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Bhatia K, Solanki S, Paes B, Chan AKC, Bhatt MD. Risk factors for neonatal thrombosis: A retrospective study conducted in a single Canadian intensive care unit. Pediatr Blood Cancer 2022; 69:e29668. [PMID: 35289485 DOI: 10.1002/pbc.29668] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 11/10/2022]
Abstract
Among children, neonates have the highest incidence of thrombosis. We conducted a retrospective review of neonatal thrombosis, in a single intensive care unit (ICU) over 4.5 years. Among 4860 ICU admissions to our center, identified through the Canadian Neonatal Network database, 186 were associated with arterial and venous thrombosis involving 195 thrombotic sites. The neonatal thrombosis incidence was 38 per 1000 neonatal ICU admissions. We assessed patient characteristics and compared the association between risk factors and thrombosis. In the multivariate analysis, central venous catheters, sepsis, and respiratory distress syndrome were significant predictors of neonatal thrombosis.
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Affiliation(s)
- Kulsajan Bhatia
- Department of Pediatrics, SUNY Downstate Health Sciences University, Brooklyn, New York.,Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Smeet Solanki
- Psychology, Neuroscience and Behavior, McMaster University, Hamilton, Ontario, Canada
| | - Bosco Paes
- Division of Neonatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Anthony K C Chan
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Mihir D Bhatt
- Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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2
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Buyukinan M, Yilmaz D, Yalaz M, Koroglu OA, Akisu M, Kavakli K, Kultursay N. Long-term ongoing coagulopathy in premature infants with respiratory distress syndrome. Clin Appl Thromb Hemost 2012; 19:535-40. [PMID: 22556372 DOI: 10.1177/1076029612444003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The previously reported activated intravascular coagulation system in the acute phase of respiratory distress syndrome (RDS) has not been evaluated in the long term. We assessed the activities of coagulation system of a cohort of premature infants with RDS in comparison with healthy premature infants (HPIs), healthy mature infants (HMIs), and pediatric laboratory controls over a 6-month period. Cord and venous blood samples were taken at birth, at the first month and sixth month. Protein C (PC), free protein S (f-PS), and antithrombin (AT) activities, thrombin-antithrombin (TAT) complex, prothrombin fragment 1 + 2 (PF1 + 2), and fibrinogen levels were measured. Mean PC, f-PS, d-dimer, and fibrinogen values were similar at all periods for HPI and RDS groups. Low neonatal anticoagulant proteins increased within 6 months in HMI and HPI groups. However, in RDS group, the AT activity remained significantly lower together with significantly higher TAT and PF1 + 2 levels both at the first month and at sixth month, suggesting a long-term consumption coagulopathy.
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Affiliation(s)
- Muammer Buyukinan
- 1Division of Neonatology, Department of Pediatrics, Ege University Faculty of Medicine, Izmir, Turkey
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Armangil D, Yurdakök M, Okur H, Gürgey A. Plasminogen Activator Inhibitor I 4G/5G Polymorphism in Neonatal Respiratory Distress Syndrome. Clin Appl Thromb Hemost 2010; 17:352-7. [DOI: 10.1177/1076029610369796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Fibrin monomers inhibit surfactant function. 4G/5G insertion/deletion polymorphism plays an important role in the regulation of plasminogen activator inhibitor 1 (PAI-1) gene expression. To examine the genotype distribution of PAI-1 polymorphism in 60 infants with respiratory distress syndrome (RDS) and 53 controls, an allele-specific polymerase chain reaction (PCR) was used. The proportion of 4G/4G, 4G/5G, and 5G/5G genotypes did not differ statistically between the RDS and control groups (P > .05). Having PAI-1 4G/4G genotype polymorphism appears to increase the risk of RDS (odds ratio [OR] =1.5; 95% confidence interval [CI], 0.5-4.3), although it was not statistically significant. No relation was found between the PAI-1 4G/5G polymorphisms and RDS, but there was an increased risk associated with the 4G variant of the PAI-1 gene. We believe that our findings of increased 4G allele of the PAI-1 gene in infants with RDS would also help to clarify the pathogenesis of RDS.
