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Wang L, Xiao J, Zhang B, Hou A. Epigenetic modifications in the development of bronchopulmonary dysplasia: a review. Pediatr Res 2024:10.1038/s41390-024-03167-7. [PMID: 38570557 DOI: 10.1038/s41390-024-03167-7] [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: 07/13/2023] [Revised: 02/25/2024] [Accepted: 03/07/2024] [Indexed: 04/05/2024]
Abstract
While perinatal medicine advancements have bolstered survival outcomes for premature infants, bronchopulmonary dysplasia (BPD) continues to threaten their long-term health. Gene-environment interactions, mediated by epigenetic modifications such as DNA methylation, histone modification, and non-coding RNA regulation, take center stage in BPD pathogenesis. Recent discoveries link methylation variations across biological pathways with BPD. Also, the potential reversibility of histone modifications fuels new treatment avenues. The review also highlights the promise of utilizing mesenchymal stem cells and their exosomes as BPD therapies, given their ability to modulate non-coding RNA, opening novel research and intervention possibilities. IMPACT: The complexity and universality of epigenetic modifications in the occurrence and development of bronchopulmonary dysplasia were thoroughly discussed. Both molecular and cellular mechanisms contribute to the diverse nature of epigenetic changes, suggesting the need for deeper biochemical techniques to explore these molecular alterations. The utilization of innovative cell-specific drug delivery methods like exosomes and extracellular vesicles holds promise in achieving precise epigenetic regulation.
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Affiliation(s)
- Lichuan Wang
- Department of Pediatrics, Sheng Jing Hospital of China Medical University, Shenyang, China
| | - Jun Xiao
- Department of Pediatrics, Sheng Jing Hospital of China Medical University, Shenyang, China
| | - Bohan Zhang
- Department of Pediatrics, Sheng Jing Hospital of China Medical University, Shenyang, China
| | - Ana Hou
- Department of Pediatrics, Sheng Jing Hospital of China Medical University, Shenyang, China.
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2
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Shen X, Patel N, Zhu W, Chen X, Lu K, Cheng R, Mo X. A nomogram for predicting the risk of Bronchopulmonary dysplasia in premature infants. Heliyon 2023; 9:e18964. [PMID: 37609396 PMCID: PMC10440517 DOI: 10.1016/j.heliyon.2023.e18964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 07/11/2023] [Accepted: 08/03/2023] [Indexed: 08/24/2023] Open
Abstract
Background Bronchopulmonary dysplasia (BPD) is a prevalent and critical complication among premature infants, with potentially long-lasting adverse effetcs. The present study aimed to establish a nomogram model to predict the risk of BPD in premature infants born at <32 weeks gestational age. Methods A retrospective single-center study was conducted on premature infants admitted to the neonatal intensive care unit (NICU) of the Children's Hospital of Nanjing Medical University from January 2018 to December 2020. Data were collected from clinical medical records, including the perinatal data and the critical information after birth. Clinical parameters and features were analyzed using univariate and multivariate logistic regression. A nomogram based on clinical data was established and validated using bootstrapping samples. The specificity and sensitivity of the nomogram were estimated using the receiver operating characteristic (ROC) based area under the curve (AUC). Results A total of 542 premature babies were included, and 152 infants (28.04%) were diagnosed with BPD. Birth weight, cesarean delivery, invasive/non-invasive ventilation at day 7 and 14 were identified as significant factors (p < 0.05) using univariate and the multivariate logistic regression analysis, and were entered into a nomogram. The calibration curve for BPD probability demonstrated a favorable concurrence between actual probability and predicted ability of the BPD nomogram. The nomogram showed potential differentiation, with an AUC of 0.925, 89.90% sensitivity, 76.71% specificity, and 86.35% accuracy. Conclusion The nomogram developed in this study provides a straightforward tool to predict the probability of BPD and assist clinicians in optimizing treatment regimens for premature infants born at <32 weeks gestational age. This study highlights the importance of identifying and monitoring significant clinical factors associated with BPD in premature infants to improve clinical outcomes.
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Affiliation(s)
- Xian Shen
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Nishant Patel
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Wen Zhu
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Xu Chen
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Keyu Lu
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Rui Cheng
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China
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Kandasamy J, Li R, Vamesu BM, Olave N, Halloran B, Jilling T, Ballinger SW, Ambalavanan N. Mitochondrial DNA Variations Modulate Alveolar Epithelial Mitochondrial Function and Oxidative Stress in Newborn Mice Exposed to Hyperoxia. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.17.541177. [PMID: 37292719 PMCID: PMC10245974 DOI: 10.1101/2023.05.17.541177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Oxidative stress is an important contributor to bronchopulmonary dysplasia (BPD), a form of chronic lung disease that is the most common morbidity in very preterm infants. Mitochondrial functional differences due to inherited and acquired mutations influence the pathogenesis of disorders in which oxidative stress plays a critical role. We previously showed using mitochondrial-nuclear exchange (MNX) mice that mitochondrial DNA (mtDNA) variations modulate hyperoxia-induced lung injury severity in a model of BPD. In this study, we studied the effects of mtDNA variations on mitochondrial function including mitophagy in alveolar epithelial cells (AT2) from MNX mice. We also investigated oxidant and inflammatory stress as well as transcriptomic profiles in lung tissue in mice and expression of proteins such as PINK1, Parkin and SIRT3 in infants with BPD. Our results indicate that AT2 from mice with C57 mtDNA had decreased mitochondrial bioenergetic function and inner membrane potential, increased mitochondrial membrane permeability and were exposed to higher levels of oxidant stress during hyperoxia compared to AT2 from mice with C3H mtDNA. Lungs from hyperoxia-exposed mice with C57 mtDNA also had higher levels of pro-inflammatory cytokines compared to lungs from mice with C3H mtDNA. We also noted changes in KEGG pathways related to inflammation, PPAR and glutamatergic signaling, and mitophagy in mice with certain mito-nuclear combinations but not others. Mitophagy was decreased by hyperoxia in all mice strains, but to a greater degree in AT2 and neonatal mice lung fibroblasts from hyperoxia-exposed mice with C57 mtDNA compared to C3H mtDNA. Finally, mtDNA haplogroups vary with ethnicity, and Black infants with BPD had lower levels of PINK1, Parkin and SIRT3 expression in HUVEC at birth and tracheal aspirates at 28 days of life when compared to White infants with BPD. These results indicate that predisposition to neonatal lung injury may be modulated by variations in mtDNA and mito-nuclear interactions need to be investigated to discover novel pathogenic mechanisms for BPD.
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Mižíková I, Thébaud B. Perinatal origins of bronchopulmonary dysplasia-deciphering normal and impaired lung development cell by cell. Mol Cell Pediatr 2023; 10:4. [PMID: 37072570 PMCID: PMC10113423 DOI: 10.1186/s40348-023-00158-2] [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: 06/30/2022] [Accepted: 03/26/2023] [Indexed: 04/20/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a multifactorial disease occurring as a consequence of premature birth, as well as antenatal and postnatal injury to the developing lung. BPD morbidity and severity depend on a complex interplay between prenatal and postnatal inflammation, mechanical ventilation, and oxygen therapy as well as associated prematurity-related complications. These initial hits result in ill-explored aberrant immune and reparative response, activation of pro-fibrotic and anti-angiogenic factors, which further perpetuate the injury. Histologically, the disease presents primarily by impaired lung development and an arrest in lung microvascular maturation. Consequently, BPD leads to respiratory complications beyond the neonatal period and may result in premature aging of the lung. While the numerous prenatal and postnatal stimuli contributing to BPD pathogenesis are relatively well known, the specific cell populations driving the injury, as well as underlying mechanisms are still not well understood. Recently, an effort to gain a more detailed insight into the cellular composition of the developing lung and its progenitor populations has unfold. Here, we provide an overview of the current knowledge regarding perinatal origin of BPD and discuss underlying mechanisms, as well as novel approaches to study the perturbed lung development.
