Patent ductus arteriosus hemodynamics in very premature infants treated with poractant alfa or beractant for respiratory distress syndrome

Risk stratification of hemodynamically significant patent ductus arteriosus by clinical and genetic factors

BACKGROUND

Hemodynamically significant patent ductus arteriosus (hsPDA) is associated with increased comorbidities in neonates. Early evaluation of hsPDA risk is critical to implement individualized intervention. The aim of the study was to provide a powerful reference for the early identification of high-risk hsPDA population and early treatment decisions.

METHODS

We enrolled infants who were diagnosed with PDA and performed exome sequencing. The collapsing analyses were used to find the risk gene set (RGS) of hsPDA for model construction. The credibility of RGS was proven by RNA sequencing. Multivariate logistic regression was performed to establish models combining clinical and genetic features. The models were evaluated by area under the receiver operating curve (AUC) and decision curve analysis (DCA).

RESULTS

In this retrospective cohort study of 2199 PDA patients, 549 (25.0%) infants were diagnosed with hsPDA. The model [all clinical characteristics selected by least absolute shrinkage and selection operator regression (all CCs)] based on six clinical variables was acquired within three days of life, including gestational age (GA), respiratory distress syndrome (RDS), the lowest platelet count, invasive mechanical ventilation, and positive inotropic and vasoactive drugs. It has an AUC of 0.790 [95% confidence interval (CI) = 0.749-0.832], while the simplified model (basic clinical characteristic model) including GA and RDS has an AUC of 0.753 (95% CI = 0.706-0.799). There was a certain consistency between RGS and differentially expressed genes of the ductus arteriosus in mice. The AUC of the models was improved by RGS, and the improvement was significant (all CCs vs. all CCs + RGS: 0.790 vs. 0.817, P < 0.001). DCA demonstrated that all models were clinically useful.

CONCLUSIONS

Models based on clinical factors were developed to accurately stratify the risk of hsPDA in the first three days of life. Genetic features might further improve the model performance. Video Abstract (MP4 86834 kb).

Comparing the clinical and economic efficiency of four natural surfactants in treating infants with respiratory distress syndrome

Surfactant therapy has revolutionized the treatment of respiratory distress syndrome (RDS) over the past few decades. Relying on a new method, the current research seeks to compare four common surfactants in the health market of Iran to determine the best surfactant according to the selected criteria. The research was a cross-sectional, retrospective study that used the data of 13,169 infants as recorded on the information system of the Iranian Ministry of Health. To rank the surfactants used, the following indicators were measured: re-dosing rate, average direct treatment cost, average length of stay, disease burden, need for invasive mechanical ventilation, survival at discharge, and medical referrals. The CRITIC (criteria importance through intercriteria correlation) method was used to determine the weight of the indicators, and MABAC (multi-attributive border approximation area comparison) was used to prioritize the surfactants. Based on the seven selected indicators in this research (re-dosing rate, average length of stay, direct medical cost per one prescription, medical referral rate, survival at discharge, disability-adjusted life years, number of newborns in need of invasive mechanical ventilation) and using multi-criteria analysis method, Alveofact was identified as the worst surfactant in infants with either more or less than 32 weeks' gestation. So that some criteria were worse in Alveofact group infants than other groups; for example, in the comparison of the Alveofact group with the average of the total population, it was found that the survival rate at discharge was 57.14% versus 66.43%, and the rate of re-dosing was 1.63 versus 1.39. BLES (bovine lipid extract surfactant) was the best alternative for infants more than 32 weeks' gestation, whereas Survanta was identified as best option for infants with less than 32 weeks' gestation. Curosurf showed an average level of functionality in the ranking. This study advises the policy makers in the field of neonatal health to increase the market share of more effective surfactants based on this study and other similar studies. On the other hand, neonatal health care providers are also advised to prioritize the use of more effective surfactants if possible, depending on the clinical conditions and desired improvements.

Eligibility Criteria and Representativeness of Randomized Clinical Trials That Include Infants Born Extremely Premature: A Systematic Review

OBJECTIVE

To assess the eligibility criteria and trial characteristics among contemporary (2010-2019) randomized clinical trials (RCTs) that included infants born extremely preterm (<28 weeks of gestation) and to evaluate whether eligibility criteria result in underrepresentation of high-risk subgroups (eg, infants born at <24 weeks of gestation).

STUDY DESIGN

PubMed and Scopus were searched January 1, 2010, to December 31, 2019, with no language restrictions. RCTs with mean or median gestational ages at birth of <28 weeks of gestation were included. The study followed the PRISMA guidelines; outcomes were registered prospectively. Data extraction was performed independently by multiple observers. Study quality was evaluated using a modified Jadad scale.

RESULTS

Among RCTs (n = 201), 32 552 infants were included. Study participant characteristics, interventions, and outcomes were highly variable. A total of 1603 eligibility criteria were identified; rationales were provided for 18.8% (n = 301) of criteria. Fifty-five RCTs (27.4%) included infants <24 weeks of gestation; 454 (1.4%) infants were identified as <24 weeks of gestation.

CONCLUSIONS

The present study identifies sources of variability across RCTs that included infants born extremely preterm and reinforces the critical need for consistent and transparent policies governing eligibility criteria.

Porcine versus bovine surfactant therapy for RDS in preterm neonates: pragmatic meta-analysis and review of physiopathological plausibility of the effects on extra-pulmonary outcomes

BACKGROUND

While porcine seems to be superior to bovine surfactants in terms of respiratory outcomes, it is unclear if a surfactant can improve extra-pulmonary outcomes in preterm neonates with respiratory distress syndrome and if there is any physiopathological/biological mechanism linking surfactant therapy to these outcomes. We aim to fill these knowledge gaps.

