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Guo X, Ma D, Li R, Zhang R, Guo Y, Yu Z, Chen C. Association between viral infection and bronchopulmonary dysplasia in preterm infants: a systematic review and meta-analysis. Eur J Pediatr 2024; 183:2965-2981. [PMID: 38634889 PMCID: PMC11192663 DOI: 10.1007/s00431-024-05565-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 04/19/2024]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common serious complication of very preterm infants (VPI) or very low birth weight (VLBW) infants. Studies implicate viral infections in etiopathogenesis. The aim of this study was to summarize the relationship between viral infections and BPD through a systematic review and meta-analysis. We searched PubMed, Embase, the Web of Science Core Collection, and the Cochrane Database on December 19, 2023. We included observational studies that examined the association between viral infections and BPD in preterm infants. We extracted data on study methods, participant characteristics, exposure assessment, and outcome measures. We assessed study risk of bias using the Newcastle-Ottawa Scale (NOS). We included 17 and 15 studies in the qualitative review and meta-analysis, respectively. The meta-analysis showed a significant association between viral infection and BPD diagnosed at 36 weeks postmenstrual age (odds ratio (OR): 2.42, 95% confidence interval: 1.89-3.09, 13 studies, very low certainty of evidence). In a subgroup analysis of specific viruses, cytomegalovirus (CMV) proved to be significantly associated with BPD diagnosed at 36 weeks postmenstrual age (OR: 2.34, 95% confidence interval: 1.80-3.05, 11 studies). We did not find an association between viral infection and BPD diagnosed on the 28th day of life, probably due to the small sample size of the included prospective studies. Conclusion: Viral infections, especially CMV, are associated with an increased risk of BPD in preterm infants. Methodologically reliable prospective studies with large samples are needed to validate our conclusions, and high-quality randomized controlled studies are needed to explore the effect of prevention or treatment of viral infections on the incidence of BPD. What is Known: • Studies have attempted to identify viral infections and bronchopulmonary dysplasia in preterm infants; however, results have been inconsistent. What is New: • Systematic demonstration that viral infections, particularly cytomegalovirus, are positively associated with bronchopulmonary dysplasia diagnosed in preterm infants at the 36th week of postmenstrual age. • The importance of screening for viral infections in preterm infants, especially cytomegalovirus. More high-quality studies should be produced in the future to investigate the causal relationship between viral infections and bronchopulmonary dysplasia.
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Affiliation(s)
- Xin Guo
- Department of Neonatology, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, 518172, Guangdong, China
| | - Defei Ma
- Department of Neonatology, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, 518172, Guangdong, China
| | - Rui Li
- Department of Neonatology, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, 518172, Guangdong, China
| | - Ruolin Zhang
- Department of Neonatology, Nanshan Maternity & Child Healthcare Hospital, Shenzhen, 518067, Guangdong, China
| | - Yanping Guo
- Department of Pediatrics, Peking University Shenzhen Hospital, Shenzhen, 518036, Guangdong, China
| | - Zhangbin Yu
- Department of Neonatology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, 518000, Guangdong, China.
| | - Cheng Chen
- Department of Neonatology, Longgang District Maternity & Child Healthcare Hospital of Shenzhen City (Longgang Maternity and Child Institute of Shantou University Medical College), Shenzhen, 518172, Guangdong, China.
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Katz TA, van Kaam AH, Zuithoff NPA, Mugie SM, Beuger S, Blok GJ, van Kempen AAMW, van Laerhoven H, Lutterman CAM, Rijpert M, Schiering IA, Ran NC, Visser F, van Straaten E, Aarnoudse-Moens CSH, van Wassenaer-Leemhuis AG, Onland W. Association between bronchopulmonary dysplasia severity and its risk factors and long-term outcomes in three definitions: a historical cohort study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-326931. [PMID: 38897634 DOI: 10.1136/archdischild-2024-326931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/26/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE To compare the association of the severity categories of the 2001-National Institutes of Health (NIH), the 2018-NIH and the 2019-Jensen bronchopulmonary dysplasia (BPD) definitions with neurodevelopmental and respiratory outcomes at 2 and 5 years' corrected age (CA), and several BPD risk factors. DESIGN Single-centre historical cohort study with retrospective data collection. SETTING Infants born between 2009 and 2015 at the Amsterdam University Medical Centers, location Amsterdam Medical Center. PATIENTS Preterm infants born at gestational age (GA) <30 weeks and surviving up to 36 weeks' postmenstrual age. INTERVENTIONS Perinatal characteristics, (social) demographics and comorbidities were collected from the electronic patient records. MAIN OUTCOME MEASURES The primary outcomes were neurodevelopmental impairment (NDI) or late death, and respiratory morbidity at 2 and 5 years' CA. Using logistic regression and Brier scores, we investigated if the ordinal grade severity is associated with incremental increase of adverse long-term outcomes. RESULTS 584 preterm infants (median GA: 28.1 weeks) were included and classified according to the three BPD definitions. None of the definitions showed a clear ordinal incremental increase of risk for any of the outcomes with increasing severity classification. No significant differences were found between the three BPD definitions (Brier scores 0.169-0.230). Respiratory interventions, but not GA, birth weight or small for GA, showed an ordinal relationship with BPD severity in all three BPD definitions. CONCLUSION The severity classification of three BPD definitions showed low accuracy of the probability forecast on NDI or late death and respiratory morbidity at 2 and 5 years' CA, with no differences between the definitions.