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Affiliation(s)
- I Mižíková
- Experimental Pulmonology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - B Thébaud
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Pediatrics, Children's Hospital of Eastern Ontario (CHEO), CHEO Research Institute, University of Ottawa, Ottawa, ON, Canada
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5
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Secreted protease ADAMTS18 in development and disease. Gene 2023; 858:147169. [PMID: 36632911 DOI: 10.1016/j.gene.2023.147169] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/07/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
ADAMTS18 was identified in 2002 as a member of the ADAMTS family of 19 secreted Zinc-dependent metalloproteinases. Prior to 2016, ADAMTS18 was known as a candidate gene associated with a wide range of pathologies, particularly various malignancies and eye disorders. However, functions and substrates of ADAMTS18 in normal conditions were unknown. Since 2016, with the development of Adamts18 knockout models, many studies had been conducted on the Adamts18 gene in vivo. These studies revealed that ADAMTS18 is essential for the morphology and organogenesis of several epithelial organs (e.g., lung, kidney, breast, salivary glands, and lacrimal glands), vascular and neuronal systems, adipose tissue, and reproductive tracts. In this review, we describe the current understanding of ADAMTS18 and its substrates and regulators. Limitations in translating new findings on ADAMTS18 to clinical practice are also discussed.
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Bronchopulmonary dysplasia and wnt pathway-associated single nucleotide polymorphisms. Pediatr Res 2022; 92:888-898. [PMID: 34853430 DOI: 10.1038/s41390-021-01851-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 10/04/2021] [Accepted: 11/02/2021] [Indexed: 11/08/2022]
Abstract
AIM Genetic variants contribute to the pathogenesis of bronchopulmonary dysplasia (BPD). The aim of this study is to evaluate the association of 45 SNPs with BPD susceptibility in a Turkish premature infant cohort. METHODS Infants with gestational age <32 weeks were included. Patients were divided into BPD or no-BPD groups according to oxygen need at 28 days of life, and stratified according to the severity of BPD. We genotyped 45 SNPs, previously identified as BPD risk factors, in 192 infants. RESULTS A total of eight SNPs were associated with BPD risk at allele level, two of which (rs4883955 on KLF12 and rs9953270 on CHST9) were also associated at the genotype level. Functional relationship maps suggested an interaction between five of these genes, converging on WNT5A, a member of the WNT pathway known to be implicated in BPD pathogenesis. Dysfunctional CHST9 and KLF12 variants may contribute to BPD pathogenesis through an interaction with WNT5A. CONCLUSIONS We suggest investigating the role of SNPs on different genes which are in relation with the Wnt pathway in BPD pathogenesis. We identified eight SNPs as risk factors for BPD in this study. In-silico functional maps show an interaction of the genes harboring these SNPs with the WNT pathway, supporting its role in BPD pathogenesis. TRIAL REGISTRATION NCT03467828. IMPACT It is known that genetic factors may contribute to the development of BPD in preterm infants. Further studies are required to identify specific genes that play a role in the BPD pathway to evaluate them as a target for therapeutic interventions. Our study shows an association of BPD predisposition with certain polymorphisms on MBL2, NFKBIA, CEP170, MAGI2, and VEGFA genes at allele level and polymorphisms on CHST9 and KLF12 genes at both allele and genotype level. In-silico functional mapping shows a functional relationship of these five genes with WNT5A, suggesting that Wnt pathway disruption may play a role in BPD pathogenesis.
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Early Salivary miRNA Expression in Extreme Low Gestational Age Newborns. Life (Basel) 2022; 12:life12040506. [PMID: 35454997 PMCID: PMC9029747 DOI: 10.3390/life12040506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/07/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background: MicroRNAs (miRNA) are small non-coding RNAs that regulate gene expression playing a key role in organogenesis. MiRNAs are studied in tracheal aspirates (TA) of preterm infants. However; this is difficult to obtain in infants who are not intubated. This study examines early salivary miRNA expression as non-invasive early biomarkers in extremely low gestational age newborns (ELGANs). Methods: Saliva was collected using DNA-genotek swabs, miRNAs were analyzed using RNA seq and RT PCR arrays. Salivary miRNA expression was compared to TA using RNA seq at 3 days of age, and longitudinal changes at 28 days of age were analyzed using RT PCR arrays in ELGANs. Results: Approximately 822 ng of RNA was extracted from saliva of 7 ELGANs; Of the 757 miRNAs isolated, 161 miRNAs had significant correlation in saliva and TA at 3 days of age (r = 0.97). Longitudinal miRNA analysis showed 29 miRNAs downregulated and 394 miRNAs upregulated at 28 days compared to 3 days of age (adjusted p < 0.1). Bioinformatic analysis (Ingenuity Pathway Analysis) of differentially expressed miRNAs identified organismal injury and abnormalities and cellular development as the top physiological system development and cellular function. Conclusion: Salivary miRNA expression are source for early biomarkers of underlying pathophysiology in ELGANs.
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Dong Y, Zhang X. Integrative analysis of lncRNAs, miRNAs, and mRNAs-associated ceRNA network in a neonatal mouse model of bronchopulmonary dysplasia. J Matern Fetal Neonatal Med 2021; 34:3234-3245. [PMID: 32924699 DOI: 10.1080/14767058.2020.1815700] [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: 12/02/2019] [Revised: 05/21/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To elucidate the potential roles of the lncRNA-mediated competitive endogenous RNA (ceRNA) network in the pathogenesis of bronchopulmonary dysplasia (BPD), we performed an integrated bioinformatics analysis based on miRNA and mRNA microarray datasets between BPD and normal samples. STUDY DESIGN The mRNA and miRNA expression profiles of BPD were downloaded from the Gene Expression Omnibus (GEO) database to perform an integrated analysis. The limma package was used to identify differentially expressed genes (DEGs) and differentially expressed miRNA (DEmiRs), followed by functional enrichment analysis of DEGs. DEmiR-DEG and DEmiRNA-lncRNA interactions were predicted. Subsequently, the lncRNA-related ceRNA network was structured. Finally, a newborn BPD mouse model was established, and quantitative real-time PCR (qPCR) was used to validate the expression of the selected mRNAs, miRNAs, and lncRNAs. RESULTS A total of 445 DEGs and 155 DEmiRs were obtained by comparing BPD samples and normal samples. Functional enrichment analysis showed that DEGs were primarily enriched in GO terms such as cell division and inflammatory response; and DEGs were mainly involved in the p53 signaling pathway. The miR17hg-miR-130b-3p-roundabout guidance receptor 2 (Robo2) and GM20455-miR-34a-5p-BMP/retinoic acid-inducible neural specific 1 (Brinp1) ceRNA axes were obtained by constructing the ceRNA network. In addition, the upregulation of Robo2 and miR17hg while the downregulation of miR-130b-3p; as well as the upregulation of Brinp1 and GM20455 but the downregulation of miR-34a-5p were validated by qPCR. CONCLUSION The miR17hg-miR-130b-3p-Robo2 and GM20455-miR-34a-5p-Brinp1 axes may serve important role in the development of BPD. These findings might provide novel insight for a comprehensive understanding of molecular mechanisms in BPD, and genes in the ceRNA network might be considered as potential biomarkers and therapeutic targets against BPD.
