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Litwin M. Pathophysiology of primary hypertension in children and adolescents. Pediatr Nephrol 2024; 39:1725-1737. [PMID: 37700113 PMCID: PMC11026201 DOI: 10.1007/s00467-023-06142-2] [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: 06/05/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
The progress in research on the physiology of the cardiovascular system made in the last 100 years allowed for the development of the pathogenesis not only of secondary forms of hypertension but also of primary hypertension. The main determinants of blood pressure are described by the relationship between stroke volume, heart rate, peripheral resistance, and arterial stiffness. The theories developed by Guyton and Folkow describe the importance of the volume factor and total peripheral resistance. However, none of them fully presents the pathogenesis of essential hypertension. The multifactorial model of primary hypertension pathogenesis developed by Irving Page in the 1940s, called Page's mosaic, covers most of the pathophysiological phenomena observed in essential hypertension. The most important pathophysiological phenomena included in Page's mosaic form a network of interconnected "nodes". New discoveries both from experimental and clinical studies made in recent decades have allowed the original Page mosaic to be modified and the addition of new pathophysiological nodes. Most of the clinical studies confirming the validity of the multifactorial pathogenesis of primary hypertension concern adults. However, hypertension develops in childhood and is even perinatally programmed. Therefore, the next nodes in Page's mosaic should be age and perinatal factors. This article presents data from pediatric clinical trials describing the most important pathophysiological processes associated with the development of essential hypertension in children and adolescents.
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Affiliation(s)
- Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland.
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2
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Czeszyk A, Hautz W, Bulsiewicz D, Jaworski M, Czech-Kowalska J. The long-term influence of perinatal factors on macular morphology and vessel density in preterm children. Early Hum Dev 2024; 192:105993. [PMID: 38643639 DOI: 10.1016/j.earlhumdev.2024.105993] [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: 12/31/2023] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Increased survival rate of extremely preterm children is associated with a higher risk of retinopathy of prematurity (ROP) and long-term sequelae, which implicate retinal changes. PURPOSE To assess an influence of perinatal characteristics on morphology and retinal vascularity of the macula in preterm children. METHODS A cohort of 123 preterm children at the age of 10.5 years (IQR: 8.12-12.77) was prospectively assessed. Optical coherence tomography angiography (OCTA) was performed using RTVueXR Avanti. Foveal thickness, parafoveal thickness, size of foveal avascular zone (FAZ), superficial and deep vessel density, central choroidal thickness (CCT) were analyzed. The associations between OCTA results and perinatal factors, including the presence of ROP and therapy requirements were assessed in preterm children. RESULTS Significantly smaller FAZ, higher foveal thickness and vessel density were noted in children with ROP, Respiratory Distress Syndrome, Bronchopulmonary Dysplasia, required erythropoietin, transfusion or steroids. Foveal thickness was increased in children with ROP (p < 0.001) and following laser treatment (p < 0.05). Thinner CCT was noted in children with a history of sepsis (p < 0.05) and ROP required treatment (p < 0.05). Pregnancy bleeding was associated with higher superficial foveal vessel density (p < 0.05) and smaller FAZ (p < 0.05). CONCLUSION Neonatal factors have a huge impact on retinal development, but the role of prenatal factors should not be neglected in preterm children.
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Affiliation(s)
- Agnieszka Czeszyk
- Department of Ophthalmology, The Children's Memorial Health Institute, 04-730 Warsaw, Poland.
| | - Wojciech Hautz
- Department of Ophthalmology, The Children's Memorial Health Institute, 04-730 Warsaw, Poland.
| | - Dorota Bulsiewicz
- Department of Neonatology and Neonatal Intensive Care, The Children's Memorial Health Institute, 04-730 Warsaw, Poland.
| | - Maciej Jaworski
- Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children's Memorial Health Institute, 04-730 Warsaw, Poland.
| | - Justyna Czech-Kowalska
- Department of Neonatology and Neonatal Intensive Care, The Children's Memorial Health Institute, 04-730 Warsaw, Poland.