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Affiliation(s)
- Trixie A Katz
- Neonatology, Emma Children's Hospital UMC, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - S M Mugie
- Department of Pediatrics, Tergooi Medical Center, Hilversum, The Netherlands
- Emma Children's Hospital UMC, Amsterdam, The Netherlands
| | - Sabine Beuger
- Department of Pediatrics and Neonatology, North West Hospital Group, Alkmaar, The Netherlands
| | - Geert Jan Blok
- Department of Pediatrics and Neonatology, North West Hospital Group, Alkmaar, The Netherlands
| | | | | | | | - Maarten Rijpert
- Department of Pediatrics, Zaans Medical Center, Zaandam, The Netherlands
| | - Irene A Schiering
- Department of Pediatrics, Spaarne Hospital Haarlem, Haarlem, The Netherlands
| | - Nicolien C Ran
- Department of Pediatrics, Red Cross Hospital, Beverwijk, The Netherlands
| | - Fenna Visser
- Department of Pediatrics, Amstelland Hospital, Amstelveen, The Netherlands
| | - Els van Straaten
- Department of Pediatrics, Bovenij Hospital, Amsterdam, The Netherlands
| | | | - Aleid G van Wassenaer-Leemhuis
- Neonatology, Emma Children's Hospital UMC, Amsterdam, The Netherlands
- Department of Neonatology, Emma Children's Hospital UMC, Amsterdam, The Netherlands
| | - Wes Onland
- Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
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Ramos-Navarro C, Sánchez-Luna M, Pérez-Tarazona S, Sanz-López E, Maderuelo-Rodriguez E, Rueda-Esteban S, Sánchez-Torres A, Concheiro-Guisán A, Sánchez-Solís M. Pulmonary function and bronchopulmonary dysplasia classification: insights from the Spanish Registry. Eur J Pediatr 2024:10.1007/s00431-024-05629-w. [PMID: 38858227 DOI: 10.1007/s00431-024-05629-w] [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: 04/15/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/12/2024]
Abstract
In 2016, the Spanish Research Group on Bronchopulmonary Dysplasia (BPD) (GEIDIS) established a national registry with participation of 66 hospitals to collect information on clinical characteristics and long-term outcomes of BPD infants into adulthood. The aim of this observational study is to examine forced spirometry data in early childhood and to assess their correlation with the respiratory support required at 36 weeks postmenstrual age (PMA). The study analyzed data from preterm infants with BPD born between January 2016 and December 2017 who underwent forced spirometry at 5-7 years of age. Statistical analyses were conducted to investigate the relationships between spirometry results, perinatal factors, and the required respiratory support at 36 weeks PMA. The study involved 143 patients with a median gestational age (GA) of 27.3 weeks (range 25.7-28.7) and a median weight of 880 g (range 740-1135). Abnormal spirometry results were observed in 39.2% (56) of the patients. Among patients diagnosed with BPD type 3, those requiring over 30% oxygen at 36 weeks PMA exhibited an increased risk of abnormal spirometry results (OR 4.48; 95% CI 1.11-18.13) compared to those requiring positive pressure with less than 30% oxygen. In addition, this subgroup had a higher risk of developing a restrictive-mixed pattern compared to those with BPD type 1 (OR 10.65; 95% CI 2.06-54.98) and BPD type 2 (OR 6.76; 95% CI 1.09-42.06). No significant differences were found in the incidence of an obstructive pattern between BPD types. Conclusion: The requirement of more than 30% oxygen at 36 weeks PMA serves as a risk indicator for pulmonary function impairment in school-aged children with BPD. These findings suggest persistent airway and parenchymal injury in this specific patient population, and highlight the importance of careful monitoring to evaluate their long-term effects on lung function. What is Known: • Premature patients with bronchopulmonary dysplasia (BPD) may present abnormalities in pulmonary function tests during school age. However, the predictive accuracy of consensus BPD severity classification remains uncertain. What is New: • The requirement of more than 30% oxygen at 36 weeks postmenstrual age (PMA) indicates a potential risk of pulmonary function impairment in school-aged children with BPD. Additionally, a significant correlation has been observed between a restrictive-mixed pattern with exposure to mechanical ventilation and the development of severe forms of BPD.