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Affiliation(s)
- Yan Dong
- Department of Pediatrics, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xiaoying Zhang
- Department of Pediatrics, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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Singer D, Thiede LP, Perez A. Adults Born Preterm: Long-Term Health Risks of Former Very Low Birth Weight Infants. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:521-527. [PMID: 33734986 DOI: 10.3238/arztebl.m2021.0164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/02/2020] [Accepted: 02/22/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Advances in neonatology now enable increasing numbers of very low birth weight neonates (<1500 g) to survive into early adulthood and beyond. What are the implications for their long-term care? METHODS Selective literature search on the outcome of very low birth weight neonates in adulthood ("adults born preterm"). RESULTS Robust data are available on the pulmonary, metabolic, cardiovascular, renal, neurocognitive, sensory-visual, social-emotional, mental, reproductive, and musculoskeletal long-term risks. On the somatic level, elevated rates have been documented for asthma (odds Ratio [OR] 2.37), diabetes mellitus (OR 1.54), and chronic renal disease (hazard ratio [HR] 3.01), along with the cardiovascular and cerebrovascular sequelae of a tendency toward arterial hypertension. On the psychosocial level, the main findings are deficits in romantic partnerships (OR 0.72) and a lower reproduction rate (relative risk [RR] male/female 0.24/0.33). The affected women also have an elevated risk of preterm delivery. CONCLUSION A risk profile with both somatic and psychosocial aspects can be discerned for adults who were born prematurely, even if some of these risks are present in low absolute numbers. As the ability to compensate for latent deficits declines with age, such adults may suffer from "premature aging as the late price of premature birth." A holistic approach to care with personalized prevention strategies-which for most of them was discontinued at discharge from pediatric follow-up-therefore seems appropriate in adulthood as well.
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Abstract
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease that occurs in preterm infants, usually those receiving substantial respiratory support with either mechanical ventilation or supplementation with oxygen. The pathogenesis of BPD is multifactorial, and the clinical phenotype is variable. BPD is associated with substantial mortality and short- and long-term morbidity. The incidence of BPD has remained stable or increased, as advances in neonatal care have led to improved survival of more extremely preterm infants. Extensive basic science, translational, and clinical research focusing on BPD has improved the current understanding of the factors that contribute to BPD pathogenesis. However, despite a better understanding of its pathophysiology, BPD continues to be challenging to prevent and manage adequately. The current review aims to provide a clinically useful synopsis of evidence on the prevention and management of BPD in preterm infants.
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Amatya S, Rajbhandari S, Pradhan S, Trinh V, Paudel U, Parton LA. Hedgehog signaling pathway gene variant influences bronchopulmonary dysplasia in extremely low birth weight infants. World J Pediatr 2021; 17:298-304. [PMID: 33860472 DOI: 10.1007/s12519-021-00427-y] [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: 12/14/2020] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Genome wide association study identified hedgehog interacting protein gene (HHIP) variants with chronic obstructive pulmonary disease and asthma. Loss of HHIP, a key regulator of the hedgehog signaling pathway, leads to impaired lung morphogenesis and lethality in animal models, through unimpeded sonic hedgehog expression blocking mesenchymal-expressed fibroblast growth factor 10 (FGF10). Since bronchopulmonary dysplasia (BPD) is also associated with altered lung development and worsens with stimuli including mechanical ventilation, reactive oxygen species, and inflammation, HHIP and FGF10 may be candidate genes. METHODS This was an observational, cohort study including extremely low birth weight infants that who developed BPD and those who did not. DNA was isolated from buccal swabs and subjected to allelic discrimination, using specific HHIP and FGF10 probes. Protein levels were measured in tracheal aspirates. Student's t test, Chi-square, Z test and logistic regression were used. RESULTS Demographic characteristics did not differ except that birth weight (715 ± 153 vs. 835 ± 132 g) and gestational age (25 vs. 26 weeks) were less in babies with BPD. HHIP variant rs13147758 (GG genotype) was found to be independently protective for BPD (odds ratio 0.35, 95% confidence interval 0.15-0.82, P = - 0.02). Early airway HHIP protein levels were increased in infants with BPD compared to those without [median (interquartile range) 130.6 (55.6-297.0) and 41.2 (22.1-145.6) pg/mL, respectively; P = 0.05]. The FGF10 single nucleotide polymorphisms were not associated with BPD. CONCLUSION HHIP, as a regulator of lung bud formation, affects BPD susceptibility, and may be valuable in understanding the specific mechanisms for this disease as well as for identifying therapeutic targets in the era of personalized medicine.
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Affiliation(s)
- Shaili Amatya
- Newborn Medicine Division, The Regional Neonatal Intensive Care Unit, Maria Fareri Children's Hospital At Westchester Medical Center, Valhalla, NY, USA.,Department of Pediatrics, New York Medical College, Valhalla, NY, USA.,Department of Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
| | - Sharina Rajbhandari
- Newborn Medicine Division, The Regional Neonatal Intensive Care Unit, Maria Fareri Children's Hospital At Westchester Medical Center, Valhalla, NY, USA.,Department of Pediatrics, New York Medical College, Valhalla, NY, USA.,Novant Health Presbyterian Medical Center, Charlotte, NC, USA
| | - Sandeep Pradhan
- Department of Public Health, Penn State University, Hershey, PA, USA
| | - Van Trinh
- Newborn Medicine Division, The Regional Neonatal Intensive Care Unit, Maria Fareri Children's Hospital At Westchester Medical Center, Valhalla, NY, USA.,Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - Umesh Paudel
- Department of Pediatrics, Harlem Hospital-Columbia University Irving Medical Center, New York, NY, USA
| | - Lance A Parton
- Newborn Medicine Division, The Regional Neonatal Intensive Care Unit, Maria Fareri Children's Hospital At Westchester Medical Center, Valhalla, NY, USA. .,Department of Pediatrics, New York Medical College, Valhalla, NY, USA.
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Single cell transcriptomic analysis of murine lung development on hyperoxia-induced damage. Nat Commun 2021; 12:1565. [PMID: 33692365 PMCID: PMC7946947 DOI: 10.1038/s41467-021-21865-2] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 02/09/2021] [Indexed: 12/15/2022] Open
Abstract
During late lung development, alveolar and microvascular development is finalized to enable sufficient gas exchange. Impaired late lung development manifests as bronchopulmonary dysplasia (BPD) in preterm infants. Single-cell RNA sequencing (scRNA-seq) allows for assessment of complex cellular dynamics during biological processes, such as development. Here, we use MULTI-seq to generate scRNA-seq profiles of over 66,000 cells from 36 mice during normal or impaired lung development secondary to hyperoxia with validation of some of the findings in lungs from BPD patients. We observe dynamic populations of cells, including several rare cell types and putative progenitors. Hyperoxia exposure, which mimics the BPD phenotype, alters the composition of all cellular compartments, particularly alveolar epithelium, stromal fibroblasts, capillary endothelium and macrophage populations. Pathway analysis and predicted dynamic cellular crosstalk suggest inflammatory signaling as the main driver of hyperoxia-induced changes. Our data provides a single-cell view of cellular changes associated with late lung development in health and disease.