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3
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Mynard JP, Kowalski R, Harrington HA, Kondiboyina A, Smolich JJ, Cheung MMH. Superiority of a Representative MRI Flow Waveform over Doppler Ultrasound for Aortic Wave Reflection Assessment in Children and Adolescents With/Without a History of Heart Disease. Ann Biomed Eng 2023; 51:2772-2784. [PMID: 37561232 PMCID: PMC10632254 DOI: 10.1007/s10439-023-03339-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/29/2023] [Indexed: 08/11/2023]
Abstract
Wave separation analysis (WSA) reveals the impact of forward- and backward-running waves on the arterial pressure pulse, but the calculations require a flow waveform. This study investigated (1) the variability of the ascending aortic flow waveform in children and adolescents with/without a childhood heart disease history (CHD); (2) the accuracy of WSA obtained with a representative flow waveform (RepFlow), compared with the triangulation method and published ultrasound-derived adult representative flow; (3) the impact of limitations in Doppler ultrasound on WSA; and (4) generalizability of results to adults with a history of CHD. Phase contrast MRI was performed in youth without (n = 45, Group 1, 10-19 years) and with CHD (n = 79, Group 2, 7-18 years), and adults with CHD history (n = 29, Group 3, 19-59 years). Segmented aortic cross-sectional area was used as a surrogate for the central pressure waveform in WSA. A subject-specific virtual Doppler ultrasound was performed on MRI data by extracting velocities from a sample volume. Time/amplitude-normalized ascending aortic flow waveforms were highly consistent amongst all groups. WSA with RepFlow therefore yielded errors < 10% in all groups for reflected wave magnitude and return time. Absolute errors were typically 1.5-3 times greater with other methods, including subject-specific (best-case/virtual) Doppler ultrasound, for which velocity profile skewing introduced waveform errors. Our data suggest that RepFlow is the optimal approach for pressure-only WSA in children and adolescents with/without CHD, as well as adults with CHD history, and may even be more accurate than subject-specific Doppler ultrasound in the ascending aorta.
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Affiliation(s)
- Jonathan P Mynard
- Heart Research, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville VIC, Australia.
- Department of Biomedical Engineering, University of Melbourne, Parkville VIC, Australia.
| | - Remi Kowalski
- Heart Research, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville VIC, Australia
- Department of Cardiology, Royal Children's Hospital, Parkville VIC, Australia
| | - Hilary A Harrington
- Heart Research, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Avinash Kondiboyina
- Heart Research, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville VIC, Australia
| | - Joseph J Smolich
- Heart Research, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville VIC, Australia
| | - Michael M H Cheung
- Heart Research, Murdoch Children's Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville VIC, Australia
- Department of Cardiology, Royal Children's Hospital, Parkville VIC, Australia
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Ferrigno S, Conigliaro P, Rizza S, Longo S, Nesi C, Carlucci F, Bergamini A, Mancino R, Nucci C, Federici M, Chimenti MS, Cesareo M. Relationship between retinal microvascular impairment and subclinical atherosclerosis in SLE. Lupus Sci Med 2023; 10:e000977. [PMID: 37852671 PMCID: PMC10603324 DOI: 10.1136/lupus-2023-000977] [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: 06/17/2023] [Accepted: 09/19/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVES Patients with SLE have higher cardiovascular (CV) risk compared with healthy controls (HC) and are characterised by accelerated atherosclerosis; intima media thickness (IMT), marker of subclinical atherosclerosis, is higher in patients with SLE than in HCs. Retinal microvascular impairment detected through optical coherence tomography angiography (OCTA) was