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Affiliation(s)
- Cristina Ramos-Navarro
- Neonatologist at Neonatology Department, Gregorio Marañón University Hospital, Madrid, Spain.
| | - Manuel Sánchez-Luna
- Neonatologist at Neonatology Department, Gregorio Marañón University Hospital, Madrid, Spain
| | | | - Ester Sanz-López
- Neonatologist at Neonatology Department, Gregorio Marañón University Hospital, Madrid, Spain
| | | | - Santiago Rueda-Esteban
- Pediatric Pulmonologist at Pulmonology Department, San Carlos University Hospital, Madrid, Spain
| | - Ana Sánchez-Torres
- Neonatologist at Neonatology Department, La Paz University Hospital, Madrid, Spain
| | - Ana Concheiro-Guisán
- Neonatologist at Neonatology Department, Alvaro Cunqueiro University Hospital, Vigo, Spain
| | - Manuel Sánchez-Solís
- Pediatric Pulmonologist at Pulmonology Department, Virgen Arrixaca University Hospital Murcia, Murcia, Spain
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Donlon J, Bhat V, Hunter K, Kushnir A, Bhandari V. Impact of severity and age with variable definitions of bronchopulmonary dysplasia on neurodevelopmental outcomes. Pediatr Res 2024:10.1038/s41390-024-03304-2. [PMID: 38830970 DOI: 10.1038/s41390-024-03304-2] [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: 09/25/2023] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is associated with neurodevelopmental impairment (NDI). METHODS To compare the ability of NICHD 2001 and Jensen 2019 definitions of BPD and respiratory support at 40 weeks postmenstrual age (PMA) to predict NDI, a retrospective study (1/2010-12/2020) was conducted in infants with gestational age <32 weeks and birth weight <1500 g. The primary outcome measure was NDI at 18-24 months corrected age. RESULTS Of 1119 infants, 227 (20.7%) met the inclusion criteria and had adequate follow-up data. Multivariate regression analysis showed that the NICHD 2001 definition was not predictive of NDI. Infants with Grade 2 or 3 BPD (Jensen 2019) had 4.75 (95% CI: 1.282-17.563) times greater odds of having NDI than infants without BPD. Infants requiring respiratory support at 40 weeks PMA had 4.95 (95% CI: 1.490-16.47) times greater odds of having NDI. Receiver operating characteristic curves demonstrated that the 2 definitions of BPD and the need for respiratory support at 40 weeks PMA were similar in their ability to predict NDI. CONCLUSION There is no significant difference in the ability of the NICHD 2001 and Jensen 2019 BPD definitions, as well as the need for respiratory support at 40 weeks, for predicting NDI. IMPACT STATEMENT Current bronchopulmonary dysplasia (BPD) definitions may not effectively predict neurodevelopmental impairment (NDI) in preterm infants. Grades 2/3 BPD (Jensen 2019 criteria) significantly associate with NDI. Infants requiring respiratory support at 40 weeks post-menstrual age (PMA) have 5 times higher odds of NDI than those on room air at 40 weeks PMA. The NICHD 2001, Jensen 2019 definitions, and the requirement for respiratory support at 40 weeks PMA, do not differ in their ability to predict NDI. Future studies should include multiple centers, with level III-IV NICUs, catering to socioeconomic, culturally, and racially diverse populations.
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Affiliation(s)
- Jack Donlon
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Vishwanath Bhat
- Cooper Medical School of Rowan University, Camden, NJ, USA
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, NJ, USA
| | - Krystal Hunter
- Cooper Medical School of Rowan University, Camden, NJ, USA
- Cooper Research Institute, Cooper University Hospital, Camden, NJ, USA
| | - Alla Kushnir
- Cooper Medical School of Rowan University, Camden, NJ, USA
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, NJ, USA
| | - Vineet Bhandari
- Cooper Medical School of Rowan University, Camden, NJ, USA.
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, NJ, USA.