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Affiliation(s)
- Didem Armangil
- Department of Pediatrics, Neonatology Unit, Faculty of Medicine, Hacettepe University, Ankara, Turkey,
| | - Murat Yurdakök
- Department of Pediatrics, Neonatology Unit, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Hamza Okur
- Department of Pediatrics, Hematology Unit, Faculty of Medicine, Hacettepe University, Ankara Turkey
| | - Aytemiz Gürgey
- Department of Pediatrics, Hematology Unit, Faculty of Medicine, Hacettepe University, Ankara Turkey
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Iman SS, El-Sahrigy S, Sedki M, Baker S, Marey S. Role of protein Z and protein C in neonates with respiratory distress syndrome in Egypt (experience of one centre). Pak J Biol Sci 2009; 12:1468-1473. [PMID: 20180321 DOI: 10.3923/pjbs.2009.1468.1473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The aim of this study is to evaluate Protein Z (PTZ) and protein C (PTC) levels in newborns suffering from RDS, healthy preterm and full term newborns and to compare PTZ serum levels in RDS preterm infants with healthy preterm before and after recovery. Sixty newborn infants, recruited from the neonatal unit, were enrolled in the study and divided into 3 groups: Group (I): 20 preterm with RDS, Group (II): 20 healthy preterm control newborns (CPT) and Group (III): 20 healthy full term control newborns (CFT). Protein Z and C were measured using ELISA kits. The results of the study showed lower levels of protein Z were obtained in RDS group compared to preterm controls whose levels were significantly lower than in full-term controls. A significant increase in PTZ levels in RDS' group after recovery, when compared to preterm controls. In RDS, no significant correlations existed between PTZ levels (before and after recovery) and routine investigations except for a significant negative correlation with platelets count. No significant differences were found in PTC levels between the 3 studied groups. To conclude: premature newborns suffering from RDS showed decreased serum protein Z levels than normal preterm control newborns with further increase in its pattern after recovery. Further studies are recommended to evaluate the role of PTZ on outcome in premature newborns with RDS and to evaluate the relationship between protein PTZ and PTC and other coagulation factors incriminated in the development of RDS.
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Affiliation(s)
- Safaa S Iman
- Department of Pediatric, Ain Shams University, Egypt
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Gursoy T, Tekinalp G, Yurdakok M, Ozcebe O, Korkmaz A, Gurgey A. Thrombin activatable fibrinolysis inhibitor activity, thrombin-antithrombin complex and D-dimer levels in preterm neonates with early respiratory distress syndrome. Am J Hematol 2008; 83:50-3. [PMID: 17654683 DOI: 10.1002/ajh.21010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Intraalveolar fibrin deposition found in neonates with respiratory distress syndrome (RDS) is explained by the activation of the coagulation system and inefficient fibrinolysis. However, thrombin activatable fibrinolysis inhibitor activity (TAFIa), an inhibitor of fibrinolysis, and the ratio of D-dimer to thrombin-antithrombin complex (D-dimer/TAT), an index of fibrinolytic activity, have not been reported previously in neonatal RDS. Aim of this study is to evaluate the influence of plasma TAFIa levels on the fibrinolytic state in neonatal RDS. The RDS group (Group 1) consisted of 29 neonates, and 18 neonates served as the control group (Group 2). Plasma TAFIa levels and D-dimer/TAT ratios were evaluated in all neonates in the first 6 hr of life. Neonates in the RDS group were further divided into two subgroups; Group 1a consisted of 12 neonates with evidence of mild asphyxia (Apgar score at 5 min <7 and cord pH <7.26), and Group 1b consisted of 17 nonasphyxiated neonates. No significant difference was found in TAFIa levels and D-dimer/TAT ratios between Groups 1 and 2 [214% (56.2-361%) and 124.3 (4.4-3,921) in Group 1 and 201% (60.3-381%) and 147 (5.9-1,426) in Group 2]. There were negative correlations between cord pH and TAFIa levels in both groups. Increased TAFIa levels and decreased D-dimer/TAT ratios and platelet counts were detected in mildly asphyxiated neonates when compared with nonasphyxiated ones. TAFIa is not responsible for the hypofibrinolytic state reported in RDS. However, asphyxia influences TAFIa levels and increased TAFIa levels depress fibrinolysis.
