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Wang B, Zhang J, Cheng R. Safety assessment of sildenafil use in neonates: a real-world data analysis based on the FDA adverse event reporting system (FAERS). Expert Opin Drug Saf 2024:1-6. [PMID: 39039760 DOI: 10.1080/14740338.2024.2383710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND The safety of neonatal sildenafil use remains uncertain. This study aimed to investigate adverse events (AEs) associated with sildenafil use in neonates. RESEARCH DESIGN AND METHODS We collected data on AEs associated with sildenafil use in neonates from the US Food and Drug Administration Adverse Event Reporting System database, spanning from its inception of the database in 2004 to 2023. Disproportionality measures were employed to analyze the correlation between AEs and sildenafil. RESULTS Sildenafil was identified as the primary suspect drug in 75 AE reports, involving 214 AEs. Three system organ classes, namely, eye disorders, hepatobiliary disorders, and vascular disorders were associated with sildenafil use. Six preferred terms, namely, flushing, retinopathy of prematurity, hyperbilirubinemia, pulmonary hemorrhage, hypotension, and diarrhea were associated with sildenafil use. Notably, hyperbilirubinemia and pulmonary hemorrhage were previously unreported AEs associated with sildenafil use. CONCLUSION The results highlight the ongoing uncertainty surrounding the safety of neonatal sildenafil use and provide vital support for risk monitoring and identification in neonates receiving sildenafil. Additionally, the study underscores the need for continuous safety surveillance in neonates treated with sildenafil and suggests further exploration of the precise causal relationships between AEs and sildenafil.
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Affiliation(s)
- Bo Wang
- Department of Pediatrics, The Affiliated Suqian First People's Hospital of Nanjing Medical University, Suqian, China
| | - Jia Zhang
- Department of Pediatrics, The Affiliated Suqian First People's Hospital of Nanjing Medical University, Suqian, China
| | - Rui Cheng
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing, China
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Morales-Demori R, Coleman R, Mallory GB. Pediatric Pulmonary Hypertension. Pediatr Rev 2024; 45:251-259. [PMID: 38689108 DOI: 10.1542/pir.2023-006010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Affiliation(s)
| | | | - George B Mallory
- Section of Pulmonology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Kiskaddon A, Dang T, Mauriello D. Tadalafil in Neonates and Infants With Pulmonary Hypertension Secondary to Bronchopulmonary Dysplasia. J Pediatr Pharmacol Ther 2024; 29:140-143. [PMID: 38596414 PMCID: PMC11001203 DOI: 10.5863/1551-6776-29.2.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/30/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVES The primary outcome of this study was to describe the dosing regimen of tadalafil in neonates and infants diagnosed with pulmonary hypertension (PH) secondary to bronchopulmonary dysplasia (BPD). Secondary outcomes included tolerability, efficacy, adverse events, discontinuation of therapy, and changes in echocardiography. METHODS This was a single-center, retrospective review of neonates and infants <1 year of age at initiation of tadalafil for PH secondary to BPD from January 2010 to November 2021. Data collected from the electronic medical record included patient demographics, tadalafil dosing, oxygen support, mechanical ventilation, concomitant PH medications, adverse events, and echocardiography information. RESULTS Forty-two patients-4 neonates and 38 infants-met the inclusion criteria. The postnatal and post-menstrual age (median, IQR) at diagnosis were 121 (35.5-153.5) days and 42.6 (40.6-47.6) weeks, respectively. The initial and highest tadalafil doses (median, range) were 1 (0.25-2) and 1 (0.5-2) mg/kg/day. Only 1 patient experienced pulmonary overcirculation and required tadalafil to be discontinued. Over half (57.1%) of the patients in this study discontinued tadalafil therapy owing to improvements in pulmonary artery pressures. CONCLUSIONS Tadalafil 1 mg/kg/day was the most commonly used dose regimen in neonates and infants. Tadalafil at this dose of 1 mg/kg/day appears well tolerated in neonates and infants with PH secondary to BPD and correlates with improvements in pulmonary artery pressures. Further studies evaluating tadalafil in comparison to other phosphodiesterase-5 inhibitors in neonates with PH secondary to BPD are warranted.
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Affiliation(s)
- Amy Kiskaddon
- Department of Pharmacy (AK), Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Pediatrics, Division of Cardiology (AK), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tanaka Dang
- Department of Pharmacy (TD), Texas Children’s Hospital, Houston, TX
| | - Daniel Mauriello
- Division of Pediatric Cardiology (DM), Johns Hopkins All Children’s Hospital, St. Petersburg, FL
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4
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Collaco JM, Abman SH, Austin ED, Avitabile CM, Bates A, Fineman JR, Freire GA, Handler SS, Ivy DD, Krishnan US, Mullen MP, Varghese NP, Yung D, Nies MK, Everett AD, Zimmerman KO, Simmons W, Chakraborty H, Yenokyan G, Newell‐Sturdivant A, Christensen E, Eyzaguirre LM, Hanley DF, Rosenzweig EB, Romer LH. Kids Mod PAH trial: A multicenter trial comparing mono- versus duo-therapy for initial treatment of pediatric pulmonary hypertension. Pulm Circ 2023; 13:e12305. [PMID: 37915400 PMCID: PMC10617301 DOI: 10.1002/pul2.12305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/20/2023] [Indexed: 11/03/2023] Open
Abstract
Pulmonary hypertension (PH) is a significant health problem that contributes to high morbidity and mortality in diverse cardiac, pulmonary, and systemic diseases in children. Evidence-based advances in PH care have been challenged by a paucity of quality endpoints for assessing clinical course and the lack of robust clinical trial data to guide pharmacologic therapies in children. While the landmark adult AMBITION trial demonstrated the benefit of up-front combination PH therapy with ambrisentan and tadalafil, it remains unknown whether upfront combination therapy leads to more rapid and sustained clinical benefits in children with various categories of PH. In this article, we describe the inception of the Kids Mod PAH Trial, a multicenter Phase III trial, to address whether upfront combination therapy (sildenafil and bosentan vs. sildenafil alone) improves PH outcomes in children, recognizing that marked differences between the etiology and therapeutic response between adults and children exist. The primary endpoint of this study is WHO functional class (FC) 12 months after initiation of study drug therapy. In addition to the primary outcome, secondary endpoints are being assessed, including a composite measure of time to clinical worsening, WHO FC at 24 months, echocardiographic assessment of PH and quantitative assessment of right ventricular function, 6-min walk distance, and NT-proBNP levels. Exploratory endpoints include selected biomarkers, actigraphy, and assessments of quality of life. This study is designed to pave the way for additional clinical trials by establishing a robust infrastructure through the development of a PPHNet Clinical Trials Network.