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Nguyen KL, Fitzgerald DA, Webb A, Bajuk B, Popat H. Neurodevelopmental outcomes of extremely preterm infants with bronchopulmonary dysplasia (BPD) - A retrospective cohort study. Paediatr Respir Rev 2024; 50:23-30. [PMID: 38490918 DOI: 10.1016/j.prrv.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVE To investigate the neurodevelopmental outcomes for preterm infants born < 29 weeks gestation with/without bronchopulmonary dysplasia (BPD). STUDY DESIGN Preterm infants < 29 weeks' gestation born 2007-2018 in New South Wales and the Australian Capital Territory, Australia, were included. Infants who died < 36 weeks' postmenstrual age and those with major congenital anomalies were excluded. Subjects were assessed at 18-42 months corrected age using the Bayley Scales of Infant Development, 3rd edition. RESULTS 1436 infants without BPD (non-BPD) and 1189 infants with BPD were followed. The BPD group, 69 % infants were discharged without respiratory support (BPD1), 29 % on oxygen (BPD2) and 2 % on pressure support/tracheostomy (BPD3). Moderate neurodevelopmental impairment (NDI) was evident in 5.7 % of non-BPD infants, 11 % BPD1, 15 % BPD2, 15 % BPD3 infants. Severe NDI was seen in 1.7 % non-BPD infants, 3.4 % BPD1, 7.3 % BPD2, 35 % BPD3 infants. After adjusting for confounders, infants with BPD2 (OR 2.24, 99.9 % CI 1.25 to 5.77) or BPD3 (OR 5.99, 99.9 % CI 1.27 to 46.77) were more likely to have moderate-severe NDI compared to non-BPD infants. CONCLUSION The majority of infants with BPD were discharged home without respiratory support and had better neurocognitive outcomes in early childhood compared to those that required home-based oxygen or respiratory support.
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Affiliation(s)
- Khoa L Nguyen
- The Children's Hospital at Westmead, Locked Bag 4001 Westmead, NSW, 2145, Australia.
| | - Dominic A Fitzgerald
- The Children's Hospital at Westmead, Locked Bag 4001 Westmead, NSW, 2145, Australia; Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, Faculty of Medicine, Discipline of Health Sciences, University of Sydney, NSW, Australia
| | - Annabel Webb
- Cerebral Palsy Alliance Research Institute, Sydney, Australia
| | - Barbara Bajuk
- Neonatal Intensive Care Units' (NICUS) Data Collection, NSW Pregnancy and Newborn Services Network (PSN) , Australia
| | - Himanshu Popat
- The Children's Hospital at Westmead, Locked Bag 4001 Westmead, NSW, 2145, Australia; Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, Faculty of Medicine, Discipline of Health Sciences, University of Sydney, NSW, Australia; NHMRC Clinical Trial Centre, Levels 4-6 Medical Foundation Building, 92-94 Parramatta Rd, Camperdown, NSW 2050, Australia
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6
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Huang J, Xing G, Kong X. Lower peripheral blood CD4 + lymphocyte ratio is associated with severe bronchopulmonary dysplasia. Pediatr Pulmonol 2024. [PMID: 38780202 DOI: 10.1002/ppul.27071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 04/25/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To elucidate the characteristics of lymphocyte subsets in bronchopulmonary dysplasia (BPD) diagnosis following Jensen's criterion to understand the spectrum of lymphocytes in different degrees of BPD. STUDY DESIGN This single-center retrospective cohort study included 120 neonates admitted to the neonatal intensive care unit between 1 July 2014 and 30 June 2021, who had undergone peripheral blood lymphocyte subpopulation detection. RESULTS Thirty-one neonates were included in the control group, whereas 33 infants with BPD were included in the case group. In addition, we selected 56 infants with a gestational age (GA) <37 weeks without BPD who were receiving oxygen therapy. Among the three groups, the B cell and NK cell frequencies were significantly higher and the frequencies of T cells and CD4+ cells were significantly lower in the BPD group. In newborns without BPD, the distribution of T lymphocyte subsets was similar at different GAs. Comparing different degrees of BPD, the patients in the grades 2-3 BPD group had significantly lower percentages of T lymphocytes and CD4+ T cells than those in the other groups. Remarkably, the frequencies of NK cells were significantly higher in patients with grades 2-3 BPD, and the Treg cells slightly increased with BPD severity, although the differences were not significant. CONCLUSION Healthy neonates had similar ratios of lymphocyte subsets among different GAs; although as the GAs increased, the percentage of lymphocytes increased slightly. Severe BPD was associated with lower CD4+ T cells and higher NK cells. However, whether such changes were the cause or the consequence of BPD has not been determined.