investigated as a marker of systemic vascular involvement in SLE.The aim of the study was to evaluate the relationship between retinal vascular impairment and IMT in SLE. METHODS Cross-sectional study recruiting patients with SLE and HCs. Data of the study population were collected. CV risk was evaluated through the American College of Cardiology/American Heart Association (ACC/AHA) guidelines, Framingham and QRESEARCH risk estimator V.3 (QRISK3) scores. Both groups underwent OCTA and carotid ultrasound with IMT assessment.Statistical analysis was accomplished using Pearson/Spearman, t-test/Mann-Whitney or χ2 test. Variables statistically significant at univariate regression analysis were tested in an age-corrected and sex-corrected multivariate regression model. RESULTS 43 patients with SLE and 34 HCs were recruited. Patients with SLE showed higher triglycerides (p=0.019), Triglycerides-Glucose (TyG) Index (p=0.035), ACC/AHA guidelines (p=0.001), Framingham Risk Scores (p=0.008) and a reduced superficial (p<0.001) and deep (p=0.005) whole retinal vessel density (VD) compared with HCs.In SLE univariate analysis, deep whole VD showed a negative correlation with IMT (p=0.027), age (p=0.001), systolic blood pressure (p=0.011), QRISK3 Score (p<0.001), Systemic Lupus International Collaborating Clinics Damage Index (p=0.006) and apolipoprotein B (p=0.021), while a positive correlation was found with female sex (p=0.029). Age-adjusted and sex-adjusted multivariate analysis confirmed QRISK3 Score (p=0.049) and IMT (p=0.039) to be independent risk factors for reduced retinal VD. CONCLUSIONS Patients with SLE showed lower retinal VD and higher CV risk indicators compared with HCs. Among patients with SLE, QRISK3 Score and IMT were found to be independent risk factors for retinal vascular impairment, suggesting a role of OCTA in evaluating preclinical CV involvement in SLE. Moreover, TyG Index could represent a biomarker of CV risk in patients with SLE compared with HCs.
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Affiliation(s)
- Sara Ferrigno
- Rheumatology, Allergology and Clinical Immunology, Department of 'Medicina dei Sistemi', University of Rome Tor Vergata, Rome, Italy
| | - Paola Conigliaro
- Rheumatology, Allergology and Clinical Immunology, Department of 'Medicina dei Sistemi', University of Rome Tor Vergata, Rome, Italy
| | - Stefano Rizza
- Department of 'Medicina dei Sistemi', University of Rome Tor Vergata, Rome, Italy
| | - Susanna Longo
- Department of 'Medicina dei Sistemi', University of Rome Tor Vergata, Rome, Italy
| | - Carolina Nesi
- Ophtalmology, Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Federico Carlucci
- Ophtalmology, Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Alberto Bergamini
- Rheumatology, Allergology and Clinical Immunology, Department of 'Medicina dei Sistemi', University of Rome Tor Vergata, Rome, Italy
| | - Raffaele Mancino
- Ophtalmology, Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Carlo Nucci
- Ophtalmology, Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Massimo Federici
- Department of 'Medicina dei Sistemi', University of Rome Tor Vergata, Rome, Italy
| | - Maria Sole Chimenti
- Rheumatology, Allergology and Clinical Immunology, Department of 'Medicina dei Sistemi', University of Rome Tor Vergata, Rome, Italy
| | - Massimo Cesareo
- Ophtalmology, Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
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5
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Mynard JP, Chaturvedi S, Cheung MMH, Clark M, Gabb G, Jeffries-Stokes C, Jennings GL, McNab S, Medley T, Mihailidou AS, Schlaich M, Larkins NG, Quinlan C. A Call for Australian Clinical Practice Guidelines for Paediatric Hypertension. Heart Lung Circ 2023; 32:1032-1034. [PMID: 37495429 DOI: 10.1016/j.hlc.2023.06.726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Jonathan P Mynard
- Heart Research, Murdoch Children's Research Institute, Melbourne, Vic, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia; Department of Biomedical Engineering, University of Melbourne, Melbourne, Vic, Australia.