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Affiliation(s)
- Joseph M. Collaco
- Departments of Pediatrics, Neurology, Anesthesiology and Critical Care Medicine, and BiostatisticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Steven H. Abman
- Department of PediatricsChildren's Hospital ColoradoAuroraColoradoUSA
| | - Eric D. Austin
- Department of PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Catherine M. Avitabile
- Department of Pediatrics, Children's Hospital of PhiladelphiaUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Angela Bates
- Departments of Pediatrics, Neurology, Anesthesiology and Critical Care Medicine, and BiostatisticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jeffrey R. Fineman
- Department of PediatricsUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Grace A. Freire
- Department of PediatricsJohns Hopkins All Children's HospitalSt. PetersburgFloridaUSA
| | | | - Dunbar D. Ivy
- Department of PediatricsChildren's Hospital ColoradoAuroraColoradoUSA
| | - Usha S. Krishnan
- Department of Pediatrics, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Mary P. Mullen
- Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Nidhy P. Varghese
- Department of Pediatrics, Baylor College of MedicineTexas Children's HospitalHoustonTexasUSA
| | - Delphine Yung
- Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Melanie K. Nies
- Departments of Pediatrics, Neurology, Anesthesiology and Critical Care Medicine, and BiostatisticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Allen D. Everett
- Departments of Pediatrics, Neurology, Anesthesiology and Critical Care Medicine, and BiostatisticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Kanecia O. Zimmerman
- Departments of Biostatistics and Bioinformatics, Department of Pediatrics, Duke Clinical Research InstituteDuke UniversityDurhamNorth CarolinaUSA
| | - William Simmons
- Departments of Biostatistics and Bioinformatics, Department of Pediatrics, Duke Clinical Research InstituteDuke UniversityDurhamNorth CarolinaUSA
| | - Hrishikesh Chakraborty
- Departments of Biostatistics and Bioinformatics, Department of Pediatrics, Duke Clinical Research InstituteDuke UniversityDurhamNorth CarolinaUSA
| | - Gayane Yenokyan
- Departments of Pediatrics, Neurology, Anesthesiology and Critical Care Medicine, and BiostatisticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Allison Newell‐Sturdivant
- Departments of Pediatrics, Neurology, Anesthesiology and Critical Care Medicine, and BiostatisticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Neurology, Johns Hopkins School of MedicineBIOS Clinical Trials Coordinating Center (CTCC)BaltimoreMarylandUSA
| | - Eric Christensen
- Departments of Pediatrics, Neurology, Anesthesiology and Critical Care Medicine, and BiostatisticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Neurology, Johns Hopkins School of MedicineBIOS Clinical Trials Coordinating Center (CTCC)BaltimoreMarylandUSA
| | - Lindsay M. Eyzaguirre
- Departments of Pediatrics, Neurology, Anesthesiology and Critical Care Medicine, and BiostatisticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Neurology, Johns Hopkins School of MedicineBIOS Clinical Trials Coordinating Center (CTCC)BaltimoreMarylandUSA
| | - Daniel F. Hanley
- Departments of Pediatrics, Neurology, Anesthesiology and Critical Care Medicine, and BiostatisticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Neurology, Johns Hopkins School of MedicineBIOS Clinical Trials Coordinating Center (CTCC)BaltimoreMarylandUSA
| | - Erika B. Rosenzweig
- Department of Pediatrics, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Lewis H. Romer
- Departments of Pediatrics, Neurology, Anesthesiology and Critical Care Medicine, and BiostatisticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Li Y, Fu Y, Liu Y, Zhao D, Liu L, Bourouis S, Algarni AD, Zhong C, Wu P. An optimized machine learning method for predicting wogonin therapy for the treatment of pulmonary hypertension. Comput Biol Med 2023; 164:107293. [PMID: 37591162 DOI: 10.1016/j.compbiomed.2023.107293] [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: 04/16/2023] [Revised: 06/25/2023] [Accepted: 07/28/2023] [Indexed: 08/19/2023]
Abstract
Human health is at risk from pulmonary hypertension (PH), characterized by decreased pulmonary vascular resistance and constriction of the pulmonary vessels, resulting in right heart failure and dysfunction. Thus, preventing PH and monitoring its progression before treating it is vital. Wogonin, derived from the leaves of Scutellaria baicalensis Georgi, exhibits remarkable pharmacological activity. In this study, we examined the effectiveness of wogonin in mitigating the progression of PH in mice using right heart catheterization and hematoxylin-eosin (HE) staining. As an alternative to minimize the possibility of harming small animals, we present a scientifically effective feature selection method (BSCDWOA-KELM) that will allow us to develop a novel simpler noninvasive prediction method for wogonin in treating PH. In this method, we use the proposed enhanced whale optimizer (SCDWOA) in conjunction with the kernel extreme learning machine (KELM). Initially, we let SCDWOA perform global optimization experiments on the IEEE CEC2014 benchmark function set to verify its core advantages. Lastly, 12 public and PH datasets are examined for feature selection experiments using BSCDWOA-KELM. As shown in the experimental results for global optimization, the proposed SCDWOA has better convergence performance. Meanwhile, the proposed binary SCDWOA (BSCDWOA) significantly improves the ability of KELM to classify data. By utilizing the BSCDWOA-KELM, key indicators such as the Red blood cell (RBC), the Haemoglobin (HGB), the Lymphocyte percentage (LYM%), the Hematocrit (HCT), and the Red blood cell distribution width-size distribution (RDW-SD) can be efficiently screened in the Pulmonary hypertension dataset, and one of its most essential points is its accuracy of greater than 0.98. Consequently, the BSCDWOA-KELM introduced in this study can be used to predict wogonin therapy for treating pulmonary hypertension in a simple and noninvasive manner.
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Affiliation(s)
- Yupeng Li
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin 130032, China.
| | - Yujie Fu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.
| | - Yining Liu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.
| | - Dong Zhao
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin 130032, China.
| | - Lei Liu
- College of Computer Science, Sichuan University, Chengdu, Sichuan 610065, China.
| | - Sami Bourouis
- Department of Information Technology, College of Computers and Information Technology, Taif University, P.O.Box 11099, Taif 21944, Saudi Arabia.
| | - Abeer D Algarni
- Department of Information Technology, College of Computer and Information Sciences, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia.
| | - Chuyue Zhong
- The First Clinical College, Wenzhou Medical University, Wenzhou 325000, China.
| | - Peiliang Wu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.
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Awad AK, Gad ER, Abdelgalil MS, Elsaeidy AS, Ahmed O, Elbadawy MA. Sildenafil for congenital heart diseases induced pulmonary hypertension, a meta-analysis of randomized controlled trials. BMC Pediatr 2023; 23:372. [PMID: 37474896 PMCID: PMC10360284 DOI: 10.1186/s12887-023-04180-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/05/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Sildenafil was first prescribed for angina pectoris and then for erectile dysfunction from its effects on vascular smooth muscle relaxation and vasodilatation. Recently, sildenafil has been proposed for congenital heart diseases induced pulmonary hypertension, which constitutes a huge burden on children's health and can attribute to fatal complications due to presence of unoxygenated blood in the systemic circulation. Therefore, our meta-analysis aims to further investigate the safety and efficacy of sildenafil on children population. METHODS We searched the following electronic databases: PubMed, Cochrane CENTRAL, WOS, Embase, and Scopus from inception to April 20th, 2022. Randomized controlled trials that assess the efficacy of using sildenafil in comparison to a placebo or any other vasodilator drug were eligible for inclusion. The inverse variance method was used to pool study effect estimates using the random effect model. Effect sizes are provided in the form of mean difference (MD) with 95% confidence intervals (CI). RESULTS Our study included 14 studies with (n = 849 children) with a mean age of 7.9 months old. Sildenafil showed a statistically significant decrease over placebo in mean and systolic pulmonary artery pressure (PAP) with MD -7.42 (95%CI [-13.13, -1.71], P = 0.01) and -8.02 (95%CI [-11.16, -4.88], P < 0.0001), respectively. Sildenafil revealed a decrease in mean aortic pressure and pulmonary artery/aortic pressure ratio over placebo with MD -0.34 (95%CI [-2.42, 1.73], P = 0.75) and MD -0.10 (95%CI [-0.11, -0.09], P < 0.00001), respectively. Regarding post corrective operations parameters, sildenafil had a statistically significant lower mechanical ventilation time, intensive care unit stay, and hospital stay over placebo with MD -19.43 (95%CI [-31.04, -7.81], s = 0.001), MD -34.85 (95%CI [-50.84, -18.87], P < 0.00001), and MD -41.87 (95%CI [-79.41, -4.33], P = 0.03), respectively. Nevertheless, no difference in mortality rates between sildenafil and placebo with OR 0.25 (95%CI 0.05, 1.30], P = 0.10) or tadalafil with OR 1 (95%CI 0.06, 17.12], P = 1). CONCLUSION Sildenafil is a well-tolerated treatment in congenital heart diseases induced pulmonary hypertension, as it has proven its efficacy not only in lowering both PAP mean and systolic but also in reducing the ventilation time, intensive care unit and hospital stay with no difference observed regarding mortality rates.
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Affiliation(s)
- Ahmed K. Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | | | | | | | - Omar Ahmed
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
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7
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Zhang H, D'Alessandro A, Li M, Reisz JA, Riddle S, Muralidhar A, Bull T, Zhao L, Gerasimovskaya E, Stenmark KR. Histone deacetylase inhibitors synergize with sildenafil to suppress purine metabolism and proliferation in pulmonary hypertension. Vascul Pharmacol 2023; 149:107157. [PMID: 36849042 PMCID: PMC10067337 DOI: 10.1016/j.vph.2023.107157] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/22/2023] [Indexed: 02/27/2023]
Abstract
RATIONALE Sildenafil, a well-known vasodilator known to interfere with purinergic signaling through effects on cGMP, is a mainstay in the treatment of pulmonary hypertension (PH). However, little is known regarding its effects on the metabolic reprogramming of vascular cells, which is a hallmark of PH. Purine metabolism, especially intracellular de novo purine biosynthesis is essential for vascular cell proliferation. Since adventitial fibroblasts are critical contributors to proliferative vascular remodeling in PH, in this study we aimed to investigate if sildenafil, beyond its well-known vasodilator role in smooth muscle cells, impacts intracellular purine metabolism and proliferation of fibroblasts derived from human PH patients. METHODS Integrated omics approaches (plasma and cell metabolomics) and pharmacological inhibitor approaches were employed in plasma samples and cultured pulmonary artery fibroblasts from PH patients. MEASUREMENTS AND MAIN RESULTS Plasma metabolome analysis of 27 PH patients before and after treatment with sildenafil, demonstrated a partial, but specific effect of sildenafil on purine metabolites, especially adenosine, adenine, and xanthine. However, circulating markers of cell stress, including lactate, succinate, and hypoxanthine were only decreased in a small subset of sildenafil-treated patients. To better understand potential effects of sildenafil on pathological changes in purine metabolism (especially purine synthesis) in PH, we performed studies on pulmonary fibroblasts from PAH patients (PH-Fibs) and corresponding controls (CO-Fibs), since these cells have previously been shown to demonstrate stable and marked PH associated phenotypic and metabolic changes. We found that PH-Fibs exhibited significantly increased purine synthesis. Treatment of PH-Fibs with sildenafil was insufficient to normalize cellular metabolic phenotype and only modestly attenuated the proliferation. However, we observed that treatments which have been shown to normalize glycolysis and mitochondrial abnormalities including a PKM2 activator (TEPP-46), and the histone deacetylase inhibitors (HDACi), SAHA and Apicidin, had significant inhibitory effects on purine synthesis. Importantly, combined treatment with HDACi and sildenafil exhibited synergistic inhibitory effects on proliferation and metabolic reprogramming in PH-Fibs. CONCLUSIONS While sildenafil alone partially rescues metabolic alterations associated with PH, treatment with HDACi, in combination with sildenafil, represent a promising and potentially more effective strategy for targeting vasoconstriction, metabolic derangement and pathological vascular remodeling in PH.