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Affiliation(s)
- Jieting Huang
- Department of Neonatal Intensive Care Unit, Senior Department of Pediatrics, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Guosheng Xing
- Fourth Department of Internal Pediatrics, Senior Department of Pediatrics, The Seventh Medical Center of PLA General Hospital, Beijing, China
| | - Xiangyong Kong
- Department of Neonatal Intensive Care Unit, Senior Department of Pediatrics, The Seventh Medical Center of PLA General Hospital, Beijing, China
- Clinical Medical College, The Seventh Medical center of PLA General hospital, The Second School of Clinical Medicine, Southern Medical University, Beijing, China
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Kim C, Kim S, Kim H, Hwang J, Kim SH, Yang M, Ahn SY, Sung SI, Chang YS. Long-term impact of late pulmonary hypertension requiring medication in extremely preterm infants with severe bronchopulmonary dysplasia. Sci Rep 2024; 14:8705. [PMID: 38622180 PMCID: PMC11018761 DOI: 10.1038/s41598-024-58977-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/05/2024] [Indexed: 04/17/2024] Open
Abstract
This study investigated whether late pulmonary hypertension (LPH) independently increases the risk of long-term mortality or neurodevelopmental delay (NDD) in extremely preterm infants (EPIs) with severe bronchopulmonary dysplasia (BPD). Using prospectively collected data from the Korean Neonatal Network, we included EPIs with severe BPD born at 22-27 weeks' gestation between 2013 and 2021. EPIs having severe BPD with LPH (LPH, n = 124) were matched 1:3 with those without pulmonary hypertension (PH) as controls (CON, n = 372), via propensity score matching. LPH was defined as PH with the initiation of medication after 36 weeks' corrected age (CA). Long-term mortality after 36 weeks' CA or NDD at 18-24 months' CA was analyzed. NDD was assessed using composite scores based on various neurodevelopmental assessment modalities. LPH had significantly higher long-term mortality or NDD (45.2% vs. 23.1%, P < 0.001), mortality (24.2% vs. 4.84%, P < 0.001), and NDD (68.4% vs. 37.8%, P = 0.001), respectively than CON, even after adjusting for different demographic factors. Multivariable regression demonstrated that LPH independently increased the risk of mortality or NDD (adjusted odds ratio, 1.95; 95% confidence intervals, 1.17-3.25). When LPH occurs in EPIs with severe BPD, special monitoring and meticulous care for long-term survival and neurodevelopment are continuously needed.
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Affiliation(s)
- Chan Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-ku, Seoul, 06351, Republic of Korea
| | - Sumin Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-ku, Seoul, 06351, Republic of Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Hanna Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-ku, Seoul, 06351, Republic of Korea
| | - Jieun Hwang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-ku, Seoul, 06351, Republic of Korea
| | - Seung Hyun Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-ku, Seoul, 06351, Republic of Korea
| | - Misun Yang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-ku, Seoul, 06351, Republic of Korea
- Cell and Gene Therapy Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - So Yoon Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-ku, Seoul, 06351, Republic of Korea
- Cell and Gene Therapy Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-ku, Seoul, 06351, Republic of Korea
- Cell and Gene Therapy Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-ku, Seoul, 06351, Republic of Korea.
- Cell and Gene Therapy Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea.
- Department of Health Science and Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea.
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Ahn SY, Chang YS, Lee MH, Sung S, Kim AR, Park WS. Five-year follow-up of phase II trial of stromal cells for bronchopulmonary dysplasia. Thorax 2023; 78:1105-1110. [PMID: 37604693 DOI: 10.1136/thorax-2022-219622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 07/03/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND We previously performed a phase II randomised double-blind clinical trial of mesenchymal stromal cell (MSCs) transplantation to prevent bronchopulmonary dysplasia in extremely premature infants. Subsequently, we followed the infants enrolled in this clinical trial to determine the safety and effectiveness of MSCs against bronchopulmonary dysplasia at 5-year follow-up. METHODS We evaluated infants at 5 years of age receiving placebo or MSCs in a prospective follow-up study. RESULTS In terms of the primary end point of composite respiratory morbidities, including respiratory problem-related readmission, emergency department visits or oxygen therapy, the MSC group had a rate of 60.7% for composite morbidities, while the control group showed a tendency of higher rate of 83.9% for the same outcomes without statistical significance. In terms of the secondary outcomes, the MSC group infants showed a tendency of being less likely to visit emergency department (control 67.7% vs MSC 35.7%) and to receive oxygen therapy (control 29.0% vs MSC 3.6%). No difference was observed in the incidence of respiratory problem-related hospital readmission or wheezing episodes between the groups. CONCLUSION Intratracheally instilled MSCs showed the possibility of potential to decrease respiratory symptom-related emergency department visits and oxygen therapy episodes in infants born extremely preterm during the 5 years after a phase II randomised controlled, double-blind trial of MSCs transplantation for bronchopulmonary dysplasia. This small size study suggests preliminary insights that can be further tested using larger sample sizes. TRIAL REGISTRATION NUMBER NCT01897987.