| | - Swasti Chaturvedi
- Department of Nephrology, Sydney Children's Hospital, Sydney, NSW, Australia; Menzies School of Health Research Darwin, NT, Australia
| | - Michael M H Cheung
- Heart Research, Murdoch Children's Research Institute, Melbourne, Vic, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia; Department of Cardiology, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Malcolm Clark
- Department of General Practice, University of Melbourne, Melbourne, Vic, Australia
| | - Genevieve Gabb
- Department of Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Garry L Jennings
- National Heart Foundation of Australia, Melbourne, Vic, Australia
| | - Sarah McNab
- Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia; Department of General Medicine, Royal Children's Hospital, Melbourne, Vic, Australia; Clinical Paediatrics, Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Tanya Medley
- Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia; Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Anastasia S Mihailidou
- Department of Cardiology and Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Markus Schlaich
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit and RPH, Perth, WA, Australia; Research Foundation, The University of Western Australia, Perth, WA, Australia; Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia; Department of Nephrology, Royal Perth Hospital, Perth, WA, Australia
| | - Nicholas G Larkins
- Department of Nephrology, Perth Children's Hospital, Perth, WA, Australia; School of Paediatrics and Child Health, University of Western Australia, Perth, WA, Australia
| | - Catherine Quinlan
- Department of Paediatrics, University of Melbourne, Melbourne, Vic, Australia; Department of Nephrology, Royal Children's Hospital, Melbourne, Vic, Australia; Digital Health, Melbourne Children's Centre for Health Analytics, Melbourne, Vic, Australia; Kidney Flagship, Murdoch Children's Research Institute, Melbourne, Vic, Australia
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Abstract
Primary hypertension (PH) is most common during adolescence with increasing prevalence globally, alongside the epidemic of obesity. Unlike in adults, there are no data on children with uncontrolled hypertension and their future risk of hard cardiovascular and cerebrovascular outcomes. However, hypertension in childhood is linked to hypertensive-mediated organ damage (HMOD) which is often reversible if treated appropriately. Despite differing guidelines regarding the threshold for defining hypertension, there is consensus that early recognition and prompt management with lifestyle modification escalating to antihypertensive medication is required to ameliorate adverse outcomes. Unfortunately, many unknowns remain regarding pathophysiology and optimum treatment of childhood hypertension.
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Affiliation(s)
- Emily Haseler
- Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys & St Thomas NHS Foundation Trust, Westminster Bridge Road, 3rd Floor Beckett House, London SE1 7EH, United Kingdom; Kings College London, United Kingdom
| | - Manish D Sinha
- Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys & St Thomas NHS Foundation Trust, Westminster Bridge Road, 3rd Floor Beckett House, London SE1 7EH, United Kingdom; Kings College London, United Kingdom.
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Disparities between determinants of impaired vascular structure and function in young people with primary hypertension: a systematic review. J Hypertens 2022; 40:1369-1379. [PMID: 35762477 DOI: 10.1097/hjh.0000000000003155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Early effects of primary hypertension on arterial structure and function in children and young people (CYP) and their determinants remain elusive. We aimed to review independent determinants of carotid intima-media thickness (cIMT), carotid wall cross-sectional area (WCSA) and carotid-femoral pulse wave velocity (cfPWV) in CYP with primary hypertension. METHODS We performed a systematic review of studies reporting multivariable analysis of cfPWV, cIMT and WCSA in CYP (up to 25 years of age) with primary hypertension. Literature search was performed in PubMed database and 13, 12 and two articles including 3860 (age range 4-25 years, 50% male individuals), 2038 children (5-25 years, 55% male individuals) and 136 children (5-17 years, 85% male individuals) were selected for final analysis of cfPWV, cIMT and WCSA, respectively. RESULTS Ninety and 86% of the studies reported higher cfPWV and cIMT in CYP with elevated blood pressure (BP) compared with normotensive controls. Different indices of BP were positively associated with cfPWV in 92% of studies, whereas BMI showed association in 31%. Carotid IMT associated with BP indices in 50% and with BMI in 25% of the studies. WCSA was studied longitudinally and its improvement associated with decrease in measures of central obesity. CONCLUSION We found a disparity between the determinants of structural and functional impairment of arterial tree in CYP with primary hypertension. In contrast to cIMT and WCSA, increase of cfPWV is almost exclusively determined by BP.