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Affiliation(s)
- Hui Zhang
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics and Medicine, University of Colorado School of Medicine, Denver, USA
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Denver, USA
| | - Min Li
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics and Medicine, University of Colorado School of Medicine, Denver, USA
| | - Julie A Reisz
- Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Denver, USA
| | - Suzette Riddle
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics and Medicine, University of Colorado School of Medicine, Denver, USA
| | - Akshay Muralidhar
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Denver, USA
| | - Todd Bull
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Denver, USA
| | - Lan Zhao
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Evgenia Gerasimovskaya
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics and Medicine, University of Colorado School of Medicine, Denver, USA
| | - Kurt R Stenmark
- Cardiovascular Pulmonary Research Laboratories, Department of Pediatrics and Medicine, University of Colorado School of Medicine, Denver, USA.
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Youssef DE, Handler SS, Richards SM, Sheppard CA, Smith J, Tillman K, Pietrosanu M, Kirkpatrick E, Bates A. Multicenter review of a tadalafil suspension formulation for infants and children with pulmonary hypertension: A North American experience. Front Pediatr 2023; 11:1055131. [PMID: 36776903 PMCID: PMC9909267 DOI: 10.3389/fped.2023.1055131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/09/2023] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Phosphodiesterase type 5 (PDE5) inhibitors, with sildenafil the earliest among them, are widely used in the management of pediatric pulmonary arterial hypertension (PAH). Tadalafil is a PDE5 inhibitor with a long half life (16 h), stable pharmacokinetics and pharmacodynamics, and minimal adverse effects. However, the utility of tadalafil suspensions in this setting has not been widely explored due to a lack of clinical experience. We present a multicenter experience that details the safety and tolerability of a tadalafil suspension, either alone or in combination with another vasodilator, for the management of pediatric pulmonary hypertension (PH). METHODS AND MATERIALS This is a retrospective chart review of infants and children at Children's Wisconsin and the Stollery Children's Hospital enrolled in pediatric PH programs between December 2013 and April 2022 managed with a tadalafil suspension. Patients aged six years of age and under who were treated with a tadalafil suspension were included. Demographics, clinical information, echocardiographic and hemodynamic measurements, and laboratory data were collected before and six months after tadalafil initiation. RESULTS Over the study period, 154 children with a median age of 1.0 (range 0.0-6.9) years were treated with tadalafil therapy. Of these, 39 (25.3%) were in group 1 (PAH), 79 (51.3%) were in group 3 (lung disease), and 33 (21.4%) were in group 5 (pulmonary hypertensive vascular disease). The median initial dose of tadalafil was 1.0 mg/kg once daily. Eleven (7.1%) patients in the cohort were established on tadalafil therapy de novo. The suspension formulation was necessary for 103 (66.9%) patients due to an inability to take enteral tablets and for 49 (31.8%) due to a need for feeding via gastric or jejunal tubes. We observed a statistically significant increase in tricuspid annular plane systolic excursion as well as significant decreases in right-ventricular systolic pressure and NT-proBNP. Tadalafil therapy was well tolerated over the six-month period: at six months, no adverse effects were reported aside from gastrointestinal disturbances by 2 (1.3%) patients. CONCLUSION Tadalafil, a long-acting PDE5 inhibitor, when administered in a suspension formulation, has a safe and tolerable adverse effect profile. Following six months of therapy, our cohort showed improvements in clinical parameters, echocardiographic measurements, and laboratory results. Patient compliance was good and adverse effects were rare, minor, and manageable with nonpharmacological means.
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Affiliation(s)
- David Edward Youssef
- Division of Pediatrics, Department of Pediatric Pulmonary Hypertension, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Stephanie S Handler
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Susan Marjorie Richards
- Division of Pediatrics, Department of Pediatric Pulmonary Hypertension, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Catherine Anne Sheppard
- Division of Pediatrics, Department of Pediatric Pulmonary Hypertension, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Jenna Smith
- Department of Pharmacy, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Kathryn Tillman
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Matthew Pietrosanu
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Edward Kirkpatrick
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Angela Bates
- Division of Pediatrics, Department of Pediatric Pulmonary Hypertension, Stollery Children's Hospital, Edmonton, AB, Canada.,Division of Pediatric Critical Care, Division of Pediatrics, University of Alberta, Edmonton, AB, Canada
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10
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Medical Therapies for Heart Failure in Hypoplastic Left Heart Syndrome. J Cardiovasc Dev Dis 2022; 9:jcdd9050152. [PMID: 35621863 PMCID: PMC9143150 DOI: 10.3390/jcdd9050152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 02/05/2023] Open
Abstract
Significant surgical and medical advances over the past several decades have resulted in a growing number of infants and children surviving with hypoplastic left heart syndrome (HLHS) and other congenital heart defects associated with a single systemic right ventricle (RV). However, cardiac dysfunction and ultimately heart failure (HF) remain the most common cause of death and indication for transplantation in this population. Moreover, while early recognition and treatment of single ventricle-related complications are essential to improving outcomes, there are no proven therapeutic strategies for single systemic RV HF in the pediatric population. Importantly, prototypical adult HF therapies have been relatively ineffective in mitigating the need for cardiac transplantation in HLHS, likely due to several unique attributes of the failing HLHS myocardium. Here, we discuss the most commonly used medical therapies for the treatment of HF symptoms in HLHS and other single systemic RV patients. Additionally, we provide an overview of potential novel therapies for systemic ventricular failure in the HLHS and related populations based on fundamental science, pre-clinical, clinical, and observational studies in the current literature.
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11
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Shi B, Zhou T, Lv S, Wang M, Chen S, Heidari AA, Huang X, Chen H, Wang L, Wu P. An evolutionary machine learning for pulmonary hypertension animal model from arterial blood gas analysis. Comput Biol Med 2022; 146:105529. [PMID: 35594682 DOI: 10.1016/j.compbiomed.2022.105529] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/03/2022]
Abstract
Pulmonary hypertension (PH) is a rare and fatal condition that leads to right heart failure and death. The pathophysiology of PH and potential therapeutic approaches are yet unknown. PH animal models' development and proper evaluation are critical to PH research. This work presents an effective analysis technology for PH from arterial blood gas analysis utilizing an evolutionary kernel extreme learning machine with multiple strategies integrated slime mould algorithm (MSSMA). In MSSMA, two efficient bee-foraging learning operators are added to the original slime mould algorithm, ensuring a suitable trade-off between intensity and diversity. The proposed MSSMA is evaluated on thirty IEEE benchmarks and the statistical results show that the search performance of the MSSMA is significantly improved. The MSSMA is utilised to develop a kernel extreme learning machine (MSSMA-KELM) on PH from arterial blood gas analysis. Comprehensively, the proposed MSSMA-KELM can be used as an effective analysis technology for PH from arterial Blood gas analysis with an accuracy of 93.31%, Matthews coefficient of 90.13%, Sensitivity of 91.12%, and Specificity of 90.73%. MSSMA-KELM can be treated as an effective approach for evaluating mouse PH models.
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Affiliation(s)
- Beibei Shi
- Affiliated People's Hospital of Jiangsu University, 8 Dianli Road, Zhenjiang, Jiangsu, 212000, China.
| | - Tao Zhou
- The First Clinical College, Wenzhou Medical University, Wenzhou, 325000, China.
| | - Shushu Lv
- The First Clinical College, Wenzhou Medical University, Wenzhou, 325000, China.
| | - Mingjing Wang
- College of Computer Science and Artificial Intelligence, Wenzhou University, Wenzhou, 325035, China.
| | - Siyuan Chen
- Affiliated People's Hospital of Jiangsu University, 8 Dianli Road, Zhenjiang, Jiangsu, 212000, China.
| | - Ali Asghar Heidari
- School of Surveying and Geospatial Engineering, College of Engineering, University of Tehran, Tehran, Iran; Department of Computer Science, School of Computing, National University of Singapore, Singapore, Singapore.
| | - Xiaoying Huang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
| | - Huiling Chen
- College of Computer Science and Artificial Intelligence, Wenzhou University, Wenzhou, 325035, China.
| | - Liangxing Wang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
| | - Peiliang Wu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
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12
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Kumar G, Saini M, Kundu S. Therapeutic enzymes as non-conventional targets in cardiovascular impairments:A Comprehensive Review. Can J Physiol Pharmacol 2021; 100:197-209. [PMID: 34932415 DOI: 10.1139/cjpp-2020-0732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Over the last few decades, substantial progress has been made towards the understanding of cardiovascular diseases (CVDs). In-depth mechanistic insights have also provided opportunities to explore novel therapeutic targets and treatment regimens to be discovered. Therapeutic enzymes are an example of such opportunities. The balanced functioning of such enzymes protects against a variety of CVDs while on the other hand, even a small shift in the normal functioning of these enzymes may lead to deleterious outcomes. Owing to the great versatility of these enzymes, inhibition and activation are key regulatory approaches to counter the onset and progression of several cardiovascular impairments. While cardiovascular remedies are already available in excess and of course they are efficacious, a comprehensive description of novel therapeutic enzymes to combat CVDs is the need of the hour. In light of this, the regulation of the functional activity of these enzymes also opens a new avenue for the treatment approaches to be employed. This review describes the importance of non-conventional enzymes as potential candidates in several cardiovascular disorders while highlighting some of the recently targeted therapeutic enzymes in CVDs.