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Bonadies L, Zaramella P, Porzionato A, Perilongo G, Muraca M, Baraldi E. Present and Future of Bronchopulmonary Dysplasia. J Clin Med 2020; 9:jcm9051539. [PMID: 32443685 PMCID: PMC7290764 DOI: 10.3390/jcm9051539] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/04/2020] [Accepted: 05/18/2020] [Indexed: 12/13/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most common respiratory disorder among infants born extremely preterm. The pathogenesis of BPD involves multiple prenatal and postnatal mechanisms affecting the development of a very immature lung. Their combined effects alter the lung's morphogenesis, disrupt capillary gas exchange in the alveoli, and lead to the pathological and clinical features of BPD. The disorder is ultimately the result of an aberrant repair response to antenatal and postnatal injuries to the developing lungs. Neonatology has made huge advances in dealing with conditions related to prematurity, but efforts to prevent and treat BPD have so far been only partially effective. Seeing that BPD appears to have a role in the early origin of chronic obstructive pulmonary disease, its prevention is pivotal also in long-term respiratory outcome of these patients. There is currently some evidence to support the use of antenatal glucocorticoids, surfactant therapy, protective noninvasive ventilation, targeted saturations, early caffeine treatment, vitamin A, and fluid restriction, but none of the existing strategies have had any significant impact in reducing the burden of BPD. New areas of research are raising novel therapeutic prospects, however. For instance, early topical (intratracheal or nebulized) steroids seem promising: they might help to limit BPD development without the side effects of systemic steroids. Evidence in favor of stem cell therapy has emerged from several preclinical trials, and from a couple of studies in humans. Mesenchymal stromal/stem cells (MSCs) have revealed a reparatory capability, preventing the progression of BPD in animal models. Administering MSC-conditioned media containing extracellular vesicles (EVs) have also demonstrated a preventive action, without the potential risks associated with unwanted engraftment or the adverse effects of administering cells. In this paper, we explore these emerging treatments and take a look at the revolutionary changes in BPD and neonatology on the horizon.
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Affiliation(s)
- Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy; (L.B.); (P.Z.)
| | - Patrizia Zaramella
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy; (L.B.); (P.Z.)
| | - Andrea Porzionato
- Human Anatomy Section, Department of Neurosciences, University of Padova, 35128 Padova, Italy;
| | - Giorgio Perilongo
- Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy;
| | - Maurizio Muraca
- Institute of Pediatric Research “Città della Speranza”, Stem Cell and Regenerative Medicine Laboratory, Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy;
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University of Padova, 35128 Padova, Italy; (L.B.); (P.Z.)
- Correspondence: ; Tel.: +39-049-821-3560; Fax: +39-049-821-3502
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Ryan FJ, Drew DP, Douglas C, Leong LEX, Moldovan M, Lynn M, Fink N, Sribnaia A, Penttila I, McPhee AJ, Collins CT, Makrides M, Gibson RA, Rogers GB, Lynn DJ. Changes in the Composition of the Gut Microbiota and the Blood Transcriptome in Preterm Infants at Less than 29 Weeks Gestation Diagnosed with Bronchopulmonary Dysplasia. mSystems 2019; 4:e00484-19. [PMID: 31662429 PMCID: PMC6819732 DOI: 10.1128/msystems.00484-19] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/09/2019] [Indexed: 12/21/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a common chronic lung condition in preterm infants that results in abnormal lung development and leads to considerable morbidity and mortality, making BPD one of the most common complications of preterm birth. We employed RNA sequencing and 16S rRNA gene sequencing to profile gene expression in blood and the composition of the fecal microbiota in infants born at <29 weeks gestational age and diagnosed with BPD in comparison to those of preterm infants that were not diagnosed with BPD. 16S rRNA gene sequencing, performed longitudinally on 255 fecal samples collected from 50 infants in the first months of life, identified significant differences in the relative levels of abundance of Klebsiella, Salmonella, Escherichia/Shigella, and Bifidobacterium in the BPD infants in a manner that was birth mode dependent. Transcriptome sequencing (RNA-Seq) analysis revealed that more than 400 genes were upregulated in infants with BPD. Genes upregulated in BPD infants were significantly enriched for functions related to red blood cell development and oxygen transport, while several immune-related pathways were downregulated. We also identified a gene expression signature consistent with an enrichment of immunosuppressive CD71+ early erythroid cells in infants with BPD. Intriguingly, genes that were correlated in their expression with the relative abundances of specific taxa in the microbiota were significantly enriched for roles in the immune system, suggesting that changes in the microbiota might influence immune gene expression systemically.IMPORTANCE Bronchopulmonary dysplasia (BPD) is a serious inflammatory condition of the lung and is the most common complication associated with preterm birth. A large body of evidence now suggests that the gut microbiota can influence immunity and inflammation systemically; however, the role of the gut microbiota in BPD has not been evaluated to date. Here, we report that there are significant differences in the gut microbiota of infants born at <29 weeks gestation and subsequently diagnosed with BPD, which are particularly pronounced when infants are stratified by birth mode. We also show that erythroid and immune gene expression levels are significantly altered in BPD infants. Interestingly, we identified an association between the composition of the microbiota and immune gene expression in blood in early life. Together, these findings suggest that the composition of the microbiota may influence the risk of developing BPD and, more generally, may shape systemic immune gene expression.
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Affiliation(s)
- Feargal J Ryan
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Damian P Drew
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Chloe Douglas
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lex E X Leong
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Max Moldovan
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Miriam Lynn
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Naomi Fink
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Anastasia Sribnaia
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Irmeli Penttila
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew J McPhee
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Carmel T Collins
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Maria Makrides
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Robert A Gibson
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Agriculture, Food, and Wine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Geraint B Rogers
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - David J Lynn
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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15
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The discovery BPD (D-BPD) program: study protocol of a prospective translational multicenter collaborative study to investigate determinants of chronic lung disease in very low birth weight infants. BMC Pediatr 2019; 19:227. [PMID: 31279333 PMCID: PMC6612113 DOI: 10.1186/s12887-019-1610-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 07/02/2019] [Indexed: 01/21/2023] Open
Abstract
Background Premature birth is a growing and serious public health problem affecting more than one of every ten infants worldwide. Bronchopulmonary dysplasia (BPD) is the most common neonatal morbidity associated with prematurity and infants with BPD suffer from increased incidence of respiratory infections, asthma, other forms of chronic lung illness, and death (Day and Ryan, Pediatr Res 81: 210–213, 2017; Isayama et la., JAMA Pediatr 171:271–279, 2017). BPD is now understood as a longitudinal disease process influenced by the intrauterine environment during gestation and modulated by gene-environment interactions throughout the neonatal and early childhood periods. Despite of this concept, there remains a paucity of multidisciplinary team-based approaches dedicated to the comprehensive study of this complex disease. Methods The Discovery BPD (D-BPD) Program involves a cohort of infants < 1,250 g at birth prospectively followed until 6 years of age. The program integrates analysis of detailed clinical data by machine learning, genetic susceptibility and molecular translation studies. Discussion The current gap in understanding BPD as a complex multi-trait spectrum of different disease endotypes will be addressed by a bedside-to-bench and bench-to-bedside approach in the D-BPD program. The D-BPD will provide enhanced understanding of mechanisms, evolution and consequences of lung diseases in preterm infants. The D-BPD program represents a unique opportunity to combine the expertise of biologists, neonatologists, pulmonologists, geneticists and biostatisticians to examine the disease process from multiple perspectives with a singular goal of improving outcomes of premature infants. Trial registration Does not apply for this study. Electronic supplementary material The online version of this article (10.1186/s12887-019-1610-8) contains supplementary material, which is available to authorized users.