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Affiliation(s)
- So Yoon Ahn
- Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Cell and Gene Therapy Institute, Samsung Medical Center, Seoul, South Korea
| | - Yun Sil Chang
- Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Cell and Gene Therapy Institute, Samsung Medical Center, Seoul, South Korea
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Myung Hee Lee
- Social Information Research Institute, Seoul, South Korea
| | - Sein Sung
- Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ai-Rhan Kim
- Pediatrics, University of Ulsan, Ulsan, South Korea
| | - Won Soon Park
- Pediatrics, Gangnam CHA Hospital, CHA University School of Medicine, Seoul, South Korea
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Kostekci YE, Bakırarar B, Okulu E, Erdeve O, Atasay B, Arsan S. An Early Prediction Model for Estimating Bronchopulmonary Dysplasia in Preterm Infants. Neonatology 2023; 120:709-717. [PMID: 37725910 DOI: 10.1159/000533299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/22/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Accurate assessment of the risk for bronchopulmonary dysplasia (BPD) is critical to determine the prognosis and identify infants who will benefit from preventive therapies. Clinical prediction models can support the identification of high-risk patients. In this study, we investigated the potential risk factors for BPD and compared machine learning models for predicting the outcome of BPD/death on days 1, 7, 14, and 28 in preterm infants. We also developed a local BPD estimator. METHODS This study involved 124 infants. We evaluated the composite outcome of BPD/death at a postmenstrual age of 36 weeks and identified risk factors that would improve BPD/death prediction. SPSS for Windows Version 11.5 and Weka 3.9 software were used for the data analysis. RESULTS To evaluate the combined effect of all variables, all risk factors were taken into consideration. Gestational age, birth weight, mode of respiratory support, intraventricular hemorrhage, necrotizing enterocolitis, surfactant requirement, and late-onset sepsis were risk factors on postnatal days 7, 14, and 28. In a comparison of four different time points (postnatal days 1, 7, 14, and 28), the day 7 model provided the best prediction. According to this model, when a patient was diagnosed with BPD/death, the accuracy rate was 89.5%. CONCLUSION The postnatal day 7 model was the best predictor of BPD or death. Future validation studies will help identify infants who may benefit from preventive therapies and develop individualized care.
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Affiliation(s)
- Yasemin Ezgi Kostekci
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Batuhan Bakırarar
- Department of Biostatistics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Emel Okulu
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Omer Erdeve
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Begum Atasay
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Saadet Arsan
- Division of Neonatology, Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
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10
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Soni S, Jiang Y, Zhang L, Thakur A, Cataltepe S. AMPK-driven Macrophage Responses Are Autophagy Dependent in Experimental Bronchopulmonary Dysplasia. Am J Respir Cell Mol Biol 2023; 68:279-287. [PMID: 36306501 PMCID: PMC9989474 DOI: 10.1165/rcmb.2022-0282oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/28/2022] [Indexed: 12/13/2022] Open
Abstract
The pathogenesis of bronchopulmonary dysplasia (BPD) remains incompletely understood. Recent studies suggest insufficient AMP-activated protein kinase (AMPK) activation as a potential cause of impaired autophagy in rodent and nonhuman primate models of BPD. Impaired autophagy is associated with enhanced inflammatory signaling in alveolar macrophages (AMs) and increased severity of murine BPD induced by neonatal hyperoxia exposure. The goal of this study was to determine the role of autophagy and AMPK activation in macrophage responses in murine BPD. C57BL/6J mice were exposed to neonatal hyperoxia starting on postnatal day (P)1 and treated with the AMPK activator 5-aminoimidazole-4-carboxamide ribonucleotide (AICAR) between P3 and P6. Mice were euthanized on P7, and markers of AMPK activation and autophagy were assessed by immunoblotting. Alveolarization was assessed using radial alveolar counts, mean linear intercept measurements, and quantification of alveolar septal myofibroblasts. Relative mRNA expression of M1-like and M2-like genes was assessed in AMs isolated from BAL fluid from wild-type, LysMCre--Becn1fl/fl, and LysMCre+-Becn1fl/fl mice after neonatal hyperoxia exposure. AICAR treatment resulted in AMPK activation and induction of autophagic activity in whole-lung and BAL cell lysates and attenuated hyperoxia-induced alveolar simplification in neonatal lungs. AICAR-treated control but not Beclin1-deficient AMs demonstrated significantly decreased expression of M1-like markers and significantly increased expression of M2-like markers. In conclusion, pharmacologic activation of AMPK by AICAR resulted in induction of autophagy and played a protective role, at least in part, through attenuation of proinflammatory signaling in AMs via autophagy-dependent mechanisms in a murine model of BPD.