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Affiliation(s)
- Gaurav Kumar
- University of Delhi - South Campus, 93081, Biochemistry, New Delhi, Delhi, India;
| | - Manisha Saini
- University of Delhi - South Campus, 93081, Biochemistry, New Delhi, Delhi, India;
| | - Suman Kundu
- University of Delhi - South Campus, 93081, Biochemistry, New Delhi, Delhi, India;
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13
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He Z, Zhu S, Zhou K, Jin Y, He L, Xu W, Lao C, Liu G, Han S. Sildenafil for pulmonary hypertension in neonates: An updated systematic review and meta-analysis. Pediatr Pulmonol 2021; 56:2399-2412. [PMID: 33983650 DOI: 10.1002/ppul.25444] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To provide an updated review and meta-analysis on the efficacy and safety of sildenafil for treating persistent pulmonary hypertension in neonates (PPHN). METHODS PubMed/Medline, SCOPUS, Cochrane Central Register of Controlled Trials, and Web of Science were searched from the inception of publication to January 2021. The principal outcomes include oxygenation parameters, hemodynamic metrics and echocardiographic measurements, as well as adverse outcomes. RESULTS A total of eight studies were included with 216 term and premature neonates with PPHN. Compelling evidence showed the use of sildenafil could improve the prognosis of PPHN neonates, compared with baseline or placebo in neonates with PPHN, and a time-dependent pattern of the improvements can be observed. After 24 h of treatment, the Oxygenation index suggested a steady decrease (SD: -1.80, 95% confidence interval [CI]: -2.92, -0.67) and sildenafil exerted peak effects after 72 h of treatment (SD: -4.02, 95% CI: -5.45, -2.59). No clinically significant side effects were identified. Egger's test and funnel plots of the major outcomes were performed, and the publication bias was not significant. CONCLUSION Improvements were shown in oxygenation index, pulmonary arterial pressure, and adverse outcomes after using sildenafil for PPHN in neonates. However, future research with robust longitudinal or randomized controlled design is still needed.
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Affiliation(s)
- Zonglin He
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China.,Faculty of Medicine, International School, Jinan University, Guangzhou, China
| | - Sui Zhu
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China
| | - Kai Zhou
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China.,Faculty of Medicine, International School, Jinan University, Guangzhou, China
| | - Ya Jin
- Department of Neonatology and Pediatrics, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Longkai He
- Department of Neonatology and Pediatrics, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Weipeng Xu
- Department of Neonatology and Pediatrics, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - CheokUn Lao
- Department of Neonatology and Pediatrics, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Guosheng Liu
- Department of Neonatology and Pediatrics, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Shasha Han
- Department of Neonatology and Pediatrics, The First Affiliated Hospital, Jinan University, Guangzhou, China
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14
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Marulanda K, Tsihlis ND, McLean SE, Kibbe MR. Emerging antenatal therapies for congenital diaphragmatic hernia-induced pulmonary hypertension in preclinical models. Pediatr Res 2021; 89:1641-1649. [PMID: 33038872 PMCID: PMC8035353 DOI: 10.1038/s41390-020-01191-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 09/09/2020] [Accepted: 09/24/2020] [Indexed: 02/07/2023]
Abstract
Congenital diaphragmatic hernia (CDH)-related deaths are the largest contributor to in-hospital neonatal deaths in children with congenital malformations. Morbidity and mortality in CDH are directly related to the development of pulmonary hypertension (PH). Current treatment consists of supportive measures. To date, no pharmacotherapy has been shown to effectively reverse the hallmark finding of pulmonary vascular remodeling that is associated with pulmonary hypertension in CDH (CDH-PH). As such, there is a great need for novel therapies to effectively manage CDH-PH. Our review aims to evaluate emerging therapies, and specifically focuses on those that are still under investigation and not approved for clinical use by the Food and Drug Administration. Therapies were categorized into antenatal pharmacotherapies or antenatal regenerative therapies and assessed on their method of administration, safety profile, the effect on pulmonary vascular pathophysiology, and overall efficacy. In general, emerging antenatal pharmaceutical and regenerative treatments primarily aim to alleviate pulmonary vascular remodeling by restoring normal function and levels of key regulatory factors involved in pulmonary vascular development and/or in promoting angiogenesis. Overall, while these emerging therapies show great promise for the management of CDH-PH, most require further assessment of safety and efficacy in preclinical models before translation into the clinical setting. IMPACT: Emerging antenatal therapies for congenital diaphragmatic hernia-induced pulmonary hypertension (CDH-PH) show promise to effectively mitigate vascular remodeling in preclinical models. Further investigation is needed in preclinical and human studies to evaluate safety and efficacy prior to translation into the clinical arena. This review offers a comprehensive and up-to-date summary of emerging therapies currently under investigation in experimental animal models. There is no cure for CDH-PH. This review explores emerging therapeutic options for the treatment of CDH-PH and evaluates their impact on key molecular pathways and clinical markers of disease to determine efficacy in the preclinical stage.
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Affiliation(s)
- Kathleen Marulanda
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Nick D Tsihlis
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Sean E McLean
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
- Division of Pediatric Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Melina R Kibbe
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
- Department of Biomedical Engineering, University of North Carolina, Chapel Hill, NC, USA.
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15
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Muehlbacher T, Bassler D, Bryant MB. Evidence for the Management of Bronchopulmonary Dysplasia in Very Preterm Infants. CHILDREN-BASEL 2021; 8:children8040298. [PMID: 33924638 PMCID: PMC8069828 DOI: 10.3390/children8040298] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/15/2022]
Abstract
Background: Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD. Objective: The goal of our review is to summarize the evidence on these daily procedures and provide evidence-based recommendations for the management of BPD. Methods: We conducted a systematic literature research using MEDLINE/PubMed on antenatal corticosteroids, surfactant-replacement therapy, caffeine, ventilation strategies, postnatal corticosteroids, inhaled nitric oxide, inhaled bronchodilators, macrolides, patent ductus arteriosus, fluid management, vitamin A, treatment of pulmonary hypertension and stem cell therapy. Results: Evidence provided by meta-analyses, systematic reviews, randomized controlled trials (RCTs) and large observational studies are summarized as a narrative review. Discussion: There is strong evidence for the use of antenatal corticosteroids, surfactant-replacement therapy, especially in combination with noninvasive ventilation strategies, caffeine and lung-protective ventilation strategies. A more differentiated approach has to be applied to corticosteroid treatment, the management of patent ductus arteriosus (PDA), fluid-intake and vitamin A supplementation, as well as the treatment of BPD-associated pulmonary hypertension. There is no evidence for the routine use of inhaled bronchodilators and prophylactic inhaled nitric oxide. Stem cell therapy is promising, but should be used in RCTs only.
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16
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Mondéjar-Parreño G, Cogolludo A, Perez-Vizcaino F. Potassium (K +) channels in the pulmonary vasculature: Implications in pulmonary hypertension Physiological, pathophysiological and pharmacological regulation. Pharmacol Ther 2021; 225:107835. [PMID: 33744261 DOI: 10.1016/j.pharmthera.2021.107835] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 02/06/2023]
Abstract
The large K+ channel functional diversity in the pulmonary vasculature results from the multitude of genes expressed encoding K+ channels, alternative RNA splicing, the post-transcriptional modifications, the presence of homomeric or heteromeric assemblies of the pore-forming α-subunits and the existence of accessory β-subunits modulating the functional properties of the channel. K+ channels can also be regulated at multiple levels by different factors controlling channel activity, trafficking, recycling and degradation. The activity of these channels is the primary determinant of membrane potential (Em) in pulmonary artery smooth muscle cells (PASMC), providing an essential regulatory mechanism to dilate or contract pulmonary arteries (PA). K+ channels are also expressed in pulmonary artery endothelial cells (PAEC) where they control resting Em, Ca2+ entry and the production of different vasoactive factors. The activity of K+ channels is also important in regulating the population and phenotype of PASMC in the pulmonary vasculature, since they are involved in cell apoptosis, survival and proliferation. Notably, K+ channels play a major role in the development of pulmonary hypertension (PH). Impaired K+ channel activity in PH results from: 1) loss of function mutations, 2) downregulation of its expression, which involves transcription factors and microRNAs, or 3) decreased channel current as a result of increased vasoactive factors (e.g., hypoxia, 5-HT, endothelin-1 or thromboxane), exposure to drugs with channel-blocking properties, or by a reduction in factors that positively regulate K+ channel activity (e.g., NO and prostacyclin). Restoring K+ channel expression, its intracellular trafficking and the channel activity is an attractive therapeutic strategy in PH.