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16
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Abstract
Bronchopulmonary Dysplasia (BPD) is a disorder with a multifactorial etiology and highly variable clinical phenotype. Several traditional biomarkers have been identified, but due to the complex disease phenotype, these biomarkers have low predictive accuracy for BPD. In recent years, newer technologies have facilitated the in-depth and unbiased analysis of 'big data' in delineating the diagnosis, pathogenesis, and mechanisms of diseases. Novel systems-biology based 'omic' approaches, including but not limited to genomics, microbiomics, proteomics, and metabolomics may help define the multiple cellular and humoral interactions that regulate normal as well as abnormal lung development and response to injury that are the hallmarks of BPD.
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Affiliation(s)
- Charitharth Vivek Lal
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Women and Infants Center, 176F Suite 9380, 619 South 19th Street, Birmingham, AL 35249-7335, United States.
| | - Vineet Bhandari
- Department of Pediatrics, Drexel University, Philadelphia, PA, United States
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Women and Infants Center, 176F Suite 9380, 619 South 19th Street, Birmingham, AL 35249-7335, United States
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17
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Hamvas A, Feng R, Bi Y, Wang F, Bhattacharya S, Mereness J, Kaushal M, Cotten CM, Ballard PL, Mariani TJ. Exome sequencing identifies gene variants and networks associated with extreme respiratory outcomes following preterm birth. BMC Genet 2018; 19:94. [PMID: 30342483 PMCID: PMC6195962 DOI: 10.1186/s12863-018-0679-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 10/01/2018] [Indexed: 12/28/2022] Open
Abstract
Background Previous studies have identified genetic variants associated with bronchopulmonary dysplasia (BPD) in extremely preterm infants. However, findings with genome-wide significance have been rare, and not replicated. We hypothesized that whole exome sequencing (WES) of premature subjects with extremely divergent phenotypic outcomes could facilitate the identification of genetic variants or gene networks contributing disease risk. Results The Prematurity and Respiratory Outcomes Program (PROP) recruited a cohort of > 765 extremely preterm infants for the identification of markers of respiratory morbidity. We completed WES on 146 PROP subjects (85 affected, 61 unaffected) representing extreme phenotypes of early respiratory morbidity. We tested for association between disease status and individual common variants, screened for rare variants exclusive to either affected or unaffected subjects, and tested the combined association of variants across gene loci. Pathway analysis was performed and disease-related expression patterns were assessed. Marginal association with BPD was observed for numerous common and rare variants. We identified 345 genes with variants unique to BPD-affected preterm subjects, and 292 genes with variants unique to our unaffected preterm subjects. Of these unique variants, 28 (19 in the affected cohort and 9 in unaffected cohort) replicate a prior WES study of BPD-associated variants. Pathway analysis of sets of variants, informed by disease-related gene expression, implicated protein kinase A, MAPK and Neuregulin/epidermal growth factor receptor signaling. Conclusions We identified novel genes and associated pathways that may play an important role in susceptibility/resilience for the development of lung disease in preterm infants. Electronic supplementary material The online version of this article (10.1186/s12863-018-0679-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aaron Hamvas
- Department of Pediatrics, Northwestern University, Chicago, IL, USA. .,Ann and Robert H. Lurie Children's Hospital of Chicago and Northwestern University, Chicago, IL, USA.
| | - Rui Feng
- Department of Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Yingtao Bi
- Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - Fan Wang
- Department of Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Jared Mereness
- Department of Pediatrics, University of Rochester, Rochester, NY, USA
| | - Madhurima Kaushal
- Center for Biomedical Informatics, Washington University, St. Louis, MO, USA
| | | | - Philip L Ballard
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Thomas J Mariani
- Department of Pediatrics, University of Rochester, Rochester, NY, USA. .,Division of Neonatology and Pediatric Molecular and Personalized Medicine Program University of Rochester Medical Center, 601 Elmwood Ave, Box 850, Rochester, NY, 14642, USA.
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18
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Lal CV, Olave N, Travers C, Rezonzew G, Dolma K, Simpson A, Halloran B, Aghai Z, Das P, Sharma N, Xu X, Genschmer K, Russell D, Szul T, Yi N, Blalock JE, Gaggar A, Bhandari V, Ambalavanan N. Exosomal microRNA predicts and protects against severe bronchopulmonary dysplasia in extremely premature infants. JCI Insight 2018. [PMID: 29515035 DOI: 10.1172/jci.insight.93994] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Premature infants are at high risk for developing bronchopulmonary dysplasia (BPD), characterized by chronic inflammation and inhibition of lung development, which we have recently identified as being modulated by microRNAs (miRNAs) and alterations in the airway microbiome. Exosomes and exosomal miRNAs may regulate cell differentiation and tissue and organ development. We discovered that tracheal aspirates from infants with severe BPD had increased numbers of, but smaller, exosomes compared with term controls. Similarly, bronchoalveolar lavage fluid from hyperoxia-exposed mice (an animal model of BPD) and supernatants from hyperoxia-exposed human bronchial epithelial cells (in vitro model of BPD) had increased exosomes compared with air controls. Next, in a prospective cohort study of tracheal aspirates obtained at birth from extremely preterm infants, utilizing independent discovery and validation cohorts, we identified unbiased exosomal miRNA signatures predictive of severe BPD. The strongest signal of reduced miR-876-3p in BPD-susceptible compared with BPD-resistant infants was confirmed in the animal model and in vitro models of BPD. In addition, based on our recent discovery of increased Proteobacteria in the airway microbiome being associated with BPD, we developed potentially novel in vivo and in vitro models for BPD combining Proteobacterial LPS and hyperoxia exposure. Addition of LPS led to a larger reduction in exosomal miR 876-3p in both hyperoxia and normoxia compared with hyperoxia alone, thus indicating a potential mechanism by which alterations in microbiota can suppress miR 876-3p. Gain of function of miR 876-3p improved the alveolar architecture in the in vivo BPD model, demonstrating a causal link between miR 876-3p and BPD. In summary, we provide evidence for the strong predictive biomarker potential of miR 876-3p in severe BPD. We also provide insights on the pathogenesis of neonatal lung disease, as modulated by hyperoxia and microbial product-induced changes in exosomal miRNA 876-3p, which could be targeted for future therapeutic development.