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Affiliation(s)
- Tugba Gursoy
- Neonatology Unit, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Gotsch F, Romero R, Kusanovic JP, Mazaki-Tovi S, Pineles BL, Erez O, Espinoza J, Hassan SS. The fetal inflammatory response syndrome. Clin Obstet Gynecol 2007; 50:652-83. [PMID: 17762416 DOI: 10.1097/grf.0b013e31811ebef6] [Citation(s) in RCA: 384] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The fetal inflammatory response syndrome (FIRS) is a condition characterized by systemic inflammation and an elevation of fetal plasma interleukin-6. This syndrome has been observed in fetuses with preterm labor with intact membranes, preterm prelabor rupture of the membranes, and also fetal viral infections such as cytomegalovirus. FIRS is a risk factor for short-term perinatal morbidity and mortality after adjustment for gestational age at delivery and also for the development of long-term sequelae such as bronchopulmonary dysplasia and brain injury. Multiorgan involvement in FIRS has been demonstrated in the hematopoietic system, thymus, adrenal glands, skin, kidneys, heart, lung, and brain. This article reviews the fetal systemic inflammatory response as a mechanism of disease. Potential interventions to control an exaggerated inflammatory response in utero are also described.
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Affiliation(s)
- Francesca Gotsch
- Perinatology Research Branch, Intramural Division, NICHD/NIH/DHHS, Hutzel Women's Hospital, Bethesda, Maryland, USA
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Abstract
BACKGROUND Acquired Antithrombin (AT) deficiency is a common and prognostically important finding in sick preterm infants with respiratory distress syndrome (RDS). It has been hypothesised that AT concentrate may improve clinical outcomes in preterm infants with RDS. OBJECTIVES To determine whether the administration of AT concentrate decreases mortality in preterm infants with RDS compared with placebo or no treatment. SEARCH STRATEGY An electronic literature search in the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE in August 2006 was performed. No language restriction was applied. References from identified studies were cross-checked for possible additional studies. Experts in the field and pharmaceutical companies were contacted for unpublished data. Abstracts of the American Society of Pediatric Research and European Society of Pediatric Research meetings (1983-2005) were searched and authors of relevant studies were contacted to obtain additional information. SELECTION CRITERIA Randomized controlled trials comparing any dose and duration of AT therapy with placebo or no treatment in preterm infants with RDS. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data from included studies regarding mortality, intraventricular hemorrhage, mechanical ventilation, and other reported events in the clinical course of the patients. Data for similar outcomes were combined where appropriate, using a fixed-effects model in MetaView 4.2 (Update Software). MAIN RESULTS Two trials consisting of 182 preterm infants, fulfilled the inclusion criteria. Mean gestational age of patients included was 28 weeks. In one trial, patients had to be intubated and ventilated for RDS to be eligible for the study. In the other trial, RDS was not mentioned as an inclusion criteria, however the vast majority of infants in the study received surfactant. No individual trial showed a significant difference in mortality. One of the trials was stopped early because of an increase in deaths in the AT group. The pooled analysis for mortality within the first week of life showed a typical relative risk of 2.67 (95% CI 0.72-9.83) in favour of the control group. Only the trial that was stopped early followed the infants long enough to report neonatal mortality. This trial reported 7 deaths (11.5%) in the AT group and two deaths (3.3%) in the placebo group within 28 days of life. Secondary outcomes included days of mechanical ventilation and supplemental oxygen which were only reported in 1 trial. Both outcomes were in favour of the control group and statistically significant (p < 0.05). AUTHORS' CONCLUSIONS Preterm infants with RDS are unlikely to benefit from AT treatment and may be harmed.
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Affiliation(s)
- D Bassler
- McMaster University Medical Center, Department of Pediatrics/NICU, Room 4G40, 1200 Main Street West, Hamilton, Ontario, Canada.