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Affiliation(s)
- Gema Mondéjar-Parreño
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), Spain
| | - Angel Cogolludo
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), Spain
| | - Francisco Perez-Vizcaino
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), Spain.
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17
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Phosphodiesterase 5 (PDE5): Structure-function regulation and therapeutic applications of inhibitors. Biomed Pharmacother 2020; 134:111128. [PMID: 33348311 DOI: 10.1016/j.biopha.2020.111128] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/06/2020] [Accepted: 12/08/2020] [Indexed: 12/21/2022] Open
Abstract
Phosphodiesterase 5 (PDE5) is one of the most well-studied phosphodiesterases (PDEs) that specifically targets cGMP typically generated by nitric oxide (NO)-mediated activation of the soluble guanylyl cyclase. Given the crucial role of cGMP generated through the activation of this cellular signaling pathway in a variety of physiologically processes, pharmacological inhibition of PDE5 has been demonstrated to have several therapeutic applications including erectile dysfunction and pulmonary arterial hypertension. While they are designed to inhibit PDE5, the inhibitors show different affinities and specificities against all PDE subtypes. Additionally, they have been shown to induce allosteric structural changes in the protein. These are mostly attributed to their chemical structure and, therefore, binding interactions with PDE catalytic domains. Therefore, understanding how these inhibitors interact with PDE5 and the structural basis of their selectivity is critically important for the design of novel, highly selective PDE5 inhibitors. Here, we review the structure of PDE5, how its function is regulated, and discuss the clinically available inhibitors that target phosphodiesterase 5, aiming to better understand the structural bases of their affinity and specificity. We also discuss the therapeutic indications of these inhibitors and the potential of repurposing for a wider range of clinical applications.
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18
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Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, Meckler GD, Roberts KE, Sutton RM, Schexnayder SM. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S469-S523. [PMID: 33081526 DOI: 10.1161/cir.0000000000000901] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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19
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Rasaeifar B, Gomez-Gutierrez P, Perez JJ. Molecular Features of Non-Selective Small Molecule Antagonists of the Bradykinin Receptors. Pharmaceuticals (Basel) 2020; 13:E259. [PMID: 32967280 PMCID: PMC7558388 DOI: 10.3390/ph13090259] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 02/07/2023] Open
Abstract
Angiotensin converting enzyme 2 (ACE2) downregulation is a key negative factor for the severity of lung edema and acute lung failure observed in patients infected with SARS-CoV-2. ACE2 downregulation affects the levels of diverse peptide mediators of the renin-agiotensin-aldestosterone and kallikrein-kinin systems, compromising vascular hemostasis. Increasing evidence suggests that the inflammatory response observed in covid-19 patients is initiated by the action of kinins on the bradykinin receptors. Accordingly, the use of bradykinin antagonists should be considered as a strategy for therapeutic intervention against covid-19 illness progression. Presently, icatibant is the only bradykinin antagonist drug approved. In the present report, we investigated the molecular features characterizing non-selective antagonists targeting the bradykinin receptors and carried out a in silico screening of approved drugs, aimed at the identification of compounds with a non-selective bradykinin antagonist profile that can be evaluated for drug repurposing. The study permitted to identify eight compounds as prospective non-selective antagonists of the bradykinin receptors, including raloxifene; sildenafil; cefepime; cefpirome; imatinib; ponatinib; abemaciclib and entrectinib.
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Affiliation(s)
| | | | - Juan J. Perez
- Department of Chemical Engineering, Universitat Politecnica de Catalunya. ETSEIB. Av. Diagonal, 647, 08028 Barcelona, Spain; (B.R.); (P.G.-G.)
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20
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Uschner FE, Glückert K, Paternostro R, Gnad T, Schierwagen R, Mandorfer M, Magdaleno F, Ortiz C, Schwarzkopf K, Kamath PS, Alessandria C, Boesecke C, Pfeifer A, Reiberger T, Kreisel W, Sauerbruch T, Ferlitsch A, Trebicka J, Klein S. Combination of phosphodiesterase-5-inhibitors and beta blockers improves experimental portal hypertension and erectile dysfunction. Liver Int 2020; 40:2228-2241. [PMID: 32627946 DOI: 10.1111/liv.14586] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/29/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Phosphodiesterase-5 inhibitors (PDE-5-I) are used for treatment of erectile dysfunction (ED), which is common in patients with cirrhosis. They may improve portal hypertension (PH), but contradictory data on efficacy and side-effects have been reported. Non-selective beta blockers (NSBB) reduce portal pressure, but might aggravate ED. Thus, we evaluated the combination of PDE-5-I with NSBB and its impact on PH and ED in experimental cirrhosis. METHODS ED was assessed in cirrhotic patients (n = 86) using standardized questionnaire. Experimental cirrhosis was induced by bile-duct-ligation or carbon-tetrachloride intoxication in rats. Corpus cavernosum pressure - a surrogate of ED -, as well as systemic and portal haemodynamics, were measured in vivo and in situ after acute administration of udenafil alone or in combination with propranolol. mRNA and protein levels of PDE-5 signalling were analysed using PCR and western Blot. RESULTS ED in humans was related to severity of liver disease and to NSBB treatment. PDE-5 was mainly expressed in hepatic stellate cells and upregulated in human and experimental cirrhosis. Propranolol reduced corpus cavernosum pressure in cirrhotic rats and it was restored by udenafil. Even though udenafil treatment improved PH, it led to a reduction of mean arterial pressure. The combination of udenafil and propranolol reduced portal pressure and hepatic resistance without systemic side-effects. CONCLUSIONS ED is common with advanced cirrhosis and concomitant NSBB treatment. The combination of PDE-5-I and NSBB improves ED and PH in experimental cirrhosis.
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Affiliation(s)
- Frank E Uschner
- Department of Internal Medicine I, Hospital of the Goethe University, Frankfurt, Germany
| | - Kathleen Glückert
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Rafael Paternostro
- Hepatic Hemodynamic Lab, Medical University Vienna, Vienna, Austria.,Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thorsten Gnad
- Institute of Pharmacology and Toxicology, University Hospital, University of Bonn, Bonn, Germany
| | - Robert Schierwagen
- Department of Internal Medicine I, Hospital of the Goethe University, Frankfurt, Germany
| | - Mattias Mandorfer
- Hepatic Hemodynamic Lab, Medical University Vienna, Vienna, Austria.,Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Fernando Magdaleno
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Cristina Ortiz
- Department of Internal Medicine I, Hospital of the Goethe University, Frankfurt, Germany
| | - Katharina Schwarzkopf
- Department of Internal Medicine I, Hospital of the Goethe University, Frankfurt, Germany
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Christoph Boesecke
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Alexander Pfeifer
- Institute of Pharmacology and Toxicology, University Hospital, University of Bonn, Bonn, Germany
| | - Thomas Reiberger
- Hepatic Hemodynamic Lab, Medical University Vienna, Vienna, Austria.,Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Kreisel
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Tilman Sauerbruch
- Department of Internal Medicine I, Hospital of the Goethe University, Frankfurt, Germany
| | - Arnulf Ferlitsch
- Hepatic Hemodynamic Lab, Medical University Vienna, Vienna, Austria.,Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jonel Trebicka
- Department of Internal Medicine I, Hospital of the Goethe University, Frankfurt, Germany.,European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Sabine Klein
- Department of Internal Medicine I, Hospital of the Goethe University, Frankfurt, Germany
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21
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Zhao X, Lorent K, Escobar-Zarate D, Rajagopalan R, Loomes KM, Gillespie K, Mesaros C, Estrada MA, Blair I, Winkler JD, Spinner NB, Devoto M, Pack M. Impaired Redox and Protein Homeostasis as Risk Factors and Therapeutic Targets in Toxin-Induced Biliary Atresia. Gastroenterology 2020; 159:1068-1084.e2. [PMID: 32505743 PMCID: PMC7856536 DOI: 10.1053/j.gastro.2020.05.080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 05/08/2020] [Accepted: 05/27/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Extrahepatic biliary atresia (BA) is a pediatric liver disease with no approved medical therapy. Recent studies using human samples and experimental modeling suggest that glutathione redox metabolism and heterogeneity play a role in disease pathogenesis. We sought to dissect the mechanistic basis of liver redox variation and explore how other stress responses affect cholangiocyte injury in BA. METHODS We performed quantitative in situ hepatic glutathione redox mapping in zebrafish larvae carrying targeted mutations in glutathione metabolism genes and correlated these findings with sensitivity to the plant-derived BA-linked toxin biliatresone. We also determined whether genetic disruption of HSP90 protein quality control pathway genes implicated in human BA altered biliatresone toxicity in zebrafish and human cholangiocytes. An in vivo screening of a known drug library was performed to identify novel modifiers of cholangiocyte injury in the zebrafish experimental BA model, with subsequent validation. RESULTS Glutathione metabolism gene mutations caused regionally distinct changes in the redox potential of cholangiocytes that differentially sensitized them to biliatresone. Disruption of human BA-implicated HSP90 pathway genes sensitized zebrafish and human cholangiocytes to biliatresone-induced injury independent of glutathione. Phosphodiesterase-5 inhibitors and other cyclic guanosine monophosphate signaling activators worked synergistically with the glutathione precursor N-acetylcysteine in preventing biliatresone-induced injury in zebrafish and human cholangiocytes. Phosphodiesterase-5 inhibitors enhanced proteasomal degradation and required intact HSP90 chaperone. CONCLUSION Regional variation in glutathione metabolism underlies sensitivity to the biliary toxin biliatresone and may account for the reported association between BA transplant-free survival and glutathione metabolism gene expression. Human BA can be causatively linked to genetic modulation of protein quality control. Combined treatment with N-acetylcysteine and cyclic guanosine monophosphate signaling enhancers warrants further investigation as therapy for BA.