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Affiliation(s)
- Sourabh Soni
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yujie Jiang
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China; and
| | - Liang Zhang
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Neonatology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Abhijeet Thakur
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sule Cataltepe
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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11
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Katz TA, van Kaam AH, Schuit E, Mugie SM, Aarnoudse-Moens CSH, Weber EH, de Groof F, van Laerhoven H, Counsilman CE, van der Schoor SRD, Rijpert M, Schiering IA, Wilms J, Leemhuis AG, Onland W. Comparison of New Bronchopulmonary Dysplasia Definitions on Long-Term Outcomes in Preterm Infants. J Pediatr 2023; 253:86-93.e4. [PMID: 36150504 DOI: 10.1016/j.jpeds.2022.09.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the discriminative performances of the 2018 National Institutes of Health (NIH) and the 2019 Jensen definitions of bronchopulmonary dysplasia (BPD) with the 2001 NIH definition on adverse neurodevelopmental and respiratory outcomes at 2 years and 5 years corrected age. STUDY DESIGN In this single-center retrospective cohort study, outcomes of infants born at <30 weeks of gestational age were collected. The 3 definitions of BPD were compared by adding the different definitions to the National Institute of Child Health and Human Development's outcome prediction model for neurodevelopmental impairment (NDI) or death. Discriminative performance was compared for both outcomes at 2 years and 5 years corrected age by calculating the areas under the receiver operating characteristic curve and z-statistics. RESULTS The presence of BPD and its severity were determined in 584 infants. There were considerable shifts in BPD grading among the different definitions. At both time points, all BPD definition models had comparable discriminating power for NDI and respiratory morbidity, with one exception. Compared with the 2001 NIH definition, the 2018 NIH definition had less predictive power for the neurologic outcome at 2 years corrected age. CONCLUSIONS Our comparison of the 3 BPD definitions shows similar discriminative performance on long term neurodevelopmental and respiratory outcomes at 2 years and 5 years corrected age.
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Affiliation(s)
- Trixie A Katz
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Suzanne M Mugie
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Cornelieke S H Aarnoudse-Moens
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Elske H Weber
- Department of Pediatrics, Northwest Clinics, Alkmaar, The Netherlands
| | - Femke de Groof
- Department of Pediatrics, Northwest Clinics, Alkmaar, The Netherlands
| | | | | | | | - Maarten Rijpert
- Department of Pediatrics, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Irene A Schiering
- Department of Pediatrics, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Janneke Wilms
- Department of Pediatrics, Bovenij ziekenhuis, Amsterdam, The Netherlands
| | - Aleid G Leemhuis
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Amsterdam Reproduction & Development, Amsterdam, The Netherlands.
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12
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Hwang JK, Shin SH, Kim EK, Kim SH, Kim HS. Association of newer definitions of bronchopulmonary dysplasia with pulmonary hypertension and long-term outcomes. Front Pediatr 2023; 11:1108925. [PMID: 36873629 PMCID: PMC9977292 DOI: 10.3389/fped.2023.1108925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/11/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND The definition of bronchopulmonary dysplasia (BPD) has been evolved recently from definition by the National Institute of Child Health and Human Development in 2001 (NICHD 2001) to the definition reported in 2018 (NICHD 2018) and that proposed by Jensen et al. in 2019 (NICHD 2019). The definition was developed based on the evolution of non-invasive respiratory support and to achieve better prediction of later outcomes. Our objective was to evaluate the association between different definitions of BPD and occurrence of pulmonary hypertension (PHN) and long term outcomes. METHODS This retrospective study enrolled preterm infants born at < 32 weeks of gestation between 2014 and 2018. The association between re-hospitalization owing to a respiratory illness until a corrected age (CA) of 24 months, neurodevelopmental impairment (NDI) at a CA of 18-24 months, and PHN at a postmenstrual age (PMA) of 36 weeks was evaluated, with the severity of BPD defined based on these three definitions. RESULTS Among 354 infants, the gestational age and birth weight were the lowest in severe BPD based on the NICHD 2019 definition. In total, 14.1% of the study population experienced NDI and 19.0% were re-hospitalized owing to a respiratory illness. At a PMA of 36 weeks, PHN was identified in 9.2% of infants with any BPD. Multiple logistic regression analysis showed that the adjusted odds ratio (OR) for re-hospitalization was the highest for Grade 3 BPD of the NICHD 2019 criteria (5.72, 95% confidence interval [CI]: 1.37-23.92), while the adjusted OR of Grade 3 BPD was 4.96 (95% CI: 1.73-14.23) in the NICHD 2018 definition. Moreover, no association of the severity of BPD was found in the NICHD 2001 definition. The adjusted ORs for NDI (12.09, 95% CI: 2.52-58.05) and PHN (40.37, 95% CI: 5.15-316.34) were also the highest for Grade 3 of the NICHD 2019 criteria. CONCLUSION Based on recently suggested criteria by the NICHD in 2019, BPD severity is associated with long-term outcomes and PHN at a PMA of 36 weeks in preterm infants.