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Chan A, Jayasuriya K, Berry L, Roth-Kleiner M, Post M, Belik J. Volutrauma activates the clotting cascade in the newborn but not adult rat. Am J Physiol Lung Cell Mol Physiol 2005; 290:L754-L760. [PMID: 16326757 DOI: 10.1152/ajplung.00339.2005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Coagulopathy and alveolar fibrin deposition are common in sick neonates and attributed to the primary disease, as opposed to their ventilatory support. Hypothesizing that high tidal volume ventilation activates the extrinsic coagulation pathway, we air ventilated newborn and adult rats at low (10 ml/kg) or high (30 ml/kg) tidal volume and compared them with age-matched nonventilated controls. Blood was collected at the end of the experiment for measurement of clot time, tissue factor, and other coagulation factor content. Similar measurements were obtained from lung lavage material. The newborn clot time (44+/-1) was lower and plasma tissue factor content higher (103.4+/-0.4) than adults (88+/-4 s and 26.6+/-1.4 units; P<0.01). High, but not low, tidal volume ventilation of newborns for as little as 15 min significantly reduced clot time and increased plasma tissue factor content (P<0.01). High volume ventilation increased plasma factor Xa (0.1+/-0.1 to 1.6+/-0.4 nM; P<0.01) and thrombin (1.3+/-0.2 to 2.2+/-0.4 nM; P<0.05) and decreased antithrombin (0.12+/-0.01 to 0.05+/-0.01; P<0.01) in the newborn. Lung lavage material of high volume-ventilated newborns showed increased (P<0.01) factor Xa and thrombin. No changes in these parameters were observed in adult rats that were high volume ventilated for up to 90 min. Compared with adults, newborn rats have a greater propensity for volutrauma-activated intravascular coagulation. These data suggest that mechanical ventilation promotes neonatal thrombosis via lung tissue factor release.
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Affiliation(s)
- Anthony Chan
- Department of Pediatrics, Hospital for sick children, Toronto, Ontario, Canada
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Dammann O, Leviton A, Gappa M, Dammann CEL. Lung and brain damage in preterm newborns, and their association with gestational age, prematurity subgroup, infection/inflammation and long term outcome. BJOG 2005; 112 Suppl 1:4-9. [PMID: 15715586 DOI: 10.1111/j.1471-0528.2005.00576.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Compared with those born at term, preterm newborns are at an increased risk of short term disorders of the lung (bronchopulmonary dysplasia; BPD) and the brain (white matter damage; WMD), and of long term developmental and pulmonary dysfunctions. Although all of these adverse outcomes are associated with low gestational age, brain, but not lung, damage appears to be associated with the prematurity subgroup [spontaneous preterm labour and/or preterm prelabour rupture of membranes (PPROM) vs pregnancy-induced hypertension (PIH)]. Part of the association between brain damage and prematurity subgroup might be due to a differential exposure of members of these subgroups to perinatal infection/inflammation. There is a lack of studies evaluating the association of antenatal and perinatal risk factors with late childhood pulmonary dysfunction among those born during the second trimester. In this paper we discuss the complexities that paediatricians, perinatologists and perinatal epidemiologists face as they try to understand the contributions of factors associated with preterm birth to neonatal and childhood disorders.
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Affiliation(s)
- Olaf Dammann
- Perinatal Infectious Disease Epidemiology Unit, Department of Obstetrics and Pediatrics, OE 6415 Hannover Medical School, 30623 Hannover, Germany
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10
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Bassler D, Schmidt B. Antithrombin replacement in neonates: is there any indication? Thromb Res 2005; 118:107-11. [PMID: 16709479 DOI: 10.1016/j.thromres.2005.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2005] [Revised: 01/05/2005] [Accepted: 01/18/2005] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Activation of the coagulation system and severe acquired antithrombin (AT) deficiency are common and prognostically important findings in sick and preterm neonates. It has been hypothesised that treatment of the acquired AT deficiency with AT concentrate may improve the outcome of conditions such as the neonatal respiratory distress syndrome (RDS), intracranial hemorrhage (ICH) and sepsis. MATERIALS AND METHODS We performed a systematic review of randomised controlled trials (RCTs) of AT replacement therapy in newborn infants. RESULTS Two full-length trial reports were found. Both were placebo-controlled. The first RCT examined the effects of AT therapy in 122 preterm infants with RDS. Administration of AT prolonged rather than shortened the duration of mechanical ventilation and oxygen therapy. The second RCT determined whether AT replacement decreased the incidence of ICH in 60 preterm infants who were born before 30 weeks of gestation. No beneficial effect on ICH was found. CONCLUSIONS Preterm infants with RDS do not benefit from therapy with AT concentrate and may be harmed. There is also little evidence that the administration of AT reduces the risk of ICH. The role of AT replacement during neonatal sepsis remains uncertain.
