingolipid metabolism components in pre-NEC stools compared to controls, but our data urge circumspection before using sphingolipids as broadly applicable predictive biomarkers.
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Affiliation(s)
- B Rusconi
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - X Jiang
- Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - R Sidhu
- Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - D S Ory
- Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - B B Warner
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - P I Tarr
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
- Department of Molecular Microbiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
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29
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Oltman SP, Rogers EE, Baer RJ, Anderson JG, Steurer MA, Pantell MS, Partridge JC, Rand L, Ryckman KK, Jelliffe-Pawlowski LL. Initial Metabolic Profiles Are Associated with 7-Day Survival among Infants Born at 22-25 Weeks of Gestation. J Pediatr 2018; 198:194-200.e3. [PMID: 29661562 PMCID: PMC6016556 DOI: 10.1016/j.jpeds.2018.03.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/02/2018] [Accepted: 03/14/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the association between early metabolic profiles combined with infant characteristics and survival past 7 days of age in infants born at 22-25 weeks of gestation. STUDY DESIGN This nested case-control consisted of 465 singleton live births in California from 2005 to 2011 at 22-25 weeks of gestation. All infants had newborn metabolic screening data available. Data included linked birth certificate and mother and infant hospital discharge records. Mortality was derived from linked death certificates and death discharge information. Each death within 7 days was matched to 4 surviving controls by gestational age and birth weight z score category, leaving 93 cases and 372 controls. The association between explanatory variables and 7-day survival was modeled via stepwise logistic regression. Infant characteristics, 42 metabolites, and 12 metabolite ratios were considered for model inclusion. Model performance was assessed via area under the curve. RESULTS The final model included 1 characteristic and 11 metabolites. The model demonstrated a strong association between metabolic patterns and infant survival (area under the curve [AUC] 0.885, 95% CI 0.851-0.920). Furthermore, a model with just the selected metabolites performed better (AUC 0.879, 95% CI 0.841-0.916) than a model with multiple clinical characteristics (AUC 0.685, 95% CI 0.627-0.742). CONCLUSIONS Use of metabolomics significantly strengthens the association with 7-day survival in infants born extremely premature. Physicians may be able to use metabolic profiles at birth to refine mortality risks and inform postnatal counseling for infants born at <26 weeks of gestation.
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Affiliation(s)
- Scott P Oltman
- Department of Epidemiology and Biostatistics and the Preterm Birth Initiative, University of California San Francisco, San Francisco, CA.
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Rebecca J Baer
- Preterm Birth Initiative, University of California San Francisco, San Francisco, CA; Department of Pediatrics, University of California San Diego, La Jolla, CA
| | - James G Anderson
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Martina A Steurer
- Department of Epidemiology and Biostatistics and Pediatrics, University of California San Francisco, San Francisco, CA
| | - Matthew S Pantell
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - J Colin Partridge
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Larry Rand
- Preterm Birth Initiative, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Kelli K Ryckman
- Department of Epidemiology and Pediatrics, University of Iowa, Iowa City, IA
| | - Laura L Jelliffe-Pawlowski
- Department of Epidemiology and Biostatistics and the Preterm Birth Initiative, University of California San Francisco, San Francisco, CA
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30
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Rusconi B, Good M, Warner BB. The Microbiome and Biomarkers for Necrotizing Enterocolitis: Are We Any Closer to Prediction? J Pediatr 2017; 189:40-47.e2. [PMID: 28669607 PMCID: PMC5614810 DOI: 10.1016/j.jpeds.2017.05.075] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/24/2017] [Accepted: 05/26/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Brigida Rusconi
- Division of Gastroenterology, Hepatology & Nutrition, Pathobiology Research Unit, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Misty Good
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Barbara B. Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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31
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Rusconi B, Warner BB. The Hidden Treasure of Neonatal Screening: Identifying New Risk Factors and Possible Mechanisms of Necrotizing Enterocolitis Through Big Data. J Pediatr 2017; 181:9-11. [PMID: 27931825 PMCID: PMC5507359 DOI: 10.1016/j.jpeds.2016.11.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 11/07/2016] [Indexed: 11/18/2022]
Affiliation(s)
| | - Barbara B Warner
- Division of Newborn Medicine Department of Pediatrics Washington University School of Medicine St Louis, Missouri.
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