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Affiliation(s)
- Jae Kyoon Hwang
- Department of Pediatrics, Hanyang University Guri Hospital, Gyeonggi-do, Republic of Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seh Hyun Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
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13
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Artificial intelligence in bronchopulmonary dysplasia- current research and unexplored frontiers. Pediatr Res 2023; 93:287-290. [PMID: 36385519 DOI: 10.1038/s41390-022-02387-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 10/21/2022] [Accepted: 10/30/2022] [Indexed: 11/17/2022]
Abstract
Provide an overview of bronchopulmonary dysplasia, its definitions, and their shortcomings. Explore the areas where machine learning may be used to further our understanding of bronchopulmonary dysplasia.
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14
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Jeon GW, Oh M, Lee J, Jun YH, Chang YS. Comparison of definitions of bronchopulmonary dysplasia to reflect the long-term outcomes of extremely preterm infants. Sci Rep 2022; 12:18095. [PMID: 36302832 PMCID: PMC9613988 DOI: 10.1038/s41598-022-22920-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/20/2022] [Indexed: 12/30/2022] Open
Abstract
Survivors of neonatal bronchopulmonary dysplasia (BPD) have persistent respiratory, neurodevelopmental, and growth impairment over the first few years of life and later childhood, which represents an emerging burden for health systems. Therefore, there is an increasing need for a new definition and grading system of BPD that predicts long-term outcomes of high-risk infants who need timely and proper intervention to improve outcomes. We compared new definitions of BPD (National Institute of Child Health and Human Development [NICHD] 2018 and Neonatal Research Network [NRN] 2019) to the original NICHD 2001 definition at 3 years of age using a nationwide cohort of extreme preterm infants. New definitions and severity grading were clearly related to respiratory, neurodevelopmental, and growth impairments at 3 years of age and at 18-24 months corrected age (CA), whereas the original NICHD 2001 definition was not. Furthermore, the negative effect of BPD on growth was ameliorated at 3 years of age compared to 18-24 months CA. However, the negative effect of BPD in neonates on the respiratory system and neurodevelopment persisted at 3 years of age. These new definitions should be adopted to identify high-risk infants and improve long-term outcomes by exact diagnosis and BPD severity classification.
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Affiliation(s)
- Ga Won Jeon
- grid.202119.90000 0001 2364 8385Department of Pediatrics, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Minkyung Oh
- grid.411612.10000 0004 0470 5112Department of Pharmacology, Inje University College of Medicine, Busan, South Korea
| | - Juyoung Lee
- grid.202119.90000 0001 2364 8385Department of Pediatrics, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Yong Hoon Jun
- grid.202119.90000 0001 2364 8385Department of Pediatrics, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
| | - Yun Sil Chang
- grid.264381.a0000 0001 2181 989XDepartment of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351 South Korea ,grid.414964.a0000 0001 0640 5613Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Samsung Medical Center, Seoul, Korea
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15
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Jeon GW, Lee JH, Oh M, Chang YS. Serial Short-Term Outcomes of Very-Low-Birth-Weight Infants in the Korean Neonatal Network From 2013 to 2020. J Korean Med Sci 2022; 37:e229. [PMID: 35880505 PMCID: PMC9313972 DOI: 10.3346/jkms.2022.37.e229] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/20/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND We aimed to determine the current survival rate and short-term outcomes of very-low-birth-weight infants (VLBWIs) in Korea, as well as whether the survival rate and short-term outcomes have improved over time since 2013, which was when the Korean Neonatal Network (KNN) was launched. METHODS This study used data from the annual reports of the KNN from 2013 to 2020. A total of 16,351 VLBWIs born at gestational age (GA) ≥ 22 weeks between January 1, 2013, and December 31, 2020, and who were registered in the KNN were enrolled. Serial outcomes were analyzed according to era (2013-14, 2015-16, 2017-18, and 2019-20). RESULTS More mothers delivered by cesarean section, had diabetes or hypertension during their pregnancy, and received antenatal steroids when analyzed by era. Fewer infants were intubated at birth and had air leaks when analyzed by era. The overall survival rate of VLBWIs between 2013 and 2020 was 87%. The rate of respiratory distress syndrome was 77% and that of bronchopulmonary dysplasia was 32% between 2013 and 2020. The rates of intraventricular hemorrhage (grade ≥ 3), periventricular leukomalacia, and sepsis decreased over time. The survival rate of infants with a GA of 26 weeks has improved serially according to era. CONCLUSION Since the launch of the KNN in 2013, the survival rates of infants with GA 26 weeks and short-term outcomes have improved, which implies a quality improvement in antenatal and delivery room care. Further studies on the long-term neurodevelopmental outcomes of these KNN registrants are warranted.
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Affiliation(s)
- Ga Won Jeon
- Department of Pediatrics, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - Jang Hoon Lee
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Minkyung Oh
- Department of Pharmacology, Inje University College of Medicine, Busan, Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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