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Affiliation(s)
- Dirk Bassler
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Schettini F, Laforgia N, Altomare M, Mautone A, Del Vecchio GC. Plasma protein Z levels in healthy and high-risk newborn infants. Acta Paediatr 2004; 93:654-7. [PMID: 15174790 DOI: 10.1111/j.1651-2227.2004.tb02992.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To evaluate plasma protein Z (PZ) levels in healthy and high-risk newborn infants. METHODS A longitudinal observational study was conducted. Inclusion criteria were: healthy term and preterm newborns normal for gestational age and newborns belonging to one of the following groups: newborns small for gestational age (SGA), newborns affected by respiratory distress syndrome (RDS), newborns from mothers with pre-eclampsia. Newborns with sepsis, congenital malformation or haemorrhagic disorders were excluded. Plasma PZ levels, protein C (PC) concentration, PC activity and protein-induced vitamin K absence levels were measured. RESULTS 53 newborns were enrolled into the study. PZ and PC antigen levels varied significantly among analysed subgroups on day 1 (p < 0.01): lower levels of these inhibitors were found in RDS newborns (group C), newborns from mothers affected by pre-eclampsia (group D) and SGA newborns (group E) than in healthy term and preterm newborns (groups A and B). CONCLUSION PZ deficiency occurs in newborns affected by severe RDS, in newborns from pre-eclamptic mothers and in SGA newborns, probably owing to activated coagulation in the first two conditions and to reduced PZ synthesis in the last condition.
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Affiliation(s)
- F Schettini
- Dipartimento di Biomedicina dell'Età Evolutiva, Sezione di Neonatologia e Terapia Intensiva Neonatale, University of Bari, Italy.
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Abstract
Indicators of coagulation activation are sometimes increased in the blood of newborns and adults who have a systemic inflammatory response. These coagulation factors have the ability to exacerbate inflammation, which in turn can promote coagulation. Therapies directed solely at coagulation factors and therapies directed solely at inflammation factors have not proved effective in reducing mortality in adults with a systemic inflammatory response syndrome and multi-organ dysfunction (SIRS/MOD). On the other hand, the only therapy that has reduced mortality in SIRS/MOD is activated protein C, which has both anti-coagulation and anti-inflammatory effects. This and other observations support the view that activated coagulation factors enhance inflammation. Since newborns at risk of cerebral white matter damage and cerebral palsy are more likely than their peers to have a systemic inflammatory response, which is sometimes accompanied by elevated blood levels of coagulation factors, we suggest that activated coagulation factors contribute to the occurrence of cerebral white matter damage by exacerbating inflammatory phenomena, rather than by occluding cerebral blood vessels.
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Affiliation(s)
- Alan Leviton
- Neuroepidemiology Unit, Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Dik WA, Zimmermann LJI, Naber BA, Janssen DJ, van Kaam AHLC, Versnel MA. Thrombin contributes to bronchoalveolar lavage fluid mitogenicity in lung disease of the premature infant. Pediatr Pulmonol 2003; 35:34-41. [PMID: 12461737 DOI: 10.1002/ppul.10219] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic lung disease of prematurity (CLD) is a common consequence of neonatal respiratory distress syndrome (RDS) and is characterized by pulmonary fibrosis. Increased thrombin activity in the alveolar compartment is associated with pulmonary fibrosis in adults and animals, and contributes to bronchoalveolar lavage (BAL) fluid mitogenicity for fibroblasts. We hypothesized that BAL fluid from infants who develop CLD contains increased mitogenic activity for lung fibroblasts compared to BAL fluid from resolving RDS, and that increased thrombin levels contribute to this activity. Sequential BAL (postnatal days 2-14) was obtained from 37 premature infants who were ventilated for RDS. Twenty-six infants developed CLD, whereas 11 resolved. BAL fluid mitogenic activity was determined in a proliferation assay, using human fetal lung fibroblasts. The contribution of thrombin to mitogenic activity was determined using the thrombin inhibitor PPACK. Furthermore, thrombin levels in BAL fluid were measured using a specific substrate to detect thrombin activity and by measuring thrombin-antithrombin III complex (TATIII). BAL fluid mitogenic activity was comparable between CLD and RDS (CLD, 33% proliferation on day 2 to 41% on day 14; RDS, 21% on day 2 to 54% on day 7). Thrombin inactivation by PPACK completely inhibited mitogenic activity in BAL samples obtained on days 2 and 4 (CLD, P < 0.001 on days 2 and 4; RDS, P < 0.05 on day 4). From day 7 onwards, inhibition of thrombin only partly reduced (P < 0.05) CLD BAL fluid mitogenic activity, indicating that other mitogenic factors contribute as well. Surprisingly, thrombin activity and TATIII were decreased in BAL fluid from CLD compared with RDS patients on days 2 and 4. In conclusion, our study shows that BAL fluid from infants with and without CLD development is equally mitogenic for lung fibroblasts, and that thrombin is a major mitogen in these samples. This suggests that fibroproliferation may occur early in the lungs from infants with both CLD and RDS, and that thrombin contributes to this.