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Affiliation(s)
- Charitharth Vivek Lal
- Department of Pediatrics.,Translational Research in Disordered and Normal Development Program, and.,Program in Protease and Matrix Biology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Nelida Olave
- Department of Pediatrics.,Translational Research in Disordered and Normal Development Program, and
| | | | - Gabriel Rezonzew
- Department of Pediatrics.,Translational Research in Disordered and Normal Development Program, and
| | | | | | - Brian Halloran
- Department of Pediatrics.,Translational Research in Disordered and Normal Development Program, and
| | - Zubair Aghai
- Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, Pennsylvania, USA
| | - Pragnya Das
- Department of Pediatrics, Drexel University, Philadelphia, Pennsylvania, USA
| | - Nirmal Sharma
- Division of Pulmonary, Allergy and Critical Care Medicine, and
| | - Xin Xu
- Program in Protease and Matrix Biology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, and
| | - Kristopher Genschmer
- Program in Protease and Matrix Biology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, and
| | - Derek Russell
- Program in Protease and Matrix Biology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, and
| | - Tomasz Szul
- Program in Protease and Matrix Biology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, and
| | - Nengjun Yi
- Department of Biostatistics, School of Public Health, UAB, Alabama, USA
| | - J Edwin Blalock
- Program in Protease and Matrix Biology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, and
| | - Amit Gaggar
- Program in Protease and Matrix Biology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA.,Division of Pulmonary, Allergy and Critical Care Medicine, and
| | - Vineet Bhandari
- Department of Pediatrics, Drexel University, Philadelphia, Pennsylvania, USA
| | - Namasivayam Ambalavanan
- Department of Pediatrics.,Translational Research in Disordered and Normal Development Program, and
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19
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Suresh G, King BC, Jain SK. Screening for pulmonary hypertension in preterm infants-not ready for prime time. J Perinatol 2018; 38:206-210. [PMID: 29180768 DOI: 10.1038/s41372-017-0014-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 10/12/2017] [Accepted: 10/17/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Gautham Suresh
- Department of Pediatric, Baylor College of Medicine, Section Head and Service Chief of Neonatology, Texas Children's Hospital, 6621 Fannin, Suite W6104 Houston, TX, 77030, USA
| | - Brian C King
- Instructor of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, Suite W6104, Houston, TX, 77030, USA
| | - Sunil K Jain
- Department of Pediatric, Baylor College of Medicine, Section Head and Service Chief of Neonatology, Texas Children's Hospital, 6621 Fannin, Suite W6104 Houston, TX, 77030, USA.
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20
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Berkhout DJC, Niemarkt HJ, Benninga MA, Budding AE, van Kaam AH, Kramer BW, Pantophlet CM, van Weissenbruch MM, de Boer NKH, de Meij TGJ. Development of severe bronchopulmonary dysplasia is associated with alterations in fecal volatile organic compounds. Pediatr Res 2018; 83:412-419. [PMID: 29053703 DOI: 10.1038/pr.2017.268] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 10/02/2017] [Indexed: 02/07/2023]
Abstract
BackgroundThe aim of this study was to evaluate the potential of fecal volatile organic compounds (VOCs), obtained by means of an electronic nose device (Cyranose 320), as early non-invasive biomarker for BPD.MethodsIn this nested case-control study performed at three Neonatal Intensive Care Units, fecal samples obtained at postnatal age of 7, 14, 21, and 28 days from preterm infants with severe bronchopulmonary dysplasia (BPD) were compared with fecal VOC profiles from matched controls. Microbiota analysis was performed by means of IS-pro technique on fecal samples collected at 28 days postnatally.ResultsVOC profiles of infants developing severe BPD (n=15) could be discriminated from matched controls (n=15) at postnatal age of 14 days (area under the curve (±95% confidence interval), P-value, sensitivity, specificity; 0.72 (0.54-0.90), 0.040, 60.0%, 73.3%), 21 days (0.71 (0.52-0.90), 0.049, 66.7%, 73.3%) and 28 days (0.77 (0.59-0.96), 0.017, 69.2%, 69.2%) but not at 7 days. Intestinal microbiota did not differ between BPD subjects and controls.ConclusionFecal VOC profiles of infants developing BPD could be differentiated from controls at postnatal day 14, 21, and 28. VOC differences could not be directed to intestinal microbiota alterations but presumably reflect local and systemic metabolic and inflammatory pathways associated with BPD.
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Affiliation(s)
- Daniel J C Berkhout
- Department of Pediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Hendrik J Niemarkt
- Neonatal Intensive Care Unit, Máxima Medical Center, Veldhoven, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Andries E Budding
- Department of Microbiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Neonatal Intensive Care Unit, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - Boris W Kramer
- Department of Pediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Charlene M Pantophlet
- Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Tim G J de Meij
- Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
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21
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Shen L, Zhang T, Lu H. Overexpression of AGT promotes bronchopulmonary dysplasis via the JAK/STAT signal pathway. Oncotarget 2017; 8:96079-96088. [PMID: 29221188 PMCID: PMC5707082 DOI: 10.18632/oncotarget.21712] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 07/25/2017] [Indexed: 12/25/2022] Open
Abstract
Angiotensinogen (AGT) is involved in the production of angiotensin II which is the main mediator of action of the rennin-angiotensin system (RAS), whereas the RAS mediates the regulation of sodium homeostasis, blood pressure, and inflammation. The present study aimed to investigate the roles of the AGT in the progression of broncopulmonary dysplasia in premature newborns. By bioinformatics analysis, AGT was found to be the major node in molecular interaction networks of BPD mouse model. Quantitative PCR and western blot analyses were applied to examine AGT expression in A549 cells which were treated with the hyperoxic condition. The AGT inhibitor Valsartan and the AGT agonist ANGII were employed to investigate the roles of AGT in cell growth and the inflammation. Results show that hyperoxic treatment induced upregulation of AGT expression in A549 cells. Overexpression of AGT resulted in the inflammation via the JAK/STAT signal pathway, ultimately suppressed the proliferation of the A549 cell. In conclusion, increased expression of AGT was demonstrated to be associated with the development and progression of BPD, and may be regarded as a promising therapeutic target for BPD.
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Affiliation(s)
- Lili Shen
- Department of Pediatrics, The Affiliated Hospital of Jiangsu University, Zhenjiang, China.,Department of Pediatrics, Suzhou Kowloon Hospital Shanghai Jiao Tong University School of Medicine, Suzhou, China
| | - Tiancheng Zhang
- Institute of Reproduction and Development, Fudan University, Shanghai, China.,China National Population and Family Planning Key Laboratory of Contraceptive Drugs and Devices, Shanghai Institute of Planned Parenthood Research (SIPPR), Shanghai, China
| | - Hongyan Lu
- Department of Pediatrics, The Affiliated Hospital of Jiangsu University, Zhenjiang, China
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22
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Pulmonary hypertension associated with bronchopulmonary dysplasia in preterm infants. J Reprod Immunol 2017; 124:21-29. [PMID: 29035757 DOI: 10.1016/j.jri.2017.09.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 09/11/2017] [Accepted: 09/29/2017] [Indexed: 12/12/2022]
Abstract
Bronchopulmonary dysplasia (BPD) and BPD-associated pulmonary hypertension (BPD-PH) are chronic inflammatory cardiopulmonary diseases with devastating short- and long-term consequences for infants born prematurely. The immature lungs of preterm infants are ill-prepared to achieve sufficient gas exchange, thus usually necessitating immediate commencement of respiratory support and oxygen supplementation. These therapies are life-saving, but they exacerbate the tissue damage that is inevitably inflicted on a preterm lung forced to perform gas exchange. Together, air-breathing and necessary therapeutic interventions disrupt normal lung development by aggravating pulmonary inflammation and vascular remodelling, thus frequently precipitating BPD and PH via an incompletely understood pathogenic cascade. BPD and BPD-PH share common risk factors, such as low gestational age at birth, fetal growth restriction and perinatal maternal inflammation; however, these risk factors are not unique to BPD or BPD-PH. Occurring in 17-24% of BPD patients, BPD-PH substantially worsens the morbidity and mortality attributable to BPD alone, thus darkening their outlook; for example, BPD-PH entails a mortality of up to 50%. The absence of a safe and effective therapy for BPD and BPD-PH renders neonatal cardiopulmonary disease an area of urgent unmet medical need. Besides the need to develop new therapeutic strategies, a major challenge for clinicians is the lack of a reliable method for identifying babies at risk of developing BPD and BPD-PH. In addition to discussing current knowledge on pathophysiology, diagnosis and treatment of BPD-PH, we highlight emerging biomarkers that could enable clinicians to predict disease-risk and also optimise treatment of BPD-PH in our tiniest patients.