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Affiliation(s)
- Xiao Zhao
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristin Lorent
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Diana Escobar-Zarate
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ramakrishnan Rajagopalan
- Division of Genomic Diagnostics, Department of Pathology, The Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kathleen M. Loomes
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kevin Gillespie
- Department of System Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Clementina Mesaros
- Department of System Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Ian Blair
- Department of System Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey D. Winkler
- Department of Chemistry, University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy B. Spinner
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marcella Devoto
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA.,Departments of Pediatrics and of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Translational and Precision Medicine, University La Sapienza, Rome, Italy
| | - Michael Pack
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cell and Developmental Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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22
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Dada FA, Oyeleye SI, Adefegha SA, Oboh G. Extracts from Almond (Terminalia catappa) leaf and stem bark mitigate the activities of crucial enzymes and oxidative stress associated with hypertension in cyclosporine A-stressed rats. J Food Biochem 2020; 45:e13435. [PMID: 32794232 DOI: 10.1111/jfbc.13435] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/24/2020] [Accepted: 07/23/2020] [Indexed: 12/15/2022]
Abstract
We investigated the effect of extracts from the leaf (ALE) and stem bark (ABE) of Almond tree on activities of some crucial enzymes [angiotensin-1 converting enzyme (ACE), arginase, acetylcholinesterase (AChE), phosphodiesterase-5 (PDE-5), adenosine deaminase (ADA), superoxide dismutase (SOD), catalase], and thiobarbituric acid reactive species (TBARS) associated with hypertension in normal adult male Wistar albino rats and Cyclosporine A (CsA)-stressed rats. The result revealed that CsA-stressed rats treated with captopril and extracts (ALE and ABE) had lowered ACE, arginase, AChE, PDE-5, ADA activities, and TBARS level, coupled with improved SOD and catalase activities compared with untreated CsA-stressed rats, which had reversed these biochemicals compared to normal rats. This suggests that the extracts could be explored to suppress hypertension and other cardiac injury known with CsA treatment; the potentials that could be linked with the constituent polyphenols. However, further studies including blood pressure should be determined to ascertain this claim. PRACTICAL APPLICATIONS: Drug-induced cardiotoxicity, hypertension, and organ damage are among the most common side effects of pharmaceutics. Therefore, it becomes imperative to find natural, effective, and alternative therapy with little or no side effect to combat drug toxicity. The use of Almond (leaf and stem bark) in folklore for the treatment/management of hypertension and other heart-related diseases without full scientific basis is on the increase. Hence, this study provides some biochemical evidences on the effect of Almond leaf and stem back extracts on crucial enzymes and oxidative stress markers involve in the incidence of hypertension in the course of Cyclosporine A administration. The findings of this study indicated that the studied plant materials could be promoted as nutraceutical agents to neutralize drug-induced cardiac injury and hypertension.
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Affiliation(s)
- Felix Abayomi Dada
- Biochemistry Unit, Science Laboratory Technology Department, Federal Polytechnic Ede, Ede, Nigeria
| | - Sunday Idowu Oyeleye
- Biochemistry Department, Federal University of Technology, Akure, Nigeria.,Department of Biomedical Technology, Federal University of Technology, Akure, Nigeria
| | | | - Ganiyu Oboh
- Biochemistry Department, Federal University of Technology, Akure, Nigeria
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23
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Garcia AM, Beatty JT, Nakano SJ. Heart failure in single right ventricle congenital heart disease: physiological and molecular considerations. Am J Physiol Heart Circ Physiol 2020; 318:H947-H965. [PMID: 32108525 PMCID: PMC7191494 DOI: 10.1152/ajpheart.00518.2019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 12/27/2022]
Abstract
Because of remarkable surgical and medical advances over the past several decades, there are growing numbers of infants and children living with single ventricle congenital heart disease (SV), where there is only one functional cardiac pumping chamber. Nevertheless, cardiac dysfunction (and ultimately heart failure) is a common complication in the SV population, and pharmacological heart failure therapies have largely been ineffective in mitigating the need for heart transplantation. Given that there are several inherent risk factors for ventricular dysfunction in the setting of SV in addition to probable differences in molecular adaptations to heart failure between children and adults, it is perhaps not surprising that extrapolated adult heart failure medications have had limited benefit in children with SV heart failure. Further investigations into the molecular mechanisms involved in pediatric SV heart failure may assist with risk stratification as well as development of targeted, efficacious therapies specific to this patient population. In this review, we present a brief overview of SV anatomy and physiology, with a focus on patients with a single morphological right ventricle requiring staged surgical palliation. Additionally, we discuss outcomes in the current era, risk factors associated with the progression to heart failure, present state of knowledge regarding molecular alterations in end-stage SV heart failure, and current therapeutic interventions. Potential avenues for improving SV outcomes, including identification of biomarkers of heart failure progression, implications of personalized medicine and stem cell-derived therapies, and applications of novel models of SV disease, are proposed as future directions.
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Affiliation(s)
- Anastacia M Garcia
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
| | - Jonathan-Thomas Beatty
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Stephanie J Nakano
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
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24
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Jin Q, Bhatta A, Pagaduan JV, Chen X, West-Foyle H, Liu J, Hou A, Berkowitz D, Kuo SC, Askin FB, Nguyen TD, Gracias DH, Romer LH. Biomimetic human small muscular pulmonary arteries. SCIENCE ADVANCES 2020; 6:eaaz2598. [PMID: 32232160 PMCID: PMC7096158 DOI: 10.1126/sciadv.aaz2598] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 01/03/2020] [Indexed: 05/04/2023]
Abstract
Changes in structure and function of small muscular arteries play a major role in the pathophysiology of pulmonary hypertension, a burgeoning public health challenge. Improved anatomically mimetic in vitro models of these microvessels are urgently needed because nonhuman vessels and previous models do not accurately recapitulate the microenvironment and architecture of the human microvascular wall. Here, we describe parallel biofabrication of photopatterned self-rolled biomimetic pulmonary arterial microvessels of tunable size and infrastructure. These microvessels feature anatomically accurate layering and patterning of aligned human smooth muscle cells, extracellular matrix, and endothelial cells and exhibit notable increases in endothelial longevity and nitric oxide production. Computational image processing yielded high-resolution 3D perspectives of cells and proteins. Our studies provide a new paradigm for engineering multicellular tissues with precise 3D spatial positioning of multiple constituents in planar moieties, providing a biomimetic platform for investigation of microvascular pathobiology in human disease.
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Affiliation(s)
- Qianru Jin
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Anil Bhatta
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Jayson V. Pagaduan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Xing Chen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Hoku West-Foyle
- Microscope Facility, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jiayu Liu
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Annie Hou
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dan Berkowitz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scot C. Kuo
- Microscope Facility, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frederic B. Askin
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thao D. Nguyen
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - David H. Gracias
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA
- Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD, USA
- Corresponding author. (D.H.G.); (L.H.R.)
| | - Lewis H. Romer
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Cell Dynamics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Corresponding author. (D.H.G.); (L.H.R.)