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MESH Headings
- Activin Receptors, Type I/metabolism
- Antithrombin III/metabolism
- Bronchoalveolar Lavage Fluid/cytology
- Cell Division
- Fibroblasts/pathology
- Gestational Age
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/pathology
- Peptide Hydrolases/metabolism
- Protein Serine-Threonine Kinases
- Pulmonary Fibrosis/etiology
- Pulmonary Fibrosis/pathology
- Receptor, Transforming Growth Factor-beta Type I
- Receptors, Transforming Growth Factor beta/metabolism
- Respiration, Artificial
- Respiratory Distress Syndrome, Newborn/complications
- Respiratory Distress Syndrome, Newborn/pathology
- Thrombin/metabolism
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Affiliation(s)
- Willem A Dik
- Department of Immunology, Erasmus MC, Rotterdam, The Netherlands.
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Yurdakök M, Korkmaz A, Kirazli S, Aygün C, Yigit S. Global fibrinolytic capacity in early respiratory distress syndrome: a pilot study. Am J Hematol 2002; 69:255-7. [PMID: 11921019 DOI: 10.1002/ajh.10060] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fibrin deposits found in the pulmonary microcirculation and in the small airways of preterm infants with severe respiratory distress syndrome (RDS) has been explained by the activation of the coagulation system and/or insufficient fibrinolysis. Previous studies suggest that disseminated intravascular coagulation is not prominent in the early stages of RDS, and there is a reduced fibrinolytic activity in these patients. The in vitro evaluation of body's fibrinolytic potential is difficult in contrast to blood clotting because fibrinolysis is only activated after coagulation. To solve this problem a standardized assay was developed to measure the global fibrinolytic capacity (GFC) in plasma. This assay allows us a sensitive and reliable parameter to evaluate the fibrinolytic potency of plasma in vitro. We therefore studied GFC in the first 6 hr after birth in preterm infants who later developed RDS. Global fibrinolytic capacity which is expressed as generated D-dimer concentrations was significantly lower in preterm infants who later developed RDS compared to the control group in this study. These findings support our previous hypothesis of "reduced fibrinolytic state in early RDS".
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Affiliation(s)
- Murat Yurdakök
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Koehne PS, Wagner MH, Willam C, Sonntag J, Bührer C, Obladen M. Soluble intercellular cell adhesion molecule-1 and L-selectin plasma concentrations and response to surfactant in preterm infants. Pediatr Crit Care Med 2002; 3:23-8. [PMID: 12793918 DOI: 10.1097/00130478-200201000-00006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate whether plasma concentrations of soluble intercellular cell adhesion molecule (ICAM)-1 and L-selectin at 24 hrs of life are related to good or poor response to exogenous surfactant in preterm infants. DESIGN Prospective study of markers of inflammation in circulating blood at 24 hrs of life. SETTING Level III neonatal intensive care unit. PATIENTS Twenty-nine preterm newborns suffering from severe respiratory distress syndrome (Fio(2) > 0.4) without signs of infection or fetal acidosis, and 17 healthy preterm newborns of similar gestational age serving as controls. INTERVENTIONS Infants with respiratory distress were treated with natural surfactant at 0.3-5 hrs of life. A response to surfactant, defined as a decrease of Fio(2) >50% within 6 hrs after surfactant, was seen in 21 infants. MEASUREMENTS AND MAIN RESULTS Soluble ICAM-1 and L-selectin concentrations were determined in plasma samples taken at 24 hrs of age. ICAM-1 was elevated (p <.001) in infants who responded poorly to surfactant (median, 392 ng/mL; range, 58.26-4884.24 ng/mL) compared with good responders (20.52 ng/mL, 2.32-138.58 ng/mL) or controls (21.91 ng/mL, 2.61-65.73 ng/mL), without differences between controls and good responders. L-selectin was lower (p =.004) in surfactant-treated infants (4.45 nmol/L, 2.0-10.4 ng/mL) than in controls (6.0/2.35-10.25 nmol/L) without differences between surfactant good and poor responders. However, infants requiring supplemental oxygen at 36 wks of gestational age had reduced L-selectin at 24 hrs of age (3.2/2.0-3.45 vs. 5.0/2.35-10.4 nmol/L, p =.004), whereas there was no difference in ICAM-1. CONCLUSIONS In preterm infants with respiratory distress, a poor response to surfactant within 6 hrs of administration is associated with elevated circulating ICAM-1 concentrations at 24 hrs of age. Low plasma L-selectin at 24 hrs of age predicts prolonged requirement for supplemental oxygen.