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23
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Histologic Chorioamnionitis and Bronchopulmonary Dysplasia in Preterm Infants: The Epidemiologic Study on Low Gestational Ages 2 Cohort. J Pediatr 2017; 187:98-104.e3. [PMID: 28583707 DOI: 10.1016/j.jpeds.2017.05.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 04/12/2017] [Accepted: 05/05/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate the association between histologic chorioamnionitis (HCA) and bronchopulmonary dysplasia (BPD) in very preterm infants, both in a general population and for those born after spontaneous preterm labor and after preterm premature rupture of membranes (pPROM). STUDY DESIGN This study included 2513 live born singletons delivered at 24-31 weeks of gestation from a national prospective population-based cohort of preterm births; 1731 placenta reports were available. HCA was defined as neutrophil infiltrates in the amnion, chorion of the membranes, or chorionic plate, associated or not with funisitis. The main outcome measure was moderate or severe BPD. Analyses involved logistic regressions and multiple imputation for missing data. RESULTS The incidence of HCA was 28.4% overall: 38% in cases of preterm labor, 64% in cases of pPROM, and less than 5% in cases of vascular disorders. Overall, the risk of BPD after adjustment for gestational age, sex, and antenatal steroids was reduced for infants with HCA (HCA alone: aOR 0.6 [95% CI 0.4-0.9]; associated with funisitis: aOR 0.5 [95% CI 0.3-0.8]). This finding was explained by the high rate of BPD and low rate of chorioamnionitis among children with fetal growth restriction. HCA was not associated with BPD in the preterm labor (13.4% vs 8.5%; aOR 0.9; 95% CI 0.5-1.8) or in the pPROM group (12.9% vs 12.1%; aOR 0.6; 95% CI 0.3-1.3). CONCLUSION In homogeneous groups of infants born after preterm labor or pPROM, HCA is not associated with BPD.
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24
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Collins JJP, Tibboel D, de Kleer IM, Reiss IKM, Rottier RJ. The Future of Bronchopulmonary Dysplasia: Emerging Pathophysiological Concepts and Potential New Avenues of Treatment. Front Med (Lausanne) 2017; 4:61. [PMID: 28589122 PMCID: PMC5439211 DOI: 10.3389/fmed.2017.00061] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/02/2017] [Indexed: 12/13/2022] Open
Abstract
Yearly more than 15 million babies are born premature (<37 weeks gestational age), accounting for more than 1 in 10 births worldwide. Lung injury caused by maternal chorioamnionitis or preeclampsia, postnatal ventilation, hyperoxia, or inflammation can lead to the development of bronchopulmonary dysplasia (BPD), one of the most common adverse outcomes in these preterm neonates. BPD patients have an arrest in alveolar and microvascular development and more frequently develop asthma and early-onset emphysema as they age. Understanding how the alveoli develop, and repair, and regenerate after injury is critical for the development of therapies, as unfortunately there is still no cure for BPD. In this review, we aim to provide an overview of emerging new concepts in the understanding of perinatal lung development and injury from a molecular and cellular point of view and how this is paving the way for new therapeutic options to prevent or treat BPD, as well as a reflection on current treatment procedures.
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Affiliation(s)
- Jennifer J P Collins
- Department of Pediatric Surgery, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Ismé M de Kleer
- Division of Pediatric Pulmonology, Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Robbert J Rottier
- Department of Pediatric Surgery, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, Netherlands
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25
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Abstract
The pathogenesis of Bronchopulmonary Dysplasia (BPD) is multifactorial and the clinical phenotype of BPD is extremely variable. Predicting BPD is difficult, as it is a disease with a clinical operational definition but many clinical phenotypes and endotypes. Most biomarkers studied over the years have low predictive accuracy, and none are currently used in routine clinical care or shown to be useful for predicting longer-term respiratory outcome. Targeted cellular and humoral biomarkers and novel systems biology 'omic' based approaches including genomic and microbiomic analyses are described in this review.
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Hibbs AM, Muhlebach MS. Infection and Inflammation: Catalysts of Pulmonary Morbidity in Bronchopulmonary Dysplasia. RESPIRATORY OUTCOMES IN PRETERM INFANTS 2017. [PMCID: PMC7121702 DOI: 10.1007/978-3-319-48835-6_13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio USA
| | - Marianne S. Muhlebach
- Department of Pediatrics, University of North Carolina Chapel Hill, Chapel Hill, North Carolina USA
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Chorioamnionitis and subsequent bronchopulmonary dysplasia in very-low-birth weight infants: a 25-year cohort. J Perinatol 2016; 36:1045-1048. [PMID: 27583395 DOI: 10.1038/jp.2016.138] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 07/26/2016] [Accepted: 08/01/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine whether chorioamnionitis (CA) or sepsis were associated with bronchopulmonary dysplasia (BPD) in a 25-year cohort of very-low-birth weight (VLBW) infants. STUDY DESIGN VLBW infants ⩽32 weeks gestation admitted to the neonatal intensive care unit between 1989 and 2014 were reviewed. BPD was defined using the National Institutes of Health consensus definition. CA was defined clinically. Logistic regression models were used for BPD prediction. RESULTS One thousand six hundred and eighty-seven infants were included; 44% (n=740) had moderate or severe BPD. In multivariable analysis, lower gestational age (odds ratio (OR) 1.12 per week (95% confidence interval (CI) 1.11, 1.14)), sepsis (OR 2.03 (95% CI 1.49, 2.77)) and birth year ⩾1995 (OR 1.49 (95% CI 1.09, 2.04)) were significant predictors of BPD. CA was not associated with BPD (OR 1.18 (95% CI 0.66, 2.11)). CONCLUSION Sepsis, but not CA, is associated with the development of moderate or severe BPD in VLBW infants after controlling for gestational age.