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25
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Perioperative Considerations in Pediatric Patients With Pulmonary Hypertension. Int Anesthesiol Clin 2019; 57:25-41. [PMID: 31503094 DOI: 10.1097/aia.0000000000000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Bernier ML, Romer LH, Bembea MM. Spectrum of Current Management of Pediatric Pulmonary Hypertensive Crisis. Crit Care Explor 2019; 1:e0037. [PMID: 32166278 PMCID: PMC7063944 DOI: 10.1097/cce.0000000000000037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Pulmonary hypertension is a growing pediatric problem and children may present with pulmonary hypertensive crisis-a life-threatening emergency requiring acute interventions. The aim of this study was to characterize the broad spectrum of care provided in North American PICUs for children who present with pulmonary hypertensive crisis. DESIGN Electronic cross-sectional survey. Survey questions covered the following: demographics of the respondents, institution, and patient population; pulmonary hypertension diagnostic modalities; pulmonary hypertension-specific pharmacotherapies; supportive therapies, including sedation, ventilation, and inotropic support; and components of multidisciplinary teams. SETTING PICUs in the United States and Canada. SUBJECTS Faculty members from surveyed institutions. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS The response rate was 50% of 99 identified institutions. Of the respondents, 82.2% were pediatric intensivists from large units, and 73.9% had over a decade of experience beyond training. Respondents provided care for a median of 10 patients/yr with acute pulmonary hypertensive crisis. Formal echocardiography protocols existed at 61.1% of institutions with varying components reported. There were no consistent indications for cardiac catheterization during a pulmonary hypertensive crisis admission. All institutions used inhaled nitric oxide, and enteral phosphodiesterase type 5 inhibitor was the most frequently used additional targeted vasodilator therapy. Milrinone and epinephrine were the most frequently used vasoactive infusions. Results showed no preferred approach to mechanical ventilation. Fentanyl and dexmedetomidine were the preferred sedative infusions. A formal pulmonary hypertension consulting team was reported at 51.1% of institutions, and the three most common personnel were pediatric cardiologist, pediatric pulmonologist, and advanced practice nurse. CONCLUSIONS The management of critically ill children with acute pulmonary hypertensive crisis is diverse. Findings from this survey may inform formal recommendations - particularly with regard to care team composition and pulmonary vasodilator therapies - as North American guidelines are currently lacking. Additional work is needed to determine best practice, standardization of practice, and resulting impact on outcomes.
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Affiliation(s)
- Meghan L Bernier
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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27
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Jiang Z, Zheng X, Li Z, Pan S, Wang X, Zhang C, Li Z, Luo HB, Wu D, Cai X. 3D-QSAR modeling of Phosphodiesterase-5 inhibitors: evaluation and comparison of the receptor- and ligand-based alignments. Med Chem Res 2019. [DOI: 10.1007/s00044-019-02311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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28
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Shahin HI, Vinjamuri BP, Mahmoud AA, Shamma RN, Mansour SM, Ammar HO, Ghorab MM, Chougule MB, Chablani L. Design and evaluation of novel inhalable sildenafil citrate spray-dried microparticles for pulmonary arterial hypertension. J Control Release 2019; 302:126-139. [DOI: 10.1016/j.jconrel.2019.03.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/28/2019] [Accepted: 03/29/2019] [Indexed: 10/27/2022]
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29
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Rosenzweig EB, Abman SH, Adatia I, Beghetti M, Bonnet D, Haworth S, Ivy DD, Berger RMF. Paediatric pulmonary arterial hypertension: updates on definition, classification, diagnostics and management. Eur Respir J 2019; 53:1801916. [PMID: 30545978 PMCID: PMC6351335 DOI: 10.1183/13993003.01916-2018] [Citation(s) in RCA: 332] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 12/16/2022]
Abstract
Paediatric pulmonary arterial hypertension (PAH) shares common features of adult disease, but is associated with several additional disorders and challenges that require unique approaches. This article discusses recent advances, ongoing challenges and distinct approaches for the care of children with PAH, as presented by the Paediatric Task Force of the 6th World Symposium on Pulmonary Hypertension. We provide updates of the current definition, epidemiology, classification, diagnostics and treatment of paediatric PAH, and identify critical knowledge gaps. Several features of paediatric PAH including the prominence of neonatal PAH, especially in pre-term infants with developmental lung diseases, and novel genetic causes of paediatric PAH are highlighted. The use of cardiac catheterisation as a diagnostic modality and haemodynamic definitions of PAH, including acute vasoreactivity, are addressed. Updates are provided on issues related to utility of the previous classification system to reflect paediatric-specific aetiologies and approaches to medical and interventional management of PAH, including the Potts shunt. Although a lack of clinical trial data for the use of PAH-targeted therapy persists, emerging data are improving the identification of appropriate targets for goal-oriented therapy in children. Such data will likely improve future clinical trial design to enhance outcomes in paediatric PAH.
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Affiliation(s)
- Erika B Rosenzweig
- Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Steven H Abman
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Ian Adatia
- Glenwood Children's Heart Clinic, Edmonton, AB, Canada
| | - Maurice Beghetti
- Pediatric Cardiology Unit and Centre Universitaire de Cardiologie et Chirurgie Cardiaque Pédiatrique, University Hospitals of Geneva and Lausanne, Lausanne, Switzerland
| | - Damien Bonnet
- Hôpital Necker Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | | | - D Dunbar Ivy
- University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Pediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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30
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Wade BE, Zhao J, Ma J, Hart CM, Sutliff RL. Hypoxia-induced alterations in the lung ubiquitin proteasome system during pulmonary hypertension pathogenesis. Pulm Circ 2018; 8:2045894018788267. [PMID: 29927354 PMCID: PMC6146334 DOI: 10.1177/2045894018788267] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Pulmonary hypertension (PH) is a clinical disorder characterized by sustained
increases in pulmonary vascular resistance and pressure that can lead to right
ventricular (RV) hypertrophy and ultimately RV failure and death. The molecular
pathogenesis of PH remains incompletely defined, and existing treatments are
associated with suboptimal outcomes and persistent morbidity and mortality.
Reports have suggested a role for the ubiquitin proteasome system (UPS) in PH,
but the extent of UPS-mediated non-proteolytic protein alterations during PH
pathogenesis has not been previously defined. To further examine UPS
alterations, the current study employed C57BL/6J mice exposed to normoxia or
hypoxia for 3 weeks. Lung protein ubiquitination was evaluated by mass
spectrometry to identify differentially ubiquitinated proteins relative to
normoxic controls. Hypoxia stimulated differential ubiquitination of 198
peptides within 131 proteins (p < 0.05). These proteins were
screened to identify candidates within pathways involved in PH pathogenesis.
Some 51.9% of the differentially ubiquitinated proteins were implicated in at
least one known pathway contributing to PH pathogenesis, and 13% were involved
in three or more PH pathways. Anxa2, App, Jak1, Lmna, Pdcd6ip, Prkch1, and Ywhah
were identified as mediators in PH pathways that undergo differential
ubiquitination during PH pathogenesis. To our knowledge, this is the first study
to report global changes in protein ubiquitination in the lung during PH
pathogenesis. These findings suggest signaling nodes that are dynamically
regulated by the UPS during PH pathogenesis. Further exploration of these
differentially ubiquitinated proteins and related pathways can provide new
insights into the role of the UPS in PH pathogenesis.
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Affiliation(s)
- Brandy E Wade
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Atlanta Veterans' Affairs and Emory University Medical Centers, Decatur, Georgia, USA
| | - Jingru Zhao
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Atlanta Veterans' Affairs and Emory University Medical Centers, Decatur, Georgia, USA
| | - Jing Ma
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Atlanta Veterans' Affairs and Emory University Medical Centers, Decatur, Georgia, USA
| | - C Michael Hart
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Atlanta Veterans' Affairs and Emory University Medical Centers, Decatur, Georgia, USA
| | - Roy L Sutliff
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Atlanta Veterans' Affairs and Emory University Medical Centers, Decatur, Georgia, USA
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31
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Andersson KE. PDE5 inhibitors - pharmacology and clinical applications 20 years after sildenafil discovery. Br J Pharmacol 2018; 175:2554-2565. [PMID: 29667180 DOI: 10.1111/bph.14205] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/01/2018] [Accepted: 03/05/2018] [Indexed: 11/28/2022] Open
Abstract
The discovery of the nitric oxide/cGMP pathway was the basis for our understanding of many normal physiological functions and the pathophysiology of several diseases. Since the discovery and introduction of sildenafil, inhibitors of PDE5 have been the first-line therapy for erectile dysfunction (ED). The success of sildenafil in the treatment of ED stimulated research in the field of PDE5 inhibition and led to many new applications, such as treatment of lower urinary symptoms, and pulmonary arterial hypertension, which are now approved indications. However, PDE5 inhibitors have also been used in several other disorders not discussed in this review, and the fields of clinical use are increasing. In the present review, the pharmacological basis of the NO/cGMP pathway and the rationale and clinical use of PDE5 inhibitors in different diseases are discussed.