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Affiliation(s)
- Petra S Koehne
- Department of Neonatology, Charité Virchow-Hospital, Humboldt University, Berlin, Germany
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Abstract
Despite the considerable advances made in understanding the pathophysiology of systemic inflammation during critical illness, clinical progress has been elusive as it remains a very deadly condition. Cortisol and thyroid hormone levels can be as predictive of outcome as the commonly used severity parameters (i.e. APACHE). Indeed, levels of endocrine humoral substances such as arachidonic acids, nitric oxide, endothelin, calcitonin precursors, leptin and adenosine correlate with the severity and outcome of critical illness. Furthermore, calcitonin precursors represent a potentially new hormokine paradigm, being transcriptionally activated in all cells in response to infection. The cytokines are immune markers that often correlate with severity and outcome, but their release is transient. In contrast, the so-called acute phase proteins, such as C-reactive protein and serum amyloid A, are highly sensitive to inflammatory activity and can be important markers of severity and outcome. Leukocyte esterase, adhesion molecules, platelet activating factor and activated protein C are additional humoral immune markers; the replacement of the latter has been shown to be a promising therapeutic option. Natriuretic peptides are neurocrine humoral markers that have important cardiovascular implications. The level of macrophage migrating inhibitory factor, released by the pituitary, is elevated in sepsis and counteracts glucocorticoid action. Cellular markers to severe stress include the enhanced expression of protective substances in the form of heat shock proteins. High mobility group-1 is a DNA-binding protein and a late mediator of the inflammatory response. Apoptotic markers such as the soluble fas ligand are also elevated in inflammation. In summary, during critical illness, the endocrine, immune and nervous systems elaborate a multitude of humoral markers, the roles of which merit further scrutiny in order to improve therapeutic outcome.
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Affiliation(s)
- E S Nylén
- Department of Medicine, Section of Endocrinology, George Washington University School of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
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17
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Jaarsma AS, Braaksma MA, Geven WB, Van Oeveren W, Oetomo SB. Early activation of inflammation and clotting in the preterm lamb with neonatal RDS: comparison of conventional ventilation and high frequency oscillatory ventilation. Pediatr Res 2001; 50:650-7. [PMID: 11641462 DOI: 10.1203/00006450-200111000-00019] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In neonatal respiratory distress syndrome activation of inflammation and clotting is demonstrated. High frequency oscillatory ventilation (HFOV) is considered to be less damaging to the human preterm lung, resulting in less activation of inflammation and clotting compared with conventional ventilation (CV). To assess the sequence of events of activation of inflammation and clotting and to compare the impact of HFOV to CV, we ventilated preterm lambs delivered by cesarean section at 132 d gestational age (term 145 d) for 8 h by CV (n = 10) or HFOV (n = 11). Fifteen minutes after birth and at 2-h intervals thereafter blood samples, from umbilical catheters, were analyzed for AP50 (complement activation), number of polymorphonuclear leukocytes, beta-glucuronidase, platelet function, activated partial thromboplastin time, thrombin time and thrombin inhibition, and bronchoalveolar lavage fluid was analyzed for elastase, thrombin and protein. We found complement activation, low number of polymorphonuclear leukocytes and high levels of beta-glucuronidase already at 15 min after birth. Within 2 to 4 h after birth platelet function deteriorated, activated partial thromboplastin time prolonged, and thrombin inhibition decreased. Activation of inflammation and clotting in the lungs was demonstrated by increased levels of elastase and thrombin in bronchoalveolar lavage fluid. In the HFOV group, AP50 remained significantly higher than in the CV group, reflecting less complement activation, and platelet function analysis remained significantly lower, reflecting better platelet function. We conclude that systemic activation of inflammation can be found in the ventilated preterm lamb with respiratory distress syndrome within 15 min after birth. Afterward, or due to activation of inflammation, clotting is activated. HFOV possibly attenuates activation of inflammation.