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Czeszyk A, Hautz W, Jaworski M, Bulsiewicz D, Czech-Kowalska J. Morphology and Vessel Density of the Macula in Preterm Children Using Optical Coherence Tomography Angiography. J Clin Med 2022; 11:1337. [PMID: 35268428 PMCID: PMC8911277 DOI: 10.3390/jcm11051337] [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: 01/12/2022] [Revised: 02/20/2022] [Accepted: 02/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Retinal morphology changes may be associated with prematurity and can lead to visual impairment. Optical coherence tomography angiography may contribute to understanding the pathomechanism of structural and vascular retinal impairment in premature children. The aim of this study was to assess an influence of prematurity, neonatal clinical characteristics, and a history of retinopathy of prematurity (ROP) on the morphology and retinal vascularity of macula in children. Methods: A case−control study of 123 preterm children and 86 full-term children was performed. The age of the subjects was 10.45 years (IQR: 8.12−12.77), while the age of the control group was 11.78 years (IQR: 8.81−13.79). Optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA, angio-OCT) were performed using RTVueXR Avanti (Optovue, Fremont, CA, USA). Ganglion cell complex (GCC), foveal thickness (FT), parafoveal thickness (PFT), size of foveal avascular zone (FAZ) in superficial plexus, superficial capillary vessel density (sVD), deep capillary vessel density (dVD), central choroidal thickness (CCT), and presence of macular hypoplasia were analyzed. The association between OCT/angio-OCT results and clinical characteristics including the degree of ROP and therapy requirements was assessed in preterm infants. Results: Foveal morphology was affected in preterm children with high incidence of foveal hypoplasia (24.77%). GCC was thinner in preterm children compared to controls: avgGG 93 μm vs. 100 μm, p < 0.001. No associations between GCC and gestational age (R = −0.085; p = 0.228) and birth weight (R = −0.054; p = 0.446) were found. FAZ in preterm group was smaller than in controls (0.13 ± 0.09 vs. 0.22 ± 0.09; p < 0.001). FAZ area correlated with gestational age (R = 0.456; p < 0.001) and birth weight (R = 0.472; p < 0.001). Deep vessel density in the fovea was higher in preterm children than in control group (p < 0.001). PFT was significantly lower in preterm children compared to control group. However, increased thickness in the fovea was noted in preterm children (p < 0.001). FT was inversely correlated with gestational age (R = −0.562; p < 0.001) and birth weight (R = −0.508, p < 0.001). CCT was lower in preterm children (312 μm vs. 337.5 μm, p < 0.001) Parameters of GCC and FT were higher in patients with ROP required treatment compared to patients without ROP and spontaneously regressed retinopathy. FAZ was smaller in patients with retinopathy than in preterm children without ROP. Conclusion: Prematurity has a significant negative impact on GCC, macular morphology, and vascularization. In premature children, decreased FAZ, increased FT, and vessel density were strongly associated with gestational age, birth weight, Apgar score, ROP stage, and treatment requirement. Optical coherence tomography angiography is a useful tool for detecting retinal changes in premature children.
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Affiliation(s)
- Agnieszka Czeszyk
- Department of Ophthalmology, Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Wojciech Hautz
- Department of Ophthalmology, Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Maciej Jaworski
- Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Dorota Bulsiewicz
- Department of Neonatology and Neonatal Intensive Care, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (D.B.); (J.C.-K.)
| | - Justyna Czech-Kowalska
- Department of Neonatology and Neonatal Intensive Care, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (D.B.); (J.C.-K.)
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