METHODS

Systematic and pragmatic review coupled with meta-analysis of randomized controlled trials of bovine or porcine surfactants administered to treat RDS in preterm neonates; common extra-pulmonary neonatal intensive care outcomes were considered. As additional analysis, animal or human translational studies about mechanisms linking surfactant replacement to extra-pulmonary neonatal outcomes were also systematically reviewed.

RESULTS

Porcine surfactant is associated with lower incidence of patent ductus arteriosus (OR:0.655; 95%CI:0.460-0.931); p = 0.018; 12 trials; 1472 patients); prenatal steroids (coeff.:-0.009, 95%CI:-0.03-0.009, p = 0.323) and gestational age (coeff.:0.079, 95%CI:-0.18-0.34, p = 0.554) did not influence this effect size. No significant differences were found between porcine and bovine surfactants on neonatal intensive care unit length of stay (mean difference (days):-2.977; 95%CI:-6.659-0.705; p = 0.113; 8 trials; 855 patients), intra-ventricular hemorrhage of any grade (OR:0.860; 95%CI:0.648-1.139); p = 0.293; 15 trials; 1703 patients), severe intra-ventricular hemorrhage (OR:0.852; 95%CI:0.624-1.163); p = 0.313; 15 trials; 1672 patients), necrotizing entero-colitis (OR:1.190; 95%CI:0.785-1.803); p = 0.412; 9 trials; 1097 patients) and retinopathy of prematurity (OR:0.801; 95%CI:0.480-1.337); p = 0.396; 10 trials; 962 patients).

CONCLUSIONS

Physiopathological mechanisms explaining the effect of surfactant have been found for patent ductus arteriosus only, while they are lacking for all other endpoints. Porcine surfactant is associated with lower incidence of PDA than bovine surfactants. As there are no differences in terms of other extra-pulmonary outcomes and no physiopathological plausibility, these endpoints should not be used in future trials.

REGISTRATION

PROSPERO n.CRD42018100906.

Impact of the shift to neonatal noninvasive ventilation in Poland: a population study

OBJECTIVE

This study was undertaken to document the real impact of a directed shift in the standard of neonatal practice to a pervasive use of noninvasive respiratory support.

DESIGN

Before-after observational study.

SETTING

All 18 neonatal ICUs in the capital region of Poland.

PATIENTS

Every infant admitted to a neonatal ICU who received respiratory pressure support over a 7-year period of interest (12-month transition to the new noninvasive standard and 36 months before and after).

INTERVENTION

Education as to the benefits of noninvasive respiratory support and widespread availability of Infant Flow noninvasive ventilation systems.

MEASUREMENTS AND MAIN RESULTS

Five thousand five hundred fifty-one infants required respiratory support in this period. Of these, 14% were less than 28 weeks estimated gestational age, 33% between 28 and 32 weeks, 31% between 33 and 36 weeks, and 22% more than 36 weeks. The use of noninvasive support, as the first form of respiratory support, increased by 19% (p < 0.001). The use of noninvasive support, for weaning following extubation, increased by 32% (p = 0.06). The increased use in weaning was the most pronounced in infants younger than or equal to 32 weeks estimated gestational age (p < 0.001). There were two prospective primary endpoints, mortality and bad outcome among survivors younger than or equal to 32 weeks estimated gestational age. Mortality decreased from 11% to 7%, and the difference remained statistically significant after controlling for baseline factors (p < 0.001). The reduced mortality was more apparent in infants younger than or equal to 32 weeks estimated gestational age. In infants younger than or equal to 32 weeks estimated gestational age, bad outcome in survivors (grade III bronchopulmonary dyplasia and retinopathy of prematurity requiring laser treatment) did not increase (p = 0.669) after controlling for significant baseline variables.

CONCLUSIONS

We believe that the adoption of an approach emphasizing noninvasive ventilation in Poland resulted in decreased mortality without an increase in significant pulmonary or retinal morbidity.

Efficacy of porcine versus bovine surfactants for preterm newborns with respiratory distress syndrome: systematic review and meta-analysis

OBJECTIVE

To compare the efficacy of a porcine surfactant (poractant alfa) versus bovine surfactants (beractant and calfactant) with respect to clinical outcomes among preterm infants with respiratory distress syndrome.

METHODS

A search of major electronic databases, including Medline (1980-2010) and the Cochrane Central Register of Controlled Trials, for randomized controlled trials that compared poractant alfa versus beractant and/or calfactant among preterm infants with respiratory distress syndrome who required intubation and surfactant treatment was performed. The primary outcome was oxygen requirement at a postmenstrual age of 36 weeks.

RESULTS

Five randomized controlled trials involving 529 infants compared poractant alfa versus beractant for rescue treatment. No trials studied surfactant prophylaxis, and none compared poractant alfa versus calfactant. The incidences of oxygen dependence at a postmenstrual age of 36 weeks were similar for poractant alfa and beractant. Infants treated with poractant alfa at 100 mg/kg (low dose) or 200 mg/kg (high dose) exhibited statistically significant reductions in deaths (relative risk: 0.51 [95% confidence interval: 0.30-0.89]), the need for redosing (relative risk: 0.71 [95% confidence interval: 0.57-0.88]), oxygen requirements, duration of oxygen treatment, and duration of mechanical ventilation. The test of heterogeneity yielded positive results for the latter 2 outcomes. The difference remained statistically significant for deaths and the need for redosing with high-dose poractant alfa but not for low dose poractant alfa.

CONCLUSIONS

There were significant reductions in deaths and the need for redosing with high-dose poractant alfa but not low-dose poractant alfa, compared with beractant.