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Affiliation(s)
- A S Jaarsma
- Department of Pediatrics, Division of Neonatology, University Hospital Groningen, The Netherlands.
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18
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Brus F, Oetomo SB, Schieving J, Groothuis E, Okken A, van Oeveren W. Increased tissue-type plasminogen activator antigen release is not accompanied by increased systemic fibrinolytic activity in severe neonatal respiratory distress syndrome. Pediatr Res 1999; 45:588-94. [PMID: 10203153 DOI: 10.1203/00006450-199904010-00020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intravascular and intraalveolar fibrin depositions in preterm infants with severe respiratory distress syndrome (RDS) have been attributed to activation of clotting. We questioned whether in the face of activated clotting, fibrinolysis is sufficient in these infants. We found, in infants with severe RDS within 6 to 12 h of birth, increased median thrombin-antithrombin III complex formation (11.1 versus 1.3 ng/mL in the group with mild-to-moderate RDS, p < 0.001), indicating activation of clotting. Simultaneously, we found increased tissue-type plasminogen activator antigen (t-PA) release in plasma of these infants represented by increased median t-PA plasma concentrations (8.3 versus 2.5 ng/mL in the group with mild-to-moderate RDS, p < 0.01). This increased t-PA release was not accompanied with more plasminogen and antiplasmin consumption and with more fibrin and fibrinogen degradation than in the infants with mild-to-moderate RDS because plasma plasminogen and antiplasmin activity and total fibrin and fibrinogen degradation product concentrations were similar in both groups. We have found that activated clotting and t-PA plasma concentrations are positively correlated with arterial-to-alveolar oxygen tension ratio and ventilator efficiency index values. Plasminogen and antiplasmin activity, and total fibrin and fibrinogen degradation product concentrations were not correlated with these continuous measures of RDS severity. In neonatal RDS, clotting activity contributes to disease severity. Insufficient fibrinolysis likely facilitates the deleterious effects of activated clotting.
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Affiliation(s)
- F Brus
- Beatrix Childrens Hospital, Division of Neonatology, University of Groningen, The Netherlands
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Schmidt B, Gillie P, Mitchell L, Andrew M, Caco C, Roberts R. A placebo-controlled randomized trial of antithrombin therapy in neonatal respiratory distress syndrome. Am J Respir Crit Care Med 1998; 158:470-6. [PMID: 9700123 DOI: 10.1164/ajrccm.158.2.9712116] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Neonatal respiratory distress syndrome (RDS) is associated with decreased plasma activity of antithrombin (AT) and increased formation of thrombin. We tested whether AT reduces thrombin formation, improves gas exchange, and decreases the duration of mechanical ventilation and supplemental oxygen. One hundred twenty-two infants were randomized to pasteurized AT concentrate or to placebo. Two ml/kg (equivalent to 100 IU AT/kg) were followed by 1 ml/kg (50 IU/kg) every 6 h for 48 h. Outcome measures included plasma AT activity, thrombin-AT (TAT) complex, prothrombin fragment (F1+2), the ratio of arterial to alveolar oxygen pressure [(a/A)PO2], and the ventilator efficiency index (VEI). In the AT group (n = 61), mean (SD) birth weight was 1,198 (301) g, mean (SD) gestational age (GA) was 28.3 (2.0) wk, 54% were male. In the placebo group (n = 61), mean (SD) birth weight was 1,201 (315) g, mean (SD) GA was 28.8 (2. 3) wk, 51% were male. In treated infants, AT activity was raised to means of 1.69 and 2.25 U/ml at 24 and 48 h, respectively. Corresponding means in control infants were 0.37 and 0.44 U/ml (p < 0.0001). F1+2, but not TAT, was significantly reduced by AT (p = 0. 004). VEI and (a/A)PO2 were similar in both groups throughout the first week of life. Median days receiving mechanical ventilation were 7.1 (AT) versus 4.8 (placebo), p = 0.0014. Median days receiving supplemental oxygen were 7.9 (AT) versus 5.5 (placebo), p < 0.0001. There were seven (11.5%) deaths in the AT group and three (4.9%) deaths in the placebo group. We conclude that treatment with AT cannot be recommended in premature infants with RDS.
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Affiliation(s)
- B Schmidt
- Departments of Paediatrics, Radiology, and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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