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Affiliation(s)
- K-E Andersson
- Institute for Regenerative Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA.,Institute of Laboratory Medicine, Lund University, 223 62, Lund, Sweden
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32
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Cheng Y, Gong Y, Qian S, Mou Y, Li H, Chen X, Kong H, Xie W, Wang H, Zhang Y, Huang Z. Identification of a Novel Hybridization from Isosorbide 5-Mononitrate and Bardoxolone Methyl with Dual Activities of Pulmonary Vasodilation and Vascular Remodeling Inhibition on Pulmonary Arterial Hypertension Rats. J Med Chem 2018; 61:1474-1482. [PMID: 29377691 DOI: 10.1021/acs.jmedchem.7b01153] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Yusheng Cheng
- Department
of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029, P. R. China
| | | | | | | | | | | | - Hui Kong
- Department
of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029, P. R. China
| | - Weiping Xie
- Department
of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029, P. R. China
| | - Hong Wang
- Department
of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029, P. R. China
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33
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Mehler K, Udink Ten Cate FE, Keller T, Bangen U, Kribs A, Oberthuer A. An Echocardiographic Screening Program Helps to Identify Pulmonary Hypertension in Extremely Low Birthweight Infants with and without Bronchopulmonary Dysplasia: A Single-Center Experience. Neonatology 2018; 113:81-88. [PMID: 29131022 DOI: 10.1159/000480694] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 08/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) affects 1 in 6 infants with a birthweight <1,000 g (extremely low birthweight; ELBW) and is frequently associated with bronchopulmonary dysplasia (BPD). If untreated, the mortality rates of the disease are high. OBJECTIVES The aim of this study was to characterize risk factors for PH in ELBW infants and to describe the timing of onset of the disease by setting up a screening program. METHODS ELBW infants treated at the Department of Neonatology (level III neonatal intensive care unit at the University of Cologne Medical Centre, Germany) between January 2010 and March 2015 were included. Echocardiography screening for PH was performed either before discharge or if BPD was diagnosed. Additionally, infants had at least 1 echocardiographic scan after discharge. Survival with PH, age at diagnosis of PH, and risk factors associated with PH were assessed. RESULTS In total, 34/188 (18%) infants had PH. Of these, 14 (41%) were identified after discharge. Another 11 (32%) were diagnosed with PH without suffering from moderate or severe BPD. The risk factors for diagnosis of PH were moderate (odds ratio, OR 4 [2-8]) or severe BPD (OR 13 [2-71]), prolonged rupture of membranes >7 days (OR 5 [1-19]), and birthweight below the 3rd percentile (OR 3 [1-9]). All infants with PH before discharge and 50% diagnosed after discharge were treated with sildenafil (2.0 mg/kg/day). PH resolved and sildenafil was discontinued in all patients after a median duration of 13 months (IQR 8-20). CONCLUSIONS An echocardiographic screening program may help to identify infants with PH. Examinations should include all ELBW infants irrespective of the presence of BPD and be continued after discharge.
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Affiliation(s)
- Katrin Mehler
- Division of Neonatology, Children's Hospital, University of Cologne, Cologne, Germany
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34
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Barreto Ortiz S, Hori D, Nomura Y, Yun X, Jiang H, Yong H, Chen J, Paek S, Pandey D, Sikka G, Bhatta A, Gillard A, Steppan J, Kim JH, Adachi H, Barodka VM, Romer L, An SS, Shimoda LA, Santhanam L, Berkowitz DE. Opsin 3 and 4 mediate light-induced pulmonary vasorelaxation that is potentiated by G protein-coupled receptor kinase 2 inhibition. Am J Physiol Lung Cell Mol Physiol 2017; 314:L93-L106. [PMID: 28882814 DOI: 10.1152/ajplung.00091.2017] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We recently demonstrated that blue light induces vasorelaxation in the systemic mouse circulation, a phenomenon mediated by the nonvisual G protein-coupled receptor melanopsin (Opsin 4; Opn4). Here we tested the hypothesis that nonvisual opsins mediate photorelaxation in the pulmonary circulation. We discovered Opsin 3 (Opn3), Opn4, and G protein-coupled receptor kinase 2 (GRK2) in rat pulmonary arteries (PAs) and in pulmonary arterial smooth muscle cells (PASMCs), where the opsins interact directly with GRK2, as demonstrated with a proximity ligation assay. Light elicited an intensity-dependent relaxation of PAs preconstricted with phenylephrine (PE), with a maximum response between 400 and 460 nm (blue light). Wavelength-specific photorelaxation was attenuated in PAs from Opn4-/- mice and further reduced following shRNA-mediated knockdown of Opn3. Inhibition of GRK2 amplified the response and prevented physiological desensitization to repeated light exposure. Blue light also prevented PE-induced constriction in isolated PAs, decreased basal tone, ablated PE-induced single-cell contraction of PASMCs, and reversed PE-induced depolarization in PASMCs when GRK2 was inhibited. The photorelaxation response was modulated by soluble guanylyl cyclase but not by protein kinase G or nitric oxide. Most importantly, blue light induced significant vasorelaxation of PAs from rats with chronic pulmonary hypertension and effectively lowered pulmonary arterial pressure in isolated intact perfused rat lungs subjected to acute hypoxia. These findings show that functional Opn3 and Opn4 in PAs represent an endogenous "optogenetic system" that mediates photorelaxation in the pulmonary vasculature. Phototherapy in conjunction with GRK2 inhibition could therefore provide an alternative treatment strategy for pulmonary vasoconstrictive disorders.
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Affiliation(s)
- Sebastian Barreto Ortiz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Daijiro Hori
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.,Division of Cardiac Surgery, Johns Hopkins University , Baltimore, Maryland
| | - Yohei Nomura
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.,Division of Cardiac Surgery, Johns Hopkins University , Baltimore, Maryland
| | - Xin Yun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Asthma and Allergy Center, Johns Hopkins University , Baltimore, Maryland
| | - Haiyang Jiang
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Asthma and Allergy Center, Johns Hopkins University , Baltimore, Maryland
| | - Hwanmee Yong
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - James Chen
- Department of Biomedical Engineering, Johns Hopkins University , Baltimore, Maryland
| | - Sam Paek
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Deepesh Pandey
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Gautam Sikka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Anil Bhatta
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Andrew Gillard
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Jae Hyung Kim
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Hideo Adachi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Viachaslau M Barodka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland
| | - Lewis Romer
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.,Department of Biomedical Engineering, Johns Hopkins University , Baltimore, Maryland.,Departments of Cell Biology, Pediatrics, and the Center for Cell Dynamics, Johns Hopkins University , Baltimore, Maryland
| | - Steven S An
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Larissa A Shimoda
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Asthma and Allergy Center, Johns Hopkins University , Baltimore, Maryland
| | - Lakshmi Santhanam
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.,Department of Biomedical Engineering, Johns Hopkins University , Baltimore, Maryland
| | - Dan E Berkowitz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland.,Department of Biomedical Engineering, Johns Hopkins University , Baltimore, Maryland
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35
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Shafiee-Nick R, Afshari AR, Mousavi SH, Rafighdoust A, Askari VR, Mollazadeh H, Fanoudi S, Mohtashami E, Rahimi VB, Mohebbi M, Vahedi MM. A comprehensive review on the potential therapeutic benefits of phosphodiesterase inhibitors on cardiovascular diseases. Biomed Pharmacother 2017; 94:541-556. [PMID: 28779712 DOI: 10.1016/j.biopha.2017.07.084] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 07/02/2017] [Accepted: 07/19/2017] [Indexed: 12/18/2022] Open
Abstract
Phosphodiesterases are a group of enzymes that hydrolyze cyclic nucleotides, which assume a key role in directing intracellular levels of the second messengers' cAMP and cGMP, and consequently cell function. The disclosure of 11 isoenzyme families and our expanded knowledge of their functions at the cell and molecular level stimulate the improvement of isoenzyme selective inhibitors for the treatment of various diseases, particularly cardiovascular diseases. Hence, future and new mechanistic investigations and carefully designed clinical trials could help reap additional benefits of natural/synthetic PDE inhibitors for cardiovascular disease in patients. This review has concentrated on the potential therapeutic benefits of phosphodiesterase inhibitors on cardiovascular diseases.
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Affiliation(s)
- Reza Shafiee-Nick
- Pharmacological Research Center of Medicinal Plants, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmacology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir R Afshari
- Pharmacological Research Center of Medicinal Plants, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmacology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Hadi Mousavi
- Medical Toxicology Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abbasali Rafighdoust
- Department of Cardiology, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vahid Reza Askari
- Department of Pharmacology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamid Mollazadeh
- Department of Physiology and Pharmacology, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Sahar Fanoudi
- Department of Pharmacology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elmira Mohtashami
- Department of Pharmacodynamic and Toxicology, Faculty of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vafa Baradaran Rahimi
- Department of Pharmacology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Moein Mohebbi
- Department of Internal Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Mahdi Vahedi
- Department of Pharmacology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran.
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Sildenafil in Infants and Children. CHILDREN-BASEL 2017; 4:children4070060. [PMID: 28737730 PMCID: PMC5532552 DOI: 10.3390/children4070060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/08/2017] [Accepted: 07/21/2017] [Indexed: 11/19/2022]
Abstract
Pulmonary arterial hypertension (PAH) management has been transformed in recent times with the advent of cheap and effective diagnostic tools and therapy. Sildenafil, a phosphodiesterase-V inhibitor, has been at the centre of this treatment, and its success in treating PAH has led to its widespread uptake in adult and paediatric pulmonary hypertension (PH), as a first line treatment choice. This might apply to persistent pulmonary hypertension of the newborn (PPHN) or bronchopulmonary dysplasia, as well as to more complex diseases, such as idiopathic pulmonary hypertension. Although recent data regarding long-term mortality and the repeal of Food and Drug Administration (FDA) approval has complicated the issue, Sildenafil continues to be the major treatment option for paediatric PH for patients in a variety of contexts, and this does not seem likely to change in the foreseeable future. In this review, we provide a summary of pulmonary hypertension in infants and children and the use of Sildenafil for such diseases.
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