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Cui H, He J, Chen H, Chen J, Qian X, Huang W. Erythropoietin attenuates hyperoxia-induced lung injury by upregulating epidermal growth factor-like domain 7 in newborn rats. Biomed Rep 2016; 6:32-38. [PMID: 28123704 PMCID: PMC5244802 DOI: 10.3892/br.2016.820] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/03/2016] [Indexed: 01/23/2023] Open
Abstract
The aim of the present study was to observe the effects of recombinant human erythropoietin (rhEPO) on the expression of epidermal growth factor-like domain 7 (EGFL7) and cell apoptosis in lung tissue following hyperoxic lung injury in newborn rats. The 96 Sprague-Dawley newborn rats were randomly divided into 4 groups (n=24) as follows: Room air-exposed control group, room air-exposed rhEPO-treated group, hyperoxia-exposed group and the hyperoxia-exposed rhEPO-treated group. Pups (n=8) from each group were sacrificed on postnatal days 3, 7 and 14. The pulmonary morphometric and microvessel density changes were observed. In addition, the mRNA and protein expression levels of EGFL7, B-cell lymphoma 2 (Bcl-2) and Bcl-2-like protein 4 (Bax) in lung tissue samples were measured. The rats in the hyperoxia-exposed group exhibited alveolar and pulmonary vascular dysplasia, as well as low mRNA and protein expression levels of EGFL7 and Bcl-2, in addition to high level of Bax in the lung tissue samples when compared with the room air-exposed control group (P<0.05). However, in the hyperoxia-exposed rhEPO-treated group the lung histopathology was improved, and the protein and mRNA expression levels of EGFL7 and Bcl-2 were increased compared with the hyperoxia-exposed group (P<0.05). Furthermore, the expression level of Bax was lower than that of the hyperoxia-exposed group (P<0.05). The present study demonstrated that rhEPO promotes alveolar development and increases pulmonary vascular density by upregulating the expression level of EGFL7 in hyperoxia-induced lung injury of newborn rats.
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Affiliation(s)
- Huanjin Cui
- Department of Neonatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Jiayu He
- Department of Neonatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Hongwu Chen
- Department of Neonatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Jinwen Chen
- Department of Neonatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Xinhua Qian
- Department of Neonatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Weimin Huang
- Department of Neonatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
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29
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Kennedy KA, Cotten CM, Watterberg KL, Carlo WA. Prevention and management of bronchopulmonary dysplasia: Lessons learned from the neonatal research network. Semin Perinatol 2016; 40:348-355. [PMID: 27742002 PMCID: PMC5279709 DOI: 10.1053/j.semperi.2016.05.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite remarkable improvements in survival of extremely premature infants, the burden of BPD among survivors remains a frustrating problem for parents and caregivers. Advances, such as antenatal steroids and surfactant replacement, which have dramatically improved survival, have not reduced BPD among survivors. Other advances that have significantly improved the combined outcome of death or BPD, such as vitamin A and avoidance of mechanical ventilation, have had smaller magnitude effects on the outcome of BPD alone. Postnatal steroids have a clear beneficial effect on BPD, but the optimal preparation, dose, and timing for maximizing benefit and minimizing harm have yet to be determined. This persistent burden of BPD among the most immature survivors remains a challenge for the NRN and other researchers in neonatal medicine.
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Affiliation(s)
- Kathleen A Kennedy
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX.
| | | | | | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
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30
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Ambalavanan N, Morty RE. Searching for better animal models of BPD: a perspective. Am J Physiol Lung Cell Mol Physiol 2016; 311:L924-L927. [PMID: 27663992 DOI: 10.1152/ajplung.00355.2016] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/16/2016] [Indexed: 11/22/2022] Open
Abstract
There have been many efforts to develop good animal models of bronchopulmonary dysplasia (BPD) to better understand the pathophysiology and mechanisms underlying development of BPD as well as to test potential strategies for its prevention and treatment. This Perspectives summarizes the features of common animal models of BPD and the strengths and limitations of such models. Potential optimal approaches to development of animal models are indicated, with the underlying concepts that require emphasis.
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Affiliation(s)
- Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Rory E Morty
- Department of Lung Development and Remodelling, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
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31
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Hütten MC, Wolfs TGAM, Kramer BW. Can the preterm lung recover from perinatal stress? Mol Cell Pediatr 2016; 3:15. [PMID: 27075524 PMCID: PMC4830776 DOI: 10.1186/s40348-016-0043-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
After birth, adequate lung function is necessary for the successful adaptation of a preterm baby. Both prenatal and postnatal insults and therapeutic interventions have an immediate effect on lung function and gas exchange but also interfere with fetal and neonatal lung development. Prenatal insults like chorioamnionitis and prenatal interventions like maternal glucocorticosteroids interact but might also determine the preterm baby's lung response to postnatal interventions ("second hit") like supplementation of oxygen and drug therapy. We review current experimental and clinical findings on the influence of different perinatal factors on preterm lung development and discuss how well-established interventions in neonatal care might be adapted to attenuate postnatal lung injury.
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Affiliation(s)
- Matthias C Hütten
- Neonatology, Department of Pediatrics, Maastricht University Medical Center, Maastricht, Netherlands.,Neonatology, Department of Pediatrics, Aachen University Hospital, Aachen, Germany.,Neonatology, Department of Pediatrics, Würzburg University Hospital, Würzburg, Germany.,Faculty of Health, Medicine and Lifesciences, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Tim G A M Wolfs
- Neonatology, Department of Pediatrics, Maastricht University Medical Center, Maastricht, Netherlands.,Faculty of Health, Medicine and Lifesciences, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Boris W Kramer
- Neonatology, Department of Pediatrics, Maastricht University Medical Center, Maastricht, Netherlands. .,Faculty of Health, Medicine and Lifesciences, School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.
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32
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Bhandari A, Carroll C, Bhandari V. BPD Following Preterm Birth: A Model for Chronic Lung Disease and a Substrate for ARDS in Childhood. Front Pediatr 2016; 4:60. [PMID: 27379219 PMCID: PMC4908128 DOI: 10.3389/fped.2016.00060] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/26/2016] [Indexed: 11/13/2022] Open
Abstract
It has been suggested that pediatric acute respiratory distress syndrome (PARDS) may be a different entity, vis-à-vis adult acute respiratory distress syndrome (ARDS), based on its epidemiology and outcomes. A more pediatric-specific definition of PARDS to include the subgroup of patients with underlying lung (and heart) disease has been proposed. Epidemiological data suggest that up to 13% of the children with ARDS have a history of prematurity and/or underlying chronic lung disease. However, the specific contribution of bronchopulmonary dysplasia (BPD), the most common chronic lung disease in infants, to the development of PARDS is not known. BPD leads to damaged lungs with long-term consequences secondary to disordered growth and immune function. These damaged lungs could potentially act as a substrate, which given the appropriate noxious stimuli, can predispose a child to PARDS. Interestingly, similar biomarkers [KL-6, interleukin (IL)-6, IL-8, sICAM-1, angiopoietin-2, and matrix metalloproteinase-8 and -9] of pulmonary injury have been associated both with BPD and ARDS. Recognition of a unique pattern of clinical symptomatology and/or outcomes of PARDS, if present, could potentially be useful for investigating targeted therapeutic interventions.
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Affiliation(s)
- Anita Bhandari
- Division of Pediatric Pulmonology, Connecticut Children's Medical Center, University of Connecticut School of Medicine , Hartford, CT , USA
| | - Christopher Carroll
- Division of Pediatric Critical Care Medicine, Connecticut Children's Medical Center, University of Connecticut School of Medicine , Hartford, CT , USA
| | - Vineet Bhandari
- Section of Neonatology, St. Christopher's Hospital for Children, Drexel University College of Medicine , Philadelphia, PA , USA
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